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

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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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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National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010–2016

International Journal of Stroke ◽

10.1177/1747493019884526 ◽

2019 ◽

pp. 174749301988452 ◽

Cited By ~ 1

Author(s):

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Kunihiro Nishimura ◽

Nobuyuki Sakai ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Temporal Trends ◽

Stroke Severity ◽

Stroke Patients ◽

Poor Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. Aims To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. Methods This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1–25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3–6) at discharge were examined using hierarchical logistic regression models. Results Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010–2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95–0.99), 0.97 (0.95–0.998), 1.07 (1.04–1.10), and 1.21 (1.14–1.28), respectively). Conclusions This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

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Abstract TP453: The Effect of Case Volume and Comprehensive Stroke Centre Capabilities on Patient Outcomes of Clipping and Coiling for Subarachnoid Haemorrhage

Stroke ◽

10.1161/str.51.suppl_1.tp453 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ryota Kurogi ◽

Akiko Kada ◽

Kuniaki Ogasawara ◽

Takanari Kitazono ◽

Yoshiaki Shiokawa ◽

...

Keyword(s):

Subarachnoid Haemorrhage ◽

Hospital Mortality ◽

Patient Outcomes ◽

Functional Outcomes ◽

Retrospective Cohort ◽

Short Term ◽

Case Volume ◽

Diagnosis Procedure Combination ◽

Poor Outcomes ◽

Stroke Centre

Objectives: To examine whether hospital case volume and comprehensive stroke centre(CSC) capabilities affect patient outcomes of clipping and coiling for subarachnoid haemorrhage (SAH). Methods: We conducted a nationwide retrospective cohort study. Using the J-ASPECT Diagnosis Procedure Combination database, we identified 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015. The CSC capabilities of each hospital were assessed using a validated scoring system (CSC score: 1-25 points). We classified the hospitals into quartiles based on CSC score and case volume of clipping or coiling for SAH. Results: In clipped patients, a high case volume ( > 14 cases / year) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 odds ratios (ORs) 0.71 [95% confidence interval 0.55 - 0.90]) but not poor outcome. In coiled patients, a high case volume ( > 9 cases / year) was associated with reduced in-hospital mortality (Q4 0.69 [0.53 - 0.90]) and poor outcomes (Q3 ( > 5 cases / year) 0.75 [0.59 - 0.96], Q4 0.65 [0.51 - 0.82]). A high CSC score ( > 19 points) was significantly associated with reduced in-hospital mortality of clipped (0.68 [0.54 - 0.86]) but not coiled patients. There was no association between CSC capabilities and poor outcomes. Conclusions: The effect of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients was different between clipping and coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

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Abstract W P307: Novel Application of Reversible Parental Anti-platelets in Patients with Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.wp307 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Siddhart Mehta ◽

Mohammed Hussain ◽

Jaskiran Brar ◽

Daniel Korya ◽

Harina Chahal ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Coil Embolization ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Antiplatelet Agents ◽

