- The document summarizes key findings from a nationwide survey of 91 hospitals regarding stroke specialist call coverage. - Nearly two-thirds of neurologists and neurosurgeons take call 7 or more days per month. Combined call schedules are most common. - Since 2009, more hospitals have separate stroke call from general neurology call. Payment for call is also more prevalent. - Over half of neuroendovascular specialists and neurosurgeons are now employed by hospitals. Employment of neurologists and use of mid-level providers to support call coverage has also increased significantly.

1. N A T I O N W I D E S U R V E Y
STROKE SPECIALIST CALL
R E S E A R C H R E S U L T S
Executive Summary
P U B L I S H E D N O V E M B E R 2 0 1 3
®

2. 17 North State Street, Suite 1700, Chicago, 60602 t 312.644.4780 f 312.644.4782 www.neustrategy.com
Authors
Debbie Lombardi Hill, Partner, NeuStrategy, Inc.
Theodore W. Michalke, Managing Partner, NeuStrategy, Inc.
Kevin D. Dunne, Partner, NeuStrategy, Inc.
Acknowledgements
NeuStrategy extends its appreciation to…
Survey participants for sharing their experience and strategies around stroke specialist call coverage
Disclaimer
The findings reported herein largely reflect the results of primary or field research involving survey, interview
and observation methods. Due to the limitations of primary research and the dynamic nature of the topic,
general patterns or trends noted may rapidly change.
About NeuStrategy
NeuStrategy is rooted in a legacy of focused healthcare industry expertise. As the creator of the COE
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completed more than 200 customized neuroscience, orthopedic, oncology and behavioral health specialty
healthcare engagements for academic and community health systems across the country.
© Copyright 2013 by NeuStrategy, Inc. All rights reserved.
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3. F O R E W O R D
Then and Now
In the last decade, stroke care has edged from calmer
backwaters into swift currents, joining heart attack and
trauma in the world of 24/7 emergent care. A steep
ramp-up in certified primary – and more recently
comprehensive – stroke centers bears witness to
organizational and physician will to markedly improve
stroke systems of care. The industry’s sweeping
embrace has even landed stroke a pedigreed spot
among hospital accreditation core measures.
Organizations with the requisite infrastructure found
stroke and cerebrovascular referrals seeping in from all
directions. Telestroke – now the backbone of broader
telemedicine initiatives – emerged to fill triage and
patient management voids, especially for smaller
hospitals or those unable to secure 24/7 acute stroke
call coverage from their own physicians. Neurology,
neuroendovascular and neurosurgery specialists at
successful stroke programs across the country bore the
brunt of this new frontline offensive.
Now, after years of escalating tensions between
hospitals, emergency physicians and stroke specialists,
NeuStrategy’s 2013 Stroke Specialist Call Survey
demonstrates that many organizations are investing in
stroke care. More are employing stroke specialists.
More are paying for call. More still, are providing staff to
support on-call stroke specialists and to help physicians
formalize best practice and standardize stroke care.
Perhaps stroke program development has been more
evolutionary than revolutionary since 2009, when
NeuStrategy first fielded this industry survey. However,
the long-term view is now clear. Patients are receiving
better care. Families are getting greater support.
Physicians are more engaged than ever. And along the
way, many organizations have gleaned a healthy dose
of respect for a service line that can contribute to a
hospital’s bottom line.
Thanks for your support,
THE NEUSTRATEGY TEAM
T A B L E O F C O N T E N T S
IN T R O D U C T I O N ..........................1
RE S E A R C H ME T H O D S ..................2
RE S P O N D E N T PR O F I L E ................2
KE Y FI N D I N G S …........................4
CO N C L U S I O N .............................8

