I read with interest the article by Wu et al1 showing better outcomes when patients with asthma are managed by specialists rather than generalists. Although this may not come as a surprise to some, it should be of concern to all, not only in the United States but in other countries, such as the United Kingdom, where the majority of patients with asthma are managed by generalists. Studies from the United Kingdom have confirmed that inpatient care of patients with asthma is better when delivered by pulmonologists rather than by general physicians.2 A study has also demonstrated that management is better when pulmonologists treat their asthmatic patients on specialist respiratory wards rather than general medical wards, suggesting that some of the improved care from specialists is a result of the process of care such as provided by nurses experienced in the care of asthmatic patients.3 Similar evidence exists for patients with chronic obstructive pulmonary disease.4,5 This trend in care exists despite the publication of numerous treatment guidelines.6- 9 I agree with the authors that the study raises more questions than it answers. As asthma and chronic obstructive pulmonary disease are common diseases, we can conclude not only that a large number of patients are receiving suboptimal care but that steps need to be taken to ensure our patients' care is not compromised further. With continuing restriction of patient access to specialists, either through managed health care or lack of trained specialists as in the United Kingdom, there needs to be improved uptake of current guidelines. Guidelines to select patients with respiratory disease who are the most likely to gain added benefit from specialist care must also be implemented.
Packham S. Outcomes of Adults With Respiratory Disease Treated by Specialists and Generalists. Arch Intern Med. 2002;162(11):1310-1311. doi: