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Knowledge, patterns of care, and outcomes of care for generalists and specialists

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Abstract

OBJECTIVE: To critically evaluate the differences between generalist physicians and specialists in terms of knowledge, patterns of care, and clinical outcomes of care.

METHODS: English-language articles (January 1981 to January 1998) were identified through a Medline search and examination of bibliographies of identified articles. Systematic evaluation of articles relevant to adult medicine that had a direct comparison between generalist physicians and specialists in terms of knowledge relative to widely accepted standards of care, patterns of care (including use of medications, ancillary services, procedures, and resource utilization), and outcomes of care was performed.

MAIN RESULTS: In many survey studies, specialists were reported to be more knowledgeable about conditions encompassed within their specialty. In terms of overall practice patterns, specialists practicing in their area of expertise were more likely to use medications associated with improved survival and to comply with routine health maintenance screening guidelines; they used more resources including diagnostic tests, procedures, and longer hospital stays. In the limited number of studies examining the care of patients with acute myocardial infarction, acute nonhemorrhagic stroke, and asthma, specialists had superior outcomes compared with generalists.

CONCLUSIONS: There is evidence in the literature suggesting differences between specialists and generalists in terms of knowledge, patterns of care, and clinical outcomes of care for a broad range of diseases. In published studies, specialists were generally more knowledgeable about their area of expertise and quicker to adopt new and effective treatments than generalists. More research is needed to examine whether these patterns of care translate into superior outcomes for patients. Further work is also needed to delineate the components of care for which generalists and specialists should be responsible, in order to provide the highest quality of care to patients while most effectively utilizing existing physician manpower.

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References

  1. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA. 1994;272:222–30.

    Article  PubMed  CAS  Google Scholar 

  2. Cooper RA. Seeking a balanced physician workforce for the 21st century. JAMA. 1994;272:680–7.

    Article  PubMed  CAS  Google Scholar 

  3. DeMaria AN, Lee TH, Leon DF, et al. Effect of managed care on cardiovascular specialists: involvement, attitudes and practice adaptations. J Am Coll Cardiol. 1996;28:1884–95.

    Article  PubMed  CAS  Google Scholar 

  4. Kravitz RL, Greenfield S. Variations in resource utilization among medical specialties and systems of care. Annu Rev Public Health. 1995;16:431–45.

    Article  PubMed  CAS  Google Scholar 

  5. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267:1624–30.

    Article  PubMed  CAS  Google Scholar 

  6. Kassirer JP. Access to specialty care. N Engl J Med. 1994;331:1151–3.

    Article  PubMed  CAS  Google Scholar 

  7. Rhee SO, Luke RD, Lyons TF, Payne BC. Domain of practice and the quality of physician performance. Med Care. 1981;19:14–23.

    Article  PubMed  CAS  Google Scholar 

  8. Hoechst Marion Roussel Managed Care Digest Series. Kansas City, Mo: Hoechst Marion Roussel; 1997.

  9. Group Health Association of America. Patterns in HMO Enrollment. Washington, DC: Group Health Association of America, June 1995.

    Google Scholar 

  10. Jensen GA, Morrisey MA, Gaffney S, Liston DK. The new dominance of managed care: insurance trends in the 1990s. Health Aff. 1997;16:125–36.

    Article  CAS  Google Scholar 

  11. Recommendations of the American Society of Internal Medicine. Patient Access to Internist-Subspecialists in Gatekeeper Health Plans; ASIM, Washington, DC. August 1995.

    Google Scholar 

  12. Committee of the American College of Rheumatology Council on Health Care Research. Role of specialty care for chronic diseases: a report from an Ad Hoc committee of the American College of Rheumatology. Mayo Clin Proc. 1996;71:1179–81.

    Google Scholar 

  13. NIH Consensus Development Panel on Helicobacter pylori in Peptic Ulcer Disease. Helicobacter pylori in peptic ulcer disease. JAMA. 1994;272:65–9.

    Article  Google Scholar 

  14. American Cancer Society. 1989 survey of physicians’ attitudes and practices in early cancer detection. CA Cancer J Clin. 1990;40:77–101.

