OBJECTIVES: Delayed cerebral ischemia (DCI) occurs in 20% to 50% of patients with aneurysmal subarachnoid hemorrhage (aSAH) and is associated with cerebral infarction, functional disability, as well as death. This study quantified the benefit-risk trade-offs that clinicians are willing to make when evaluating the use of new endothelin-1 receptor antagonists (ERAs) for reducing the risk of DCI after aSAH.

METHODS: An online best-worst choice experiment (BW-CE) was completed by neurologists, intensive care physicians, and neurosurgeons in the US and UK. The design of the BW-CE was based on a feasibility assessment, telephone interviews, a qualitative pilot and a quantitative pilot. Within the BW-CE, clinicians made trade-offs between the likelihood of DCI and the probability of lung complications, hypotension, and anemia. The presented patient scenario assumed a Glasgow Coma Scale score of 13 and Fisher grade I. A correlated mixed logit model was used for analysis. Relative attribute importance (RAI) scores with associated highest density intervals (HDIs) and maximum acceptable risks (MAR) of DCI were obtained.

RESULTS: The BW-CE was completed by 350 clinicians (116 neurologists, 129 intensive care physicians, and 105 neurosurgeons). Reducing the likelihood of DCI (RAI = 56.5% [HDI, 53.6-59.5%]) was most important to clinicians, followed by avoiding the risks of lung complications (RAI = 29.6% [HDI, 27.1-32.3%]), hypotension (RAI = 9.2% [HDI, 7.5-10.8%]), and anemia (RAI = 4.7% [HDI, 3.7-5.8%). Clinicians expected the likelihood of DCI to decrease by ≥8.1% to accept a 20% increase in the risk of lung complications, by ≥2.4% for a 20% increase in the risk of hypotension, and by ≥1.2% for a 20% increase in the risk of anemia.

CONCLUSIONS: The study findings emphasize the importance of DCI as an endpoint and suggests that clinicians may value the use of ERAs for the medical management of aSAH post-aneurysm repair.