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DURHAM, N.C. -- Elderly patients treated in a hospital for a
heart attack were 12 percent less likely to die from the
ailment if their doctor was a cardiologist rather than a
primary care physician, a Duke University Medical Center study
has shown.

The researchers say the findings have wide implications in
view of the current strategies of managed care to limit access
to specialists. "Up to now, most efforts to reform expensive
traditional medicine have focused on containing cost by
increasing use of primary care physicians. This study indicates
we also need to pay close attention to patient outcomes," said
the primary author, cardiologist Dr. James Jollis.

The study, published in the Dec. 19 issue of the New England
Journal of Medicine, is the first reported that assesses
whether the type of physician treating acute heart attack
patients makes a difference in outcomes. Heart attack is the
single largest killer of Americans. Annually, about 1.5 million
people suffer a heart attack, about 750,000 are hospitalized,
and one-third of them die, according to the American Heart
Association.

The study was funded by the federal Agency for Health Care
Policy and Research and conducted at the Duke Clinical Research
Institute. Working with Jollis were Duke cardiologists Drs.
Daniel Mark, Robert Califf, Donald Fortin, and Eric Peterson,
and Duke statisticians Elizabeth DeLong and Lawrence
Mohlbaier.

The researchers studied all 220,535 Medicare patients who
suffered a heart attack in 1992 and found that the 64 percent
of the patients admitted to a hospital and attended by primary
care physicians had a lower chance of survival than the 34
percent of patients under the care of cardiologists. They say
the results could not be explained by hospital or patient
characteristics.

"It stands to reason that a doctor who focuses on hearts
would likely provide a different level of care than those who
treat a wide variety of diseases, and this study bears out that
assumption," Jollis said. "Cardiologists are trained to
recognize and treat heart attacks and to manage
complications."

"It's not that cardiologists are better doctors than primary
care physicians. Rather, the study validates the saying that
'practice makes perfect,'" said co-author Mark, a cardiologist
and director of the Outcomes Research and Assessment Group at
Duke. "Doctors with a lot of experience caring for a particular
disorder do a better job on average than physicians who treat
that disease infrequently, especially in high risk patients.
The same notion exists within cardiology, too. We've found that
physicians need to do many by-pass surgeries and angioplasties
to have the highest quality results."

Primary care physicians include internists, who treat only
adults, and family care practitioners. Some managed care plans
concentrate care with primary care physicians as much as
possible, and in many traditional fee-for-services medical
plans, primary care physicians can admit patients to hospitals
and be their patient's attending doctor.

The authors say the study flags several major issues that
should be addressed in the U.S. health care system. "Although
the results of the study alone cannot be used to justify a
policy requiring all patients with acute heart attacks to be
cared for by a cardiologist, our findings indicate a critical
need to define better the differences between specialty and
primary care and the effects of those differences on outcomes,"
Jollis said.

Additionally, researchers and physicians need to determine
the point at which heart disease is severe enough that patients
would benefit from seeing a cardiologist. "Severely ill
patients in this study represented one end of the spectrum of
disease, and we recognize that there is some level of illness
below which primary care would be similar, if not superior to,
specialty care, such as treatment of high blood pressure by a
physician who knows a patient's complete medical history," said
Jollis. "We need further study to determine where specialty
care begins to make a difference, and so is worth the added
expense."

Indeed, the study did find that along with saving more
lives, cardiologists cost the health care system more than
primary care physicians. Patients admitted by cardiologists
underwent more diagnostic and therapeutic procedures, had
longer hospital stays, and received more medication to control
their heart disease than patients treated by other
physicians.

"In fact, the study identified one of the mechanisms that
may have led to improved survival," Jollis said. "Patients
treated by cardiologists were more likely to receive
survival-prolonging medications, including thrombolytic
therapy, beta blockers, and aspirin.

"This suggests that one strategy to improve care among
patients by primary care physicians would be to increase the
use of those medications through guidelines and training,"
Jollis said. "In addition, other beneficial approaches may
include the use of cardiology consultations and the transfer of
patients to specialty services in certain situations."

Study researchers first examined the records of all Medicare
patients who had a heart attack in the U.S. in 1992. The mean
age of the patients was 76 and they were split evenly between
men and women.

The researchers looked to see what happened to the 220,535
patients one year after they were hospitalized for a heart
attack, and they found that 38 percent of the patients seen by
primary care physicians had died, compared to 30 percent who
had seen a cardiologist.

Then the researchers examined the medical records on a
subset of these Medicare patients for which detailed clinical
and outcome information was available. They looked at the
outcome of 8,241 patients in four states, Alabama, Connecticut,
Iowa, and Wisconsin.

In examining this group, the researchers statistically
adjusted for disease severity and other factors, such as
hospital type, to arrive at an accurate comparison of the
treatment given to patients per type of physician -- an
analysis not possible for the larger group of patients because
comparison information was limited in their records. In the
small group, for example, researchers found out that patients
referred to care by cardiologists tended to be several years
younger and male, according to Jollis, and they statistically
adjusted this "bias" in the analysis, he said. After adjusting
for these differences in patient and hospital characteristics,
the researchers found that patients treated by cardiologists
had a 12 percent lower risk of death at one year.

Among other results, the researchers found that: