Patient Travel Distance to Neurologist Visits.

BACKGROUND AND OBJECTIVES: The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. METHODS: We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. RESULTS: We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. DISCUSSION: We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites.

BACKGROUND AND PURPOSE: Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. METHODS: Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. RESULTS: From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]). CONCLUSIONS: Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Clinical Practice Guideline: Ménière's Disease.

OBJECTIVE: Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid (endolymph) volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Conventional imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many and typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies. PURPOSE: The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Clinical Practice Guideline: Ménière's Disease Executive Summary.

OBJECTIVE: Ménière's disease (MD) is a clinical condition defined by spontaneous vertigo attacks (each lasting 20 minutes to 12 hours) with documented low- to midfrequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. It also presents with fluctuating aural symptoms (hearing loss, tinnitus, or ear fullness) in the affected ear. The underlying etiology of MD is not completely clear, yet it has been associated with inner ear fluid volume increases, culminating in episodic ear symptoms (vertigo, fluctuating hearing loss, tinnitus, and aural fullness). Physical examination findings are often unremarkable, and audiometric testing may or may not show low- to midfrequency sensorineural hearing loss. Imaging, if performed, is also typically normal. The goals of MD treatment are to prevent or reduce vertigo severity and frequency; relieve or prevent hearing loss, tinnitus, and aural fullness; and improve quality of life. Treatment approaches to MD are many, and approaches typically include modifications of lifestyle factors (eg, diet) and medical, surgical, or a combination of therapies. PURPOSE: The primary purpose of this clinical practice guideline is to improve the quality of the diagnostic workup and treatment outcomes of MD. To achieve this purpose, the goals of this guideline are to use the best available published scientific and/or clinical evidence to enhance diagnostic accuracy and appropriate therapeutic interventions (medical and surgical) while reducing unindicated diagnostic testing and/or imaging.

Ethnic Differences in 90-Day Poststroke Medication Adherence.

Background and Purpose- We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods- Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ2 tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results- Mexican Americans (n=692) were younger (median 65 years versus 68 years, P<0.001), had more diabetes mellitus ( P<0.001) and hypertension ( P<0.001) and less atrial fibrillation ( P=0.003), smoking ( P=0.003), and education ( P<0.001) than non-Hispanic whites (n=422). Sex, insurance status, high cholesterol, previous stroke/transient ischemic attack history, excessive alcohol use, tPA (tissue-type plasminogen activator) treatment, National Institutes of Health Stroke Scale score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the 5 drug classes between Mexican Americans and non-Hispanic whites. Conclusions- This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.

Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study.

BACKGROUND: Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS: This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS: 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS: Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.

Claims data analyses unable to properly characterize the value of neurologists in epilepsy care.

OBJECTIVE: To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy. METHODS: Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery). RESULTS: After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001). CONCLUSIONS: Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.

Benign paroxysmal positional vertigo: opportunities squandered.

Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV--the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively--are supported by two evidence-based guidelines (American Academy of Otolaryngology--Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice.

Is Physician Work in Procedure and Test Codes More Highly Valued Than That in Evaluation and Management Codes?

OBJECTIVES: To determine whether the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule confers higher value for physician work in procedure and test codes than in Evaluation and Management (E/M) codes. BACKGROUND: Medicare Payment Advisory Commission previously demonstrated that time for medical services is the dominant element in valuing physician work in the CMS Physician Fee Schedule. In contrast, a more recent analysis suggests that more relative value units (RVUs) per unit time are issued for work in procedure codes than in E/M codes. Both prior analyses had important limitations for evaluating a possible systematic differential valuation of medical services. METHODS: Data regarding RVUs, physician work times (minutes), and claims were obtained for all active level I Current Procedural Terminology (CPT) codes from 2011 CMS files. Linear regression was used to assess the associations of work time components and CPT category with work RVUs, including a model that weighted codes by the number of claims. RESULTS: Included in the analysis were 6522 CPT codes (87 E/M codes, 6435 procedure/test codes). Compared with E/M codes, procedure/test codes did not have a significant difference in work RVUs adjusting for time (-0.631; 95% confidence interval, -1.427 to 0.166). The analysis also did not indicate a work RVU advantage specifically for Surgical CPT codes compared with E/M adjusting for time (-0.760; 95% confidence interval, -1.560 to 0.040). This pattern was not altered after weighting codes by the number of claims, indicating that an increase in RVUs per minute was not concentrated in a small number of highly utilized procedure codes. CONCLUSIONS: We did not find evidence of a systematic higher valuation of physician work in procedure/test codes than in E/M codes in the CMS RVU system.

HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness.

OBJECTIVES: Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]). METHODS: This was a cross-sectional study of high-risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0-7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three-component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-) were assessed for stroke and other central causes, and the results were stratified by age. False-negative initial neuroimaging was also assessed. RESULTS: A total of 190 adult AVS patients were assessed (1999-2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR- of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR- was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR- was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR- was 0.01 for HINTS "plus" (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI. CONCLUSIONS: HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

Use of BPPV processes in emergency department dizziness presentations: a population-based study.

