Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

Vishank A Shah; Syed Omar Kazmi; Rahul Damani; Alyssa Hartsell Harris; Samuel F Hohmann; Eusebia Calvillo; Jose I Suarez

doi:10.3389/fneur.2022.908609

Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

Front Neurol. 2022 Jun 16:13:908609. doi: 10.3389/fneur.2022.908609. eCollection 2022.

Authors

Vishank A Shah¹, Syed Omar Kazmi², Rahul Damani³, Alyssa Hartsell Harris⁴, Samuel F Hohmann⁴, Eusebia Calvillo¹, Jose I Suarez¹

Affiliations

¹ Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
² Salem Health Hospital, Salem, OR, United States.
³ Department of Neurology, Baylor College of Medicine, Houston, TX, United States.
⁴ Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, United States.

Abstract

Background and objectives: Regional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes.

Methods: A retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models.

Results: Of 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use.

Discussion: Multiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.

Keywords: clinical practice variability; clinical practice variation; critical care; discharge outcomes; hospital care; subarachnoid hemorrhage (SAH).