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

Jian-Yi Huang; Hong-Yu Lin; Qing-Qing Wei; Xing-Hua Pan; Ning-Chao Liang; Wen Gao; Sheng-Liang Shi

doi:10.1097/md.0000000000027852

Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states

Journal of Neurosurgery ◽

10.3171/jns.2003.99.5.0810 ◽

2003 ◽

Vol 99 (5) ◽

pp. 810-817 ◽

Cited By ~ 162

Author(s):

DeWitte T. Cross ◽

David L. Tirschwell ◽

Mary Ann Clark ◽

Dan Tuden ◽

Colin P. Derdeyn ◽

...

Keyword(s):

Emergency Department ◽

Subarachnoid Hemorrhage ◽

Mortality Rate ◽

Hospital Volume ◽

High Volume ◽

Mortality Rates ◽

Case Volume ◽

Content Type ◽

Hospital Case ◽

Fine Print

Object. The goal of this study was to determine whether a hospital's volume of subarachnoid hemorrhage (SAH) cases affects mortality rates in patients with SAH. For certain serious illnesses and surgical procedures, outcome has been associated with hospital case volume. Subarachnoid hemorrhage, usually resulting from a ruptured cerebral aneurysm, yields a high mortality rate. There has been no multistate study of a diverse set of hospitals to determine whether in-hospital mortality rates are influenced by hospital volume of SAH cases. Methods. The authors conducted an analysis of a retrospective, administrative database of 16,399 hospitalizations for SAH (9290 admitted through emergency departments). These hospitalizations were from acute-care hospitals in 18 states representing 58% of the US population. Both univariate and multivariate analyses were used to assess the case volume—mortality rate relationship. The authors used patient age, sex, Medicaid status, hospital region, data source year, hospital case volume quartile, and a comorbidity index in multivariate generalized estimating equations to model the relationship between hospital volume and mortality rates after SAH. Patients with SAH who were treated in hospitals in which low volumes of patients with SAH are admitted through the emergency department had 1.4 times the odds of dying in the hospital (95% confidence interval 1.2–1.6) as patients admitted to high-volume hospitals after controlling for patient age, sex, Medicaid status, hospital region, database year, and comorbid conditions. Conclusions. Patients with a diagnosis of SAH on their discharge records who initially presented through the emergency department of a hospital with a high volume of SAH cases had significantly lower mortality rates. Concentrating care for this disease in high-volume SAH treatment centers may improve overall survival.

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Impact of hospital case-volume on subarachnoid hemorrhage outcomes: A nationwide analysis adjusting for hemorrhage severity

Journal of Critical Care ◽

10.1016/j.jcrc.2016.09.009 ◽

2017 ◽

Vol 37 ◽

pp. 240-243 ◽

Cited By ~ 14

Author(s):

Barret Rush ◽

Kali Romano ◽

Mohammad Ashkanani ◽

Robert C. McDermid ◽

Leo Anthony Celi

Keyword(s):

Subarachnoid Hemorrhage ◽

Case Volume ◽

Hospital Case

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Hospital Case Volume Is Associated With Mortality in Patients Hospitalized With Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/neu.0000000000000475 ◽

2014 ◽

Vol 75 (5) ◽

pp. 500-508 ◽

Cited By ~ 20

Author(s):

Shyam Prabhakaran ◽

Gregg C. Fonarow ◽

Eric E. Smith ◽

Li Liang ◽

Ying Xian ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Case Volume ◽

Hospital Case

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Abstract TMP83: Association Between Hospital Procedural Volumes and Clinical Outcomes For Patients With Non-Traumatic Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.51.suppl_1.tmp83 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Dana Leifer ◽

Gregg Fonarow ◽

Anne Hellkamp ◽

David Baker ◽

Brian Hoh ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Clinical Outcomes ◽

Sensitivity And Specificity ◽

Case Volume ◽

Logistic Regression Models ◽

Improved Outcomes ◽

Volume Outcome ◽

Traumatic Subarachnoid Hemorrhage

Introduction: Previous studies of patients with non-traumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume-outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke centers (CSC) certification. Methods: The 8,512 SAH discharges in the National Inpatient Sample (NIS) from 2010-11 were analyzed. Logistic regression models were used to evaluate the association between clinical outcomes (in-hospital mortality and the NIS-SAH Outcome Measure (NIS-SOM)) and 3 measures of hospital annual case volume (ACV) (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable clinical outcomes with different volume thresholds were performed. Results: 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2%for in-hospital mortality and 38.6% for poor outcome on the NIS-SOM. The mean (range) of SAH ACV, coiling ACV, and clipping ACV were 30.9 (1-195), 8.7 (0-94), and 6.1 (0-69). Logistic regression demonstrated improved outcomes with increasing ACVs of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/yr. Sensitivity and specificity analyses with different ACV thresholds confirmed the results. Analysis of previously proposed ACV thresholds, including those used as minimum standards for CSC certification, showed that hospitals with more than 35 SAH cases annually had better outcomes compared to hospitals with fewer cases, but some hospitals below this threshold had similar outcomes to those with more cases. The adjusted odds ratio favoring better outcomes with SAH ACV ≥ 35 compared to SAH 20 to 34 was 0.82 for the NIS-SOM (p=0.0054) and 0.80 (p=0.0055) for in-hospital mortality. Conclusions: Outcomes for SAH patients improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

