Publications by authors named "Gregory J Esper"

39 Publications

Delayed diagnosis of cranial neuropathies from perineural spread of skin cancer.

Taiwan J Ophthalmol 2021 Jan-Mar;11(1):86-88. Epub 2020 Nov 19.

Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA.

Perineural spread (PNS) to cranial nerves (CNs) by cutaneous malignancies is difficult to diagnose given the indolent course and often late or absent findings on brain imaging. A 68-year-old white man with multiple cranial neuropathies secondary to PNS by squamous cell carcinoma had negative high-quality neuroimaging for 5.25 years. He first developed left facial numbness, followed 39 months later by a left CN VI palsy. Subsequent examinations over 2 years showed involvement of left seventh, right trigeminal V1-V3, and right sixth, and bilateral third nerve palsies. Repeat high-quality brain magnetic resonance imaging (MRIs) during this time showed no identifiable CNs abnormality. Full body positron emission tomography imaging and cerebrospinal fluid studies were normal. 5.25 years after initial sensory symptom onset, MRI showed new enhancement along the right mandibular branch of the trigeminal nerve with foramen ovale widening. Autopsy showed squamous cell carcinoma within both CNs sixth. A long interval to diagnosis of PNS is associated with high morbidity, emphasizing the need for earlier methods of detection when clinical suspicion is high.
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http://dx.doi.org/10.4103/tjo.tjo_62_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7971445PMC
November 2020

Five-Year Trends in Payments for Neurologist-Prescribed Drugs in Medicare Part D.

Neurology 2021 04 10;96(16):e2132-e2137. Epub 2021 Mar 10.

From the University of Utah (A.d.H., A.D., S.D., P.W., N.S.), Salt Lake City; University of Michigan (B.C.), Ann Arbor; Boston University (J.N.), MA; Emory University (G.J.E.), Atlanta, GA; American Academy of Neurology (B.M.), Minneapolis, MN; and University of Colorado (K.V.N.), Denver.

Objective: To determine whether there was an increase in payments for neurologist-prescribed drugs, we performed a retrospective analysis of prescription claims in the Medicare Part D Prescriber Public Use Files from 2013 to 2017.

Methods: We included claims prescribed by providers with the taxonomy "neurology" and included drugs present in all 5 years. Drugs were designated in 2013 as generic (GEN), brand name only (BNO), and brand name prescribed even though a generic equivalent is available (BNGE). To observe payment trends, the percentage change in the per claim payment was compared between drug classes.

Results: We included 520 drugs, of which 322 were GEN, 61 were BNO, and 137 were BNGE, representing 90,716,536 claims and generating payments of $26,654,750,720. While the number of claims from 2013 to 2017 increased only 7.6%, the total payment increased 50.4%. Adjusted for inflation, claim payments for GEN drug increased 0.6%, compared to significant increases in BNO and BNGE drugs of 42.4% and 45.0% ( < 0.001). The percentage of overall GEN claims increased from 81.9% to 88.0%, BNO increased from 4.9% to 6.2%, and BNGE decreased from 13.3% to 5.8%. Neuroimmunology/multiple sclerosis drugs represented >50% of the total payments despite being only 4.3% of claims.

Conclusions: Payments for neurologist-prescribed brand name, but not generic, drugs in Medicare Part D increased consistently and well above inflation from 2013 to 2017. Unless the overall trend stabilizes or is reversed or high cost-to-claim drugs are addressed, this trend will place an increasing burden on the neurologic Medicare budget.
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http://dx.doi.org/10.1212/WNL.0000000000011712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166447PMC
April 2021

Current Procedural Terminology-based Procedure Categorization Enhances Cost Prediction of Medicare Severity Diagnosis Related Group in Spine Surgery.

Spine (Phila Pa 1976) 2021 Mar;46(6):391-400

Emory Orthopaedics & Spine Center, Emory University School of Medicine, Atlanta, GA.

Study Design: Retrospective cohort study.

Objective: The aim of this study was to analyze how a Current Procedural Terminology (CPT)-based categorization method can predict cost variation in surgical spine procedures.

Summary Of Background Data: Neck and back disorders affect a majority of the adult population and account for tens of billions of dollars in health care spending each year. In the era of bundled payments and value-based reimbursement, it is imperative for surgeons to identify sources of cost variability across surgical spine procedures. Historically, this has been accomplished using Medicare Severity Diagnosis Related Group (MS-DRG) codes, but they utilize an overly simplistic categorization of surgical procedures. The specificity and familiarity of the CPT coding structure makes it a better option for categorizing differences in surgical decision making and technique.

Methods: Hospital billing data for patients undergoing a surgical spine procedure requiring an overnight, in-patient stay was retrospectively collected over 4 fiscal years (2012-2016) from a single health care system. Linear regression analysis was performed to assess the correlation between cost variation and: spine-specific MS-DRG codes; a novel CPT-based categorization method; and the combination of MS-DRG codes and CPT-based categorization.

Results: There were 5020 surgical procedures were analyzed with respect to 16 different MS-DRG codes and 30 distinct CPT-based surgical categories (CSCs). Linear regression results were: MS-DRG R2 = 0.6545 (P < 0.001); CSC R2 = 0.5709 (P < 0.001); and R2 = 0.744 for the combined MS-DRG and CSC methods (P < 0.05). Median difference between the actual and predicted cost for the combined model was -$261.00, compared with -$727.50 for the CSC model and -$478.70 for the MS-DRG model.

