December 6, 1996

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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, M.D., Ph.D., director, Center for Clinical Evaluation Sciences, Emory University School of Medicine, and others in the November's issue of Stroke.

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 if 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 (death) 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 therefore could better individualize treatment plans.

"...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, M.D., 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..."

Dr. 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."

Dr. Ballard (second author) co-authored the medical outcomes study with Janet B. Mitchell, Ph.D., (first author) and Carol J. Ammering of Health Economics Research, Inc., Waltham, Mass.; Jack P. Whisnant, M.D., Department of Health Sciences Research, The Mayo Clinic; Gregory P. Samsa, Ph.D., 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, M.D., principal investigator of the Stroke PORT and director of Duke's Center for Health Policy Research and Education.

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Copyright ©Emory University, 1996. All Rights Reserved.
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