Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies Propensity Score Analysis of Clipping Versus Coiling Jennifer S McDonald Robert J McDonald Jiaquan Fan David F Kallmes Giuseppe Lanzino and Harry J Cloft Stroke 2013 44 988 994 originally published online February 28 2013 doi 10 1161 STROKEAHA 111 000196 Stroke is published by the American Heart Association 7272 Greenville Avenue Dallas TX 75231 Copyright 2013 American Heart Association Inc All rights reserved Print ISSN 0039 2499 Online ISSN 1524 4628 The online version of this article along with updated information and services is located on the World Wide Web at http stroke ahajournals org content 44 4 988 Permissions Requests for permissions to reproduce figures tables or portions of articles originally published in Stroke can be obtained via RightsLink a service of the Copyright Clearance Center not the Editorial Office Once the online version of the published article for which permission is being requested is located click Request Permissions in the middle column of the Web page under Services Further information about this process is available in the Permissions and Rights Question and Answer document Reprints Information about reprints can be found online at http www lww com reprints Subscriptions Information about subscribing to Stroke is online at http stroke ahajournals org subscriptions Downloaded from http stroke ahajournals org at CORNELL UNIVERSITY on October 1 2014 Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies Propensity Score Analysis of Clipping Versus Coiling Jennifer S McDonald PhD Robert J McDonald MD PhD Jiaquan Fan PhD David F Kallmes MD Giuseppe Lanzino MD Harry J Cloft MD PhD 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 F or patients harboring an unruptured cerebral aneurysm treatment options vary and may include surgery endovascular 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 associated 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 outcomes 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 retrospective studies may have been affected by selection bias because patients were not randomized to clipping or coiling To outcome assessment health care address this concern of selection bias we performed a propensity 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 treatment modalities Recent trends in treatment utilization were also examined Methods Study Population and Design The 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 Received 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 mcdonald jennifer mayo edu 2013 American Heart Association Inc Stroke is available at http stroke ahajournals org DOI 10 1161 STROKEAHA 111 000196 Downloaded from http stroke ahajournals org 988 at CORNELL UNIVERSITY on October 1 2014 McDonald et al Clipping Versus Coiling of Unruptured Aneurysms 989 ICD 9 CM International Classification of Diseases 9 th Revision Clinical Modification codes were used to identify all cases of unruptured aneurysm
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