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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 include carpal tunnel syndrome, compressed spinal nerves (radiculopathies); muscle disorders (myopathies) and peripheral nerve injuries. Such testing is often a critical component of diagnostic algorithms that influence surgical decision-making. Patients with electrodiagnostically confirmed carpal tunnel syndrome, for example, are more likely to undergo subsequent surgical decompression. Spine surgeons often use electrodiagnostic confirmation of radiculopathy before undertaking surgery.
Although concerns about practice variation and inappropriate use of diagnostic tests have a prompted a large and growing literature in medicine, little is known about the extent to which electrodiagnostic (EDX) testing affects long-term outcomes of patients in general and even less is known about the quality of EDX care by providers of different specialties. The results of this study will better inform strategies to improve the quality of care and lay the foundation for development of evidence-based EDX recommendations.
OBJECTIVE(S):
In this project we seek to determine the scope, quality, and outcomes for EDX service provision in the Veterans Health system and among elderly Medicare beneficiaries. Specifically, our aims are:
SPECIFIC AIM 1. To determine the scope of electrodiagnostic service provision in the Veterans Health Administration (VHA) and the Medicare programs, and to examine variations in electrodiagnostic (EDX) care provided to Veterans and elderly Medicare beneficiaries. EDX care received by American Veterans and elderly Medicare beneficiaries will be 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 will be examined by selected characteristics of the provider- most notably, physician or non-physician, specialty training, provider volume of EDX procedures, facility volume of EDX procedures, and region of the country - as well as by key patient characteristics, including beneficiary status (Veteran receiving care at the VA only, Veteran dual VA-Medicare service user, and non-VA Medicare beneficiaries), age, gender, race/ethnicity and number, type and severity of comorbidities.
SPECIFIC AIM 2. To examine the relationship between EDX testing characteristics, adherence to EDX guidelines, and subsequent outcomes. A variety of outcomes will be considered, including (i) the diagnosis derived at the time of EDX testing, (ii) subsequent surgical interventions, and (iii) subsequent use of health care resources. Characteristics of EDX testing and adherence to guidelines will be correlated with outcomes, adjusting for differences in patient's characteristics and referral reasons, using multivariate regression techniques.
METHODS:
Variations in testing are examined by selected characteristics of the provider- most notably, physician or non-physician, specialty training, facility and 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. A variety of outcomes are considered, 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 are correlated with outcomes, adjusting for differences in provider's and patient's characteristics, using multivariate regression techniques.
Using VHA Inpatient and Outpatient data, two cohorts were identified. The first cohort is comprised of Veterans undergoing EDX testing in 2005. The 12-month post-EDX care trajectory of this first cohort will be used to examine prospectively the relationship between patient and provider characteristics, EDX guideline adherence, and outcomes. For this first cohort we will also examine data from 6 months preceding the electrodiagnostic study to determine the referral reason and involved body region - facilitating better interpretation of guideline compliance. The second cohort consists of Veterans 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. For this second cohort, we will examine pre-operative service use, including whether or not an EDX test was performed, in the 12-month period preceding surgery.
FINDINGS/RESULTS:
Considerable progress has been made on this project. VHA inpatient and outpatient databases (Outpatient Event (SE); Inpatient Encouter (IE) as well as Acute Care, Extended Care, Observation Care and Non-VA Care) were accessed and downloaded from the Austin VA data repository. A link was established with Austin on our secure computer and the 2005-2006 data files scanned for inclusion criteria (EDX and surgical cohorts). Using these data, we have (i) refined the sample selection criteria using 6-month pre-EDX referral reason; (ii) defined guideline compliance based on literature review and input of Expert Panel for all specific referral reasons; (iii) implemented an algorithm to measure compliance based on claims data; (iv) conducted analyses of the factors associated with compliant studies; (v) conducted analyses of the correlates of referral patterns to alternative professionals, and (vi) implemented an algorithm for identifying relevant outcomes 2-months post index EDX.
Statistical analyses have been completed for two manuscripts examining (i) referral patterns and (ii) guideline adherence in EDX evaluation of low back symptoms, respectively. An abstract for the latter was submitted to the American Association of Neuromuscular and Electrodiagnostic Medicine for the 2008 Annual meeting in Rhode Island and accepted for poster presentation (abstract below).
GUIDELINE ADHERENCE IN ELECTRODIAGNOSTIC EVALUATION
OF LOW BACK SYMPTOMS
Introduction: Low back symptoms (LBS) account for a large number of referrals for electrodiagnostic (EDX) studies.
Objective: To examine factors associated with provider adherence to EDX guidelines among patients referred for LBS.
Methods: A nationally representative retrospective cohort of Veterans Affairs beneficiaries who received EDX testing following referral for LBS in 2005 was identified using medical claims. The groups of Veterans were categorized according to the professional providing services, the extent of nerve conduction and electromyography testing performed, and the degree to which providers adhered to EDX guidelines, as identified by a national panel of experts. Variations in testing were examined by considering patient characteristics (age, gender, race/ethnicity, comorbidities), the provider (physician/non-physician, specialty training), and facility (geographic region and EDX volume) using univariate and multivariate techniques.
Results: The research indicated that 17,151 Veterans underwent EDX testing for LBS (and no other symptoms). Multivariate results indicated that younger male Veterans and those with less comorbidity were more likely to receive compliant EDX testing. However, Veterans treated by nonphysician providers were less likely to receive compliant care. Substantial regional variation was noted in the provision of compliant care. Facility volume consistently, positively, and significantly correlated with compliant care.
Conclusions: Guideline adherence is an important aspect regarding the quality of patient care. This study identifies patient, provider, and organizational characteristics that are associated with compliant care. These findings suggest benefits associated with the provision of EDX care by specialists and the centralization of EDX care in high-volume facilities.
IMPACT:
We anticipate that the results of this study will have direct relevance to the VA and CMS as well as the practice of electrodiagnostic medicine in the United States. Electrodiagnostic testing influences surgical decision-making and subsequent interventions. Despite their importance, little is known about the quality or efficacy of EDX consultations. This study provides a unique opportunity to examine variations in EDX testing and the relationship between these processes and the outcomes of care for a large cohort of VA and Medicare beneficiaries with a variety of musculoskeletal and neurological conditions that prompted EDX testing. We anticipate the results of the study to be used in several ways. First, the effort will result in the development of measures that can be used in future studies to uniformly document variations in EDX care and correlate these variations with outcomes. Application of these measures to this large population will provide important new data on the variations in EDX care currently provided to patients. In some cases we will be able to identify aspects of EDX testing that are clearly related to good outcomes but not universally provided to all VA beneficiaries.
Our latest findings suggest that physicians practicing at high volume centers are most likely to render compliant care.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems
DRE:
Diagnosis and Prognosis, Treatment
Keywords:
Cost, Practice patterns, Utilization patterns
MeSH Terms:
none
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