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Outcome of outpatient neurology consultations: Physician's evaluations compared to patients' perceptions
Journal of the Neurological Sciences 276 (2009) 175–178
Contents lists available at ScienceDirect
Journal of the Neurological Sciences j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j n s
Outcome of outpatient neurology consultations: Physician's evaluations compared to patients' perceptions☆,☆☆ Pushpa Narayanaswami a,⁎, Jill C. Hahne b a b
Dept. of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, TCC-8, 330 Brookline Avenue, Boston MA 02215, USA Department of Internal Medicine/Neurology, Mary Lanning Memorial Hospital, 715 N. St. Joseph Avenue, Hastings, NE 68901, USA
a r t i c l e
i n f o
Article history: Received 23 May 2008 Received in revised form 28 August 2008 Accepted 19 September 2008 Available online 20 November 2008 Keywords: Neurology consultations Office Outpatient Ambulatory Patient perceptions Outcome
a b s t r a c t The outcome of outpatient neurologic consultations has not been previously evaluated. There is also no data regarding patients' perceptions of outpatient neurologic consultations. In this study, we assessed the physician's evaluations of the outcome and utility of neurologic consultations by reviewing office records of 108 patients referred for consultation to a secondary level neurology clinic. Predefined criteria were used to determine diagnosis and treatment changes resulting from the consultation and the usefulness of the consultation. Outcome was defined as “resolved/improved”, “unchanged”, or “worse”. The patients' perceptions of the usefulness of the neurologic consultations were assessed by a questionnaire survey. The questionnaire evaluated patients' perceptions of diagnosis and treatment changes, outcome and usefulness of the consultation. The physician's evaluation was compared to the patients' perceptions. Neurologic consultations resulted in diagnosis changes in 62% and treatment changes in 85%. Either diagnosis or treatment changed in 92% of consultations, which were regarded as “useful”. Seventy-four percent of patients concurred with the physician's evaluation of outcome and 96% concurred that the consultation was useful. Although small, this study found that outpatient neurologic consultations result in diagnosis and treatment changes in a substantial proportion of patients. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Quality of medical care may be assessed on the basis of structure (characteristics of physicians and hospitals), process (components of the encounter between healthcare provider and patient, such as tests ordered) or outcome (patient's health status subsequent to the encounter) [1]. One method of evaluating process and outcome is by reviewing a data source such as medical records [1,2]. It has been argued that process data may not be able to predict outcomes satisfactorily, and the sole use of process data to improve care may result in increased costs of medical care without corresponding improvement in healthcare [3]. The use of outcome measures such as improvement in the patient's health status subsequent to the encounter may also not be entirely valid. Differences in outcomes between patients receiving the same treatment may be because of factors that are not directly under the control of the health care provider, such as differences in patient characteristics. As an additional tool, surveys of the views of patients on the help they receive from consultation may be useful in neurologic “audit” [4]. ☆ Presented at the Annual Meeting, American Academy of Neurology, San Diego, CA April 2006 (Neurology 2006;66(5)Suppl.2:A231-232). ☆☆ Disclosures: The authors report no conflicts of interest. ⁎ Corresponding author. Tel.: +617 667 8130; fax: +617 667 3175. E-mail address: [email protected] (P. Narayanaswami). 0022-510X/$ – see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2008.09.036
As “pay for performance” initiatives for quality improvement gain impetus, measurement of the quality and demonstration of the utility of neurological care becomes important. In a study of inpatient neurologic consultations in a university setting, Hillen and Sage [5] reported that only 43% of consultations were deemed “useful”. In this study, a consultation was deemed “useful” if the neurologist suggested a diagnosis that had not been considered by the referring physician, or recommended a procedure that was useful in making the diagnosis or in eliminating alternative diagnoses. There are no studies that evaluate the outcome of outpatient neurologic consultations. This study utilizes medical record review to evaluate the outcome of outpatient neurologic consultations and compares the results so obtained to the results of a questionnaire survey of the same cohort, reflecting the patients' perceptions of usefulness of the consultation. 2. Methods 2.1. Study design 1. Questionnaire survey of patients referred for neurologic consultation. 2. Review of medical records of these patients. 3. Comparison of the results of the questionnaire survey with the results of the record review. This study was carried out at Hastings Neurology Clinic, affiliated with Mary Lanning Memorial Hospital, Nebraska, USA. It is the
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secondary level community neurology referral center for a population of about 50,000 from the surrounding counties in Nebraska and Kansas. The clinic is staffed by one neurologist (PN). The referral network to the clinic includes family practice physicians, internists, nurse practitioners who provide primary care, orthopedic surgeons, psychiatrists, one neurosurgeon and one rheumatologist. The study was approved by the Ethics Committee of Mary Lanning Memorial Hospital. All new patients seen at the clinic between February and June 2005 were given a two-part questionnaire (Appendix A). At the initial visit, the patient or a family member completed Part 1 (demographic data and reason for neurology consultation). Patients or their accompanying family completed Part 2 at a return visit, after diagnostic or therapeutic decisions had been taken and recommendations made to the referring physician. All questionnaires were completed before or at the fourth return visit. The non-physician author (JH) reviewed the patients' records to determine whether the evaluation was complete, and decided when each patient would complete Part 2 of the questionnaire. If a new medication had been introduced, the neurologist author (PN) determined if enough time had been allowed for medication changes to become effective before patients completed Part 2. In Part 2, the patient or family member was asked to record the diagnosis and treatment changes that resulted from the consultation, whether the problem for which they were referred had “resolved”, “improved”, was “unchanged” or “worse” and if the neurologic consultation was “useful” or not. These terms were not defined in the questionnaire, and were left to the patients' interpretation. 2.2. Data analysis The neurologist (PN) reviewed all patient questionnaires. The following data was recorded: diagnosis change, treatment change, outcome (if the condition for which they were referred had “resolved”, “improved”, was “unchanged” or “worse”) and usefulness of the consultation. The nurse (JH) reviewed the office records and recorded the initial, or referring, diagnosis and final diagnosis. The initial diagnosis was defined as the diagnosis made by the referring physician, and was determined from the referring physicians' request for consultation. If patients were referred for a symptom such as headache or weakness rather than with a specific diagnosis, we considered the symptom as the referring diagnosis for the purposes of this study. The final diagnosis was defined as the diagnosis made by the neurologist (PN) and was obtained from the office note on or before the date of completion of Part 2 of the patient questionnaire. A “change in diagnosis” was defined as a diagnosis made following
Fig. 1. Comparison of physician/patient responses for diagnosis/treatment changes and usefulness of consultation.
Table 1 Concordance between physician evaluations and patient responses Diagnosis Change (yes and no) Treatment Change (yes and no) Consult useful Outcome (improved or otherwise)
61/108 (56%) 75/108 (69%) 95/99a (96%) 80/108 (74%)
a 9 consultations were considered “not useful” on physician evaluation, since neither diagnosis nor treatment changed.
neurologic evaluation which was different from or in addition to the initial, referring diagnosis. “Treatment change” was defined as a change in the dosage of an ongoing medication, the recommendation of a new medication, surgical intervention or non-pharmacological measures such as physical therapy, irrespective of whether the patients followed through with the recommendations. Outcomes were defined prior to conducting the record review as follows: “resolved”, wherein the problem for which the consultation was sought completely resolved (as in carpal tunnel syndrome after surgery), “improved” wherein patients or the neurologist reported objective improvement (such as decrease in migraine frequency on a headache diary, or examination documenting improvement in tremor), “unchanged”(where the notes documented that the problem for which the consultation was sought was unchanged), or “worse”. The “outcome” of each consultation was determined from the information obtained in the office notes on or before the date of completion of Part 2 of the questionnaire. The consultation was considered “useful” if either diagnosis or treatment changed. The neurologist's evaluation of “diagnosis changes”, “treatment changes”, “outcome” and whether the consultation was “useful” or not was compared with patient responses and concordance was calculated. Descriptive statistics were utilized. 3. Results Between February and June 2005, 187 new patients were seen for consultation. All patients completed Part 1 of the questionnaire. 118 (63%) patients completed both parts of the questionnaire. Ten surveys were incomplete. Complete surveys were available in 108 patients (58%), who were included in the study. Of the 69 (37%) who did not complete Part 2, 43 (62%) did not return for follow-up, and 2 (3%) refused the recommended work-up. In 22 patients (32%) the initial evaluation suggested a non-neurological cause of their symptoms; they were therefore not seen in follow-up consultation, and were excluded from the study. Two patients died (3%) [myocardial infarction (1), sudden death (1)]. On review of the medical records, the physician documented a diagnosis change in 67/108 patients (62%). Only 22 of these 67 patients (33%) identified the diagnosis changes on their questionnaires. Two other patients responded that the consultation resulted in a diagnosis
Fig. 2. Comparison of physician/patient responses for outcome of consultations.
