Regional differences in outcome from subarachnoid haemorrhage: comparative audit
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《英国医生杂志》
1 Department of Neurosurgery, University of Newcastle upon Tyne, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, 2 Department of Neurosurgery, Queen's Medical Centre, Nottingham NG7 2UH
Correspondence to: P Mitchell Patrick.Mitchell@ncl.ac.uk
Introduction
The Newcastle neurosurgery unit serves a population of 2.4 million2 and has 78 adult beds. It is one of five units in the British Isles that are deemed by Safe Neurosurgery 2000 to have enough beds for their populations.2 The Nottingham unit serves a population of three million2 and has 36 beds. It is one of the three most under-resourced units in the British Isles.
We audited all patients presenting with a subarachnoid haemorrhage confirmed on computed tomography or lumbar puncture between 1992 and 1998. Patients' demographic and presenting clinical data were recorded during their admission. Outcome was recorded at clinic follow up, by postal questionnaire, or telephone and was obtained for 1822 of the 1851 cases in the study. The shortest interval between presentation and follow up was 6 months, and the average 12 months; these were similar for both units.
Full time research assistants were employed in each unit to collect the data. After careful and in-depth work, important errors were found and corrected in a quarter of cases. Funding was not available after 1998.
Good recovery and moderate disability (according to the Glasgow outcome score3) were classed as favourable outcomes; severe disability, vegetative state, or death were unfavourable.
We used the 2 test to compare the unfavourable outcome rates of the two units and the time periods (up to or after 1995), and we used logistic regression to include age and presenting condition (according to the World Federation of Neurological Surgeons' (WFNS) grading4).
The rate of an unfavourable outcome was 35% in Newcastle and 19% in Nottingham. This difference was significant (P < 0.0001). The results in Newcastle worsened over time. These differences disappeared when the effects of age and presenting condition were included. Newcastle operated a less selective admissions policy than Nottingham because it did not have the deficiency of beds that Nottingham had. Between 1992 and 1998 Newcastle became progressively less selective, admitting more patients with a poor WFNS grading and more older patients. The table shows the independent effects of age, WFNS grade, and neurosurgery unit.
Logistic regression of outcomes
Comment
Sahs AL. Aneurysmal subarachnoid haemorrhage. Report of the cooperative study. Baltimore, MA: Urban & Schwarzenberg, 1981.
Nelson MJ. Safe neurosurgery 2000. London: Society of British Neurological Surgeons, 1999.
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1: 480-4.
Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988;68: 985-6.(P Mitchell, senior lectur)
Correspondence to: P Mitchell Patrick.Mitchell@ncl.ac.uk
Introduction
The Newcastle neurosurgery unit serves a population of 2.4 million2 and has 78 adult beds. It is one of five units in the British Isles that are deemed by Safe Neurosurgery 2000 to have enough beds for their populations.2 The Nottingham unit serves a population of three million2 and has 36 beds. It is one of the three most under-resourced units in the British Isles.
We audited all patients presenting with a subarachnoid haemorrhage confirmed on computed tomography or lumbar puncture between 1992 and 1998. Patients' demographic and presenting clinical data were recorded during their admission. Outcome was recorded at clinic follow up, by postal questionnaire, or telephone and was obtained for 1822 of the 1851 cases in the study. The shortest interval between presentation and follow up was 6 months, and the average 12 months; these were similar for both units.
Full time research assistants were employed in each unit to collect the data. After careful and in-depth work, important errors were found and corrected in a quarter of cases. Funding was not available after 1998.
Good recovery and moderate disability (according to the Glasgow outcome score3) were classed as favourable outcomes; severe disability, vegetative state, or death were unfavourable.
We used the 2 test to compare the unfavourable outcome rates of the two units and the time periods (up to or after 1995), and we used logistic regression to include age and presenting condition (according to the World Federation of Neurological Surgeons' (WFNS) grading4).
The rate of an unfavourable outcome was 35% in Newcastle and 19% in Nottingham. This difference was significant (P < 0.0001). The results in Newcastle worsened over time. These differences disappeared when the effects of age and presenting condition were included. Newcastle operated a less selective admissions policy than Nottingham because it did not have the deficiency of beds that Nottingham had. Between 1992 and 1998 Newcastle became progressively less selective, admitting more patients with a poor WFNS grading and more older patients. The table shows the independent effects of age, WFNS grade, and neurosurgery unit.
Logistic regression of outcomes
Comment
Sahs AL. Aneurysmal subarachnoid haemorrhage. Report of the cooperative study. Baltimore, MA: Urban & Schwarzenberg, 1981.
Nelson MJ. Safe neurosurgery 2000. London: Society of British Neurological Surgeons, 1999.
Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1: 480-4.
Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988;68: 985-6.(P Mitchell, senior lectur)