What difference does a neurologist make in a general hospital? Estimating the impact of neurology consultations on in-patient care

Seizure management in a Model Three hospital: what does specialist neurology add?

BACKGROUND

The commonest reason for admissions to hospital in Ireland annually for patients with a neurological condition is due to convulsions/epilepsy and their care is often managed by Internal Medicine physicians.

AIMS

The study aims to evaluate the care provided for patients admitted with seizures in a Model Three hospital before and after the commencement of a specialist onsite neurology service.

METHODS

Retrospective chart review of patients admitted from Emergency Department (ED) with the term "seizure" during a 4-month period in 2018 and 2019 was undertaken. Charts evaluated for patient demographics, Length of Stay (LOS), driving and lifestyle advice offered, and rescue medications prescribed upon discharge.

RESULTS

In 2018, a total of 58 patients were admitted with a seizure over a period of 4 months of audit and the mean LOS was 4.25 days (SD = 4.43). Driving advice was documented in 9 patients and Buccal midazolam (Buccalam) for rescue therapy for prolonged seizures was prescribed once. Following the appointment of a neurologist, LOS for patients admitted with seizure dropped to 2.6 days (SD = 3.44, p < 0.05) in the same time frame in 2019. Driving status/recommendations were documented in 27(42%) and buccal midazolam was prescribed for 25 (39%) patients.

CONCLUSION

Access to expert neurology review in a Model Three hospital in Ireland not only improved the provision of safe, timely, and equitable care but also significantly reduced the LOS for patients admitted with seizures.

Improving liaison neurology services

Liaison neurology (consulting with inpatient ward referrals) is the main way that most patients admitted with neurological disease will access neurology services. Most liaison neurology services are responsive, seeing referrals on request, but they also can be proactive, with a regular neurology presence in the acute medical unit. Fewer than half of hospitals in England have electronic systems, yet these can facilitate the process-allowing electronic responses to advise on investigations before seeing the patient, and arranging follow-up after-as well as prioritising referrals and documenting the process. In this time of COVID-19, there are additional benefits in providing prompt remote advice. Improving the way liaison neurology is delivered can improve patient outcomes and save money by shortening admissions. This hidden work of the neurologists needs to be recorded and recognised.

Consultation Intervention Rates for the Otolaryngology Service: A Large Metropolitan Hospital Experience

CONTEXT

The purpose of this study was to evaluate the types of consultations received by an otolaryngology service at a 772-bed large metropolitan, MI-based hospital.

METHODS

The authors performed a retrospective review of the specific types of consultations received during calendar year 2016.

RESULTS

A total of 518 consultations were reviewed and analyzed by the first and second authors (MM, CB). Consultations with low intervention rates included dysphagia (difficulty swallowing) (32.3%), dysphonia (difficulty speaking) (16%), otalgia (earache) (20.8%), hearing loss (13.3%), rule out vocal cord dysfunction (0%), and vertigo/dizziness (0%). Epistaxis (nosebleed) was the most frequent reason for consultations, and angioedema (lip or airway swelling) was the most common airway-related consultation. Notably, emergent or urgent surgery was only performed on 4.6% of sample patients. Several common consultation reasons (e.g., longer-term hearing loss evaluation and cerumen (“earwax”) removal) could have been deferred for clinic-based evaluation where audiograms and microscopes are more readily available.

CONCLUSIONS

These findings suggest areas for continuing education for primary care provider and resident education to place more appropriate hospital consultations. Annual resident lectures to prepare junior residents for the most common call scenarios (i.e., control epistaxis and incision and drainage of peritonsillar abscesses) could be helpful in this area. In addition, didactic lectures for primary care physicians on how to evaluate patients with dysphagia may be of value as this was a common consult for otolaryngologist referrals.

