Acute Care/Hospitalization

Patient and hospital factors may contribute to worse outcomes for patients who suffer heart attacks

Patients who suffer heart attacks usually have higher mortality rates when their physician is a generalist rather than a cardiologist. This has led some to conclude that cardiologists know better than generalists how to manage heart attacks. However, patient and hospital factors may contribute to these different outcomes, suggests a new study. University of Iowa investigators Arthur Hartz, M.D., Ph.D., and Paul A. James, M.D., reviewed articles published from 1990 to 2003 that compared the mortality rates of heart attack patients of cardiologists and generalist physicians. They identified factors in each study that could have influenced the comparisons.

The studies consistently found that patients of generalists had higher unadjusted mortality rates. However, generalists' patients also were at greater risk of dying from both cardiac and noncardiac risk factors. After adjusting for patient risk factors for dying, the differences between cardiologists and generalists decreased. The studies that seemed to do the best job of taking into account patient differences had similar adjusted mortality rates for patients of cardiologists and generalists. No studies adequately took into account reasons the patient did not have care by a cardiologist, such as patient preference, severity of coexisting disease, general health status, or resource availability.

Thus, patient outcomes are often influenced by important patient or resource characteristics that were not taken into account in the studies reviewed, note the researchers. For example, the generalists may have treated higher risk patients, because patients who were too old or sick to want heroic intervention measures or revascularization procedures did not want to be referred to cardiologists. Also, generalists' patients may have had greater delay in accessing care, which increased their risk of dying. Nevertheless, this review did not resolve the appropriate role for generalists in managing heart attack patients. The study was supported in part by the Agency for Healthcare Research and Quality (HS10739).

More details are in "A systematic review of studies comparing myocardial infarction mortality for generalists and specialists: Lessons for research and health policy," by Drs. Hartz and James, in the May 2006 Journal of the American Board of Family Medicine 19(3), pp. 291-302.

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