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Circ Cardiovasc Qual Outcomes. 2014 May;7(3):430-6. doi: 10.1161/CIRCOUTCOMES.113.000745. Epub 2014 Apr 8.

Fragmentation of care and the use of head computed tomography in patients with ischemic stroke.

Author information

1
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.
2
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.).

Abstract

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.

METHODS AND 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.

KEYWORDS:

Medicare; multidetector computed tomography; stroke

PMID:
24714599
PMCID:
PMC4236029
DOI:
10.1161/CIRCOUTCOMES.113.000745
[Indexed for MEDLINE]
Free PMC Article

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