Background Recent evidence indicates that multidisciplinary care improves patient outcomes in cerebrovascular (CV) disease. A multidisciplinary integrated CV program was recently instituted at a high-volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction.
Objective To evaluate outcomes after treatment of patients with intracranial aneurysm in relation to the introduction of a CV program at our institution.
Methodology A retrospective chart review was performed on all new patient encounters for a 6-month period each before and immediately after the introduction of the CV program, as well as at a more recent 6-month period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course and modified Rankin score at discharge and follow up.
Results The total number of patients treated increased from 55 in the 6-month period before the introduction of the CV program to 112 in the most recent time period (p<0.05). Both the surgical clipping and endovascular coiling procedures increased (p<0.05). A significant increase occurred in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). The mean length of stay decreased from 12.22±13.26 days before the program to 9.23±12.04 days in the most current data (p<0.05).
Conclusions Creation of an integrated CV program at a large-volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data for developing an integrated model of multidisciplinary care for the management of CV disease.
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The current treatments for cerebrovascular (CV) diseases include a host of surgical, endovascular and medical options that are provided by different medical subspecialties. Integration of a multidisciplinary stroke care model has resulted in improved patient outcomes and therefore forms the basis for care of patients with ischemic stroke in comprehensive stroke centers.1 In a recent study of patients with stroke, an outpatient clinic that combined internal medicine, neurology, physical therapy, nursing and health psychology resulted in improved care and outcomes as well as increased patient satisfaction without an increase in healthcare costs.2
It is likely that this multidisciplinary approach for patients with hemorrhagic stroke can also result in improved patient outcomes. Historically, better outcomes with intracranial aneurysm treatment are associated with unruptured status, good neurological condition at presentation,3 choice of endovascular coiling4 and treatment at high-volume centers.5–9 Recent prospective randomized trials with a multidisciplinary approach to treating ruptured aneurysms showed improved outcomes over historical data.10 ,11 Subsequently, the American Stroke Association has recommended this practice for the joint evaluation of all patients with aneurysms.12 More recently, advances in neurocritical care have resulted in further improvement in outcomes of patients with intracranial aneurysm.13 The modern care of patients with aneurysm is therefore a joint endeavor of a comprehensive and multidisciplinary CV team.
Four years ago the traditionally separate neurosurgical, neurointerventional and neurology programs were integrated into a Comprehensive Stroke and Cerebrovascular Program at the Medical University of South Carolina (MUSC). This provides an opportunity to compare the outcomes of patients with intracranial aneurysms treated at our institution before and after the introduction of the CV program.
Under an IRB approved protocol, a retrospective chart review was performed on all new patient encounters for the 6-month period each before (September 2007 to March 2008) and immediately after (September 2008 to March 2009) the introduction of the CV program. The development of the MUSC comprehensive CV program occurred over a 6-month period. During this period a focused group of neurosurgeons, neurointerventionalists, neurocritical care, stroke neurologists and emergency room physicians developed and instituted a protocol-driven methodology for care of patients with ruptured and unruptured aneurysms. Subsequent changes to the protocol were made along the course as improvements in healthcare technique and technology evolved. To study the long-term effects of the CV program, a similar chart review was performed for new patient encounters in a more recent time period (January to June 2011).
Demographic variables (age, gender and ethnicity), existing comorbidities (hypertension, hyperlipidemia, coronary artery disease, stroke and other systemic illnesses) and rupture status were reviewed. For patients with subarachnoid hemorrhage (SAH), the presence of hydrocephalus on initial imaging, seizures, cranial nerve palsy or other neurological deficits was also noted. The hospital course was reviewed for occurrence of neurological complications, systemic complications and mortality. Systemic complications included ventilator-associated pneumonia, catheter-associated infection, acute renal failure, urinary tract infection and sepsis. Neurological complications primarily comprised ventriculostomy-associated meningitis and treatment-related neurological deficits. For patients with SAH, the development of symptomatic vasospasm was assessed based on a combination of clinical suspicion and radiographic confirmation. The length of hospital stay was classified into the total number of days from admission to discharge, intensive care unit days and floor days. The imaging studies obtained to evaluate the nervous system were also analyzed. Modified Rankin scores (mRS) were retrospectively assigned based on the patient assessment by the clinical and physical therapy teams at discharge and at last follow-up. Significant disability was defined as mRS ≥3.