4. STROKESPECIALISTCALLSURVEYRESULTS
1
Introduction
Hospitals across the nation continue to face
challenges securing and maintaining emergency call
coverage for their Primary and Comprehensive
Stroke Centers. In late 2009, NeuStrategy released
the first real-time national data reporting neurology
and stroke call arrangements. Expanded and re-
fielded in 2012 and 2013, NeuStrategy’s latest report
allows hospitals and physicians to compare their call
arrangements to emerging national trends for:
 Neurologists
 Neuroendovascular Specialists
 Cerebrovascular Neurosurgeons
 Telestroke Access to Stroke Specialists
This report summarizes key findings of
NeuStrategy’s nationwide survey of 91 hospitals and
health systems. The full details will be available after
the webinar at:
http://neustrategy.com/Media/surveys.html
Factors Affecting Stroke Call
Limited Specialist Availability
 Neurology, neurosurgery and neuroendovascular
specialists shortage outside major urban areas
 Call burden undermines quality of life expectations
Onerous Hospital-Based Obligations
 Stroke center certification and telestroke call
burden and compliance demands
 Riskier 24/7 ER and hospital demands disruptive
to elective, higher revenue practices
Strategies to Close Gaps
Expanded Physician Resource Pool
 Neuro-specialist employment
 Call pay (increasingly prevalent for private practice)
 ED, neurocritical care and hospitalist engagement
Formalized Support
 Team to buffer and support on-call specialists
 Formalized stroke program infrastructure
 Stroke services value proposition awareness

5. STROKESPECIALISTCALLSURVEYRESULTS
2
Research Methods
NeuStrategy used a web-based survey tool to
determine current call arrangements, telestroke
network development and alignment strategies
between hospitals and stroke specialists across
numerous settings including academic, tertiary,
community (teaching and non-teaching), private,
not-for-profit, single hospitals and multi-campus
health systems.
Fielded in August and September 2013, the survey
is comprised of multiple-choice questions. Results
are largely self-reported. Proprietary and public data
sources were used to complete or validate certain
self-reported information.
Respondent Profile
The findings represent 91 survey participants across
28 states. Almost 70% of the respondents represent
hospitals with a Level I or II trauma designation.
98% are certified stroke centers.
While 28% are academic medical centers and 72%
are community hospitals, nearly 70% of participants
are engaged in physician training. Compared with
2009, more than twice as many participants now
employ neurologists.
75% of 2013 survey participants are part of a health
system and 95% are non-profit. 90% are located in
urban (50%) and suburban (40%) markets.

6. STROKESPECIALISTCALLSURVEYRESULTS
3
Volume and Bed Size
The survey probed the relationship between
respondent bed size and stroke volume.
 Nearly half the 2013 participants report more than
500 strokes annually, compared to only one-third
of 2009 participants
Breadth of Stroke and
Neurovascular Care Services
Participating hospitals described the scope of
services they currently provide.
 All provide medical stroke care and nearly all
administer IV rt-PA
 About three quarters perform neuroendovascular
procedures
Network Development
The survey queried participants on their participation
and role in telestroke programs.
 Just under 60% of participants are now involved in
telestroke networks – nearly a six-fold increase
from 2009
 Two thirds of hospitals not engaged in telestroke
services are evaluating their options
 The majority of HUB hospitals cover fewer than
three SPOKE hospitals

7. STROKESPECIALISTCALLSURVEYRESULTS
4
Key Findings
Call Frequency and Structures
The survey captured the frequency and structure of
call for neurologists and neurosurgeons. To
understand specialization impact on call schedules,
participants indicated the presence of combined
versus separate call schedules.
 Almost two-thirds of neurologists and neurosurgeons
on combined schedules are on call 7 or more days
per month
 Combined neurosurgery (versus separate
cerebrovascular neurosurgery and general
neurosurgery) call schedules are most common
 Combined neurology (versus separate stroke and
general neurology) call schedules are also most
common
 Since 2009, 40% more hospitals have segregated
stroke call from a combined, general neurology
call schedule

8. STROKESPECIALISTCALLSURVEYRESULTS
5
Stroke Specialist Call Pay
Questions queried the presence of call pay, call
arrangements and the amount paid for call.
 Prevalence of neurosurgery call pay is higher than
neurology, but the gap is closing
 Hospitals not paying for neuroendovascular call are
less likely to consider paying in the future
 40% more hospitals are paying neurologists for call in
2013 than in 2009
 With a largely employed medical staff, academic
medical centers are less likely to pay for call than
community hospitals with a larger complement of
private practice physicians

9. STROKESPECIALISTCALLSURVEYRESULTS
6
Stroke Specialist Employment
The survey questioned whether stroke specialists
were employed. While neurology employment was
explored in 2009 and 2013, neuroendovascular
specialists and neurosurgeons were added in 2013.
 Neurology employment jumped roughly 50%
between 2009 and 2013
 More than half of neuroendovascular specialists
and neurosurgeons are employed
 Mid-level providers are more often employed by
the hospital, especially to support on-call
neurologists and neuroendovascular specialists
On-Call Support
The survey also probed for the presence of allied
providers to lessen the burden of stroke specialist
call coverage. If available to support on-call
neurology, neuroendovascular or neurosurgery,
nurse or mid-level provider (RNs, ARNPs, PAs) and
resident roles and employment relationships were
investigated.
 On-call neurologist support has almost doubled
since 2009
 Proceduralists (neuroendovascular specialists and
neurosurgeons) tend to have more nursing and
mid-level (NPs, PAs) on-call support than
neurologists
 Physician extenders typically triage, facilitate care
and provide patient education and outreach
support

