title: Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Internal Medicine, William Beaumont Hospital, Royal Oak, MI 48073, USA.
authors.forename: T L
authors.initials: TL
authors.lastname: Schreiber
authors.forename: A
authors.initials: A
authors.lastname: Elkhatib
authors.forename: C L
authors.initials: CL
authors.lastname: Grines
authors.forename: W W
authors.initials: WW
authors.lastname: O'Neill
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000175:diagnosis / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D002309:Cardiology / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003953:Diagnosis-Related Groups; D005260:Female; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data; D006764:Hospitals, Community / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007388:Internal Medicine / Q000191:economics / Q000592:standards* / Q000706:statistics & numerical data; D008297:Male; D008824:Michigan / Q000453:epidemiology; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012189:Retrospective Studies