Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1036 — Double Head Images? Dual Brain Imaging in Veterans Hospitalized with Acute Ischemic Stroke (IS)

Author List:
Levine DA (Deep South Center on Effectiveness)
Allison JJ (Deep South Center on Effectiveness)
Kirk KA (Deep South Center on Effectiveness)
King PH (Birmingham VA Medical Center)
Houston TK (Deep South Center on Effectiveness)
Safford MM (Deep South Center on Effectiveness)
Williams LS (Roudebush VA Medical Center)
Kiefe CI (Deep South Center on Effectiveness)

Objectives:
Costly diagnostic brain imaging is performed routinely in acute ischemic stroke (IS) patients, even in those ineligible for thrombolysis. Dual brain imaging with CT and magnetic resonance imaging (MRI) is done in the absence of guidelines recommending such testing. We assessed the prevalence and regional variation of dual brain imaging in veterans hospitalized for IS across the VA’s regional networks (VISNs).

Methods:
We identified 9306 consecutive non-transferred patients aged 40-85 years discharged from any VA medical center with a primary diagnosis of IS (ICD-9 codes 434.xx and 436.xx) using DSS National Data Extracts and Medical SAS Datasets (PTF and OPC) in FY2001-03. The 18 VISNs with race identified in >88% of patients were included. We compared the frequency of in-hospital dual brain imaging by VISN. With multivariable logistic regression, we adjusted associations between dual brain imaging and VISN for race, age, sex, prior cerebrovascular disease, hypertension, diabetes, and length of stay (LOS).

Results:
VISNs differed in the number of IS patients (range 182-1185), percentage of blacks (4-43%; P<0.0001), age 65 or older (49-70%, P<0.0001) and women (1-4%; P=0.06). The prevalence of prior cerebrovascular disease (24-35%; P=0.001), hypertension (83-90%, P=0.02) and diabetes (37-51%, P=0.03) differed significantly by VISN. Mean length of stay varied from 5.6 (SD 5.2) to 11.3 (SD 37.8) days. Overall, 43% of IS patients received dual brain imaging with CT and MRI, varying significantly by VISN (27-59%, P<0.0001). These differences in dual brain imaging by VISN persisted after adjustment (P<0.0001). Other factors independently associated with dual brain imaging included black (compared to white) race, adjusted odds ratio (OR) 1.54, 95% CI (1.39-1.70), age 65 or older, OR 0.80 (0.73-0.87), prior cerebrovascular disease, OR 0.64 (0.58-0.70), and LOS greater than 1 day, OR 3.01 (2.50-3.63).

Implications:
Dual brain imaging of veterans hospitalized for IS occurs commonly and differs by VISN, perhaps reflecting the lack of guidelines regarding such imaging. Blacks received dual brain imaging 50% more than whites, a finding that warrants further study.

Impacts:
Dual brain imaging may produce unnecessary stroke-related health care costs. The development and implementation of guidelines on dual brain imaging may reduce costs in IS.