The Source for Neurovascular News and Education

May 28, 2024


The findings highlight the need to maintain funding of teaching hospitals, such as through graduate medical education support.


Safety-net hospitals provide the same quality treatment of emergent subarachnoid hemorrhage (SAH) as do low-burden hospitals, according to a retrospective database analysis conducted in the United States. Many of the high-burden centers in the analysis were teaching hospitals, which highlights their important role in providing high-quality, lifesaving care to the underinsured.


Patients with SAH “come in with an acute problem, they usually require a sophisticated procedure, . . . and they usually require a good 2-week period of ICU care,” senior author Alexander A. Khalessi, MD (University of California San Diego, La Jolla), told Neurovascular Exchange. “So it’s a medical condition where the timeliness, sophistication, and quality of overall care make a big difference in terms of patients’ ultimate outcome.”


The investigators, he said, were concerned that if there were differences in care across hospitals this might translate into poorer outcomes for some patients.


Led by Christian Lopez Ramos, MPH (University of California San Diego), the researchers identified 34,647 adults who underwent clipping and 23,687 who underwent coiling for the treatment of ruptured cerebral aneurysms in the emergent setting between 2002 and 2011 in the Nationwide Inpatient Sample.


Safety-net burden was defined as the proportion of Medicaid and uninsured patients treated at each hospital. Centers that performed clipping and coiling were stratified into low, medium, and high burden.


High-burden hospitals were more likely than low-burden hospitals to treat black, Hispanic, Medicaid, and uninsured patients (P < 0.001). They were also more likely to be associated with teaching hospitals (P < 0.001).


There were no significant differences among the burden levels with respect to the severity of SAH. After adjusting for patient demographics and hospital characteristics, treatment at a high-burden hospital did not predict in-hospital mortality, poor outcome, length of stay, costs, or likelihood of a hospital-acquired condition.


The findings were published online recently ahead of print in the Journal of Neurosurgery.


An Unrecognized but Crucial Service


“This really demonstrated that there is an unrecognized service being provided by safety-net hospitals in providing fairly sophisticated care to patients who are often presenting on the worst day of their lives,” said Khalessi.


“Most of the high-burden hospitals in our sample were teaching hospitals,” he continued. “A lot of the care, when looking at the underinsured, is uncompensated care.”


Khalessi added: “This is one more unfunded mandate that is being managed right now by teaching hospitals. As teaching hospitals have less and less in the way of resources [due to reductions in indirect graduate medical education funding], they are going to be in a weaker position to provide this care that is saving lives.”


He speculated on a few reasons why outcomes remained the same in this study of SAH, whereas other studies on conditions such as cancer have yielded poorer outcomes for those treated at safety-net hospitals. Firstly, uninsured or underinsured patients may present for treatment later than insured patients for diseases like cancer, whereas SAH represents an acute event for which most anyone would present immediately for emergency care.


Secondly, conditions like cancer require integrated outpatient management and coordination of care services for optimal outcomes, and these services may not be available through safety-net hospitals. Furthermore, uninsured or underinsured patients may lack the social support they need when undergoing treatment and recovery for conditions such as cancer.


Conversely, he observed, while some follow-up care and rehabilitation are beneficial following SAH, especially for patients with neurological deficits, the interventions most important for good long-term outcomes occur during the initial hospital stay.


“If the goal is to have a well-integrated, meaningful medical safety net, you want to recognize that the investments made in safety-net hospitals in providing, for example, level 1 trauma care or complex neurovascular care, have paid dividends,” said Khalessi. “Those resources are saving lives. But we want to recognize where we still have gaps. Clear differences are in situations where early diagnosis is important, or the patient requires coordinated outpatient care.”


Other notable findings of the study, he added, included a nonsignificant trend toward better outcome in high-volume centers. In addition, there was a substantial trend away from open surgery and toward use of coiling, even in the setting of safety-net hospitals, where the upfront costs of coiling have been seen as a barrier. Ultimately, the costs of each procedure were similar.




Lopez Ramos C, Rennert RC, Brandel MG, et al. The effect of hospital safety-net burden on outcomes, cost, and reportable quality metrics after emergent clipping and coiling of ruptured cerebral aneurysms. J Neurosurg. 2019;Epub ahead of print.



  • Khalessi reports being a consultant to Medtronic.
  • Lopez Ramos reports no relevant conflicts of interest.