Conclusion: Addition of the CPT-based categorization method to MS-DRG coding provides an enhanced method to evaluate the association between predicted and actual cost when using linear regression analysis to assess cost variation in spine surgery.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003801DOI Listing
March 2021

Increasing Out-of-Pocket Costs for Neurologic Care for Privately Insured Patients.

Neurology 2021 01 23;96(3):e322-e332. Epub 2020 Dec 23.

From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.

Objective: To measure the out-of-pocket (OOP) costs of evaluation and management (E/M) services and common diagnostic testing for neurology patients.

Methods: Using a large, privately insured health care claims database, we identified patients with a neurologic visit or diagnostic test from 2001 to 2016 and assessed inflation-adjusted OOP costs for E/M visits, neuroimaging, and neurophysiologic testing. For each diagnostic service each year, we estimated the proportion of patients with OOP costs, the mean OOP cost, and the proportion of the total service cost paid OOP. We modeled OOP cost as a function of patient and insurance factors.

Results: We identified 3,724,342 patients. The most frequent neurologic services were E/M visits (78.5%), EMG/nerve conduction studies (NCS) (7.7%), MRIs (5.3%), and EEGs (4.5%). Annually, 86.5%-95.2% of patients paid OOP costs for E/M visits and 23.1%-69.5% for diagnostic tests. For patients paying any OOP cost, the mean OOP cost increased over time, most substantially for EEG, MRI, and E/M. OOP costs varied considerably; for an MRI in 2016, the 50th percentile paid $103.10 and the 95th percentile paid $875.40. The proportion of total service cost paid OOP increased. High deductible health plan (HDHP) enrollment was associated with higher OOP costs for MRI, EMG/NCS, and EEG.

Conclusion: An increasing number of patients pay OOP for neurologic diagnostic services. These costs are rising and vary greatly across patients and tests. The cost sharing burden is particularly high for the growing population with HDHPs. In this setting, neurologic evaluation might result in financial hardship for patients.
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http://dx.doi.org/10.1212/WNL.0000000000011278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884984PMC
January 2021

Geographic Variation in Neurologist Density and Neurologic Care in the United States.

Neurology 2021 01 23;96(3):e309-e321. Epub 2020 Dec 23.

From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA.

Objective: To describe geographic variation in neurologist density, neurologic conditions, and neurologist involvement in neurologic care.

Methods: We used 20% 2015 Medicare data to summarize variation by Hospital Referral Region (HRR). Neurologic care was defined as office-based evaluation/management visits with a primary diagnosis of a neurologic condition.

Results: Mean density of neurologists varied nearly 4-fold from the lowest to the highest density quintile (9.7 [95% confidence interval (CI) 9.2-10.2] vs 43.1 [95% CI 37.6-48.5] per 100,000 Medicare beneficiaries). The mean prevalence of patients with neurologic conditions did not substantially differ across neurologist density quintile regions (293 vs 311 per 1,000 beneficiaries in the lowest vs highest quintiles, respectively). Of patients with a neurologic condition, 23.5% were seen by a neurologist, ranging from 20.6% in the lowest quintile regions to 27.0% in the highest quintile regions (6.4% absolute difference). Most of the difference comprised dementia, pain, and stroke conditions seen by neurologists. In contrast, very little of the difference comprised Parkinson disease and multiple sclerosis, both of which had a very high proportion (>80%) of neurologist involvement even in the lowest quintile regions.

Conclusions: The supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not. As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson disease and multiple sclerosis). These data provide insight for policy makers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.
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http://dx.doi.org/10.1212/WNL.0000000000011276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884982PMC
January 2021

Comparing Activity Trackers With vs. Without Alarms to Increase Postoperative Ambulation: A Randomized Control Trial.

Am Surg 2021 Jul 14;87(7):1093-1098. Epub 2020 Dec 14.

Department of Surgery, 12239Emory University School of Medicine, Atlanta, GA, USA.

Early ambulation is a key component to postoperative recovery; however, measuring steps taken is often inconsistent and nonstandardized. This study aimed to determine whether an activity tracker with alarms would increase postoperative ambulation in patients after elective colorectal procedures. Forty-eight patients were randomly assigned to either trackers with 5 daily alarms or activity trackers alone. Over 223 total patient days, the trackers recorded a complete data set for 216 patient days (96.9%). Increasing the postoperative day significantly affected the number of steps taken, while age, sex, Risk Analysis Index score, and approach (laparoscopic versus open) did not show a significant effect. The mean steps per day in the intervention group were 1468 (median 495; interquartile range (IQR) 1345) and in the control group was 1645 (median 1014; IQR 2498). The use of trackers with alarms did not significantly affect the number of daily steps compared to trackers alone (ANOVA, = .93). Although activity trackers with alarms did not increase postoperative ambulation compared with trackers with no alarms, we demonstrated a strategy to operationalize the use of trackers into postoperative care to provide a quantitative value for ambulation. This enables quantification of a key component in the Enhanced Recovery After Surgery protocol.
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http://dx.doi.org/10.1177/0003134820973364DOI Listing
July 2021

Impact of COVID-19 on Outcomes in Ischemic Stroke Patients in the United States.

J Stroke Cerebrovasc Dis 2021 Feb 9;30(2):105535. Epub 2020 Dec 9.

Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT 84132, United States. Electronic address:

Background: Studies have shown worse outcomes in patients with comorbid ischemic stroke (IS) and coronavirus disease 2019 (COVID-19), but have had small sample sizes.

Methods: We retrospectively identified patients in the Vizient Clinical Data Base® with IS as a discharge diagnosis. The study outcomes were in-hospital death and favorable discharge (home or acute rehabilitation). In the primary analysis, we compared IS patients with laboratory-confirmed COVID-19 (IS-COVID) discharged April 1-July 31, 2020 to pre-COVID IS patients discharged in 2019 (IS controls). In a secondary analysis, we compared a matched cohort of IS-COVID patients to patients within the IS controls who had pneumonia (IS-PNA), created with inverse-probability-weighting (IPW).

Results: In the primary analysis, we included 166,586 IS controls and 2086 IS-COVID from 312 hospitals in 46 states. Compared to IS controls, IS-COVID were less likely to have hypertension, dyslipidemia, or be smokers, but more likely to be male, younger, have diabetes, obesity, acute renal failure, acute coronary syndrome, venous thromboembolism, intubation, and comorbid intracerebral or subarachnoid hemorrhage (all p<0.05). Black and Hispanic patients accounted for 21.7% and 7.4% of IS controls, respectively, but 33.7% and 18.5% of IS-COVID (p<0.001). IS-COVID, versus IS controls, were less likely to receive alteplase (1.8% vs 5.6%, p<0.001), mechanical thrombectomy (4.4% vs. 6.7%, p<0.001), to have favorable discharge (33.9% vs. 66.4%, p<0.001), but more likely to die (30.4% vs. 6.5%, p<0.001). In the matched cohort of patients with IS-COVID and IS-PNA, IS-COVID had a higher risk of death (IPW-weighted OR 1.56, 95% CI 1.33-1.82) and lower odds of favorable discharge (IPW-weighted OR 0.63, 95% CI 0.54-0.73).

Conclusions: Ischemic stroke patients with COVID-19 are more likely to be male, younger, and Black or Hispanic, with significant increases in morbidity and mortality compared to both ischemic stroke controls from 2019 and to patients with ischemic stroke and pneumonia.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832426PMC
February 2021

Rapid Systemwide Implementation of Outpatient Telehealth in Response to the COVID-19 Pandemic.

J Healthc Manag 2020 Nov-Dec;65(6):443-452

EHC Telehealth Team and Emory University School of Medicine Department of Radiology and Imaging Sciences.

Executive Summary: The COVID-19 pandemic, with its resultant social distancing, has disrupted the delivery of healthcare for both patients and providers. Fortunately, changes to legislation and regulation in response to the pandemic allowed Emory Healthcare to rapidly implement telehealth care. Beginning in early March 2020 and continuing through the initial 2-month implementation period (when data collection stopped), clinicians received telehealth training and certification. Standard workflows created by means of a hub-and-spoke operational model enabled rapid sharing and deployment of best practices throughout the system's physician group practice. Lean process huddles facilitated successful implementation. In total, 2,374 healthcare professionals, including 986 attending physicians, 416 residents and fellows, and 555 advanced practice providers, were trained and certified for telehealth; 53,751 new- and established-patient audio-video telehealth visits and 10,539 established-patient telephone visits were performed in 8 weeks for a total of 64,290 virtual visits. This initiative included a new COVID-19 virtual patient clinic that saw 705 patients in a 6-week period. A total of $14,662,967 was charged during this time; collection rates were similar to in-person visits. Initial patient satisfaction scores were equivalent to in-person visits. We conclude that rapid deployment of virtual visits can be accomplished through a structured, organized approach including training, certification, and Lean principles. A hub-and-spoke model enables bidirectional feedback and timely improvements, thus facilitating swifter implementation and a quick rise in patient volume. Financial sustainability is achievable, but to sustain that, telehealth requires the support of continued deregulation by legislative and regulatory bodies.
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http://dx.doi.org/10.1097/JHM-D-20-00131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671820PMC
December 2020

The effects of the Medicare NCS reimbursement policy: Utilization, payments, and patient access.

Neurology 2020 08 17;95(7):e930-e935. Epub 2020 Jul 17.

From the Health Services Research Program (E.L.R., K.A.K., C.H., L.B.D.L.), Department of Neurology, University of Michigan; Veterans Affairs Healthcare System (B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.

Objective: To determine whether the 2013 nerve conduction study (NCS) reimbursement reduction changed Medicare use, payments, and patient access to Medicare physicians by performing a retrospective analysis of Medicare data (2012-2016 fee-for-service data from the CMS Physician and Other Supplier Public Use File).

Methods: Individual billable services were identified by Healthcare Common Procedure Coding System Current Procedural Terminology and G codes. Medicare use and payments were stratified by specialty and type of service (electrodiagnostic tests, including NCS and EMG, and other neurologic procedures). We also assessed access to Medicare physicians using the annual number of unique beneficiaries receiving initial Evaluation and Management (E/M) services.

