Comparative Effectiveness of Ruptured Cerebral Aneurysm Therapies: Propensity Score Analysis of Clipping versus Coiling

The authors evaluated a national, multihospital database containing information on over 5200 patients to examine recent trends in ruptured aneurysm therapies and to compare peri-procedural outcomes between clipping and coiling treatments. Clipping therapy frequency decreased from 27% in 2006 to 21% in 2011. Unfavorable outcomes were more common after clipping compared with coiling, including discharge to long-term care, ischemic complications, neurologic complications, and other surgical complications. BACKGROUND AND PURPOSE: The relative merits of treating ruptured aneurysms with clipping versus coiling continue to be a topic of debate. We evaluated a national, multihospital patient data base to examine recent trends in ruptured aneurysm therapies and to compare peri-procedural outcomes between clipping and coiling treatments. MATERIALS AND METHODS: The Premier Perspective data base was used to identify patients hospitalized between 2006-2011 for ruptured aneurysm who underwent clipping or coiling therapy. A propensity score model, representing the probability of receiving clipping, was generated for each patient by use of relevant patient and hospital variables. After Greedy-type matching of the propensity score, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts. RESULTS: A total of 5229 patients with ruptured aneurysm (1228 clipping, 4001 coiling) treated at 125 hospitals were identified. Clipping therapy frequency decreased from 27% in 2006 to 21% in 2011. After propensity score adjustment, in-hospital mortality risk was similar between groups (OR = 0.94 [95% CI, 0.73-1.21]; P = .62). However, unfavorable outcomes were more common after clipping compared with coiling, including discharge to long-term care (OR = 1.32 [95% CI, 1.12-1.56]; P = .0006), ischemic complications (OR = 1.51 [95% CI, 1.24-1.83]; P = .0009), neurologic complications (OR = 1.64 [95% CI, 1.18-2.27]; P = .0018), and other surgical complications (OR = 1.55 [95% CI, 1.05-2.33]; P = .0240). CONCLUSIONS: This study of a data base of multiple hospitals in the United States demonstrates that clipping of ruptured cerebral aneurysms resulted in greater adjusted morbidity compared with coiling.