Tests and Expenditures in the Initial Evaluation of Peripheral Neuropathy

Department of Neurology, University of Michigan, Ann Arbor, MI 48104, USA.
Archives of internal medicine (Impact Factor: 17.33). 01/2012; 172(2):127-32. DOI: 10.1001/archinternmed.2011.1032
Source: PubMed


Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing.
We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods.
Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001).
Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

13 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Little is known about what constitutes appropriate diagnostic testing in patients with distal symmetric polyneuropathy (DSP). Methods: Utilizing an ICD-9 screening method and medical record abstraction, we determined the number of new cases of DSP within community neurology practices in Nueces County, Texas. We then compared 2 case capture methods (ICD-9 vs. all-case review screening). Results: The ICD-9 case capture method identified 52 cases over a 3-month period. Comparing case capture methods, the ICD-9 method identified 16 of 17 cases identified by the all-case review method (94%). The ICD-9 method required screening of 84% fewer charts compared with the all-case review. Conclusions: Many new cases of DSP occur each month within Nueces County. The ICD-9 screening technique combined with medical abstraction is an efficient method to identify new DSP cases in this community. These findings are critical for future epidemiological investigations into patients with DSP.
    Muscle & Nerve 12/2012; 46(6). DOI:10.1002/mus.23449 · 2.28 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Peripheral neuropathy is a common disorder, often prompting an extensive initial laboratory evaluation. The initial evaluation is particularly challenging to primary care physicians and neurologists because of the broad differential diagnosis. Although screening thyroid and rheumatologic tests are frequently ordered, the diagnostic yield of these tests is unclear. Data from our institution were collected on patient demographics, clinical characteristics including warning signs suggestive of a diagnosis other than distal symmetric polyneuropathy, history of thyroid or rheumatologic disease, and laboratory tests ordered. Thyroid and rheumatologic screening tests are commonly ordered in the evaluation of peripheral neuropathy. Our findings suggest a low aggregate value of these tests based on low yield and infrequent changes in the suspected etiology or management of these patients.
    Neurology: Clinical Practice (Print) 04/2013; 3(2):90-98. DOI:10.1212/CPJ.0b013e31828d9f2c
  • [Show abstract] [Hide abstract]
    ABSTRACT: To determine if diabetes or pre-diabetes is associated with monofilament insensitivity and peripheral neuropathy symptoms. The 10-g Semmes-Weinstein monofilament test and Michigan Neuropathy Screening Instrument symptom questionnaire were administered to participants in the Study of Women's Health Across the Nation - Michigan site (n=396). We determined the concordance of monofilament insensitivity and symptoms and used chi-square tests, ANOVA, and logistic regression to quantify the relationships among diabetes status, monofilament insensitivity and symptoms. The prevalence of monofilament insensitivity was 14.3% and 19.4% of women reported symptoms of peripheral neuropathy. With monofilament testing, 11.7% of women with normal fasting glucose, 14.4% of women with impaired fasting glucose (IFG) and 18.3% of women with diabetes had monofilament insensitivity (p-value=0.33). For symptoms, 14.0% of women with normal fasting glucose, 16.5% of women with IFG and 31.2% of women with diabetes reported symptoms of peripheral neuropathy. Women who reported symptoms of small fiber nerve dysfunction alone were unlikely to have monofilament insensitivity. Compared to women with normal fasting glucose, women with diabetes were more likely to report peripheral neuropathy symptoms [OR 2.8 (95% CI: 1.5, 5.1)]. Women with diabetes were also more likely to report symptoms than women with IFG (p=0.02). There was no difference in the frequency of symptoms between women with normal fasting glucose and IFG. Women with diabetes were more likely to report peripheral neuropathy symptoms. The prevalence of monofilament insensitivity and peripheral neuropathy symptoms did not differ between women with normal fasting glucose and IFG.
    07/2013; 7(4). DOI:10.1016/j.pcd.2013.07.001
Show more