- Email: [email protected]
“July Effect” on Care for Aneurysmal Subarachnoid Hemorrhage
Perspective Commentary on: The Effect of July Admission on Inpatient Morbidity, Mortality, and Discharge Disposition After Endovascular Coiling in Subarachnoid Hemorrhage by De la Garza Ramos et al. World Neurosurg 2017 https://doi.org/10.1016/j.wneu.2017.09.126
“July Effect” on Care for Aneurysmal Subarachnoid Hemorrhage Giovanni Grasso
S
ubarachnoid hemorrhage (SAH) following a ruptured intracranial aneurysm accounts for about 5% of strokes, with an incidence of 10.5 per 100,000 person years (about 27,000 patients per year).1 Outcome after aneurysmal SAH depends on several factors, including the severity of the initial hemorrhage, rebleeding, perioperative medical management, and the timing and technical success for aneurysm exclusion from the cerebral circulation.2 The overall mortality rates range from 32% to 67% with 10%e20% of patients with long-term dependence due to brain damage. In this regard, 12% of patients die before medical treatment can be given and 25% die within the first 24 hours.3 A further 40%e60% mortality rate occurs within 30 days.3 Among the surviving patients, about one third remain dependent.4 Accordingly, only a small minority of all patients with SAH has a good outcome. Despite advances in diagnostic, anesthetic, and intraoperative neurosurgical techniques,5 as well as preoperative and postoperative management of patients, the ultimate overall outcome in patients with aneurysmal SAH remains unsatisfactory.6 The primary goal of treatment is to exclude the aneurysm sac from the intracranial circulation while preserving the parent artery. In unruptured aneurysms, the decision as to whether to treat or observe the malformation is made on a case-by-case basis. In this regard, the natural history must be carefully evaluated. The International Study of Unruptured Intracranial Aneurysm suggested that aneurysm size and location were independent predictors for aneurysm rupture.7 Most recently, the Unruptured Cerebral Aneurysm Study yielded results similar to the International Study of Unruptured
Key words Aneurysm - Coil - Complication - Endovascular - July effect - Subarachnoid hemorrhage -
WORLD NEUROSURGERY 110: 71-72, FEBRUARY 2018
Intracranial Aneurysm.8 For ruptured cerebral aneurysms, it is well known that exclusion of the vascular malformation from the cerebral circulation should be performed as soon as possible.9 In this scenario, both surgical clipping and endovascular techniques are valid treatment modalities to achieve such a goal. Few randomized, prospective studies have compared both techniques. Among these, the International Subarachnoid Aneurysm Trial have strongly modified the management of ruptured cerebral aneurysm since it reported an improved survival with coiling, which was statistically significant when compared with surgical treatment at 12 months follow-up.10 Although the rate of occlusion was higher in clipped aneurysms (82%) as compared with coiled aneurysms (66%), coiling resulted in a significantly decreased rate of death or dependency as compared with clipping. Despite the fact that the results of this study stimulated criticism, the treatment of ruptured cerebral aneurysms has dramatically changed over the years and is to date the endovascular treatment approach chosen for most ruptured intracranial aneurysms. Endovascular coiling requires adequate hospital infrastructure and a successful interaction of a multidisciplinary and experienced team. In this scenario, the so-called “July effect” has been a matter of controversy for years. First described about 3 decades ago,11 this phenomenon refers to the supposed belief that U.S. teaching hospitals staff (i.e., students, residents, fellows, young doctors) first beginning training in July may contribute to an increased rate of adverse events during patient care, resulting in increase in mortality and morbidity. Actually, large
Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), University of Palermo, Palermo, Italy To whom correspondence should be addressed: Giovanni Grasso, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 110:71-72. https://doi.org/10.1016/j.wneu.2017.10.136
www.WORLDNEUROSURGERY.org
71
PERSPECTIVE
studies in many surgical specialties have demonstrated an increase in adverse outcomes in late summer, suggesting an association between this transition period and poorer patient care.12 However, few studies have investigated the “July effect” in the field of neurosurgery and most of them generally did not find clear evidence for it.13 In a recent issue of WORLD NEUROSURGERY, De la Garza Ramos et al14 report the results of a study evaluating whether aneurysmal SAH-affected patients, admitted during the early academic year, had higher rates of complications, mortality, or a nonroutine discharge after undergoing endovascular treatment. Clinical data were extrapolated querying the National Inpatient Sample (NIS) database from 2012 until 2014. Aneurysmal SAHaffected patients who underwent endovascular therapy at a teaching hospital were identified and admissions during July were compared with other months. Outcome measures included inpatient morbidity and mortality and nonroutine discharges. A total of 8515 patients were identified. Among these, 665 (7.8%) were admitted in July and 7850 (92.2%) in other months. No differences in any of the examined outcomes, including morbidity and mortality, were found. Accordingly, the authors concluded that patients with SAH due to ruptured aneurysms who undergo endovascular treatment during the beginning of the academic year in July might not have worse short-term outcomes compared with admissions during other months. These results, therefore, provide evidence that critical care for patients with SAH treated by endovascular techniques, in U.S. teaching hospitals, is well maintained regardless of the month of presentation.