Results: We identified 676,113 Medicare providers included in all analysis years from 2012 to 2016 (10,599 neurologists, 5,881 physiatrists, and 659,633 other specialties). Comparing 2016 to 2012 showed that 21.1% fewer neurologists, 28.6% fewer physiatrists, and 69.3% fewer other specialists performed NCS and 3.8% fewer neurologists, 21.7% fewer physiatrists, and 5.6% fewer other specialists performed EMG. For NCS providers in 2012, the mean number of unique Medicare beneficiaries increased for neurologists (1.2%) and physiatrists (4.8%) but decreased for other specialists (-6.5%) by 2016. After the NCS cut, the number of providers performing autonomic and evoked potential testing increased substantially.

Conclusions: The Medicare NCS reimbursement policy resulted in a larger decrease in NCS providers than in EMG providers. Despite fewer neurologists and physiatrists performing NCS, Medicare access to these physicians for E/M services was not affected. Increased autonomic and evoked potential testing may be an unintended consequence of NCS reimbursement change.
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http://dx.doi.org/10.1212/WNL.0000000000010090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605505PMC
August 2020

Feasibility and Acceptability of Inpatient Palliative Care E-Family Meetings During COVID-19 Pandemic.

J Pain Symptom Manage 2020 09 4;60(3):e28-e32. Epub 2020 Jun 4.

Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.

Family meetings are fundamental to the practice of palliative medicine and serve as a cornerstone of intervention on the inpatient palliative care consultation service. The COVID-19 pandemic disrupted the structure and process of in-patient family meetings, owing to necessary but restrictive visitor policies that did not allow families to be present in the hospital. We describe implementation of telemedicine to facilitate electronic family (e-family) meetings to facilitate in-patient palliative care. Of 67 scheduled meetings performed by the palliative care service, only two meetings were aborted for a 97% success rate of scheduled meetings occurring. On a five-point Likert-type scale, the average clinician rating of the e-family meeting overall quality was 3.18 (SD, .96). Of the 10 unique family participants who agreed to be interviewed, their overall ratings of the e-family meetings were high. Over 80% of respondent families participants reported that they agreed or strongly agreed that they were able to ask all of their questions, felt comfortable expressing their thoughts and feelings with the clinical team, felt like they understood the care their loved one received, and that the virtual family meeting helped them trust the clinical team. Of patients who were able to communicate, 50% of family respondents reported that the e-family meeting helped them understand their loved one's thoughts and wishes.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272163PMC
September 2020

Feasibility of a Nonmydriatic Ocular Fundus Camera in an Outpatient Neurology Clinic.

Neurologist 2020 Mar;25(2):19-23

Ophthalmology and Neurology, Emory University, Atlanta, GA.

Objective: To determine the feasibility of nonmydriatic fundus photography in the neurology outpatient setting and to record frequency of clinically relevant fundus findings.

Methods: Over 5 weeks, fundus photographs were obtained using a nonmydriatic fundus camera in both eyes of adult patients attending our general neurology and headache clinics. A neurologist, who had received 15 minutes of training on the use of the camera, took the photographs. Quality of photographs was graded. Photographs were reviewed by 2 neuro-ophthalmologists. Treating neurologists completed a survey on the use of this technology in the neurology clinic. Feasibility parameters including ease, comfort, speed, quality, and clinical relevance of nonmydriatic fundus photography was assessed.

Results: We obtained 505 fundus photographs of 206 patients. Median time to completion of photographs per patient was 2.12 minutes. Mean rating for ease, comfort, and speed was 9.7 out of 10. Among these, 160 had normal and 44 had abnormal findings. In 114 of 206 patients, neurologists relied on photographs for ocular fundus assessment. In the remaining 92 patients, 18 patients had abnormal photographs, of which neurologists missed the abnormality in 14 (78%). All neurologists preferred nonmydriatic fundus photography over direct ophthalmoscopy.

Conclusions: Using nonmydriatic fundus photography in an outpatient neurology clinic is feasible without disrupting patient flow or causing patient discomfort. Findings of optic nerve pallor, optic nerve swelling, or normal optic nerves were particularly relevant to these patients seen for headaches or demyelinating disease and helped inform immediate diagnosis and management.
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http://dx.doi.org/10.1097/NRL.0000000000000259DOI Listing
March 2020

Association of out-of-pocket costs on adherence to common neurologic medications.

Neurology 2020 03 19;94(13):e1415-e1426. Epub 2020 Feb 19.

From the Health Services Research Program, Department of Neurology (E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and the Department of Neurology (G.J.E.), Emory University, Atlanta, GA.

Objective: To determine the association between out-of-pocket costs and medication adherence in 3 common neurologic diseases.

Methods: Utilizing privately insured claims from 2001 to 2016, we identified patients with incident neuropathy, dementia, or Parkinson disease (PD). We selected patients who were prescribed medications with similar efficacy and tolerability, but differential out-of-pocket costs (neuropathy with gabapentinoids or mixed serotonin/norepinephrine reuptake inhibitors [SNRIs], dementia with cholinesterase inhibitors, PD with dopamine agonists). Medication adherence was defined as the number of days supplied in the first 6 months. Instrumental variable analysis was used to estimate the association of out-of-pocket costs and other patient factors on medication adherence.

