Specialty Classifications of Physicians Who Provide Neurocritical Care in the United States

Abstract

Background: We sought to characterize the specialty classification of US physicians who provide critical care for neurological/neurosurgical disease.

Methods: Using inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries, we selected hospitalizations for neurological/neurosurgical diseases with potential to result in life-threatening manifestations requiring critical care. Using Current Procedural Terminology^® codes, we determined the medical specialty of providers submitting critical care claims, and, using National Provider Identifier numbers, we merged in data from the United Council for Neurologic Subspecialties (UCNS) to determine whether the provider was a UCNS diplomate in neurocritical care. We defined providers with a clinical neuroscience background as neurologists, neurosurgeons, and/or UCNS diplomates in neurocritical care. We defined neurocritical care service as a critical care claim with a qualifying neurological/neurosurgical diagnosis in patients with a relevant primary hospital discharge diagnosis and ≥ 3 total critical care claims, excluding claims from the first day of hospitalization since these were mostly emergency-department claims. Our findings were reported using descriptive statistics with exact confidence intervals (CI).

Results: Among 1,952,305 Medicare beneficiaries, we identified 99,937 hospitalizations with at least one claim for neurocritical care. In our primary analysis, neurologists accounted for 28.0% (95% CI, 27.5-28.5%) of claims, neurosurgeons for 3.7% (95% CI, 3.5-3.9%), UCNS-certified neurointensivists for 25.8% (95% CI, 25.3-26.3%), and providers with any clinical neuroscience background for 42.8% (95% CI, 42.2-43.3%). The likelihood of management by physicians with a clinical neuroscience background increased proportionally with patients' county-level socioeconomic status and such providers were 3 times more likely to be based at an academic medical center than other physicians who billed for critical care in our sample (odds ratio, 2.9; 95% CI, 1.1-8.1).

Conclusions: Physicians with a dedicated clinical neuroscience background accounted for less than half of neurocritical care service in US Medicare beneficiaries.

Keywords: Care delivery; Neurocritical care; Physician specialty; Staffing model; Unit organization.

Figure 1:

Distribution of Specialties of Physicians Submitting Critical Care Claims During Hospitalizations for Neurological or Neurosurgical Disease. Caption: • Definition A: Critical care claims with a qualifying neurological/neurosurgical diagnosis in patients with a relevant primary hospital discharge diagnosis and ≥3 total critical care claims, excluding claims from the first day of hospitalization. • Definition B: Critical care claims from hospitalizations with a primary hospital discharge diagnosis of neurological/neurosurgical disease. • Definition C: Critical care claims with an associated neurological diagnosis. • Definition D: Critical care claims excluding the first day of hospitalization. • Definition E: Critical care claims excluding hospitalizations for cardiac arrest. • Definition F: Critical care claims from hospitalizations with at least 3 critical care claims. • Definition G: Any critical care claim..

Figure 2:

Proportion of Neurocritical Care Provided by Physicians with a Dedicated Clinical Neuroscience Background Based on County Socioeconomic Advantage Score. Caption: Each county’s socioeconomic advantage score was calculated based on six variables representing wealth and income, education, and occupation (9). Socioeconomic data was obtained from the American Communities Survey (13). The resulting quantity represents the z-score, or the number of standard deviations from the mean socioeconomic score.