Simone A Dijkland1, Blessing N R Jaja2,3,4, Mathieu van der Jagt5, Bob Roozenbeek6,7, Mervyn D I Vergouwen8, Jose I Suarez9, James C Torner10, Michael M Todd11, Walter M van den Bergh12, Gustavo Saposnik3,4,13, Daniel W Zumofen14,15, Michael D Cusimano2,3,4,16, Stephan A Mayer17, Benjamin W Y Lo18, Ewout W Steyerberg1,19, Diederik W J Dippel6, Tom A Schweizer2,3,4,16, R Loch Macdonald2,3,4,16, Hester F Lingsma1. 1. Departments of1Public Health. 2. 2Division of Neurosurgery and. 3. 3Neuroscience Research Program, Li Ka Shing Knowledge Institute, and. 4. 4Institute of Medical Science and. 5. 5Intensive Care. 6. 6Neurology, and. 7. 7Radiology and Nuclear Medicine, Erasmus MC-University Medical Center, Rotterdam. 8. 8Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. 9. 9Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University, Baltimore, Maryland. 10. 10Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa. 11. 11Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota. 12. 12Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen. 13. 13Decision Neuroscience Unit, Division of Neurology, St. Michael's Hospital, University of Toronto. 14. 14Department of Neurosurgery and. 15. 15Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, University of Basel, Basel, Switzerland. 16. 16Department of Surgery, University of Toronto, Toronto, Ontario. 17. 17Department of Neurology, Henry Ford Health System, Detroit, Michigan; and. 18. 18Departments of Neurology, Neurosurgery, and Critical Care, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada. 19. 19Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden.
Abstract
OBJECTIVE: Differences in clinical outcomes between centers and countries may reflect variation in patient characteristics, diagnostic and therapeutic policies, or quality of care. The purpose of this study was to investigate the presence and magnitude of between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS: The authors analyzed data from 5972 aSAH patients enrolled in randomized clinical trials of 3 different treatments from the Subarachnoid Hemorrhage International Trialists (SAHIT) repository, including data from 179 centers and 20 countries. They used random effects logistic regression adjusted for patient characteristics and timing of aneurysm treatment to estimate between-center and between-country differences in unfavorable outcome, defined as a Glasgow Outcome Scale score of 1-3 (severe disability, vegetative state, or death) or modified Rankin Scale score of 4-6 (moderately severe disability, severe disability, or death) at 3 months. Between-center and between-country differences were quantified with the median odds ratio (MOR), which can be interpreted as the ratio of odds of unfavorable outcome between a typical high-risk and a typical low-risk center or country. RESULTS: The proportion of patients with unfavorable outcome was 27% (n = 1599). The authors found substantial between-center differences (MOR 1.26, 95% CI 1.16-1.52), which could not be explained by patient characteristics and timing of aneurysm treatment (adjusted MOR 1.21, 95% CI 1.11-1.44). They observed no between-country differences (adjusted MOR 1.13, 95% CI 1.00-1.40). CONCLUSIONS: Clinical outcomes after aSAH differ between centers. These differences could not be explained by patient characteristics or timing of aneurysm treatment. Further research is needed to confirm the presence of differences in outcome after aSAH between hospitals in more recent data and to investigate potential causes.
OBJECTIVE: Differences in clinical outcomes between centers and countries may reflect variation in patient characteristics, diagnostic and therapeutic policies, or quality of care. The purpose of this study was to investigate the presence and magnitude of between-center and between-country differences in outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS: The authors analyzed data from 5972 aSAH patients enrolled in randomized clinical trials of 3 different treatments from the Subarachnoid Hemorrhage International Trialists (SAHIT) repository, including data from 179 centers and 20 countries. They used random effects logistic regression adjusted for patient characteristics and timing of aneurysm treatment to estimate between-center and between-country differences in unfavorable outcome, defined as a Glasgow Outcome Scale score of 1-3 (severe disability, vegetative state, or death) or modified Rankin Scale score of 4-6 (moderately severe disability, severe disability, or death) at 3 months. Between-center and between-country differences were quantified with the median odds ratio (MOR), which can be interpreted as the ratio of odds of unfavorable outcome between a typical high-risk and a typical low-risk center or country. RESULTS: The proportion of patients with unfavorable outcome was 27% (n = 1599). The authors found substantial between-center differences (MOR 1.26, 95% CI 1.16-1.52), which could not be explained by patient characteristics and timing of aneurysm treatment (adjusted MOR 1.21, 95% CI 1.11-1.44). They observed no between-country differences (adjusted MOR 1.13, 95% CI 1.00-1.40). CONCLUSIONS: Clinical outcomes after aSAH differ between centers. These differences could not be explained by patient characteristics or timing of aneurysm treatment. Further research is needed to confirm the presence of differences in outcome after aSAH between hospitals in more recent data and to investigate potential causes.
Entities:
Keywords:
CI = confidence interval; GOS = Glasgow Outcome Scale; IHAST = Intraoperative Hypothermia for Aneurysm Surgery Trial; IQR = interquartile range; MASH = Magnesium Sulfate in Aneurysmal Subarachnoid Hemorrhage; MOR = median odds ratio; RCT = randomized clinical trial; SAHIT = Subarachnoid Hemorrhage International Trialists; TBI = traumatic brain injury; WFNS = World Federation of Neurosurgical Societies; aSAH = aneurysmal subarachnoid hemorrhage; aneurysmal subarachnoid hemorrhage; center effects; mRS = modified Rankin Scale; outcome; quality of care; vascular disorders
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