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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

Daniel H. Solomon, MD; David W. Bates, MD, MS; Richard S. Panush, MD; and Jeffrey N. Katz, MD, MS
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From Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts; and Saint Barnabas Medical Center, University of Medicine and Dentistry of New Jersey, and New Jersey Medical School, Livingston, New Jersey. Acknowledgments: The authors thank Drs. John Z. Ayanian and Neil A. Solomon for their insightful comments on earlier drafts of this manuscript and Matthew Liang, MD, MPH, for valuable feedback and encouragement. Grant Support: In part by a grant from the American Academy of Orthopedic Surgeons, grant AR36308 from the National Institutes of Health, a Physician Scientist Development Award (Dr. Solomon), and an Arthritis Foundation Clinical Science Award (Dr. Katz). Requests for Reprints: Jeffrey N. Katz, MD, MS, Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Division of Rheumatology and Immunology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Current Author Addresses: Drs. Solomon and Katz: Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Division of Rheumatology and Immunology, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02115. Dr. Bates: Division of General Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115. Dr. Panush: Department of Medicine, Saint Barnabas Medical Center, Old Short Hills Road, Livingston, NJ 07039.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;127(1):52-60. doi:10.7326/0003-4819-127-1-199707010-00009
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Purpose: To compare the outcomes of care provided by generalists with that provided by specialists for patients with musculoskeletal and rheumatic conditions.

Data Sources: English-language studies published between 1966 and April 1996 were identified through a MEDLINE search.

Study Selection: Studies that compared generalists' and specialists' treatment preferences, appropriateness of care, or outcomes with regard to musculoskeletal and rheumatic conditions were examined.

Data Extraction: Studies were reviewed for methodologic rigor and outcomes.

Data Synthesis: Low back pain is treated by many types of providers, without consistent differences in outcomes across provider types. In one study, however, patients were more satisfied with chiropractic care than with care provided by primary care physicians, although the former cost twice as much as the latter. For osteoarthritis of the hip, rheumatologists and primary care providers reported using different therapeutic regimens. For acute mono- and oligoarthritis, rheumatologists performed arthrocentesis more appropriately than nonrheumatologists and produced shorter durations of hospitalization. In the management of gout, rheumatologists used colchicine during the introduction of urate-lowering therapy more appropriately than other providers. In two population-based cohorts of patients with rheumatoid arthritis, patients cared for by rheumatologists were prescribed significantly more disease-modifying agents and had less disability than patients cared for by generalists.

Conclusions: Although empirical data are scant, there seem to be differences between generalists and specialists for a range of outcomes in various musculoskeletal and rheumatic conditions. Studies to date have important methodologic limitations that need to be addressed in future research.

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