Abstract W P127: Epidemiology of Cerebrovascular Disease: Association Between Geographic Location and In-Hospital Mortality

Abstract

Background: Extant literature suggests that the South has the lowest ground and air access to Neurocritical Care Units (NCUs) and has the highest number of admissions for subarachnoid hemorrhages (SAH) and intracerebral hemorrhages (ICH) than in other regions. NCUs have been shown to improve outcomes for patients with SAH and ICH, and delayed access may be potentially harmful. Evaluating for in-hospital mortality after SAH or ICH in regions with less access to NCUs may prove useful in determining the need for adequate access. Objectives: We sought to determine the in-hospital mortality trends for SAH and ICH from 1979 to 2008 per geographic region in relation to the US 2000 standard death rate to derive adjusted comparisons. Methods: The sample was obtained from the National Hospital Discharge Survey (NHDS) and cases were identified using the ICD-9-CM codes 430 for SAH and 431 for ICH. Age and geographic regions were divided into subgroups according to NHDS recommendations. Annual data was divided into 6 epochs for analysis of temporal changes. Results: We identified 612,600 cases of SAH and 1,530,613 cases of ICH in the US over a 30-year study period. Overall, crude in-hospital mortality after SAH or ICH was highest in the South [32% (95% CI, 29-35%) and 34% (95% CI, 32-35%), respectively] ( p = 0.001). Crude in-hospital mortality after SAH and ICH per epoch demonstrated a positive temporal trend supported by the Cochran-Armitage trend test (p < 0.0001) and was highest in the South during the sixth epoch (2004-2008) at 24% (95% CI, 22-26%) ( p = 0.001). After adjusting to the US 2000 standard death rate, there was excess mortality in the South with a standard mortality ratio of 1.25 (99% CI, 1.24-1.26) ( p < 0.01) as compared to other regions except for in the Northeast, which was an unanticipated finding. Conclusions: In-hospital mortality specific to SAH and ICH is higher in US regions identifiable with less access to NCUs when adjusted for all-cause mortality in the US. This study raises numerous questions regarding impact of NCU access and highlights the need for additional data and efforts to maximize access in an efficient manner.