Neurosurgery Blog: The Effect of Transfer and Hospital Volume in Subarachnoid Hemorrhage Patients

Abstract

Introduction

Prompt management of aneurysmal subarachnoid hemorrhage (SAH) is critical. Literature is inconclusive regarding outcomes for patients directly admitted to specialized centers versus transferred from lower-volume hospitals. Providers are often unclear about the safety of transferring critical patients. This study evaluated the "transfer effect" in a large sample of aneurysmal SAH patients undergoing treatment.

Methods

Using Nationwide Inpatient Sample 2002–2007 data, we analyzed outcomes of SAH patients treated with coil or clip procedures. Analyses studied the effect of direct-admit versus transfer admission on mortality, discharge disposition, complications, length of stay (LOS), and total charges.

Results

Of 47,114 patients, 31,711 (67.3 %) were direct-admits and 15,403 (32.7 %) were transfers. More transfer patients were coiled than direct-admits (45.3 vs. 33.7 %, p < 0.0001) and fewer underwent ventriculostomy (26.6 vs. 31.5 %, p = 0.003). Older age (OR 1.2, p < 0.0001), higher disease severity (OR 1.4, p < 0.0001), lower volume (OR 1.5, p < 0.0001), and ventriculostomy (OR 2.1, p < 0.0001) increased mortality and predicted non-routine discharge, complications, LOS, and charges. Transfer patients had similar mortality (OR 0.9, p = 0.13) and complications (OR 0.9, p = 0.22) as direct-admits, but incurred higher non-routine discharge (OR 1.3, p = 0.002). Analysis of grade V patients demonstrated similar outcomes between direct-admits and transfers; however, charges for treating transfer patients were notably higher (401,386 vs.242,774, p = 0.03).

Conclusion

Patients treated in the lowest volume hospitals were 1.6 times more likely to die than those treated at the highest quintile hospitals. Among the critically ill grade V patients, transfer to higher-volume specialized centers did not increase the likelihood of a poor prognosis.

Content Type Journal Article
Category Original Article
Pages 1-12
DOI 10.1007/s12028-012-9740-y
Authors
- Miriam Nuño, Department of Neurosurgery, Cedars-Sinai Medical Center, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, 8631 W. Third Street, Suite 800E, Los Angeles, CA 90048, USA
- Chirag G. Patil, Department of Neurosurgery, Cedars-Sinai Medical Center, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, 8631 W. Third Street, Suite 800E, Los Angeles, CA 90048, USA
- Patrick Lyden, Department of Neurology, Cedars-Sinai Medical Center, Thalians E240, 8730 Alden Drive, Los Angeles, CA 90048, USA
- Doniel Drazin, Department of Neurosurgery, Cedars-Sinai Medical Center, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, 8631 W. Third Street, Suite 800E, Los Angeles, CA 90048, USA