REFERENCES 1. Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke. 1996;27:625-629. 2. Grasso G, Alafaci C, MacDonald RL. Management of aneurysmal subarachnoid hemorrhage: state of the art and future perspectives. Surg Neurol Int. 2017;8:11. 3. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke. 1994;25:1342-1347. 4. Hop JW, Rinkel GJ, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke. 1997;28:660-664. 5. Grasso G, Landi A, Alafaci C. Multimodal intraoperative neuromonitoring in aneurysm surgery. World Neurosurg. 2017;101:763-765. 6. Grasso G. An overview of new pharmacological treatments for cerebrovascular dysfunction after experimental subarachnoid hemorrhage. Brain Res Brain Res Rev. 2004;44:49-63. 7. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, et al. International Study of Unruptured Intracranial Aneurysms: unruptured intracranial aneurysms:
72
www.SCIENCEDIRECT.com
This is a timely study by addressing a topic that has not been totally resolved in many fields of medicine including neurosurgery. The authors are to be commended for investigating this issue, yet it should be emphasized that this work is not a study on the influence of resident experience but rather an examination of different parts of the academic year. Also, the results of the study have significant spill-over effects only on U.S. teaching hospitals being the academic organization, in terms of activities beginning, different in the other countries. Notably, as acknowledged by the authors, the findings in the present study are limited by the use of an administrative database not specific to neurosurgical patients. In this regard, many of the previous studies were limited in their assessment of neurosurgical outcomes because, for the most part, they used the same NIS database. Although the authors point out the absence of specific data such as Hunt & Hess grade for SAH or presence/absence of neurologic deficits, it should be taken into consideration that this database lacks many other important specific variables, such as resident involvement in a particular operation, or outcomes following patient discharge. The lack of data on outcomes after the patient leaves the hospital represents a significant drawback of the NIS database because more than 30% of adverse events occur within the first 30 days after discharge.15 In light of these observations, further studies are needed with similar, longer-term outcomes after discharge that can include nonacademic hospitals as control groups.
natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003; 362:103-110. 8. Investigators UJ, Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366:2474-2482. 9. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. American Heart Association Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40: 994-1025. 10. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International Subarachnoid Aneurysm Trial Collaborative G International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366: 809-817. 11. Buchwald D, Komaroff AL, Cook EF, Epstein AM. Indirect costs for medical education. Is there a July phenomenon? Arch Intern Med. 1989;149:765-768.
academic year: retrospective cohort study. BMJ. 2009;339:b3974. 13. McDonald JS, Clarke MJ, Helm GA, Kallmes DF. The effect of July admission on inpatient outcomes following spinal surgery. J Neurosurg Spine. 2013;18:280-288. 14. De la Garza Ramos R, Haranhalli N, Kobets AJ, Nakhla J, Brook AL, Yassari R, et al. The effect of July admission on inpatient morbidity, mortality, and discharge disposition after endovascular coiling in subarachnoid hemorrhage [e-pub ahead of print]. World Neurosurg. doi:10.1016/j.wneu. 2017.09.126, accessed November 9, 2017. 15. Bilimoria KY, Cohen ME, Ingraham AM, Bentrem DJ, Richards K, Hall BL, et al. Effect of postdischarge morbidity and mortality on comparisons of hospital surgical quality. Ann Surg. 2010;252:183-190.
