First trimester stroke prophylaxis in pregnant women with a history of stroke.

BACKGROUND AND PURPOSE: Current recommendations for stroke prevention during early pregnancy in women with a prior stroke history are based on limited evidence. In view of the uncertainty involved in balancing the fetal risk of medication against the maternal risk of recurrent stroke, a substantial variation in clinical decision making was anticipated. Thus, a survey was performed to describe the current practices of U.S. neurologists with a particular interest in stroke with regards to treatment of such patients. METHODS: A survey was sent to 384 actively practicing U.S. members of the American Academy of Neurology Stroke and Vascular Neurology section asking what antithrombotic, if any, they would use during first trimester pregnancy in women with a prior history of stroke, either unrelated or related to a previous pregnancy. RESULTS: 230 practitioners responded. Some form of antithrombotic therapy was selected by 75% of practitioners for women with a history of prior stroke not related to pregnancy and by 88% of practitioners for women with a history of prior stroke related to pregnancy. Aspirin and low molecular weight heparin were chosen by 51% and 7%, respectively, for stroke unrelated to pregnancy and by 41% and 25%, respectively, for stroke related to pregnancy. CONCLUSIONS: Most practitioners agree that women with a history of stroke should receive prophylaxis during the first trimester. However, much disagreement exists regarding which drug(s) to use. A national registry would be the most practical method of obtaining maternal and fetal outcome data to guide practice in this setting.

Outpatient practice patterns after stroke hospitalization among neurologists.

BACKGROUND AND PURPOSE: Care after stroke hospitalization can provide several opportunities to optimize vascular risk reduction. However, not much is known about poststroke practice patterns among neurologists. Such knowledge may help direct specific efforts to improve the impact of practicing neurologists on clinical outcomes after stroke. METHODS: A survey soliciting information on processes of care in the outpatient setting after recent hospitalization for ischemic stroke or transient ischemic attack was mailed to a random sample of 833 US and Canadian neurologist-members of the American Academy of Neurology. RESULTS: A total of 475 (57%) responses were received. Practice demographics of survey responders and nonresponders were largely similar. Fourteen percent of respondents identified themselves as vascular neurologists. Overall, respondents reported frequently checking for medication adherence and counseling patients on lifestyle modification. However, neurologists reported screening more frequently for diabetes, hypertension, and dyslipidemia than actually treating these conditions (all P<0.0001) Vascular neurologists were more likely than general neurologists to screen for hypertension (97% versus 86%, P=0.016), dyslipidemia (94% versus 68%, P<0.001), diabetes (89% versus 62%, P<0.001), and sleep apnea (94% versus 79%, P=0.007) as well as to treat hypertension (71% versus 45%, P<0.001), dyslipidemia (82% versus 50%, P<0.001), diabetes (45% versus 21%, P<0.001), and current smoking (77% versus 59%, P=0.005). Neurologists with mostly government-insured and uninsured patients were significantly more likely to engage in vascular risk reduction treatment than neurologists with mostly commercially insured patients. CONCLUSIONS: Self-reported rates of screening and treatment of major vascular risk factors by most neurologists after stroke hospitalization are substantial but not universal. Bridging knowledge gaps or adopting a systematic management approach in coordination with primary care physicians could help optimize poststroke care.

Sports neurology topics in neurologic practice: A survey of AAN members.

We sought to assess neurologists' interest in sports neurology and learn about their experience in treating sports-related neurologic conditions. A survey was sent to a random sample of American Academy of Neurology members. A majority of members (77%) see at least some patients with sports-related neurologic issues. Concussion is the most common sports-related condition neurologists treat. More than half of survey participants (63%) did not receive any formal or informal training in sports neurology. At least two-thirds of respondents think it is very important to address the following issues: developing evidence-based return-to-play guidelines, identifying risk factors for long-term cognitive-behavioral sequelae, and developing objective diagnostic criteria for concussion. Our findings provide an up-to-date view of the subspecialty of sports neurology and identify areas for future research.

Status of neurology medical school education: results of 2005 and 2012 clerkship director survey.

