Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

Abstract

Background and ObjectivesRegional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes.MethodsA retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models.ResultsOf 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use.DiscussionMultiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.

Case Fatality of Aneurysmal Subarachnoid Hemorrhage Varies by Geographic Region Within Finland

“…Besides these population-based studies, some hospital-based studies have reported within-country differences in the in-hospital mortality of SAH. 15,48 Notably, a recent US study 15 reported that differences in the admission severity of illness, nimodipine use, and aneurysm repair may have contributed to the modest regional variation in in-hospital mortality. Similar to our findings, within-country differences in CFRs have also been observed for other cardiovascular diseases, such as acute myocardial infarction, 49 intracerebral hemorrhage, 50 and ischemic stroke.…”

“…Several factors related to patient characteristics and SAH care may contribute to the geographical variation and timedependent changes in SAH CFRs. 15 For instance, the regions with the highest CFRs-Western, Central, and Eastern Finland-also had the highest median age during SAH (Spearman correlation ρ = 0.60, p = 0.01) (eTable 4, links.lww.com/WNL/D134). Similarly, the mean age of hospitalized patients with SAH and the proportion of people who live alone 16 (significant risk factors of fatal SAH 17,18 ) increased the least in Southern and Central Finland during the study period (eFigure 4, links.lww.com/ WNL/D132).…”

Association between serum sodium levels within 24 h of admission and all-cause mortality in critically ill patients with non-traumatic subarachnoid hemorrhage: a retrospective analysis of the MIMIC-IV database

“…Furthermore, recent systematic reviews and meta-analyses have demonstrated that serum sodium is an accurate tool for predicting the prognosis of critically ill patients ( 15 , 20 , 21 ). According to research, hypertension, diabetes, congestive heart failure, and renal failure are typical co-morbidities in individuals with non-traumatic SAH ( 22 , 23 ). Despite the fact that these co-morbidities were linked to poor outcomes, our stratified and subgroup analyses had no impact on the final outcome.…”

Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist

“…Many factors have likely led to this improvement, including earlier timing of aneurysm treatment [ 113 ], and specialized neurocritical care management [ 114 ]. There is tremendous variability in aSAH care [ 115 ] and associated outcomes [ 116 ], and evidence-based and guideline-driven care [ 30 ] have the potential to improve population outcomes for aSAH. Long-term outcomes in aSAH trials and observational studies have been historically measured on scales of function such as modified Rankin Score (mRS) or Glasgow Outcome Scale or Extended (GOS/GOSE), and are dichotomized by researchers inconsistently into good or poor outcomes.…”