Donoho Daniel A, Patel Arati, Buchanan Ian A, Chow Frances, Ding Li, Amar Arun P, Attenello Frank, Mack William J
Department of Neurological Surgery, University of Southern California, Los Angeles, California.
Keck School of Medicine, University of Southern California, Los Angeles, California.
World Neurosurg. 2018 Dec;120:e434-e439. doi: 10.1016/j.wneu.2018.08.101. Epub 2018 Sep 8.
Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment.
Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days).
Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals.
After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.
成功进行动脉瘤性蛛网膜下腔出血（aSAH）的血管内治疗需要及时获取大量资源。先前的研究表明治疗时间与患者预后之间存在关联。在安全网医院接受治疗的患者被认为在获取需要大量技术资源的干预措施方面特别容易受到差异对待。我们假设在安全网医院接受治疗的aSAH患者延迟接受血管内治疗的风险更高。
纳入2002年至2011年在全国住院患者样本中接受血管内栓塞术的成年人。医疗补助患者或未参保患者比例最高的四分位数中的医院被定义为安全网医院。构建了一个包括患者层面和医院层面因素的多变量模型，以分析血管内治疗的延迟情况（定义为治疗时间>3天）。
分析包括2002年至2011年7109例接受血管内线圈栓塞术的aSAH患者出院病例。所有患者进行线圈栓塞的中位时间为1天；10.1%的患者等待>3天才接受治疗。在多变量分析中，与在低负担医院接受治疗的患者相比，在安全网医院接受治疗的患者进行线圈栓塞的时间更长的可能性更大（比值比=1.32，P<0.01）。
在控制了患者和医院因素后，2002年至2011年在安全网医院接受治疗的aSAH患者比在非安全网医院接受治疗的患者更有可能延迟进行血管内线圈栓塞。这种差异可能会影响患者的预后。
