Fast-Track Hospital Course for Subarachnoid Hemorrhage: a Cost-Utility Analysis

Saturday, May 4, 2024

4:14 PM – 4:19 PM CT

Location: S402ab

Presenting Author(s)

Stefan W. Koester, n/a

Medical Student
Vanderbilt University School of Medicine
Nashville, TN, US

Co-Author(s)

Felipe Albuquerque, MD

Attending
Barrow Neurological Institue
Phoenix, Arizona, United States
Joshua Catapano, MD

Neurosurgeon
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, 85013, Arizona, USA
Phoenix, Arizona, United States
AD

Andrew Ducruet, MD

Associate Professor of Neurosurgery
Barrow Neurological Institue
Phoenix, Arizona, United States
JH

Joelle N. Hartke, MD

Resident
Barrow Neurological Institue
Phoenix, Arizona, United States
AJ

Ashutosh Jadhav, MD

Attending
Barrow Neurological Institue, Arizona, United States
Michael T. Lawton, MD

Professor of Neurosurgery
Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, 85013, Arizona, USA
Phoenix, AZ, US
Redi Rahmani, MD

Fellow
Barrow Neurological Institue
Penfield, New York, United States

Disclosure(s):

Stefan W. Koester, n/a: No financial relationships to disclose

Michael T. Lawton, MD: No financial relationships to disclose

Introduction: Patients with aneurysmal subarachnoid hemorrhage (aSAH) often suffer from vasospasm. Previous literature has proposed a “fast-track” (FT) for patients based on the absence of early angiographic vasospasm and early discharge, but the effect on cost and resources has not been analyzed.

Methods: All aSAH patients treated from August 1, 2007, to July 31, 2019, at a single tertiary center were reviewed. Patients undergoing diagnostic digital subtraction angiography (DSA) on post-aSAH days 5 to 7 were analyzed. The FT cohort was defined as those without angiographic vasospasm as reported by attending neurovascular surgeons. The primary outcome was total 1-year cost including hospital, discharge facility, emergency department revisits, and all follow-up. Utility was derived from the validated modified Rankin Scale utility score, and cost-utility was defined as total cost divided by the utility score. A lower cost-utility score signifies a potentially more cost-effective treatment strategy.

Results: Of 405 patients with cost and angiographic evaluation information available, 106 (26.2%) received angiography on post-bleed days 5-7. Of those that received angiography, 40 (38%) patients were considered FT. Age as well as prognostic measures such as admission GCS, Hunt and Hess, and Fisher Grade were not significantly different between the FT and non-FT cohorts. FT patients have a lower length of stay (18 sD 8 vs 24 sD 9, p< 0.001), lower total cost (101,162 sD 43,193 vs 132,733 sD 33,163, p< 0.001), lower variable cost (64,125 sD 29,213 vs 81,269 sD 27,217, p=0.003), and more favorable cost-utility (1,483,650 sD3,300,481 vs 3,249,513 sD4,788,519, p< 0.001). The total cost savings for each FT patient is approximately $31,571. In a multivariable model adjusted for index aSAH treatment type (open vs endovascular) and functional mRS status at discharge, FT status was an independent predictor of lower cost by $24,464 (95%CI 42,511, 6,418, p=0.008).

Conclusion : The lack of angiographic vasospasm on post-bleed days 5 to 7 confers a potential timely discharge route for patients with significant cost-utility, reducing both the cost burden to patients as well as the healthcare system.