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Primary Errors

Reducing access to medical specialists will worsen American health care.

12:00 AM, Sep 9, 2009 • By STANLEY GOLDFARB
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Recent studies of the effectiveness of primary care based approaches to the management of more common illnesses suggests that even in our current system, limited access to specialty care has important negative consequences. Patients with an acute myocardial infarction were studied in 2004 at two hospitals in Norwich, England where guidelines dictated a set approach to care as determined by the National Health Service. While these guidelines included the rule that patients who suffered the heart attack would be seen by a cardiologist during their hospitalization, one group of nearly 300 patients did see the cardiologist but another quite similar group of patients never saw a cardiologist and were cared for by a primary care physician. Over the ensuing 18 months, the mortality rate was 75 percent higher in the group that did not see the specialist. The increased mortality was attributable to the failure of the primary care physicians to adhere to prescribing medications known to be effective in preventing late death after myocardial infarction. A similar set of observations have been made in the U.S.

Perhaps myocardial infarction care is too intense an example. Yet studies of the management of hypertension, a condition certainly highly familiar to primary care physicians, reveal a frustratingly similar set of results. In an assessment carried out by investigators at Johns Hopkins University School of Medicine in 2008, primary care doctors failed to increase antihypertensive medications when clearly indicated in 87 percent of over 1300 patient visits where a substantial increase in previous blood pressure levels were found.

How about management of well recognized risk factors for cardiac disease? After all, much more robust preventative medicine is one goal of health care reform. By using a standard case vignette and querying family physicians and general internists about how they would treat a patient with well-defined cardiovascular risk factors, researchers at the University of California at San Francisco found that two thirds of primary care physicians inappropriately would choose to prescribe low dose aspirin to patients who, according to standard guidelines, should not have been treated in this manner. Additionally, 40 percent did not follow a recommended guideline for lowering cholesterol level.

Other research shows similar deficiencies. In a study of the appropriate referral for colonoscopy in patients found to have blood in their stool after screening tests, 31 percent of the time, patients were not appropriately referred for the procedure in a study conducted at the University of Pennsylvania School of Medicine and Thomas Jefferson University.

Perhaps the most discouraging finding in my own field of nephrology is the failure to appropriately refer patients with advanced kidney disease to a specialist. It has been clearly shown that primary care physicians typically refer patients with advanced kidney disease to nephrologists less than 6 months before the need for dialysis or kidney transplantation leading to increased mortality rates. Researchers at Bay State Medical Center and Tufts University School of Medicine have found that 62 percent of patients with moderately severe kidney disease were not recognized to have kidney disease by primary care physicians and were therefore not receiving specialist referrals or the medications that might slow the progression of their kidney disease.

Many individual primary care physicians are highly capable and knowledgeable and can provide high quality preventive care. As a group, however, they apparently do not achieve those goals. In truth, they really cannot be expected to given the growth in new information in each field of medicine. They must rely on specialists to support them and to achieve the highest quality care. To rely on guideline-driven, primary care to solve the problems of the high cost of medical care is an example of the triumph of hope over reality.