10. STROKESPECIALISTCALLSURVEYRESULTS
7
Physician-Hospital Alignment
The survey explored business relationships between
hospitals and stroke specialists. These included
medical directorships, quality initiatives, program
development and/or management stipends, call pay,
employment and joint ventures.
 Neurologist employment has jumped roughly 50%
since 2009
 More than half of hospitals are using employment
of neurologists, neuroendovascular physicians and
neurosurgeons as an alignment strategy
 Pay for quality (nearly double) and JVs (up 50%)
are on the rise
Stroke Network Development
Telestroke network development was examined in
the survey. With an increasing interest in telestroke,
the impact on volume of stroke interventions was
explored.
 Of the 60% of participants involved in telestroke,
almost all HUB hospitals are planning to expand
their SPOKE partnerships over the next year
 Two thirds of those not engaged in telestroke
services are evaluating their options
 The majority of HUB hospitals report increases in
stroke volume of all types – medical and
procedural patients
 SPOKE hospitals have seen the greatest increase
in IV rt-PA intervention

11. STROKESPECIALISTCALLSURVEYRESULTS
8
Conclusion
Hospitals are investing significantly to address the
stroke call dilemma, combining specialist
employment, call pay and on-call support.
Leveraging allied hospital-based stroke and neuro-
hospitalists may be most feasible in larger, more
comprehensive stroke centers, but engaging
emergency physicians and expanding mid-level
support and nursing depth, such as neurovascular-
trained advanced practice nurses (ANVP),
neurovascular and stroke certified registered nurses
(NVRN and SCRN), are effective strategies that all
hospitals can embrace to backstop stroke specialist
call burden.
Over the long run, population health management
will require even more hospital-physician alignment
to create seamless, cost-effective stroke systems of
care. Hospitals must simultaneously support acute
stroke care and move toward greater use of the OP
setting. Stroke clinics focused on initial and
secondary prevention will help providers manage
risk and reduce readmissions.
The bar has been set. The industry has embraced
universal metrics encompassing the Centers for
Medicare and Medicaid (CMS), the American Stroke
Association’s Target Stroke Initiative, individual state
and hospital accrediting and primary and
comprehensive stroke center certifying organizations
to measure quality. Continued focus on the right mix
of stroke physician and physician support resources
will be critical.
Where From Here?
The following steps will help hospitals and
physicians move toward greater accountability
for stroke care and outcomes:
 Add shared accountability for standardized, best
practice care
 Adjust resource pools to ensure competency –
too many in the on-call pool results in limited
experience and erodes best practice
 Partner with local/regional/national allied health
teaching programs to ensure neuro-trained mid-
level and nursing resource pools
 Participate in registries and surveys such as this
tool to benchmark for performance improvement

12. Webinar FAQs
WHAT MORE WILL I LEARN IN THE WEBINAR?
The complimentary Executive Summary provides survey highlights. Join the webinar if you want more detail on:
 Call Pay Amounts and Days/Month for Physicians on Subspecialty versus General or Combined Call Schedules
o Stroke and General Neurology versus Combined Call Schedules
o Cerebrovascular Neurosurgery and General Neurosurgery versus Combined Call Schedules
o Neuroendovascular Call Schedules
 Call Pay Trends and 2013 Facts and Figures
o Employed versus Private Practice
o Academic versus Community Hospitals
o Comprehensive versus Primary Stroke Centers
o System versus Independent Hospitals
o Urban versus Suburban versus Rural Settings
 Telestroke Development Trends and 2013 Facts and Figures
o HUB versus SPOKE Hospital Benefits
o HUB versus SPOKE Hospital Perceptions of Value Proposition
o HUB versus SPOKE Hospital Telestroke Costs
WHAT IF I CANNOT PARTICIPATE IN THE WEBINAR ON NOVEMBER 21?
You have the option to purchase the webinar slide deck and listen a previously recorded version of the webinar.
Contact us for details or check our website: www.NeuStrategy.com