Rostrum

Specialty differences in the treatment of asthma

Through the early twentieth century, asthmatics were advised to move to a more suitable climate, or to vacation in one during their worst season. In the late nineteenth century, physicians sought to quantify the ideal temperature, humidity, altitude, and pollen count to help travellers to select a suitable place, but these investigations led some physicians to question contradictions between expected and actual conditions. Given that even the best climate was not perfect at all times, and that many patients could not afford to travel or relocate, a group of physicians—who came to be known as allergists—sought ways to adapt their patients to any climate through changes in their indoor environments and treatments to manage their symptoms. Their approach included changes in household design, furnishings, and cleaning techniques, especially a strict avoidance of dust, which could carry feathers, animal hair, skin debris, pollen, moulds, and an unknown ‘dust’ allergen. Air filtering and air conditioning were also promoted as ways to protect asthmatics and hay fever sufferers. These modifications of patients and their microenvironments signalled both a move away from climactic approaches to asthma and toward the sanitary, modernist home of the twentieth century.

Background: The interrelationships between optimal inhaled corticosteroid (IC) therapy, allergy specialist care, and reduced emergency hospital care for asthma have not been well defined. Objective: We sought to evaluate the independent effectiveness of various levels of IC dispensing and allergy specialist care in reducing subsequent emergency asthma hospital use. Methods: Asthmatic patients (n = 9608) aged 3 to 64 years were identified from an electronic database of a large health maintenance organization. The outcome was any year 2000 asthma hospitalization or emergency department visit. The main predictors were at least one allergy department visit and the number of IC canisters dispensed in 1999. Analyses were adjusted for age, sex, insurance type, and asthma severity (1999 emergency asthma hospital use, β-agonist use, and oral corticosteroid use). Results: Dispensing of 7 or more canisters of ICs (odds ratio [OR], 0.64; 95% CI, 0.43-0.94) and allergy care (OR, 0.73; 95% CI, 0.55-0.97) were associated with reduced subsequent emergency asthma hospital use. More patients with allergy specialist care than those without such care received 7 or more dispensations of ICs (24.7% vs 8.3%, P < .001). When 7 or more dispensations of ICs and allergy specialist care were simultaneously included in an adjusted model, both ICs (OR, 0.68; 95% CI, 0.46-1.00) and allergy care (OR, 0.77; 95% CI, 0.58-1.02) were independently associated with a lower risk of year 2000 emergency asthma hospital care, although significance was borderline. Conclusion: Allergy care reduces emergency hospital use for asthma by increasing use of ICs but probably also has an independent effect. (J Allergy Clin Immunol 2003;111:503-8.)

In this era of cost containment, gastroenterologists must demonstrate that they provide effective and efficient care. The aim of this study was to evaluate the process and outcomes of care provided by gastroenterologists and generalist physicians (internists, family physicians, general surgeons) for GI conditions.

We conducted a systematic literature review using a MEDLINE search of English language articles (January 1980 to September 1998). A total of 2157 articles were identified; 10 met inclusion criteria for systematic review. In addition, there were nine articles that described the results of physician surveys, and examined the process of care among gastroenterologists and generalist physicians.

Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. There was no difference between gastroenterologists and generalists in terms of colonoscopy procedure time, and family physicians detected a greater number of cancers. Furthermore, there was no difference in the outcomes of gastroesophageal reflux disease therapy in patients seen by gastroenterologists, versus those educated by nurses. The survey articles suggested that gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists.

We reached the following conclusions: 1) The results suggest that gastroenterologists deliver effective and efficient care for GI bleeding and diverticulitis and provide more effective diagnosis in certain disorders. 2) Studies are limited by retrospective design, small sample size, and lack of control groups. 3) To fully evaluate care by gastroenterologists, prospective comparisons with greater attention to methodology are needed.

Atopic disorders, which afflict millions of Americans and hundreds of millions worldwide, are at epidemic levels with concomitant increases in morbidity and mortality. Environmental and lifestyle changes over the past three to five decades are proposed causes for this pandemic and as such present major burdens to reverse. The scope of allergy practice bridges directly on this challenge. Allergy as a specialty is a major leader in developing effective strategies to confront this epidemic. Allergists have made major contributions to the understanding of the risk factors, immunology, pathophysiology, immunomodulation, and prevention of atopic and immunologic disorders. Allergist epidemiologists and clinicians have helped develop and implement national and international guidelines in the recognition, management, and prevention of asthma and rhinitis. Allergist clinical researchers are active in (1) outcomes research that demonstrates convincingly the value of allergy as a specialty in asthma, allergic rhinitis, anaphylaxis, drug and food allergy, and other atopic disorders, (2) National Institutes of Health clinical trials that will form the basis for the future treatment of asthma and allergic disease, and (3) pharmaceutical trials that evaluate new, effective, and safe medication to treat atopic disease. Allergist educators, comprising academic and practicing allergists, supported by allied health professionals, national associations, and affiliated lay organizations, provide comprehensive education to fellows, residents, colleague physicians, media, the public, and patients. Documentation of the value of allergists in improving patient-centered and societal outcomes in their core domain, allergy, is the appropriate final topic contribution in the important series “New millennium: The conquest of allergy.” (J Allergy Clin Immunol 2000;106:995-1018.)

PURPOSE: Previous studies have suggested that specialists may achieve better clinical outcomes for patients, albeit often at greater cost. We sought to compare outcomes of care and resource utilization among patients with shoulder or knee problems who were treated by general internists, rheumatologists, and orthopedic surgeons.

SUBJECTS AND METHODS: Outpatients with knee or shoulder complaints who were seen by general internists, rheumatologists, or orthopedic surgeons at an academic medical center were administered questionnaires at enrollment in the study and again 3 months later. The questionnaires included validated measures of satisfaction, functional status, and pain severity, as well as resource utilization. We compared baseline clinical characteristics, satisfaction with care, resource utilization, and changes in function and symptoms during 3 months of follow-up among patients who were cared for by the three different types of providers.

RESULTS: A total of 534 patients responded to the baseline survey and 436 (82%) to the 3-month follow-up survey. About 60% (n = 323) had knee pain. Orthopedists cared for 40% (n = 211) of the patients, with the remainder treated in approximately equal numbers by general internists or rheumatologists. At baseline, patients of internists had less severe pain (differences of 0.3 to 0.6 points on a 1 to 5 scale, P <0.05) and functional limitations (differences of 0.4 to 0.6 points on a 1 to 5 scale, P <0.0006) than patients of rheumatologists and orthopedic surgeons. Adjusting for baseline differences, there were no significant differences among provider groups in pain relief or functional improvement during follow-up. However, in adjusted analyses, patients with shoulder pain who were cared for by orthopedic surgeons were least satisfied with the office environment [adjusted mean (± SD) satisfaction score of 1.6 ± 0.8 on a 1 to 4 scale for orthopedic surgeons vs 1.3 ± 0.8 for rheumatologists and 1.4 ± 0.8 for internists, P = 0.004]. Among patients with knee pain, those treated by rheumatologists and orthopedic surgeons were more satisfied with the doctor–patient interaction (adjusted mean satisfaction scores of 1.1 ± 0.9 for rheumatologists and 1.2 ± 0.7 for orthopedic surgeons on a 1 to 4 scale vs 1.4 ± 0.8 for general internists, P = 0.003). Orthopedic surgeons obtained significantly more radiographs of the knee or shoulder and more magnetic resonance imaging scans of the knee. Rheumatologists performed significantly more aspirations or injection procedures. Among all patients, those treated by rheumatologists were most satisfied with the physician interaction, and those treated by orthopedic surgeons were most satisfied with treatment results.

CONCLUSION: The relative benefits of specialist compared with generalist care for patients with knee or shoulder pain depend on the importance attached to resource utilization, patient satisfaction, and health outcomes.