Collaborative Comanagement Between Neurohospitalists and Internal Medicine Hospitalists Decreases Provider Costs and Enhances Satisfaction With Neurology Care at an Academic Medical Center

Background and Purpose

The majority of academic medical centers are moving to a neurohospitalist model of care for hospital neurology coverage. Potential benefits over a more traditional academic model of patient care include greater expertise in acute neurologic disease, increased efficiency, and improved availability to patients, providers, and learners. Despite these perceived advantages, switching to a neurohospitalist model can come at substantial financial cost, so finding ways to maximize the positive impact of a limited number of neurohospitalists is very important to the future health of academic neurology departments. Over the past 7 years, we have implemented a model for inpatient neurological care based on an intimate collaborative relationship between the neurology and hospital medicine services at our main academic hospital. Our goal was to optimize the value of care by decreasing cost while improving quality.

Methods

Cost and revenue associated with professional services was evaluated on a yearly basis. As part of ongoing quality improvement efforts, yearly surveys were administered to referring providers during the transition to a collaborative care model in which NHs and medicine hospitalists comanage neurology inpatients.

Results

Net operating loss was dramatically decreased upon transition to the new care model. Concomitantly, there was a robust positive impact on perception of overall quality, timeliness, and communication skills of neurology services.

Conclusions

Collaborative comanagement is an effective strategy to improve overall satisfaction with neurology services at a tertiary academic medical center while maintaining financial viability.

Accuracy of claims-based algorithms for epilepsy research: Revealing the unseen performance of claims-based studies

OBJECTIVE

To evaluate published algorithms for the identification of epilepsy cases in medical claims data using a unique linked dataset with both clinical and claims data.

METHODS

Using data from a large, regional health delivery system, we identified all patients contributing biologic samples to the health system's Biobank (n = 36K). We identified all subjects with at least one diagnosis potentially consistent with epilepsy, for example, epilepsy, convulsions, syncope, or collapse, between 2014 and 2015, or who were seen at the epilepsy clinic (n = 1,217), plus a random sample of subjects with neither claims nor clinic visits (n = 435); we then performed a medical chart review in a random subsample of 1,377 to assess the epilepsy diagnosis status. Using the chart review as the reference standard, we evaluated the test characteristics of six published algorithms.

RESULTS

The best-performing algorithm used diagnostic and prescription drug data (sensitivity = 70%, 95% confidence interval [CI] 66-73%; specificity = 77%, 95% CI 73-81%; and area under the curve [AUC] = 0.73, 95%CI 0.71-0.76) when applied to patients age 18 years or older. Restricting the sample to adults aged 18-64 years resulted in a mild improvement in accuracy (AUC = 0.75,95%CI 0.73-0.78). Adding information about current antiepileptic drug use to the algorithm increased test performance (AUC = 0.78, 95%CI 0.76-0.80). Other algorithms varied in their included data types and performed worse.

SIGNIFICANCE

Current approaches for identifying patients with epilepsy in insurance claims have important limitations when applied to the general population. Approaches incorporating a range of information, for example, diagnoses, treatments, and site of care/specialty of physician, improve the performance of identification and could be useful in epilepsy studies using large datasets.

Patient-reported financial barriers to adherence to treatment in neurology

Objective

Many effective medical therapies are available for treating neurological diseases, but these therapies tend to be expensive and adherence is critical to their effectiveness. We used patient-reported data to examine the frequency and determinants of financial barriers to medication adherence among individuals treated for neurological disorders.

Patients and methods

Patients completed cross-sectional surveys on iPads as part of routine outpatient care in a neurology clinic. Survey responses from a 3-month period were collected and merged with administrative sources of demographic and clinical information (eg, insurance type). We explored the association between patient characteristics and patient-reported failure to refill prescription medication due to cost in the previous 12 months, termed here as “nonadherence”.

Results

The population studied comprised 6075 adults who were presented between July and September 2015 for outpatient neurology appointments. The mean age of participants was 56 (standard deviation: 18) years, and 1613 (54%) were females. The patients who participated in the surveys (2992, 49%) were comparable to nonparticipants with respect to gender and ethnicity but more often identified English as their preferred language (94% vs 6%, p<0.01). Among respondents, 9.8% (n=265) reported nonadherence that varied by condition. These patients were more frequently Hispanic (16.7% vs 9.8% white, p=0.01), living alone (13.9% vs 8.9% cohabitating, p<0.01), and preferred a language other than English (15.3% vs 9.4%, p=0.02).

