Consultation Between Cardiologists and Generalists in the Management of Acute Myocardial Infarction

Abstract

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.