Subspecialisation in cardiology care and outcome: should clinical services be redesigned, again?

BACKGROUND: Inpatient management of cardiac patients by cardiologists results in reduced mortality and hospitalisation. With increasing subspecialisation of the field because of growing management complexity and use of technological innovations, the impact of sub-specialisation on patient outcomes is unclear. AIM: To investigate whether management by subspecialty cardiologists impacts the outcomes of patients with subspecialty-specific diseases. METHODS: All patients admitted to a tertiary centre over nine years with a diagnosis of heart failure, acute coronary syndrome (ACS) or primary arrhythmia were reviewed. The outcomes of these patients managed by cardiologists subspecialised in their admission diagnosis (heart failure specialists, interventionalists and electrophysiologists) were compared with those treated by general cardiologists. RESULTS: Heart failure was diagnosed in 1704 patients, ACS in 7763 and arrhythmia in 4398. There was no difference in length of stay (LOS) (P = 0.26), mortality (P = 0.57) or cardiovascular readmissions (P = 0.50) in heart failure patients treated by general cardiologists compared with subspecialists. In ACS patients, subspecialty management was associated with reduced LOS, cardiovascular readmissions and mortality (all P < 0.05). This reduction in mortality was seen mainly in lower risk patients (P < 0.05). There was a reduction in LOS and cardiovascular readmissions in arrhythmia patients receiving subspecialty management (both P < 0.05) but no difference in mortality (P = 0.14). ACS patients managed by interventionalists were more likely to undergo coronary intervention (P < 0.05). Electrophysiologists more frequently referred patients for catheter ablation and pacemaker implantation than general cardiologists (P < 0.05). CONCLUSIONS: The benefits of subspecialty care seem attributable to the appropriate selection of patients who would benefit from technological innovations in care. These results suggest that the development of healthcare systems which align cardiovascular disease with the subspecialist may be more effective.

Pattern of medical care services utilization in Fiji.

The present study was designed to analyze sociodemographic and health related factors that influence the utilization of medical care services in Fiji by using the method of discriminant function. Some sociodemographic and health related independent variables had significant effects on the two patterns of modern and traditional medical services utilization. Discriminant function coefficients for sex, age and race are large enough to suggest the importance of discriminating between two patterns of medical care utilization. This suggests that traditional medical service is coexistent with modern medicine in Fiji and might play an extremely important role in providing health care for rural communities in the same way as modern medicine.

Improved prognosis since 1969 of myocardial infarction treated in a coronary care unit: lack of relation with changes in severity.

OBJECTIVE: To study changes from 1969 to 1983 in the prognosis of patients with acute myocardial infarction treated in a coronary care unit. DESIGN: Mortality follow up of all patients with definite acute myocardial infarction. SETTING: The coronary care unit of the Royal Melbourne Hospital, a tertiary referral centre. SUBJECTS: 4253 Patients (3366 men, 887 women) admitted from 1969 to 1983. MAIN OUTCOME MEASURE: Mortality recorded at discharge from hospital and 12 months after admission. RESULTS: Details of clinical findings, history, electrocardiograms, arrhythmias, and radiological findings were recorded on admission. Mean ages were 63 for women and 57 for men, and women had haemodynamically more severe infarcts than men. In the later years patients were older and had less severe infarcts. Overall, hospital mortality in men was 16.7% in 1969-73 and 8.5% in 1979-83 and declined in all grades of the Norris and Killip infarct severity indices compared with a constant 19.2% in women. Even after adjustment for age and severity by logistic regression, hospital mortality fell in men by an average of 8% (95% confidence interval 4% to 11%) a year but remained constant in women. By 1983 male mortality was 60% that of women of similar age and comparable severity of infarction. Mortality of hospital survivors at 12 months declined by 7% (4% to 9%) a year in both sexes, even after adjustment for age and severity, with a male to female mortality ratio of about 0.8. New indices were derived to predict mortality in hospital and at 12 months. CONCLUSION: The observed declines in mortality cannot be explained by changes in severity of infarction or in prognostic characteristics of patients.