Outcome of Acute Myocardial Infarction According to the Specialty of the Admitting Physician
James G. Jollis, M.D., Elizabeth R. DeLong, Ph.D., Eric D. Peterson, M.D., M.P.H., Lawrence H. Muhlbaier, Ph.D., Donald F. Fortin, M.D., Robert M. Califf, M.D., and Daniel B. Mark, M.D., M.P.H.
Background In order to limit costs, health care organizationsin the United States are shifting medical care from specialiststo primary care physicians. Although primary care physiciansprovide less resource-intensive care, there is little informationconcerning the effects of this strategy on outcomes.
Methods We examined mortality according to the specialty ofthe admitting physician among 8241 Medicare patients who werehospitalized for acute myocardial infarction in four statesduring a seven-month period in 1992. Proportional-hazards regressionmodels were used to examine survival up to one year after themyocardial infarction. To determine the generalizability ofour findings, we also examined insurance claims and survivaldata for all 220,535 patients for whom there were Medicare claimsfor hospital care for acute myocardial infarction in 1992.
Results After adjustment for characteristics of the patientsand hospitals, patients who were admitted to the hospital bya cardiologist were 12 percent less likely to die within oneyear than those admitted by a primary care physician (P<0.001).Cardiologists also had the highest rate of use of cardiac proceduresand medications, including medications (such as thrombolyticagents and beta-blockers) that are associated with improvedsurvival.
Conclusions Health care strategies that shift the care of elderlypatients with myocardial infarction from cardiologists to primarycare physicians lower rates of use of resources (and potentiallylower costs), but they may also cause decreased survival. Additionalinformation is needed to elucidate how primary care physiciansand specialists should interact in the care of severely illpatients.
A common strategy of health care organizations in the UnitedStates to reduce use of medical services is to increase theuse of primary care physicians and limit access to specialists.1,2Because primary care physicians have been found to provide carethat is less resource-intensive, this fundamental shift in referralpatterns should lower medical costs.3
Whether the increasing shift to primary care for purposes ofsaving money may also involve trade-offs with respect to outcomeshas not been adequately studied, particularly in the case ofacutely ill patients. Studies have suggested that replacingsubspecialty care with primary care for patients with acutecardiac illnesses may lead to worse outcomes for patients.4,5Ayanian and colleagues5 reported that family practitioners andinternists were less aware of or less certain about effectiveand life-saving drugs for the treatment of acute myocardialinfarction than were cardiologists. In order to examine furtherthe relation between the outcomes of patients with myocardialinfarction and the type of physicians (primary care or specialist)who provide their care, we studied detailed clinical data fromthe Cooperative Cardiovascular Project (CCP) on 8241 Medicarepatients hospitalized for acute myocardial infarction duringthe period June through December 1992.6,7 To evaluate the generalizabilityof our findings, we also examined insurance claims and survivaldata for all 220,535 patients with Medicare claims for hospitalcare for acute myocardial infarction at any time in 1992.
Methods
Sources of Data
The CCP
The CCP collected data abstracted from the charts of all Medicarepatients who were discharged from the hospital with a diagnosisof acute myocardial infarction in Alabama, Connecticut, Iowa,and Wisconsin between June 1, 1992, and February 28, 1993.6,7Information collected for each patient included patient identifiers(health insurance claims numbers), dates of hospitalization,demographic characteristics, history of chest pain, Killip class,use of medications, presence or absence of contraindicationsto therapy, results of electrocardiography, results of testsfor cardiac enzymes, results of invasive and noninvasive cardiactests, occurrence and nature of complications, treatment, andvital status.
Medicare National Claims History File
The Medicare National Claims History File for 1992 includesclaims under both Part A (for hospital care) and Part B (forphysicians' services and outpatient care) for approximately95 percent of all hospitalizations for acute myocardial infarctionamong patients over the age of 65 years in the United Statesduring the study period.8 Part A claims contain demographicdata and limited clinical information on all inpatients whosehospital care was billed to Medicare, including the patient'shealth insurance claims number and the unique physician identificationnumber (UPIN) of the attending physician. Part B claims containdemographic data and limited clinical information from billsfrom physicians and bills for outpatient care, including thepatient's health insurance claims number, the service or procedureprovided, according to Current Procedural Terminology (CPT)codes, and the UPIN of the physician submitting the bill.9
Patients
For the principal analyses, we selected all patients listedby the CCP who had a confirmed acute myocardial infarction (accordingto clinical criteria) for whom there were records in the 1992Medicare files (matched according to the patient's health insuranceclaims number and the dates of hospitalization). As in previousstudies, the criteria for myocardial infarction included eithera serum creatine kinase MB index above 3 percent or any twoof the following three criteria: chest pain; a doubling of theserum creatine kinase concentration or a lactate dehydrogenaseisoenzyme 1 concentration greater than the concentration oflactate dehydrogenase isoenzyme 2; and evidence of acute myocardialinfarction on electrocardiography.6,7 For secondary analyses,all 1992 Medicare hospital claims involving acute myocardialinfarction in a patient over 65 years of age were selected accordingto previously described methods.10 To avoid counting patientsmore than once, we analyzed only the first hospitalization forany given patient.