Citation: World Neurosurg. (2018) 110:71-72. https://doi.org/10.1016/j.wneu.2017.10.136 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
12. Haller G, Myles PS, Taffe P, Perneger TV, Wu CL. Rate of undesirable events at beginning of
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.10.136
“July Effect” on Care for Aneurysmal Subarachnoid Hemorrhage Giovanni Grasso
S
ubarachnoid hemorrhage (SAH) following a ruptured intracranial aneurysm accounts for about 5% of strokes, with an incidence of 10.5 per 100,000 person years (about 27,000 patients per year).1 Outcome after aneurysmal SAH depends on several factors, including the severity of the initial hemorrhage, rebleeding, perioperative medical management, and the timing and technical success for aneurysm exclusion from the cerebral circulation.2 The overall mortality rates range from 32% to 67% with 10%e20% of patients with long-term dependence due to brain damage. In this regard, 12% of patients die before medical treatment can be given and 25% die within the first 24 hours.3 A further 40%e60% mortality rate occurs within 30 days.3 Among the surviving patients, about one third remain dependent.4 Accordingly, only a small minority of all patients with SAH has a good outcome. Despite advances in diagnostic, anesthetic, and intraoperative neurosurgical techniques,5 as well as preoperative and postoperative management of patients, the ultimate overall outcome in patients with aneurysmal SAH remains unsatisfactory.6 The primary goal of treatment is to exclude the aneurysm sac from the intracranial circulation while preserving the parent artery. In unruptured aneurysms, the decision as to whether to treat or observe the malformation is made on a case-by-case basis. In this regard, the natural history must be carefully evaluated. The International Study of Unruptured Intracranial Aneurysm suggested that aneurysm size and location were independent predictors for aneurysm rupture.7 Most recently, the Unruptured Cerebral Aneurysm Study yielded results similar to the International Study of Unruptured
Key words Aneurysm - Coil - Complication - Endovascular - July effect - Subarachnoid hemorrhage -
WORLD NEUROSURGERY 110: 71-72, FEBRUARY 2018
Intracranial Aneurysm.8 For ruptured cerebral aneurysms, it is well known that exclusion of the vascular malformation from the cerebral circulation should be performed as soon as possible.9 In this scenario, both surgical clipping and endovascular techniques are valid treatment modalities to achieve such a goal. Few randomized, prospective studies have compared both techniques. Among these, the International Subarachnoid Aneurysm Trial have strongly modified the management of ruptured cerebral aneurysm since it reported an improved survival with coiling, which was statistically significant when compared with surgical treatment at 12 months follow-up.10 Although the rate of occlusion was higher in clipped aneurysms (82%) as compared with coiled aneurysms (66%), coiling resulted in a significantly decreased rate of death or dependency as compared with clipping. Despite the fact that the results of this study stimulated criticism, the treatment of ruptured cerebral aneurysms has dramatically changed over the years and is to date the endovascular treatment approach chosen for most ruptured intracranial aneurysms. Endovascular coiling requires adequate hospital infrastructure and a successful interaction of a multidisciplinary and experienced team. In this scenario, the so-called “July effect” has been a matter of controversy for years. First described about 3 decades ago,11 this phenomenon refers to the supposed belief that U.S. teaching hospitals staff (i.e., students, residents, fellows, young doctors) first beginning training in July may contribute to an increased rate of adverse events during patient care, resulting in increase in mortality and morbidity. Actually, large
Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), University of Palermo, Palermo, Italy To whom correspondence should be addressed: Giovanni Grasso, M.D., Ph.D. [E-mail: [email protected]] Citation: World Neurosurg. (2018) 110:71-72. https://doi.org/10.1016/j.wneu.2017.10.136
www.WORLDNEUROSURGERY.org
71
PERSPECTIVE
studies in many surgical specialties have demonstrated an increase in adverse outcomes in late summer, suggesting an association between this transition period and poorer patient care.12 However, few studies have investigated the “July effect” in the field of neurosurgery and most of them generally did not find clear evidence for it.13 In a recent issue of WORLD NEUROSURGERY, De la Garza Ramos et al14 report the results of a study evaluating whether aneurysmal SAH-affected patients, admitted during the early academic year, had higher rates of complications, mortality, or a nonroutine discharge after undergoing endovascular treatment. Clinical data were extrapolated querying the National Inpatient Sample (NIS) database from 2012 until 2014. Aneurysmal SAHaffected patients who underwent endovascular therapy at a teaching hospital were identified and admissions during July were compared with other months. Outcome measures included inpatient morbidity and mortality and nonroutine discharges. A total of 8515 patients were identified. Among these, 665 (7.8%) were admitted in July and 7850 (92.2%) in other months. No differences in any of the examined outcomes, including morbidity and mortality, were found. Accordingly, the authors concluded that patients with SAH due to ruptured aneurysms who undergo endovascular treatment during the beginning of the academic year in July might not have worse short-term outcomes compared with admissions during other months. These results, therefore, provide evidence that critical care for patients with SAH treated by endovascular techniques, in U.S. teaching hospitals, is well maintained regardless of the month of presentation.