Data analysis was carried out using SPSS V.19. For continuous variables, mean and standard deviations were calculated and frequencies and percentages were calculated for categorical variables. A χ2 test was used to compare between-group differences for categorical variables and a two-way ANOVA test to detect between-group differences for continuous variables.
The mean age, gender and ethnic distribution were comparable across the three time periods (table 1). The total number of patients treated steadily increased from 55 for the period before the introduction of the CV program to 73 for the period immediately after the introduction of the CV program and to 112 during the most recent time period. The number of both elective and ruptured aneurysms increased during this time period (p<0.05). The referral of patients with multiple comorbidities (≥2 comorbidities) showed a significant increase (30.5% vs 34.7%, p=0.035; table 2). Similarly, the number of patients with a history of hypertension increased during this time period (38.9% vs 57.1%, p=0.024). Lastly, the proportion of patients with evidence of hydrocephalus on initial imaging increased from 8.3% to 32.7% (p=0.008).
Number of procedures performed
The number of open surgical clipping and endovascular coiling procedures increased in the time periods studied (p<0.05). The increase in the number of aneurysms clipped was seen in the unruptured aneurysm category (5 vs 28 vs 23) while coiling numbers increased in both the elective and ruptured aneurysm categories (elective aneurysms 14 vs 10 vs 31 and ruptured aneurysms 17 vs 16 vs 38). The ratio of aneurysms coiled also showed a steady increase in both elective (21% vs 26.3% vs 57.4%) and ruptured (51.5% vs 45.7% vs 77.5%) categories.
Outcome measures: length of stay, number of radiographic studies, systemic and neurological complications
The mean length of hospital stay decreased from 12.22±13.26 days to 9.23±12.04 days (table 1). A statistically significant decrease in ICU length of stay was observed for patients with a ruptured aneurysm between the period before the introduction of the CV program and the current time period (figure 1). The number of radiographic studies obtained to evaluate the nervous system showed a significant decline during the three time periods (8.84±12.44 vs 9.23±2.82 vs 2.57±2.71 images; p<0.05). This marked decline was mainly apparent in care of patients with ruptured aneurysms (12.69±13.88 vs 17.49±14.22 vs 4.06±3.24).
For ruptured aneurysms, fewer systemic complications were observed in the most recent time period compared with the period before the introduction of the CV program (table 2). Also, a trend towards a decrease in symptomatic vasospasm was observed in these patients (41.7% vs 30.6%, p=0.57).
The overall mean mRS at discharge and last follow-up are comparable to that in the time periods before and after the introduction of the CV program. However, among the patients with ruptured aneurysms, the proportion of patients with significant disability (mRS ≥3) decreased from 50% to 36.7% at discharge (p=0.019) and from 33.3% to 19.5% (p=0.003) at last follow-up.
Traditional care of ICA at MUSC before 2008
Located in the heart of the stroke belt, the Medical University of South Carolina center is a major referral center for CV disease on the east coast of the USA and is the only tertiary referral center in South Carolina. The department of neuroscience at MUSC was founded in 2004 after merging neurosurgery, neurology and basic neuroscience.14 ,15 The department has seen tremendous growth in faculty recruitment, patient encounters and extramural funding since its inception.14
Before 2008, patients with brain aneurysms were typically referred either to neurosurgery or neurointerventional surgery (figure 2). The attending physician discussed the available treatment options and offered a choice between aneurysm clipping and coiling. A referral to the other service was made if the patient chose a treatment modality not offered by the attending physician.