    Google Scholar 

  15. National Institutes of Health. The treatment of primary breast cancer: management of local disease. Consensus Development Conference, Bethesda, Md, June 5, 1979.

  16. National Institutes of Health. Adjuvant chemotherapy for breast cancer. Consensus Development Conference, Bethesda, Md, July 14–16, 1980.

  17. National Institutes of Health. Adjuvant chemotherapy for breast cancer. Consensus Development Conference, Bethesda, Md, September 9–11, 1985.

  18. National Institutes of Health. Treatment of early-stage breast cancer. Consensus Development Conference, Bethesda, Md, June 18–21, 1990.

  19. Gunnar RM, Bourdillon PD, Dixon DW, et al. ACC/AHA guidelines for the early management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures. Circulation. 1990;82:664–707.

    Google Scholar 

  20. Markson LE, Cosler LE, Turner BJ. Implications of generalists’ slow adoption of zidovudine in clinical practice. Arch Intern Med. 1994;154:1497–504.

    Article  PubMed  CAS  Google Scholar 

  21. Mauskopf J, Turner BJ, Markson LE, Houchens RL, Fanning TR, McKee L. Patterns of ambulatory care for AIDS patients, and association with emergency room use. Health Serv Res. 1994;29:489–510.

    PubMed  CAS  Google Scholar 

  22. Braun MM, Weisner PJ. Tuberculosis prevention practices and perspectives of physicians in DeKalb County, Ga. Public Health Rep. 1994;109:259–65.

    PubMed  CAS  Google Scholar 

  23. Vollmer WM, O’Hollaren M, Ettinger KM, et al. Specialty differences in the management of asthma: a cross-sectional assessment of allergists’ patients and generalists’ patients in a large HMO. Arch Intern Med. 1997;157:1201–8.

    Article  PubMed  CAS  Google Scholar 

  24. Zeiger RS, Heller S, Mellon MH, Wald J, Falkoff R, Schatz M. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991;87:1160–8.

    Article  PubMed  CAS  Google Scholar 

  25. Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994;331:1136–42.

    Article  PubMed  CAS  Google Scholar 

  26. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet. 1986;1:397–402.

    Google Scholar 

  27. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2:349–60.

    Google Scholar 

  28. Antiplatelet Trialists’ Collaboration. Secondary prevention of vascular disease by prolonged antiplatelet treatment. BMJ. 1988;296:320–31.

    Google Scholar 

  29. The Norwegian Multicenter Study Group. Timolol-induced reduction in mortality and reinfarction in patients surviving acute myocardial infarction. N Engl J Med. 1981;304:801–7.

    Article  Google Scholar 

  30. β-Blocker Heart Attack Trial Research Group. A randomized trial of propranolol in patients with acute myocardial infarction. I: mortality results. JAMA. 1982;247:1707–14.

    Article  Google Scholar 

  31. Yusuf S, Peto R, Lewis J, Collins R, Sleight P. Beta blockade during and after myocardial infarction: an overview of the randomized trials. Prog Cardiovasc Dis. 1985;27:335–71.

    Article  PubMed  CAS  Google Scholar 

  32. The Danish Study Group on Verapamil in Myocardial Infarction. Verapamil in acute myocardial infarction. Eur Heart J. 1984;5:516–28.

    Google Scholar 

  33. The Israeli Sprint Study Group. Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT): a randomized intervention trial of nifedipine in patients with acute myocardial infarction. Eur Heart J. 1988;9:354–64.

    Google Scholar 

  34. The Multicenter Diltiazem Postinfarction Trial Research Group. The effect of diltiazem on mortality and reinfarction after myocardial infarction. N Engl J Med. 1988;319:385–92.

    Article  Google Scholar 

  35. Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina: an overview. BMJ. 1989;299:1187–92.

    PubMed  CAS  Google Scholar 

  36. MacMahon S, Collins R, Peto R, Koster RW, Yusuf S. Effects of prophylactic lidocaine in suspected acute myocardial infarction: an overview of results from the randomized, controlled trials. JAMA. 1988;260:1910–6.

