Hospital case-volume is associated with case-fatality after aneurysmal subarachnoid hemorrhage

Lindgren, Antti; Burt, Sarah; Turner, Ellie Bragan; Meretoja, Atte; J, Lee; Hemmen, Thomas; Alberts, Mark J.; Lemmens, Robin; Vergouwen, Mervyn D.I.; Rinkel, Gabriël J.E.

doi:10.1177/1747493018790073

Cited by 16 publications

(17 citation statements)

References 19 publications

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“…Aneurysmal subarachnoid haemorrhage (aSAH) is a multisystemic disease associated with a high number of medical and neurological complications that increase mortality rate and length of stay (LOS) [1]. Some institutional factors influence aSAH outcomes, including in which hospital facility the patient is initially evaluated and the volume of subarachnoid haemorrhage (SAH) patients treated [2–5]. SAH management guidelines recommend an early referral to high‐volume centres with experienced neurosurgeons and endovascular services, and state that patients should be continuously observed either in intensive care units (ICUs) or in intermediate care facilities of stroke or neurovascular units [6,7].…”

Section: Introductionmentioning

confidence: 99%

Stroke units could be a valid alternative to intensive care units for patients with low‐grade aneurysmal subarachnoid haemorrhage

Llull

Mayà

Torné³

et al. 2020

Euro J of Neurology

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Background and purposeAccording to current guidelines, patients with aneurysmal subarachnoid haemorrhage (aSAH) are mostly managed in intensive care units (ICUs) regardless of baseline severity. We aimed to assess the prognostic and economic implications of initial admission of patients with low‐grade aSAH into a stroke unit (SU) compared to initial ICU admission.MethodsWe reviewed prospectively registered data from consecutive aSAH patients with a World Federation of Neurosurgery Societies grade <3, admitted to our Comprehensive Stroke Centre between April 2013 and September 2018. Clinical and radiological baseline traits, in‐hospital complications, length of stay (LOS) and poor outcome at 90 days (modified Rankin Scale score > 2) were compared between the ICU and SU groups in the whole population and in a propensity‐score‐matched cohort.ResultsOf 131 patients, 74 (56%) were initially admitted to the ICU and 57 (44%) to the SU. In‐hospital complication rates were similar in the ICU and SU groups and included rebleeding (10% vs. 7%; P = 0.757), angiographic vasospasm (61% vs. 60%; P = 0.893), delayed cerebral ischaemia (12% vs. 12%; P = 0.984), pneumonia (6% vs. 4%; P = 0.697) and death (10% vs. 5%; P = 0.512). LOS did not differ between groups (median [interquartile range] 22 [16–30] vs. 19 [14–26] days; P = 0.160). In adjusted multivariate models, the location of initial admission was not associated with long‐term poor outcome either in the whole population (odds ratio [OR] 1.16, 95% confidence interval [CI] 0.32–4.19; P = 0.825) or in the matched cohort (OR 0.98, 95% CI 0.24–4.06; P = 0.974).ConclusionsA dedicated SU, with care from a multidisciplinary team, might be an optimal alternative to ICU for initial admission of patients with low‐risk aSAH.

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Section: Introductionmentioning

confidence: 99%

Stroke units could be a valid alternative to intensive care units for patients with low‐grade aneurysmal subarachnoid haemorrhage

Llull

Mayà

Torné³

et al. 2020

Euro J of Neurology

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“…Additionally, the proposed minimum numbers for centres ( n = 100 UIA patients per year) and for operators ( n = 30 procedures per operator per year) may seem high for individual centres or operators. However, in line with the increasing body of data on improved outcomes in relation to aneurysm treatment numbers (irrespective of treatment modality), 31,80 the entire MWG agreed that the introduction of quality measures for the care of UIA patients are required, because this will result in more specialised and centralised care of UIA patients. Since the underlying studies for PICOs were predominantly single-arm studies and lacked a comparison, we were not able to provide risk of bias and/or GRADE tables for all PICOs.…”

