Specialist or generalist care? A study of the impact of a selective admitting policy for patients with cardiac failure

Context. The debate on the respective roles of medical specialists and generalists has tended to portray them as alternatives, rather than seeking ways to build on the complementary skills of these professional groups. Objective. We wished to evaluate the impact of a selective admitting policy that attempts to exploit the complementary, strengths of specialists and generalists. Design. Prospective cohort study of patients admitted to hospital with congestive heart failure. Setting. Public hospital in New South Wales, Australia. Patients. Subjects aged 60 years or more with congestive heart failure defined by the Framingham criteria (see Appendix). Intervention. A selective admission policy which referred patients with identifiable single system disorders to the relevant subspecialist, while patients with multiple medical problems were admitted under a general physician. Main outcome measures. Length of hospital stay, survival, quality, of life and satisfaction with care. Results. Two-hundred and seventy-five patients with congestive heart failure were followed up from admission to 1 year after discharge from hospital. Of these, 102 were cared for by cardiologists and 154 by generalists. The patients under the generalists were older, had greater co-morbidity but appeared to have less severe cardiac disease than those cared for by cardiologists. The use of cardiac drugs and investigations was similar in the two groups. The generalists' patients had a longer length of hospital stay, but the cardiologists' patients had a higher mortality during the early follow-up period. There were no differences in levels of satisfaction with care or in health-related quality of life between the two groups of patients. Multivariate analysis suggested that any differences in outcomes between the two groups of patients were due to the severity of underlying disease, and co-morbidity, rather than the quality of care that was provided by the physicians. Conclusions. It is possible to implement a hospital admission policy that selectively refers patients with congestive heart failure to specialists or generalists, according to the presence of co-morbid conditions, without adversely affecting the outcomes of care. Such a policy should represent optimum use of the complementary skills of these professional groups.