Fehnel Corey R, Lee Yoojin, Wendell Linda C, Thompson Bradford B, Stevenson Potter N, Mor Vincent
Division of Neurocritical Care, Brown University Alpert Medical School, Rhode Island Hospital, 593 Eddy St, APC-712.6, Providence, RI, 02903, USA.
Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University School of Public Health, Providence, RI, USA.
Aging Clin Exp Res. 2017 Aug;29(4):631-638. doi: 10.1007/s40520-016-0615-5. Epub 2016 Aug 5.
While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial.
To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC.
Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data.
Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC.
There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.
虽然临床试验数据支持减压性颅骨切除术（DHC）可提高重症缺血性中风患者的生存率，但老年人的生活质量结果仍存在争议。
为了辅助决策并了解实践差异，我们对全国范围内接受DHC治疗的缺血性中风患者队列的长期结局和区域差异模式进行了测量。
使用2008年65岁以上的医疗保险按服务收费的缺血性中风病例建立一个队列，在中风和DHC手术后随访2年（2009 - 2010年）。计算死亡率、急性医院再入院率和长期护理（LTC）利用率。使用多元逻辑回归来确定机构LTC的个体预测因素。通过汇总并与州级数据合并来计算DHC的区域差异。
在397,503例急性缺血性中风患者中，130例（0.03%）接受了DHC。平均年龄为72岁，75%的患者年龄在65至74岁之间。死亡率在最初30天内最高（38%）。在2年时，原队列中有59%的患者死亡。急性医院再入院的30天率为25%。在幸存者中，75%在首次中风入院1年后回家。人均医疗支出较高的州与DHC利用率的更大差异相关。
接受DHC治疗的老年中风患者死亡率很高。虽然大多数DHC幸存者没有永久性地入住机构，但美国各地DHC的利用率存在很大差异。
