Fragmentation of care and the use of head computed tomography in patients with ischemic stroke

Circ Cardiovasc Qual Outcomes. 2014 May;7(3):430-6. doi: 10.1161/CIRCOUTCOMES.113.000745. Epub 2014 Apr 8.


Background: Computed tomographic (CT) scans are central diagnostic tests for ischemic stroke. Their inefficient use is a negative quality measure tracked by the Centers for Medicare and Medicaid Services.

Methods and results: We performed a retrospective analysis of Medicare fee-for-service claims data for adults admitted for ischemic stroke from 2008 to 2009, with 1-year follow-up. The outcome measures were risk-adjusted rates of high-intensity CT use (≥4 head CT scans) and risk- and price-adjusted Medicare expenditures in the year after admission. The average number of head CT scans in the year after admission, for the 327 521 study patients, was 1.94, whereas 11.9% had ≥4. Risk-adjusted rates of high-intensity CT use ranged from 4.6% (Napa, CA) to 20.0% (East Long Island, NY). These rates were 2.6% higher for blacks than for whites (95% confidence interval, 2.1%-3.1%), with considerable regional variation. Higher fragmentation of care (number of different doctors seen) was associated with high-intensity CT use. Patients living in the top quintile regions of fragmentation experienced a 5.9% higher rate of high-intensity CT use, with the lowest quintile as reference; the corresponding odds ratio was 1.77 (95% confidence interval, 1.71-1.83). Similarly, 1-year risk- and price-adjusted expenditures exhibited considerable regional variation, ranging from $31 175 (Salem, MA) to $61 895 (McAllen, TX). Regional rates of high-intensity CT scans were positively associated with 1-year expenditures (r=0.56; P<0.01).

Conclusions: Rates of high-intensity CT use for patients with ischemic stroke reflect wide practice patterns across regions and races. Medicare expenditures parallel these disparities. Fragmentation of care is associated with high-intensity CT use.

Keywords: Medicare; multidetector computed tomography; stroke.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Blacks*
  • Female
  • Follow-Up Studies
  • Head / diagnostic imaging*
  • Health Care Costs
  • Humans
  • Ischemic Attack, Transient / diagnosis*
  • Ischemic Attack, Transient / therapy
  • Male
  • Patient Acceptance of Health Care / statistics & numerical data*
  • Retrospective Studies
  • Tomography, X-Ray Computed / methods*
  • United States