COSTS, OUTCOMES, AND PATIENT SATISFACTION BY PROVIDER TYPE FOR PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL CONDITIONS - A CRITICAL-REVIEW OF THE LITERATURE AND PROPOSED METHODOLOGIC STANDARDS

Purpose: To compare the outcomes of care provided by generalists with that provided by specialists for patients with musculoskeletal and rhe umatic conditions. Data Sources: English-language studies published be tween 1966 and April 1996 were identified through a MEDLINE search. St udy Selection: Studies that compared generalists' and specialists' tre atment preferences, appropriateness of care, or outcomes with regard t o musculoskeletal and rheumatic conditions were examined. Data Extract ion: Studies were reviewed for methodologic rigor and outcomes. Data S ynthesis: Low back pain is treated by many types of providers, without consistent differences in outcomes across provider types. In one stud y, however, patients were more satisfied with chiropractic care than w ith care provided by primary care physicians, although the former cost twice as much as the latter. For osteoarthritis of the hip, rheumatol ogists and primary care providers reported using different therapeutic regimens. For acute mono- and oligoarthritis, rheumatologists perform ed arthrocentesis more appropriately than nonrheumatologists and produ ced shorter durations of hospitalization. In the management of gout, r heumatologists used colchicine during the introduction of urate-loweri ng therapy more appropriately than other providers. In two population- based cohorts of patients with rheumatoid arthritis, patients cared fo r by rheumatologists were prescribed significantly more disease-modify ing agents and had less disability than patients cared for by generali sts. Conclusions: Although empirical data are scant, there seem to be differences between generalists and specialists for a range of outcome s in various musculoskeletal and rheumatic conditions. Studies to date have important methodologic limitations that need to be addressed in future research.