Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States

Alis J Dicpinigaitis; Michael P Fortunato; Anjali Goyal; Shoaib A Syed; Rohan Patel; Galadu Subah; Jon B Rosenberg; Christian A Bowers; Stephan A Mayer; Brian Jankowitz; Chirag D Gandhi; Fawaz Al-Mufti

doi:10.1136/jnis-2023-021330

Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States

J Neurointerv Surg. 2024 Feb 20:jnis-2023-021330. doi: 10.1136/jnis-2023-021330. Online ahead of print.

Authors

Affiliations

¹ New York Presbyterian - Weill Cornell Medical Center, New York, New York, USA.
² School of Medicine, New York Medical College, Valhalla, New York, USA.
³ Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.
⁴ Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, Utah, USA.
⁵ Hackensack Meridian Neuroscience Institute, JFK University Medical Center, Hackensack, New Jersey, USA.
⁶ School of Medicine, New York Medical College, Valhalla, New York, USA fawaz.al-mufti@wmchealth.org.

PMID: 38378239
DOI: 10.1136/jnis-2023-021330

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.

Keywords: Aneurysm; Hemorrhage; Subarachnoid.