The comparison of outcomes among generalists and specialist remains a matter of considerable and sometime acrimonious debate. A number of recent studies, usually using intermediate outcomes, have resulted in differing conclusions as to who provides the “best” care. Confounding factors, including referral biases, shared care, and illness burden remain methodological challenges and both groups continue to argue the point.^1,2 Methodological shortcomings aside, the paper in this issue by McAlister et al³(see page 6) is novel in that it uses all-cause mortality for patients with new onset diabetes as a criterion by which to compare specialists and generalists. All-cause mortality is perhaps the ultimate summary outcome, and one that has previously been proposed as a quality measure for assessing quality of outpatient care for systems of care.⁴ The provocative finding of the current study is that specialist care is associated with a survival disadvantage. This survival disadvantage occurred despite the seemingly better performance of specialists in process measures of diabetes quality such as use of statins, antiplatelet agents, and ACE inhibitors, and was robust across several sets of analyses.


 The provocative finding of the current study is that specialist care was associated with a survival disadvantage

In the era of public reporting and pay for performance in the UK and US, this paper raises a number of issues for how and whether to assess quality measurement among different clinical groups, using diabetes as the example. First, sample size limitations would preclude the use of mortality comparisons at the individual physician and probably at the system level as well. Furthermore, it is clear from both the current manuscript and prior work that even system level comparisons require high quality …