P. Narayanaswami, J.C. Hahne / Journal of the Neurological Sciences 276 (2009) 175–178
change without documented diagnosis changes in their medical records (Fig. 1). In all, 61/108 (56%) patients concurred with the physician's evaluation of whether the diagnosis changed or not (Table 1). On medical record review, treatment changes were documented in 92/108 patients (85%). Of these, 60/92 (65%) patients identified the changes (Fig. 1). As a group, 75/108 (69%) patients agreed with the physician's evaluation of whether treatment had changed or not (Table 1). Of the 33 (31%) who did not concur, 32 did not recall documented medication changes. One patient responded, “yes” in the absence of documented treatment changes. In 2 patients who did not recall the treatment changes, [Parkinson's disease (1), multiple sclerosis (1)] “treatment change” consisted of physical therapy. In these 2 patients, although medication options were discussed, no medications were prescribed. Review of the physician's notes for “outcomes” as defined previously resulted in 57/108 patients (53%) being classified as “improved”/ “resolved” (Fig. 2). Fifty-one patients (89%) concurred with the evaluation. Four patients said they were “unchanged”, and 2, “worse”. The outcome was considered to be “unchanged” from the review of office notes in 51/108 (47%) patients (Fig. 2). Twenty-nine of the 51 patients (57%) concurred; 13/51 (25%) said they were “improved”, 9/51 (18%) said they were “worse”. Overall concordance for outcome, in the “improved/resolved” and “unchanged” categories was 74% (80/108) (Table 1). Medical record review did not reveal a “worse” outcome in any of the 108 patients. However, 11 patients (10%) said that the outcome was “worse” after consultation (Fig. 2). These included Parkinson's disease (2), monosymptomatic multiple sclerosis (2), progressive supranuclear palsy, cognitive impairment, intractable myoclonus associated with renal failure, complex partial seizures, lumbar stenosis, multiple symptoms with negative work-up, and ulnar entrapment at the elbow (1 each). The physician's evaluation of outcome in these patients was as follows: “unchanged” in 9 [monosymptomatic multiple sclerosis (2), Parkinson's disease (2), myoclonus (1), progressive supranuclear palsy (1), complex partial seizures (1), lumbar stenosis (1) and multiple symptoms with negative work-up (1)]; the outcome was classified as “improved” in the remaining 2 [improved cognitive function after depression was treated (1) and ulnar entrapment across the elbow, post-surgery (1)]. Overall, neurologic consultation resulted in a change in either diagnosis or treatment in 99/108 (92%), and both in 60/108 (56%) patients. The 99/108 (92%) consultations that resulted in a change
Table 2 Diagnoses made after neurologic consultations⁎ Diagnoses
Patients
Carpal tunnel syndrome Chronic tension type headache Cerebrovascular accident, transient ischemic attack Depression Epilepsy Migraine with aura Migraine without aura Mixed dementia, Alzheimer's Disease, mild cognitive impairment Multiple sclerosis and variants Exclusion of multiple sclerosis Other headache syndromes (analgesic rebound, indomethacin responsive syndromes) Parkinson's disease/Parkinsonism Peripheral neuropathy Radiculopathy Syncope, post traumatic dizziness Writer's cramp, subacute combined degeneration, ALS, polymyalgia rheumatica, benign positional vertigo, progressive supranuclear palsy, segmental myoclonus, myoclonus with renal failure, meralgia paresthetica, ulnar entrapment at elbow, mixed tremor, neurogenic claudication.
4 5 2 4 4 3 5 3 5 2 11
⁎Some patients had more than one diagnosis.
4 4 3 2 each 1 each
177
either in diagnosis or treatment were defined as “useful”. Ninety-five of the 99 patients (96%) concurred with the physician's evaluation (Fig. 1, Table 1). Four patients responded that the consultation was “neither useful nor harmful”. Of the 9 (8%) consultations evaluated by the physician as “not useful”, meaning that neither diagnosis or treatment changed as a result of the consultation, 7 patients said that the consultation was “useful” and 2 answered that it was “neither useful nor harmful”. The referring diagnoses in these patients were: multiple sclerosis (2), epilepsy (2), Parkinson's disease (2), tinnitus (1), leg pain (1), and generalized weakness (1). Table 2 summarizes the diagnoses resulting from the neurologic consultation. 4. Discussion A few studies have evaluated the utility and outcome of consultations in specific neurological conditions. Most of these studies have utilized process data obtained by medical record review. In an Irish study by Costello et al. [6], inpatient neurologic consultations contributed to patient management in three ways: by establishing a new diagnosis (41%), by a change in pre-existing diagnoses (11%), or therapeutic changes (48%). Petty et al. [7] found that neurology evaluation was associated with better survival for patients with ischemic stroke, but not those with atrial fibrillation. In their study, neurologists used carotid ultrasound, cerebral angiography and carotid endarterectomy more frequently than non-neurologists. The authors suggest that neurologists' greater attention to pathophysiologic mechanisms of non-cardioembolic stroke may be responsible for the improved outcome. In a study of diagnostic outcomes in multiple sclerosis, two-thirds of patients referred to a university based multiple sclerosis center had an alternative diagnosis [8]. Benbadis et al. [9] found that only 32% of patients with chronic back pain had a neurologic cause such as radiculopathy or myelopathy. In their study, two-thirds of these patients were treated similarly to those with uncomplicated spondylosis. Patients who needed surgery or epidural blocks were referred to another specialist. The authors concluded that with the exception of electromyography for radiculopathy, neurologists do not make a significant contribution to the care of patients with back pain [9]. Other studies have utilized questionnaire surveys of patients to evaluate outcomes. Salvesen and Bekkelund, [10,11] in a questionnaire survey of patients with headache, found that neurologic evaluation for headaches resulted in greater improvement and better quality of life, and that 63% of patients with migraine were satisfied with the consultation. In these studies, patients were more likely to have relief of their headaches if they received a diagnosis. Interestingly, there was no significant improvement in quality of life if treatment was prescribed, suggesting that patient information may be an important aspect of the consultative process [10]. The outcome of outpatient neurologic consultations as a whole has not been studied previously. In this study we have attempted to assess the utility of ambulatory neurologic consultations in 2 ways; firstly, after care was provided, the process data (diagnosis changes, treatment changes) and outcomes data (pre-determined definitions of outcomes and usefulness of the consultation) were assessed by a medical record review. Secondly, a “neurologic audit” was performed using a questionnaire survey of the patients. There are limitations to this study. The major limiting factor is that it reflects the findings in a single physician neurology practice. The neurologic consultation was provided by the same team that performed the study, thus introducing a bias. In an attempt to minimize this bias, the medical records were reviewed by the nurse (JH), after the patients had completed Part 2 of the questionnaire, with pre-determined criteria for initial and final diagnoses, diagnosis and treatment changes, “outcome” and “usefulness” of the consultation. The neurologist reviewed the patient questionnaires without knowledge of the results of the record review.
