Evaluating Time-To-Aneurysm Repair As A Performance Measure In Aneurysmal Subarachnoid Hemorrhage.

Background: Implementation of evidence-based performance metrics drive standardized care and improve patient outcomes. Limited performance metrics have been developed for implementation in the aneurysmal subarachnoid hemorrhage (aSAH) population. Timely aneurysm repair following an aSAH is associated with rebleeding prevention and mortality. The purpose of this study was to evaluate time to aneurysm repair as a candidate performance metric by testing a model that includes hospital and patient characteristics as predictors of time to aneurysm repair and mortality, with time to aneurysm repair as a potential influence on these relationships in aSAH. Methods: A retrospective, cross-sectional analysis of patient discharge data from 2014 in the state of Florida was conducted. Data were derived from The Agency for Healthcare Research and Quality, HealthCare Utilization Project, State Inpatient Dataset, and the American Hospital Association Annual Survey. Patients with a primary ICD-9 diagnosis of aSAH and principle procedure of clipping or coiling were included (n=387). The study outcome was in-hospital mortality. Independent variables were level of stroke center, age, race, sex, and type of aneurysm repair. Hierarchical logistic regression was used to estimate the probability of in-hospital death. Results: Patients who underwent endovascular repair of an aneurysm were more likely to be treated in <24 hours compared to those undergoing aneurysm clipping (OR = 0.54, CI = .35-.84, p =0.01). Patients treated at a comprehensive stroke center (CSC) had a 72% reduction in odds of death compared to those treated at primary stroke centers (OR =0.28, CI = 0.10-0.77, p =0.01), controlling for disease severity and comorbidity. Time to aneurysm repair was not significantly associated with mortality and did not influence the relationship between hospital and patient characteristics and mortality. Conclusions: Treatment at a certified CSC was the only significant predictor of surviving aSAH. Time to aneurysm repair did not influence the relationship between hospital and patient characteristics associated with mortality. Further research is needed to identify appropriate measures and to define what should be tracked for performance in the aSAH population.