Person:

Pearson, Steven

AT THE TIME of this report, approximately 5 million Medicare patients received care from capitated health maintenance organizations (HMOs), representing a 360% increase from 1991; this number is expected to grow to more than 12 million by 2005.1 A common perception is that economic incentives in HMOs may reduce the speed and provision of urgent, essential care, especially in vulnerable patients like the elderly.2- 4 Unfortunately, there are virtually no data showing how the rapid shift to managed care may be affecting the quality of acute care for elderly patients.5,6

Some organizational processes and incentives in HMOs may raise the quality of care for acute conditions, while others may lower quality. For example, large HMOs often have 24-hour telephone triage systems and patient education to encourage patients with acute conditions to use emergency transportation to the hospital. Health maintenance organizations may also be more likely to establish quality-improvement systems (eg, treatment protocols or clinical pathways).7 Finally, HMOs are more likely to employ younger physicians, who may have more up-to-date knowledge about the safety and efficacy of newer drug treatments.8,9

On the other hand, in efforts to contain costs, primary care gatekeepers in HMOs attempt to reduce the inappropriate use of emergency departments, specialty care, and hospital care. Conceivably, this might result in delays in approval of the necessary use of ambulances and emergency departments. DeMaria et al4 have also expressed concern that such gatekeepers might reduce access to appropriate specialty care in emergency conditions.

The treatment of acute myocardial infarction (AMI) provides an ideal model for studying the quality of acute care for elderly HMO patients. Cardiovascular disease is the leading cause of disability and death in the elderly; 80% of all deaths caused by AMI occur in those aged 65 years or older.10 Strong evidence from large randomized clinical trials shows that early treatment with aspirin, thrombolytic agents, and β-blockers increases the rate of survival among elderly patients with AMI.11- 16 Because the benefits of treatment with thrombolytics decline rapidly within 6 hours after initial symptom onset,17 the time from symptom onset to hospital presentation is an important determinant of survival. Unfortunately, elderly patients with AMI are more likely to have atypical symptoms, delayed hospital presentation,18 and less frequent use of thrombolytic, β-blocker, and aspirin therapy.19

In this study, we reviewed the medical records of 2304 elderly patients admitted with AMI at 20 urban community hospitals in Minnesota to compare the quality of emergency care under HMO vs FFS insurance coverage. Specifically, we compared the use of emergency transportation, treatment delay (≥6 hours), time to electrocardiogram (ECG), use of drug treatments known to reduce morbidity and mortality in eligible patients with AMI (aspirin, thrombolytics, and β-blockers), and time from hospital arrival to thrombolytic administration (door-to-needle time). Unlike previous investigations,5 we attempted to identify specific mechanisms that might explain any observed insurance-related differences in quality of care, such as use of specialists.

Background: The "gatekeeping" model of access to specialty care has been an essential managed care tool, intended to control costs of care and promote coordination between generalists and specialists. Objective: To investigate the impact of removing gatekeeping on specialist utilization. Methods: A capitated multispecialty group discontinued a gatekeeping system on April 1, 1998. We assessed the overall number and distribution of patient visits to primary care physicians and specialists and initial patient visits to specialists before and after the removal of gatekeeping. We performed focused analyses for specific specialties, children with chronic conditions, and children with specific diagnoses. Results: Elimination of gatekeeping was not associated with changes in the mean number of visits to specialists (0.28 visits per 6 months before and after gatekeeping was removed) or the percentage of all child visits to specialists (11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The proportion of all specialist visits that were initial consultations increased after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95% CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%). New patient visits to specialists by children with chronic conditions as a proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). Conclusions: Replacing a gatekeeping system with open access to all specialty physicians in a managed care organization resulted in minimal changes on the utilization of specialists. Visits to specialists by children with chronic conditions increased after the removal of gatekeeping.

Background The rapid expansion of managed care in the United States has increased debate regarding the appropriate mix of generalist and specialist involvement in medical care.

Objective To compare the quality of medical care when generalists and cardiologists work separately or together in the management of patients with acute myocardial infarction (AMI).

Methods We reviewed the charts of 1716 patients with AMI treated at 22 Minnesota hospitals between 1992 and 1993. Patients eligible for thrombolytic aspirin, β-blockers, and lidocaine therapy were identified using criteria from the 1991 American College of Cardiology guidelines for the management of AMI. We compared the use of these drugs among eligible patients whose attending physician was a generalist with no cardiologist input, a generalist with a cardiologist consultation, and a cardiologist alone.

Results Patients cared for by a cardiologist alone were younger, presented earlier to the hospital, were more likely to be male, had less severe comorbidity, and were more likely to have an ST elevation of 1 mm or more than generalists' patients. Controlling for these differences, there was no variation in the use of effective agents between patients cared for by a cardiologist attending physician and a generalist with a consultation by a cardiologist. However, there was a consistent trend toward increased use of aspirin, thrombolytics, and β-blockers in these patients compared with those with a generalist attending physician only (P<.05 for β-blockers only). Differences between groups in the use of lidocaine were not statistically significant. The adjusted probabilities of use of thrombolytics for consultative care and cardiologist attending physicians were 0.73 for both. Corresponding probabilities were 0.86 and 0.85 for aspirin and 0.59 and 0.57 for β-blockers, respectively.

Conclusions For patients with AMI, consultation between generalists and specialists may improve the quality of care. Recent policy debates that have focused solely on access to specialists have ignored the important issue of coordination of care between generalist and specialist physicians. In hospitals where cardiology services are available, generalists may be caring for patients with AMI who are older and more frail. Future research and policy analyses should examine whether this pattern of selective referral is true for other medical conditions.

THE RAPID expansion of managed care in the United States has increased public and scientific debate regarding the appropriate mix of generalist and specialist involvement in medical care. Previous research suggests that cardiologists have better knowledge than generalists concerning efficacious therapies in the treatment of acute myocardial infarction (AMI).1 However, previous studies2 also suggest that there is little relationship between knowledge or self-reported practice and actual behavior. Despite intense controversy, few studies3 exist comparing the care provided to comparable patients by generalists and specialists.

The focus on comparative performance of generalists and specialists ignores opportunities for sharing of knowledge and experience through formal and informal consultation. In 1 study,4 the quality of psychoactive drug prescribing in nursing homes was highest among generalists who reported frequent consultations with psychiatrists. A recent study5 of a US health maintenance organization showed that an intervention fostering collaborative care between generalists and psychiatrists improved adherence to antidepressant regimens, patient satisfaction, and other outcomes in patients with major depression.

In contrast to previous studies1,6,7 that used survey data to measure differences between generalist and specialist care, we investigated differences in quality of care actually provided to patients with AMI when generalists and cardiologists work separately and in consultation. Quality of care was defined as care consistent with nationally recognized evidence-based practice guidelines. Specifically, we examined the use of drugs known to reduce morbidity and mortality in eligible patients (aspirin, thrombolytics, and β-blockers),8- 11 and nonindicated use of lidocaine, which may cause increased mortality.12 We compared use of these drugs among patients whose attending physician was (1) a generalist with no cardiologist input, (2) a generalist with cardiologist consultation, and (3) a cardiologist.