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Generalist versus specialist care for acute myocardial infarction
I S Nash1, R R Corrato, M J Dlutowski
1Zena and Michael A. Wiener Cardiovascular Institute of the Mount Sinai Medical Center, New York, New York 10029, USA. ira.nash@mssm.edu
Insights
Cardiologist care did not significantly improve patient outcomes for acute myocardial infarction (AMI). Higher physician caseload, not specialty, was linked to lower inpatient mortality, especially in older AMI patients.
Area of Science:
- Cardiology
- Health Services Research
Background:
- Conflicting evidence exists on whether cardiologist-directed care improves patient outcomes for acute myocardial infarction (AMI).
- Understanding the influence of physician specialty and caseload on inpatient mortality is crucial for optimizing AMI patient care.
Purpose of the Study:
- To determine the impact of physician specialty (cardiologist vs. generalist) on inpatient mortality for AMI.
- To investigate the mechanisms, including physician caseload and referral bias, influencing these outcomes.
Main Methods:
- Analysis of 30,351 AMI admissions from the Pennsylvania Health Care Cost Containment Council.
- Development and validation of age-stratified logistic regression models to predict inpatient mortality.
- Explicitly addressing referral bias and physician caseload as key variables.
Main Results:
- No significant difference in adjusted odds of mortality for patients < 65 years receiving cardiologist care (OR 0.89, p=0.49).
- A trend towards lower mortality for older patients (>= 65) with cardiologist care (OR 0.86, p=0.10).
- Higher cardiologist caseload was inversely associated with inpatient mortality (OR 0.82 for cardiologist care, p=0.007). Physician caseload was a significant predictor, independent of specialty.
Conclusions:
- Physician caseload, rather than cardiologist specialty alone, appears to be a significant factor in reducing inpatient mortality for AMI.
- Higher physician caseloads, common among cardiologists, likely explain the observed trend toward better outcomes in their patients, particularly older adults.
Abstract:
Early studies conflict regarding improved patient outcomes with cardiologist-directed care for acute myocardial infarction (AMI). We sought to assess the magnitude and mechanism of the influence of physician specialty on inpatient mortality for AMI. Using data from the Pennsylvania Health Care Cost Containment Council and elsewhere, we developed age-stratified logistic regression models of inpatient mortality, utilizing a split sample strategy for model development and validation. Referral bias and physician caseload were explicitly addressed. We analyzed 30,351 admissions for AMI. In patients < 65 years old, the adjusted odds ratio (OR) for mortality with cardiologist care was 0.89 (95% confidence interval [CI] 0.640 to 1.24, p = 0.49) relative to generalist care. In patients > or = 65 years of age, the adjusted OR was 0.86 (95% CI 0.72 to 1.03, p = 0.10). Caseload was significantly higher among cardiologists and was inversely related to inpatient mortality. Mortality models with caseload but not physician designation or physician designation without caseload found each predictor statistically significant in the absence of the other (OR for cardiologist care 0.82, 95% CI 0.71 to 0.95, p = 0.007; OR for patients with low volume physicians relative to high volume 1.27, 95% CI 1.05 to 1.51, p = 0.014). Older patients of physicians with higher case loads had a lower risk adjusted inpatient mortality for AMI. This probably explains the trend toward better outcomes among patients of cardiologists rather than noncardiologists.