Identification of Physicians' Specialties
The admitting physician was considered to be the physician whosubmitted the Medicare Part B claim for initial hospital care(CPT 99221-3). For patients without a claim for initial hospitalcare, the physician listed on the bill from the earliest hospitalday for critical care services (CPT 99291-2) or subsequent hospitalcare (CPT 99231-3) was used in the analyses of physicians' specialties.Each physician's specialty was identified by linking his orher UPIN with a directory of physician-reported specialtiesmaintained by the Health Care Financing Administration. As acheck on the sensitivity of our findings to the method usedto identify the physician's specialty, we repeated all the analysesusing the attending physician listed in Medicare Part A claimsfrom 1992. For patients who were transferred between hospitalsbefore discharge, the attending physician identified on thefirst hospital's claim was used in the analyses of physicians'specialties.
Statistical Analysis
The primary analysis examined survival of patients listed inthe CCP up to one year after acute myocardial infarction accordingto their physicians' specialties. The physician's specialtywas classified as primary care (for those in internal medicine,family medicine, or general practice), cardiology, or "other"(for physicians with other medical specialties, surgical specialties,or missing, incomplete, or unmatched UPINs). We used Cox proportional-hazardsregression models to determine the prognostic importance ofthe physician's specialty, according to the difference in thelog-likelihood chi-square between models that included the physician'sspecialty and those that did not.11
Adjustment for imbalances in patients' characteristics was performedby adding the component variables from a previously publishedmodel of mortality due to acute myocardial infarction, developedby the Global Utilization of Streptokinase and Tissue PlasminogenActivator for Occluded Coronary Arteries (GUSTO) investigators,to the proportional-hazards models.12 The variables from theGUSTO model included age, systolic blood pressure at admission,pulse, location of the myocardial infarction, Killip class,height, weight, history of infarction, history of bypass surgery,smoking status, and the presence or absence of diabetes, hypertension,and cerebrovascular disease. Additional models adjusted forcharacteristics of the hospitals (availability of coronary angiography,angioplasty, or bypass surgery at the admitting hospital andurban or rural location in relation to federally designatedMetropolitan Statistical Areas).13 Mortality in the Medicarecohort was also examined with adjustment for hospital characteristicsand data relevant to the severity of illness from the Medicarefiles, including age, sex, race, location of the myocardialinfarction, and Charlson comorbidity score.14 All analyses ofdata from the CCP and Medicare files were repeated after wereclassified the physicians' specialties on the basis of theattending physician listed in Medicare Part A claims. Sincethese results did not alter our conclusions, only the analysesof data on admitting physicians are presented.
Results
Characteristics of the Patients
A total of 220,535 patients were identified in the 1992 Medicarefiles as having had an acute myocardial infarction; the admittingphysician was identified from the Medicare Part B claim for182,747 of these patients, and the attending physician was identifiedfrom the Medicare Part A claim for 216,703 patients. We identifieda subgroup of 8241 patients for whom there were CCP data whomet the clinical criteria for acute myocardial infarction. Thedistributions of patients according to the specialty of theadmitting physician in the CCP and Medicare cohorts are shownin Table 1 and Table 2, respectively.
Table 1. Demographic Characteristics and Indicators of the Severity of Illness among Patients in the Cooperative Cardiovascular Project Data Base, According to the Specialty of the Admitting Physician.
Table 2. Demographic Characteristics and Indicators of the Severity of Illness among Patients in the Medicare Insurance-Claims Data Base, According to the Specialty of the Admitting Physician.
