Sex and Racial Disparity in Outcome of Aneurysmal Subarachnoid Hemorrhage in the United States: A 20-Year Analysis

Abstract

Background: Aneurysmal subarachnoid hemorrhage is associated with high rate of morbidity and mortality. We aimed to assess prognostic impact of sex, race, and ethnicity in these patients. Methods: Nationwide Inpatient Sample (2000–2019) was used to identify patients presenting with aneurysmal subarachnoid hemorrhage as primary diagnosis. Patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities, type of the hospital, and treatment modality used for aneurysm repair were extracted. The previously validated Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale was used to estimate the clinical severity. Discharge destination and in-hospital mortality was used as outcome measured. The impact of race/ethnicity and sex on clinical outcome was analyzed using multivariate regression models. Results: A total of 161 086 patients with aneurysmal subarachnoid hemorrhage were identified. Mean age was 55.0±13.8 years. Sixty-nine percent of the patients were female, 60% White patients, and 17% Black patients. There was no difference in the Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale score between the 2 sexes. Women had significantly lower odds of good clinical outcome (defined as discharge to home or acute rehabilitation facility; RR, 0.83 [95% CI, 0.74–0.94]; P =0.004). Hispanic patients (RR, 1.12 [95% CI, 1.07–1.17]; P <0.001) had higher odds of excellent clinical outcome compared with White patients, and lower risk of mortality were observed in Black patients (RR, 0.73 [95% CI, 0.66–0.81]) and Hispanic patients (RR, 0.78 [95% CI, 0.70–0.86]) compared with the White patients. Conclusions: In this nationally representative study, women were less likely to have excellent outcomes following aneurysmal subarachnoid hemorrhage, and White patients had disproportionately higher likelihood of worse clinical outcomes. Lower rates of mortality were seen among Black and Hispanic patients.

Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage

“…Interestingly, a recent study found that Hispanic patients were more likely to have an excellent outcome (ie, patient being discharged home; RR=1.12 [1.07-1.17]) and that White patients were the most likely to have a poor outcome (ie, patient being discharged to a skilled nursing facility or long-term acute care hospital). 19 In contrast, in the present study, we found that compared with White patients, the adjusted discharge mRS scores were significantly worse for Hispanic patients (aOR, 1.44 [1.05-1.99]). These differences remained significant after comparing non-White versus White patients, with the former having a lower likelihood of achieving mRS scores of 0 to 2 at discharge.…”

“…17,18 In contrast, a recent study found that compared with White patients, Black and Hispanic patients had a lower likelihood of in-hospital mortality (RR, 0.73 [0.66–0.81] and RR, 0.78 [0.7–0.86], respectively). 19 Our study demonstrated that although in-hospital mortality rates were higher among Asian and Hispanic patients, the overall risk was similar across the different racial and ethnic groups; consistently, previous studies have shown that after adjusting for important confounders of outcomes, survival rates are comparable among White, Black, and Hispanic populations. 17,20 Nonetheless, this lack of difference should not infer the impact of patient race and ethnicity on long-term neurological and cognitive impairments faced by aSAH survivors.…”

“…Thus, DCI may involve a multifactorial process that deserves a more thorough study that accounts for baseline differences across all racial and ethnic groups. 4,5,19…”

Treatment of Spontaneous Subarachnoid Hemorrhage: A 20-year National Inpatient Sample Review

“…26 In conjunction with the decreased odds of mortality in the highest income group this raises concern for a widening health disparity, as further discussed by Schupper et al . 27…”

“…16 The slight bias of increasing aSAH within the lower income demographic is consistent with increased prevalence of stroke risk factors among patients of lower socioeconomic status and a potential lack of access to or desire for elective treatment. 26 In conjunction with the decreased odds of mortality in the highest income group this raises concern for a widening health disparity, as further discussed by Schupper et al 27 Improving outcome profiles…”