    Article  PubMed  CAS  Google Scholar 

  37. Hine LK, Laird N, Hewitt P, Chalmers TC. Meta-analytic evidence against prophylactic use of lidocaine in acute myocardial infarction. Arch Intern Med. 1989;149:2694–8.

    Article  PubMed  CAS  Google Scholar 

  38. Hlatky MA, Cotugno H, O’Connor C, Mark DB, Pryor DB, Califf RM. Adoption of thrombolytic therapy in the management of acute myocardial infarction. Am J Cardiol. 1988;61:510–4.

    Article  PubMed  CAS  Google Scholar 

  39. Hlatky MA, Cotugno HE, Mark DB, O’Connor C, Califf RM, Pryor DB. Trends in physician management of uncomplicated acute myocardial infarction, 1970 to 1987. Am J Cardiol. 1988;61:515–8.

    Article  PubMed  CAS  Google Scholar 

  40. Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996;335:1880–7.

    Article  PubMed  CAS  Google Scholar 

  41. Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med. 1997;157:2570–6.

    Article  PubMed  CAS  Google Scholar 

  42. Nash IS, Nash DB, Fuster V. Do cardiologists do it better? J Am Coll Cardiol. 1997;29:475–8.

    Article  PubMed  CAS  Google Scholar 

  43. Friedmann PD, Brett AS, Mayo-Smith MF. Differences in generalists’ and cardiologists’ perceptions of cardiovascular risk and the outcomes of preventive therapy in cardiovascular disease. Ann Intern Med. 1996;124:414–21.

    PubMed  CAS  Google Scholar 

  44. Lipid Research Clinics Program. The lipid research clinics coronary primary prevention trial results. I: reduction in incidence of coronary heart disease. JAMA. 1984;251:351–64.

    Article  Google Scholar 

  45. Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study: primary-prevention trial with gemfibrizol in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease. N Engl J Med. 1987;317:1237–45.

    Article  PubMed  CAS  Google Scholar 

  46. SHEP Cooperative Research Group. Prevention of stroke by anti-hypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the systolic hypertension in the elderly program (SHEP). JAMA. 1991;265:3255–64.

    Article  Google Scholar 

  47. Takaro T, Peduzzi P, Detre KM, et al. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Artery Occlusive Disease. Circulation. 1982;66:14–22.

    PubMed  CAS  Google Scholar 

  48. Chaitman BR, Fisher LD, Bourassa MG, et al. Effect of coronary bypass surgery on survival patterns in subsets of patients with left main coronary artery disease: report of the Collaborative Study in Coronary Artery Surgery (CASS). Am J Cardiol. 1981;48:765–77.

    Article  PubMed  CAS  Google Scholar 

  49. Chin MH, Friedmann PD, Cassel CK, Lang RM. Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med. 1997;12:523–30.

    Article  PubMed  CAS  Google Scholar 

  50. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med. 1991;325:293–302.

    Article  Google Scholar 

  51. The SOLVD Investigators. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med. 1992;327:685–91.

    Article  Google Scholar 

  52. Chin MH, Wang JC, Zhang JX, Lang RM. Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure: effect of physician specialty and patient characteristics. J Gen Intern Med. 1997;12:563–6.

    Article  PubMed  CAS  Google Scholar 

  53. Stafford RS, Blumenthal D, Pasternak RC. Variations in cholesterol management practices of US physicians. J Am Coll Cardiol. 1997;29:139–46.

    Article  PubMed  CAS  Google Scholar 

  54. Young MJ, Fried LS, Eisenberg J, Hershey J, Williams S. Do cardiologists have higher thresholds for recommending coronary arteriography than family physicians? Health Serv Res. 1987;22:623–35.

    PubMed  CAS  Google Scholar 

  55. Glassman PA, Kravitz RL, Petersen LP, Rolph JE. Differences in clinical decision making between internists and cardiologists. Arch Intern Med. 1997;157:506–12.

    Article  PubMed  CAS  Google Scholar 

  56. Greenwald HP, Peterson ML, Garrison LP, et al. Interspecialty variation in office-based care. Med Care. 1984;22:14–29.

