Gastroenterologist specialist care and care provided by generalists--an evaluation of effectiveness and efficiency.

OBJECTIVE: In this era of cost containment, gastroenterologists must demonstrate that they provide effective and efficient care. The aim of this study was to evaluate the process and outcomes of care provided by gastroenterologists and generalist physicians (internists, family physicians, general surgeons) for GI conditions. METHODS: We conducted a systematic literature review using a MEDLINE search of English language articles (January 1980 to September 1998). A total of 2157 articles were identified; 10 met inclusion criteria for systematic review. In addition, there were nine articles that described the results of physician surveys, and examined the process of care among gastroenterologists and generalist physicians. RESULTS: Care provided by gastroenterologists for GI bleeding and diverticulitis resulted in significantly shorter length of hospital stay. Gastroenterologists diagnosed celiac disease more accurately than generalists, and more adequately diagnosed colorectal cancer and prescribed antimicrobials for peptic ulcer disease. There was no difference between gastroenterologists and generalists in terms of colonoscopy procedure time, and family physicians detected a greater number of cancers. Furthermore, there was no difference in the outcomes of gastroesophageal reflux disease therapy in patients seen by gastroenterologists, versus those educated by nurses. The survey articles suggested that gastroenterologists were more likely to test and treat for Helicobacter pylori in patients with peptic ulcer disease, and were more likely recommended for medical versus surgical therapy. Gastroenterologists had a lower threshold for ordering ERCP before cholecystectomy than surgeons, but had similar responses regarding indications for surgery in inflammatory bowel disease. Finally, primary care physicians were less likely to associate symptoms of profuse watery diarrhea with cryptosporidium infection compared with gastroenterologists and infectious disease specialists. CONCLUSIONS: We reached the following conclusions: 1) The results suggest that gastroenterologists deliver effective and efficient care for GI bleeding and diverticulitis and provide more effective diagnosis in certain disorders. 2) Studies are limited by retrospective design, small sample size, and lack of control groups. 3) To fully evaluate care by gastroenterologists, prospective comparisons with greater attention to methodology are needed.

Duke Scholars

Author Douglas Charles McCrory Medicine, General Internal Medicine