1Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka.
2Department of Clinical Trials and Research, National Hospital Organization, Nagoya Medical Center, Nagoya.
J Neurosurg. 2020 Mar 13;134(3):929-939. doi: 10.3171/2019.12.JNS192584. Print 2021 Mar 1.
Improved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH.
The authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1-25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH.
Overall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55-0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53-0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59-0.96 vs Q4 OR 0.65, 95% CI 0.51-0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54-0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes.
The effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.
已有报道称，在高容量中心治疗的蛛网膜下腔出血（SAH）患者的预后得到改善。作者旨在研究医院病例量和综合卒中中心（CSC）能力是否会影响接受夹闭或血管内治疗的 SAH 患者的结局。
作者在 2010 年至 2015 年间，在 621 家机构中对 27490 名接受夹闭或血管内治疗的 SAH 患者进行了全国性回顾性队列研究，其数据来自日本全国性 J-ASPECT 诊断程序组合数据库。每个医院的 CSC 能力通过使用基于先前报告的 25 项问卷的验证评分系统（CSC 评分 1-25 分）进行评估。根据夹闭或血管内治疗 SAH 的病例量和 CSC 评分，将医院分为四分位数。
总体而言，高病例量与低病例量以及高 CSC 评分与低 CSC 评分之间的绝对风险降低相对较小。然而，在接受夹闭治疗的患者中，高病例量（>14 例/年）与住院死亡率降低显著相关（Q1 为对照，Q4 OR 0.71，95%CI 0.55-0.90），但与短期不良结局无关。在接受血管内治疗的患者中，高病例量（>9 例/年）与住院死亡率降低相关（Q4 OR 0.69，95%CI 0.53-0.90）和短期不良结局相关（Q3 [>5 例/年] OR 0.75，95%CI 0.59-0.96 与 Q4 OR 0.65，95%CI 0.51-0.82）。高 CSC 评分（>19 分）与夹闭治疗的住院死亡率降低显著相关（OR 0.68，95%CI 0.54-0.86），但与血管内治疗无关。CSC 能力与短期不良结局之间没有关联。
病例量和 CSC 能力对夹闭和血管内治疗的 SAH 患者的住院死亡率和短期功能结局的影响不同。在现代血管内治疗时代，在具有高 CSC 能力的设施中，夹闭治疗的效果可能更好。
