Geographic variation and regional trends in adoption of endovascular techniques for cerebral aneurysms

Clinical article

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Object

Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed.

Methods

The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored.

Results

The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%–92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations.

Conclusions

The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.

Abbreviations used in this paper: AHRQ = Agency for Health Care Research and Quality; CHF = congestive heart failure; ISAT = International Subarachnoid Aneurysm Trial; LOS = length of stay; NIS = National Inpatient Sample; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: John K. Ratliff, M.D., Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, Pennsylvania 19107. email: john.ratliff@jefferson.edu.

Please include this information when citing this paper: published online February 11, 2011; DOI: 10.3171/2011.1.JNS101528.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Line graph showing the increase in endovascular therapies in both ruptured and unruptured cerebral aneurysms from 2002 to 2008, based on assessment of the AHRQ NIS database.

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    Line graph showing the relationship between advancing patient age (in years) and choice of endovascular therapy in ruptured and unruptured cerebral aneurysms from 2002 to 2008, based on assessment of the AHRQ NIS database.

  • View in gallery

    Maps illustrating the geographic disparity in adoption of endovascular techniques. Color-coding illustrates the percentage of aneurysms (ruptured and unruptured) treated endovascularly. There was a substantial increase in endovascular therapy between 2002 and 2008, with specific increases concentrated along the eastern portion of the US and along the Pacific Coast.

  • View in gallery

    Line graph demonstrating the relationship between hospital charges, patient presenting diagnosis (ruptured vs unruptured cerebral aneurysm), and choice of treatment (endovascular vs open surgery). Endovascular and open treatments had very similar hospital charges, with the primary disparity arising from differences in patient presentation.

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