Hospitalists series: the Neurohospitalist

October 8, 2013 at 8:00 AM Leave a comment


In our last post, we introduced our hospitalist series  (“Hospitalists rising: a brief overview”), in which we’ll discuss the various aspects of the hospitalist trend that has emerged in the last decade or so. This week we’ll take a closer look at the neurohospitalist, one of several emerging hospitalist subspecialties that has gained momentum in the last few years.

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The popularity and fast growth of the internal medicine hospitalist profession has inevitably led to similar trends in several medical specialties, especially those with large outpatient populations and small inpatient volumes.  In other words, community-based specialists are often overloaded with office visits and ambulatory/outpatient procedures, and they are less and less willing to make trips to the hospital, which account for a much smaller portion of their patient volume. Installing physicians as hospitalists in specialty areas allows community-based specialists to focus on outpatient care.

A neurohospitalist is a physician whose subspecialty interest is the management of inpatients with neurological disorders, without outpatient responsibilities.1 They are poised to replace community-based neurologists in the inpatient setting for three key reasons:

1) Neurohospitalists evaluate and treat a spectrum of neurologic conditions, just like their community-based counterparts, but their accessibility in the hospital and familiarity with hospital systems of care allow neurohospitalists to respond much faster to situations in which timeliness and close monitoring are imperative, such as stroke, epilepsy disorders, and encephalopathy.1,3

2) There is decreased incentive for community based neurologists to take on inpatient work due to reduced reimbursement, increased litigation risk and higher malpractice premiums.

3) Inpatient neurologic care has grown increasingly complex in the last decade with increased focus on quality metrics, end of life care for terminal neurological disorders, and improved outcomes for all neurologic patients. Community-based neurologists may not have the time or interest to take on the expanded responsibilities of today’s inpatient neurology practice.2

Cover page of the Neurohospitalist online journal.

The last point is most important, as neurohospitalists are well-suited to become drivers of the quality metrics that will impact hospitals’ bottom lines under healthcare reform. For example, a 24-month retrospective study of 533 cases in which patients were discharged with a diagnosis of ischemic stroke  showed that the average length of stay for patients treated by hospitalists was significantly lower than that of patients treated by community-based neurologists. They also achieved a higher compliance rate for 10 of the Joint Commission’s 11 stroke quality metrics for Primary Stroke Center certification, such as smoking cessation education and IV tPA administration. This suggests that neurohospitalists can not only help reduce hospital costs by reducing average LOS for common neurologic conditions, but they can also help improve compliance with quality metrics necessary for hospitals to maintain Primary Stroke Center certification.4

LOS study

Study results show that neurohospitalists achieved a significantly lower (P=.005) mean LOS of (± S.D.) 4.9 days compared to non-neurohospitalists with mean LOS of (± S.D.) 6.5 days.

Studies have also shown that neurohospitalists can greatly improve timely treatment of stroke.  tPA, or tissue plasminogen activator, is the gold standard in ischemic stroke treatment and works by dissolving the clot and improving blood flow to the part of the brain that is deprived of blood.5 tPA must be administered within 3.5-4.5 hours of stroke in order for it to be effective, and as such, is not administered in many cases where patients have been tPA eligible, due to a lack of neurology coverage in the ED and to delayed presentation.4 A 2007 study in the Circulation journal of the American Heart Association indicated that in community hospitals, the employment of neurohospitalists raised the rate of tPA administration by as much as 25%.6

A more recent study showed that neurohospitalists are better than community-based neurologists at meeting the best-practices strategy of a “door-to needle time” (DNT) of 60 minutes or less set by the American Heart Association/American Stroke Association (AHA/ASA). In other words, neurohospitalists can more quickly and efficiently evaluate stroke patients for tPA eligibility and administer the treatment, often doing so in the ideal time frame of 60 minutes or less after the onset of stroke, which leads to better chances of recovery from stroke. They were also better at meeting inpatient quality and safety metrics and had less protocol violations than community-based neurologists.7

These findings are significant and indicate that neurohospitalists can be important providers of efficient, high quality inpatient neurologic care, but it doesn’t mean that the neurohospitalist model will be universally adopted. Hospitals in areas with low outpatient volumes may not see the value of employing a separate neurohospitalist, and the nature of neurology makes good communication and rapport between community-based neurologists and neurohospitalists (who will oftentimes co-manage patients) all the more crucial, so systems must be in place for effective use of neurohospitalists. However, communities with large outpatient volumes could greatly benefit from neurohospitalists, and large hospitals may find them indispensable for meeting today’s quality and safety standards.

Tune in next week for our next entry in the Hospitalist series. 

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Sources:

1. http://nho.sagepub.com/content/1/1/5.full

2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726081/

3. http://www.neurology.org/content/74/2/e9.full.pdf+html

4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726083/

5. http://www.strokeassociation.org/STROKEORG/AboutStroke/Treatment/Stroke-Treatments_UCM_310892_Article.jsp

6. http://wweb.uta.edu/faculty/ricard/PDFs/Trowbridge%20%282008%29%20Kinematic%20and%20kinetic%20changes.pdf (see Malone, K. et al: Utilizing Neurohospitalists for Continued Improvement of Acute Stroke Carein a Community Hospital)

7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726106/

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Entry filed under: Hospital Care, Hospital trends, Hospitalists, Medical Specialties, Neurology.

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