Although the small number of patients in the study prevents a precise estimation of the effect of surgery, “the observed treatment effect was so large that the benefit of AMTR seems unequivocal,” wrote Donald L. Schomer, MD, Professor of Neurology at Harvard University in Boston, and Roger J. Lewis, MD, PhD, of the David Geffen School of Medicine, UCLA, in an accompanying editorial. “Just as important, these results are consistent with prior work, additional strong evidence that the treatment effect is real rather than some artifact of early termination,” they added.
Engel J Jr, McDermott MP, Wiebe S, et al. Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA. 2012;307(9):922-930.
Schomer DL, Lewis RJ. Stopping seizures early and the surgical epilepsy trial that stopped even earlier. JAMA. 2012;307(9):966-968.
Inefficient Neuroimaging in Stroke May Increase Health Care Costs
About 95% of patients with stroke who had undergone an MRI had also received a CT scan, researchers reported in the February issue of Annals of Neurology. From 1999 to 2008, MRI use increased by 38%, but CT use did not change. In 2008, MRI use ranged from a low of 55% in Oregon to a high of 79% in Arizona.
“These data suggest that neuroimaging practices in stroke are neither standardized nor efficient,” wrote James F. Burke, MD, Clinical Lecturer of Neurology at the University of Michigan Medical School in Ann Arbor, and colleagues. “Absent a credible alternative explanation, variation in physician practice patterns likely accounts for much of the variation in MRI utilization,” he added.
To track MRI use, Dr. Burke and his colleagues studied records from 1999 through 2008 for 624,842 patients in 11 states. States were chosen for geographic and racial diversity. Investigators examined discharges for patients with stroke older than 18 who had been admitted to the emergency room. Patients’ mean age was 73, and 54% were female. Approximately 61% of patients were white, 7% were black, and 13% were Hispanic.
Diagnostic imaging was the second largest cost center from 1999 to 2007. During those years, MRI costs increased 413%, thus outpacing the rate at which costs for diagnostic imaging overall increased. From 1997 to 2007, mean hospital costs increased from $9,058 to $12,842 in the states with the most complete cost data.
“Our findings suggest stroke neuroimaging may be unnecessarily costly,” Dr. Burke’s group commented. Physicians could contain neuroimaging costs by minimizing multiple imaging studies, he added. Instead of ordering a CT scan immediately, physicians may safely allow some patients to wait for an MRI.
The investigators’ study offers “a startling demonstration of the physician’s role in rising health care costs,” wrote S. Claiborne Johnston, MD, PhD, of the Neurovascular Disease and Stroke Center, University of California, San Francisco, and Stephen L. Hauser, MD, Chair of Neurology at the University of California, San Francisco, in an accompanying editorial. “The added value of MRI in patients who have already received a CT in the acute setting is questionable; it is unlikely to alter the care plan,” they added.
Burke JF, Kerber KA, Iwashyna TJ, Morgenstern LB. Wide variation and rising utilization of stroke magnetic resonance imaging: Data from 11 states. Ann Neurol. 2012;71(2):179-185.
Johnston SC, Hauser SL. Modern care for neurological problems must address waste. Ann Neurol. 2012;71(2):A5-A6.