High in-hospital blood pressure variability and severe disability or death in primary intracerebral hemorrhage patients.

OBJECTIVE: To quantify in-hospital systolic blood pressure variability among patients with intracerebral hemorrhage, determine the association between high systolic blood pressure variability (HSBPV) and 90-day severe disability or death, and examine the association between pre-hospital factors and HSBPV. METHODS: Adult, radiologically confirmed, intracerebral hemorrhage patients enrolled in a multi-site cohort were included. Using a semi-automated algorithm, systolic blood pressure values recorded from routine non-invasive systolic blood pressure monitoring in critical and acute care settings were extracted for the duration of hospitalization. Inter and intra-patient systolic blood pressure variability was quantified using generalized estimating equation methods. Modified Poisson and logistic regression models were fit to determine the association between HSBPV and 90-day severe disability or death and between pre-hospital characteristics and HSBPV, respectively. RESULTS: A total of 566 patients managed at four certified stroke centers were included. Over 120,000 systolic blood pressure readings were analyzed, and a standard deviation (SD) of 13.0 was parameterized as a cut-off point to categorize HSBPV. Patients with HSBPV had a greater risk of 90-day severe disability or death (relative risk: 1.20, 95% confidence interval: 1.04-1.39), after controlling for age, pre-morbid functional status, and other disease severity measures. Greater likelihood of in-hospital HSBPV was independently observed in elderly, female patients, and in patients with high admission systolic blood pressure. CONCLUSION: Quantification of HSBPV is feasible utilizing routinely collected systolic blood pressure readings, and a singular cut-off parameter for systolic blood pressure variability demonstrated association with 90-day severe disability or death. Elderly, female, and patients with high admission systolic blood pressure may be more likely to demonstrate HSBPV during hospitalization.

Rationale and Design of a Statewide Cohort to examine efficient resource utilization for patients with Intracerebral hemorrhage (EnRICH).

BACKGROUND: Intracerebral hemorrhage is a devastating disease with no specific treatment modalities. A significant proportion of patients with intracerebral hemorrhage are transferred to large stroke treatment centers, such as Comprehensive Stroke Centers, because of perceived need for higher level of care. However, evidence of improvement in patient-centered outcomes for these patients treated at larger stroke treatment centers as compared to community hospitals is lacking. METHODS / DESIGN: "Efficient Resource Utilization for Patients with Intracerebral Hemorrhage (EnRICH)" is a prospective, multisite, state-wide, cohort study designed to assess the impact of level of care on long-term patient-centered outcomes for patients with primary / non-traumatic intracerebral hemorrhage. The study is funded by the Texas state legislature via the Lone Star Stroke Research Consortium. It is being implemented via major hub hospitals in large metropolitan cities across the state of Texas. Each hub has an extensive network of "spoke" hospitals, which are connected to the hub via traditional clinical and administrative arrangements, or by telemedicine technologies. This infrastructure provides a unique opportunity to track outcomes for intracerebral hemorrhage patients managed across a health system at various levels of care. Eligible patients are enrolled during hospitalization and are followed for functional, quality of life, cognitive, resource utilization, and dependency outcomes at 30 and 90 days post discharge. As a secondary aim, an economic analysis of the incremental cost-effectiveness of treating intracerebral hemorrhage patients at higher levels of care will be conducted. DISCUSSION: Findings from EnRICH will provide much needed evidence of the effectiveness and efficiency of regionalized care for intracerebral hemorrhage patients. Such evidence is required to inform policy and streamline clinical decision-making.