Published online before print August 21, 2003, doi: 10.1161/01.STR.0000089683.66849.5E
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Stroke. 2003;34:2206.)
© 2003 American Heart Association, Inc.
Original Contributions |
Editorial Comment—Spontaneous Subarachnoid Hemorrhage: Volume, Experience, and Outcome
Division of Neurosurgery, University of Alabama, Birmingham, Alabama
In recent years, there has been a trend in neurosurgery and other fields toward both subspecialization (as evidenced by the recent accreditation of the specialty Endovascular Surgical Neuroradiology by the ACGME) and regional specialization. This trend has been propelled by increases in medical and technical knowledge. The current medicolegal environment also has probably fueled this trend. It has been hypothesized that regional specialization permits greater efficiency and improved outcome while minimizing costs and complications. Accordingly, Kalkanis et al examined a cohort of patients with cranial neuralgia who required microvascular decompression.1 These authors found that higher-volume hospitals and surgeons had better discharge outcomes with fewer complications and more discharges to home. Similarly, Long and colleagues examined patients who received craniotomies for tumor resection.2 The mortality rates, hospital costs, and length of stay were all more favorable in higher-volume centers.
Focusing on subarachnoid hemorrhage (SAH), Bardach et al reviewed the admission diagnoses of SAH over a 10-year period in California using an available database for nonfederal hospitals.3 Rates of mortality, adverse outcome, length of stay, and hospital charges were computed and analyzed with multivariate analysis. Hospital volume directly impacted mortality, with the lowest quartile having a 49% rate compared with the highest quartile (32%, P<0.001). In multivariate analysis, the difference persisted with an odds ratio of 0.57 (95% CI 0.48 to 0.67, P<0.001). In looking at therapy for SAH in patients older than 65 with Medicare, Taylor and colleagues undertook an analysis to determine if a relationship existed between surgical volume and mortality rates.4 These authors found that surgical treatment of aneurysms improved with the number of craniotomies (>5 craniotomies per year) performed. Johnston and colleagues examined the impact of endovascular therapy in a different cohort.5 Over a 9-year period, 2069 patients were treated for unruptured aneurysm in California, with 82% undergoing surgery. Adverse outcomes and in-hospital mortality were significantly lower in patients treated with endovascular therapy, as were hospital charges and length of stay.
In this issue of Stroke, Berman and colleagues carried out an analysis of a cohort of patients treated for cerebral aneurysm. Over a 6-year period, these authors obtained information on hospital discharges from a central database in New York State. The diagnosis of SAH or unruptured cerebral aneurysm was used as an inclusion criterion. Data were collected on surgical clipping and endovascular treatment. Adverse outcome was defined appropriately as a discharge to a facility other than home. Rates of mortality and adverse outcome were recorded along with standard demographic data. Both univariate and multivariate analyses were undertaken. However, the focus of the article, through multivariate analysis, was on the relationship to adverse outcome/mortality and hospital volume, length of stay, and cost.
During the 6-year period of 1995 to 2000, 13 399 discharges were related to cerebral aneurysm, with 5963 patients undergoing treatment. Of those treated, 63.1% had suffered SAH. One hundred thirteen of 257 hospitals reported performing either craniotomy for clipping/wrapping of an aneurysm and/or endovascular therapy. During this period, the volume of patients treated for cerebral aneurysm increased significantly, as did the frequency for which endovascular therapy was utilized. As expected, patients treated before aneurysm rupture had better outcomes with less use of hospital resources.
Multivariate analyses revealed that greater hospital procedural experience was associated with fewer adverse outcomes and in-hospital deaths for both unruptured and ruptured aneurysms and was associated with a decreased length of stay for unruptured aneurysms. The propensity to use endovascular therapy was also linked to a lower mortality and shorter hospital stay. The outcome from surgical clipping was more favorable in higher-volume centers.
The authors should be commended on their work. This study by Berman and colleagues is a detailed analysis of a cohort of patients with cerebral aneurysms treated at several hospitals with different treatment modalities. All patients appeared eligible for either therapy; no bias was shown toward hospital selection. According to evidence-based guidelines, this cohort analysis would best represent class II data from which a treatment guideline could be drawn. For a disease as complex as cerebral aneurysm, it would not be surprising to observe the results obtained by Berman et al. Hospitals with higher volumes of cerebral aneurysms have more staff and resources dedicated to the treatment of these difficult patients. Consequently, these centers would be expected to have fewer adverse outcomes and in-hospital mortality rates. The conclusion from the study of Berman et al should be that regionalization of SAH treatment be considered.
One must avoid the tendency, though, to conclude that small-volume centers cannot adequately treat SAH and that regionalization of SAH is a simple task. Naso et al evaluated a series of 68 patients who underwent surgical treatment of aneurysms presenting with SAH over a 3-year period.6 These authors found acceptable clinical outcomes in their series for all grades of SAH patients. Regionalization of SAH may be easier said than done. Many SAH patients may have difficulty tolerating hospital transfer. Other studies have shown that interhospital transfers may have a negative impact on outcomes.7 As Berman and colleagues alluded to in their study, many high-volume centers may already be taxed in terms of the acuity of their patients and the availability of resources and staff.
 |
References |
|---|
 Top References |
|---|
1. Kalkanis SN, Eskandar EN, Carter BS, Barker FG2nd. Microvascular decompression surgery in the United States, 1996 to 2000: mortality rates, morbidity rates, and the effects of hospital and surgeon volumes. Neurosurgery. 2003; 52: 1251–1261.[Medline] [Order article via Infotrieve]
2. Long DM, Gordon T, Bowman H, et al. Outcome and cost of craniotomy performed to treat tumors in regional academic referral centers. Neurosurgery. 2003; 52: 1056–1063.[CrossRef][Medline] [Order article via Infotrieve]
3. Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC. Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke. 2002; 33: 1851–1856.
4. Taylor CL, Yuan Z, Selman WR, Ratcheson RA, Rimm AA. Mortality rates, hospital length of stay, and the cost of treating subarachnoid hemorrhage in older patients: institutional and geographical differences. J Neurosurg. 1997; 86: 583–588.[Medline] [Order article via Infotrieve]
5. Johnston SC, Zhao S, Dudley RA, Berman MF, Gress DR. Treatment of unruptured cerebral aneurysms in California. Stroke. 2001; 32: 597–605.
6. Naso WB, Rhea AH, Poole A. Management and outcome in a low-volume cerebral aneurysm practice. Neurosurgery. 2001; 48: 91–99.[Medline] [Order article via Infotrieve]
7. Gordon HS, Rosenthal GE. Impact of interhospital transfers on outcomes in an academic medical center: implications for profiling hospital quality. Med Care. 1996; 34: 295–309.[CrossRef][Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  J. B. Bederson, E. S. Connolly Jr, H. H. Batjer, R. G. Dacey, J. E. Dion, M. N. Diringer, J. E. Duldner Jr, R. E. Harbaugh, A. B. Patel, and R. H. Rosenwasser Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association Stroke, March 1, 2009; 40(3): 994 - 1025. [Full Text] [PDF]
|
|
|
|
 |
|
 N. S. Bardach, S. J. Olson, J. S. Elkins, W. S. Smith, M. T. Lawton, and S. C. Johnston Regionalization of Treatment for Subarachnoid Hemorrhage: A Cost-Utility Analysis Circulation, May 11, 2004; 109(18): 2207 - 2212. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||