title: Do subspecialists working outside of their specialty provide less efficient and lower-quality care to hospitalized patients than do primary care physicians?
abstract: BACKGROUND
  Studies show that subspecialists can provide better quality care than primary care physicians when working within their subspecialty for patients with some medical conditions. However, many subspecialists care for patients outside of their chosen subspecialty. The present study compared the quality of care provided by subspecialists practicing outside of their specialty, general internists, and subspecialists practicing within their specialty.
  
  
  METHODS
  The severity-adjusted mortality rate and the severity-adjusted length of stay were used as indexes of quality of care. Data from 5112 hospital admissions (301 different physicians) for community-acquired pneumonia, acute myocardial infarction, congestive heart failure, or upper gastrointestinal hemorrhage at 6 hospitals in the greater Cleveland, Ohio, area were used in this study. The data were severity adjusted with the CHOICE Severity of Illness System.
  
  
  RESULTS
  Subspecialists working outside of their subspecialty cared for 25% of hospitalized patients. When comparing patients cared for by subspecialists practicing outside of their subspecialty, severity-adjusted lengths of stay were longer for patients with congestive heart failure (23% longer; 95% confidence interval [CI], 15%-32%), upper gastrointestinal hemorrhage (22% longer; 95% CI, 7%-39%), and community-acquired pneumonia (14% longer; 95% CI, 5%-24%) than for patients cared for by subspecialists practicing within their subspecialty. Patients also had a slightly higher hospital mortality rate when cared for by subspecialists practicing outside of their specialty than by subspecialists practicing within their subspecialty (mortality rate odds ratio, 1.46; P =.047). In addition, patients cared for by subspecialists practicing outside of their subspecialty had longer lengths of stay, and prolongations of stay were observed for patients with congestive heart failure (16% longer; 95% CI, 8%-26%), upper gastrointestinal hemorrhage (15% longer; 95% CI, 2%-30%), and community-acquired pneumonia (18% longer; 95% CI, 9%-28%) than patients cared for by general internists.
  
  
  CONCLUSIONS
  Subspecialists commonly care for patients outside of their subspecialty, despite the fact that their patients may have longer lengths of stay than those cared for by subspecialists practicing within their specialty or by general internists. In addition, such patients may have slightly higher mortality rates than those cared for by subspecialists practicing within their subspecialty.
authors.affiliation: Department of Health Services Research, Zynx Health, Inc, Cedars-Sinai Health System, 9100 Wilshire Blvd, Suite 655E, Beverly Hills, CA 90212, USA. weingarten@zynx.com
authors.forename: Scott R
authors.initials: SR
authors.lastname: Weingarten
authors.forename: Lynne
authors.initials: L
authors.lastname: Lloyd
authors.forename: Chiun-Fang
authors.initials: CF
authors.lastname: Chiou
authors.forename: Glenn D
authors.initials: GD
authors.lastname: Braunstein
mesh_terms: D000368:Aged; D017714:Community-Acquired Infections; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000628:therapy; D006333:Heart Failure / Q000628:therapy; D006801:Humans; D007388:Internal Medicine; D007902:Length of Stay; D008297:Male; D008511:Medicine; D008875:Middle Aged; D009203:Myocardial Infarction / Q000628:therapy; D009820:Ohio; D011014:Pneumonia / Q000628:therapy; D011787:Quality of Health Care; D012720:Severity of Illness Index; D013038:Specialization