    Article  PubMed  CAS  Google Scholar 

  57. Schreiber TL, Elkhatib A, Grines CL, O’Neill WW. Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes. J Am Coll Cardiol. 1995;26:577–82.

    Article  PubMed  CAS  Google Scholar 

  58. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. Results from the Medical Outcomes Study. JAMA. 1995;274:1436–44.

    Article  PubMed  CAS  Google Scholar 

  59. Clark RA, Rietschel RL. The cost of initiating appropriate therapy for skin disease: a comparison of dermatologists and family physicians. J Am Acad Dermatol. 1983;9:787–96.

    Article  PubMed  CAS  Google Scholar 

  60. Fendrick AM, Hirth RA, Chernew ME. Differences between generalist and specialist physicians regarding Helicobacter pylori and peptic ulcer disease. Am J Gastroenterol. 1996;91:1544–8.

    PubMed  CAS  Google Scholar 

  61. Mahajan RJ, Barthel JS, Marshall JB. Appropriateness of referrals for open-access endoscopy: how do physicians in different medical specialties do? Arch Intern Med. 1996;156:2065–9.

    Article  PubMed  CAS  Google Scholar 

  62. American Society for Gastrointestinal Endoscopy. Appropriate Use of Gastrointestinal Endoscopy. Manchester, Mass: American Society for Gastrointestinal Endoscopy; 1992.

    Google Scholar 

  63. Morin CA, Roberts CL, Mshar PA, Addiss DG, Hadler JL. What do physicians know about cryptosporidiosis? A survey of Connecticut physicians. Arch Intern Med. 1997;157:1017–22.

    Article  PubMed  CAS  Google Scholar 

  64. Mitchell JB, Ballard DJ, Whisnant JP, Ammering CJ, Samsa GP, Matchar DB. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke. 1996;27:1937–43.

    PubMed  CAS  Google Scholar 

  65. McFall SL, Warnecke RB, Kaluzny AD, Aitken M, Ford L. Physician and practice characteristics associated with judgements about breast cancer treatment. Med Care. 1993;32:106–17.

    Article  Google Scholar 

  66. Wachtel TJ, Mor V. Physicians’ use of health resources for terminal cancer patients: clinical setting versus physician specialty. South Med J. 1987;80:1120–4.

    PubMed  CAS  Google Scholar 

  67. Roetzheim RG, Van Durme DJ, Brownlee HJ, Herold AH, Pamies RJ, Woodard L. Compliance with screening mammography: survey of primary care physicians. J Fla Med Assoc. 1991;78:426–9.

    PubMed  CAS  Google Scholar 

  68. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women. Does the sex of the physician matter? N Engl J Med. 1993;329:478–82.

    Article  PubMed  CAS  Google Scholar 

  69. Taplin SH, Taylor V, Montano D, Chinn R, Urban N. Specialty differences and the ordering of screening mammography by primary care physicians. J Am Board Fam Pract. 1994;7:375–86.

    PubMed  CAS  Google Scholar 

  70. Grisso JA, Baum CR, Turner BJ. What do physicians in practice do to prevent osteoporosis? J Bone Miner Res. 1990;5:213–9.

    Article  Google Scholar 

  71. Dietrich AJ, Goldberg H. Preventive content of adult primary care: do generalists and specialists differ? Am J Public Health. 1984;74:223–7.

    Article  PubMed  CAS  Google Scholar 

  72. Minister of Supply and Services Canada. Periodic Health Examination Report of a Task Force to the Conference of Deputy Ministers of Health, Ottawa, Canada, 1980.

  73. Meredith LS, Wells KB, Camp P. Clinical specialty and treatment style for depressed outpatients with and without medical comorbidities. Arch Fam Med. 1994;3:1065–72.

    Article  PubMed  CAS  Google Scholar 

  74. Strauss MJ, Conrad D, LoGerfo JP, Hudson LD, Bergner M. Cost and outcome of care for patients with chronic obstructive lung disease. Med Care. 1986;24:915–24.

