UNSTABLE ANGINA - SPECIALTY-RELATED DISPARITIES IN IMPLEMENTATION OF PRACTICE GUIDELINES

Background: The Agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care of patie nts with unstable angina. Prior to publication, studies demonstrated t hat when compared with cardiologists, internists were less likely to u se effective pharmacologic therapies or revascularization in patients with unstable angina. Hypothesis: The study was undertaken to determin e whether the AHCPR guideline publication abolished specialty-related disparities in care. Methods: We performed a chart review of consecuti ve patients hospitalized at a university-affiliate institution with an admission diagnosis of chest pain in the absence of myocardial infarc tion and a noncardiac etiology. Treatment and diagnostic cardiac testi ng were compared between risk-stratified patients cared for by a gener alist (n = 125) and those whose care was guided by a cardiologist (n = 211). Results: In those with low-risk unstable angina, generalists we re less likely to prescribe recommended aspirin (71 vs. 88%, p < 0.01) and beta blockers (9 vs. 37%, p < 0.001), and heparin (20 vs. 49%, p < 0.001), and to perform a recommended diagnostic stress test or cardi ac catheterization (28 vs. 60%, p < 0.001). In those with at least int ermediate risk, generalists were less likely to prescribe beta blocker s (19 vs. 52%, p < 0.001), heparin (19 vs. 66%, p < 0.001), and nitrat es (77 vs. 96%, p < 0.001), and to refer for diagnostic testing (19 vs . 65%, p < 0.001). Generalists' care was associated with significantly lower hospital charges. Conclusions: AHCPR guidelines for the evaluat ion and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studi es are necessary to evaluate the barriers to implementation of the AHC PR guidelines.