CLINICAL STUDIES
Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction
Paul N. Casale, MD, FACCa,
Jayne L. Jones, MPH*,
Flossie E. Wolf, MS*,
Yanfen Pei, MS* and
L. Marlin Eby, PhD
a The Lancaster Heart Foundation, Lancaster, Pennsylvania, USA
* The Pennsylvania Health Care Cost Containment Council, Harrisburg, Pennsylvania, USA
Messiah College, Grantham, Pennsylvania, USA
Manuscript received December 19, 1997;
revised manuscript received June 3, 1998,
accepted June 12, 1998.
Address for correspondence: Dr. Paul N. Casale, The Lancaster Heart Foundation, 217 Harrisburg Avenue, Lancaster, Pennsylvania 17603
lanheart{at}redrose.net
Objectives. We sought to determine the effect of specialty care on in-hospital mortality in patients with acute myocardial infarction.
Background. There has been increasing pressure to limit access to specialists as a method to reduce the cost of health care. There is little known about the effect on outcome of this shift in the care of acutely ill patients.
Methods. We analyzed the data from 30,715 direct hospital admissions for the treatment of acute myocardial infarction in Pennsylvania in 1993. A risk-adjusted in-hospital mortality model was developed in which 12 of 20 clinical variables were significant independent predictors of in-hospital mortality. To determine whether there were factors other than patient risk that significantly influenced in-hospital mortality, multiple logistic regression analysis was performed on physician, hospital and payer variables.
Results. After adjustment for patient characteristics, a multiple logistic regression analysis identified treatment by a cardiologist (odds ratio = 0.83 [confidence interval {CI} = 0.74 to 0.94] p < 0.003) and physicians treating a high volume of acute myocardial infarction patients (odds ratio = 0.89 [CI = 0.80 to 0.99] p < 0.03) as independent predictors of lower in-hospital mortality. Treatment by a cardiologist as compared to primary care physicians was also associated with a significantly lower length of stay for both medically treated patients (p < 0.01) and those undergoing revascularization (p < 0.01).
Conclusions. Treatment by a cardiologist is associated with approximately a 17% reduction in hospital mortality in acute myocardial infarction patients. In addition, patients of physicians treating a high volume of patients have approximately an 11% reduction in mortality. This has important implications for the optimal treatment of acute myocardial infarction in the current transformation of the health care delivery system.
|
Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | CABG | = coronary artery bypass graft surgery | | HMO | = health maintenance organization | | PTCA | = percutaneous transluminal coronary angioplasty |
|
This article has been cited by other articles:
|
|
|
|
 
K. C. Stange and R. L. Ferrer
The Paradox of Primary Care
Ann. Fam. Med,
July 1, 2009;
7(4):
293 - 299.
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. M. Dunlay, K. P. Alexander, C. Melloni, J. L. Kraschnewski, L. Liang, W. B. Gibler, M. T. Roe, E. M. Ohman, and E. D. Peterson
Medical Records and Quality of Care in Acute Coronary Syndromes: Results From CRUSADE
Arch Intern Med,
August 11, 2008;
168(15):
1692 - 1698.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. L. Daugherty, P. M. Ho, J. A. Spertus, P. G. Jones, R. G. Bach, H. M. Krumholz, E. D. Peterson, J. S. Rumsfeld, and F. A. Masoudi
Association of Early Follow-up After Acute Myocardial Infarction With Higher Rates of Medication Use
Arch Intern Med,
March 10, 2008;
168(5):
485 - 491.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. D. Ketcham, L. C. Baker, and D. MacIsaac
Physician Practice Size And Variations In Treatments And Outcomes: Evidence From Medicare Patients With AMI
Health Aff.,
January 1, 2007;
26(1):
195 - 205.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Hartz and P. A. James
A systematic review of studies comparing myocardial infarction mortality for generalists and specialists: lessons for research and health policy.
J Am Board Fam Med,
May 1, 2006;
19(3):
291 - 302.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. K. Lindenauer, R. Behal, C. K. Murray, W. Nsa, P. M. Houck, and D. W. Bratzler
Volume, quality of care, and outcome in pneumonia.
Ann Intern Med,
February 21, 2006;
144(4):
262 - 269.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. F. Sonel, C. B. Good, J. Mulgund, M. T. Roe, W. B. Gibler, S. C. Smith Jr, M. G. Cohen, C. V. Pollack Jr, E. M. Ohman, E. D. Peterson, et al.
Racial Variations in Treatment and Outcomes of Black and White Patients With High-Risk Non-ST-Elevation Acute Coronary Syndromes: Insights From CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?)
Circulation,
March 15, 2005;
111(10):
1225 - 1232.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Bansal, V. Gaddam, Y. W. Aude, J. Bissett, I. Fahdi, L. Garza, J. Joseph, B. Molavi, B. V. Pai, A. Sinha, et al.
Trends in the Care of Patients With Acute Myocardial Infarction at a University-Affiliated Veterans Afffairs Medical Center
Journal of Cardiovascular Pharmacology and Therapeutics,
January 1, 2005;
10(1):
39 - 44.
[Abstract]
[PDF]
|
|
|
|
|
|
|
W. B. Fye
Introduction: the origins and implications of a growing shortage of cardiologists
J. Am. Coll. Cardiol.,
July 21, 2004;
44(2):
221 - 232.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Hirshfeld Jr and W. B. Fye
Summary of Task Force recommendations to address the growing shortage of cardiologists
J. Am. Coll. Cardiol.,
July 21, 2004;
44(2):
272 - 275.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. M. Ho, F. A. Masoudi, E. D. Peterson, G. K. Grunwald, A. E. Sales, K. E. Hammermeister, and J. S. Rumsfeld
Cardiology management improves secondary prevention measures among patients with coronary artery disease
J. Am. Coll. Cardiol.,
May 5, 2004;
43(9):
1517 - 1523.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. B. Fye
Cardiology's Workforce Shortage: Implications for Patient Care and Research
Circulation,
February 24, 2004;
109(7):
813 - 816.
