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VBCN - April 2016 Volume 3, No 1 - Value in Neurology
Charles Bankhead

Neurologist-directed ambulatory care for chronic neurologic diseases resulted in higher costs but fewer adverse events and less use of acute care services, according to an American Academy of Neurology–supported study (Ney JP, et al. Neurology. 2016;86:367-374).

Across 10 different chronic neurologic conditions, neurologist involvement led to direct costs that were 25% to 100% greater than when the same conditions were managed without a neurologist. At the same time, however, neurologist involvement was associated with fewer fractures, infections, emergent care, and inpatient admissions, as well as increased use of disease-specific treatments.

These results can inform efforts to enhance the quality of care provided by neurologists, suggest Ney and colleagues.

“The results depicted here provide a substantial contribution to health services research on neurologist involvement with care and provide a model to study the value of specialist care in general,” Dr Ney and colleagues wrote. “These data and methods may help to confirm that neurologists provide high-quality care with fewer adverse events.”

Payers are increasingly seeking reliable data to inform coverage, regulatory, and policy decisions on a variety of issues, including the impact of specialty care on healthcare costs and utilization. In that respect, the impact of neurologist involvement in the care of patients with chronic neurologic diseases remains unclear, Dr Ney and colleagues noted.

Analysis of large administrative claims data sets can help provide insights into the clinical and economic implications of neurologist involvement in patient care. Toward that end, the American Academy of Neurology supported a review of the proprietary administrative database of Optum, Inc, a Philadelphia-based healthcare consulting firm. The primary objective of this analysis was to investigate the value of neurologist care.

The study comprised 2 phases. During the first phase, Dr Ney and colleagues examined the economic burden imposed by various neurologic conditions, focusing on neurologist involvement and the cost of care. During the second phase of this analysis, the investigators examined disease-specific metrics of utilization, treatment, and screening for selected conditions.

Dr Ney and colleagues identified episodes of care for specific neurologic conditions, relying on the proprietary episode treatment group software used by Optum. Episode treatment groups gather inpatient, outpatient, and pharmacy services data attributable to specific diagnoses over time.

Study Findings

The analysis resulted in 1,913,605 episode treatment groups for 10 index neurologic conditions, with the most common being migraine (998,036) and epilepsy (279,173), and the least common being amyotrophic lateral sclerosis (3271). The remaining conditions included developmental disorder, autism, Parkinson’s disease, dementia, Alzheimer’s disease, multiple sclerosis, and acute stroke.

Neurologist involvement was documented for 593,101 episodes related to 10 neurologic conditions. The frequency of neurologist involvement ranged from 6% of episodes related to developmental disorder to 73% and 75% of episodes related to multiple sclerosis and acute stroke, respectively. Neurologists participated infrequently (<12%) in episode treatment groups associated with dementias and autism, but were involved in more than 50% of episodes related to amyotrophic lateral sclerosis, epilepsy, and Parkinson’s disease.

The total allowed payments were greater with neurologist involvement for all 10 conditions. The greatest difference occurred with neurologist involvement in the care of multiple sclerosis (100% increase vs no neurologist involvement), and the smallest differences occurred with Alzheimer’s disease and acute stroke (25%).

During the second phase of the study, episode treatment groups with neurologist ambulatory care were associated with fewer fracture diagnoses and related care, fewer pneumonia admissions, and less coincident depression compared with noninvolvement among patients with multiple sclerosis or Parkinson’s disease.

Compared with noninvolvement, discharge to postacute care (skilled nursing facility or home health agency) occurred significantly less often with neurologist involvement in treatment for multiple sclerosis (skilled nursing facility), stroke, and Parkinson’s disease.

In addition, neurologist ambulatory care for epilepsy was associated with lower annual rates of emergency department visits compared with noninvolvement, and higher-severity episodes for epilepsy were associated with a significantly reduced likelihood of inpatient admission from the emergency department compared with noninvolvement.

Impact of Neurologist Involvement

Neurologist involvement increased the likelihood that patients would receive disease-specific therapies, including immunotherapy for multiple scle­rosis, deep-brain stimulation for Parkinson’s disease, dopaminergic drug therapy for Parkinsons disease, and anti­coagulation for stroke associated with atrial fibrillation.

In addition, neurologist ambulatory care in stroke led to the greater use of speech therapy and sleep studies compared with noninvolvement.

This analysis yielded 3 major findings:

  1. Episode treatment groups with neurologist involvement resulted in greater allowed payment versus noninvolvement
  2. Adverse events and the use of acute care and postacute care decreased with neurologist ambulatory care
  3. The use of disease-specific therapies and screening improved with the involvement of a neurologist in patient care.

Measuring Value in Neurology

In an accompanying editorial by Jones and Nuwer (Jones LK Jr, Nuwer MR. Neurology. 2016;86:320-321), the authors suggest that as the nation examines its priorities for investment in healthcare, medical specialties have a growing responsibility to demonstrate their value to the healthcare system.

Making a case for the value of neurology care requires measuring the quality and the cost component of a complex equation.

“Quality of medical care is hard to define and difficult to measure,” wrote Drs Jones and Nuwer. “Pricing in health care is notoriously opaque. Despite these barriers, there is growing interest among policymakers, payers, providers, and the public to consider the value of care delivered to patients.”

“It is difficult to overstate the need to measure value in ways that are meaningful to clinicians and patients,” Drs Jones and Nuwer added.

The claims data set analysis by Ney and colleagues represented a step toward demonstrating the value that neurologists provide to patients with chronic neurologic conditions. At the same time, the findings raised questions, Drs Jones and Nuwer say. Did the higher costs associated with neurologist care represent greater severity or simply the involvement of a neurologist? After adjusting for disease severity, can neurologist involvement reduce the costs by means of cost avoidance? Would risk-matched comparisons demonstrate that patients who see neurologists attain better outcomes?

Administrative data sets, such as the one used by Ney and colleagues, have limited clinical detail of the type needed to get at the core of quality and value, Drs Jones and Nuwer noted. For example, did patients’ seizure frequency decrease with appropriate medication management? Such questions require data from disease-specific sources, such as the Axon Registry, which is being developed by the American Academy of Neurology.

“Measuring the value of neurology is one thing. Demonstrating that we are valuable is another,” Drs Jones and Nuwer concluded. “We applaud Ney et al. for their work, and hope to see further systematic investigation into the value of neurology in the future.”

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