Socioeconomic Barriers Affecting Neurological Recovery Facing the Aneurysmal Subarachnoid Population

Abstract

Abstract INTRODUCTION Socioeconomic status is a known contributor to healthcare discrepancies in the United States. Pathologies requiring significant amounts of resources, such as ruptured cerebral aneurysms, are most representative. We aim to investigate if a healthcare discrepancy exists in the ruptured cerebral aneurysm population undergoing microsurgical intervention at our institution, and identify variables unrelated to aneurysmal features contributing to differences in neurologic outcomes. METHODS We retrospectively reviewed medical records of the ruptured intracranial aneurysm patients treated with microsurgical intervention at our tertiary referral University Hospital (UH) and safety net County Hospital (CH) from 2010 to 2015. Demographic information, insurance status, Glasgow coma scale score (GCS), Hunt-Hess (HH) and Fisher grade, aneurysm characteristics, surgical data, modified Rankin scale score (mRS), complications, and disposition were recorded for statistical analysis. RESULTS A total of 73 patients from UH and 58 patients from CH were identified for analysis. There was no statistically significant difference in demographics, Fisher score, presenting GCS, hospital days, aneurysm location, or complications between the 2 cohorts. Patients at UH had a shorter time duration between rupture and intervention (P < .001), and higher rates of intubation at the time of admission (P = .01). UH patients with clinical vasospasm were moderately more likely to receive verapamil infusions as compared to CH patients (P = .08), though there was no difference in delayed cerebral ischemia (DCI) (P = .15). The majority of CH cohort was either uninsured (19%; UH 0%) or Medicaid (67.2%; UH 35.6%) (P < .001). Private insurance was more prevalent in the UH cohort (49.3%; CH 12.1%) (P < .0001). UH patients had significantly more dispositions to home or rehabilitation centers (nonskilled nursing facilities) as compared to CH patients (82% versus 67.3% respectively; P = .04) despite similar neurological outcomes at the time of discharge. Neurological recovery from the time of discharge to clinical follow-up was statistically superior favoring UH over CH patients (P = .0004). CONCLUSION Limited resource availability in a safety net hospital system could be a major driving force behind the healthcare discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced in-patient acute care technologies, and, more importantly, post acute care environments can narrow the outcome gap.