and Harry J. CloftJennifer S. McDonald, Robert J. McDonald, Jiaquan Fan, David F. Kallmes, Giuseppe LanzinoScore Analysis of Clipping Versus CoilingComparative Effectiveness of Unruptured Cerebral Aneurysm Therapies: PropensityPrint ISSN: 0039-2499. Online ISSN: 1524-4628 Copyright © 2013 American Heart Association, Inc. All rights reserved.is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke doi: 10.1161/STROKEAHA.111.0001962013;44:988-994; originally published online February 28, 2013;Stroke. http://stroke.ahajournals.org/content/44/4/988World Wide Web at: The online version of this article, along with updated information and services, is located on the http://stroke.ahajournals.org//subscriptions/is online at: Stroke Information about subscribing to Subscriptions: http://www.lww.com/reprints Information about reprints can be found online at: Reprints: document. Permissions and Rights Question and Answer process is available in theRequest Permissions in the middle column of the Web page under Services. Further information about thisOnce the online version of the published article for which permission is being requested is located, click can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office.Strokein Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions: at CORNELL UNIVERSITY on October 1, 2014http://stroke.ahajournals.org/Downloaded from at CORNELL UNIVERSITY on October 1, 2014http://stroke.ahajournals.org/Downloaded from988For patients harboring an unruptured cerebral aneurysm, treatment options vary and may include surgery, endovas-cular treatment, or no treatment at all. The subsequent risk of subarachnoid hemorrhage after discovery of an unruptured aneurysm is often relatively low, and therefore the risks asso-ciated with either surgical or endovascular treatment must be low in order to justify treatment.1,2 Treatment strategies for unruptured aneurysms have changed substantially during the past 2 decades, primarily as a result of the increasing role of endovascular therapy with coiling. In light of these evolving changes in clinical practice, it is critical to monitor the impact of these changes on patient treatment trends and clinical out-comes. Previously published large patient database studies have demonstrated that patients who underwent clipping for unruptured aneurysms had worse outcomes compared with patients who underwent coiling.3–7 However, these retrospec-tive studies may have been affected by selection bias, because patients were not randomized to clipping or coiling. To address this concern of selection bias, we performed a propen-sity score analysis of patients treated with clipping or coiling of unruptured aneurysms between 2006 and 2011 to assess for disparities in periprocedural outcomes between these 2 treat-ment modalities. Recent trends in treatment utilization were also examined.MethodsStudy Population and DesignThe Perspective database (Premier Inc, Charlotte, NC) is a voluntary, fee-supported collection of data developed to assess the quality and resource utilization of health care delivery within the United States.8 As of 2011, the Perspective database consisted of ≈15% of hospitalizations nationwide and represented >600 US hospitals. Detailed information of a patient’s hospitalization, including patient demographics, hospital information, diagnoses, procedures, discharge status, and all billed items, are recorded. Time of procedures and administration of billed items, tests, and exams are reported in relation to the day of admission.Background and Purpose—Endovascular therapy has increasingly become the most common treatment for unruptured cerebral aneurysms in the United States. We evaluated a national, multi-hospital database to examine recent utilization trends and compare periprocedural outcomes between clipping and coiling treatments of unruptured aneurysms.Methods—The Premier Perspective database was used to identify patients hospitalized between 2006 to 2011 for unruptured cerebral aneurysm who underwent clipping or coiling therapy. A logistic propensity score was generated for each patient using relevant patient, procedure, and hospital variables, representing the probability of receiving clipping. Covariate balance was assessed using conditional logistic regression. Following propensity score adjustment using 1:1 matching methods, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts.Results—A total of 4899 unruptured aneurysm patients (1388 clipping, 3551 coiling) treated at 120 hospitals were identified. Following propensity score adjustment, clipping patients had a similar likelihood of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.49–4.44; P=0.47) but a significantly higher likelihood of unfavorable outcomes, including discharge to long-term care (OR, 4.78; 95% CI, 3.51–6.58; P<0.0001), ischemic complications (OR, 3.42; 95% CI, 2.39–4.99; P<0.0001), hemorrhagic complications (OR, 2.16; 95% CI, 1.33–3.57; P<0.0001), postoperative neurological complications (OR, 3.39; 95% CI, 2.25–5.22; P<0.0001), and ventriculostomy (OR, 2.10; 95% CI, 1.01–4.61; P=0.0320) compared with coiling patients.Conclusions—Among patients treated for unruptured intracranial aneurysms in a large sample of hospitals in the United States, clipping was associated with similar mortality risk but significantly higher periprocedural morbidity risk compared with coiling. (Stroke. 2013;44:988-994.)Key Words: aneurysm ■ comparative effectiveness research ■ outcome assessment (health care)Comparative Effectiveness of Unruptured Cerebral Aneurysm TherapiesPropensity Score Analysis of Clipping Versus CoilingJennifer S. McDonald, PhD; Robert J. McDonald, MD, PhD; Jiaquan Fan, PhD; David F. Kallmes, MD; Giuseppe Lanzino, MD; Harry J. Cloft, MD, PhDReceived December 14, 2012; accepted January 2, 2013.From the Departments of Radiology (J.S.M., R.J.M., D.F.K., G.L., H.J.C.), Health Sciences Research (J.F.), and Neurosurgery (D.F.K., G.L., H.J.C.), Mayo Clinic, Rochester, MN.Correspondence to Jennifer S. McDonald, PhD, Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. E-mail [email protected]© 2013 American Heart Association, Inc.Stroke is available at http://stroke.ahajournals.org
View Full Document
Unlocking...