The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms

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Safety-net hospitals deliver care to a substantial share of vulnerable patient populations and are disproportionately impacted by hospital payment reform policies. Complex elective procedures performed at safety-net facilities are associated with worse outcomes and higher costs. The effects of hospital safety-net burden on highly specialized, emergent, and resource-intensive conditions are poorly understood. The authors examined the effects of hospital safety-net burden on outcomes and costs after emergent neurosurgical intervention for ruptured cerebral aneurysms.


The authors conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) from 2002 to 2011. Patients ≥ 18 years old who underwent emergent surgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage (SAH) were included. Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital included in the NIS database. Hospitals that performed clipping and coiling were stratified as low-burden (LBH), medium-burden (MBH), and high-burden (HBH) hospitals.


A total of 34,647 patients with ruptured cerebral aneurysms underwent clipping and 23,687 underwent coiling. Compared to LBHs, HBHs were more likely to treat black, Hispanic, Medicaid, and uninsured patients (p < 0.001). HBHs were also more likely to be associated with teaching hospitals (p < 0.001). No significant differences were observed among the burden groups in the severity of subarachnoid hemorrhage. After adjusting for patient demographics and hospital characteristics, treatment at an HBH did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.


Despite their financial burden, safety-net hospitals provide equitable care after surgical clipping and endovascular coiling for ruptured cerebral aneurysms and do not incur higher hospital costs. Safety-net hospitals may have the capacity to provide equitable surgical care for highly specialized emergent neurosurgical conditions.

ABBREVIATIONS CCI = Charlson Comorbidity Index; CMS = Centers for Medicare and Medicaid Services; DVT/PE = deep venous thrombosis/pulmonary embolism; HAC = hospital-acquired condition; HBH = high-burden hospital; HCUP = Healthcare Cost and Utilization Project; HHRP = Hospital Readmissions Reduction Program; ICD-9 = International Classification of Diseases, Ninth Revision; LBH = low-burden hospital; LOS = length of stay; MBH = medium-burden hospital; NIS = Nationwide Inpatient Sample; NIS-SOM = NIS-SAH Outcome Measure; NIS-SSS = NIS–Subarachnoid Severity Score; SAH = subarachnoid hemorrhage; SSI = surgical site infection; VBP = value-based purchasing.

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Contributor Notes

Correspondence Alexander A. Khalessi: University of California, San Diego, CA. WHEN CITING Published online February 22, 2019; DOI: 10.3171/2018.10.JNS18103.Disclosures Dr. Khalessi is a consultant for Medtronic. Dr. Pannell is a consultant for Stryker.


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