Marked reduction in mortality in patients with severe traumatic brain injury: Clinical article

Linda M. Gerber, Ya Lin Chiu, Nancy Carney, Roger Härtl, Jamshid Ghajar

Research output: Contribution to journalArticle

107 Citations (Scopus)

Abstract

Object. In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods. The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results. From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p <0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p <0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p <0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p <0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001). Conclusions. There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.

Original languageEnglish (US)
Pages (from-to)1583-1590
Number of pages8
JournalJournal of Neurosurgery
Volume119
Issue number6
DOIs
StatePublished - Dec 2013

Fingerprint

Guideline Adherence
Mortality
Intracranial Hypertension
Intracranial Pressure
Guidelines
Cerebrovascular Circulation
Trauma Centers
Traumatic Brain Injury
Cluster Analysis
Logistic Models
Regression Analysis
Morbidity

Keywords

  • Guidelines
  • Intracranial pressure monitoring
  • Mortality
  • Traumatic brain injury

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Marked reduction in mortality in patients with severe traumatic brain injury : Clinical article. / Gerber, Linda M.; Chiu, Ya Lin; Carney, Nancy; Härtl, Roger; Ghajar, Jamshid.

In: Journal of Neurosurgery, Vol. 119, No. 6, 12.2013, p. 1583-1590.

Research output: Contribution to journalArticle

Gerber, Linda M. ; Chiu, Ya Lin ; Carney, Nancy ; Härtl, Roger ; Ghajar, Jamshid. / Marked reduction in mortality in patients with severe traumatic brain injury : Clinical article. In: Journal of Neurosurgery. 2013 ; Vol. 119, No. 6. pp. 1583-1590.
@article{01d65aeccf7c4fe3802f543507c3b93c,
title = "Marked reduction in mortality in patients with severe traumatic brain injury: Clinical article",
abstract = "Object. In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods. The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results. From 2001 to 2009, the case-fatality rate decreased from 22{\%} to 13{\%} (p <0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95{\%} CI 0.39-0.70; p <0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56{\%} to 75{\%} (p <0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15{\%} to 48{\%} (p <0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42{\%} to 29{\%} (p = 0.0001). Conclusions. There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.",
keywords = "Guidelines, Intracranial pressure monitoring, Mortality, Traumatic brain injury",
author = "Gerber, {Linda M.} and Chiu, {Ya Lin} and Nancy Carney and Roger H{\"a}rtl and Jamshid Ghajar",
year = "2013",
month = "12",
doi = "10.3171/2013.8.JNS13276",
language = "English (US)",
volume = "119",
pages = "1583--1590",
journal = "Journal of Neurosurgery",
issn = "0022-3085",
publisher = "American Association of Neurological Surgeons",
number = "6",

}

TY - JOUR

T1 - Marked reduction in mortality in patients with severe traumatic brain injury

T2 - Clinical article

AU - Gerber, Linda M.

AU - Chiu, Ya Lin

AU - Carney, Nancy

AU - Härtl, Roger

AU - Ghajar, Jamshid

PY - 2013/12

Y1 - 2013/12

N2 - Object. In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods. The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results. From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p <0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p <0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p <0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p <0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001). Conclusions. There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.

AB - Object. In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods. The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results. From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p <0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p <0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p <0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p <0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001). Conclusions. There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.

KW - Guidelines

KW - Intracranial pressure monitoring

KW - Mortality

KW - Traumatic brain injury

UR - http://www.scopus.com/inward/record.url?scp=84889246650&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84889246650&partnerID=8YFLogxK

U2 - 10.3171/2013.8.JNS13276

DO - 10.3171/2013.8.JNS13276

M3 - Article

AN - SCOPUS:84889246650

VL - 119

SP - 1583

EP - 1590

JO - Journal of Neurosurgery

JF - Journal of Neurosurgery

SN - 0022-3085

IS - 6

ER -