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A Systematic Review and Methodologic Critique

Gerald W. Smetana, MD; Bruce E. Landon, MD, MBA; Andrew B. Bindman, MD; Helen Burstin, MD, MPH; Roger B. Davis, ScD; Jennifer Tjia, MD, MSc; Eugene C. Rich, MD

Arch Intern Med. 2007;167(1):10-20.

Background  Studies of clinical outcomes for generalist vs specialist care for diagnoses within a specialist's narrow domain have tended to favor specialty care.

Methods  A MEDLINE search from January 1, 1980, through April 1, 2005, and a hand search of retrieved bibliographies of English-language studies that compared generalist vs specialist care for individual patients with a single discrete medical condition were performed. Two reviewers determined eligibility for each study and abstracted data onto a standardized instrument.

Results  A total of 49 articles met our inclusion criteria: 24 studies favored specialty care, 13 found no difference in outcomes, 7 varied by individual outcome, 1 depended on physician experience, and 4 favored generalist care. Only 8 studies reported integration into health delivery systems, 4 considered physician experience, 3 documented information technology support, and 2 considered the impact of care management programs. Selection bias was adequately addressed in 58% of studies that favored specialty care and in 71% of studies that found no difference or favored generalist care (P = .52). Studies that favored specialty care were less likely to consider 4 key, potentially confounding physician or practice characteristics compared with studies that found no difference or favored generalist care (3% vs 15% of potential instances, respectively; P = .009).

Conclusions  The literature regarding the influence of generalist vs specialist care on outcomes for patients with a single discrete condition suffers from important methodologic shortcomings. Further research is needed to inform health care policy as it pertains to the optimal role of generalists and specialists in the physician marketplace.

Author Affiliations: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center (Drs Smetana, Landon, and Davis) and Department of Health Care Policy (Dr Landon), Harvard Medical School, Boston, Mass; Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco (Dr Bindman); Center for Primary Care, Prevention, and Clinical Partnerships, Agency for Healthcare Research and Quality, Rockville, Md (Dr Burstin); Division of Geriatric Medicine, University of Pennsylvania School of Medicine, Philadelphia (Dr Tjia); and Department of Medicine, Creighton University School of Medicine, Omaha, Neb (Dr Rich).

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