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Press Release Date: Tuesday, May 5, 1998
Two new studies appearing in the May 6 issue of the Journal of the American Medical
Association have implications for improving the quality of health care. Both studies received
funding from the federal government's Agency for Health Care Policy and Research.
The Generalist Role of Specialty Physicians: Is There a Hidden System of Primary
Care?, by Roger A. Rosenblatt, M.D., and others, concludes that most specialists do not assume
the same degree of responsibility as do generalist physicians for the everyday health problems of
elderly patients, even though a substantial percentage of these patients depend on specialists for
most of their health care. This raises questions about the quality of primary care provided by
The researchers found that, in Washington State between 1994 and 1995, one of every six
fee-for-service Medicare patients aged 65 and older relied exclusively on specialists for
outpatient care. But the specialists were less likely than the generalists, such as family
practitioners and general internists, to immunize these patients against influenza—a major killer
of the elderly. Generalists gave flu shots to 55.4 percent of the Medicare patients who depended
mostly on them for care, compared with 47.7 percent of the medical specialists' regular patients,
and 39.6 percent of those who depended on surgical specialists for routine care.
The researchers also found that about half—49.8 percent—the ambulatory care visits
made to generalists were those of patients who depended on them for the majority of their care.
In contrast, 21 percent of all ambulatory care visits to medical specialists, and 11.7 percent of
those to surgical specialists, were made by patients who relied mostly on those types of
physicians for most of their care. Pulmonologists, general surgeons and gynecologists were
more likely than other specialists to provide services outside their discipline.
The University of Washington-led study was co-funded by the Robert Wood Johnson
Foundation and the Health Resources and Services Administration, an agency of the U.S.
Department of Health and Human Services.
Effect of Local Medical Opinion Leaders on Quality of Care for Acute Myocardial
Infarction: A Randomized Controlled Trial, by Stephen B. Soumerai, Sc.D., and others, suggests
that hospitals could improve quality of care for heart attack patients by using local physicians
respected by their peers for their knowledge of treating the condition to educate other medical
staff. The goal of the study involving 37 Minnesota hospitals was to increase adherence to an
American College of Cardiology/American Heart Association guideline recommending use of
three proven but under-utilized, potentially life-saving drug therapies—aspirin, beta blockers and
thrombolytic drugs—in eligible patients. Adherence to the guideline has been variable, in spite
of wide dissemination to hospitals and other providers.
The study found that, in hospitals using local medical opinion leaders, the proportion of
eligible elderly heart attack patients given aspirin or beta blockers increased by 21 percent for
aspirin use and by 33 percent for beta blocker use, compared with other hospitals in the study
which only received written information on the use of study drugs (aspirin and beta blockers) for
doctors practicing there. Use of lidocaine, a drug whose use is discouraged by the guideline, fell
50 percent in both the experimental and control hospitals, while the proportion of patients given
thrombolytic therapy stayed about the same. According to Dr. Soumerai, who is with Harvard
Medical School and Harvard Pilgrim Health Care, the failure to increase thrombolytic therapy
may be explained by the large number of patients who were very old, had other severe illnesses
as well, or presented late to the hospital, thus reducing benefits in relation to risks of the drugs.
AHCPR's administrator John M. Eisenberg, M.D., called the intervention, "confirmation
that information alone is necessary, but not sufficient to improve the quality of health care. This
study clearly shows that the role of professional leadership is one of the most important in
improving health care quality."
Additional co-funding was provided by the Harvard Pilgrim Health Care Foundation and
the hospitals and health plans associated with the Healthcare Education and Research
For additional information, please contact AHCPR Press Office:
Karen Migdail (301) 427-1855 (KMigdail@ahrq.gov); Salina Prasad, (301) 427-1864 (SPrasad@ahrq.gov).