title: In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996-2000: the effect of hospital and surgeon volume.
abstract: OBJECTIVE
  We sought to determine the risk of adverse outcome after contemporary surgical treatment of patients with unruptured intracranial aneurysms in the United States. Patient, surgeon, and hospital characteristics were tested as potential outcome predictors, with particular attention to the surgeon's and hospital's volume of care.
  
  
  METHODS
  We performed a retrospective cohort study with the Nationwide Inpatient Sample, 1996 to 2000. Multivariate logistic and ordinal regression analyses were performed with endpoints of mortality, discharge other than to home, length of stay, and total hospital charges.
  
  
  RESULTS
  We identified 3498 patients who were treated at 463 hospitals, and we identified 585 surgeons in the database. Of all patients, 2.1% died, 3.3% were discharged to skilled-nursing facilities, and 12.8% were discharged to other facilities. The analysis adjusted for age, sex, race, primary payer, four variables measuring acuity of treatment and medical comorbidity, and five variables indicating symptoms and signs. The statistics for median annual number of unruptured aneurysms treated were eight per hospital and three per surgeon. High-volume hospitals had fewer adverse outcomes than hospitals that handled comparatively fewer unruptured aneurysms: discharge other than to home occurred after 15.6% of operations at high-volume hospitals (20 or more cases/yr) compared with 23.8% at low-volume hospitals (fewer than 4 cases/yr) (P = 0.002). High surgeon volume had a similar effect (15.3 versus 20.6%, P = 0.004). Mortality was lower at high-volume hospitals (1.6 versus 2.2%) than at hospitals that handled comparatively fewer unruptured aneurysms, but not significantly so. Patients treated by high-volume surgeons had fewer postoperative neurological complications (P = 0.04). Length of stay was not related to hospital volume. Charges were slightly higher at high-volume hospitals, partly because arteriography was performed more frequently than at hospitals that handled comparatively fewer unruptured aneurysms.
  
  
  CONCLUSIONS
  For patients with unruptured aneurysms who were treated in the United States between 1996 and 2000, surgery performed at high-volume institutions or by high-volume surgeons was associated with significantly lower morbidity and modestly lower mortality.
authors.affiliation: Neurosurgical Service, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Boston, Massachusetts.
authors.forename: Fred G
authors.initials: FG
authors.lastname: Barker
authors.forename: Sepideh
authors.initials: S
authors.lastname: Amin-Hanjani
authors.forename: William E
authors.initials: WE
authors.lastname: Butler
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ogilvy
authors.forename: Bob S
authors.initials: BS
authors.lastname: Carter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000191:economics / Q000401:mortality* / Q000601:surgery*; D002648:Child; D015331:Cohort Studies; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D002532:Intracranial Aneurysm / Q000191:economics / Q000401:mortality* / Q000601:surgery*; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000191:economics / Q000401:mortality*; D016526:Workload / Q000191:economics / Q000706:statistics & numerical data*