title: Trends and quality of care in outpatient visits to generalist and specialist physicians delivering primary care in the United States, 1997-2010.
abstract: BACKGROUND
  Although many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.
  
  
  OBJECTIVE
  To describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.
  
  
  METHODS
  Cross-sectional study and time trend analysis.
  
  
  METHODS
  Nationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010.
  
  
  METHODS
  Proportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.
  
  
  RESULTS
  Among 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p = 0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p < 0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p < 0.01), primarily for preventive care (54.0 %, p < 0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.
  
  
  CONCLUSIONS
  Medical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.
authors.affiliation: Section of General Internal Medicine, Veterans Affairs (VA) Boston Healthcare System, Boston, MA, USA.
authors.forename: Samuel T
authors.initials: ST
authors.lastname: Edwards
authors.forename: John N
authors.initials: JN
authors.lastname: Mafi
authors.forename: Bruce E
authors.initials: BE
authors.lastname: Landon
mesh_terms: D002908:Chronic Disease / Q000453:epidemiology / Q000628:therapy; D003430:Cross-Sectional Studies; D005260:Female; D058005:General Practitioners / Q000592:standards / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data / Q000639:trends; D010043:Outcome and Process Assessment, Health Care; D018802:Patient-Centered Care / Q000379:methods / Q000592:standards; D058007:Physicians, Primary Care / Q000145:classification; D010818:Practice Patterns, Physicians' / Q000639:trends*; D011320:Primary Health Care / Q000379:methods / Q000639:trends; D019984:Quality Indicators, Health Care; D013038:Specialization / Q000592:standards / Q000706:statistics & numerical data; D014481:United States; D000078329:Workforce