Section: Discussionmentioning

confidence: 99%

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Etminan

Sousa

Tiseo

et al. 2022

European Stroke Journal

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Unruptured intracranial aneurysms (UIA) occur in around 3% of the population. Important management questions concern if and how to perform preventive UIA occlusion; if, how and when to perform follow up imaging; and non-interventional means to reduce the risk of rupture. Using the Standard Operational Procedure of ESO we prepared guidelines according to GRADE methodology. Since no completed randomised trials exist, we used interim analyses of trials, and meta-analyses of observational and case-control studies to provide recommendations to guide UIA management. All recommendations were based on very low evidence. We suggest preventive occlusion if the estimated 5-year rupture risk exceeds the risk of preventive treatment. In general, we cannot recommend endovascular over microsurgical treatment, but suggest flow diverting stents as option only when there are no other low-risk options for UIA repair. To detect UIA recurrence we suggest radiological follow up after occlusion. In patients who are initially observed, we suggest radiological monitoring to detect future UIA growth, smoking cessation, treatment of hypertension, but not treatment with statins or acetylsalicylic acid with the indication to reduce the risk of aneurysm rupture. Additionally, we formulated 15 expert-consensus statements. All experts suggest to assess UIA patients within a multidisciplinary setting (neurosurgery, neuroradiology and neurology) at centres consulting >100 UIA patients per year, to use a shared decision-making process based on the team recommendation and patient preferences, and to repair UIA only in centres performing the proposed treatment in >30 patients with (ruptured or unruptured) aneurysms per year per neurosurgeon or neurointerventionalist. These UIA guidelines provide contemporary recommendations and consensus statement on important aspects of UIA management until more robust data come available

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“…In-hospital mortality [3,8] 18,362 0.39 (0.16-0.96) .04 84.1 .012 Mortality within 30 d of admission [4,7] 19,299 0.52 (0.23-1.16) .11 59.7 .115 14-day case-fatality rates [5] 8525 0.50 (0.33-0.74) .001 NA NA Volume grouping Dichotomizations [7] 355 0.277 (0.091-0.842) .024 NA NA Tertiles [4,5,8] 33,027 0.48 (0.29-0.78) .004 81.2 .005 Quartiles [3] 12,804 0.58 (0.49-0.68) .000 NA NA Sample size < 10,000 [5,7,8] 31,748 0.35 (0.20-0.61) .000 49.5 .138 > 10,000 [3,4] 14,438 0.64 (0.54-0.74) .000 59.9 .114 Surgical patiets All [4,5] 27,469 0.62 (0.47-0.82) .001 51.8 .150 Part [3,7,8] 18,717 0.37 (0. that included patients who received any treatment (P = .006). The results were consistent in each subgroup.…”

Section: Regionmentioning

confidence: 99%

“…Asian [4,7,8] 24,857 0.38 (0.16-0.89) .026 82.2 .004 Other region [3,5] 21,329 0.57 (0.49-0.66) .000 0.0 .504 Treatments Surgical clipping or endovascular treatment [3,5] 21,329 0.57 (0.49-0.66) .000 0.0 .504 Craniotomy or trephination surgery [4] 18,944 0.68 (0.61-0.76) .000 NA NA NR [7,8] 5913 0.24 (0.13-0.44) .000 0.0 .782 Endpoints…”

Section: Regionmentioning

confidence: 99%

Relationship between annualized case volume and in-hospital motality in subarachnoid hemorrhage

Huang¹,

HongYu²,

Wei³

et al. 2021

Medicine

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Studies on the relationship between hospital annualized case volume and in-hospital mortality in patients with subarachnoid hemorrhage (SAH) have shown conflicting results. Therefore, we performed a meta-analysis to further examine this relationship. The authors searched the PubMed and Embase databases from inception through July 2020 to identify studies that assessed the relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Studies that reported in-hospital mortality in SAH patients and an adjusted odds ratio (OR) comparing mortality between low-volume and high-volume hospitals or provided core data to calculate an adjusted OR were eligible for inclusion. No language or human subject restrictions were imposed. Five retrospective cohort studies with 46,186 patients were included for analysis. The pooled estimate revealed an inverse relationship between annualized case volume and in-hospital mortality (OR, 0.53; 95% confidence interval, 0.42–0.68, P < .0001). This relationship was consistent in almost all subgroup analyses and was robust in sensitivity analyses. This meta-analysis confirms an inverse relationship between hospital annualized SAH case volume and in-hospital SAH mortality. Higher annualized case volume was associated with lower in-hospital mortality.

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Hospital case-volume is associated with case-fatality after aneurysmal subarachnoid hemorrhage

Cited by 16 publications

References 19 publications

Stroke units could be a valid alternative to intensive care units for patients with low‐grade aneurysmal subarachnoid haemorrhage

Stroke units could be a valid alternative to intensive care units for patients with low‐grade aneurysmal subarachnoid haemorrhage

European Stroke Organisation (ESO) guidelines on management of unruptured intracranial aneurysms

Relationship between annualized case volume and in-hospital motality in subarachnoid hemorrhage

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