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Heart Disease/Stroke

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Specialists and generalists working together provide the best care for heart disease patients

Numerous studies comparing cardiologist and generalist care for patients with coronary heart disease conclude that specialists are more aware of effective drug therapies and tend to use more appropriate cardiac procedures than generalists. However, there are certain problems with these comparisons, notes John Ayanian, M.D., M.P.P., of Harvard Medical School, in a recent editorial. For example, most studies have compared cardiac treatments and outcomes based solely on the specialty of admitting or attending physicians, without determining whether cardiologists collaborated as consultants in the care of generalists' patients.

One study found that use of thrombolytic therapy, aspirin, and beta blockers was equivalent whether cardiologists cared for heart attack patients as attending or consulting physicians and was higher than when generalists cared for these patients alone. Another study showed that use of beta blockers was actually higher for heart attack patients receiving collaborative care than when cardiologists or generalists provided care alone. A third study of outpatients with congestive heart failure demonstrated that those with reduced left ventricular function were more likely to receive an angiotensin converting enzyme inhibitor at adequate dosage when treated by general internists or by internists and cardiologists working together than when treated by cardiologists alone.

According to Dr. Ayanian, whose work is supported by the Agency for Healthcare Research and Quality (HS09718), rather than focusing on "either-or" comparisons of generalists and specialists, a more productive approach would be to design and evaluate systems of care in which specialists play a greater or lesser role in the care of specific types of patients. The key question is not whether specialists provide value in patient care, but instead, for what types of patients and clinical decisions is their value greatest?

See "Generalists and specialists caring for patients with heart disease: United we stand, divided we fall," by Dr. Ayanian, in the February 15, 2000, American Journal of Medicine 108(3), pp. 259-261.

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