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On record review, an outcome category of “worse” was not seen in any of the patients. This is not unexpected, since the duration of the study was too short to detect worsening of chronic illnesses such as Parkinson's disease or amyotrophic lateral sclerosis. In the short time frame of the study, no serious adverse effects causing a worsening of the patient's condition were noted with any therapeutic intervention. In this study, a change in diagnosis or treatment was required to term the consultation “useful”, although it may be argued that a consultation may be useful even if it only confirms the referring physician's diagnosis. Additionally, the consultation may also be considered to have been useful in the 22 patients wherein a neurological cause for their symptoms was excluded. These patients were not included in the study, since they were not seen again and their questionnaire responses were therefore not available. Almost half of the patients were classified by the physician to have an “unchanged” outcome. This category reflects patients with chronic, ongoing illnesses such as multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis, epilepsy and chronic headaches other than migraine. In patients with epilepsy or chronic headaches, the short time frame of the study may have been insufficient to discern improvement, since trials of multiple medications and interventions are often necessary in these conditions, thus reducing the number of patients who may have otherwise been classified as “improved”. The concordance between the physician's evaluation and patient responses for outcome (74%) and usefulness of the consultation (96%) was high, although the patients' assessment of usefulness was purely subjective, in contrast to the physician's evaluation where a change in either diagnosis or treatment was required to call a consultation “useful”. Since concordance for diagnosis changes (56%) and treatment changes (69%) was lower than the concordance for outcome (74%) and usefulness (96%), it is possible that the non-blinded nature of the questionnaires may have influenced patient responses in a positive direction. Additionally, the assessment of “outcome” both by the patients and physician was more subjective than the evaluation of diagnosis and treatment changes. The non-blinded questionnaires may also explain the discrepancy between the number of patients who identified diagnosis changes (33%), treatment changes (65%) and
the number of patients who said that the consultation was “useful” (96%). However, like “outcome”, “usefulness” is also more subjective than the actual recollection of specific diagnosis and treatment changes. It may reflect patient satisfaction with the consultation overall, which may be related to factors that were beyond the measure of this study, such as physician–patient rapport. Notwithstanding these limitations, this small study suggests that outpatient neurologic consultations result in diagnostic or therapeutic changes in the majority of patients. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jns.2008.09.036. References [1] Brook RH, McGlynn EA, Cleary PD. Quality of healthcare. Part 2: Measuring quality of care. N Engl J Med 1996;335:966–70. [2] Brook RH, Appel FA. Quality-of-care assessment: choosing a method for peer review. N Engl J Med 1973;288:1323–9. [3] Ellwood PM. Outcomes Management: a technology of patient experience. N Engl J Med 1973;288:1323–9. [4] Hopkins A. Clinical audit and neurology. J Neurol Neurosurg Psychiatry 1992;55:19–25 [Suppl]. [5] Hillen ME, Sage JI. Proving the worth of neurologists? Neurology 1996;46:276–7. [6] Costello DJ, Renganathan R, O'Hare A, Murray B, Lynch T. Audit of an inpatient neurology consultation service in a tertiary referral center: value of the consulting neurologist. Ir Med J 2005;98:134–7. [7] Petty GW, Brown Jr RD, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke: outcomes, patient mix, and practice variation for neurologists and generalists in a community. Neurology 1998;50:1669–78. [8] Carmosino MJ, Brousseau KM, Arciniegas DB, Corboy JR. Initial evaluations for multiple sclerosis in a university multiple sclerosis center: outcomes and role of magnetic resonance imaging in referral. Arch Neurol 2005;62:585–90. [9] Benbadis SR, Herrera M, Orazi U. Does the neurologist contribute to the care of patients with chronic back pain? Eur Neurol 2002;48:61–4. [10] Salvesen R, Bekkelund SI. Aspects of referral care for headache associated with improvement. Headache 2003;43:779–83. [11] Bekkelund SI, Salvesen R. Patient satisfaction with a neurological specialist consultation for headache. Scand J Prim Health Care 2002;20:157–60.
