Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes.

OBJECTIVES This study sought to assess the impact of generalist versus specialist direction on the pattern of care and outcome in patients admitted to the hospital for unstable angina. BACKGROUND Physicians trained as internists or as cardiologists may have different approaches to treating patients with unstable angina. METHODS We reviewed a prospectively collected cohort of patients discharged with a diagnosis-related group (DRG) diagnosis of unstable angina from William Beaumont Hospital, a large community-based hospital in southeast Michigan. Of 890 consecutive patients, 225 were treated by internists and 665 by cardiologists. We compared these two groups with respect to patterns of use of established pharmacotherapies for unstable angina, diagnostic testing and clinical outcome. RESULTS Patients treated by internists less often had a previous cardiac history (53% vs. 80%, p < or = 0.0001). Internists were less likely to use aspirin (68% vs. 78%, p = 0.032), heparin (67% vs. 84%, p < or = 0.001) or beta-adrenergic blocking agents (18% vs. 30%, p < or = 0.004) in their initial management. Exercise tests were performed more frequently by internist-treated patients (37% vs. 22%, p < or = 0.001), but catheterization (27% vs. 61%, p < or = 0.0001) and angioplasty (7% vs. 40%, p < or = 0.0001) were utilized less frequently. The incidence of myocardial infarction was similar (11% vs. 9%) in the two groups, but the mortality rate tended to be higher (4.0% vs. 1.8%, p = 0.06) in the internist group. CONCLUSIONS Patients with unstable angina treated by internists were less likely to receive effective medical therapy or revascularization procedures and experienced a trend to poorer outcome. This study does not support a positive gatekeeper role for generalists in the treatment of unstable angina.

[1]  W. Salter.  Clinical Catalytic Chemistry , 1943 .

[2]  E. Braunwald,et al.  Unstable angina. A classification. , 1989, Circulation.

[3]  Setting limits in clinical medicine. , 1994 .

[4]  K. Swedberg,et al.  EFFECT ON MORTALITY OF METOPROLOL IN ACUTE MYOCARDIAL INFARCTION A Double-blind Randomised Trial , 1981, The Lancet.

[5]  D. Williams,et al.  Anticoagulant treatment in unstable angina , 1986, The British journal of clinical practice.

[6]  R. Kronmal,et al.  Determinants of operative mortality and long-term survival in patients with unstable angina. The CASS experience. , 1985, The Journal of thoracic and cardiovascular surgery.

[7]  J. Colwill.  Where have all the primary care applicants gone? , 1992, The New England journal of medicine.

[8]  S. Rahimtoola,et al.  Ten-year survival after coronary bypass surgery for unstable angina. , 1983, The New England journal of medicine.

[9]  M. LeWinter,et al.  Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study. , 1983, The New England journal of medicine.

[10]  B. Clinton.  The Clinton health care plan. , 1992, The New England journal of medicine.

[11]  A. Johns,et al.  Calcium regulation in vascular smooth muscle contractility. , 1987, The American journal of cardiology.

[12]  A randomized trial of aspirin and sulfinpyrazone in threatened stroke. , 1978, The New England journal of medicine.

[13]  J. Lubsen,et al.  Efficacy of nifedipine and metoprolol in the early treatment of unstable angina in the coronary care unit: findings from the Holland Interuniversity Nifedipine/metoprolol Trial (HINT). , 1987, The American journal of cardiology.

[14]  C. Madden.  Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease: The RISC Group Lancet 336: 827–830 Oct 1990 , 1991 .

[15]  D. Murphy,et al.  Setting limits in clinical medicine. , 1994, Archives of internal medicine.

[16]  B. Rosner,et al.  Nifedipine and conventional therapy for unstable angina pectoris: a randomized, double-blind comparison. , 1984, Circulation.

[17]  P. Théroux,et al.  Aspirin, heparin, or both to treat acute unstable angina. , 1988, The New England journal of medicine.

[18]  J. Wittes,et al.  Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. , 1988, JAMA.

[19]  Bradford H. Gray,et al.  Controlling Costs and Changing Patient Care? The Role of Utilization Management , 1989 .

[20]  L. Wallentin,et al.  Aspirin (75 mg/day) after an episode of unstable coronary artery disease: long-term effects on the risk for myocardial infarction, occurrence of severe angina and the need for revascularization. Research Group on Instability in Coronary Artery Disease in Southeast Sweden. , 1991, Journal of the American College of Cardiology.

[21]  J. Fleiss,et al.  Detection and significance of myocardial ischemia in stable patients after recovery from an acute coronary event. Multicenter Myocardial Ischemia Research Group. , 1993, JAMA.

[22]  E. Graves.  Detailed diagnoses and procedures, national hospital discharge survey, 1990. , 1992, Vital and health statistics. Series 13, Data from the National Health Survey.

[23]  J. Fleiss,et al.  Detection and Significance of Myocardial Ischemia in Stable Patients after Recovery from an Acute Coronary Event , 1993 .

[24]  J. Fernandez-Solà,et al.  The Relation of Alcoholic Myopathy to Cardiomyopathy , 1994, Annals of Internal Medicine.

[25]  The Risc Group.  Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease , 1990, The Lancet.

[26]  W. O’Neill,et al.  A new clinical classification for hospital prognosis of unstable angina pectoris. , 1995, The American journal of cardiology.

[27]  R Peto,et al.  Why do we need some large, simple randomized trials? , 1984, Statistics in medicine.

[28]  G. Timmis,et al.  Randomized Trial of Thrombolysis Versus Heparin in Unstable Angina , 1992, Circulation.

[29]  E. Shapiro,et al.  Effect of the addition of propranolol to therapy with nifedipine for unstable angina pectoris: a randomized, double-blind, placebo-controlled trial. , 1986, Circulation.

[30]  A. Fogelman.  Strategies for Training Generalists and Subspecialists , 1994, Annals of Internal Medicine.

[31]  D. Sackett,et al.  Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. , 1985, The New England journal of medicine.

[32]  W. Hoyt,et al.  Letter: Suprastriate hemianopia. , 1974, Lancet.

[33]  D. Waters,et al.  Reactivation of unstable angina after the discontinuation of heparin. , 1992, The New England journal of medicine.

[34]  Arthur Schafer,et al.  Ethics of the randomized clinical trial. , 1982, The New England journal of medicine.

[35]  M. Yamamoto.  The place of primary health care in a comprehensive health system. , 1986, Social science & medicine.

[36]  A. Telford,et al.  TRIAL OF HEPARIN VERSUS ATENOLOL IN PREVENTION OF MYOCARDIAL INFARCTION IN INTERMEDIATE CORONARY SYNDROME , 1981, The Lancet.

[37]  Graves Ej,et al.  Detailed diagnoses and procedures, National Hospital Discharge Survey, 1994. , 1997, Vital and health statistics. Series 13, Data from the National Health Survey.

[38]  F. Harrell,et al.  Importance of clinical measures of ischemia in the prognosis of patients with documented coronary artery disease. , 1988, Journal of the American College of Cardiology.