Conclusion

Overall, the magnitude of financial barriers to medication adherence appears to vary across neurological conditions and demographic characteristics.

Pattern of in-patient neurologic review: An experience from a Tertiary Hospital North-Western Nigeria

Background:

Increase in neurologic diseases burden has increased the demand for neurology services globally, despite the shortcomings of shortage and maldistribution of neurologists worldwide, including Sub-Saharan Africa. This has placed significant pressure on the few available neurologists to provide optimal and effective services in our resource-challenged settings.

Methods:

Neurology referrals were prospectively reviewed over a period of 3 months. Sociodemographic characteristics of the patients, the initial diagnosis by the requesting team, the reasons for the consult/referral, the requesting personnel, duration of hospital stay before request, the time interval between receiving the request and review, the working and final diagnosis after the review, and the diagnostic outcome of neurologic review were analyzed using Predictive Analytics Software^® version 18.0.0 for Windows (Chicago, Illinois, USA).

Results:

Fifty-three hand written in-patient requests were reviewed over the period of study given an average rate of 4.4/week. The mean age was 50.8 ± 16.1 years, and the median length of stay before a review was 1 day (interquartile range: 1–2.5 days). Diagnostic outcome of the reviews were; new diagnoses in 4 (11.3%), the incorrect diagnosis changed in 8 (15.1%), contribution to the differential diagnosis in 15 (28.3%), and contribution to management plans in 24 (45.3%) patients. The association between diagnostic outcomes and mortality in our study was not statistically significant (χ² = 6.66, P = 0.08).

Conclusion:

Our study showed that in-patient neurologic reviews led to significant improvement in diagnostic and management plans. Appropriate policy guidelines should focus more on efficient ways of maximizing benefits of these reviews to patients without overburdening the few available neurologists in our environment.

Descriptive analysis of neurological in-hospital consultations in a tertiary hospital

INTRODUCTION

In-hospital consultations (IHC) are essential in clinical practice in tertiary hospitals. The aim of this study is to analyse the impact of neurological IHCs.

PATIENTS AND METHOD

One-year retrospective descriptive study of neurological IHCs conducted from May 2013 to April 2014 at our tertiary hospital.

RESULTS

A total of 472 patients were included (mean age, 62.1 years; male patients, 56.8%) and 24.4% had previously been evaluated by a neurologist. Patients were hospitalised a median of 18 days and 19.7% had been referred by another hospital. The departments requesting the most in-hospital consultations were intensive care (20.1%), internal medicine (14.4%), and cardiology (9.1%). Reasons for requesting an IHC were stroke (26.9%), epilepsy (20.6%), and confusional states (7.6%). An on-call neurologist evaluated 41.9% of the patients. The purpose of the IHC was to provide a diagnosis in 56.3% and treatment in 28.2% of the cases; 69.5% of the patients required additional tests. Treatment was adjusted in 18.9% of patients and additional drugs were administered to 27.3%. While 62.1% of cases required no additional IHCs, 11% required further assessment, and 4.9% were transferred to the neurology department. Of the patient total, 16.9% died during hospitalisation (in 37.5%, the purpose of the consultation was to certify brain death); 45.6% were referred to the neurology department at discharge and 6.1% visited the emergency department due to neurological impairment within 6 months of discharge.

CONCLUSIONS

IHCs facilitate diagnosis and management of patients with neurological diseases, which may help reduce the number of visits to the emergency department. On-call neurologists are essential in tertiary hospitals, and they are frequently asked to diagnose brain death.