Contents lists available at ScienceDirect
Journal of the Neurological Sciences j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j n s
Outcome of outpatient neurology consultations: Physician's evaluations compared to patients' perceptions☆,☆☆ Pushpa Narayanaswami a,⁎, Jill C. Hahne b a b
Dept. of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, TCC-8, 330 Brookline Avenue, Boston MA 02215, USA Department of Internal Medicine/Neurology, Mary Lanning Memorial Hospital, 715 N. St. Joseph Avenue, Hastings, NE 68901, USA
a r t i c l e
i n f o
Article history: Received 23 May 2008 Received in revised form 28 August 2008 Accepted 19 September 2008 Available online 20 November 2008 Keywords: Neurology consultations Office Outpatient Ambulatory Patient perceptions Outcome
a b s t r a c t The outcome of outpatient neurologic consultations has not been previously evaluated. There is also no data regarding patients' perceptions of outpatient neurologic consultations. In this study, we assessed the physician's evaluations of the outcome and utility of neurologic consultations by reviewing office records of 108 patients referred for consultation to a secondary level neurology clinic. Predefined criteria were used to determine diagnosis and treatment changes resulting from the consultation and the usefulness of the consultation. Outcome was defined as “resolved/improved”, “unchanged”, or “worse”. The patients' perceptions of the usefulness of the neurologic consultations were assessed by a questionnaire survey. The questionnaire evaluated patients' perceptions of diagnosis and treatment changes, outcome and usefulness of the consultation. The physician's evaluation was compared to the patients' perceptions. Neurologic consultations resulted in diagnosis changes in 62% and treatment changes in 85%. Either diagnosis or treatment changed in 92% of consultations, which were regarded as “useful”. Seventy-four percent of patients concurred with the physician's evaluation of outcome and 96% concurred that the consultation was useful. Although small, this study found that outpatient neurologic consultations result in diagnosis and treatment changes in a substantial proportion of patients. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Quality of medical care may be assessed on the basis of structure (characteristics of physicians and hospitals), process (components of the encounter between healthcare provider and patient, such as tests ordered) or outcome (patient's health status subsequent to the encounter) [1]. One method of evaluating process and outcome is by reviewing a data source such as medical records [1,2]. It has been argued that process data may not be able to predict outcomes satisfactorily, and the sole use of process data to improve care may result in increased costs of medical care without corresponding improvement in healthcare [3]. The use of outcome measures such as improvement in the patient's health status subsequent to the encounter may also not be entirely valid. Differences in outcomes between patients receiving the same treatment may be because of factors that are not directly under the control of the health care provider, such as differences in patient characteristics. As an additional tool, surveys of the views of patients on the help they receive from consultation may be useful in neurologic “audit” [4]. ☆ Presented at the Annual Meeting, American Academy of Neurology, San Diego, CA April 2006 (Neurology 2006;66(5)Suppl.2:A231-232). ☆☆ Disclosures: The authors report no conflicts of interest. ⁎ Corresponding author. Tel.: +617 667 8130; fax: +617 667 3175. E-mail address: [email protected] (P. Narayanaswami). 0022-510X/$ – see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.jns.2008.09.036
As “pay for performance” initiatives for quality improvement gain impetus, measurement of the quality and demonstration of the utility of neurological care becomes important. In a study of inpatient neurologic consultations in a university setting, Hillen and Sage [5] reported that only 43% of consultations were deemed “useful”. In this study, a consultation was deemed “useful” if the neurologist suggested a diagnosis that had not been considered by the referring physician, or recommended a procedure that was useful in making the diagnosis or in eliminating alternative diagnoses. There are no studies that evaluate the outcome of outpatient neurologic consultations. This study utilizes medical record review to evaluate the outcome of outpatient neurologic consultations and compares the results so obtained to the results of a questionnaire survey of the same cohort, reflecting the patients' perceptions of usefulness of the consultation. 2. Methods 2.1. Study design 1. Questionnaire survey of patients referred for neurologic consultation. 2. Review of medical records of these patients. 3. Comparison of the results of the questionnaire survey with the results of the record review. This study was carried out at Hastings Neurology Clinic, affiliated with Mary Lanning Memorial Hospital, Nebraska, USA. It is the
176
