Assessment of Current Care Practices for Treatment of Chronic Subdural Hematoma in Medicare Claims Data

Introduction: Treatment paradigms for subacute or chronic subdural hematoma (scSDH) are changing as data supporting utilization of middle meningeal artery embolization (MMAE) increases. This analysis aims to capture a snapshot of real-world management and summarize current treatment of scSDH.

Methods: Medicare claims were queried (01/2018–09/2020) for adults hospitalized for scSDH. Patient cohorts were: (1) surgery [craniostomy, craniotomy, or craniectomy] and MMAE [S+MMAE], (2) surgery alone, (3) MMAE alone, or (4) observational (non-surgical) treatment. Estimated index retreatment was defined as any of the following procedural sequences during initial hospitalization: surgery followed by 1+ days of additional procedural treatment (surgery/MMAE), MMAE followed by surgery 3+ days later, or 3+ days of procedural treatment. Post-discharge all-cause readmission and scSDH-related retreatment were evaluated during a 90-day follow-up period.

Results: A total of 21,158 patients met selection criteria: 138 (0.7%) S+MMAE, 5,267 (24.9%) Surgery, 232 (1.1%) MMAE, and 15,521 (73.4%) Observational. Mean age was 74 years for procedural cohorts and 77 for the Observational cohort (P < 0.01). The average length of stay was shorter for Observational and MMAE patients versus Surgery and S+MMAE patients (5.4, 5.8, 9.6, and 11.8 days, respectively; P< 0.01). Most patients were discharged home; however, patients who underwent any surgery had lower rates (MMAE=56.0%, Observational=50.3%, Surgery=32.7%, S+MMA=31.2%; P< 0.01). Ninety-day all-cause readmissions were not significantly different across cohorts (P=0.82). Among procedural patients (n=5,637), the index, 90-day, and overall retreatment rates were 4.2%, 3.4% and 7.6%, respectively—with index retreatment accounting for 55.7% of all retreatments. Among Observational patients, 1.5% received procedural treatment for scSDH during follow-up. Among all patients who underwent procedural treatment for scSDH during follow-up (n=421), the average time to treatment was 25.7 days—which was not significantly different across cohorts (P=0.249).

Conclusion : Additional studies able to conclusively distinguish between planned and unplanned procedures are necessary for accurate comparisons of retreatment by initial scSDH treatment.