Long-term outcomes among octogenarians with aneurysmal subarachnoid hemorrhage

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OBJECTIVE

Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH.

METHODS

Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008–2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model.

RESULTS

A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post–acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54–0.81), male sex (aHR 0.70, 95% CI 0.57–0.87), tracheostomy (aHR 0.63, 95% CI 0.47–0.85), gastrostomy (aHR 0.60, 95% CI 0.48–0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92–0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05–1.13), tracheostomy (aHR 2.06, 95% CI 1.46–2.91), gastrostomy (aHR 1.55, 95% CI 1.14–2.10), male sex (aHR 1.66, 95% CI 1.20–2.23), and worse SAH severity 1.51 (95% CI 1.04–2.18) were associated with reduced survival.

CONCLUSIONS

In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.

ABBREVIATIONS aHR = adjusted hazard ratio; CI = confidence interval; CMS = Centers for Medicare & Medicaid Services; ICD-9-CM = International Classification of Diseases, 9th Revision, Clinical Modification; NIS = Nationwide Inpatient Sample; NIS-SSS = NIS SAH Severity Score; SAH = subarachnoid hemorrhage.

Article Information

Correspondence Corey R. Fehnel: Hebrew SeniorLife, Institute for Aging Research, Boston, MA. cfehnel@bidmc.harvard.edu.

INCLUDE WHEN CITING Published online August 17, 2018; DOI: 10.3171/2018.3.JNS173057.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Disposition of the entire study population over the 2-year study period. Black indicates acute hospital care. Gray indicates institutional care (i.e., rehabilitation, nursing home/skilled nursing facility). Dark gray indicates return to home. Lightest gray indicates death/hospice care.

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    Kaplan-Meier time-to-event curves comparing microsurgical clipping and endovascular coiling. The entire cohort was hospitalized at the time of aneurysm treatment. Mortality and institutional care at any location other than home (acute hospital, rehabilitation, nursing home/skilled nursing facility) were combined for the analysis. Time to return home was significantly less for the endovascular coiling group than for the microsurgical clipping group (p < 0.0001).

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