OBJECTIVE: A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use. STUDY DESIGN: Prospective population-based surveillance study. SETTING: Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011. SUBJECTS AND METHODS: Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability. RESULTS: A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use. CONCLUSION: Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

The impact of MRI on stroke management and outcomes: a systematic review.

RATIONALE, AIMS AND OBJECTIVES: Magnetic resonance imaging (MRI) is widely used in stroke evaluation and is superior to computed tomography for the detection of acute ischaemia. We sought to evaluate the evidence that conventional MRI influences doctor management or patient outcomes in routine care. METHODS: We systematically searched PubMED, EMBASE and proceedings of the International Stroke Conference. Studies were included if they included patients presenting with possible stroke syndromes and they reported MRI results and resulting changes in management or outcome. Multiple reviewers determined inclusion/exclusion for each study, abstracted study characteristics and assessed study quality. RESULTS: Of 1813 articles screened, nine studies met inclusion criteria. None were randomized controlled trials, cohort studies or case-control studies. We found little evidence that MRI affects outcomes - one single-centre case series presented three patients. The remaining articles were studies of diagnostic tests or vignette-based studies that described changes in doctor management attributed to MRI. In the studies that suggested MRI influenced management, it did so in two ways. First, MRI distinguished stroke from mimics (e.g. brain tumours), thus enabling more appropriate selection of therapies. Second, even when MRI confirmed a suspected stroke diagnosis, it sometimes provided information (on stroke mechanism, localization, timing or pathophysiology) that influenced management. CONCLUSIONS: The impact of MRI on management and outcomes in stroke patients has been inadequately studied. Further research is needed to understand how MRI may productively affect stroke management and outcomes.

Potentially inappropriate medication utilization in the emergency department visits by older adults: analysis from a nationally representative sample.

OBJECTIVES: The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage. METHODS: The data examined during the study were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). This study utilized the nationally representative ED data from 2000-2006 NHAMCS surveys. Our sample included older adults (age 65 years and greater) who were treated in the ED and discharged home. Estimated frequencies of PIM-associated ED visits were calculated. A multivariable logistic regression model was created to assess demographic, clinical, and hospital factors associated with PIM administration and to assess temporal trends. RESULTS: Approximately 19.5 million patients, or 16.8% (95% confidence interval [CI]=16.1% to 17.4%) of eligible ED visits, were associated with one or more PIMs. The five most common PIMs were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine. The total number of medications prescribed or administered during the ED visit was most strongly associated with PIM use. Other covariates associated with PIM use included rural location outside of the Northeast, being seen by a staff physician only (and not by a resident or intern), presenting with an injury, and the combination of female sex and age 65-74 years. There was a small but significant decrease in the proportion of visits associated with a PIM over the study period. CONCLUSIONS: Potentially inappropriate medication administration in the ED remains common. Given rising concerns about preventable complications of medical care, this area may be of high priority for intervention. Substantial regional and hospital type (teaching versus nonteaching) variability appears to exist.

Dizziness presentations in U.S. emergency departments, 1995-2004.

OBJECTIVES: The objectives were to describe presentation characteristics and health care utilization information pertaining to dizziness presentations in U.S. emergency departments (EDs) from 1995 through 2004. METHODS: From the National Hospital Ambulatory Medical Care Survey (NHAMCS), patient visits to EDs for "vertigo-dizziness" were identified. Sample data were weighted to produce nationally representative estimates. Patient characteristics, diagnoses, and health care utilization information were obtained. Trends over time were assessed using weighted least squares regression analysis. Multivariable logistic regression analysis was used to control for the influence of age on the probability of a vertigo-dizziness visit during the study time period. RESULTS: Vertigo-dizziness presentations accounted for 2.5% (95% confidence interval [CI] = 2.4% to 2.6%) of all ED presentations during this 10-year period. From 1995 to 2004, the rate of visits for vertigo-dizziness increased by 37% and demonstrated a significant linear trend (p < 0.001). Even after adjusting for age (and other covariates), every increase in year was associated with increased odds of a vertigo-dizziness visit. At each visit, a median of 3.6 diagnostic or screening tests (95% CI = 3.2 to 4.1) were performed. Utilization of many tests increased over time (p < 0.01). The utilization of computerized tomography and magnetic resonance imaging (CT/MRI) increased 169% from 1995 to 2004, which was more than any other test. The rate of central nervous system diagnoses (e.g., cerebrovascular disease or brain tumor) did not increase over time. CONCLUSIONS: In terms of number of visits and important utilization measures, the impact of dizziness presentations on EDs is substantial and increasing. CT/MRI utilization rates have increased more than any other test.