Introduction: Prior research has shown that the utilization of decompressive hemicraniectomy (DHC) for stroke is increasing in the United States. The goal of this study was to evaluate what patient demographics (including social determinants of health) and hospital characteristics were associated with DHC utilization.
Methods: Patients with an acute ischemic stroke were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariate logistic regression evaluated independent predictors of DHC utilization. Predictors screened included year of admission, weekend admission, patient age, sex, insurance coverage, socioeconomic status, race/ethnicity, comorbidities, stroke risk factors (anticoagulation, atrial fibrillation, carotid dissection, carotid stenosis, hypercoaguablility, hyperlipidemia, tobacco use), and hospital characteristics. Severity indices (including neurologic deficits, altered sensorium, cerebral edema, and herniation) as well as treatment variables were covariates in regression constructs to account for severity of infarction.
Results: Of 774,595 ischemic stroke admissions, 1,705 underwent DHC (0.02%). A predictive model evaluated predictors of DHC utilization, which had excellent discrimination (C-statistic: 0.96). Older age predicted non-surgical treatment: age >70 years (OR: 0.11, 95% CI: 0.08-0.14); age 61-70; (OR: 0.11, 95% CI: 0.08-0.14); age 46-60 (OR: 0.61, 95% CI: 0.51-0.73). Payer status was also associated with DHC utilization, and patients with private insurance were most likely to undergo DHC: Medicare recipients (odds ratio (OR) 0.63, 95% confidence interval (CI): 0.54-0.74, p<0.001) and uninsured patients (OR: 0.69, 95% CI: 0.53-0.88) had reduced DHC utilization compared to those with private insurance. Additionally, teaching (OR: 2.24, 95% CI: 1.63-3.08); large (OR: 1.96, 95% CI: 1.61-2.38); and urban hospitals (OR: 1.82, 95% CI: 1.13-2.95) had increased DHC utilization. Other social determinants of health, including race/ethnicity and socioeconomic status, were not associated with utilization.
Conclusions: In this national analysis, larger, urban, and teaching hospitals were associated with increased hemicraniectomy utilization, while Medicare and self-pay, as well as older age, were associated with reduced utilization.
Patient Care: Decompressive hemicraniectomy is an effective treatment for malignant cerebral edema after stroke, and by identifying factors predicting DHC underutilization, we have elucidated aspects of current clinical practice that warrant further investigation.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of patient selection for decompressive craniectomy patients, 2) Discuss in small groups the relevance and implications of individual predictors for surgery, and 3) Identify that more research is needed to understand if payer status and increased age are valid reasons for not undergoing decompressive craniectomy.
References: Back L, Nagaraja V, Kapur A, Eslick GD. Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: A meta-analysis of randomised trials. Internal medicine journal. 2015;45:711-717
Vahedi K, Hofmeijer J, Juettler E, Vicaut E, George B, Algra A, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: A pooled analysis of three randomised controlled trials. The Lancet. Neurology. 2007;6:215-222
Juttler E, Unterberg A, Woitzik J, Bosel J, Amiri H, Sakowitz OW, et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. The New England journal of medicine. 2014;370:1091-1100