Kevin A Kerber

Concordia University–Ann Arbor, Ann Arbor, Michigan, United States

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Publications (77)362.44 Total impact

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    ABSTRACT: Objective: To estimate the ability of bedside information to risk stratify stroke in acute dizziness presentations. Methods: Surveillance methods were used to identify patients with acute dizziness and nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was defined as acute infarction or intracerebral hemorrhage on a clinical or research MRI performed within 14 days of dizziness onset. Bedside information comprised history of stroke, the ABCD(2) score (age, blood pressure, clinical features, duration, and diabetes), an ocular motor (OM)-based assessment (head impulse test, nystagmus pattern [central vs other], test of skew), and a general neurologic examination for other CNS features. Multivariable logistic regression was used to determine the association of the bedside information with stroke. Model calibration was assessed using low (<5%), intermediate (5% to <10%), and high (≥10%) predicted probability risk categories. Results: Acute stroke was identified in 29 of 272 patients (10.7%). Associations with stroke were as follows: ABCD(2) score (continuous) (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.20-2.51), any other CNS features (OR 2.54; 95% CI 1.06-6.08), OM assessment (OR 2.82; 95% CI 0.96-8.30), and prior stroke (OR 0.48; 95% CI 0.05-4.57). No stroke cases were in the model's low-risk probability category (0/86, 0%), whereas 9 were in the moderate-risk category (9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%). Conclusion: In acute dizziness presentations, the combination of ABCD(2) score, general neurologic examination, and a specialized OM examination has the capacity to risk-stratify acute stroke on MRI.
    Neurology 10/2015; DOI:10.1212/WNL.0000000000002141 · 8.29 Impact Factor
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    ABSTRACT: To increase neurologist awareness and inform future efficiency efforts, we identified all neurology-related Choosing Wisely items. Items were categorized by neurologic specialty, disease/symptom, and test/treatment. Of 370 items provided by 65 medical societies, 74 (20%) items were relevant to neurologists. Twelve were duplicated by multiple societies. Items pertaining to 10 neurologic subspecialties were identified, but none for movement disorders and neuromuscular disease. While many recommendations question the use of imaging, few address other high-cost neurologic tests such as EMG/nerve conduction studies and EEG. A rapidly growing number of neurology-related Choosing Wisely recommendations exist including areas of consensus and areas with few recommendations despite high costs. Consensus items should be prioritized for near-term interventions, while areas with few recommendations represent opportunities for future research.
    Neurology: Clinical Practice (Print) 10/2015; 5(5):439-447. DOI:10.1212/CPJ.0000000000000189
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    ABSTRACT: Study objective: Delay to hospital arrival limits acute stroke treatment. Use of emergency medical services (EMS) is key in ensuring timely stroke care. We aim to identify neighborhoods with low EMS use and to evaluate whether neighborhood-level factors are associated with EMS use. Methods: We conducted a secondary analysis of data from the Brain Attack Surveillance in Corpus Christi project, a population-based stroke surveillance study of ischemic stroke and intracerebral hemorrhage cases presenting to emergency departments in Nueces County, TX. The primary outcome was arrival by EMS. The primary exposures were neighborhood resident age, poverty, and violent crime. We estimated the association of neighborhood-level factors with EMS use, using hierarchic logistic regression, controlling for individual factors (stroke severity, ethnicity, and age). Results: During 2000 to 2009 there were 4,004 identified strokes, with EMS use data available for 3,474. Nearly half (49%) of stroke cases arrived by EMS. Adjusted stroke EMS use was lower in neighborhoods with higher family income (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.75 to 0.97) and a larger percentage of older adults (OR 0.70; 95% CI 0.56 to 0.89). Individual factors associated with stroke EMS use included white race (OR 1.41; 95% CI 1.13 to 1.76) and older age (OR 1.36 per 10-year age increment; 95% CI 1.27 to 1.46). The proportion of neighborhood stroke cases arriving by EMS ranged from 17% to 71%. The fully adjusted model explained only 0.3% (95% CI 0% to 1.1%) of neighborhood EMS stroke use variance, indicating that individual factors are more strongly associated with stroke EMS use than neighborhood factors. Conclusion: Although some neighborhood-level factors were associated with EMS use, patient-level factors explained nearly all variability in stroke EMS use. In this community, strategies to increase EMS use should target individuals rather than specific neighborhoods.
    Annals of emergency medicine 09/2015; DOI:10.1016/j.annemergmed.2015.07.524 · 4.68 Impact Factor
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    Neurologic Clinics 08/2015; 33(3):xiii-xv. DOI:10.1016/j.ncl.2015.05.001 · 1.40 Impact Factor
  • Kevin A Kerber · David E Newman-Toker ·
