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Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians

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Abstract

Background and Aims

Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27–44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy.

Methods

We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs.

Results

Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6–93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8–72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8–41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5–15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006).

Conclusions

Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.

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Acknowledgements

We gratefully acknowledge Drs. Sam Shen and Deepika Mohan for providing valuable suggestions to the survey design. In addition, we wish to thank the Dean’s Summer Research Program at the University of Pittsburgh School of Medicine and Stanford Healthcare for supporting the study.

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Authors and Affiliations

  1. University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, USA

    Aarti Kumar

  2. Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, USA

    Kian Niknam, Angela Lumba-Brown, Joseph R. Bledsoe & Prasanthi Govindarajan

  3. Department of Epidemiology and Biostatistics, University of California - San Francisco, San Francisco, USA

    Kian Niknam & Michael A. Kohn

  4. Department of Emergency Medicine, Intermountain Healthcare, Salt Lake City, USA

    Michael Woodruff & Joseph R. Bledsoe

  5. Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada

    Jeffrey J. Perry

Authors
  1. Aarti Kumar
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  2. Kian Niknam
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  3. Angela Lumba-Brown
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  4. Michael Woodruff
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  5. Joseph R. Bledsoe
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  6. Michael A. Kohn
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  7. Jeffrey J. Perry
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  8. Prasanthi Govindarajan
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Contributions

AK contributed to data analysis, manuscript writing and editing. KN contributed to data analysis and manuscript writing. ALB contributed to building the survey instrument on REDCap and manuscript editing. MW contributed to project development. JB, JJP contributed to project development and manuscript editing, PG contributed to project development, data analysis and manuscript editing. MAK contributed to data analysis and manuscript editing.

Corresponding author

Correspondence to Prasanthi Govindarajan.

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No financial support was used for this study.

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The authors confirm that there are no known conflicts of interest associated with this publication.

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The study was approved by the Institutional Review Board, Stanford University.

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Kumar, A., Niknam, K., Lumba-Brown, A. et al. Practice Variation in the Diagnosis of Aneurysmal Subarachnoid Hemorrhage: A Survey of US and Canadian Emergency Medicine Physicians. Neurocrit Care 31, 321–328 (2019). https://doi.org/10.1007/s12028-019-00679-7

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  • DOI: https://doi.org/10.1007/s12028-019-00679-7

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