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Stubbs DJ, Khanna S, Davies BM, Vivian ME, Bashford T, Adatia K, Chen P, Clarkson PJ, McGlennan C, Indurawage L, Patel M, Tyagunenko R, Burnstein R, Menon DK, Hutchinson PJ, Joannides A. Challenges and patient outcomes in chronic subdural haematoma at the level of a regional care system A multi-centre, mixed-methods study from the East of England. Age Ageing 2024; 53:afae076. [PMID: 38610063 PMCID: PMC11014781 DOI: 10.1093/ageing/afae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Chronic subdural haematoma (cSDH) is a common neurosurgical pathology affecting older patients with other health conditions. A significant proportion (up-to 90%) of referrals for surgery in neurosciences units (NSU) come from secondary care. However, the organisation of this care and the experience of patients repatriated to non-specialist centres are currently unclear. OBJECTIVES This study aimed to clarify patient outcome in non-specialist centres following NSU discharge for cSDH surgery and to understand key system challenges. The study was set within a representative neurosurgical care system in the east of England. DESIGN AND METHODS We performed a retrospective cohort analysis of patients referred for cSDH surgery. Alongside case record review, patient and staff experience were explored using surveys as well as an interactive c-design workshop. Challenges were identified from thematic analysis of survey responses and triangulated by focussed workshop discussions. RESULTS Data on 381 patients referred for cSDH surgery from six centres was reviewed. One hundred and fifty-six (41%) patients were repatriated following surgery. Sixty-one (39%) of those repatriated suffered an inpatient complication (new infection, troponin rise or renal injury) following NSU discharge, with 58 requiring institutional discharge or new care. Surveys for staff (n = 42) and patients (n = 209) identified that resourcing, communication, and inter-hospital distance posed care challenges. This was corroborated through workshop discussions with stakeholders from two institutions. CONCLUSIONS A significant amount of perioperative care for cSDH is delivered outside of specialist centres. Future improvement initiatives must recognise the system-wide nature of delivery and the challenges such an arrangement presents.
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Affiliation(s)
- Daniel James Stubbs
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Sam Khanna
- Department of Perioperative, Acute, Critical, and Emergency Care (PACE), University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Benjamin M Davies
- Department of Clinical Neurosurgery, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Mark E Vivian
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Tom Bashford
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
- Department of Engineering, Health Systems Design Group, Trumpington Street, Cambridge CB2 1PZ, UK
| | - Krishma Adatia
- Department of Anaesthesia, North West Anglia Foundation Trust, Peterborough City Hospital, Peterborough PE3 9GZ, UK
| | - Ping Chen
- Department of Anaesthesia, Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust, Gayton Road, Kings Lynn, PE30 4ET, UK
| | - Peter John Clarkson
- Department of Engineering, Health Systems Design Group, Trumpington Street, Cambridge CB2 1PZ, UK
| | - Catherine McGlennan
- Department of Anaesthesia, Bedfordshire Hospital NHS Foundation Trust, Luton and Dunstable University Hspital, Lewsey Road, Luton, LU4 ODZ, UK
| | - Lalani Indurawage
- Department of Anaesthesia, James Paget University Hospitals NHS Foundation Trust, Lowestoft Road, Gorleston-on-Sea, Great Yarmouth NR31 6LA, UK
| | - Martyn Patel
- Older People’s Medicine Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, UK
- Clinical Associate Professor in Translational and Clinical Medicine, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Rada Tyagunenko
- Department of Anaesthesia, Northwest Anglia NHS Foundation Trust, Hinchingbrooke Hospital, Parkway Hinchingbrooke, Huntingdon PE29 6NT, UK
| | - Rowan Burnstein
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - David K Menon
- Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Peter J Hutchinson
- Department of Clinical Neurosurgery, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Alexis Joannides
- Department of Clinical Neurosurgery, University of Cambridge, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Stubbs DJ, Davies B, Hutchinson P, Menon DK. Challenges and opportunities in the care of chronic subdural haematoma: perspectives from a multi-disciplinary working group on the need for change. Br J Neurosurg 2022; 36:600-608. [PMID: 35089847 DOI: 10.1080/02688697.2021.2024508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/27/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION A chronic subdural haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance. METHODS We convened a cross-disciplinary working group (the 'Improving Care in Elderly Neurosurgery Initiative') in October 2020. This comprised experts in neurosurgical care and a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement. RESULTS The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care and presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognizant of the complex, system-wide nature of the problem, and may require a combination of targeted trials at points of clinical equipoise (such as anesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation. CONCLUSION The care of cSDH is a growing clinical problem. Lessons may be learned from the standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.
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Affiliation(s)
- Daniel J Stubbs
- Department of Medicine, University Division of Anaesthesia, Cambridge University Hospital, Cambridge
- Department of Engineering, Healthcare Design Group, Cambridge, UK
| | - Benjamin Davies
- Department of Academic Neurosurgery, Department of Neurosurgery, Cambridge University Hospital, Cambridge, UK
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Stubbs DJ, Vivian ME, Davies BM, Ercole A, Burnstein R, Joannides AJ. Incidence of chronic subdural haematoma: a single-centre exploration of the effects of an ageing population with a review of the literature. Acta Neurochir (Wien) 2021; 163:2629-2637. [PMID: 34181085 PMCID: PMC8357776 DOI: 10.1007/s00701-021-04879-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/13/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Chronic subdural haematoma (cSDH) is a common neurosurgical pathology frequently occurring in older patients. The impact of population ageing on cSDH caseload has not been examined, despite relevance for health system planning. METHODS This is a single-centre study from the UK. Operated cases of cSDH (n = 446) for 2015-2018 were identified. Crude and directly standardised incidence rates were calculated. Medline and EMBASE were systematically searched to identify studies reporting on the incidence of cSDH by year, so an estimate of rate of incidence change could be determined. Local incidence rates were then applied to population projections for local catchment area to estimate operated cSDH numbers at 5 yearly intervals due to shifting demographics. RESULTS We identified nine studies presenting incidence estimates. Crude estimates for operative cases ranged from 1.3/100,000/year (1.4-2.2) to 5.3/100,000/year (4.3-6.6). When non-operated cases were included, incidence was higher: 8.2/100,000/year (6.0-11.2) to 48/100,000/year (37.7-61.1). Four pairs of studies demonstrated incidence rate increases of 200-600% over the last 50 years, but data was deemed too heterogeneous to generate formal estimate of incidence change. Local crude incidence of operated cSDH was 3.50/100,000/year (3.19-3.85). Directly standardised incidence was 1.58/100,000/year (1.26-1.90). After applying local incidence rates to population projections, case numbers were predicted to increase by 53% over the next 20 years. CONCLUSIONS The incidence of cSDH is increasing. We project a 53% increase in operative caseload within our region by 2040. These are important findings for guiding future healthcare planning.
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Affiliation(s)
- D. J. Stubbs
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - M. E. Vivian
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - B. M. Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ UK
| | - A. Ercole
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - R. Burnstein
- University Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - A. J. Joannides
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ UK
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