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Impact of case volume on aneurysmal subarachnoid hemorrhage outcomes

Journal of Critical Care ◽

10.1016/j.jcrc.2015.01.007 ◽

2015 ◽

Vol 30 (3) ◽

pp. 469-472 ◽

Cited By ~ 16

Author(s):

Tiffany R. Chang ◽

Robert G. Kowalski ◽

J. Ricardo Carhuapoma ◽

Rafael J. Tamargo ◽

Neeraj S. Naval

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Case Volume

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

International Journal of Stroke ◽

10.1177/1747493018790073 ◽

2018 ◽

Vol 14 (3) ◽

pp. 282-289 ◽

Cited By ~ 2

Author(s):

Antti Lindgren ◽

Sarah Burt ◽

Ellie Bragan Turner ◽

Atte Meretoja ◽

Jin-Moo Lee ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Treatment Modality ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Tertiary Care ◽

Case Fatality ◽

High Volume ◽

Day Case ◽

Case Volume ◽

Hospital Case ◽

Low Volume

Background Inverse association between hospital case-volume and case-fatality has been observed for various nonsurgical interventions and surgical procedures. Aims To study the impact of hospital case-volume on outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods We included aSAH patients who underwent aneurysm coiling or clipping from tertiary care medical centers across three continents using the Dr Foster Stroke GOAL database 2007–2014. Hospitals were categorized by annual case-volume (low volume: <41/year; intermediate: 41–70/year; high: >70/year). Primary outcome was 14-day in-hospital case-fatality. We calculated proportions, and used multiple logistic regression to adjust for age, sex, differences in comorbidity or disease severity, aneurysm treatment modality, and hospital. Results We included 8525 patients (2363 treated in low volume hospitals, 3563 treated in intermediate volume hospitals, and 2599 in high-volume hospitals). Crude 14-day case-fatality for hospitals with low case-volume was 10.4% (95% confidence interval (CI) 9.2–11.7%), for intermediate volume 7.0% (95% CI 6.2–7.9%; adjusted odds ratio (OR) 0.63 (95%CI 0.47–0.85)) and for high volume 5.4% (95% CI 4.6–6.3%; adjusted OR 0.50 (95% CI 0.33–0.74)). In patients with clipped aneurysms, adjusted OR for 14-day case-fatality was 0.46 (95% CI 0.30–0.71) for hospitals with intermediate case-volume and 0.42 (95% CI 0.25–0.72) with high case-volume. In patients with coiled aneurysms, adjusted OR was 0.77 (95% CI 0.55–1.07) for hospitals with intermediate case-volume and 0.56 (95% CI 0.36–0.87) with high case-volume. Conclusions Even within a subset of large, tertiary care centers, intermediate and high hospital case-volume is associated with lower case-fatality after aSAH regardless of treatment modality, supporting centralization to higher volume centers.

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Abstract WP268: Associations Between Case Volume and Outcomes in the Subarachnoid Hemorrhage Patients With Clipping or Coiling: J-ASPECT Study

Stroke ◽

10.1161/str.49.suppl_1.wp268 ◽

2018 ◽

Vol 49 (Suppl_1) ◽

Author(s):

Ryota Kurogi ◽

Akiko Kada ◽

Kunihiro Nishimura ◽

Satoru Kamitani ◽

Kuniaki Ogasawara ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Case Volume

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Effects of case volume and comprehensive stroke center capabilities on patient outcomes of clipping and coiling for subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.12.jns192584 ◽

2020 ◽

pp. 1-11 ◽

Cited By ~ 1

Author(s):

Ryota Kurogi ◽

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Nobuyuki Sakai ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Absolute Risk ◽

High Volume ◽

Short Term ◽

Case Volume ◽

Improved Outcomes ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

OBJECTIVEImproved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH.METHODSThe authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1–25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH.RESULTSOverall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55–0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53–0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59–0.96 vs Q4 OR 0.65, 95% CI 0.51–0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54–0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes.CONCLUSIONSThe effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

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Association Between Hospital Volumes and Clinical Outcomes for Patients With Nontraumatic Subarachnoid Hemorrhage

Journal of the American Heart Association ◽

10.1161/jaha.120.018373 ◽

2021 ◽

Author(s):

Dana Leifer ◽

Gregg C. Fonarow ◽

Anne Hellkamp ◽

David Baker ◽

Brian L. Hoh ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Clinical Outcomes ◽

Sensitivity And Specificity ◽

Case Volume ◽

Logistic Regression Models ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume‐outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification. Methods and Results Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in‐hospital mortality and the NIS‐SAH Outcome Measure [NIS‐SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in‐hospital mortality and 38.6% for poor outcome on the NIS‐SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1–195), 8.7 (0–94), and 6.1 (0–69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS‐SOM (95% CI, 0.71–094; P =0.0054) and 0.80 (95% CI, 0.68–0.93; P =0.0055) for in‐hospital mortality. Conclusions Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

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