Need for neurology specialists to be dedicated to hospital care in Italy

Any patients admitted to healthcare facilities with a neurological diseases deserves to be managed by a neurologist. This is particularly important for acute onset neurological disorders, because of their severity and the requirement of early and appropriate diagnostic-therapeutic approach. In addition, this may reduce both unnecessary admissions and length of stay, with a significant saving of resources for the National Health System (NHS). To ensure this, it is important to evaluate predictable needs for hospital neurologists in Italy. The hospital discharges for neurological medical diseases of the Major Disease Category (MDC) 1 were 455,132 in 2009 and 491,836 in 2008, more than 50 % of which were acute neurological disorders. Stroke and transient ischemic attacks (TIA) accounted for about 170,000 per year. Currently available neurologists in Italian healthcare facilities are largely insufficient to assist such a large number of patients. The 270 Neurological Care Units in Italy (of which 243 open to the emergency care) are equipped with an average number of 7.7 neurologists per unit, inadequate to ensure on duty care 24 h a day, 7 days a week. In addition, the mean age of hospital neurologists is quite high, with provision for large retirement. It is therefore required to increase in the next few years the number of neurologists by at least 30 %, with an increase of 562 units. To meet the need for neurology specialists committed to hospital care in Italy is also necessary to increase the number of scholarships for residents in post-graduate schools.

Technical and clinical analysis of microEEG: a miniature wireless EEG device designed to record high-quality EEG in the emergency department

BACKGROUND

We describe and characterize the performance of microEEG compared to that of a commercially available and widely used clinical EEG machine. microEEG is a portable, battery-operated, wireless EEG device, developed by Bio-Signal Group to overcome the obstacles to routine use of EEG in emergency departments (EDs).

METHODS

The microEEG was used to obtain EEGs from healthy volunteers in the EEG laboratory and ED. The standard system was used to obtain EEGs from healthy volunteers in the EEG laboratory, and studies recorded from patients in the ED or ICU were also used for comparison. In one experiment, a signal splitter was used to record simultaneous microEEG and standard EEG from the same electrodes.

RESULTS

EEG signal analysis techniques indicated good agreement between microEEG and the standard system in 66 EEGs recorded in the EEG laboratory and the ED. In the simultaneous recording the microEEG and standard system signals differed only in a smaller amount of 60 Hz noise in the microEEG signal. In a blinded review by a board-certified clinical neurophysiologist, differences in technical quality or interpretability were insignificant between standard recordings in the EEG laboratory and microEEG recordings from standard or electrode cap electrodes in the ED or EEG laboratory. The microEEG data recording characteristics such as analog-to-digital conversion resolution (16 bits), input impedance (>100MΩ), and common-mode rejection ratio (85 dB) are similar to those of commercially available systems, although the microEEG is many times smaller (88 g and 9.4 × 4.4 × 3.8 cm).

CONCLUSIONS

Our results suggest that the technical qualities of microEEG are non-inferior to a standard commercially available EEG recording device. EEG in the ED is an unmet medical need due to space and time constraints, high levels of ambient electrical noise, and the cost of 24/7 EEG technologist availability. This study suggests that using microEEG with an electrode cap that can be applied easily and quickly can surmount these obstacles without compromising technical quality.

Payment reform and the changing landscape in medical practice: Implications for neurologists

The growth in health care spending in the United States, though slowed in the last few years, remains unsustainable. Since higher health care spending does not correlate with most measures of improved patient outcome, there are new attempts to define "value" in health care as the ratio of quality to cost. This article reviews newer proposed models for provider payment and organization and their possible effects on neurologic practice.

The role of emergency neurology in Italy: outcome of a consensus meeting for a Intersociety position

A possible definition of clinical, educational and organizing aspects of emergency neurology in Italy is reported in this position paper of Emergency Neurology Intersociety Group, created in 2008 among the two neurological Societies in Italy: Società Italiana di Neurologia and Società di Neuroscienze Ospedaliere. The aim of this Group has been the evaluation of the role of neurologist in the emergency setting of Italian hospitals, as well as of the description of different scenarios in which a ward dedicated to a semi-intensive care of neurological emergencies could have a role in the actual organization of academic or general hospitals in our Country. The actual great relevance of neurologist activity in the inpatients treatment, in fact, is actually misleaded as it is the considerable significance of neurological expertise, techniques and support in hospital care pathways also involving neurological manifestations throughout the course of other diseases. Finally, the possible contents of educational programs orienting neurological specialty towards a better comprehension and management of emergency neurological problems either in terms of specific formation or of techniques to be learned by emergency neurologist, are reported as a results of the Consensus Workshop hold in Castiglioncello (LI) in September 12th, 2009.