Population Trends and Disparities in Outpatient Utilization of Neurologists for Ischemic Stroke

How the National Ambulatory Medical Care Survey has been used to identify health disparities in the care of patients in the United States

BACKGROUND

Healthcare disparities negatively impact patient health outcomes; addressing disparities could improve quality of life and decrease overall healthcare cost. The National Ambulatory Medical Care Survey (NAMCS) is an objective and reliable source for collecting information on United States (U.S.) ambulatory medical care service visits and may be a useful tool for identifying potential disparities in care.

OBJECTIVE

The purpose of this literature review is to describe studies utilizing NAMCS to capture U.S. healthcare disparities.

METHODS

PubMed was searched for scientific articles that utilized NAMCS to determine health disparities in the U.S. The keywords queried included "NAMCS" or "National Ambulatory Medical Care Survey" and "disparity" or "disparities" as a pair or additionally paired with one of the following: "race", "ethnicity", "age", "gender", "geography", or "insurance".

RESULTS

66 studies were found that incorporated NAMCS data from 1980-2016 into their methods to measure outcomes relating to health disparities. Disparities were found in the following categories: race/ethnicity, geographic location, age, insurance type, gender, specialist care versus primary care, body habitus, and preexisting conditions affecting patient outcomes. Disparities were identified in pain management, neurology, dermatology, psychiatry, patient communication access, and non-specialty specific or primary care visits related to disease conditions, screening, and treatment plans.

LIMITATIONS

Only PubMed was utilized as a search engine and may not encompass all studies on NAMCS and health disparities. NAMCS is a cross-sectional database and does not allow for longitudinal analyses.

CONCLUSIONS

NAMCS may be an underused tool given the limited number of articles that identify health disparities using it. Research studies utilizing NAMCS may identify potential disparities ultimately leading to better healthcare outcomes.

Teleneurology Comprehensive Inpatient Consultations Expedite Access to Care and Decreases Hospital Length of Stay

Background and Purpose

While the successful provision of telestroke care has been well documented in the literature, studies on the impact of comprehensive teleneurology service (TN) to hospital measures are lacking. We evaluated 3 traditional health services metrics of hospital performance: time from consult request to consult completion, inpatient length of stay (LOS), and the rate of patients transferred for tertiary care.

Methods

Medical records (n = 899) from 3 community hospitals and our TN consultation database were retrospectively reviewed during the 2 years before (n = 703, 3 hospitals) and 4 months (n = 2 hospitals) to 2 years (n = 1 hospital) after implementation (n = 196) of a TN program for routine and urgent consult requests. Consult order time, consult completion time, total length of stay and discharge disposition were compared across the pre-TN implementation group, which consisted of in-person consultations and the post-TN implementation group, which consisted of TN consultations only.

Results

After TN implementation, median length of stay decreased 28% (3.9 vs. 2.8 days, p < 0.0001) and median time from consult order to consult completion decreased by 74% across all diagnoses (5.8 vs. 1.5 hours, p < 0.0001). There were no significant differences in the percentage of patients discharged home (52.3% vs. 56.1%, p = 0.10) or transferred to tertiary care (6.1% to 9.2%, p = 0.10).

Conclusions

Implementation of TN program was associated with significant reductions in LOS and time to consultation completion without an increase in shunting of patients to more advanced facilities. Further research is warranted to confirm these findings in independent cohorts and other models of teleneurology delivery.

Trends in antihypertensive drug prescription patterns among ambulatory stroke patients in the United States, 2000-2009

BACKGROUND

Although the ambulatory setting is recognized as the best arena for optimizing antihypertensive drug treatment after a stroke, little is known about recent office-based antihypertensive drug treatment patterns in the United States. We assessed national trends in antihypertensive treatment for stroke patients in office-based medical practice.

METHODS

Data from the 2000-2009 National Ambulatory Medical Care Surveys were analyzed comprising outpatient visits to physicians in office-based practice by patients aged 40 years or older with a diagnosis of stroke (weighted estimate=46,317,269). The main outcome measure was visits with a prescription of antihypertensive medication(s).

RESULTS

The proportion of total visits that included a prescription of antihypertensive medication was 35.6% in 2000-2002, 29.5% in 2003-2005, and 49.3% in 2006-2009 (P=.002); 50.9% were primary care physician (PCP) visits versus 26.2% neurologist visits (P<.0001). Age-adjusted logistic regression analyses confirmed a higher prescription rate in 2006-2009 versus 2000-2002 (1.81; 95% confidence interval [CI], 1.10-2.96) and PCP versus neurologists (2.82; 95% CI, 1.86-4.27). Use of 2 or more agent classes was 31.6% in 2000-2002, 44.2% in 2003-2005, and 56.7% in 2006-2009 (P=.014). Age-adjusted logistic regression analyses confirmed a higher prescription rate of 2 or more agent classes in 2006-2009 versus 2000-2002 (2.96; 95% CI, 1.40-6.24). There were no significant differences in agent class type or number between neurologists versus PCPs.

CONCLUSIONS

Over the last decade, there was a significant rise in the use of antihypertensive drugs and combination of agent classes for patients aged 40 years or older seen in an ambulatory setting with a diagnosis of stroke. PCPs were more likely than neurologists to prescribe these agents.