Unstable angina: specialty-related disparities in implementation of practice guidelines.
BACKGROUND
The agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care patients with unstable angina. Prior to publication, studies demonstrated that when compared with cardiologists, internists were less likely to use effective pharmacologic therapies or revascularization in patients with unstable angina.


OBJECTIVE
The study was undertaken to determine whether the AHCPR guideline publication abolished specialty-related disparities in care.


METHODS
We performed a chart review of consecutive patients hospitalized at a university-affiliated institution with an admission diagnosis of chest pain in the absence of myocardial infarction and a noncardiac etiology. Treatment and diagnostic cardiac testing were compared between risk-stratified patients cared for by a generalist (n = 125) and those whose care was guided by a cardiologist (n = 211).


RESULTS
In those with low-risk unstable angina, generalists were less likely to prescribe recommended aspirin (71 vs. 88%, p < 0.01) and beta blockers (9 vs. 37%, p < 0.001), and heparin (20 vs. 49%, p < 0.001), and to perform a recommended diagnostic stress test or cardiac catheterization (28 vs. 60%, p < 0.001). In those with at least intermediate risk, generalists were less likely to prescribe beta blockers (19 vs. 52%, p < 0.001), heparin (19 vs. 66%, p < 0.001), and nitrates (77 vs. 96%, p < 0.001), and to refer for diagnostic testing (19 vs. 65%, p < 0.001). Generalists' care was associated with significantly lower hospital charges.


CONCLUSIONS
AHCPR guidelines for the evaluation and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studies are necessary to evaluate the barriers to implementation of the AHCPR guidelines.
Reis
S E
SE
Department of Medicine, University of Pittsburgh, Pennsylvania, USA.
Holubkov
R
R
Zell
K A
KA
Edmundowicz
D
D
Shapiro
A H
AH
Feldman
A M
AM
D000368:Aged; D000789:Angina, Unstable / Q000175:diagnosis / Q000188:drug therapy*; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D002309:Cardiology / Q000592:standards; D005080:Exercise Test / Q000706:statistics & numerical data; D005194:Family Practice / Q000592:standards; D005260:Female; D006801:Humans; D007388:Internal Medicine / Q000592:standards; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012307:Risk Factors; D014481:United States; D016270:United States Agency for Healthcare Research and Quality