Fragmentation of care and the use of head computed tomography in patients with ischemic stroke.
BACKGROUND
Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services.


RESULTS
We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (≥4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had ≥4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%-3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71-1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01).


CONCLUSIONS
Rates of high-intensity CT use for patients with ischemic stroke reflect wide practice patterns across regions and races. Medicare expenditures parallel these disparities. Fragmentation of care is associated with high-intensity CT use.
From the Section of Neurosurgery (K.B., D.W.R.) and Department of Neurology (D.W.R.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH (D.W.R.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (W.Z., J.S.); and Department of Economics, Dartmouth College, Hanover, NH (J.S.). kbekelis@gmail.com.
Kimon
K
Bekelis
From the Section of Neurosurgery (K.B., D.W.R.) and Department of Neurology (D.W.R.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH (D.W.R.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (W.Z., J.S.); and Department of Economics, Dartmouth College, Hanover, NH (J.S.).
David W
DW
Roberts
From the Section of Neurosurgery (K.B., D.W.R.) and Department of Neurology (D.W.R.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH (D.W.R.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (W.Z., J.S.); and Department of Economics, Dartmouth College, Hanover, NH (J.S.).
Weiping
W
Zhou
From the Section of Neurosurgery (K.B., D.W.R.) and Department of Neurology (D.W.R.), Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH (D.W.R.); Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (W.Z., J.S.); and Department of Economics, Dartmouth College, Hanover, NH (J.S.).
Jonathan S
JS
Skinner
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044383:Black People; D005260:Female; D005500:Follow-Up Studies; D006257:Head / Q000000981:diagnostic imaging*; D017048:Health Care Costs; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis* / Q000628:therapy; D008297:Male; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014481:United States; D001741:Black or African American
Medicare; multidetector computed tomography; stroke