Association of a higher density of specialist neuroscience providers with fewer deaths from stroke in the United States population

Abstract

Object. Stroke is a leading cause of death and disability. Given that neurologists and neurosurgeons have special expertise in this area, the authors hypothesized that the density of neuroscience providers is associated with reduced mortality rates from stroke across US counties.Methods. This is a retrospective review of the Area Resource File 2009-2010, a national county-level health information database maintained by the US Department of Health and Human Services. The primary outcome variable was the 3-year (2004)(2005)(2006) average in cerebrovascular disease deaths per million population for each county. The primary independent variable was the combined density of neurosurgeons and neurologists per million population in the year 2006. Multiple regression analysis was performed, adjusting for density of general practitioners (GPs), urbanicity of the county, and socioeconomic status of the residents of the county.Results. In the 3141 counties analyzed, the median number of annual stroke deaths was 586 (interquartile range [IQR] 449-754), the median number of neuroscience providers was 0 (IQR 0-26), and the median number of GPs was 274 (IQR 175-410) per million population. On multivariate adjusted analysis, each increase of 1 neuroscience provider was associated with 0.38 fewer deaths from stroke per year (p < 0.001) per million population. Rural location (p < 0.001) and increased density of GPs (p < 0.001) were associated with increases in stroke-related mortality.Conclusions. Higher density of specialist neuroscience providers is associated with fewer deaths from stroke. This suggests that the availability of specialists is an important factor in survival after stroke, and underlines the importance of promoting specialist education and practice throughout the country.

The Growing Shortage of Vascular Neurologists in The Era of Health Reform

“…5 Although the American Stroke Association does not explicitly mandate that a neurologist be the sole provider of care to patients with acute stroke, best practices indicate that VNs should play the leading role in stroke units. [9][10][11] The American Board of Psychiatry and Neurology began certifying VNs in the United States in 2005 as a way to formally recognize those who completed special training and who demonstrate competence in all aspects of vascular neurology care. 12 The background of those VNs is diverse.…”

Regional Density of Cardiologists and Rates of Mortality for Acute Myocardial Infarction and Heart Failure

“…9,10 Additionally, several studies in other specialties have shown relationships between regional density of healthcare providers and outcomes. Regions with a higher density of primary care physicians have a lower mortality for ambulatory care–sensitive conditions; 11 regions with a higher density of neurologists and neurosurgeons have a lower stroke mortality; 12 and regions with a higher density of gastroenterologists have lower rates of end-stage colorectal cancer. 13 However, the relationship between density of cardiologists and outcomes for cardiac conditions such as AMI and HF is unknown.…”

Editorial: Stroke, geography, and provider density

“…The most powerful result reported by Desai et al 6 is the much higher stroke-related mortality for rural residents. Stroke is a time-sensitive disease, and for many US residents it is inevitable that the nearest hospital will lack sophisticated stroke care: most US towns smaller than 30,000 residents have no neurosurgeon, and most smaller than 20,000 have no neurologist.…”

“…Stroke incidence and mortality rates in the US are well known to have substantial geographic variation, some of which is explained by demographic characteristics-the level of stroke risk factors in the resident population, such as smoking, obesity, and other cardiovascular risk factors. Desai and colleagues 6 used the US Department of Health and Human Services Area Resource File (ARF) to investigate the number of specialist and generalist physicians practicing in US counties as a predictor of stroke-related mortality in the resident population from 2004 to 2006. The investigators report a lower risk of death from stroke in counties with a higher density of neuroscience providers (neurologists and neurosurgeons), with 1 less death per million population per year for every 3 more neuroscience providers practicing in a county.…”

“…Increased use of telestroke services and the operation of market forces promoting the creation of more comprehensive stroke centers may be more fruitful ways to bring high-quality stroke care to all US residents. The article by Desai et al 6 offers evidence that we have a ways to go before we achieve this goal. We thank Dr. Barker for his thoughtful editorial review and commentary on our study.…”