Focus on Primary Care Detrimental

A Harvard study released Thursday suggests that the increasing national focus on primary health care may be disastrous for patients requiring specialized treatment.

Primary care physicians are two to three times less likely than cardiologists to prescribe certain life-saving drugs for heart attacks, according to a Medical School study published in this week's New England Journal of Medicine.

This alarming discrepancy between the way in which general practicioners and specialists treat heart attacks could have important consequences for victims of this country's leading source of death.

The study found that general practitioners are less likely to prescribe helpful drugs for heart attacks and more likely to prescribe useless and potentially harmful drugs than specialists.

For example, the researchers found that beta-blockers, which have been shown to increase survival of heart attack victims, are likely to be prescribed by 78 percent of cardiologists but only by 53 percent of family practitioners.

"Generalists were less confident or certain of both the positive and negative effects of the various treatments," said study co-author Dr. Paul Hauptman of Brigham and Women's Hospital. "Specialists may be delivering the more up-to-date care and be more aware of the true risks and benefits."

The results of the study suggest that the country's increasing dependence on managed care may dangerously restrict patient access to specialized care, said Dr. Elliott M. Antman, associate professor at the Medical School and head of the coronary unit at Brigham and Women's Hospital.

"The paper raises a red flag and says we must be careful not to limit access to specialists," Antman said.

Researchers surveyed 1211 cardiologists, internists and family practitioners in the states of New York and Texas about their tendency to prescribe five common heart attack drugs, including aspirin, lidocaine and thrombolytic agents which dissolve blood clots.

The discrepancy in prescribing practices may arise because "cardiologists spend 100 percent of their time looking at hearts," while general practitioners must acquaint themselves with a wide variety of medical concerns, said Chris L. Pashos, project director of the Patient Outcome Research Team which conducted the study.

"To ask [family practitioners] to be up to date is a big challenge," said Dr. Barbara J. McNeil, a co-author of the study and founder of the Medical School's Department of Health Care Policy.

To shrink the knowledge gap between specialists and generalists, the paper suggests continuing education programs, broader dissemination of guidelines and more rigorous recertification processes for general practitioners.

Antman said yesterday that there is "clearly a need to improve education and information transfer" between specialists and general practitioners, particularly in light of the "current health care reform initiative putting much more emphasis on the primary care physician."

The authors advise that those in danger of suffering a heart attack should make sure to see either a cardiologist directly or a primary care physician in consultation with a cardiologist.