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Articles
September 22, 2003
Letter to the Editor

VA Stroke Study
Neurologist care is associated with increased testing but improved outcomes

September 23, 2003 issue
61 (6) 792-796

Abstract

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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Letters to the Editor
3 December 2003
Reply to Cheng et al
Larry B. Goldstein, Durham VAMC & Duke University
David B. Matchar, Jennifer Hoff-Lindquist, Gregory P. Samsa, Ronnie D. Horner

We thank Drs. Cheng, Birbeck and Vickrey for their comments. We carefully pointed out in the Discussion section of our report that VASt was an observational cohort study, and that factors underlying the observed differences can only be partially inferred based on the data that was collected. The potential for confounding due to unmeasured factors is inherent in all studies of this type.

However, we feel that biases based on acuity or weekend hospital admissions are unlikely. Although the difference was not significant, patients primarily cared for by a neurologist had slightly greater acuity than those cared for by non- neurologists (mean+/-S.E.M time from symptom onset to admission= 1.2+/-0.1 days for neurologists vs. 1.5+/-0.2 days for non-neurologists, Wilcoxon test, p=0.42). Although there were differences in the levels of organization of stroke care among the sites, there was no difference in outcome when sites with or without a stroke unit or stroke team were compared.

Further, stroke severity, the most important predictor of outcome, was virtually identical between patients primarily cared for by neurologists and those cared for by non-neurologists. Unfortunately, we do not have specific data to address the other points raised, but any causal interpretations would be subject to the same limitations pointed out by Cheng et al. Hypothesis-driven data collection is required to directly address these issues. Despite its limitations, the study is consistent with previous work suggesting a benefit of specialist care. Additional studies are needed to determine why stroke patients primarily cared for by neurologists have better outcomes.

3 December 2003
VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes
Eric M Cheng, MD, MS, Greater Los Angeles VA Healthcare System
Gretchen Birbeck, Barbara Vickrey

We read with interest the article by Goldstein et al [1] that reported twice the rate of deterioration in the first 24 hours, and worse discharge functional status and mortality rates among acute stroke patients cared for by non-neurologists compared to those having neurologist attendings. These findings, based on a prospective, observational study conducted at nine VA hospitals, are carefully reported as associations, not causal.

Though the investigators adjusted for stroke severity (via Canadian Neurologic Scale) and comorbidity, the potential for confounding due to other, unmeasured prognostic characteristics remains high. At the West Los Angeles VA Hospital, assignment of stroke patients to inpatient neurology service vs. inpatient "non-neurology" service is not random and is highly influenced by the patients' clinical state and perceived acuity. Stroke patients deemed by the neurology service to have a high risk for deterioration - such as those with stroke onset less than 72 hours - are admitted to the inpatient medical intensive care service for access to resources (i.e. 24-hour cardiac monitoring, nursing staff who can perform frequent neurological assessments, residents who are in-house overnight) that are not available on the inpatient neurology service. Therefore, we would expect higher rates of deterioration and worse outcomes among patients cared for on a non-neurology service at this VA hospital. This would not be due to differences in quality of care, but to local triage policy, itself driven by acuity (a characteristic not measured on the Canadian Neurologic Scale). [2]

There may be other kinds of local hospital policies regarding admission triage elsewhere, for example, policies that patients presenting over a weekend be admitted to a medicine service. Weekend admissions have been associated with increased mortality. [3]

The investigators also found differences in use of some diagnostic tests and treatments. Additional data could help discern whether such differences either explain or result from differences in outcomes. For example, higher rates of speech therapy in the neurologist group might have resulted from their better prognosis and hospital course, or – if speech therapy was a venue for a swallowing evaluation early in the hospitalization - it might have resulted in lower rates of aspiration pneumonia. Information on the timing of this evaluation and on rates of aspiration pneumonia would be useful. Data regarding blood pressure management in the first 24 hours could also help explain early deterioration and link outcome differences across groups to process measures of quality of care. [4]

References

1. Goldstein LB, Matchar DB, Hoff-Lindquist J, Samsa GP, Horner RD. VA Stroke Study: Neurologist care is associated with increased testing but improved outcomes. Neurology 2003; 61:792-796.

2. Cote R, Battista RN, Wolfson C, Boucher J, Adam J, Hachinski V. The Canadian Neurological Scale: validation and reliability assessment. Neurology 1989; 39:638-643.

3. Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with weekdays. N Engl J Med 2001; 345:663-668.

4. Oliveira-Filho J, Silva SCS, Trabuco CC, Pedreira BB, Sousa EU, Bacellar A. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke onset. Neurology 2003; 61:1047-1051.

Information & Authors

Information

Published In

Neurology®
Volume 61Number 6September 23, 2003
Pages: 792-796
PubMed: 14504322

Publication History

Received: March 26, 2003
Accepted: May 18, 2003
Published online: September 22, 2003
Published in print: September 23, 2003

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Authors

Affiliations & Disclosures

L.B. Goldstein, MD
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.
D.B. Matchar, MD
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.
J. Hoff-Lindquist, MS
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.
G.P. Samsa, PhD
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.
R.D. Horner, PhD
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.

Notes

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: [email protected]

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