Challenges in the Identification of Cobalamin-Deficiency Polyneuropathy

Saperstein, David; Wolfe, Gil I.; Gronseth, Gary S.; Nations, Sharon P.; Herbelin, Laura; Bryan, Wilson W.; Barohn, Richard J.

doi:10.1001/archneur.60.9.1296

Cited by 122 publications

(100 citation statements)

References 22 publications

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“…We selected tests based on their relevance to the diagnostic evaluation of peripheral neuropathy and included fasting glucose level, hemoglobin A1C (HA1C), GTT, SPEP, B 12 , antinuclear antibodies (ANA), erythrocyte sedimentation rate (ESR), thyroid-stimulating hormone (TSH), complete blood count (CBC), comprehensive metabolic panel, electrodiagnostic tests, and MRI studies (brain, cervical, thoracic, or lumbosacral spine).…”

Section: Diagnostic Testsmentioning

confidence: 99%

“…Laboratory tests endorsed by the AAN guideline (fasting glucose, B 12 , SPEP, GTT) were more commonly ordered in patients seen by a neurologist with the exception of fasting glucose, which had similar utilization between provider types (table 2). The 3 tests with the largest absolute difference in utilization between patients seen by neurologists and non-neurologists were nerve conduction studies (50% vs 17%, p , 0.0001), MRIs of at least one component of the neuroaxis (45% vs 13%, p , 0.0001), and EMG (37% vs 10%, p , 0.0001).…”

Section: Test Utilizationmentioning

confidence: 99%

“…By comparison, non-neurologists had much lower utilization of MRIs and electrodiagnostic tests, but also had lower utilization of AAN-recommended laboratory tests for neuropathy, 12 and SPEP have been shown to have a substantial yield in neuropathy presentations and abnormal results influence further relevant management including specific treatments. 8,11,12 This result highlights the fact that more testing does not equate with overutilization. Furthermore, the low utilization of AANrecommended tests by all provider types emphasizes the opportunity we have to improve the care of many patients with neuropathy.…”

Section: Test Utilizationmentioning

confidence: 99%

“…Both vitamin B 12 and SPEP have been shown to have a substantial yield in neuropathy presentations and abnormal results influence further relevant management including specific treatments.…”

Section: Test Utilizationmentioning

confidence: 99%

“…While peripheral neuropathy comprises many different subtypes that may affect what constitutes appropriate testing, the vast majority of patients have a distal symmetric polyneuropathy. 8 Recently, the AAN published a systematic review of diagnostic testing in distal symmetric polyneuropathy, and found evidence to support routine testing with serum protein electrophoresis (SPEP), B 12 , fasting glucose test, and glucose tolerance test (GTT). 8 However, the strength of the evidence is modest (Class C), and the review does not address other commonly ordered tests for this condition, including MRIs of the neuroaxis and electrodiagnostic tests.…”

mentioning

confidence: 99%

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Expenditures in the elderly with peripheral neuropathy

et al. 2013

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SummaryTo optimize care in the evaluation of peripheral neuropathy, we sought to define which tests drive expenditures and the role of the provider type. We investigated test utilization and expenditures by provider type in those with incident neuropathy in a nationally representative elderly, Medicare population. Multivariable logistic regression was used to determine predictors of MRI and electrodiagnostic utilization. MRIs of the neuroaxis and electrodiagnostic tests accounted for 88% of total expenditures. Mean and aggregate diagnostic expenditures were higher in those who saw a neurologist. Patients who saw a neurologist were more likely to receive an MRI and an electrodiagnostic test. MRIs and electrodiagnostic tests are the main contributors to expenditures in the evaluation of peripheral neuropathy, and should be the focus of future efficiency efforts.

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Section: Diagnostic Testsmentioning

confidence: 99%

Section: Test Utilizationmentioning

confidence: 99%

Section: Test Utilizationmentioning

confidence: 99%

Section: Test Utilizationmentioning

confidence: 99%

mentioning

confidence: 99%

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Expenditures in the elderly with peripheral neuropathy

et al. 2013

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Tests and Expenditures in the Initial Evaluation of Peripheral Neuropathy

Callaghan

McCammon

Kerber³

et al. 2012

Arch Intern Med

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Background Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing. We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. Methods The 1996–2007 Health and Retirement Study (HRS) - Medicare Claims linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using ICD-9 codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization performed 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods. Results Of the 12,673 patients, 1,031(8.1%) received a new ICD-9 diagnosis of neuropathy and met our inclusion criteria. Of the 15 tests considered, a median of 4 (inter-quartile range (IQR)=2–5) tests were performed with over 400 patterns of testing. An MRI of the brain and/or spine was ordered in 23.2%, whereas a glucose tolerance test was rarely obtained (1%). Medicare expenditures were significantly higher in the diagnostic period compared to the baseline period (mean $14,363 versus $8,067, p<0.0001). Conclusions Patients diagnosed with peripheral neuropathy typically undergo many tests but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield MRIs while very few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

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