Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

Abstract

Purpose: To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers.Methods: This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient-and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers. Results:A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01). Conclusions:Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial betweencenter variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.

Characteristics, management and outcomes of patients with severe traumatic brain injury in Victoria, Australia compared to United Kingdom and Europe: A comparison between two harmonised prospective cohort studies

“…Also, we did not observe any substantial differences in outcome between Victoria, Australia, the UK and Europe, confirming the results of a recent study. (32) Although this could be the result of a homogenous standard of treatment in the three regions, this might also suggest that the differences in therapies may be discordant and urges the need for future studies that study the effect of these therapies in isolation. The IMPACT CT prognostic scheme accounts for only about a third of outcome variance, and outcomes in all three regions may have been affected by unmeasured confounders.…”

Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study

“…We specifically focused on patients who did not survive their ICU stay. In an earlier publication of Huijben et al [ 13 ], more information on the whole cohort of ICU patients was reported.…”

Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study

“…For example, a MOR of 2 for outcomes indicates that if two TBI patients with the same injury severity and characteristics presented to two random centers in our sample, one patient will have an over twofold probability of poor outcome. 9,10 Kaplan-Meier survival analysis was performed in 13098 patients with discharge or death time, with patients discharged alive treated as censored data at the time of discharge and subsequently multivariable mixed effect Cox proportional hazards regression was applied to identify the risk factors for survival. To assess for proportionality, we checked if the survival curves crossed for each variable.…”