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secondary level community neurology referral center for a population of about 50,000 from the surrounding counties in Nebraska and Kansas. The clinic is staffed by one neurologist (PN). The referral network to the clinic includes family practice physicians, internists, nurse practitioners who provide primary care, orthopedic surgeons, psychiatrists, one neurosurgeon and one rheumatologist. The study was approved by the Ethics Committee of Mary Lanning Memorial Hospital. All new patients seen at the clinic between February and June 2005 were given a two-part questionnaire (Appendix A). At the initial visit, the patient or a family member completed Part 1 (demographic data and reason for neurology consultation). Patients or their accompanying family completed Part 2 at a return visit, after diagnostic or therapeutic decisions had been taken and recommendations made to the referring physician. All questionnaires were completed before or at the fourth return visit. The non-physician author (JH) reviewed the patients' records to determine whether the evaluation was complete, and decided when each patient would complete Part 2 of the questionnaire. If a new medication had been introduced, the neurologist author (PN) determined if enough time had been allowed for medication changes to become effective before patients completed Part 2. In Part 2, the patient or family member was asked to record the diagnosis and treatment changes that resulted from the consultation, whether the problem for which they were referred had “resolved”, “improved”, was “unchanged” or “worse” and if the neurologic consultation was “useful” or not. These terms were not defined in the questionnaire, and were left to the patients' interpretation. 2.2. Data analysis The neurologist (PN) reviewed all patient questionnaires. The following data was recorded: diagnosis change, treatment change, outcome (if the condition for which they were referred had “resolved”, “improved”, was “unchanged” or “worse”) and usefulness of the consultation. The nurse (JH) reviewed the office records and recorded the initial, or referring, diagnosis and final diagnosis. The initial diagnosis was defined as the diagnosis made by the referring physician, and was determined from the referring physicians' request for consultation. If patients were referred for a symptom such as headache or weakness rather than with a specific diagnosis, we considered the symptom as the referring diagnosis for the purposes of this study. The final diagnosis was defined as the diagnosis made by the neurologist (PN) and was obtained from the office note on or before the date of completion of Part 2 of the patient questionnaire. A “change in diagnosis” was defined as a diagnosis made following
Fig. 1. Comparison of physician/patient responses for diagnosis/treatment changes and usefulness of consultation.
Table 1 Concordance between physician evaluations and patient responses Diagnosis Change (yes and no) Treatment Change (yes and no) Consult useful Outcome (improved or otherwise)
61/108 (56%) 75/108 (69%) 95/99a (96%) 80/108 (74%)
a 9 consultations were considered “not useful” on physician evaluation, since neither diagnosis nor treatment changed.
neurologic evaluation which was different from or in addition to the initial, referring diagnosis. “Treatment change” was defined as a change in the dosage of an ongoing medication, the recommendation of a new medication, surgical intervention or non-pharmacological measures such as physical therapy, irrespective of whether the patients followed through with the recommendations. Outcomes were defined prior to conducting the record review as follows: “resolved”, wherein the problem for which the consultation was sought completely resolved (as in carpal tunnel syndrome after surgery), “improved” wherein patients or the neurologist reported objective improvement (such as decrease in migraine frequency on a headache diary, or examination documenting improvement in tremor), “unchanged”(where the notes documented that the problem for which the consultation was sought was unchanged), or “worse”. The “outcome” of each consultation was determined from the information obtained in the office notes on or before the date of completion of Part 2 of the questionnaire. The consultation was considered “useful” if either diagnosis or treatment changed. The neurologist's evaluation of “diagnosis changes”, “treatment changes”, “outcome” and whether the consultation was “useful” or not was compared with patient responses and concordance was calculated. Descriptive statistics were utilized. 3. Results Between February and June 2005, 187 new patients were seen for consultation. All patients completed Part 1 of the questionnaire. 118 (63%) patients completed both parts of the questionnaire. Ten surveys were incomplete. Complete surveys were available in 108 patients (58%), who were included in the study. Of the 69 (37%) who did not complete Part 2, 43 (62%) did not return for follow-up, and 2 (3%) refused the recommended work-up. In 22 patients (32%) the initial evaluation suggested a non-neurological cause of their symptoms; they were therefore not seen in follow-up consultation, and were excluded from the study. Two patients died (3%) [myocardial infarction (1), sudden death (1)]. On review of the medical records, the physician documented a diagnosis change in 67/108 patients (62%). Only 22 of these 67 patients (33%) identified the diagnosis changes on their questionnaires. Two other patients responded that the consultation resulted in a diagnosis
Fig. 2. Comparison of physician/patient responses for outcome of consultations.
