Sample: The study was conducted retrospectively at The Valley Hospital, a community hospital in Ridgewood, NJ, for a three-year period from July 1, 2014 to June 30, 2017. The baseline cohort included 424 consecutive neurological procedures. In order to be included in the study sample, patients had to be eighteen years of age or older on the date of their procedure and have 30 day follow up information available. Accounting for these inclusion criteria, the final analytical sample consisted of 349 procedures. Qualifying procedures included cerebrovascular procedures for intracranial embolization or craniotomy for cerebral aneurysms or arteriovenous malformations or intraparenchymal hemorrhages (IPH) (n=78), carotid endarterectomy or stenting (n=6), acute stroke intervention (n=16), and conventional cerebral catheter angiogram (n=249). Both elective (n=315) and urgent (n=34) procedures were included.
Data were collected from the patients’ electronic medical record, including any report of a past or present experience with anxiety, depression, or both. Of the 349 patients with cerebrovascular procedures, there were 63 patients (18.1%) who self-reported as part of their past medical history a prior or current diagnosis of anxiety (n=27), depression (n=18), or both (n=18). Due to the small sample size when broken down into these categories, we combined them into one group for our analysis.
Baseline variables included sociodemographic information and past medical history as shown in Table 1. This included factors such as a history of smoking, alcohol consumption, and migraine. Medication records were not considered for the purpose of this analysis.
This study was approved by the Western Institutional Review Board and was exempt from obtaining informed consent due to being a retrospective chart review. The data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.
Outcomes variables: As part of standard clinical protocol, patients completed the GHS and mRS assessments either by hand or interview at the time of their procedure as well as 30 days (target 28 – 45 days, n=349) and six months (target ±2 weeks) post procedure (n=326). Patient responses to each of the ten GHS items were scored on a scale from 1 to 5 (1=poor, 2=fair, 3=good, 4=very good, 5=excellent) (3).
These raw scores converted to a Global Mental Health (GMH) score and a Global Physical Health (GPH) score, each using four GHS items that pertained to mental or physical health. The t-scores ranged from 21.2 – 67.7 for GMH scores and 16.2 – 67.7 for GPH scores (3). A higher t-score indicated a better outcome. The average t-score for the general population of the United States is 50. Respondents who fall within one standard deviation of the mean will score a GMH t-score in the range of 41.1 – 59 or a GPH t-score within the range of 42.3 – 57.7 (3). The questionnaires provided to the subjects were in English. We excluded anyone who did not complete a 30 day questionnaire. Patients who were excluded were older and had a higher mRS score and lower GPH score at baseline, but they were similar in their pre-morbid reports on Anx/Dep when compared to our final analytical sample. GHS scores were not used to determine if the patient had Anx/Dep.
The mRS is a measure of functionality commonly used to evaluate patients after a stroke or cerebrovascular accident (1). The mRS is scored on a scale from 0 to 6 where 0 is no symptoms, 5 is confined to bed, and 6 is death. A simplified mRS questionnaire was used to improve reliability (1). For the purpose of this study, patients were split into groups where an mRS of 0-2 was considered an outcome with little to no disability and an mRS of 3 to 5 meant moderate to severe disability. Twelve patients were found to be deceased at their 30 day follow up (0.02%). They were excluded from this analysis because they did not have 30 day follow up information.
Length of hospital stay and days spent in the intensive care unit (ICU) were recorded from the medical record and are presented in Table 2. We also looked at hospital complications that were recorded in the medical record such as requiring re-intubation, urinary tract infections, and hyper- or hypoglycemia.
Statistical analysis: Univariate variables are presented as percentages and were analyzed using the Person Chi-Square and t-test. Multivariate logistic and linear regression analyses were used to evaluate dichotomous outcomes and all analyses were adjusted for age, gender, type and urgency of procedure, smoking, diabetes, and hypertension. In this sample specifically, type and urgency of procedure were not found to be statistically significant confounders. A p-value of p less than 0.05 is statistically significant. IBM/SPSS statistical package (Version 19.0) performed all statistical analyses.