What role do neurologists play in determining the costs and outcomes of stroke patients?

BACKGROUND AND PURPOSE: Despite growing concern over the large numbers of specialists in the United States, little information is available on how stroke treatment varies by the specialty of the attending physician. This study compares the costs and outcomes of acute stroke patients by physician specialty, especially between neurologists and other specialists. METHODS: We selected a random sample of Medicare patients aged 65 years and older admitted with cerebral infarction between January 1 and September 30, 1991, identified from the principal diagnosis on Medicare Provider Analysis and Review records. All Medicare claims for these patients were extracted from the date of admission through 90 days. The attending physician was identified as that physician billing for routine hospital visits during the first 7 days of the stay. RESULTS: Neurologists treating stroke patients were significantly more expensive than other physicians but obtained better outcomes. Ninety-day mortality rates for patients treated by neurologists were significantly lower than those for other specialists. These cost and outcome differences persisted even after adjustment for patient age, comorbidity, hospital teaching status, and other characteristics. Compared with other attending physicians, neurologists were significantly more likely to order diagnostic cerebrovascular tests (especially brain MRI scans), more likely to prescribe warfarin, and more likely to discharge patients to inpatient rehabilitation facilities. CONCLUSIONS: Systematic triaging to neurologists based on clinical characteristics unmeasured by administrative data might explain these observed differences between neurologists and other physicians. Alternatively, these specialists may have been better able to identify the mechanism of stroke, information that then affected the course of treatment. Given current pressures to substitute generalists for specialists, however, more research is needed on these stroke treatment differences.

Duke Scholars

Author David Bruce Matchar Medicine, General Internal Medicine