Effects of Institutional Caseload of Subarachnoid Hemorrhage on Mortality

McNeill, Lisa; English, Shane; Borg, Nicholas; Matta, Basil F.; Menon, David

doi:10.1161/strokeaha.112.681254

Cited by 53 publications

(38 citation statements)

References 34 publications

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“…Most previous studies of hospital volume and mortality after treatment for unruptured and ruptured intracranial aneurysms have found lower mortality in high-volume compared with low-volume hospitals, but different definitions of "low-volume hospital" make direct comparison with our study difficult. [1][2][3][4]7,8,13,14,[16][17][18] All previous studies except 1 have reported mortality at discharge. The lower mortality in high-volume hospitals may therefore have been confounded, for instance, by differences in length of stay and discharge routines.…”

Section: Discussionmentioning

confidence: 98%

Hospital volume and 1-year mortality after treatment of intracranial aneurysms: a study based on patient registries in Scandinavia

Lindekleiv¹,

Mathiesen

Førde³

et al. 2015

JNS

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OBJECT The object of this study was to examine the relationship between hospital volume and long-term mortality after treatment of intracranial aneurysms. METHODS The authors identified patients treated for intracranial aneurysms between 2002 and 2010 from patient registries of Denmark, Norway, and Sweden, and linked to data on 1-year mortality from the population registry of each country. Cox regression models were used to relate hospital volume to the risk of death and adjusted for potential confounders (age, sex, year of treatment, Charlson comorbidity index, country, and surgical treatment). RESULTS The authors identified 5773 patients with ruptured and 1756 patients with unruptured intracranial aneurysms, treated at 15 hospitals. One-year mortality rates were 15.6% for patients with ruptured aneurysms and 2.7% for patients with unruptured aneurysms. No consistent relationship was found between hospital volume and 1-year mortality for ruptured aneurysms in the unadjusted analyses, but higher hospital volume was associated with increased mortality in the analyses adjusted for potential confounders (hazard ratio [HR] per 10-patient increase 1.04, 95% CI 1.00–1.07). There was a trend toward a lower mortality rate in higher-volume hospitals after treatment for unruptured intracranial aneurysms, but this was not statistically significant after adjustment for potential confounders (HR per 10-patient increase 0.69, 95% CI 0.42–1.10). There were large variations in mortality after treatment for both ruptured and unruptured intracranial aneurysms across hospitals and between the Scandinavian countries (p < 0.01). CONCLUSIONS The findings in this study did not confirm a relationship between higher hospital volume and reduced long-term mortality after treatment of ruptured intracranial aneurysms. Prospective registries for evaluating outcomes after aneurysm treatment are highly warranted.

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Section: Discussionmentioning

confidence: 98%

Hospital volume and 1-year mortality after treatment of intracranial aneurysms: a study based on patient registries in Scandinavia

Lindekleiv¹,

Mathiesen

Førde³

et al. 2015

JNS

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“…We know that treatment in a high-volume hospital reduces morbidity and mortality. 7,8 An activity threshold of 20 cases per year used to be considered suitable, 9,10 but a more recent study showed that the impact of caseload on outcome persists well beyond this threshold. 8 In France, a neurointerventional center accepting patients with aneurysms for endovascular treatment is required to treat at least 80 patients per year.…”

Section: Discussionmentioning

confidence: 99%

“…7,8 An activity threshold of 20 cases per year used to be considered suitable, 9,10 but a more recent study showed that the impact of caseload on outcome persists well beyond this threshold. 8 In France, a neurointerventional center accepting patients with aneurysms for endovascular treatment is required to treat at least 80 patients per year. Regionalization policies have been put in place worldwide during the past 20 years, based on the assumption, proven first in surgery, that highly experienced teams obtain better clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…10 This has also been proven for the endovascular treatment of SAH. 8 Such organization is also costeffective, 10 as a significant outcome improvement because of a high-volume hospital can justify the extra transfer costs. We know that transfer is not associated with bad outcomes but it is, not surprisingly, responsible for a longer length of stay and higher cost.…”

Section: Discussionmentioning

confidence: 99%

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Transoceanic Management and Treatment of Aneurysmal Subarachnoid Hemorrhage

Mejdoubi

Schertz

Zanolla

et al. 2018

Stroke

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Background and Purpose-Because of the small number of yearly cases of ruptured cerebral aneurysms, endovascular treatment is not performed in Martinique. Therefore, patients from Martinique are sent 7000 km to Paris on commercial flights as soon as possible, where treatment is performed. Nontransportable patients are treated locally with either surgery or symptomatic care. The objective of our study was to assess patient outcomes and safety of this treatment strategy. Methods-We retrospectively examined all cases of aneurysmal subarachnoid hemorrhage in Martinique diagnosed during 2004 to 2013. Medical case records were searched for the type and location of treatment, clinical status, and transfer duration. Results-A total of 119 patients had an aneurysmal subarachnoid hemorrhage during the 10-year period. Of these, 91were transferred to Paris, 12 were surgically treated locally, and 16 received symptomatic treatment. None of the transferred patients experienced any hemorrhagic recurrence, and none suffered a significant complication related to the air transportation. The median time between aneurysmal subarachnoid hemorrhage diagnosis and arrival at the referral center was 32 hours. The 30-day case fatality rate for treated cases was 14.6% (8.8% for those treated in Paris and 58.3% for those treated locally). Conclusions-Our treatment strategy for aneurysmal subarachnoid hemorrhage resulted in a 30-day case fatality rate similar to those observed elsewhere, despite an 8-hour flight and a median treatment delay of 32 hours. This strategy therefore seems to be safe and reliable for isolated regions with small populations.

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“…Studies have shown that clinical outcomes are more favorable at high-volume centers 6,12,15 ; a better strategy would be to transport the patient to a specialized center directly. Silbergleit et al 19 showed the cost-effectiveness of helicopter transportation of acute ischemic stroke patients.…”

Section: Outcomementioning

confidence: 99%

Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US

Sonig

Lin

Krishna

et al. 2016

JNS

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OBJECT In this study, the authors used information provided in the Nationwide Inpatient Sample (NIS) to study the impact of transferring stroke patients from one facility to a center where they received some form of active stroke intervention (intravenous tissue plasminogen activator, thrombectomy, or a combination of both therapies). METHODS Patient demographic characteristics and hospital factors obtained from the 2008–2010 acute stroke NIS data were analyzed. Discharge disposition, hospitalization cost, and mortality were the dependent variables studied. Univariate analysis and multivariate binary logistic regression analysis were performed. Data analysis focused on the cohort of acute stroke patients who received some form of active intervention (55,913 of 1,311,511 patients in the NIS). RESULTS When overall outcome was considered, transferred patients had a significantly higher number of other-than-routine (OTR, i.e., other than discharge to home without home health care) discharge dispositions (p < 0.0001). In multivariate regression analysis including pertinent patient and hospital factors, transfer-in patients had significantly worse OTR discharge disposition (p < 0.0001, odds ratio [OR] 2.575, 95% CI 2.341–2.832). Mean hospitalization cost including an intervention was $70,325.11 for direct admissions and $97,546.92 for transferred patients. Transfer from another facility (p < 0.001, OR 1.677, 95% CI 1.548–1.817) was associated with higher hospitalization cost. CONCLUSIONS The study showed that hospital cost for acute stroke intervention is significantly higher for a transferred patient than for a direct admission. Moreover, the frequency of OTR discharge was significantly higher among transferred patients than direct admissions. Future strategies should focus on ways and means of transporting patients appropriately and directly to stroke centers.

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Effects of Institutional Caseload of Subarachnoid Hemorrhage on Mortality

Cited by 53 publications

References 34 publications

Hospital volume and 1-year mortality after treatment of intracranial aneurysms: a study based on patient registries in Scandinavia

Hospital volume and 1-year mortality after treatment of intracranial aneurysms: a study based on patient registries in Scandinavia

Transoceanic Management and Treatment of Aneurysmal Subarachnoid Hemorrhage

Impact of transfer status on hospitalization cost and discharge disposition for acute ischemic stroke across the US

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