REFERENCES 1. Linn FH, Rinkel GJ, Algra A, van Gijn J. Incidence of subarachnoid hemorrhage: role of region, year, and rate of computed tomography: a meta-analysis. Stroke. 1996;27:625-629. 2. Grasso G, Alafaci C, MacDonald RL. Management of aneurysmal subarachnoid hemorrhage: state of the art and future perspectives. Surg Neurol Int. 2017;8:11. 3. Broderick JP, Brott TG, Duldner JE, Tomsick T, Leach A. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke. 1994;25:1342-1347. 4. Hop JW, Rinkel GJ, Algra A, van Gijn J. Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review. Stroke. 1997;28:660-664. 5. Grasso G, Landi A, Alafaci C. Multimodal intraoperative neuromonitoring in aneurysm surgery. World Neurosurg. 2017;101:763-765. 6. Grasso G. An overview of new pharmacological treatments for cerebrovascular dysfunction after experimental subarachnoid hemorrhage. Brain Res Brain Res Rev. 2004;44:49-63. 7. Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, et al. International Study of Unruptured Intracranial Aneurysms: unruptured intracranial aneurysms:
72
www.SCIENCEDIRECT.com
This is a timely study by addressing a topic that has not been totally resolved in many fields of medicine including neurosurgery. The authors are to be commended for investigating this issue, yet it should be emphasized that this work is not a study on the influence of resident experience but rather an examination of different parts of the academic year. Also, the results of the study have significant spill-over effects only on U.S. teaching hospitals being the academic organization, in terms of activities beginning, different in the other countries. Notably, as acknowledged by the authors, the findings in the present study are limited by the use of an administrative database not specific to neurosurgical patients. In this regard, many of the previous studies were limited in their assessment of neurosurgical outcomes because, for the most part, they used the same NIS database. Although the authors point out the absence of specific data such as Hunt & Hess grade for SAH or presence/absence of neurologic deficits, it should be taken into consideration that this database lacks many other important specific variables, such as resident involvement in a particular operation, or outcomes following patient discharge. The lack of data on outcomes after the patient leaves the hospital represents a significant drawback of the NIS database because more than 30% of adverse events occur within the first 30 days after discharge.15 In light of these observations, further studies are needed with similar, longer-term outcomes after discharge that can include nonacademic hospitals as control groups.
natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet. 2003; 362:103-110. 8. Investigators UJ, Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, et al. The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med. 2012;366:2474-2482. 9. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, et al. American Heart Association Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009;40: 994-1025. 10. Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, et al. International Subarachnoid Aneurysm Trial Collaborative G International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366: 809-817. 11. Buchwald D, Komaroff AL, Cook EF, Epstein AM. Indirect costs for medical education. Is there a July phenomenon? Arch Intern Med. 1989;149:765-768.
academic year: retrospective cohort study. BMJ. 2009;339:b3974. 13. McDonald JS, Clarke MJ, Helm GA, Kallmes DF. The effect of July admission on inpatient outcomes following spinal surgery. J Neurosurg Spine. 2013;18:280-288. 14. De la Garza Ramos R, Haranhalli N, Kobets AJ, Nakhla J, Brook AL, Yassari R, et al. The effect of July admission on inpatient morbidity, mortality, and discharge disposition after endovascular coiling in subarachnoid hemorrhage [e-pub ahead of print]. World Neurosurg. doi:10.1016/j.wneu. 2017.09.126, accessed November 9, 2017. 15. Bilimoria KY, Cohen ME, Ingraham AM, Bentrem DJ, Richards K, Hall BL, et al. Effect of postdischarge morbidity and mortality on comparisons of hospital surgical quality. Ann Surg. 2010;252:183-190.
Citation: World Neurosurg. (2018) 110:71-72. https://doi.org/10.1016/j.wneu.2017.10.136 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
12. Haller G, Myles PS, Taffe P, Perneger TV, Wu CL. Rate of undesirable events at beginning of
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.10.136