Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) continues to pose significant morbidity and mortality albeit advancements in endovascular/open surgical treatments. We examine predictors of morbidity [i.e., extended length of stay (eLOS) defined as admission duration >75th percentile for group, non-home discharge, complications], and mortality in these patients stratified by treatment (clipping vs endovascular) using 20-years of national data.
Methods: We utilized the National Inpatient Sample (NIS, 2000-2020), identifying aSAH patients treated by clipping or endovascularly. Patients who received hybrid treatments were excluded. The outcomes were admission morbidity (measured separately through non-home discharge, eLOS and complications), and in-hospital mortality. Multivariable logistic regression models were constructed, controlling for clinical severity using previously-validated Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale (NIS-SAH).
Results: The clipping cohort included 85,043 patients, with mortality rate of 12.1% and a mean LOS of 19.3 (±15.0) days. Females had lower likelihood of in-hospital mortality (OR 0.88, p=0.01), with higher association with eLOS (OR 1.2, p< 0.01), while African-American race was an independent predictor of non-home discharge (OR: 1.17, p=0.03), and eLOS (OR 1.53; p=0.02). Medicare insurance was associated with non-routine discharge (OR: 1.64; p< 0.0001), but was protective against eLOS (OR: 0.76, p=0.01). Non-teaching hospital settings increased complications risk (OR: 2.61, p=0.02). Concurrently, the endovascular group comprised 118,693 patients, with 14% mortality rate and average LOS of 17.8 (±14.3) days. Similar to the clipping cohort, African-American race was an independent predictor of non-home discharge (OR: 1.15, p=0.03). Medicare coverage was associated with increased in-hospital mortality (OR: 1.18; p=0.016), and non-home discharge (OR 1.9; p< 0.0001). Similarly, self-pay insurance status was associated with in-hospital mortality (OR 1.53; p< 0.0001), while non-teaching hospitals was associated with higher risk of complications (OR: 1.47; p=0.004).
Conclusion : Clipping and endovascular treatments for aSAH have distinct, independent risk factors for morbidity and mortality, shaped by patient characteristics, insurance status, and hospital setting. These findings underscore the importance of developing tailored management strategies and interventions that address specific risk factors associated with each treatment type and individual patient profiles.
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