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(Circulation. 2004;109:2207-2212.)
© 2004 American Heart Association, Inc.

Clinical Investigation and Reports

Regionalization of Treatment for Subarachnoid Hemorrhage

A Cost-Utility Analysis

Naomi S. Bardach, MD; Scott J. Olson, MPP; Jacob S. Elkins, MD; Wade S. Smith, MD, PhD; Michael T. Lawton, MD; S. Claiborne Johnston, MD, PhD

From the School of Medicine (N.S.B.), Neurovascular Service, Department of Neurology (J.S.E., W.S.S., S.C.J.), and Division of Neurological Surgery (M.T.L.), University of California, San Francisco, and Richard and Rhoda Goldman School of Public Policy (S.J.O.), University of California, Berkeley.

Correspondence to S. Claiborne Johnston, MD, PhD, Department of Neurology, Box 0114, University of California, San Francisco, 505 Parnassus Ave, M-798, San Francisco, CA 94143-0114. E-mail clay.johnston{at}ucsfmedctr.org

Received June 27, 2003; de novo received December 3, 2003; revision received February 5, 2004; accepted February 6, 2004.

Background— Previous studies have shown that for the treatment of subarachnoid hemorrhage (SAH), outcomes are improved but costs are higher at hospitals with a high volume of admissions for SAH. Whether regionalization of care for SAH is cost-effective is unknown.

Methods and Results— In a cost-utility analysis, health outcomes for patients with SAH were modeled for 2 scenarios: 1 representing the current practice in California in which most patients with SAH are treated at the closest hospital and 1 representing the regionalization of care in which patients at hospitals with <20 SAH admissions annually (low volume) would be transferred to hospitals with 20 SAH admissions annually (high volume). Using a Markov model, we compared net quality-adjusted life-years (QALYs) and cost per QALY. Inputs were chosen from the literature and derived from a cohort study in California. Transferring a patient with SAH from a low- to a high-volume hospital would result in a gain of 1.60 QALYs at a cost of $10 548/QALY. For transfer to result in only borderline cost-effectiveness ($50 000/QALY), differences in case fatality rates between low- and high-volume hospitals would have to be one fifth as large (2.2%) or risk of death during transfer would have to be 5 times greater (9.8%) than estimated in the base case.

Conclusions— Transfer of patients with SAH from low- to high-volume hospitals appears to be cost-effective, and regionalization of care may be justified. However, current estimates of the impact of hospital volume on outcome require confirmation in more detailed cohort studies.

Key Words: cost-benefit analysis • quality of health care • hemorrhage, subarachnoid

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