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    ABSTRACT: This article highlights 5 pitfalls in the diagnosis of common vestibular disorders: (1) overreliance on dizziness symptom type to drive diagnostic inquiry; (2) underuse and misuse of timing and triggers to categorize patients; (3) underuse, misuse, and misconceptions linked to hallmark eye examination findings; (4) overweighting age, vascular risk factors, and neuroexamination to screen for stroke; and (5) overuse and overreliance on head computed tomography to rule out neurologic causes. This article discusses the evidence base describing each pitfall's frequency and likely causes, and potential alternative strategies that might be used to improve diagnostic accuracy or mitigate harms. Copyright © 2015 Elsevier Inc. All rights reserved.
    Neurologic Clinics 08/2015; 33(3):565-575. DOI:10.1016/j.ncl.2015.04.009 · 1.40 Impact Factor
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    Neurologic Clinics 08/2015; 33(3):i. DOI:10.1016/S0733-8619(15)00040-7 · 1.40 Impact Factor
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    ABSTRACT: To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis. The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients ≥65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls. We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32% vs 25%, p = 0.008), 5.0 years for pain (36% vs 27%, p = 0.002), and 5.0 years for good to excellent self-rated health (61% vs 74%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed. In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome. © 2015 American Academy of Neurology.
    Neurology 05/2015; 85(1). DOI:10.1212/WNL.0000000000001714 · 8.29 Impact Factor
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    ABSTRACT: Little is known about how neurology payments vary by service type (i.e., evaluation and management [E/M] vs tests/treatments) and compare to other specialties, yet this information is necessary to help neurology define its position on proposed payment reform. Medicare Provider Utilization and Payment Data from 2012 were used. These data included all direct payments to providers who care for fee-for-service Medicare recipients. Total payment was determined by medical specialty and for various services (e.g., E/M, EEG, electromyography/nerve conduction studies, polysomnography) within neurology. Payment and proportion of services were then calculated across neurologists' payment categories. Neurologists comprised 1.5% (12,317) of individual providers who received Medicare payments and were paid $1.15 billion by Medicare in 2012. Sixty percent ($686 million) of the Medicare payment to neurologists was for E/M, which was a lower proportion than primary providers (approximately 85%) and higher than surgical subspecialties (range 9%-51%). The median neurologist received nearly 75% of their payments from E/M. Two-thirds of neurologists received 60% or more of their payment from E/M services and over 20% received all of their payment from E/M services. Neurologists in the highest payment category performed more services, of which a lower proportion were E/M, and performed at a facility, compared to neurologists in lower payment categories. E/M is the dominant source of payment to the majority of neurologists and should be prioritized by neurology in payment restructuring efforts. © 2015 American Academy of Neurology.
    Neurology 04/2015; 84(17). DOI:10.1212/WNL.0000000000001515 · 8.29 Impact Factor
  • Kevin A. Kerber ·
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    ABSTRACT: Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV-the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively-are supported by two evidence-based guidelines (American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice. © 2015 New York Academy of Sciences.
    Annals of the New York Academy of Sciences 03/2015; 1343(1). DOI:10.1111/nyas.12721 · 4.38 Impact Factor
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    ABSTRACT: The aim of this article is to determine the patient-level factors associated with headache neuroimaging in outpatient practice. Using data from the 2007-2010 National Ambulatory Medical Care Surveys (NAMCS), we estimated headache neuroimaging utilization (cross-sectional). Multivariable logistic regression was used to explore associations between patient-level factors and neuroimaging utilization. A Markov model with Monte Carlo simulation was used to estimate neuroimaging utilization over time at the individual patient level. Migraine diagnoses (OR = 0.6, 95% CI 0.4-0.9) and chronic headaches (routine, chronic OR = 0.3, 95% CI 0.2-0.6; flare-up, chronic OR = 0.5, 95% CI 0.3-0.96) were associated with lower utilization, but even in these populations neuroimaging was ordered frequently. Red flags for intracranial pathology did not increase use of neuroimaging studies (OR = 1.4, 95% CI 0.95-2.2). Neurologist visits (OR = 1.7, 95% CI 0.99-2.9) and first visits to a practice (OR = 3.2, 95% CI 1.4-7.4) were associated with increased imaging. A patient with new migraine headaches has a 39% (95% CI 24-54%) chance of receiving a neuroimaging study after five years and a patient with a flare-up of chronic headaches has a 51% (32-68%) chance. Neuroimaging is routinely ordered in outpatient headache patients including populations where guidelines specifically recommend against their use (migraines, chronic headaches, no red flags). © International Headache Society 2015 Reprints and permissions:
    Cephalalgia 02/2015; DOI:10.1177/0333102415572918 · 4.89 Impact Factor
  • Brian C Callaghan · Kevin A Kerber · James F Burke ·