Results: We identified 52,249 patients with neuropathy on gabapentinoids, 5,246 patients with neuropathy on SNRIs, 19,820 patients with dementia on cholinesterase inhibitors, and 3,130 patients with PD on dopamine agonists. Increasing out-of-pocket costs by $50 was associated with significantly lower medication adherence for patients with neuropathy on gabapentinoids (adjusted incidence rate ratio [IRR] 0.91, 0.89-0.93) and dementia (adjusted IRR 0.88, 0.86-0.91). Increased out-of-pocket costs for patients with neuropathy on SNRIs (adjusted IRR 0.97, 0.88-1.08) and patients with PD (adjusted IRR 0.90, 0.81-1.00) were not significantly associated with medication adherence. Minority populations had lower adherence with gabapentinoids and cholinesterase inhibitors compared to white patients.

Conclusions: Higher out-of-pocket costs were associated with lower medication adherence in 3 common neurologic conditions. When prescribing medications, physicians should consider these costs in order to increase adherence, especially as out-of-pocket costs continue to rise. Racial/ethnic disparities were also observed; therefore, minority populations should receive additional focus in future intervention efforts to improve adherence.
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http://dx.doi.org/10.1212/WNL.0000000000009039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274913PMC
March 2020

Implementation of quality measures and patient-reported outcomes in an epilepsy clinic.

Neurology 2019 11 30;93(22):e2032-e2041. Epub 2019 Oct 30.

From the Department of Neurology (L.M.V.R.M., D.B.H.), Massachusetts General Hospital, Boston; American Academy of Neurology (B.M.), Minneapolis, MN; Department of Neurology (J.P.N.), Boston University, MA; Department of Neurology (E.M.C.), David Geffen School of Medicine, University of California, Los Angeles; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.

Objective: To see if systematic collection of patient-reported epilepsy quality measures can identify opportunities to improve care, and to examine the associations between these measures and physical and mental health.

Methods: We developed a patient-reported questionnaire for medication adherence, seizure frequency, medication side effects, and driving that included the Patient-Reported Outcome Measurement Information System-10 (PROMIS-10) (physical and mental health). We offered it to all adult patients seen twice in an epilepsy clinic (January 2017-January 2018). The questionnaire was available on the web as well as a tablet provided at appointment check-in. We used the first completed questionnaire to explore the relationship between patient-reported care quality and measures of physical and mental health.

Results: A total of 610 unique patients (15% of the total encounters) completed a survey. Respondents were comparable to nonrespondents. Respondents reported gaps in care or opportunities for quality improvement in 48.4% (n = 295) of the encounters. Of patients who reported at least 1 seizure per month over the previous 3 months, 55.2% (n = 100) reported problems with adherence, 30.0% (n = 131) reported having problems believed to be adverse reactions to anticonvulsants, and 15.2% (n = 41) reported driving. In addition, respondents who reported either seizures over the recent 3 months, nonadherence to treatment due to cost, or anticonvulsant-associated adverse effects had consistently worse physical and mental health (all < 0.05).

Conclusions: Systematic collection of epilepsy quality measures endorsed by the American Academy of Neurology can identify opportunities for quality improvement. Measures of epilepsy care quality predict outcomes that matter to patients.
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http://dx.doi.org/10.1212/WNL.0000000000008548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978483PMC
November 2019

The Feasibility of Measuring Gait in an Outpatient Cognitive Neurology Clinical Setting.

J Alzheimers Dis 2019 ;71(s1):S51-S55

Emory University, Department of Neurology, Atlanta, GA, USA.

There is increasing interest in gait evaluations in clinical settings given the associations between gait and health outcomes. However, efforts examining implementation of gait evaluation in neurological clinics are lacking. Herein, gait implementation within a cognitive neurology clinic is presented. Over a 21-month period, a gait evaluation was collected on 81% of eligible patients (n = 2,622; mean age 73.2±9.5; age range 49-94 years; 47% female). Patients and staff reported being satisfied with the gait assessment. These finding have implications for gait evaluations in clinical settings and for clinical research aimed at understanding the impact of cognitive symptomatology on gait.
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http://dx.doi.org/10.3233/JAD-190106DOI Listing
October 2020

Out-of-pocket costs are on the rise for commonly prescribed neurologic medications.

Neurology 2019 05 1;92(22):e2604-e2613. Epub 2019 May 1.

From the Health Services Research Program, Department of Neurology (B.C.C., K.A.K., L.E.S., J.F.B.), and the School of Public Health (E.R., M.B.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.

Objective: To determine out-of-pocket costs for neurologic medications in 5 common neurologic diseases.

Methods: Utilizing a large, privately insured, health care claims database from 2004 to 2016, we captured out-of-pocket medication costs for patients seen by outpatient neurologists with multiple sclerosis (MS), peripheral neuropathy, epilepsy, dementia, and Parkinson disease (PD). We compared out-of-pocket costs for those in high-deductible health plans compared to traditional plans and explored cumulative out-of-pocket costs over the first 2 years after diagnosis across conditions with high- (MS) and low/medium-cost (epilepsy) medications.

Results: The population consisted of 105,355 patients with MS, 314,530 with peripheral neuropathy, 281,073 with epilepsy, 120,720 with dementia, and 90,801 with PD. MS medications had the fastest rise in monthly out-of-pocket expenses (mean [SD] $15 [$23] in 2004, $309 [$593] in 2016) with minimal differences between medications. Out-of-pocket costs for brand name medications in the other conditions also rose considerably. Patients in high-deductible health plans incurred approximately twice the monthly out-of-pocket expense as compared to those not in these plans ($661 [$964] vs $246 [$472] in MS, $40 [$94] vs $18 [$46] in epilepsy in 2016). Cumulative 2-year out-of-pocket costs rose almost linearly over time in MS ($2,238 [$3,342]) and epilepsy ($230 [$443]).

