OUTCOMES OF PATIENTS WITH HYPERTENSION AND NON-INSULIN-DEPENDENT DIABETES-MELLITUS TREATED BY DIFFERENT SYSTEMS AND SPECIALTIES - RESULTS FROM THE MEDICAL OUTCOMES STUDY

Objective.-To compare the outcomes of patients with hypertension and n on-insulin-dependent diabetes mellitus (NIDDM) who were cared for in t hree different systems of care and by generalist and subspecialist phy sicians. Design.-An observational study with follow-up at three period s: (1) a 2-year study of 532 patients with hypertension and 170 patien ts with NIDDM who had entrance and exit histories, physical examinatio ns, and laboratory tests; (2) a 4-year follow-up of 1044 patients with hypertension and 317 patients with NIDDM based on patient-reported fu nctional status; and (3) 7-year mortality for 1296 patients with hyper tension and 424 patients with NIDDM. Setting and Participants.-Patient s sampled from health maintenance organizations, large multispecialty groups, and solo or single-specialty group practices in Boston, Mass, Los Angeles, Calif, and Chicago, III. Patients were designated as belo nging to one of three systems of care: fee for service; prepaid patien ts in solo or small single-specialty groups or in large multispecialty group practices, referred to as independent practice associations; an d staff-model health maintenance organizations. The principal provider s were family practitioners, general internists, cardiologists, or end ocrinologists. Main Outcome Measures.-Physiological, functional, and m ortality. For hypertension, we measured blood pressure and stroke inci dence. For NIDDM, we measured blood pressure, glycosylated hemoglobin level, visual function, vibration sense, ulcers and infections in the feet, and albumin excretion rate. Functional outcomes were assessed us ing the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36 ). Mortality was assessed for the 7 years following the entrance exami nation. Results.-We found no evidence that any one system of care or p hysician specialty achieved consistently better e-year or 4-year outco mes than others for patients with NIDDM or hypertension, Endocrinologi sts appeared to achieve better foot-ulcer and infection outcomes for p atients with NIDDM, particularly when compared with family practitione rs, However, no other specialist differences were found in any individ ual measures for either condition. Moreover, no adjusted mortality dif ferences among systems or among physician specialties were observed in the 7-year follow-up period. Conclusion.-No meaningful differences we re found in the mean health outcomes for patients with hypertension or NIDDM, whether they were treated by different care systems or by diff erent physician specialists. Although prepaid medicine relies more hea vily on generalist physicians than does fee for service, there is no e vidence from these analyses that the quality of care of moderately ill patients with these two common diseases was adversely affected, These findings must be viewed in light of the historically higher costs of fee-for-service medicine and of subspecialty physician practice.