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VA Stroke Study

Neurologist care is associated with increased testing but improved outcomes

From the Durham VA Medical Center (Drs. Goldstein and Matchar, and J. Hoff-Lindquist), Department of Medicine (Neurology [Dr. Goldstein] and General Internal Medicine [Drs. Matchar and Samsa]), Stroke Policy Program, Center for Clinical Health Policy Research (Drs. Goldstein, Matchar, and Samsa), and Center for Cerebrovascular Disease (Drs. Goldstein, Matchar, and Samsa), Duke University, Durham, NC; and the Office of Minority Health and Research (Dr. Horner), National Institute of Neurological Disorders and Stroke, Bethesda, MD.

Address correspondence and reprint requests to Dr. Larry B. Goldstein, Director, Duke Center for Cerebrovascular Disease, Head, Stroke Policy Program, Center for Clinical Health Policy Research, Box 3651, Duke University Medical Center, Durham, NC 27710; e-mail: golds004{at}mc.duke.edu

Objective: VA Stroke Study (VASt) data were analyzed to determine whether neurologist management affected the process and outcome of care of patients with ischemic stroke.

Methods: VASt prospectively identified patients with stroke admitted to nine VA hospitals (April 1995 to March 1997). Demographics, stroke severity (Canadian Neurologic Score), stroke subtype (Trial of ORG 10172 in Acute Stroke Treatment [TOAST] classification), tests/procedures, and discharge status (independent, Rankin 2, vs dead or dependent, Rankin 3 through 5) were compared between patients who were or were not cared for by a neurologist.

Results: Of 1,073 enrolled patients, 775 (neurologist care, n = 614; non-neurologist, n = 161) with ischemic stroke were admitted from home. Stroke severity (Canadian Neurologic Score 8.7 ± 0.1 vs 8.4 ± 0.2; p = 0.44), TOAST subtype (p = 0.55), and patient age (71.4 ± 0.4 vs 72.4 ± 0.7; p = 0.23) were similar for neurologists and non-neurologists. Neurologists more frequently obtained MRI (44% vs 16%; p < 0.001), transesophageal echocardiograms (12% vs 2%; p < 0.001), carotid ultrasounds (65% vs 57%; p = 0.05), cerebral angiography (8% vs 1%; p = 0.001), speech (35% vs 18%; p < 0.001), and occupational therapy (46% vs 33%; p = 0.005) evaluations. Brain CT, transthoracic echocardiogram, 24-hour ambulatory ECG use, and hospitalization durations (18.2 ± 0.8 vs 19.7 ± 4.1 days; p = 0.725) were similar. Neurologists’ patients were less likely to be dead (5.6% vs 13.5%; OR = 0.38; 95% CI 0.22, 0.68; p = 0.001) and less likely to be dead or dependent (46.1% vs 57.1%; OR = 0.64; 95% CI 0.45, 0.92; p = 0.019) at the time of discharge. The benefit remained after controlling for stroke severity and comorbidity (OR = 0.63; 95% CI 0.42, 0.94; p = 0.025).

Conclusion: Neurologist care was associated with more extensive testing, but similar lengths of hospitalization and improved outcomes.

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