Creation of integrated CV
The creation of an integrated CV program involved several steps including appointment of joint leadership, hiring of faculty with multidisciplinary training and mutually agreed patient care protocols. CV and neurointerventional surgery call schedules were instituted. A weekly CV conference was started to discuss difficult or academically interesting cases as well as morbidity and mortality. A detailed protocol for the management of all patients with acute SAH was jointly developed by neurocritical care, neurosurgery and neurointerventional radiology and followed rigorously by all clinicians involved in caring for the patients. All efforts were made to use evidence-based guidelines and to adopt American Stroke Association recommendations when developing the protocol. Finally, patient care was integrated, with collective inpatient management and the creation of a single outpatient clinic for evaluation and follow-up (figure 2).
Since the publication of the International Subarachnoid Aneurysm Trial results, the evaluation of intracranial aneurysms by experts in both open and endovascular surgery has been emphasized to offer the most suitable treatment option.10 The recently published Barrow Ruptured Aneurysm Trial results also reinforce these findings.11 Protocol-driven intensive care by a dedicated fellowship-trained neurocritical team also appears to improve outcomes in patients with SAH.13 A multidisciplinary approach has therefore been recommended for achieving high standards of care for patients with aneurysms.16 ,17
However, choice of treatment modality is only one part of the management of intracranial aneurysms. A multidisciplinary ICU team involving neurointensivists, neurosurgeons, critical care pharmacists, mid-level practitioners, respiratory therapists, dietitians and critical care nurses evaluated all patients with a consistent evidence-based approach at our institution. Our data support the beneficial effects of such multidisciplinary care teams and evidence-based management protocols with decreased length of stay, complications and improved functional outcomes. In other diseases, similar improvements in outcomes have also been observed after integration of healthcare processes.18–20
The number of patients treated at our center significantly increased after the introduction of the CV program. Furthermore, the referral of patients who were more ill with multiple comorbidities and hydrocephalus at presentation increased. This pattern may reflect an overall favorable perception of referring physicians. Another important finding is the increase in the number of both clipping and coiling operations after the introduction of the CV program, implying that increased rates of endovascular treatments do not necessarily decrease the number of open surgical cases.
Improved outcomes after the introduction of the CV program may have resulted from an increase in patient volume. For both ruptured and unruptured aneurysms, analyses of large administrative databases reveal improved outcomes after treatment at high-volume centers.5–9 More aggressive treatment protocols, the presence of specialized personnel and designated resources are probably also related to improved outcomes in these high-volume centers. While length of stay did not significantly change overall, this is viewed as a likely improvement given the fact that patients were more ill with higher rates of hydrocephalus.
The present study is not without its limitations. This analysis represents a retrospective review of prospective information and each of the 6-month intervals was chosen randomly. The information regarding the Hunt-Hess and Fisher grade on presentation was not uniformly recorded in the patient charts and therefore could not be assessed reliably. The improved outcomes observed in our study are theoretically possible from referral of good grade patients. Furthermore, the referral of patients with more than two comorbidities and an increase in the number of patients with hydrocephalus argue towards referral of patients who are more ill and have more complications. The assessment of outcomes was not performed in a blinded fashion. Additionally, no neuropsychological data or measures of patient satisfaction were obtained. Finally, conclusions regarding the cost-effectiveness of this intervention cannot be made without assessment of quality of life measures.
This study suggests that a comprehensive integrated CV program results in better outcomes with a significant increase in the number of patients including those who are more ill and have more medical complications. These data support a nationwide initiative for an integrated model for the treatment of CV disease at tertiary care centers. We envisage that, in a fashion analogous to the development of comprehensive stroke centers for the care of patients with acute ischemic stroke, comprehensive CV centers will develop to provide care for patients with brain aneurysms.
Nikesh Patel, BS – Helped collect some of the data. Timothy Monroe – helped collect some of the data.
Competing interests None.
Ethics approval Institutional IRB.
Provenance and peer review Not commissioned; externally peer reviewed.
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