Conclusions: Out-of-pocket costs for neurologic medications have increased considerably over the last 12 years, particularly for those in high-deductible health plans. Out-of-pocket costs vary widely both across and within conditions. To minimize patient financial burden, neurologists require access to precise cost information when making treatment decisions.
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http://dx.doi.org/10.1212/WNL.0000000000007564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556089PMC
May 2019

When to Consider Prophylactic Antimigraine Therapy in Children with Migraine.

Curr Treat Options Neurol 2019 Mar 14;21(4):15. Epub 2019 Mar 14.

Department of Neurology, Emory Brain Health Center, Atlanta, GA, USA.

Purpose Of Review: Headache is not an uncommon complaint in children, and recognition of migraine is increasing in children and adolescents. Treatment options consist of abortive and preventive medications; however, when to start the preventive treatment is not clear in the pediatric population. This article reviews current guidelines and practices to provide a better clinical approach in the management of migraines in children and adolescents.

Recent Findings: Currently, the only FDA-approved medical treatment option for preventive therapy in chronic migraine in adolescents is topiramate. However, the Childhood and Adolescent Migraine Prevention Study (CHAMP) did not endorse superiority of topiramate or amitriptyline over placebo. At this time, there is no clear consensus on when to start preventive therapy in children and adolescents with migraines. The decision is multifactorial and should be initiated after a thorough discussion with the patient and caregiver(s) about related risks and benefits of treatment. Education regarding various modalities of treatment and ensuring compliance is essential to treatment success.
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http://dx.doi.org/10.1007/s11940-019-0560-7DOI Listing
March 2019

Claims data analyses unable to properly characterize the value of neurologists in epilepsy care.

Neurology 2019 02 23;92(9):e973-e987. Epub 2019 Jan 23.

From the Health Services Research Program (C.E.H., C.C.L., J.F.B., K.A.K., L.E.S., B.C.C.), Department of Neurology, University of Michigan, Ann Arbor; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and American Academy of Neurology (B.M.), Minneapolis, MN.

Objective: To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy.

Methods: Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery).

Results: After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases ( ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases ( ≤ 0.001).

Conclusions: Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.
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http://dx.doi.org/10.1212/WNL.0000000000007004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404473PMC
February 2019

Association of neurologist care with headache expenditures: A population-based, longitudinal analysis.

Cephalalgia 2018 10 4;38(12):1876-1884. Epub 2018 Mar 4.

7 Emory University School of Medicine, Atlanta, GA, USA.

Objective To assess the association of neurologist ambulatory care with healthcare utilization and expenditure in headache. Methods This was a longitudinal cohort study from two-year duration panel data, pooled from 2002-2013, of adult respondents identified with diagnostic codes for headache in the Medical Expenditure Panel Survey. Those with a neurologist ambulatory care visit in year one of panel participation were compared with those who did not for the change in annual aggregate direct headache-related health care costs from year one to year two of panel participation, inflated to 2015 US dollars. Results were adjusted via multiple linear regression for demographic and clinical variables, utilizing survey variables for accurate estimates and standard errors. Results Eight hundred and eighty-seven respondents were included, with 23.3% (207/887) seeing a neurologist in year one. The neurologist group had higher year-one mean headache-related expenditures ($3032 vs. $1636), but nearly equal mean year-two expenditures compared to controls ($1900 vs. $1929). Adjusted association between neurologist care and difference in mean annual expenditures from year two to year one was -$1579 (95% CI -$2468, -$690, p < 0.001). Conclusion Among headache sufferers, particularly those with higher headache-related healthcare expenditures, neurologist care is associated with a significant reduction in costs over two years.
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http://dx.doi.org/10.1177/0333102418762572DOI Listing
October 2018

The association of neurologists with headache health care utilization and costs.

Neurology 2018 02 10;90(6):e525-e533. Epub 2018 Jan 10.

From the Health Services Research Program, Department of Neurology (B.C.C., J.F.B., K.A.K., L.E.S.), University of Michigan; Veterans Affairs Healthcare System (B.C.C., J.F.B.), Ann Arbor, MI; Boston University School of Medicine (J.P.N.), MA; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta.

Objective: To determine the association of a neurologist visit with headache health care utilization and costs.

Methods: Utilizing a large privately insured health care claims database, we identified patients with an incident headache diagnosis (ICD-9 codes 339.xx, 784.0x, 306.81) with at least 5 years follow-up. Patients with a subsequent neurologist visit were matched to controls without a neurologist visit using propensity score matching, accounting for 54 potential confounders and regional variation in neurologist density. Co-primary outcomes were emergency department (ED) visits and hospitalizations for headache. Secondary outcomes were quality measures (abortive, prophylactic, and opioid prescriptions) and costs (total, headache-related, and non-headache-related). Generalized estimating equations assessed differences in longitudinal outcomes between cases and controls.

Results: We identified 28,585 cases and 57,170 controls. ED visits did not differ between cases and controls ( = 0.05). Hospitalizations were more common in cases in year 0-1 (0.2%, 95% confidence interval [CI] 0.2%-0.3% vs 0.01%, 95% CI 0.01%-0.02%; < 0.01), with minimal differences in subsequent years. Costs (including non-headache-related costs) and high-quality and low-quality medication utilization were higher in cases in the first year and decreased toward control costs in subsequent years with small differences persisting over 5 years. Opioid prescriptions increased over time in both cases and controls.