OBJECTIVE: To survey all US medical school clerkship directors (CDs) in neurology and to compare results from a similar survey in 2005. METHODS: A survey was developed by a work group of the American Academy of Neurology Undergraduate Education Subcommittee, and sent to all neurology CDs listed in the American Academy of Neurology database. Comparisons were made to a similar 2005 survey. RESULTS: Survey response rate was 73%. Neurology was required in 93% of responding schools. Duration of clerkships was 4 weeks in 74% and 3 weeks in 11%. Clerkships were taken in the third year in 56%, third or fourth year in 19%, and fourth year in 12%. Clerkship duration in 2012 was slightly shorter than in 2005 (fewer clerkships of ≥4 weeks, p = 0.125), but more clerkships have moved into the third year (fewer neurology clerkships during the fourth year, p = 0.051). Simulation training in lumbar punctures was available at 44% of schools, but only 2% of students attempted lumbar punctures on patients. CDs averaged 20% protected time, but reported that they needed at least 32%. Secretarial full-time equivalent was 0.50 or less in 71% of clerkships. Eighty-five percent of CDs were "very satisfied" or "somewhat satisfied," but more than half experienced "burnout" and 35% had considered relinquishing their role. CONCLUSION: Trends in neurology undergraduate education since 2005 include shorter clerkships, migration into the third year, and increasing use of technology. CDs are generally satisfied, but report stressors, including inadequate protected time and departmental support.

Supply and demand analysis of the current and future US neurology workforce.

OBJECTIVE: This study estimates current and projects future neurologist supply and demand under alternative scenarios nationally and by state from 2012 through 2025. METHODS: A microsimulation supply model simulates likely career choices of individual neurologists, taking into account the number of new neurologists trained each year and changing demographics of the neurology workforce. A microsimulation demand model simulates utilization of neurology services for each individual in a representative sample of the population in each state and for the United States as a whole. Demand projections reflect increased prevalence of neurologic conditions associated with population growth and aging, and expanded coverage under health care reform. RESULTS: The estimated active supply of 16,366 neurologists in 2012 is projected to increase to 18,060 by 2025. Long wait times for patients to see a neurologist, difficulty hiring new neurologists, and large numbers of neurologists who do not accept new Medicaid patients are consistent with a current national shortfall of neurologists. Demand for neurologists is projected to increase from ∼18,180 in 2012 (11% shortfall) to 21,440 by 2025 (19% shortfall). This includes an increased demand of 520 full-time equivalent neurologists starting in 2014 from expanded medical insurance coverage associated with the Patient Protection and Affordable Care Act. CONCLUSIONS: In the absence of efforts to increase the number of neurology professionals and retain the existing workforce, current national and geographic shortfalls of neurologists are likely to worsen, exacerbating long wait times and reducing access to care for Medicaid beneficiaries. Current geographic differences in adequacy of supply likely will persist into the future.

Sedation for the imminently dying: survey results from the AAN Ethics Section.

OBJECTIVES: Sedation for the imminently dying (SFTID) is a controversial practice that involves the provision of sedation to imminently dying patients with the intent of relieving their suffering when symptoms are refractory to other interventions. The goal of this research was to ascertain the opinions regarding SFTID that are held by neurologists who are interested in ethics and end-of-life care. METHODS: Members of the American Academy of Neurology Ethics Section were surveyed regarding their familiarity and experience with SFTID and their opinions pertaining to it. To determine whether their opinions varied in relationship to clinical context, a single stem question for 5 different case scenarios was used. RESULTS: A total of 96% of respondents agreed or strongly agreed that the primary purpose of SFTID was to relieve suffering, 83% disagreed or strongly disagreed that SFTID was morally equivalent to euthanasia, and 85% disagreed or strongly disagreed that SFTID was legally equivalent to euthanasia. For the case scenarios, 92% agreed or strongly agreed that SFTID was acceptable for imminently dying patients with metastatic cancer, while 50% agreed or strongly agreed that SFTID was acceptable for patients with end-stage amyotrophic lateral sclerosis, and only 7% agreed or strongly agreed that SFTID was acceptable for posttraumatic quadriplegic patients not at risk for imminent death. CONCLUSIONS: The overwhelming majority of neurologists surveyed endorse the concept that sedation for the imminently dying differs morally and legally from euthanasia and that it is an acceptable therapeutic option for some but not all patients who are imminently dying of a terminal illness.

Health information technology and electronic health records in neurologic practice.

The tipping point for electronic health records (EHR) has been reached and universal adoption in the United States is now inevitable. Neurologists will want to choose their electronic health record prudently. Careful selection, contracting, planning, and training are essential to successful implementation. Neurologists need to examine their workflow carefully and make adjustments to ensure that efficiency is increased. Neurologists will want to achieve a significant return on investment and qualify for all applicable financial incentives from payers, including CMS. EHRs are not just record-keeping tools but play an important role in quality improvement, evidence-based medicine, pay for performance, patient education, bio-surveillance, data warehousing, and data exchange.