Demographic Characteristics
The mean age of the CCP cohort was 76.4 years; 50 percent werewomen; 94.3 percent were white, 5.1 percent were black, and0.6 percent were of other or unknown race. Demographic informationaccording to the specialty of the admitting physician is summarizedin Table 1 for the CCP cohort and in Table 2 for the Medicarecohort. As compared with patients admitted by physicians inother specialties, patients admitted by cardiologists were approximatelytwo years younger and were less likely to be female. The racialcomposition of the specialty categories was similar. Patientsadmitted by cardiologists were more likely to be admitted tourban hospitals and hospitals in which coronary angiography,angioplasty, and bypass surgery were available. Although theMedicare cohort was slightly older than the CCP cohort and hadlarger proportions of women and blacks, the variation in age,sex, and race according to the specialty of the admitting physicianfollowed a similar pattern among the subgroups in the two cohorts.
Severity of Illness
According to the CCP data, patients admitted by cardiologistswere more likely than others to have had a previous myocardialinfarction, to have undergone coronary bypass surgery, to havean anterior myocardial infarction, and to have lower blood pressureon admission — all factors associated with a greater riskof death. Several variables indicated that patients admittedby primary care physicians had more severe disease than thoseadmitted by cardiologists, notably the lower proportions ofinferior myocardial infarctions, greater rates of diabetes andcerebrovascular disease, and lower proportions of patients inKillip class 1. When we combined characteristics indicatingseverity of illness according to the method used by the GUSTOinvestigators to model mortality due to myocardial infarction,patients admitted by cardiologists had a significantly lowerpredicted 30-day mortality.12
Medications, Cardiac Procedures, and Length of Stay
As previously reported, the rate of use of medications to prolongsurvival among the patients in the CCP data set was substantiallylower than would be supported by evidence from randomized trialsavailable at the time of the study.6,7 The use of drug therapiesis shown in Table 3, according to the physician's specialty.Approximately 6 percent more patients admitted by cardiologistswere considered to be eligible for thrombolytic therapy thanwas the case for patients admitted by other physicians. Patientsadmitted by cardiologists were more likely than the other patientsto be treated with all the medications we studied except angiotensin-converting–enzymeinhibitors. When patients who were receiving these therapiesbefore admission were excluded, the patterns were similar.
Table 3. Use of Drug Therapy among Patients Listed in the Cooperative Cardiovascular Project Data Base, According to the Specialty of the Admitting Physician.
Data on the use of procedures and the length of the hospitalstay are summarized in Table 4 and Table 5. In both cohorts,patients admitted by cardiologists underwent substantially morecoronary-angiography and revascularization procedures than patientsadmitted by physicians in the other specialties. The proportionof patients who were identified as having clinically significantleft main or three-vessel coronary artery disease was similaramong all the specialties. Patients admitted by cardiologistswere also more likely to undergo other procedures, includingstress testing, nuclear imaging, Holter monitoring, and echocardiography.
Table 4. Use of Procedures and Length of the Hospital Stay among Patients in the Cooperative Cardiovascular Project Data Base, According to the Specialty of the Admitting Physician.
Table 5. Use of Procedures and Length of the Hospital Stay among Patients in the Medicare Insurance-Claims Data Base, According to the Specialty of the Admitting Physician.
The mean length of stay was 8.5 days for the CCP cohort and8.7 days for the Medicare cohort. Length of stay was shortestfor patients admitted by family medicine practitioners in boththe CCP and Medicare cohorts. When we excluded the patientswho underwent coronary revascularization before discharge, patientsadmitted by physicians in family medicine continued to havethe shortest hospital stays, whereas those admitted by physiciansspecializing in cardiology and internal medicine had the longeststays.
Survival
Crude in-hospital, 30-day, and 1-year mortality rates for patientsin the CCP data set were 14.7 percent, 19.7 percent, and 32.8percent, respectively (Table 6). Patients admitted by cardiologistshad the lowest mortality for each period. In the Medicare cohort,mortality was higher for all the periods, and patients admittedby cardiologists had the lowest crude mortality. Figure 1 showsthe hazard ratios and 95 percent confidence intervals for one-yearsurvival in the CCP cohort according to specialty, after adjustmentfor the characteristics of the patients (severity of illnessas indicated by the CCP data) and the hospitals (availabilityof coronary angiography, angioplasty, or bypass surgery andurban or rural location), with patients admitted by internistsas the reference category.
Figure 1. Hazard Ratios for Adjusted One-Year Mortality among Patients with Acute Myocardial Infarction in the Cooperative Cardiovascular Project Cohort, According to the Specialty of the Admitting Physician.