Conclusion: Compared with those without a neurologist, headache patients who visit neurologists had a transient increase in hospitalizations, but the same ED utilization. Confounding by severity is the most likely explanation given the non-headache-related cost trajectory. Claims-based risk adjustment will likely underestimate disease severity of headache patients seen by neurologists.
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http://dx.doi.org/10.1212/WNL.0000000000004925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818019PMC
February 2018

Commentary on an Excerpt From A Tale of Two Cities.

Acad Med 2017 Sep;92(9):1249

M.A. Kumarasamy is analytics program manager, Office of Quality & Risk, Emory Healthcare, Atlanta, Georgia. G.J. Esper is director, New Care Models, Emory Healthcare, Atlanta, Georgia. W.A. Bornstein is chief medical officer and chief quality officer, Emory Healthcare, Atlanta, Georgia; e-mail: Twitter:

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http://dx.doi.org/10.1097/01.ACM.0000524672.21238.b6DOI Listing
September 2017

How neurologists are paid: Part 2: Private practice, research grants, academic and nonclinical activities.

Neurol Clin Pract 2015 Oct;5(5):405-411

Vanderbilt University Medical Center (PDD), Nashville, TN; Henry Ford Hospital (GLB), Detroit, MI; Children's Hospital Medical Center of Akron (BHC), OH; Texas Neurology (DAE), Dallas; Emory University (GJE), Atlanta, GA; University of Maryland (BS), School of Medicine, Baltimore; University of Calgary (JRB), Alberta Children's Hospital, Canada; and American Academy of Neurology (AB), Minneapolis, MN.

Part 1 of this series focused on factors influencing payment for patient care services. In Part 2, we review compensation models for nonpatient activity such as medical legal reviews, committee participation, and collaboration with the pharmaceutical industry. Compensation to neurologists in private practice is commonly in the form of guaranteed salary and bonuses. Salary for neurologists in academic medicine has changed considerably over the past 3 decades, from small departments with faculty supported by grants and volunteer faculty, to large departments with faculty split between those with research grant support and those focusing on patient care and teaching. Compensation models in academic medicine range from straight salary without bonus to straight salary with personal or shared bonus and salary based on relative value units.
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http://dx.doi.org/10.1212/CPJ.0000000000000183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610320PMC
October 2015

How neurologists are paid: Part 1: The Medicare payment system.

Neurol Clin Pract 2015 Oct;5(5):397-404

Vanderbilt University Medical Center (PDD), Nashville, TN; Henry Ford Hospital (GLB), Detroit, MI; Children's Hospital Medical Center of Akron (BHC), OH; Texas Neurology (DAE), Dallas; Emory University (GJE), Atlanta, GA; University of Maryland (BS), School of Medicine, Baltimore; University of Calgary (JRB), Alberta Children's Hospital, Canada; and American Academy of Neurology (AB), Minneapolis, MN.

Neurologists are facing yearly reductions in reimbursement for rendered services. These reductions arise from changes by Medicare, Medicaid, and third-party payers to achieve cost savings. In Part 1, we discuss reimbursement for office visits and procedures, the relative value scale, the conversion factor used by Medicare to transform work into payments, and the recently repealed sustainable growth rate. The establishment of new codes for transitional care and chronic care management may augment the salaries of neurologists who care for patients with chronic conditions. Medicare's recent elimination of payment for consultations and the bundling of nerve conduction studies have dramatically affected reimbursement. Large discrepancies remain between compensation for procedures and office visits.
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http://dx.doi.org/10.1212/CPJ.0000000000000182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610318PMC
October 2015

How neurologists are paid: Part 3: Hospital support, Veterans Administration, and neurohospitalists.

Neurol Clin Pract 2015 Oct;5(5):412-418

Vanderbilt University Medical Center (PDD), Nashville, TN; Henry Ford Hospital (GLB), Detroit, MI; Children's Hospital Medical Center of Akron (BHC), OH; Texas Neurology (DAE), Dallas; Emory University (GJE), Atlanta, GA; University of Maryland (BS), School of Medicine, Baltimore; University of Calgary (JRB), Alberta Children's Hospital, Canada; and American Academy of Neurology (AB), Minneapolis, MN.

Part 1 of this series focused on factors influencing payment for patient care services and Part 2 described compensation plans for neurologists in private practice and in academic medicine. In Part 3, we review how hospital salary support and appointments to Veterans Administration hospitals contribute to the salary structure of neurologists. We also discuss neurohospitalist care and ways neurologists can potentially increase compensation from on-call pay, telemedicine, and the use of new transitional care and complex chronic care codes. We conclude with an emphasis on the important role of neurologists as team players in a health care system that will rely on efficient coordination of care among many health care workers.
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http://dx.doi.org/10.1212/CPJ.0000000000000184DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610316PMC
October 2015

Hypothalamic-pituitary sarcoidosis with vision loss and hypopituitarism: case series and literature review.

Pituitary 2016 Feb;19(1):19-29

Division of Endocrinology, Department of Medicine, Emory University, 1365 B Clifton Rd., NE, B6209, Atlanta, GA, 30322, USA.