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. A. SCOTT, K. HEATH, C. HARPER, and A. CLOUGH
An Australian comparison of specialist care of acute myocardial infarction
Int. J. Qual. Health Care,
March 1, 2003;
15(2):
155 - 161.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P Block, H Weber, P Kearney, and on behalf of the Cardiology Section of the UEMS
Manpower in cardiology II in western and central Europe (1999-2000)
Eur. Heart J.,
February 2, 2003;
24(4):
299 - 310.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Ansari, M. Alexander, A. Tutar, D. Bello, and B. M. Massie
Cardiology participation improves outcomes in patients with new-onset heart failure in the outpatient setting
J. Am. Coll. Cardiol.,
January 1, 2003;
41(1):
62 - 68.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Z. Ayanian, M. B. Landrum, E. Guadagnoli, and P. Gaccione
Specialty of Ambulatory Care Physicians and Mortality among Elderly Patients after Myocardial Infarction
N. Engl. J. Med.,
November 21, 2002;
347(21):
1678 - 1686.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Mehta, D. A. Criger, C. B. Granger, K. K. Pieper, R. M. Califf, E. J. Topol, and E. R. Bates
Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability
J. Am. Coll. Cardiol.,
September 18, 2002;
40(6):
1034 - 1040.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. A. Halm, C. Lee, and M. R. Chassin
Is Volume Related to Outcome in Health Care? A Systematic Review and Methodologic Critique of the Literature
Ann Intern Med,
September 17, 2002;
137(6):
511 - 520.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Mehta, C. K. Montoye, M. Gallogly, P. Baker, A. Blount, J. Faul, C. Roychoudhury, S. Borzak, S. Fox, M. Franklin, et al.
Improving Quality of Care for Acute Myocardial Infarction: The Guidelines Applied in Practice (GAP) Initiative
JAMA,
March 13, 2002;
287(10):
1269 - 1276.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y. Elad, W. J. French, D. M. Shavelle, L. S. Parsons, M. J. Sada, N. R. Every, and Participants in the National Registry of Myocardia
Primary angioplasty and selection bias inpatients presenting late (>12 h) after onset of chest pain and ST elevation myocardial infarction
J. Am. Coll. Cardiol.,
March 6, 2002;
39(5):
826 - 833.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. J. McNeil
Hidden Barriers to Improvement in the Quality of Care
N. Engl. J. Med.,
November 29, 2001;
345(22):
1612 - 1620.
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. H. Mehta, S. S. Rathore, M. J. Radford, Y. Wang, Y. Wang, and H. M. Krumholz
Acute myocardial infarction in the elderly: differences by age
J. Am. Coll. Cardiol.,
September 1, 2001;
38(3):
736 - 741.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Bellotti, L.P. Badano, N. Acquarone, R. Griffo, G. Lo Pinto, A.P. Maggioni, C. Mattiauda, G. Menardo, and P. Mombelloni
Specialty-related differences in the epidemiology, clinical profile, management and outcome of patients hospitalized for heart failure. The OSCUR study
Eur. Heart J.,
April 1, 2001;
22(7):
596 - 604.
[Abstract]
[PDF]
|
|
|
|
|
|
|
A. D. Auerbach, M. B. Hamel, R. M. Califf, R. B. Davis, N. S. Wenger, N. Desbiens, L. Goldman, H. Vidaillet, A. F. Connors, J. Lynn, et al.
Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure
J. Am. Coll. Cardiol.,
December 1, 2000;
36(7):
2119 - 2125.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. D. Vu, R. F Heller, L. L-Y Lim, C. D'Este, and R. L O'Connell
Mortality after acute myocardial infarction is lower in metropolitan regions than in non-metropolitan regions
J Epidemiol Community Health,
August 1, 2000;
54(8):
590 - 595.
[Abstract]
[Full Text]
|
|
|
|
|
|
|
R. A. Dudley, K. L. Johansen, R. Brand, D. J. Rennie, and A. Milstein
Selective Referral to High-Volume Hospitals: Estimating Potentially Avoidable Deaths
JAMA,
March 1, 2000;
283(9):
1159 - 1166.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. D. Auerbach, M. B. Hamel, R. B. Davis, A. F. Connors Jr., C. Regueiro, N. Desbiens, L. Goldman, R. M. Califf, N. V. Dawson, N. Wenger, et al.
Resource Use and Survival of Patients Hospitalized with Congestive Heart Failure: Differences in Care by Specialty of the Attending Physician
Ann Intern Med,
February 1, 2000;
132(3):
191 - 200.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. R. Thiemann, J. Coresh, W. J. Oetgen, and N. R. Powe
The Association between Hospital Volume and Survival after Acute Myocardial Infarction in Elderly Patients
N. Engl. J. Med.,
May 27, 1999;
340(21):
1640 - 1648.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Cardiologist-Treated Patients Have Lower MI Mortality
Journal Watch Cardiology,
October 16, 1998;
1998(1016):
7 - 7.
[Full Text]
|
|
|
|
|
|
|
Do Cardiologists Achieve Better Outcomes in MI?
Journal Watch (General),
October 16, 1998;
1998(1016):
5 - 5.
[Full Text]
|
|
|
|
