Temporal Trends and Practice Variation in Early Repair of the Ruptured Aneurysm Among Patients with Aneurysmal Subarachnoid Hemorrhage in the United States, 2012-2019

Background: Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 hours of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available.Aims: This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data.Methods: Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. Additionally, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates.Results: We identified 82,615 aSAH hospitalizations (mean age, 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% CI, 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (P for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (IQR) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0 to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI, 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital.Conclusions: Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was been observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management.