Hart Stephanie, Howard George, Cummings Doyle, Albright Karen C, Reis Pamela, Howard Virginia J
From the School of Nursing (S.H.), and Duke Clinical and Translational Science Institute (S.H.), Duke University, Durham, NC; School of Public Health (G.H., V.J.H.), University of Alabama at Birmingham; Department of Public Health (D.C.), Brody School of Medicine, East Carolina University, Greenville, NC; Department of Neurology (K.C.A.), SUNY Upstate Medical University, Syracuse, NY; and College of Nursing (P.R.), East Carolina University, Greenville, NC.
Neurology. 2024 Apr 9;102(7):e209200. doi: 10.1212/WNL.0000000000209200. Epub 2024 Mar 14.
Improving access to health care providers with clinical expertise in stroke care may influence the use of recommended strategies for reducing disparities in quality of care. Few studies have examined differences in the receipt of evaluation by neurologists during the hospital stay. We examined the proportion of individuals hospitalized for acute ischemic stroke who received evaluation by a neurologist during the hospital stay and characterized differences in receipt of neurologist evaluation by race (Black vs White), sex, age, and study region (Stroke Belt residence vs other) among those experiencing a stroke who were participating in a national cohort study.
This cross-sectional study was conducted using medical record data abstracted from 1,042 participants enrolled in the national Reasons for Geographic and Racial Differences in Stroke cohort study (2003-2007) who experienced an adjudicated ischemic stroke between 2003 and 2016. Participants with a history of stroke before baseline, in-hospital death, hospice discharge following their stroke, or incomplete records were excluded resulting in 839 cases. Differences were assessed using modified Poisson regression adjusting for participant-level and hospital-level factors.
Of the 839 incident strokes, 722 (86%) received evaluation by a neurologist during the hospital stay. There were no significant differences by age, race, or sex, yet Stroke Belt residents and those receiving care in rural hospitals were significantly less likely to receive neurologist evaluation compared with non-Stroke Belt residents (relative risk [RR] 0.95; 95% CI 0.90-1.01) and participants receiving care in urban hospitals (RR 0.74; 95% CI 0.63-0.86). Participants with a greater level of poststroke functional impairment (modified Rankin scale) and those with a greater number of risk factors were more likely to receive neurologist evaluation compared with those with lower levels of poststroke functional impairment (RR 1.04; 95% CI 1.01-1.06) and fewer risk factors (RR 1.02; 95% CI 1.00-1.04).
While differences in access to neurologists during the hospital stay were partially explained by patient need in our study, there were also significant differences in access by region and urban-rural hospital status. Ensuring access to neurologists during the hospital stay in such settings may require policy-level and/or system-level changes.
改善获得具有卒中护理临床专业知识的医疗服务提供者的机会，可能会影响推荐策略的使用，以减少护理质量的差异。很少有研究考察住院期间接受神经科医生评估的差异。我们研究了因急性缺血性卒中住院的个体在住院期间接受神经科医生评估的比例，并描述了参与一项国家队列研究的卒中患者中，按种族（黑人与白人）、性别、年龄和研究地区（居住在卒中带与其他地区）划分的接受神经科医生评估的差异。
这项横断面研究使用了从1042名参与全国卒中地理和种族差异原因队列研究（2003 - 2007年）的参与者中提取的病历数据，这些参与者在2003年至2016年期间经历了经判定的缺血性卒中。排除基线前有卒中病史、住院死亡、卒中后临终关怀出院或记录不完整的参与者，最终纳入839例病例。使用修正的泊松回归评估差异，并对参与者层面和医院层面的因素进行调整。
在839例新发卒中患者中，722例（86%）在住院期间接受了神经科医生的评估。在年龄、种族或性别方面没有显著差异，但与非卒中带居民相比，卒中带居民以及在农村医院接受治疗的患者接受神经科医生评估的可能性显著降低（相对风险[RR]为0.95；95%置信区间为0.90 - 1.01），与在城市医院接受治疗的参与者相比也是如此（RR为0.74；95%置信区间为0.63 - 0.86）。与卒中后功能障碍程度较低（改良Rankin量表）和风险因素较少的患者相比，卒中后功能障碍程度较高的参与者以及风险因素较多的参与者更有可能接受神经科医生的评估（RR为1.04；95%置信区间为1.01 - 1.06）和（RR为1.02；95%置信区间为1.00 - 1.04）。
在我们的研究中，虽然住院期间获得神经科医生服务的差异部分可以由患者需求来解释，但在地区和城乡医院状况方面也存在显著差异。在这种情况下，确保住院期间能够获得神经科医生的服务可能需要政策层面和/或系统层面的改变。
