Neuroconsultative Service by Mark Saleh, M.D.
Community neurologists are under increasing pressure to see more patients in the outpatient setting. This is driven by several factors, including rising overhead, reduced insurance reimbursement, and elimination of Medicare consultation codes. Consequently, delays in evaluating inpatients with neurological disorders may occur, which can worsen outcomes, negatively impact quality measures, and extend hospital stays. Moreover, decision making for inpatients has gotten more complex because a higher bar has been set for hospital admissions (See reference 1). These factors may explain the emergence of the neurohospitalist.
A neurohospitalist is a neurologist who practices in the inpatient setting with few or no outpatient responsibilities. Roles include providing inpatient neurological care, being available for urgent and time-sensitive treatments, developing evidence-based protocols, and preventing complications of neurological disease (See reference 2). Common acute neurological conditions that are managed include alteration in mental status, seizure, headache, syncope, central nervous system cancer, and neuromuscular respiratory failure, in addition to cerebrovascular presentations. Also, assistance in the management of chronic neurological conditions, including end-of-life issues and palliative care, can be provided (See reference 3).
Although there are currently few data on the impact of neurohospitalists, a substantial amount of literature supports the use of hospitalists in internal medicine. A 2009 systematic review of costs and quality measures demonstrated that hospitalist-provided care was associated with decreased hospital costs, length of stay, mortality and readmission rates, and improved measures of care (See reference 4). This may explain the tremendous growth in the number of hospitalists in the United States. In 1997, 1,000 hospitalists were present in the U.S., and this number has grown to more than 30,000 today, with half of U.S. hospitals using a hospitalist service (See reference 5).
Benefits of Multidisciplinary Approach to Patient Care
Additionally, overlap between neurohospitalist programs and certified stroke centers exists since they are both inpatient-based programs that can use evidence-based protocols, as well as a multidisciplinary approach to patient care. According to the 2011 Heart Disease and Stroke Statistics Update, the annual stroke death rate declined by 34.3 percent, and 30-day mortality and readmission rates were reduced from 1997 to 2007 (See reference 6). This improvement could be due to implementation of stroke center certification during this time (See reference 7), and similar improvement in patient outcomes may result from neurohospitalist programs.
By using a neurohospitalist service, more efficient inpatient care can be provided, which may result in reduced costs and greater patient satisfaction in addition to improved outcomes. Additionally, with the recent Supreme Court decision to largely uphold the Affordable Care Act that promotes pay-for-performance, hospitals may benefit from incentive payments for improving quality of care measures. In fact, the Centers for Medicare and Medicaid Services (CMS) will soon implement the Hospital Value Based Purchasing Program, which consists of value-based incentive payments to acute care hospitals based on how well the hospitals perform on certain quality measures or how much performance improves on certain quality measures relative to a baseline period. Conversely, hospitals may receive reduced reimbursement in instances of avoidable hospital-acquired complications and readmission (See reference 8). These CMS programs underscore the increasing importance for hospitals to provide high-quality, efficient care.
Other areas that may benefit from a neurohospitalist program include education of trainees and inpatient research (See reference 9). A neurohospitalist program can also serve as an important source of referrals to community physicians for patients who require outpatient follow-up.
Neuroconsultative and Referral Service
In an effort to build and improve on the neurohospitalist model, the General Neuroconsultative and Referral Service was recently introduced at CPMC. This service will provide timely consultation-based support for inpatients with nonvascular general neurological conditions that will promote a multidisciplinary approach to patient care. In addition to providing the beneficial aspects of neurohospitalist inpatient care, this service will also efficiently coordinate urgent regional referrals to CPMC. Stroke patients will continue to be managed by the Stroke Service. Planned future services include use of telemedicine for both inpatient and outpatient consultation.
- Josephson SA, Engstrom JW, Wachter RM, Neurohospitalist: An Emerging Model for Inpatient Neurological Care. Ann Neurol 2008;63:135–140.
- Freeman WD, Gronseth G, Eidelman BH. Invited article: Is it time for neurohospitalists? Neurology 2008;70:1282–1288.
- Barrett KM, Freeman WD. Emerging Subspecialties in Neurology: Neurohospitalist. Neurology. 2010 Jan 12;74(2):e9-10.
- Peterson MC. A systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. Mar 1 2009; 84(3): 248-254.
- Society of Hospital Medicine, SHM Fact Sheet: About Hospital Medicine. July 12, 2010.
- Roger VL, et al. Heart Disease and Stroke Statistics--2011 Update : A Report From the American Heart Association. Circulation. 2011;123:e18-e209;
- Mackey J, Kleindorfer D. Stroke centers and quality of stroke care: how are we doing? Neurology June 7, 2011 vol. 76 no. 23, 1956-1957.
- Department of Health and Human Services, Centers for Medicare & Medicaid Services, 42 CFR Parts 412, 413, 424, 476, and 489, pages 53-57.
- Likosky D, Shulman S, Restrepo L, Freeman WD. Survey of Neurohospitalists: Subspecialty Definition and Practice Characteristics. Front Neurol. 2010; 1(9): 1-4.
California Pacific Medical Center
- Neuroscience Institute -
The California Pacific Neuroscience Institute in San Francisco features some of the top-rated neurology physicians and neurosurgeons in the San Francisco Bay Area. This issue of the CPNI Bulletin features our wide array of general neurology consultative services, physicians and programs, neurology research, and the new Brain Health Center at CPMC.