DURHAM, N.C. -- Older people who suffer strokes appear to have a better chance of survival, with less disability, if they are cared for primarily by a neurologist rather than a medical generalist while in the hospital, according to a study of Medicare outcomes data.
The study, led by researchers at the Center for Health Policy Research and Evaluation (CHPRE) at Duke University Medical Center, found that disability and death from stroke are influenced by whether a neurologist or a non-specialist cares for the patient. Of the more than 350,000 people over age 65 who have strokes each year, about half are never seen by a neurologist, the researchers said.
The findings are reported in the November issue of the journal Stroke. This study was supported as part of a five-year project, the Stroke Patient Outcomes Research Team, funded by the federal Agency for Health Care Policy and Research. The study principal investigator is Dr. David Matchar of Duke.
"The findings are important in the context of changing patterns of care, in particular the growth of managed care," said Gregory Samsa, assistant professor, Center for Health Services Research, Rockville, Md., and project director of the study. "We need to know when redirecting patient care to generalists is both cost-effective and does not adversely affect patients. Our study indicates neurologists are a good value in the long run both for patients and the bottom-line."
The researchers found that:
- The risk of dying within 90 days after a stroke was one-third lower if a patient was cared for by a neurologist versus a generalist physician.
- One-fourth of patients cared for by generalists died within 90 days, versus 16 percent of patients cared for by neurologists.
- Patients cared for by neurologists were more likely to be discharged home or to a rehabilitation center.
- More of the patients cared for by generalists were discharged to a nursing home (40 percent versus 22 percent for neurologists).
- Neurologists ordered diagnostic tests more often than non-specialists, kept patients in the hospital longer, and may have prescribed anticoagulant drugs to prevent second strokes more frequently.
As a result, the cost of hospitalization was higher when a neurologist cared for the patient, but those patients had less disability.
"While the initial costs may be slightly higher, the decrease in long-term disability may actually lower the overall cost of caring for stroke patients," Samsa said.
The research team analyzed the claims of 38,612 Medicare patients diagnosed with a stroke in 1991. All patients were over age 65.
About 11 percent were cared for by a neurologist. One-fourth of patients were treated by both a neurologist and a generalist. Almost half were treated by a generalist physician only. The remainder were cared for by other types of specialists or their primary physician was not identified.
The researchers noted the lower death rate for people cared for by neurologists could not be accounted for by the availability of advanced technology at the admitting hospital.
"When a person has a stroke, we know that early treatment makes the biggest difference in outcomes," said Janet Mitchell of Health Economics Research Inc., Waltham, Mass., a private research organization, and the lead author of the study. "It may be that neurologists' experience and knowledge of the various treatment options, such as anticoagulant therapy can give patients an advantage."
The study adjusted for age, gender, race, other complicating diseases such as diabetes, and history of previous strokes. However, Samsa said the interpretation of the study is limited because Medicare data does not include detailed patient data, such as information about the severity of stroke.
"It may be that patients with a more severe stroke are sent to medical intensive care units that are staffed by internists," said Dr. Larry Goldstein, a Duke neurologist and member of CHPRE. "The study raises legitimate issues of why this difference in outcomes exists."
Many hospitals don't have specialized stroke units, where patients are treated by a multidisciplinary team that involves early rehabilitation, which has been shown to decrease long-term disability, Goldstein said. "The next step should be to find out the reasons for these differences, and then, if appropriate, to disseminate this information to generalist physicians because they care for the majority of stroke patients in this country. Neurologists can be leaders in that effort," he said.
The research team also included Dr. David Ballard of Emory University, Atlanta; Dr. Jack Whisnant of the Mayo Clinic, Rochester, Minn.; and Carol Ammering of Health Economics Research Inc.