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The outcome of elderly patients with myocardial infarction was better following care provided by cardiologists rather than by primary care physicians
Evidence-based health care m a n a g e m e n t
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The outcome of elderly patients with myocardial infarction was better following care provided by cardiologists rather than by primary care physicians
Jollis J G, DeLong E R, Peter E D et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. New Eng J Med 1996; 335:1880-1887 Objective To study the relationship between the specialty of the admitting physician and the outcome of care in patients over 65 who had had a myocardial infarction.
prognostic importance of the physicians' specialties. Adjustments were made for imbalances in patient characteristics using a previously tested method. Results
Setting Four states in the USA, Alabama, Connecticut, Iowa, Wisconsin. Method A review of the mortality according to specialty of the admitting physician of 8241 patients over the age of 65 with a diagnosis of myocardial infarction in 1992. The findings were also related to insurance claims and survival data for all 220 535 patients for whom there were claims for hospital care for acute myocardial infarction in 1992 in the whole of the USA. Information was collected about the severity of the patients' illness and about the medications, procedures and length of stay. In-hospital 30-day and l-year mortality rates were calculated. Literature review No explicit strategy; 20 references. Analysis
Cox proportional hazards regression models were used to determine the
JUNE 1997
After adjusting for variations in patient and hospital characteristics, 1-year survival for patients managed by cardiologists was 12% less than the survival for those managed by primary care physicians (P < 0.001). Six percent more patients admitted by cardiologists were considered eligible for thrombolytic therapy and were more likely to receive all the medications studied. The patients admitted by cardiologists also underwent more coronary angiography and revascularization procedures and had more stress testing, nuclear imaging and monitoring. They also had a longer duration of stay in hospital. Authors' conclusions The authors do not claim that the results alone can be used to justify a policy requiring all patients with acute myocardial infarction to be cared for by cardiologists. They conclude that there is a need to define better the differences between specialty and primary care and the effects of those differences on outcomes, and a need to be aware of possible changes in outcome if policy to promote primary care is adopted to control costs.
Commentary What is the most cost-effective way of prolonging life among patients with coronary heart disease? The overwhelming bulk of the evidence examines discrete interventions including drugs and invasive procedures. By comparison, estimation of the impact of doctors in general and specialists in particular has been viewed as something of a 'black box': impossible to unpick with research. It is indeed a challenge to define the elements of a doctor's practice which might affect prognosis and, furthermore, randomization to specialist vs generalist is unlikely to be feasible. JoUis et al, in a carefully designed observational study, find that patients with acute myocardial infarction presenting to cardiologists have better survival than patients cared for by primary care physicians. The paper falls short of providing strong evidence that the clinical practices of cardiologists per se prolong life. First, the type of patients cared for by the different specialties were very different in many ways which affect survival; statistical adjustment for such differences may not lead to the magical 'level playing field' as often supposed. Second, the type of care which the patients received in the Cooperative Cardiovascular Project study was so different from usual practice (e.g. the thrombolysis rate was only 16%) that the generalizability of the findings must be questioned. However the authors" cautious conclusion is justified; in this example, policy-makers should consider the potential adverse effect on patient outcomes of promoting primary care at the expense of specialist care. 'I want to see my specialist!' cries the patient. The paper by Jollis et al is one of a growing number which allows policymakers to base their response on peerreviewed scientific evidence. Dr l l a r r y Hendngway Consultant, Public Health Medicine Kensington, Chelsea and Westminster Health Authority London, UK
EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT
37
0 e ....... er4essio..ma199Z
The outcome of elderly patients with myocardial infarction was better following care provided by cardiologists rather than by primary care physicians
Jollis J G, DeLong E R, Peter E D et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. New Eng J Med 1996; 335:1880-1887 Objective To study the relationship between the specialty of the admitting physician and the outcome of care in patients over 65 who had had a myocardial infarction.
prognostic importance of the physicians' specialties. Adjustments were made for imbalances in patient characteristics using a previously tested method. Results
Setting Four states in the USA, Alabama, Connecticut, Iowa, Wisconsin. Method A review of the mortality according to specialty of the admitting physician of 8241 patients over the age of 65 with a diagnosis of myocardial infarction in 1992. The findings were also related to insurance claims and survival data for all 220 535 patients for whom there were claims for hospital care for acute myocardial infarction in 1992 in the whole of the USA. Information was collected about the severity of the patients' illness and about the medications, procedures and length of stay. In-hospital 30-day and l-year mortality rates were calculated. Literature review No explicit strategy; 20 references. Analysis
Cox proportional hazards regression models were used to determine the
JUNE 1997
After adjusting for variations in patient and hospital characteristics, 1-year survival for patients managed by cardiologists was 12% less than the survival for those managed by primary care physicians (P < 0.001). Six percent more patients admitted by cardiologists were considered eligible for thrombolytic therapy and were more likely to receive all the medications studied. The patients admitted by cardiologists also underwent more coronary angiography and revascularization procedures and had more stress testing, nuclear imaging and monitoring. They also had a longer duration of stay in hospital. Authors' conclusions The authors do not claim that the results alone can be used to justify a policy requiring all patients with acute myocardial infarction to be cared for by cardiologists. They conclude that there is a need to define better the differences between specialty and primary care and the effects of those differences on outcomes, and a need to be aware of possible changes in outcome if policy to promote primary care is adopted to control costs.
Commentary What is the most cost-effective way of prolonging life among patients with coronary heart disease? The overwhelming bulk of the evidence examines discrete interventions including drugs and invasive procedures. By comparison, estimation of the impact of doctors in general and specialists in particular has been viewed as something of a 'black box': impossible to unpick with research. It is indeed a challenge to define the elements of a doctor's practice which might affect prognosis and, furthermore, randomization to specialist vs generalist is unlikely to be feasible. JoUis et al, in a carefully designed observational study, find that patients with acute myocardial infarction presenting to cardiologists have better survival than patients cared for by primary care physicians. The paper falls short of providing strong evidence that the clinical practices of cardiologists per se prolong life. First, the type of patients cared for by the different specialties were very different in many ways which affect survival; statistical adjustment for such differences may not lead to the magical 'level playing field' as often supposed. Second, the type of care which the patients received in the Cooperative Cardiovascular Project study was so different from usual practice (e.g. the thrombolysis rate was only 16%) that the generalizability of the findings must be questioned. However the authors" cautious conclusion is justified; in this example, policy-makers should consider the potential adverse effect on patient outcomes of promoting primary care at the expense of specialist care. 'I want to see my specialist!' cries the patient. The paper by Jollis et al is one of a growing number which allows policymakers to base their response on peerreviewed scientific evidence. Dr l l a r r y Hendngway Consultant, Public Health Medicine Kensington, Chelsea and Westminster Health Authority London, UK
EVIDENCE-BASED HEALTH POLICY AND MANAGEMENT
37