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Hemorrhagic stroke
Original research
Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States
  1. Alis J Dicpinigaitis1,
  2. Michael P Fortunato2,
  3. Anjali Goyal2,
  4. Shoaib A Syed2,
  5. Rohan Patel2,
  6. Galadu Subah3,
  7. Jon B Rosenberg3,
  8. Christian A Bowers4,
  9. Stephan A Mayer3,
  10. Brian Jankowitz5,
  11. Chirag D Gandhi3,
  12. Fawaz Al-Mufti2,3
  1. 1New York Presbyterian - Weill Cornell Medical Center, New York, New York, USA
  2. 2School of Medicine, New York Medical College, Valhalla, New York, USA
  3. 3Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
  4. 4Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, Utah, USA
  5. 5Hackensack Meridian Neuroscience Institute, JFK University Medical Center, Hackensack, New Jersey, USA
  1. Correspondence to Dr Fawaz Al-Mufti, Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; fawaz.al-mufti{at}wmchealth.org

Abstract

Background and objective Although high-grade (Hunt and Hess 4 and 5) aneurysmal subarachnoid hemorrhage (aSAH) typically portends a poor prognosis, early and aggressive treatment has previously been demonstrated to confer a significant survival advantage. This study aims to evaluate geographic, demographic, and socioeconomic determinants of high-grade aSAH treatment in the United States.

Methods The National Inpatient Sample (NIS) was queried to identify adult high-grade aSAH hospitalizations during the period of 2015 to 2019 using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD) codes. The primary clinical endpoint of this analysis was aneurysm treatment by surgical or endovascular intervention (SEI), while the exposure of interest was geographic region by census division. Favorable functional outcome (assessed by the dichotomous NIS-SAH Outcome Measure, or NIS-SOM) and in-hospital mortality were evaluated as secondary endpoints in treated and conservatively managed groups.

Results Among 99 460 aSAH patients identified, 36 795 (37.0%) were high-grade, and 9210 (25.0%) of these were treated by SEI. Following multivariable logistic regression analysis, determinants of treatment by SEI included female sex (adjusted OR (aOR) 1.42, 95% CI 1.35 to 1.51), transfer admission (aOR 1.18, 95% CI 1.12 to 1.25), private insurance (ref: government-sponsored insurance) (aOR 1.21, 95% CI 1.14 to 1.28), and government hospital ownership (ref: private ownership) (aOR 1.17, 95% CI 1.09 to 1.25), while increasing age (by decade) (aOR 0.93, 95% CI 0.91 to 0.95), increasing mortality risk (aOR 0.60, 95% CI 0.57 to 0.63), urban non-teaching hospital status (aOR 0.66, 95% CI 0.59 to 0.73), rural hospital location (aOR 0.13, 95% CI 0.7 to 0.25), small hospital bedsize (aOR 0.68, 95% CI 0.60 to 0.76), and geographic region (South Atlantic (aOR 0.72, 95% CI 0.63 to 0.83), East South Central (aOR 0.75, 95% CI 0.64 to 0.88), and Mountain (aOR 0.72, 95% CI 0.61 to 0.85)) were associated with a lower likelihood of treatment. High-grade aSAH patients treated by SEI experienced significantly greater rates of favorable functional outcomes (20.1% vs 17.3%; OR 1.20, 95% CI 1.13 to 1.28, P<0.001) and lower rates of mortality (25.8% vs 49.1%; OR 0.36, 95% CI 0.34 to 0.38, P<0.001) in comparison to those conservatively managed.

Conclusion A complex interplay of demographic, socioeconomic, and geographic factors influence treatment patterns of high-grade aSAH in the United States.

  • Aneurysm
  • Hemorrhage
  • Subarachnoid

Data availability statement

The data used in this analysis as well as a comprehensive list of billing codes used to define the clinical variables in this study (other than those explicitly denoted in the body of the methods section of this manuscript) are available upon reasonable request of the corresponding author following completion of onboarding and verification procedures as specified by the Healthcare Cost and Utilization Project (HCUP).

https://doi.org/10.1136/jnis-2023-021330

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    Data availability statement

    The data used in this analysis as well as a comprehensive list of billing codes used to define the clinical variables in this study (other than those explicitly denoted in the body of the methods section of this manuscript) are available upon reasonable request of the corresponding author following completion of onboarding and verification procedures as specified by the Healthcare Cost and Utilization Project (HCUP).

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    Footnotes

    • Twitter @adicpini, @shoaibsyed123, @almuftifawaz

    • Contributors AD and FAM conceptualized the study and formulated the methodology. AD and MF wrote the manuscript. AD performed statistical analysis. AG, SS, CB, and BJ provided critical first revisions for the manuscript draft. All authors commented on the results and offered revision suggestions for the manuscript. All authors read and confirmed the final version of the manuscript. FAM and CG provided supervision for the study. AJD is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.