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Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated “Hub-and-Spoke” Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation?

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Abstract

Background

Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization.

Methods

This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a “hub-and-spoke” model of neuroscience care in which two centers service as neuroscience “hubs” and the remaining 19 centers service as referral “spokes.” Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less].

Results

A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84–1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69–1.44).

Conclusions

Within an integrated “hub-and-spoke” neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a “hub-and-spoke” care model for patients with nontraumatic ICH, although additional investigations are warranted.

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Funding

This study was funded by the Kaiser Permanente Northern California Community Health Program.

Author information

Authors and Affiliations

  1. Departments of Emergency Medicine and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA

    Dustin G. Mark

  2. Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA

    Dustin G. Mark, Jie Huang, Adina S. Rauchwerger & Mary E. Reed

  3. Division of Neuroradiology, Department of Radiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA

    D. Chris Sonne

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  1. Dustin G. Mark
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  2. Jie Huang
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  4. Adina S. Rauchwerger
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For the Kaiser Permanente CREST Network Investigators

Contributions

The final manuscript was approved by all authors: study concept and design (DGM, JH, MER, ASR), acquisition of the data (JH, DCS), analysis and interpretation of the data (DGM, JH, MER), drafting of the article (DGM), critical revision of the article for important intellectual content (JH, DCS, ASR, MER), and statistical expertise (JH, MER, DGM).

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Correspondence to Dustin G. Mark.

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Mark, D.G., Huang, J., Sonne, D.C. et al. Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated “Hub-and-Spoke” Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation?. Neurocrit Care 38, 761–770 (2023). https://doi.org/10.1007/s12028-022-01667-0

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