 |
|
A Comparison of Outcomes Resulting From Generalist vs Specialist Care for a Single Discrete Medical ConditionA 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).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati
What's this?
RELATED ARTICLE
Studies Comparing Quality of Care by Specialty: Valid, Relevant, or Neither?
Patrick G. O’Malley and Ann S. O’Malley
Arch Intern Med. 2007;167(1):8-9.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
A Typology of Specialists' Clinical Roles
Forrest
Arch Intern Med 2009;169:1062-1068.
ABSTRACT
| FULL TEXT
Ambulatory Care Provided by Office-Based Specialists in the United States
Valderas et al.
Ann Fam Med 2009;7:104-111.
ABSTRACT
| FULL TEXT
Access to and utilization of neurologists by people with multiple sclerosis
Minden et al.
Neurology 2008;70:1141-1149.
ABSTRACT
| FULL TEXT
Influence of Inpatient Service Specialty on Care Processes and Outcomes for Patients With Non-ST-Segment Elevation Acute Coronary Syndromes
Roe et al.
Circulation 2007;116:1153-1161.
ABSTRACT
| FULL TEXT
The Underuse of Screening Services Among Elderly Women With Diabetes
McBean and Yu
Diabetes Care 2007;30:1466-1472.
ABSTRACT
| FULL TEXT
Studies Comparing Quality of Care by Specialty: Valid, Relevant, or Neither?
O'Malley and O'Malley
Arch Intern Med 2007;167:8-9.
FULL TEXT
|
