Quality Assurance in Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is among the most common neurovascular diseases and remains a significant cause of death and disability. Only around 25% of those affected return to a normal and largely independent life following this event (1). In the German federal state of Hesse, SAH cases have been recorded since 2006 as part of the state-wide mandatory stroke quality assurance (stroke QA). Since 2017, imaging evidence of aneurysm has been required in addition to the ICD-10 codes. For the first time, data were subject to an evaluation aimed at gaining insights into care structures and treatment quality.

Methods

Based on the aforementioned criteria, all cases of aneurysmal SAH in the 2017–2022 reporting period were identified and included in the study. In this study, n = 253 patients were excluded if they had been double-registered, were transferred within 72 h, or were treated in non-specialized centers with up to 10 cases a year. The analysis was performed using descriptive statistical methods (Table).

Table

Patient characteristics, inpatient treatment, and treatment outcomes

Results

According to the inclusion criteria, 1359 cases of aneurysmal SAH were registered during the analysis period. The average annual number of cases was 227. The overall average age was 59.2 years, with women accounting for 67.3% of cases. A total of 42.0% of patients exhibited mild neurological deficits and impaired consciousness, which can be classified as severity grades I and II according to the World Federation of Neurosurgical Societies (WFNS) criteria. On the other hand, 43.8% of individuals had severe neurological deficits and impaired consciousness, which can be classed as severity grades IV and V.

Treatment was carried out in 10 specialized acute care hospitals. Overall, 253 patients were transferred from hospitals providing initial care to specialized centers, with this taking place on the day of initial diagnosis or the following day in 97.6% of cases.

The average annual number of cases per hospital was 23, with a range of 12–53 cases per year. At eight of 10 hospitals, the annual number of cases per center is in the range of fewer than 30 cases per year. A total of 95.6% of affected individuals received intensive care. Of the proven aneurysms, 28.8% were treated surgically and 59.6% by endovascular approach (Table). In 11.6% of cases, no aneurysm treatment was performed or no information was provided. The average duration of inpatient stay was 22.5 days. On discharge or transfer, a good clinical outcome based on the degree of disability according to the modified Rankin scale (mRS) of 0–2 was recorded in 28.5% of patients. In-hospital mortality was 23.8%. When taking WFNS severity grades into consideration, no clear associations could be seen between case numbers per center and clinical outcome of treatment. In 69.8% of cases, follow-up rehabilitation care was initiated.

Discussion

Based on the abovementioned case numbers, Hesse (6.3 million inhabitants) has an annual incidence of 3.59 cases per 100 000 persons, which is at the lower end of the range reported in meta-analyses of epidemiological studies (2, 3). One needs to bear in mind here that the incidence in Europe declined by 40% between 1980 and 2010. The age distribution and high proportion of women are within the range given in the published data (1). The timely transfer of SAH patients to specialized centers for treatment, intensive care, and the provision of endovascular and surgical aneurysm management as well as other invasive treatment measures are available and in line with the current guideline recommendations (4).

The relatively low number of cases per center is due not only to the need for treatment in the area but also to the growing number of providers in the densely populated Rhein-Main region of Germany. Clinical outcomes demonstrate that the disease continues to follow a severe course in the majority of cases. When considering the data, one needs to bear in mind that data collection is limited to the inpatient period and that neither rehabilitation measures nor long-term data are taken into account. Mortality in our cohort (23.8%) was higher compared to data from larger centers, where a decline to below 10% was seen if a center had an annual number of cases of 40 (5). In order to better assess the relationship between case numbers and clinical treatment outcome, a detailed analysis of further specific data is required. This should include information regarding the treatment measures performed as well as the complications that arose.

The current QA data entry form is geared towards the model case of ischemic stroke. Detailed information on the type and time of the diagnostically significant angiographic detection of an aneurysm is lacking, among other things, leading to imprecision in the diagnostic classification. Similarly, information on aneurysm treatment that was not carried out or not documented in 11.6% of cases is difficult to assess due to a lack of specific information. In addition, typical complications of SAH such as secondary ischemic deficits are not recorded.

The state of care in Hesse leads to relatively low center-related case numbers. The impact of this on treatment outcomes must be further analyzed as a data basis if centralization is to be pursued.

Conclusions

The existing QA for patients with aneurysmal SAH already provides data on care, treatment, and clinical outcome. An SAH-specific QA that is limited to specialized centers is required in order to facilitate data collection and analysis with the aim of further improving quality indicators and the quality of care of SAH patients.

Joachim Berkefeld, Björn Misselwitz, Marco Stein

Department of Neuroradiology, University Hospital Frankfurt, Goethe University, Frankfurt, Germany. (Berkefeld)

Quality Assurance Office Hessen, Germany (Misselwitz)

Department of Neurosurgery Gießen, University Gießen-Marburg, Germany (Stein)

Conflict of interest statement

JB states that he is a member of the extended board of the German Society of Neuroradiology (Deutsche Gesellschaft für Neuroradiologie).

The remaining authors declare that no conflict of interest exists.

Manuscript received on 22 January 2024, revised version accepted on16 May 2024.

Translated from the original German by Christine Rye.

Cite this as:
Berkefeld J, Misselwitz B, Stein M: Quality assurance in aneurysmal subarachnoid hemorrhage. Dtsch Arztebl Int 2024; 121: 573–4. DOI: 10.3238/arztebl.m2024.0107

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