P. Narayanaswami, J.C. Hahne / Journal of the Neurological Sciences 276 (2009) 175–178
change without documented diagnosis changes in their medical records (Fig. 1). In all, 61/108 (56%) patients concurred with the physician's evaluation of whether the diagnosis changed or not (Table 1). On medical record review, treatment changes were documented in 92/108 patients (85%). Of these, 60/92 (65%) patients identified the changes (Fig. 1). As a group, 75/108 (69%) patients agreed with the physician's evaluation of whether treatment had changed or not (Table 1). Of the 33 (31%) who did not concur, 32 did not recall documented medication changes. One patient responded, “yes” in the absence of documented treatment changes. In 2 patients who did not recall the treatment changes, [Parkinson's disease (1), multiple sclerosis (1)] “treatment change” consisted of physical therapy. In these 2 patients, although medication options were discussed, no medications were prescribed. Review of the physician's notes for “outcomes” as defined previously resulted in 57/108 patients (53%) being classified as “improved”/ “resolved” (Fig. 2). Fifty-one patients (89%) concurred with the evaluation. Four patients said they were “unchanged”, and 2, “worse”. The outcome was considered to be “unchanged” from the review of office notes in 51/108 (47%) patients (Fig. 2). Twenty-nine of the 51 patients (57%) concurred; 13/51 (25%) said they were “improved”, 9/51 (18%) said they were “worse”. Overall concordance for outcome, in the “improved/resolved” and “unchanged” categories was 74% (80/108) (Table 1). Medical record review did not reveal a “worse” outcome in any of the 108 patients. However, 11 patients (10%) said that the outcome was “worse” after consultation (Fig. 2). These included Parkinson's disease (2), monosymptomatic multiple sclerosis (2), progressive supranuclear palsy, cognitive impairment, intractable myoclonus associated with renal failure, complex partial seizures, lumbar stenosis, multiple symptoms with negative work-up, and ulnar entrapment at the elbow (1 each). The physician's evaluation of outcome in these patients was as follows: “unchanged” in 9 [monosymptomatic multiple sclerosis (2), Parkinson's disease (2), myoclonus (1), progressive supranuclear palsy (1), complex partial seizures (1), lumbar stenosis (1) and multiple symptoms with negative work-up (1)]; the outcome was classified as “improved” in the remaining 2 [improved cognitive function after depression was treated (1) and ulnar entrapment across the elbow, post-surgery (1)]. Overall, neurologic consultation resulted in a change in either diagnosis or treatment in 99/108 (92%), and both in 60/108 (56%) patients. The 99/108 (92%) consultations that resulted in a change
Table 2 Diagnoses made after neurologic consultations⁎ Diagnoses
Patients
Carpal tunnel syndrome Chronic tension type headache Cerebrovascular accident, transient ischemic attack Depression Epilepsy Migraine with aura Migraine without aura Mixed dementia, Alzheimer's Disease, mild cognitive impairment Multiple sclerosis and variants Exclusion of multiple sclerosis Other headache syndromes (analgesic rebound, indomethacin responsive syndromes) Parkinson's disease/Parkinsonism Peripheral neuropathy Radiculopathy Syncope, post traumatic dizziness Writer's cramp, subacute combined degeneration, ALS, polymyalgia rheumatica, benign positional vertigo, progressive supranuclear palsy, segmental myoclonus, myoclonus with renal failure, meralgia paresthetica, ulnar entrapment at elbow, mixed tremor, neurogenic claudication.
4 5 2 4 4 3 5 3 5 2 11
⁎Some patients had more than one diagnosis.
4 4 3 2 each 1 each
177
either in diagnosis or treatment were defined as “useful”. Ninety-five of the 99 patients (96%) concurred with the physician's evaluation (Fig. 1, Table 1). Four patients responded that the consultation was “neither useful nor harmful”. Of the 9 (8%) consultations evaluated by the physician as “not useful”, meaning that neither diagnosis or treatment changed as a result of the consultation, 7 patients said that the consultation was “useful” and 2 answered that it was “neither useful nor harmful”. The referring diagnoses in these patients were: multiple sclerosis (2), epilepsy (2), Parkinson's disease (2), tinnitus (1), leg pain (1), and generalized weakness (1). Table 2 summarizes the diagnoses resulting from the neurologic consultation. 4. Discussion A few studies have evaluated the utility and outcome of consultations in specific neurological conditions. Most of these studies have utilized process data obtained by medical record review. In an Irish study by Costello et al. [6], inpatient neurologic consultations contributed to patient management in three ways: by establishing a new diagnosis (41%), by a change in pre-existing diagnoses (11%), or therapeutic changes (48%). Petty et al. [7] found that neurology evaluation was associated with better survival for patients with ischemic stroke, but not those with atrial fibrillation. In their study, neurologists used carotid ultrasound, cerebral angiography and carotid endarterectomy more frequently than non-neurologists. The authors suggest that neurologists' greater attention to pathophysiologic mechanisms of non-cardioembolic stroke may be responsible for the improved outcome. In a study of diagnostic outcomes in multiple sclerosis, two-thirds of patients referred to a university based multiple sclerosis center had an alternative diagnosis [8]. Benbadis et al. [9] found that only 32% of patients with chronic back pain had a neurologic cause such as radiculopathy or myelopathy. In their study, two-thirds of these patients were treated similarly to those with uncomplicated spondylosis. Patients who needed surgery or epidural blocks were referred to another specialist. The authors concluded that with the exception of electromyography for radiculopathy, neurologists do not make a significant contribution to the care of patients with back pain [9]. Other studies have utilized questionnaire surveys of patients to evaluate outcomes. Salvesen and Bekkelund, [10,11] in a questionnaire survey of patients with headache, found that neurologic evaluation for headaches resulted in greater improvement and better quality of life, and that 63% of patients with migraine were satisfied with the consultation. In these studies, patients were more likely to have relief of their headaches if they received a diagnosis. Interestingly, there was no significant improvement in quality of life if treatment was prescribed, suggesting that patient information may be an important aspect of the consultative process [10]. The outcome of outpatient neurologic consultations as a whole has not been studied previously. In this study we have attempted to assess the utility of ambulatory neurologic consultations in 2 ways; firstly, after care was provided, the process data (diagnosis changes, treatment changes) and outcomes data (pre-determined definitions of outcomes and usefulness of the consultation) were assessed by a medical record review. Secondly, a “neurologic audit” was performed using a questionnaire survey of the patients. There are limitations to this study. The major limiting factor is that it reflects the findings in a single physician neurology practice. The neurologic consultation was provided by the same team that performed the study, thus introducing a bias. In an attempt to minimize this bias, the medical records were reviewed by the nurse (JH), after the patients had completed Part 2 of the questionnaire, with pre-determined criteria for initial and final diagnoses, diagnosis and treatment changes, “outcome” and “usefulness” of the consultation. The neurologist reviewed the patient questionnaires without knowledge of the results of the record review.
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On record review, an outcome category of “worse” was not seen in any of the patients. This is not unexpected, since the duration of the study was too short to detect worsening of chronic illnesses such as Parkinson's disease or amyotrophic lateral sclerosis. In the short time frame of the study, no serious adverse effects causing a worsening of the patient's condition were noted with any therapeutic intervention. In this study, a change in diagnosis or treatment was required to term the consultation “useful”, although it may be argued that a consultation may be useful even if it only confirms the referring physician's diagnosis. Additionally, the consultation may also be considered to have been useful in the 22 patients wherein a neurological cause for their symptoms was excluded. These patients were not included in the study, since they were not seen again and their questionnaire responses were therefore not available. Almost half of the patients were classified by the physician to have an “unchanged” outcome. This category reflects patients with chronic, ongoing illnesses such as multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis, epilepsy and chronic headaches other than migraine. In patients with epilepsy or chronic headaches, the short time frame of the study may have been insufficient to discern improvement, since trials of multiple medications and interventions are often necessary in these conditions, thus reducing the number of patients who may have otherwise been classified as “improved”. The concordance between the physician's evaluation and patient responses for outcome (74%) and usefulness of the consultation (96%) was high, although the patients' assessment of usefulness was purely subjective, in contrast to the physician's evaluation where a change in either diagnosis or treatment was required to call a consultation “useful”. Since concordance for diagnosis changes (56%) and treatment changes (69%) was lower than the concordance for outcome (74%) and usefulness (96%), it is possible that the non-blinded nature of the questionnaires may have influenced patient responses in a positive direction. Additionally, the assessment of “outcome” both by the patients and physician was more subjective than the evaluation of diagnosis and treatment changes. The non-blinded questionnaires may also explain the discrepancy between the number of patients who identified diagnosis changes (33%), treatment changes (65%) and
the number of patients who said that the consultation was “useful” (96%). However, like “outcome”, “usefulness” is also more subjective than the actual recollection of specific diagnosis and treatment changes. It may reflect patient satisfaction with the consultation overall, which may be related to factors that were beyond the measure of this study, such as physician–patient rapport. Notwithstanding these limitations, this small study suggests that outpatient neurologic consultations result in diagnostic or therapeutic changes in the majority of patients. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jns.2008.09.036. References [1] Brook RH, McGlynn EA, Cleary PD. Quality of healthcare. Part 2: Measuring quality of care. N Engl J Med 1996;335:966–70. [2] Brook RH, Appel FA. Quality-of-care assessment: choosing a method for peer review. N Engl J Med 1973;288:1323–9. [3] Ellwood PM. Outcomes Management: a technology of patient experience. N Engl J Med 1973;288:1323–9. [4] Hopkins A. Clinical audit and neurology. J Neurol Neurosurg Psychiatry 1992;55:19–25 [Suppl]. [5] Hillen ME, Sage JI. Proving the worth of neurologists? Neurology 1996;46:276–7. [6] Costello DJ, Renganathan R, O'Hare A, Murray B, Lynch T. Audit of an inpatient neurology consultation service in a tertiary referral center: value of the consulting neurologist. Ir Med J 2005;98:134–7. [7] Petty GW, Brown Jr RD, Whisnant JP, Sicks JD, O'Fallon WM, Wiebers DO. Ischemic stroke: outcomes, patient mix, and practice variation for neurologists and generalists in a community. Neurology 1998;50:1669–78. [8] Carmosino MJ, Brousseau KM, Arciniegas DB, Corboy JR. Initial evaluations for multiple sclerosis in a university multiple sclerosis center: outcomes and role of magnetic resonance imaging in referral. Arch Neurol 2005;62:585–90. [9] Benbadis SR, Herrera M, Orazi U. Does the neurologist contribute to the care of patients with chronic back pain? Eur Neurol 2002;48:61–4. [10] Salvesen R, Bekkelund SI. Aspects of referral care for headache associated with improvement. Headache 2003;43:779–83. [11] Bekkelund SI, Salvesen R. Patient satisfaction with a neurological specialist consultation for headache. Scand J Prim Health Care 2002;20:157–60.