PubMed · 6897628
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K P Birman, G Joskowicz. 1982. A system for clinical data-base applications.. https://doi.org/10.1016/0010-4809(82)90019-2
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Pressure to lower the cost of health care delivery has fostered widespread efforts to limit patients' access to specialists such as cardiologists. However, there is concern that diminished specialist involvement may lead to poorer patient outcomes for specific clinical conditions. As part of a state-sponsored effort to improve the quality of health care in Pennsylvania, the Pennsylvania Health Care Cost Containment Council gathered clinical and administrative data on all 40,684 hospital admissions for acute myocardial infarction (AMI) in that state in 1993. They prepared a detailed public report that included risk-adjusted in-hospital mortality and length of hospital stay by physician group, by hospital and by region. These data demonstrate that patients cared for by cardiologists, as a group, had a lower risk-adjusted mortality than patients cared for by either internists (risk ratio 1.26, 95% confidence interval 1.17 to 1.35) or family practitioners (risk ratio 1.29, 95% confidence interval 1.18 to 1.40). The patients of cardiologists also had a shorter length of stay than the other two groups. These data suggest that there is enhanced value in the care provided by cardiologists for patients with AMI and call into question the growing trend toward reliance on generalists instead of specialists.
Our objective was to review the available evidence of the precision and accuracy of the clinical examination for abnormal systolic murmurs. We conducted a MEDLINE search, manually reviewed all reference lists, and contacted authors of published studies. Each study was independently reviewed by 2 observers and graded for methodologic quality. We found that most studies were conducted using cardiologist examiners. In the clinical setting, the reliability of detecting systolic murmurs was fair (kappa, 0.30-0.48). The most useful findings for ruling in aortic stenosis are a slow rate of rise of the carotid pulse (positive likelihood ratio, 2.8-130), mid to late peak intensity of the murmur (positive likelihood ratio, 8.0-101), and decreased intensity of the second heart sound (positive likelihood ratio, 3.1-50). The most useful finding for ruling out aortic stenosis is the absence of murmur radiation to the right carotid artery (negative likelihood ratio, 0.05-0.10). Smaller, lower-quality studies indicate that cardiologists can accurately rule in and rule out mitral regurgitation, tricuspid regurgitation, hypertrophic cardiomyopathy, and echocardiographic mitral valve prolapse. We conclude that the clinical examination by cardiologists is accurate for detecting various causes of abnormal systolic murmurs. Studies of the clinical examination by noncardiologists are needed.
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