Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Nagoya, Japan.
BMJ Open. 2023 Apr 10;13(4):e068642. doi: 10.1136/bmjopen-2022-068642.
To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.
Retrospective study.
Six hundred and thirty-one primary care institutions in Japan.
Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.
Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points).
In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.
The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.
研究日本 6 年来接受夹闭术或血管内治疗的蛛网膜下腔出血（SAH）患者住院临床结局的全国性变化趋势，以及综合卒中中心（CSC）能力的时间变化趋势对患者结局的预后影响。
回顾性研究。
日本 631 家基层医疗机构。
使用 J-ASPECT 诊断程序组合数据库紧急住院的 4511 例 SAH 患者。
每年未接受治疗、接受夹闭术或血管内治疗的 SAH 患者数量，住院死亡率和出院时的不良功能结局（改良 Rankin 量表：3-6 分）。每个 CSC 使用经过验证的评分系统（CSC 评分：1-25 分）进行评估。
在整个队列中，住院死亡率下降（趋势年，比值比（95%可信区间）：0.97（0.96 至 0.99）），而不良功能结局的比例保持不变（1.00（0.98 至 1.02））。接受夹闭术的患者比例从 46.6%逐渐降至 38.5%，而接受血管内治疗和未接受治疗的患者比例分别从 16.9%逐渐增加至 22.6%和 35.4%。血管内治疗（0.94（0.89 至 0.98））和未治疗（0.93（0.90 至 0.96））患者的住院死亡率降低，而夹闭术患者的死亡率保持稳定。CSC 评分的提高与血管内治疗的应用增加相关（每增加 1 分，1.14（1.08 至 1.20）），但无论治疗方式如何，与短期患者结局无关。
6 年来的趋势表明，SAH 患者的住院死亡率降低（归因于更好的结局），未治疗患者的血管内治疗和多学科治疗应用增加。进一步提高 CSC 的能力可能会改善整体结局，主要是通过增加血管内治疗的应用。需要进一步的研究来确定动脉瘤复杂性等混杂因素对现代血管内时代夹闭术患者结局的影响。