The bars indicate the 95 percent confidence intervals. The hazard ratios have been adjusted for indicators of the severity of illness; the availability of facilities for coronary angiography, angioplasty, or bypass surgery at the hospital; and urban or rural hospital location. Patients admitted by physicians specializing in internal medicine served as the reference category.
After adjustment for patients' characteristics, patients admittedby cardiologists had significantly better one-year survivalthan those admitted by physicians in all the primary care specialties(hazard ratio, 0.87; P<0.001). The survival advantage forcardiology persisted and remained significant after we adjustedfor hospitals' characteristics (hazard ratio, 0.88; P<0.001).Adjusted rates of one-year survival did not differ significantlyamong the primary care specialties. Admission by a cardiologistwas also found to be significantly associated with better survivalin the Medicare cohort, after adjustment for severity-of-illnessmeasures recorded in the Medicare file and for characteristicsof the hospitals. These relations persisted when the specialtyof the attending physician listed in Medicare Part A claimswas used to reclassify patients.
Discussion
In this study, we found that cardiologists used more resourcesand achieved better outcomes than physicians in other specialtiesin caring for elderly patients with acute myocardial infarction.Patients admitted by cardiologists underwent more diagnosticand therapeutic procedures, had longer hospital stays, and receivedmore medications to treat ischemic heart disease than patientstreated by physicians in other specialties. After adjustmentfor characteristics of the patients and hospitals, patientsadmitted by cardiologists were also more likely to survive forat least one year after myocardial infarction. These findingssuggest that health care strategies that shift the care of elderlypatients with myocardial infarction from cardiologists to primarycare physicians are likely to lead not only to lower rates ofuse of resources (hence, potentially lower costs), but alsoto decreased survival.
There are at least three possible explanations for these findings.The first is that specific aspects of care by cardiologistswere responsible for the better outcomes. Cardiologists havea narrower clinical focus, and therefore more experience withpatients who have coronary disease, and more time to devoteto continuing education relevant to the treatment of such disease.Because of this additional training and experience, cardiologistswould be expected to be more familiar with the diagnosis andmanagement of complications of acute myocardial infarction,such as complete heart block or mitral-valve rupture, and toselect treatments associated with better survival.
That we found differences among the specialties in the use ofmedications and coronary-revascularization procedures, aspectsof care that are associated with outcome, supports this hypothesis.Cardiologists were more likely than other physicians to treatpatients with thrombolytic agents, beta-blockers, aspirin, nitrates,and heparin — medications that are associated with improvedsurvival.5,15,16,17 Differences in survival attributable tothese medications would be expected to become apparent duringthe initial hospitalization and to continue through the yearafter discharge. Cardiologists were not more likely to treatpatients with angiotensin-converting–enzyme inhibitors,but studies demonstrating a survival benefit associated withthe use of these drugs after myocardial infarction were notpublished until September 1992, about halfway through the studyperiod.18
Differences in the use of coronary angiography and revascularizationprocedures may also have contributed to improved survival, althoughthe survival benefits would be expected to become most apparentafter one year of follow-up. Coronary revascularization, particularlybypass surgery, has been associated with improved survival inrandomized trials predominantly involving younger, male patientstreated 10 to 20 years before the study period.19 The use ofbypass surgery in these early trials was associated with aninitial increase in mortality, followed by an improvement insurvival that became most apparent three to seven years afterthe procedure. With higher rates of coronary angiography anda similar proportion of patients found to have left main orthree-vessel coronary disease, cardiologists in this study identifiedmore patients whose coronary anatomy indicated that revascularizationwould improve survival (Table 4). They also treated more patientswith coronary revascularization. If the survival pattern amongthe older patients in this study was similar to those observedin the randomized trials, the cardiologists' greater use ofcoronary revascularization would be expected to result in increasedshort-term mortality, with improved survival beyond one yearof follow-up.
A second potential explanation for the lower mortality amongpatients admitted by cardiologists may be provided by factorsother than care by a cardiologist that are associated with admissionto a cardiology service. Such factors may include admissionto a hospital that cares for large numbers of patients withacute myocardial infarction, the presence of emergency roomphysicians who are likely to recognize acute myocardial infarctionand initiate early treatment, and the on-site availability ofprocedures for the management of complications, such as coronaryangioplasty or bypass surgery. Adjustment for the availabilityof these procedures at the admitting hospital did not accountfor observed differences, and neither did whether the hospitalwas located in an urban area, a crude marker of available technology.Because of the correlation between the physician's specialtyand these characteristics of the hospital, the influence ofthese two factors is difficult to separate, and it is most likelythat both factors improved outcomes.
