High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes.
High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes.
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DOI：
10.1227/neu.0000000000000850
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发表时间：
2015-09
期刊：
影响因子：
4.8
通讯作者：
Burke JF
中科院分区：
文献类型：
--
作者：
Pandey AS;Gemmete JJ;Wilson TJ;Chaudhary N;Thompson BG;Morgenstern LB;Burke JF
在处理包括蛛网膜下腔出血(SAH)在内的复杂情况时，高容量中心比低容量中心有更好的预后。我们的目标是量化蛛网膜下腔出血的体积-结果关联，并确定这种关联受护理的积极程度的影响。采用2002-2010年全国住院患者样本的连续横断面回顾研究。入选病例均为经急诊科入院或转至出院医院就诊的成年(18岁)SAH患者，排除外伤或动静脉畸形患者。调查加权描述性统计估计了时间趋势。多水平Logistic回归估计量-结果与住院患者死亡率和出院家庭的关系。模型根据人口统计学、年份、转移状态、保险状态、所有个体Charlson合并症、插管和APR-DRG死亡率进行了调整。重复分析，排除了没有进行积极护理的病例。共有32,336例患者出院；13,398名患者被夹住(59.1%)或卷曲(40.9%)。住院死亡率从2002年的32.2%下降到2010年的22.2%；同期出院回家的死亡率从28.5%上升到40.8%。随着蛛网膜下腔出血量的减少，死亡率从18.7%上升到19.8%(80次/年)、21.7%(60次/年)、24.5%(40次/年)和28.4%(20次/年)。随着SAH患者数量的减少，出院回家的概率从100/年的40.3%下降到60/年的38.7%和20/年的35.3%。接受积极护理的患者和未接受积极护理的患者持续获得更好的结果。短期SAH结果有所改善。高流量的医院比低流量的医院有更好的结果。这种影响是巨大的，即使对传统上被归类为大流量的医院也是如此。
High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH). We aimed to quantify the SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care. Serial cross-sectional retrospective study using Nationwide Inpatient Sample for 2002–2010. Included were all adult (>18 years) discharged patients with primary diagnosis of SAH admitted through emergency department or transferred to discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multi-level logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and APR-DRG mortality. Analyses were repeated excluding cases where aggressive care was not pursued. A total 32,336 discharges were included; 13,398 patients were clipped (59.1%) or coiled (40.9%). Inpatient mortality declined from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, mortality increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, 28.4% at 20/year. As SAH patient volume decreased, probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care. Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high-volume.