Background: Standard gamble (SG) directly measures patients’ valuation of their health state. We compare in-hospital and day-90 SG utilities (SGU) among intracerebral hemorrhage patients and report a 3-way association between SGU, EuroQoL-5 dimension, and modified Rankin Scale at day 90. Methods and Results: Patients with intracerebral hemorrhage underwent in-hospital and day-90 assessments for the modified Rankin Scale, EuroQoL-5 dimension, and SG. SG provides patients a choice between their current health state and a hypothetical treatment with varying chances of either perfect health or a painless death. Higher SGU (scale, 0–1) indicates lower risk tolerance and thus higher valuation of the current health state. Logistic regression was used to estimate the likelihood of low SGU (≤0.6), and Wilcoxon paired signed-rank test compared in-hospital and day-90 SGU. In-hospital and day-90 SG was obtained from 381 and 280 patients, respectively, including 236 paired observations. Median (interquartile range) in-hospital and day-90 SGUs were 0.85 (0.40–0.98) and 0.98 (0.75–1.00; P <0.001). In-hospital SGUs were lower with advancing age ( P =0.007), higher National Institutes of Health Stroke Scale, and intracerebral hemorrhage scores ( P <0.001). Proxy-based assessments resulted in lower SGUs; median difference (95% CI), −0.2 (−0.33 to −0.07). After adjustment, higher National Institutes of Health Stroke Scale and proxy assessments were independently associated with lower SGU, along with an effect modification of age by race. Day-90 SGU and modified Rankin Scale were significantly correlated; however, SGUs were higher than the EuroQoL-5 dimension utilities at higher modified Rankin Scale levels. Conclusions: Divergence between directly (SGU) and indirectly (EuroQoL-5 dimension) assessed utilities at high levels of functional disability warrant careful prognostication of intracerebral hemorrhage outcomes and should be considered in designing early end-of-life care discussions with families and patients.

BackgroundIntracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking.Methods / design“Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)” is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of “spoke” hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted.DiscussionFindings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.

Introduction: Systolic blood pressure (SBP) regulation is the cornerstone of intracerebral hemorrhage (ICH) management, and SBP variability (SBPV) is associated with poor outcomes. We aimed to determine SBPV patterns and associated factors in a prospective cohort of ICH patients. Methods: Primary ICH patients are consented, assessed in-hospital and followed up at 30 and 90 days. All SBP values and BP management details for the hospital stay were collected from electronic medical records. Day and night intervals were defined as 0601 - 2159hrs and 2200 - 0600hrs, respectively. Mean and standard deviation (SD) were calculated for all intervals in each patient. Overall, between and within patient SBPV for day and night was characterized by generalized estimating equation (GEE)-based methods. We identified patients with a high SBPV (HSBPV) and built logistic regression models to determine associated factors. Results: Thus far, 158 patients have been enrolled, with detailed SBP data was available for 126. Total in-hospital follow-up period is 1,446 days [Median (IQR): 8 (4.25 - 15)]. We analyzed 34,740 SBP readings, yielding 3,010 day/night intervals. The in-hospital mean (SD) SBP was 138.2 (15.6) mmHg. GEE-based estimates for mean night SBP were significantly lower compared to day (137.2 v 139.1 mmHg, p < 0.01). Mean SBP SD was 9.1 mmHg between patients while 13.4 mmHg within patients’ individual readings. HSBPV was defined as SD > 13 mmHg. Age and high admission SBP were independently associated with HSBPV after controlling for sex, race, admission NIHSS, ICH score, hemorrhage volume and Nicardipine infusion use (Figure). Enrollments are continuing and updated data with outcomes will be presented. Conclusion: Characterization of patients with HSBPV can help in triage and management decisions based on risk-stratification. Elderly patients may be at a higher risk of SBPV, warranting exploration of possible SBPV contribution to poor outcomes in the elderly.

Introduction: Assessments of health-related quality of life (QoL) are increasingly important for stroke patients; however, such data are lacking for patients with intracerebral hemorrhage (ICH). Using EuroQol-5 Dimension-5 Level (EQ5D), we describe factors associated with QoL, and explore associations between QoL and functional outcomes in ICH patients. Methods: Our study is a multisite prospective cohort aiming to examine comparative effectiveness of treating ICH patients at various levels of care across Texas. Consented patients undergo QoL assessments - including EQ5D - in-hospital and 90 days post-discharge. EQ5D health utility values (HUV) were calculated using published utility weights for US population. HUVs range from -0.11 to 1.00, with 0.00 and 1.00 representing patient-perceived QoL equivalent to death and perfect health, respectively. Median and interquartile range (IQR) are reported. Quantile regression was used to evaluate factors associated with HUVs, and we report difference in median (DIM) and 95% confidence interval (CI) for the difference. Results: Thus far 158 patients have been enrolled in the study. EQ5D HUVs were obtained from 133 patients in-hospital and 62 patients at day 90. Median in-hospital and day-90 HUVs were significantly lower for patients with higher NIHSS and ICH scores. Patients with in-hospital complications, neurosurgical procedures, and longer length of stay also had lower HUVs (Table 1). There was a significant improvement in HUVs during 90-days post-discharge (DIM: 0.37; 95% CI: 0.24-0.51), and high day-90 HUVs were associated with good functional outcome (mRS 0-3) (Figure 1, DIM: 0.65, 95% CI: 0.51-0.78, p<0.001). Enrollment continues; updated analyses to be presented. Conclusion: Our results indicate a correlation between QoL, and inpatient clinical parameters and functional outcomes. Assessment of QoL may be routinely conducted in ICH studies to generate evidence for comparative effectiveness.

Introduction: Value-based care and patient-perceived outcomes are increasingly important. Standard Gamble (SG) derived utilities directly measure patients’ preferences for health states and form the basis of health economic analyses. We describe distribution of and factors associated with SG utilities (SGU) in a cohort of intracerebral hemorrhage (ICH) patients, and explore changes in SGU over 90 days post-discharge. Methods: Our study is a multisite cohort aiming to evaluate the comparative effectiveness of ICH patient management at various levels of care across Texas. Consented patients undergo assessments including SG in-hospital, and 30 and 90 days post-discharge. The SG assesses patients’ risk-taking behavior toward achieving a perfect health status, and outputs utility on a scale of 0 - 1 (Figure 1). Median and interquartile range (IQR) are reported for inpatient and day-90 SGU. Quantile regression was used to evaluate factors associated with SGU. Difference in median (DIM) and 95% confidence interval (CI) for the difference are reported. Results: 158 patients have been enrolled. Inpatient and day-90 SG was obtained from 132 and 54 patients respectively. Median inpatient SGU are significantly lower for older patients, white patients (compared to black patients), and those with higher ICH scores (Table 1). Median day-90 SGU was higher than inpatient SGU (DIM: 0.27; 95% CI: 0.08-0.46). Age >65 and higher ICH score were independently associated with lower SGU (Age: DIM -0.30; 95% CI -0.49, -0.11) (ICH Score: DIM -0.59; 95% CI -0.97, -0.21). Patients with mRS scores 0-3 at day 90 had higher SGU values compared to those with mRS scores 4-5 (DIM: 0.25, 95% CI: 0.09 - 0.41). Enrollment continues; updated analyses to be presented. Conclusion: Direct assessment of preferences for a morbid condition like ICH provides unique insight into patient values. Assessment of SGU may be routinely conducted in ICH patient studies to generate evidence for comparative effectiveness.