Haripottawekul Ariyaporn, Stipanovich Ava, Uriarte Sarah A, Persad-Paisley Elijah M, Furie Karen L, Reznik Michael E, Mahta Ali
Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Neurocrit Care. 2025 Jun;42(3):1054-1063. doi: 10.1007/s12028-024-02197-7. Epub 2025 Jan 7.
Socioeconomic status affects outcomes in cerebrovascular disease, although its role in the withdrawal of life-sustaining treatments (WLST) remains uncertain. We aim to examine the impact of socioeconomic factors on outcomes including WLST in aneurysmal subarachnoid hemorrhage (aSAH).
We conducted a retrospective study of a cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2023. Publicly available data on median neighborhood income by zip code areas were obtained from the US census. Low economic-insurance status (EIS) was defined as using Medicaid or having no insurance or living in a zip code within the lowest two quintiles of household income. High EIS was defined as not using Medicaid and having any other insurance and living in a zip code within the highest two quintiles of household income. The rest of the cohort who was not categorized in the high or low EIS groups was defined as middle EIS. We used multivariable logistic regression analysis to assess the association between socioeconomic and demographic factors and outcomes including WLST, mortality, and 3-month modified Rankin Scale.
We included 410 patients, with mean age 57.9 years (standard deviation 13.8), who were 65% female, 70% white, 36.8% low EIS, and 35.6% high EIS. Higher EIS was associated with WLST (odds ratio 1.53 per increase in EIS, 95% confidence interval 1.07-2.18; p = 0.02) when adjusted for other predictors. In addition, a higher quintile of neighborhood income, regardless of insurance status, was associated with higher odds of WLST (odds ratio 1.41 per each quintile increase, 95% confidence interval 1.07-1.86; p = 0.014). However, there was no association between EIS and 3-month modified Rankin Scale when adjusted for disease severity factors.
Higher EIS and residing in areas with higher neighborhood incomes were associated with higher odds of WLST in aSAH. Further multicenter studies are needed to investigate the underlying mechanisms that contribute to these associations.
社会经济地位会影响脑血管疾病的预后，但其在维持生命治疗的撤除（WLST）中的作用仍不确定。我们旨在研究社会经济因素对包括动脉瘤性蛛网膜下腔出血（aSAH）患者的WLST等预后的影响。
我们对2016年至2023年期间入住一所学术中心的连续aSAH患者队列进行了回顾性研究。通过邮政编码区域从美国人口普查中获取了公开的邻里收入中位数数据。低经济保险状态（EIS）定义为使用医疗补助、没有保险或居住在家庭收入最低的两个五分位数邮政编码区域内。高EIS定义为不使用医疗补助且拥有任何其他保险并居住在家庭收入最高的两个五分位数邮政编码区域内。未被归类为高或低EIS组的其余队列被定义为中等EIS。我们使用多变量逻辑回归分析来评估社会经济和人口因素与包括WLST、死亡率和3个月改良Rankin量表在内的预后之间的关联。
我们纳入了410名患者，平均年龄57.9岁（标准差13.8），其中65%为女性，70%为白人，36.8%为低EIS，35.6%为高EIS。在调整其他预测因素后，EIS越高与WLST相关（EIS每增加一级，比值比为1.53，95%置信区间为1.07 - 2.18；p = 0.02）。此外，无论保险状态如何，邻里收入每增加一个五分位数与更高的WLST几率相关（每增加一个五分位数，比值比为1.41，95%置信区间为1.07 - 1.86；p = 0.014）。然而，在调整疾病严重程度因素后，EIS与3个月改良Rankin量表之间没有关联。
较高的EIS以及居住在邻里收入较高的地区与aSAH患者更高的WLST几率相关。需要进一步的多中心研究来调查导致这些关联的潜在机制。