    Article  PubMed  CAS  Google Scholar 

  75. Ware JE, Sherbourne CA, Davies AR. A Short-Form General Health Survey. Santa Monica, Calif: RAND; 1988. Publication P-7444.

    Google Scholar 

  76. Bellamy N, Gilbert JF, Brooks PM, Emmerson BT, Campbell J. A survey of current prescribing practices of antiinflammatory and urate lowering drugs in gouty arthritis in the province of Ontario. J Rheumatol. 1988;15:1841–7.

    PubMed  CAS  Google Scholar 

  77. Medellin MV, Erickson AR, Enzenauer RJ. Variability of treatment for gouty arthritis between rheumatologists and primary care physicians. JCR J Clin Rheumatol. 1997;3:24–7.

    CAS  Google Scholar 

  78. Mazzuca SA, Brandt KD, Katz BP, Li W, Stewart KD. Therapeutic strategies distinguish community based primary care physicians from rheumatologists in the management of osteoarthritis. J Rheumatol. 1993;20:80–6.

    PubMed  CAS  Google Scholar 

  79. Mazzuca SA, Brandt KD, Katz BP, et al. Comparison of general internists, family physicians, and rheumatologists managing patients with symptoms of osteoarthritis of the knee. Arthritis Care Res. 1997;10:289–99.

    Article  PubMed  CAS  Google Scholar 

  80. Walker DJ, Young I, Hassey GA, Smith AMM, Goring M, Platt PN. The acute hot joint in medical practice. J R Coll Physicians Lond. 1995;29:101–4.

    PubMed  CAS  Google Scholar 

  81. Carey TS, Garrett J, Jackman A, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons. N Engl J Med. 1995;333:913–7.

    Article  PubMed  CAS  Google Scholar 

  82. Shekelle PG, Markovich M, Louie R. Comparing the costs between provider types of episodes of back pain care. Spine. 1995;20:221–7.

    Article  PubMed  CAS  Google Scholar 

  83. Gunnar RM, Passamani ER, Bourdillon PD, et al. Guidelines for the early management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on assessment of diagnostic and therapeutic cardiovascular procedures. J Am Coll Cardiol. 1990;82:664–707.

    Google Scholar 

  84. Kaste M, Palomäki H, Sarna S. Where and how should elderly stroke patients be treated? Stroke. 1995;26:249–53.

    PubMed  CAS  Google Scholar 

  85. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim LL, Holme I. Benefit of a stroke unit: a randomized controlled trial. Stroke. 1991;22:1026–31.

    PubMed  CAS  Google Scholar 

  86. Adams AS, Soumerai SB, Lomas J, Ross-Degnan D. The role of social desirability in clinician self-reports of guideline adherence. J Gen Intern Med. 1997;12(suppl 1):64. Abstract.

    Google Scholar 

  87. Solomon DH, Bates DW, Panush RS, Katz JN. Costs, outcomes and patient satisfaction by provider type for patients with rheumatic and musculoskeletal conditions: a critical review of the literature and proposed methodologic standards. Ann Intern Med. 1997;127:52–60.

    PubMed  CAS  Google Scholar 

  88. Nash DB, Nash IS. Building the best team. Ann Intern Med. 1997;127:72–4.

    PubMed  CAS  Google Scholar 

  89. Matz R. Letters to the editor. JAMA. 1996;275:1083–4.

    Article  PubMed  CAS  Google Scholar 

  90. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–86.

    Article  Google Scholar 

  91. Wennberg J, Gittelsohn A. Variations in medical care among small areas. Sci Am. 1982;246:120–34.

    PubMed  CAS  Google Scholar 

  92. Hiss RG, Greenfield S. Forum three: changes in the U.S. health care system that would facilitate improved care for non-insulin-dependent diabetes mellitus. Ann Intern Med. 1996;124(1 pt 2):180–3.

    PubMed  CAS  Google Scholar 

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Harrold, L.R., Field, T.S. & Gurwitz, J.H. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J GEN INTERN MED 14, 499–511 (1999). https://doi.org/10.1046/j.1525-1497.1999.08168.x

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