Length of Hospital Stay After Stroke Cut More Than a Day by Neurohospitalists, Study Finds

Neurology Today
1 July 2010; Volume 10(13); p 40–41

HURLEY, DAN

Even while significantly cutting the median length of hospital stay for stroke patients, the neurohospitalists earned a 93 percent achievement score on the 11 quality indicators for stroke care set by the Joint Commission, compared to 80 percent for community neurologists.

TORONTO—Neurohospitalists reduced patients' length of stay in a hospital following an ischemic stroke by more than a day and a half compared to standard care by community neurologists, according to the first study seeking to quantify the effects of the emerging specialty.

The study, presented at the AAN annual meeting here in April, found that even while significantly cutting the median length of stay, the neurohospitalists earned a 93 percent achievement score on the 11 quality indicators for stroke care set by the Joint Commission, compared to 80 percent for community neurologists.

The findings were described by other neurohospitalists as an important first step in establishing the value of their growing specialty.

“This represents the first look at what impact that model of care may have on a number of different measures,” said David Likosky, MD, chair of the AAN Neurohospitalist Section and director of the stroke program at Evergreen Hospital in Seattle. “The next step is to validate this finding and apply other quality metrics as well.”

The study, from four neurologists who serve on the neurohospitalist service at the Mayo Clinic in Jacksonville, FL, involved a retrospective chart review of all acute ischemic stroke patients at a community hospital from January 2006 to December 2008. The hospital divided neurology emergency department on-call responsibility evenly, on alternating days, between community-based neurologists and neurohospitalists.

During the two-year review period, 533 patients were discharged with a diagnosis of acute ischemic stroke. Neurohospitalists admitted 313 of them, with a mean length of stay of 4.9 days. Community-based neurologists admitted 220 of the patients, with a mean length of stay of 6.5 days. The difference was statistically significant (p=0.005).

One of the reasons for the reduced length of stay may be that the neurohospitalists were on hand to deliver tissue plasminogen activator (tPA), said the first author of the study, Steven B. Dawson, MD. Dr. Dawson, a neurology resident at the Jacksonville Mayo Clinic, is preparing for a career as a neurohospitalist.

“With the neurohospitalists, 38 out of 39 eligible patients received tPA,” said Dr. Dawson. “For community-based neurologists, only one received it. The neurohospitalists were physically there when the patients needed them.”

The statistics on tPA were surprising to Vanja Douglas, MD, an assistant professor of neurology at the University of California-San Francisco, who is a neurohospitalist at Moffitt-Long Hospital. She recalled that during Dr. Dawson's presentation at the AAN meeting, he was asked why only one patient in the community hospital group was eligible to receive tPA.

“The tPA treatment rates should be equal,” Dr. Douglas said. “The reason, as I understand it, is that the neurohospitalists on staff covered tPA cases for the community group.”

She added that future studies should look at readmission rates and control for stroke severity. “It's an emerging specialty,” said Dr. Douglas. “It's important going forward that we emulate what the hospitalists have done, in terms of researching the way this model of care works so we can make informed policy decisions about it going forward.”

The Mayo Clinic in Jacksonville is one of only three hospitals in the country currently offering neurohospitalist fellowships, along with Evergreen in Seattle and Moffitt-Long in San Francisco.

Figure. DR. DAVID LIKOSKY:“This represents the first look at what impact that model of care may have on a number of different measures. The next step is to validate this finding and apply other quality metrics as well.”

[ Click here to enlarge ]

If the findings on reduced length of hospital stay associated with neurohospitalists hold up in future studies, many more hospitals are likely to embrace the model, said Dr. Likosky.

The 1.6-day reduction in length of stay seen in the study, he said, is “a very big deal, because of the way many hospitals are reimbursed, where they get a lump sum for the patient based on their diagnosis. If future studies show that neurohospitalists also improve the outcomes for patients, the model might start to make more and more sense for hospitals over time.”

Barrett KM, Freeman WD. Emerging subspecialties in neurology: neurohospitalist.” 2010; 74(2):e9-10.

Freeman WD, Gronseth G, Eidelman BH. Invited article: Is it time for neurohospitalists? 2008;70(15):1282–1288.