Stroke patients fare better
Stroke patients, as a group, have better outcomes when neurologists participate
in their care than when their care is limited to non-neurologist physicians
such as internists, family practitioners and cardiologists, reported David
J. Ballard, director, Center for Clinical Evaluation Sciences, School of
Medicine, and others in the November issue of Stroke.
when treated by neurologists
The researchers studied claims data of 20 percent of the country's Medicare
recipients 65 years and older (more than 38,000 persons) treated for a certain
type of stroke during the first nine months of 1991. The patients each had
experienced cerebral infarction, a type of stroke associated with blocked
arteries in the brain.
The researchers sought to determine whether current managed care trends
to increase treatment by primary care providers and decrease intervention
by more costly specialists would affect the outcome of stroke treatment.
Outcomes evaluated by the group included death within three months after
stroke or the patient's destination at discharge (specialized rehabilitation
facility, skilled nursing facility or home).
"Neurologists treating stroke patients were significantly more expensive
than other physicians but obtained better outcomes," the authors reported.
"Ninety-day mortality rates for patients treated by neurologists were
significantly lower than those for other specialists (approximately
16 percent of patients treated by neurologists died within three months,
compared to about 19 percent cared for by neurologist/primary care physician
teams, 23 percent cared for by internists and 25 percent cared for by family
practitioners or other specialists). "Compared with other attending
physicians, neurologists were significantly more likely to order diagnostic
cerebrovascular tests (especially brain magnetic resonance imaging [MRI]
scans), more likely to prescribe warfarin (to prevent future strokes), and
more likely to discharge patients to inpatient rehabilitation facilities."
The researchers hypothesized that stroke patients treated by neurologists
fared better because certain patients were directed, or triaged, to neurologists
because of clinical characteristics not evident in the claims data and that
those characteristics were associated with better prognoses. The group also
posed the alternative hypothesis that neurologists, because of their specialized
training and greater use of high-technology tests, better characterized
the mechanism of each patient's stroke and therefore could better individualize
"Our primary focus should be on defining the optimum care for patients
with stroke, regardless of whether a neurologist or other physician is in
charge," said Steven P. Ringel of the Department of Neurology, University
of Colorado Health Sciences Center, in an accompanying editorial in Stroke.
"With this emphasis, critical appraisal of neurological diagnostic
and treatment choices will assist payers in accurately identifying cost-effective
management of stroke patients "
Ballard, professor of medicine and epidemiology, underscores the limitations
of claims-based analyses of physician performance. However, based on the
results from this national analysis of 38,612 Medicare beneficiaries, he
argues that "until more definitive data can be generated through a
prospective cohort study with a broader range of process and outcomes measures,
these results and other findings from the Stroke PORT (patient outcomes
research team) raise concerns about managed care arrangements that impede
the ability of patients with cerebrovascular disease to have neurologists
participate in their care."
Ballard co-authored the medical outcomes study with Janet B. Mitchell and
Carol J. Ammering of Health Economics Research Inc., Waltham, Mass.; Jack
P. Whisnant, Department of Health Sciences Research, The Mayo Clinic; Gregory
P. Samsa of the Center for Health Policy Research and Education, Duke University,
and Department of Veterans Affairs Center for Health Services Research in
Primary Care, Durham, N.C.; and David B. Matchar, principal investigator
of the Stroke PORT and director of Duke's Center for Health Policy Research
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