title: Variability in outcome after elective cerebral aneurysm repair in high-volume academic medical centers.
abstract: OBJECTIVE
  Unruptured intracranial aneurysm repair is the most commonly performed procedure for the prevention of hemorrhagic stroke. Despite efforts to regionalize care in high-volume centers, overall results have improved little. This study aims to determine the effectiveness in improving outcomes of previous efforts to regionalize unruptured intracranial aneurysm repair to high-volume centers and to recommend future steps toward that goal.
  
  
  METHODS
  Using data obtained via the New York Statewide Planning and Research Cooperative System, this study included all patients admitted to any of the 10 highest volume centers in New York state between 2005 and 2010 with a principal diagnosis of unruptured intracranial aneurysm who were treated either by microsurgical or endovascular repair. Mixed-effects logistic regression was used to determine the degree to which hospital-level and patient-level variables contributed to observed variation in good outcome, defined as discharge to home, between hospitals.
  
  
  RESULTS
  Of 3499 patients treated during the study period, 2692 (76.9%) were treated at the 10 highest volume centers, with 2198 (81.6%) experiencing a good outcome. Good outcomes varied widely between centers, with 44.6% to 91.1% of clipped patients and 75.4% to 92.1% of coiled patients discharged home. Mixed-effects logistic regression revealed that procedural volume accounts for 85.8% of the between-hospital variation in outcome.
  
  
  CONCLUSIONS
  There is notable interhospital heterogeneity in outcomes among even the largest volume unruptured intracranial aneurysm referral centers. Although further regionalization may be needed, mandatory participation in prospective, adjudicated registries will be necessary to reliably identify factors associated with superior outcomes.
authors.affiliation: From the Department of Neurological Surgery, College of Physicians and Surgeons (B.E.Z., S.S.B., A.M.C., Z.L.H., K.A.V., G.A., R.A.S., E.S.C.), Department of Epidemiology, College of Physicians and Surgeons (C.R.), and Department of Health Policy and Management, Mailman School of Public Health (W.E.G.), Columbia University, New York, NY; and Gold Health Strategies, Inc, New York, NY (W.E.G., J.L.).
authors.forename: Brad E
authors.initials: BE
authors.lastname: Zacharia
authors.forename: Samuel S
authors.initials: SS
authors.lastname: Bruce
authors.forename: Amanda M
authors.initials: AM
authors.lastname: Carpenter
authors.forename: Zachary L
authors.initials: ZL
authors.lastname: Hickman
authors.forename: Kerry A
authors.initials: KA
authors.lastname: Vaughan
authors.forename: Catherine
authors.initials: C
authors.lastname: Richards
authors.forename: William E
authors.initials: WE
authors.lastname: Gold
authors.forename: June
authors.initials: J
authors.lastname: Lu
authors.forename: Geoffrey
authors.initials: G
authors.lastname: Appelboom
authors.forename: Robert A
authors.initials: RA
authors.lastname: Solomon
authors.forename: E Sander
authors.initials: ES
authors.lastname: Connolly
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000328:Adult; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data*; D057510:Endovascular Procedures / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000601:surgery / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008866:Microsurgery / Q000706:statistics & numerical data; D009518:New York; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D063868:Patient Outcome Assessment; D062606:Tertiary Care Centers
keywords: intracranial aneurysm; neurosurgery