Cardiology, for what it’s worth . David E. Kandzari, MD, and James G. JoUis, MD Durham, NC

See related article on page 491.

Both the American Heart Journal and the specialist/gen- eralist debate share the same origins. This Journal was founded in 1925 to support the newly formed organiza- tion of “heart specialists,” the American Heart Association. Two decades earlier, pioneers such as Louis Bishop, Albion Hewlett, and Paul Dudley White had imported the concept of heart specialists from clinics in Germany and England. Given the prevalence of heart disease, the availability of specialized equipment such as Einthoven’s electrocardiograph, and concentrated populations in urban areas such as New York, the specialty flourished. At the time, physicians were able to distinguish them- selves as cardiologists by merely performing electrocar- diography, sphygmomanometry, or chest fluoroscopy. With the success of cardiology, the tension between heart specialists and internists also grew regarding who would preside over patients with heart disease. Dr. White’s view was that patients with heart disease should be readily triaged to cardiology: “It is my belief that eventually the practice of medicine will be taken care of by general practitioners on the front line, better trained, to be sure, than in the past and with the special ability to direct their problems straight to specialists in all fields, and by the specialists of all varieties, rather than through middle men of general surgery and inter- nal medicine.“*

By 194 1, under the direction of internal medicine’s American College of Physicians and the American Medical Association, cardiology was formally designated a sub specialty of internal medicine rather than a separate entity. The newly formed American Board of Internal Medicine administered the first “certification exam” in cardiology. Soon after the first exam, training and com- petence in internal medicine became a requisite for car- diology certification. The need for this requirement was not obvious to all parties because many prominent car- diologists of the day had never formally trained in inter- nal medicine.

Regardless of the link to internal medicine, cardiologists and their procedures continued to flourish. The debate over who should direct the care of cardiology patients has gamed new intensity in the era of costcontainment.

From Duke Clinical Research Institute. Reprint requests: James G. Jollis, MD, Duke Cl micol Research Institute, Box 17949, Durham, NC 277 15. Am Heart J 2000; 139:392-3. 0002.8703/2000/$12.00 + 0 4/4/104239

Managed care organizations and others have noted that patients cared for by cardiologists are much more likely to undergo procedures.* With the implicit assumption that placing cardiology patients under the care of gen- eralists rather than cardiologists will result in fewer procedures and lower costs, capitated insurance systems often mandate oversight by primary care physicians. This major shift in the control of patients with heart disease directly challenges the notion of the value of medical specialization.

With the shift in control, it has become incumbent among cardiologists to demonstrate their value. More precisely, does “procedure-intensive” care lead to improved outcomes for patients with heart disease? Philbin et al3 have examined this issue among patients with heart failure in 2 recent studies,3,4 one of which is reported in this issue of the Journal. Using a New York state database of patients admitted for congestive heart failure, these investigators compared illness severity, process of care, and short-term clinical outcomes according to physician specialty. Of the nearly 45,000 patients admitted for heart failure, patients attended by cardiologists accounted for less than one fourth of the study population. Cardiology patients were 3 times more likely to undergo diagnostic catheterization or coronary revascularization, confirming a reliance on procedures established in other studies. Contrary to the assumptions that motivate generalist oversight, however, the greater procedure use was not associated with significantly greater expense compared with internal medicine, as measured by adjusted hospital costs. Lacking detailed clinical information on the issues of whether patients of cardiologists felt better or lived longer could not be addressed by the state claims data.

In a related study involving 2454 patients with heart failure in 10 New York community hospitals, Philbin et al* examined process of care over a Gmonth period according to chart review and telephone survey. Patients treated by cardiologists (attending physician or cardiology consult) were more Likely to be treated with angiotensin- converting enzyme inhibitors when indicated. Similar to the claims study, more detailed data also demonstrated that cardiology patients were younger, less likely to reside in nursing homes, and more likely to be male and involve elective admissions. These favorable differences, commonly seen in studies of specialty care, somewhat confound outcome comparisons. Keeping the potential for confounding in mind, regression models did not identify any significant differences in mortality rate or rehospitalization, other than fewer congestive heart

American Heart Journal Volume 139, Number 3

failure readmissions for the subgroup of “cardiology consult” patients.

Reasons exactly why cardiologists might fare better in the management of patients with cardiovascular disease have been offered, but it seems intuitive that improved outcomes would follow greater experience and exper- tise. Better familiarity with the diagnosis and management of cardiac illness is expected with specialists’ more nar- rowed clinical focus.s,6 This may be of particular impor- tance in the current, more complicated era of heart fail- ure management. Although an angiotensin-converting enzyme inhibitor and digoxin alone seemed appropriate 10 years ago, the addition of pblockade, spironolactone, and possibly implantable defibrillators may now offer improved clinical outcomes. To further complicate the issue of “polytherapy,” physicians treating patients with heart failure also need to recognize and treat potential adverse side effects such as worsening heart failure, renal dysfunction, or hyperkalemia.

The countervailing view that primary care physicians should direct the care of cardiology patients has more support than simple cost minimization. Patients with heart disease commonly have other illnesses, including diabetes and cerebrovascular disease, that may be better treated by generalists. Also, there are other generalist- based strategies to improving heart disease outcomes, including the dissemination of guidelines and more intensive primary care follow-up. This latter strategy, tested in a randomized fashion by the Veterans Admin- istration system resulted in greater patient satisfaction, albeit at a cost of more hospitalizations.7 Finally, the partition of care for individual illnesses requires patients to see more physicians at the potential cost of losing the valued patient-physician relationship. Taking a disease-oriented over patient-oriented approach to the delivery of care may also impart greater responsibility on the patient’s behalf to coordinate their care-keeping up with medication changes, informing each specialist of changes in treatment plans, and in some cases, even knowing which specialist is responsible for which med- ical problem.*

Another specialty that flourished during the time of the Journal’s founding involved tuberculosis. With the advent of effective antibiotics to treat Mycobacferium bacillus and the resolution of the epidemic, the value of tuberculosis specialists was greatly diminished. Thus tuberculosis physicians adapted, broadening their focus to include other pulmonary diseases and chest surgery. As heart disease continues to be prevalent among aging Western populations, heart specialists are not likely to face a similar fate in the near future. However, continued success will hinge largely on our ability to demonstrate

Kondzari and Jollis 393

value. This value will be measured by at least 3 criteria: (1) studies demonstrating improved outcomes, particu- larly in the setting of greater resource use; (2) the ability to adjust practice in response to the reversal in economic incentives for procedures; and (3) the preferences expressed by patients regarding the involvement of specialists in their care.

Because the value of specialty care is less likely to be studied in a randomized fashion, we will continue to rely on such observational studies to guide the process of care and importance of specialty care. Particularly as general physicians become more experienced, educated, and comfortable with heart failure management, the burden will remain on cardiologists to demonstrate routinely their benefit from the perspective of both economic and clinical outcomes. Cardiologists must continue to ensure treatment with therapies of proven efficacy, facilitate patient access to care, and share their experience in the creation of guidelines to advance standards of care. Still, although published guidelines offer the science of recommended treatment, they cannot substitute for the “art” of medicine or familiarity and experience reflected in real practice. If studies of the art and science of cardiology can document better outcomes, then heart disease specialists and their journals will continue to succeed.

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