    JAMA Internal Medicine 02/2015; 175(2):313-4. DOI:10.1001/jamainternmed.2014.7014 · 13.12 Impact Factor

  • Journal of Neurology Neurosurgery & Psychiatry 01/2015; DOI:10.1136/jnnp-2014-307575 · 6.81 Impact Factor

  • 43rd Annual Meeting of the Child-Neurology-Society; 10/2014

  • 43rd Annual Meeting of the Child-Neurology-Society; 10/2014

  • 43rd Annual Meeting of the Child-Neurology-Society; 10/2014
  • Kevin A Kerber · Marc Raphaelson · Gregory L Barkley · James F Burke ·
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    ABSTRACT: Objectives: To determine whether the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule confers higher value for physician work in procedure and test codes than in Evaluation and Management (E/M) codes. Background: Medicare Payment Advisory Commission previously demonstrated that time for medical services is the dominant element in valuing physician work in the CMS Physician Fee Schedule. In contrast, a more recent analysis suggests that more relative value units (RVUs) per unit time are issued for work in procedure codes than in E/M codes. Both prior analyses had important limitations for evaluating a possible systematic differential valuation of medical services. Methods: Data regarding RVUs, physician work times (minutes), and claims were obtained for all active level I Current Procedural Terminology (CPT) codes from 2011 CMS files. Linear regression was used to assess the associations of work time components and CPT category with work RVUs, including a model that weighted codes by the number of claims. Results: Included in the analysis were 6522 CPT codes (87 E/M codes, 6435 procedure/test codes). Compared with E/M codes, procedure/test codes did not have a significant difference in work RVUs adjusting for time (-0.631; 95% confidence interval, -1.427 to 0.166). The analysis also did not indicate a work RVU advantage specifically for Surgical CPT codes compared with E/M adjusting for time (-0.760; 95% confidence interval, -1.560 to 0.040). This pattern was not altered after weighting codes by the number of claims, indicating that an increase in RVUs per minute was not concentrated in a small number of highly utilized procedure codes. Conclusions: We did not find evidence of a systematic higher valuation of physician work in procedure /test codes than in E/M codes in the CMS RVU system.
    Annals of Surgery 09/2014; 262(2). DOI:10.1097/SLA.0000000000000990 · 8.33 Impact Factor

  • Annals of Neurology 09/2014; DOI:10.1002/ana.24280 · 9.98 Impact Factor
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    ABSTRACT: Background and purpose: Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design. Methods: Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences. Results: There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92). Conclusions: Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.
    Stroke 07/2014; 45(9). DOI:10.1161/STROKEAHA.114.005429 · 5.72 Impact Factor
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    ABSTRACT: Importance Distal symmetric polyneuropathy (DSP) is a prevalent condition that results in high costs from diagnostic testing. However, the role of neurologists and diagnostic tests in patient care is unknown.Objective To determine how often neurologists and diagnostic tests influence the diagnosis and management of DSP in a community setting.Design, Setting, and Participants In this retrospective cohort study, we used a validated case-capture method (International Classification of Diseases, Ninth Revision screening technique with subsequent medical record abstraction) to identify all patients with a new DSP diagnosis treated by community neurologists in Nueces County, Texas, who met the Toronto Diabetic Neuropathy Expert Group consensus criteria for probable DSP. Using a structured data abstraction process, we recorded diagnostic test results, diagnoses rendered (before and after testing), and subsequent management from April 1, 2010, through March 31, 2011.Main Outcomes and Measures Changes in DSP cause and management after diagnostic testing by neurologists.Results We identified 458 patients with DSP followed up for a mean (SD) of 435.3 (44.1) days. Neurologists identified a cause of DSP in 291 patients (63.5%) before their diagnostic testing. Seventy-one patients (15.5%) had a new DSP cause discovered after testing by neurologists. The most common new diagnoses were prediabetes (28 [6.1%]), vitamin B12 deficiency (20 [4.4%]), diabetes mellitus (8 [1.7%]), and thyroid disease (8 [1.7%]). Management changes were common (289 [63.1%]) and usually related to neuropathic pain management (224 [48.9%]). A potential disease-modifying management change was made in 113 patients (24.7%), with the most common changes being diabetes management in 45 (9.8%), treatment with vitamins in 39 (8.5%), diet and exercise in 33 (7.2%), and adjustment of thyroid medications in 10 (2.2%). Electrodiagnostic testing and magnetic resonance imaging of the neuroaxis rarely led to management changes.Conclusions and Relevance Neurologists diagnosed the cause of DSP in nearly two-thirds of patients before their diagnostic testing. Inexpensive blood tests for diabetes, thyroid dysfunction, and vitamin B12 deficiency allowed neurologists to identify a new cause of DSP in 71 patients (15.5%). In contrast, expensive electrodiagnostic tests and magnetic resonance imaging rarely changed patient care.
    JAMA Neurology 07/2014; 71(9). DOI:10.1001/jamaneurol.2014.1279 · 7.42 Impact Factor
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    ABSTRACT: Background and purpose: Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke. Methods: Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering. Results: Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment. Conclusions: State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted.
    Stroke 07/2014; 45(8). DOI:10.1161/STROKEAHA.114.005882 · 5.72 Impact Factor

Publication Stats

818 Citations
362.44 Total Impact Points


  • 2006-2015
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • University of Michigan
      • • Department of Neurology
      • • Department of Emergency Medicine
      • • Department of Health Management & Policy
      Ann Arbor, Michigan, United States
  • 2014
    • Henry Ford Hospital
      Detroit, Michigan, United States
  • 2005-2007
    • University of California, Los Angeles
      • • Department of Neurology
      • • Department of Head and Neck Surgery
      Los Angeles, CA, United States
  • 1998-2006
    • Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
      • Department of Medicine
      Torrance, California, United States