Purpose: Hypothalamic-pituitary (HP) neurosarcoidosis (NS) accounts for 0.5 % cases of sarcoidosis and 1 % of HP masses. Correlative data on endocrine and neurological outcomes is lacking.

Methods: Retrospective case series and literature review of presentation, treatment and outcome of HP NS.

Results: Our series includes 4 men, ages 34-59, followed for a median of 7.3 years (range 1.5-17). All had optic neuropathy, multiple pituitary hormone abnormalities (PHAs) and other organ involvement by sarcoidosis (lung, sino-nasal, brain/spine and facial nerve). Two patients had central diabetes insipidus and one impaired thirst with polydipsia. After treatment with high-dose glucocorticoids, optic neuropathy improved in one case and stabilized in the others. After treatment, HP lesions improved radiologically, but PHAs persisted in all cases. Review of four published series on HP NS in addition to ours yielded 46 patients, age 37 ± 11.8 years, 65 % male. PHAs consisted of anterior hypopituitarism (LH/FSH 88.8 %, TSH 67.4 %, GH 50.0 %, ACTH 48.8 %), hyperprolactinemia (48.8 %) and diabetes insipidus (65.2 %). PHAs were the first sign of disease in 54.3 % patients. Vision problems occurred in 28.3 % patients, but optic neuropathy was not well documented in previous series. Most patients (93.5 %) received high-dose glucocorticoids followed by taper; 50 % also received other immunomodulators, including methotrexate, mycophenolate mofetil, cyclosporine, azathioprine, infliximab and hydrochloroquine. Only 13 % patients showed improvement in PHAs. All-cause mortality was 8.7 %.

Conclusion: HP NS is a serious disease requiring multidisciplinary treatment and lifelong follow-up. Prospective multicentric studies are needed to determine a more standardized approach to HP NS and outline predictors of disease outcome.
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http://dx.doi.org/10.1007/s11102-015-0678-xDOI Listing
February 2016

The neurologist as a medical home neighbor.

Neurol Clin Pract 2013 Apr;3(2):134-140

Massachusetts General Hospital (DBH), Boston; Beth Israel Hospital and Mt. Sinai School of Medicine (MCH), New York, NY; Children's Hospital Medical Center of Akron (HM, BHC), Akron, OH; Emory University (GJE), Atlanta, GA; American Academy of Neurology (AB), Minneapolis, MN; and UPMC Shadyside (NAB), Pittsburgh, PA.

Recent health policy initiatives designed to improve care coordination have stimulated the resurgence of the patient-centered medical home (PCMH) model. The details of how primary and specialty care are coordinated within the PCMH model are of interest to specialists. A good medical home "neighbor" must adhere to principles that complement the PCMH team-based approach and personal relationship to the patient. One issue for neurologists considering participation in this model is whether they will function as the principal physician for some patients, only in the role of a consultant, or take some new role. It is too early to suggest any one payment method as superior, or establish the appropriate capitation fees for practicing neurologists. Recommendations are provided for neurologists considering participation in a PCMH neighborhood.
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http://dx.doi.org/10.1212/CPJ.0b013e31828d9fa6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721236PMC
April 2013

Practice and payment trends in neurology in 2012.

Neurol Clin Pract 2013 Jun;3(3):233-239

American Academy of Neurology, Minneapolis, MN.

This article describes practice and payment trends among neurologists. Data from the 2012 Practice and Payment Trends survey were compared to results from the 2010 Medical Economics survey. Both surveys were sent to a random sample of 1,000 US practicing neurologists, with a response rate of 32%. Since 2010, there has been an 8% increase in the percent of neurologists working in academic medical centers. Nearly half of neurologists reported working for a hospital-affiliated practice. Wait times have increased 40% for a new patient visit. Only 19% of neurologists indicated procedures as the primary focus of their practice. New delivery models have not yet gained traction with neurologists but the majority (>80%) of neurologists currently use electronic health records in their practice.
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http://dx.doi.org/10.1212/CPJ.0b013e318296f2efDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798513PMC
June 2013

How to select and implement an electronic health record in a neurology practice.

Neurol Clin Pract 2013 Apr;3(2):141-148

Department of Neurological Sciences (ALW), Rush University Medical Center, Chicago, IL; and Department of Neurology (GJE), Emory University, Atlanta, GA.

The purchase, implementation, and maintenance of an electronic health record (EHR) are among the most significant financial investments a practice will make. A practice's choice of EHR will have long-term and wide-ranging implications for how that practice operates. A successful EHR implementation may potentially result in increased efficiency, improved quality of patient care, and a possibly more successful practice. Extensive research and thoughtful planning, done with the involvement of all stakeholders, the commitment of adequate time, staff, and financial resources to the process, and sufficient training will increase the chances for a successful EHR implementation.
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http://dx.doi.org/10.1212/CPJ.0b013e31828d9fb7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765949PMC
April 2013

Use of information technology in the examination room.

Authors:
Gregory J Esper

JAMA 2012 Sep;308(12):1208-9; author reply 1209

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http://dx.doi.org/10.1001/2012.jama.11184DOI Listing
September 2012

Role of professionalism in improving the patient-centeredness, timeliness, and equity of neurological care.

Arch Neurol 2010 Nov;67(11):1386-90

Neurology and Research Services, Veterans Affairs Maryland Health Care System and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.

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http://dx.doi.org/10.1001/archneurol.2010.278DOI Listing
November 2010
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