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Original Investigation | Pacific Coast Surgical Association

Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

Aaron J. Dawes, MD1,2,3; Greg D. Sacks, MD, MPH1,2; H. Gill Cryer, MD, PhD1; J. Peter Gruen, MD4; Christy Preston, RN5; Deidre Gorospe, RN5; Marilyn Cohen, RN1; David L. McArthur, PhD, MPH6; Marcia M. Russell, MD1,3; Melinda Maggard-Gibbons, MD, MSHS1,3; Clifford Y. Ko, MD, MS, MSHS1,3 ; for the Los Angeles County Trauma Consortium
[+] Author Affiliations
1Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)
2Robert Wood Johnson Clinical Scholars Program, UCLA
3Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
4Department of Neurosurgery, University of Southern California, Los Angeles
5Emergency Medical Services Agency, County of Los Angeles Department of Health Services, Los Angeles, California
6Department of Neurosurgery, David Geffen School of Medicine, UCLA
JAMA Surg. 2015;150(10):965-972. doi:10.1001/jamasurg.2015.1678.
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Importance  Compliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of hospital quality. However, the association between hospital-level compliance rates and risk-adjusted clinical outcomes for patients with TBI remains poorly understood.

Objective  To examine whether hospital-level compliance with the Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy is associated with risk-adjusted mortality rates for patients with severe TBI.

Design, Setting, and Participants  All adult patients (N = 734) who presented to a regional consortium of 14 hospitals from January 1, 2009, through December 31, 2010, with severe TBI (ie, blunt head trauma, Glasgow Coma Scale score of <9, and abnormal intracranial findings from computed tomography of the head). Data analysis took place from December 2013 through January 2015. We used hierarchical mixed-effects models to assess the association between hospital-level compliance with Brain Trauma Foundation guidelines and mortality rates after adjusting for patient-level demographics, severity of trauma (eg, mechanism of injury and Injury Severity Score), and TBI-specific variables (eg, cranial nerve reflexes and findings from computed tomography of the head).

Main Outcomes and Measures  Hospital-level risk-adjusted inpatient mortality rate and hospital-level compliance with Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy.

Results  Unadjusted mortality rates varied by site from 20.0% to 50.0% (median, 42.6; interquartile range, 35.5-46.2); risk-adjusted rates varied from 24.3% to 56.7% (median, 41.1; interquartile range, 36.4-47.8). Overall, only 338 of 734 patients (46.1%) with an appropriate indication underwent placement of an intracranial pressure monitor and only 134 of 335 (45.6%) underwent craniotomy. Hospital-level compliance ranged from 9.6% to 65.2% for intracranial pressure monitoring and 6.7% to 76.2% for craniotomy. Despite widespread variation in compliance across hospitals, we found no association between hospital-level compliance rates and risk-adjusted patient outcomes (Spearman ρ = 0.030 [P = .92] for ICP monitoring and Spearman ρ = −0.066 [P = .83] for craniotomy).

Conclusions and Relevance  Hospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes in patients with severe TBI. Our results suggest that caution should be taken before using compliance with these measures as independent quality metrics. Given the complexity of TBI care, outcomes-based metrics, including functional recovery, may be more accurate than current process measures at determining hospital quality.

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Risk-Adjusted Mortality Rates by Hospital Performance on Quality Metrics

A, Hospitals according to their rates of intracranial pressure (ICP) monitor placement and risk-adjusted mortality. B, Hospitals according to their rates of craniotomy and risk-adjusted mortality.

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ICP onitoring is not a reliable, stand-alone QA indicator in TBI
Posted on July 22, 2015
Randall M Chesnut MD FACS FCCM FAANS
University of Washington Department of Neurological Surgery at Harborview Medical Center
Conflict of Interest: None Declared
Using process variables as QA indicators relies on the perceived strength of correlations that are rarely buttressed by RCT data suggesting causation. Our recent RCT on ICP monitoring suggests that ICP monitoring alone is unlikely to reliably covary with the spectrum of care that leads to improved outcomes1. This is not surprising, since, as with any monitor, it is what one does with the data that actually counts. Bulger et al found a correlation between ICP monitoring (“BTF Guidelines compliance”) but in the context of other strongly –linked covariates such as use of CT imaging and outcome but also showed confounded covariance with other indicators including neurosurgical consultation, intubation on admission, use of osmotic agents, hyperventilation, and ventriculostomy.2 They subsumed these variables under the rubric “aggressiveness” which probably better represents the theme of care leading to improved outcome. In aggregate, the BTF Guidelines strongly support aggressive TBI treatment, although their recommendations are limited by the fairly weak literature base. In this context, it appears naïve to assume that the presence of an ICP monitor alone reliably represents aggressive care, the point shown in the current paper. Although I agree with their results, the authours would do well to avoid confusing the trees for the forest in suggesting that the Guidelines have failed to improve hospital quality, as they did not actually test the Guidelines or, truly, Guidelines-compliance.

1. Chesnut RM, Temkin N, Carney N, et al. A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury. N Engl J Med. 2012;367:2471-2481.
2. Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ. Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med. 2002;30(8):1870-1876.
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