Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study.

Adult Brain Injuries, Traumatic / surgery Diagnosis-Related Groups Hospitalization Humans Neurosurgery Prospective Studies

Journal

The Lancet. Neurology

ISSN: 1474-4465

Titre abrégé: Lancet Neurol

Pays: England

ID NLM: 101139309

Informations de publication

Date de publication:
05 2022

Historique:

received: 17 09 2021

revised: 19 12 2021

accepted: 17 01 2022

pubmed: 20 3 2022

medline: 20 4 2022

entrez: 19 3 2022

Statut: ppublish

Résumé

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development. We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation. Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49). Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices. National Institute for Health Research Global Health Research Group.

Sections du résumé

BACKGROUND

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Identifiants

DOI: 10.1016/S1474-4422(22)00037-0 PMID: 35305318

pubmed: 35305318

pii: S1474-4422(22)00037-0

doi: 10.1016/S1474-4422(22)00037-0

pii:

doi:

Types de publication

Journal Article Observational Study Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

Pagination

438-449

Investigateurs

Ghayur Abbas (G)

Omar Ibrahim Abdallah (OI)

Ahmed Abdel-Lateef (A)

Khalif Abdifatah (K)

Awfa Abdullateef (A)

Ruvini Abeygunaratne (R)

Mostafa Aboellil (M)

Abass Adam (A)

Robert Adams (R)

Amos Adeleye (A)

Augustine Adeolu (A)

Novan Krisno Adji (NK)

Nur Afianti (N)

Sudarsan Agarwal (S)

Ifeanyi Kene Aghadi (IK)

Paúl Martín Méndez Aguilar (PMM)

Syeda Rida Ahmad (SR)

Daniyal Ahmed (D)

Nafees Ahmed (N)

Haider Aizaz (H)

Yunus Kuntawi Aji (YK)

Alex Alamri (A)

Augusto Jacinto Mussindo Alberto (AJM)

Luis Alcocer Alcocer (LA)

Lesly Gonzales Alfaro (LG)

Amro Al-Habib (A)

Ahmad Alhourani (A)

Syed Muhammad Rafay Ali (SMR)

Fahad Alkherayf (F)

Ahmed AlMenabbawy (A)

Aliyah Alshareef (A)

Muhammad Adil S/O Aminullah (MAS)

Madeha Amjad (M)

Robson Luis Oliveira de Amorim (RLO)

Sathiaprabhu Anbazhagan (S)

Almir Andrade (A)

Waleed Antar (W)

Theophilus T K Anyomih (TTK)

Salah Aoun (S)

Tedy Apriawan (T)

Daniele Armocida (D)

Paul Arnold (P)

Miguel Arraez (M)

Temesgen Assefa (T)

Andres Asser (A)

S P Athiththan (SP)

Deepal Attanayake (D)

Maung Maung Aung (MM)

Allan Avi (A)

Victor Enrique Antolinez Ayala (VEA)

Mohammed Azab (M)

Gaousul Azam (G)

Mohd Azharuddin (M)

Olukemi Badejo (O)

Mohamed Badran (M)

Azam Ali Baig (AA)

Rehman Ali Baig (RA)

Ankur Bajaj (A)

Paul Baker (P)

Renu Bala (R)

Artur Balasa (A)

Ross Balchin (R)

James Balogun (J)

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Bharath Kumar Reddy Bandi (BKR)

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Antonio Belli (A)

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Chaymae Benyaiche (C)

Claudio Bernucci (C)

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Declaration of interests PH is supported by the National Institute for Health Research (Global Neurotrauma Research Group, Senior Investigator Award, Cambridge Biomedical Research Centre, and Brain Injury Medtech Co-operative) and the Royal College of Surgeons of England. All other authors declare no competing interests.