A third explanation is that differences in severity of illnessled to the lower mortality among patients admitted by cardiologists.When we assessed severity of illness according to the GUSTOmodel, patients admitted by cardiologists were predicted tohave 1.6 to 1.8 percent lower mortality at 30 days than patientsadmitted by primary care physicians. However, the observed differencesin survival among the specialties were much greater than couldbe explained by base-line measures of the severity of illness.Although it is possible that additional characteristics indicatingseverity of illness were not measured, the clinical variablesfor which we did adjust accounted for more than 90 percent ofthe prognostic information available from the base-line evaluationof patients with myocardial infarction in the GUSTO study.12
In the 41,000-patient GUSTO study, age provided nearly halfthe prognostic information (30-day mortality) according to theglobal chi-square statistic, and age, systolic blood pressure,Killip class, heart rate, and location of the infarct togetherprovided approximately 90 percent of the total prognostic informationavailable among 16 clinical predictors examined. Similarly,age, systolic blood pressure, Killip class, heart rate, andweight provided 90 percent of the total prognostic informationderived from patients' characteristics in that study. It isunlikely that additional measures of the severity of illnesswould explain the differences in mortality among patients treatedby physicians in different specialties.
Use of the UPIN to Identify the Physician's Specialty
We chose to examine the outcome of acute myocardial infarctionaccording to the physician's specialty in 1992, since 1992 wasthe first year when the UPIN was required for Medicare reimbursement.A potential problem with our methods is that the specialty wasreported by the physician, rather than by a certification board.The study by Ayanian and colleagues found that the majorityof physicians who identify themselves as specializing in familymedicine, internal medicine, and cardiology were board-certified(89 percent, 78 percent, and 85 percent, respectively).5 Moreover,in identifying physicians who provide superior care to patientswith acute myocardial infarction, board-certification statusmay not be as important as the specialty reported by the physician.Physicians who are not board-certified but who identify themselvesas practicing a particular specialty may have enhanced skillsdue to their experience with their area of interest. The importanceof board certification cannot be determined from this study.
In order to avoid bias related to the referral of patients toother services, we classified patients according to the specialtyof the admitting physician. We also examined the data accordingto the specialty of the attending physician listed in claimsfor in-hospital care; this physician is defined as "the clinicianwho is primarily and largely responsible for the care of thepatient from the beginning of the hospital episode," accordingto the Uniform Hospital Discharge Data Set definitions.20 For82 percent of patients, the specialty of the physician was thesame in both sources. For the remaining 18 percent, the specialtyof the physician responsible for admission and the physicianresponsible for the majority of the patient's care were probablydifferent, and the latter was selected as the attending physician.Analyses according to the specialty of the attending physicianyielded the same findings — specifically, that receivingcare from a cardiologist was associated with lower mortality.
Conclusions
We found that patients with acute myocardial infarction whowere admitted to the hospital by a cardiologist had a betterrate of survival than those admitted by primary care physicians.We also identified one of the potential mechanisms contributingto the survival advantage: the greater use of therapies associatedwith increased survival. Care by a cardiologist was also associatedwith the use of more resources, particularly cardiac procedures.This study provides national data on patients over the age of65 in 1992, and our results should be generalizable to morerecent cohorts, at least in this age group. Although the resultsof this study alone cannot be used to justify a policy requiringthat all patients with acute myocardial infarction be caredfor by cardiologists, our findings indicate a critical needto define better the differences between specialty and primarycare and the effects of those differences on outcomes.
Supported by grants (HS-08805 and HS-06503) from the Agencyfor Health Care Policy and Research, Rockville, Md.
We are indebted to David B. Pryor, M.D., for directing the analysesof the data from the Cooperative Cardiovascular Project as partof the Ischemic Heart Disease Patient Outcome Research Teamof the Agency for Health Care Policy and Research and to JamesP. Nolan, M.D., and Caroline M. Sherman, M.B.A., for their helpfulcomments on the manuscript.
Source Information
From the Department of Medicine (J.G.J., E.D.P., D.F.F., R.M.C., D.B.M.) and the Division of Biometry, Department of Community and Family Medicine (E.R.D., L.H.M.), Duke University Medical Center, Durham, N.C.
Address reprint requests to Dr. Jollis at Box 3254, Duke University Medical Center, Durham, NC 27710.
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