Trends in Transcranial Doppler Monitoring in Aneurysmal Subarachnoid Hemorrhage: A 10-Year Analysis of the Nationwide Inpatient Sample

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Background

Transcranial Doppler (TCD) is endorsed by national guidelines for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, nationwide data on utilization of TCD for CV detection and monitoring in aSAH are lacking.

Methods

Analysis of nationwide trends in TCD prevalence was performed using Nationwide Inpatient Sample (NIS) data from 2002 to 2011. Raw counts were converted into weighted counts, which were used to generate national estimates. Teaching hospitals were examined separately for TCD utilization rates. All analyses accounted for the complex sampling design and sample discharge weights of the NIS, following Healthcare Cost and Utilization Project–NIS recommendations. The objective was to estimate the proportion of patients with aSAH receiving TCD monitoring using the NIS.

Results

Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH, of which 3850 underwent TCD monitoring. aSAH accounted for an average of 67.1 discharges per 100,000 annually (95% confidence interval [CI] 61.3-72.8). Of these, 1.5% (95% CI 0.4-2.6) underwent TCD examination. In teaching hospitals, aSAH accounted for an average of 108.5 discharges per 100,000 biennially (95% CI, 96.2-120.8), of which 2% (95% CI 1.0-4.0) underwent TCD examination. TCD utilization increased from <1% during the 2002-2005 period to ≥1.5% during the 2006-2011 period (odds ratio 2.3, 95% CI 1.0-5.7), an increase also seen in teaching hospitals.

Conclusions

TCD is underused nationally in the care of aSAH. Whereas the prevalence of TCD is low in teaching hospitals, it is nearly nonexistent in nonteaching hospitals.

Introduction

Cerebral vasospasm (CV) is a dreaded complication of aneurysmal subarachnoid hemorrhage (aSAH), seen between 5 and 14 days following aSAH in up to 70% of patients angiographically and predicted by high mean flow velocities on transcranial Doppler (TCD).1, 2, 3, 4 In aSAH, CV is strongly associated with delayed cerebral ischemia, cerebral infarction, and death.5, 6, 7, 8 The use of TCD, a safe and effective modality for detection and monitoring of CV in aSAH, is endorsed by the American Heart Association/American Stroke Association, the American Academy of Neurology, and the Neurocritical Care Society.9, 10, 11 However, it is unknown how effectively these guidelines translate into clinical practice. Moreover, although evidence and guidelines support the use of TCD in aSAH, TCD monitoring is still not mandatory in aSAH owing to lack of class I evidence demonstrating impact on clinically relevant outcomes such as functional independence and mortality.12 Pragmatic patient-centered studies designed to evaluate comparative effectiveness of TCD monitoring have the potential to establish (or refute) the utility of this modality in patients with aSAH. However, before such a study can be designed, prevalence of use of TCD in aSAH needs to be established. Thus, we sought to investigate the prevalence of TCD use in patients with aSAH over a 10-year period using the Nationwide Inpatient Sample (NIS). The NIS contains discharge data both at the patient level and at the hospital level from states that participate in the Healthcare Cost and Utilization Project (HCUP). Comprising data from approximately 1000 US hospitals annually, the NIS is designed as a stratified 20% representative sample of all nongovernment hospitals nationwide.

Section snippets

Data Source

We analyzed data from the NIS, for the years 2002-2011. The NIS is a national database of in-patient discharges maintained as part of the HCUP by the Agency for Healthcare Research and Quality. The NIS represents a probability sample of nonfederal US community-based in-patient healthcare facilities and, through the use of design variables included in the dataset, can provide weighted national estimates. Released annually, the database includes comprehensive information on in-patient discharges,

Results

Between 2002 and 2011, a total of 382,104,673 discharges were observed, with 256,089 (95% confidence interval [CI 234,049-278,129) discharges having a primary diagnosis of aSAH. TCD was performed on 3850 patients (95% CI 1093-6606), representing 1.5% of aSAH discharges. Table 1, Table 2, Table 3 illustrate the annual number of patients with aSAH per 100,000 discharges and the proportion undergoing TCD examination. TCD utilization increased from <1% during the 2002-2005 period to ≥1.5% during

Discussion

Using the NIS, we found that only 1.5% of aSAH discharges received TCD monitoring. This is the first evidence that the use of TCD monitoring for CV detection in aSAH is low, despite endorsement by national guidelines. Moreover, we observed that the majority of TCD examinations were performed at teaching hospitals. This may be the result of more severe aSAH being managed at teaching hospitals and tertiary care centers compared with nonteaching hospitals.13 A survey of Neurocritical Care Society

Conclusion

Nationwide, TCD utilization for CV surveillance is sparse in patients hospitalized with aSAH. Overall, TCD monitoring is performed in 1.5% of aSAH discharges, and teaching hospitals account for the majority of TCDs performed nationally. Given challenges of conventional trial recruitment for a study examining the clinical utility of TCD and barriers to its use in aSAH, future studies should consider pragmatic trial methodology using electronic medical record across multiple institutions (“big

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    Grant support: This study was supported by the following grant: AHA14CRP20380256.

    The findings of this paper were presented as a moderated poster at the International Stroke Conference 2016 in Los Angeles, CA.

    This article does not contain any studies with human participants or animals performed by any of the authors.

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