VA Stroke Study: neurologist care is associated with increased testing but improved outcomes.
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 < or = 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).


CONCLUSIONS
Neurologist care was associated with more extensive testing, but similar lengths of hospitalization and improved outcomes.
D000368:Aged; D015331:Cohort Studies; D003952:Diagnostic Imaging / Q000706:statistics & numerical data*; D003943:Diagnostic Techniques, Neurological / Q000706:statistics & numerical data*; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009462:Neurology / Q000706:statistics & numerical data*; D009788:Occupational Therapy / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012720:Severity of Illness Index; D013070:Speech Therapy / Q000706:statistics & numerical data; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality; D000071939:Stroke Rehabilitation; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States