Endovascular Coiling ◽

International Subarachnoid Aneurysm Trial ◽

Procedural Complications ◽

Acute Subarachnoid Hemorrhage ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and Objective: The International Subarachnoid Aneurysm Trial (ISAT) showed a greater likelihood of survival free 1 year disability in patients undergoing endovascular coiling who were started on antiplatelet agents after SAH compared to ones undergoing neurosurgical clipping. However, data on safety of acute parental antiplatelet agents after aneurysmal coiling is lacking. We report on the safety of IV Eptifibatide (rapidly reversible Glyprotein IIbIIIa inhibitor) on patients presenting with acute subarachnoid hemorrhage undergoing endovascular coiling for aneurysmal embolization. Methods: All the patients from 2009-13 who presented to our university affiliated comprehensive stroke center with aneurysmal subarachnoid hemorrhage and underwent endovascular coiling were included for the study. Patients that received IV Eptifibatide for various reasons including acute need for stent assist coiling after securing the ruptured aneurysm with endovascular coiling were reviewed. Eptifibatide was administered intra-arterially as a 135-μg/kg single-dose bolus, and then continued on intravenous infusion of 0.5-μg/kg/min post-procedurally. Charts were reviewed for all patients to assess for medical/procedural complications including symptomatic and asymptomatic intra- and extra-cranial hemorrhages, groin hematomas, epistaxis and gross hematuria. Results: Of the total of 93 patients treated with coil embolization during this period, 5 patients (mean age 56 years, 20% male [n=1]) received acute intra-procedural Eptifibatide followed by IV infusion for a mean duration of 77 hours (range 20-130 hours). Various reasons for use of Eptifibatide included: stent assist coiling [n=2], multiple stents for flow diversion [n=1], partial coil prolapse [n=1] and vascular lumen flow compromise [n=1]. None of the patients demonstrated symptomatic/asymptomatic hemorrhage, groin hematoma, epistaxis or hematuria. Conclusion: Our results may highlight safety of administering IV Eptifibatide to prevent thrombotic complications after endovascular coil embolization in select patients with aneurysmal subarachnoid hemorrhage. Multicenter prospective trials are warranted to corroborate our findings.

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E-124 Persistent TICI 0 after mechanical thrombectomy: incidence and insights at a high-volume comprehensive stroke center

10.1136/neurintsurg-2019-snis.199 ◽

2019 ◽

Author(s):

R Mattay ◽

M Cox ◽

M McCabe ◽

J Schmitt ◽

D Kung ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

High Volume ◽

Comprehensive Stroke Center ◽

Stroke Center

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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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Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Journal of Neurosurgery ◽

10.3171/2013.9.jns13640 ◽

2014 ◽

Vol 120 (3) ◽

pp. 605-611 ◽

Cited By ~ 34

Author(s):

Hieronymus D. Boogaarts ◽

Martinus J. van Amerongen ◽

Joost de Vries ◽

Gert P. Westert ◽

André L. M. Verbeek ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Random Effects ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Relative Weight ◽

High Volume ◽

Cochrane Library ◽

Endovascular Coiling ◽

Low Volume

Object Increasing evidence exists that treatment of complex medical conditions in high-volume centers is found to improve outcome. Patients with subarachnoid hemorrhage (SAH), a complex disease, probably also benefit from treatment at a high-volume center. The authors aimed to determine, based on published literature, whether a higher hospital caseload is associated with improved outcomes of patients undergoing treatment after aneurysmal subarachnoid hemorrhage. Methods The authors identified studies from MEDLINE, Embase, and the Cochrane Library up to September 28, 2012, that evaluated outcome in high-volume versus low-volume centers in patients with SAH who were treated by either clipping or endovascular coiling. No language restrictions were set. The compared outcome measure was in-hospital mortality. Mortality in studies was pooled in a random effects meta-analysis. Study quality was reported according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Results Four articles were included in this analysis, representing 36,600 patients. The quality of studies was graded low in 3 and very low in 1. Meta-analysis using a random effects model showed a decrease in hospital mortality (OR 0.77 [95% CI 0.60–0.97]; p = 0.00; I2 = 91%) in high-volume hospitals treating SAH patients. Sensitivity analysis revealed the relative weight of the 1 low-quality study. Removal of the study with very low quality increased the effect size of the meta-analysis to an OR of 0.68 (95% CI 0.56–0.84; p = 0.00; I2 = 86%). The definition of hospital volume differed among studies. Cutoffs and dichotomizations were used as well as division in quartiles. In 1 study, low volume was defined as 9 or fewer patients yearly, whereas in another it was defined as fewer than 30 patients yearly. Similarly, 1 study defined high volume as more than 20 patients annually, and another defined it as more than 50 patients a year. For comparability between studies, recalculation was done with dichotomized data if available. Cross et al., 2003 (low volume ≤ 18, high volume ≥ 19) and Johnston, 2000 (low volume ≤ 31, high volume ≥ 32) provided core data for recalculation. The overall results of this analysis revealed an OR of 0.85 (95% CI 0.72–0.99; p = 0.00; I2 = 87%). Conclusions Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.

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