Youngran Kim1,2, Songmi Lee1, Rania Abdelkhaleq1, Victor Lopez-Rivera1, Babak Navi3, Hooman Kamel3, Sean I Savitz1,4, Alexandra L Czap1,4, James C Grotta5, Louise D McCullough1, Trudy Millard Krause2, Luca Giancardo6,4, Farhaan S Vahidy7, Sunil A Sheth1,4. 1. Department of Neurology, McGovern Medical School (Y.K., S.L., R.A., V.L.-R., S.I.S., A.C., L.D.M., S.A.S.), University of Texas Health Science Center at Houston. 2. Division of Management, Policy and Community Health, School of Public Health (Y.K., T.M.K.), University of Texas Health Science Center at Houston. 3. Department of Neurology, Weill Cornell Medical College, New York, NY (B.N., H.K.). 4. Institute for Stroke and Cerebrovascular Disease (S.I.S., A.C., L.G., S.A.S.) University of Texas Health Science Center at Houston. 5. Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston (J.C.G.). 6. School of Biomedical Informatics (L.G.), University of Texas Health Science Center at Houston. 7. Center for Outcomes Research, Houston Methodist Research Institute, TX (F.V.).
Abstract
BACKGROUND: Recent clinical trials have established the efficacy of endovascular stroke therapy and intravenous thrombolysis using advanced imaging, particularly computed tomography perfusion (CTP). The availability and utilization of CTP for patients and hospitals that treat acute ischemic stroke (AIS), however, is uncertain. METHODS: We performed a retrospective cross-sectional analysis using 2 complementary Medicare datasets, full sample Texas and 5% national fee-for-service data from 2014 to 2017. AIS cases were identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision coding criteria. Imaging utilization performed in the initial evaluation of patients with AIS was derived using Current Procedural Terminology codes from professional claims. Primary outcomes were utilization of imaging in AIS cases and the change in utilization over time. Hospitals were defined as imaging modality-performing if they submitted at least 1 claim for that modality per calendar year. The National Medicare dataset was used to validate state-level findings, and a local hospital-level cohort was used to validate the claims-based approach. RESULTS: Among 50 797 AIS cases in the Texas Medicare fee-for-service cohort, 64% were evaluated with noncontrast head CT, 17% with CT angiography, 3% with CTP, and 33% with magnetic resonance imaging. CTP utilization was greater in patients treated with endovascular stroke therapy (17%) and intravenous thrombolysis (9%). CT angiography (4%/y) and CTP (1%/y) utilization increased over the study period. These findings were validated in the National dataset. Among hospitals in the Texas cohort, 100% were noncontrast head CT-performing, 77% CT angiography-performing, and 14% CTP-performing in 2017. Most AIS cases (69%) were evaluated at non-CTP-performing hospitals. CTP-performing hospitals were clustered in urban areas, whereas large regions of the state lacked immediate access. CONCLUSIONS: In state-wide and national Medicare fee-for-service cohorts, CTP utilization in patients with AIS was low, and most patients were evaluated at non-CTP-performing hospitals. These findings support the need for alternative means of screening for AIS recanalization therapies.
BACKGROUND: Recent clinical trials have established the efficacy of endovascular stroke therapy and intravenous thrombolysis using advanced imaging, particularly computed tomography perfusion (CTP). The availability and utilization of CTP for patients and hospitals that treat acute ischemic stroke (AIS), however, is uncertain. METHODS: We performed a retrospective cross-sectional analysis using 2 complementary Medicare datasets, full sample Texas and 5% national fee-for-service data from 2014 to 2017. AIS cases were identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision coding criteria. Imaging utilization performed in the initial evaluation of patients with AIS was derived using Current Procedural Terminology codes from professional claims. Primary outcomes were utilization of imaging in AIS cases and the change in utilization over time. Hospitals were defined as imaging modality-performing if they submitted at least 1 claim for that modality per calendar year. The National Medicare dataset was used to validate state-level findings, and a local hospital-level cohort was used to validate the claims-based approach. RESULTS: Among 50 797 AIS cases in the Texas Medicare fee-for-service cohort, 64% were evaluated with noncontrast head CT, 17% with CT angiography, 3% with CTP, and 33% with magnetic resonance imaging. CTP utilization was greater in patients treated with endovascular stroke therapy (17%) and intravenous thrombolysis (9%). CT angiography (4%/y) and CTP (1%/y) utilization increased over the study period. These findings were validated in the National dataset. Among hospitals in the Texas cohort, 100% were noncontrast head CT-performing, 77% CT angiography-performing, and 14% CTP-performing in 2017. Most AIS cases (69%) were evaluated at non-CTP-performing hospitals. CTP-performing hospitals were clustered in urban areas, whereas large regions of the state lacked immediate access. CONCLUSIONS: In state-wide and national Medicare fee-for-service cohorts, CTP utilization in patients with AIS was low, and most patients were evaluated at non-CTP-performing hospitals. These findings support the need for alternative means of screening for AIS recanalization therapies.
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Keywords:
health care quality, access, and evaluation; health care systems; medical imaging; population health; stroke