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In recent years, numerous studies have compared the performance of generalist and specialist physicians in the management of common conditions such as acute myocardial infarction (AMI, heart attack). Typically, these studies have shown the underuse of proven effective therapies by generalists.
A recent study supported in part by the Agency for Healthcare Research and Quality (HS07357) found that generalist attending physicians are less likely than cardiologists to use effective, though risky, medications such as thrombolytics (blood thinners) for hospitalized patients suffering from AMI. On the other hand, generalists were as likely as cardiologists to discontinue the use of widely prescribed calcium channel blockers (CCBs) when these agents were linked to an increased risk of AMI.
The researchers measured use of CCBs during hospitalization for AMI before (1992-1993) and after the publication of a series of adverse reports regarding CCBs (1995-1996), in 5,347 AMI patients admitted to 37 community-based hospitals in Minnesota. They also examined use of effective medications (aspirin, beta blockers, thrombolytic therapy) and ineffective AMI treatments (lidocaine) among attending generalists, generalists with cardiologist consultation, and attending cardiologists.
Compared with cardiologists, generalists were less likely to use aspirin (37 percent vs. 68 percent), thrombolytics (29 vs. 64 percent), and beta blockers (20 percent vs. 46 percent), although much of the difference was explained by the fact that generalists' patients were older and had more severe comorbidity. For example, after multivariate adjustment, differences between generalists and cardiologists in the use of beta blockers were no longer significant. Patients cared for by generalist attendings in consultation with cardiologists tended to have intermediate use of effective therapies. From 1992-1993 to 1995-1996, the use of CCBs in patients with AMI decreased from 24 percent to 10 percent. The odds of not using CCBs after the adverse reports (adjusted OR 0.33) were independent of physician specialty.
For more information, see "Influence of physician specialty on adoption and relinquishment of calcium channel blockers and other treatments for myocardial infarction," by Sumit R. Majumdar, M.D., M.P.H., Thomas S. Inui, M.D., Sc.M., Jerry H. Gurwitz, M.D., and others, in the June 2001 Journal of General Internal Medicine 16, pp. 351-359.
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