Dijkland Simone A, Jaja Blessing N R, van der Jagt Mathieu, Roozenbeek Bob, Vergouwen Mervyn D I, Suarez Jose I, Torner James C, Todd Michael M, van den Bergh Walter M, Saposnik Gustavo, Zumofen Daniel W, Cusimano Michael D, Mayer Stephan A, Lo Benjamin W Y, Steyerberg Ewout W, Dippel Diederik W J, Schweizer Tom A, Macdonald R Loch, Lingsma Hester F
Departments of1Public Health.
2Division of Neurosurgery and.
J Neurosurg. 2019 Aug 23;133(4):1132-1140. doi: 10.3171/2019.5.JNS19483. Print 2020 Oct 1.
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).
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.
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).
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.
不同中心和国家之间临床结局的差异可能反映患者特征、诊断和治疗策略或医疗质量的差异。本研究的目的是调查动脉瘤性蛛网膜下腔出血（aSAH）后中心间和国家间结局差异的存在情况及差异程度。
作者分析了来自蛛网膜下腔出血国际试验者（SAHIT）数据库中参与3种不同治疗方法随机临床试验的5972例aSAH患者的数据，包括来自179个中心和20个国家的数据。他们使用针对患者特征和动脉瘤治疗时机进行调整的随机效应逻辑回归，来估计3个月时不良结局的中心间和国家间差异，不良结局定义为格拉斯哥结局量表评分为1 - 3分（严重残疾、植物状态或死亡）或改良Rankin量表评分为4 - 6分（中度严重残疾、严重残疾或死亡）。中心间和国家间差异用中位数优势比（MOR）进行量化，其可解释为典型高风险中心或国家与典型低风险中心或国家之间不良结局的优势比。
不良结局患者的比例为27%（n = 1599）。作者发现中心间存在显著差异（MOR 1.26，95% CI 1.16 - 1.52），这不能用患者特征和动脉瘤治疗时机来解释（调整后的MOR 1.21，95% CI 1.11 - 1.44）。他们未观察到国家间差异（调整后的MOR 1.13，95% CI 1.00 - 1.40）。
aSAH后的临床结局在不同中心之间存在差异。这些差异不能用患者特征或动脉瘤治疗时机来解释。需要进一步研究以在更新的数据中确认aSAH后不同医院间结局差异的存在，并调查潜在原因。
