The recent review by Donohoe1 on specialist and generalist care omitted important data focusing on the treatment of adults with asthma. Taken together, these studies suggest that asthma specialists provide superior asthma care, both in terms of process and outcome measures. A recent cross-sectional study2 from a large health maintenance organization found that most patients with moderate to severe asthma treated by allergists received inhaled anti-inflammatory therapy (92%), compared with less than half of patients treated by generalists (42%). Even though the allergists treated patients with greater asthma severity, their patients had significantly better measures of generic health status (SF-36), especially physical functioning and general health. Since all patients were members of the same health maintenance organization, these differences cannot be explained by differences in health care access. Furthermore, studies of adults with severe asthma as indicated by high previous health care utilization for asthma, have demonstrated improved outcomes with specialty care. In particular, Mayo and colleagues3 randomized patients with multiple prior hospitalizations for asthma to chest clinic specialty care vs routine outpatient care. Over prospective follow-up, patients treated in the chest clinic had 3 times fewer hospitalizations than those receiving routine, generalist care. As a result, the estimated overall cost of care for patients in the chest clinic was less than half that of those receiving routine care. Similarly, another study4 assigned health maintenance organization enrollees who received emergency department care for asthma to allergist vs routine care in a consecutive-day design approaching randomness. Facilitated allergist referral was associated with a 3-time higher use of inhaled anti-inflammatory therapy and a substantial reduction (42%) in the odds of subsequent emergency department visits for asthma over 6 months' follow-up. Overall, allergy and pulmonary specialists appear to treat patients with asthma more appropriately and achieve superior outcomes, both in terms of health care utilization and health status.
Eisner MD. Impact of Asthma Specialists on Patient Outcomes. Arch Intern Med. 1999;159(2):196-197. doi: