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IIR 04-200
Electrodiagnostic Services: Guidelines, Compliance, and Outcome
Timothy R. Dillingham, MD MS Clement J. Zablocki VA Medical Center, Milwaukee, WI Milwaukee, WI Funding Period: September 2006 - August 2010 |
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BACKGROUND/RATIONALE:
Electrodiagnostic (EDX) testing is a common diagnostic procedure used to evaluate patients with a wide variety of symptoms including pain, weakness, and numbness in a limb. Some of the most common disorders diagnosed by EDX testing include carpal tunnel syndrome, compressed spinal nerves (radiculopathies); muscle disorders (myopathies) and peripheral nerve injuries. In this project we examined the scope, quality, and outcomes for EDX service provision in the Veterans Health system and among elderly Medicare beneficiaries. OBJECTIVE(S): Specifically, our aims were: (1) to determine the extent of electrodiagnostic service provision by provider type in the Veterans Health Administration (VHA) and the Medicare program, (2) to examine variations and differences in electrodiagnostic (EDX) care provided to Veterans and elderly Medicare beneficiaries; and (3) to examine the relationship between EDX testing characteristics, adherence to EDX guidelines, and subsequent outcomes of care. METHODS: Electrodiagnostic care received by American Veterans and a nationally representative sample of Medicare beneficiaries was characterized according to: i) the professional providing services, ii) the extent of nerve conduction and EMG testing performed by different providers, and iii) the degree to which providers adhered to published Electrodiagnostic Medicine guidelines. Variations in testing were examined by selected characteristics of the provider -- most notably, physician or non-physician, specialty training, provider volume of EDX procedures, and region of the country -- as well as by key patient characteristics, including age, gender, race/ethnicity and number, type and severity of comorbidities, and referral reason. We considered a variety of outcomes, including (i) the diagnosis derived at the time of EDX testing, (ii) subsequent surgical and diagnostic interventions, and (iii) subsequent use of health care resources. Characteristics of EDX testing and adherence to guidelines were correlated with outcomes, adjusting for differences in providers' and patients' characteristics, using multivariate regression techniques. Using VHA Inpatient and Outpatient data as well as Medicare claims, two cohorts were identified. The first cohort was comprised of beneficiaries undergoing EDX testing in 2004. The 12-month post-EDX care trajectory of this first cohort was examined for surgical and interventional procedures. For this first cohort, we examined referral reasons by looking at the symptom codes from three months preceding the electrodiagnostic study to determine the referral reason and involved body region - facilitating better interpretation of guideline compliance. The second cohort consisted of VHA and Medicare beneficiaries who had certain surgical interventions (e.g., carpal tunnel release, ulnar nerve decompression, tarsal tunnel surgery, cervical and lumbosacral laminectomy and discectomy, spinal stenosis decompression ) during 2006 and 2007. FINDINGS/RESULTS: The results of this study have provided unique insights into the provision of electrodiagnostic services in the VA healthsystem. These findings suggest high quality care by specialists in EDX medicine for veterans receiving these services for musculoskeletal and neurological conditions. In the VA health system, there were 69,738 veterans undergoing electrodiagnostic evaluations during 2005. Those veterans who were seen for presumed low back symptoms totaled 7614 in 2005. Specialist physicians (physiatrists and neurologists) performed 90.1% of the procedures, with 5.5% done by other physician types, and 4.4% performed by non-physicians. A total of 241,295 persons in the random Medicare sample data were identified as having received EDX testing in 2006. The majority of EDX tests were provided by specialists (52.6% neurologists and 19.7% PM&R). Nearly one in five Medicare beneficiaries received EDX care from non-specialists (21.8%) and the remainder received care from non-physician providers. This is in sharp contrast to the VA healthsystem, in which most veterans see a specialist for their electrodiagnostic testing. Geographic variations in provider care were more pronounced for CMS beneficiaries than for Veterans. Focusing on the results for Veterans presenting with a complaint of low back symptoms (and no other referral complaint, N=7,614), the majority of electrodiagnostic encounters in the VA were guideline-adherent (61.3%). Both facility volume and provider type were also related to guideline adherence. Finally, the proportion of EDX encounters that were guideline-adherent also varied across VISNs. In multivariate analyses, EDX encounters at low volume facilities were less likely to be guideline-adherent than those performed at medium (odds ratio [OR]: 1.88; 95% confidence interval [CI]: 1.59-2.23) or high volume (OR: 1.77, 95% CI: 1.54-2.03) facilities. EDX encounters were also less likely to be adherent if they were performed by a nonphysician when compared to either a specialist (OR: 1.53; 95% CI: 1.16-2.02) or nonspecialist (OR: 3.49; 95% CI: 2.01-5.03) physician. Among the CMS population where there were greater proportions of non-physican providers, we found that specialists (neurologists and physiatrists) were quite concordant in identifying common conditions (polyneuropathy, lumbosacral radiculopathy, cervical radiculopathy, carpal tunnel syndrome, and ulnar neuropathy) in a cohort with diabetes. In contrast, other providers identified widely varying rates of disorders that were not accounted for by case mix adjustment. IMPACT: The implications of these findings are important for healthcare policy makers in the CMS and VA healthcare systems. Physician providers gave more guideline-compliant care than non-physicians. In addition, the VA analyses clearly showed a compliance and facility volume relationship indicating that hospitals with high volume EDX services provide the most compliant care. In addition, the VA health system utilizes specialists (Physiatrists and Neurologists) to a greater degree (90% of all studies) than the private sector or the Medicare beneficiaries receive in the United States. Specialists are more guideline-compliant and concordant in rates of diagnoses indicating a common approach to these symptoms and that this care is consistent with published guidelines. Implications for the VA healthsystem are that optimal care is rendered at high volume facilities and to the extent possible referral patterns should be in this direction. We received a follow-up pilot grant to examine coding for EDX studies. Our preliminary results suggest that specialists probably provide even more of the care than 90%, due to coding inaccuracies. This follow-up study should be informative to the VA regarding its coding system for EDX care. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Health Systems
DRE: Diagnosis, Treatment - Observational Keywords: Cost, Practice patterns, Utilization patterns MeSH Terms: none |
