TY - JOUR
T1 - Compliance with evidence-based guidelines and interhospital variation in mortality for patients with severe traumatic brain injury
AU - Dawes, Aaron J.
AU - Sacks, Greg D.
AU - Cryer, H. Gill
AU - Gruen, J. Peter
AU - Preston, Christy
AU - Gorospe, Deidre
AU - Cohen, Marilyn
AU - McArthur, David L.
AU - Russell, Marcia M.
AU - Maggard-Gibbons, Melinda
AU - Ko, Clifford Y.
AU - Marin, Cynthia
AU - Petrik, Pavel
AU - Schneider, Laura
AU - Hinika, Gudata
AU - Cleek, Elizabeth
AU - Upperman, Jeffrey
AU - Hotz, Heidi
AU - Margulies, Daniel
AU - Murphy, Kimberly
AU - Hanpeter, David
AU - Tyler, Robin
AU - Putnam, Brant
AU - Thompson, Susan
AU - Obaid, Amal
AU - Cruz-Manglapus, Gilda
AU - Singh, Ranbir
AU - Thomas, Desiree
AU - Acker, Brian
AU - Crowley, Melanie
AU - Saad, Shawki
AU - Smith, Renee
AU - Shepherd, Tchaka
AU - Meier, Patricia
AU - Murray, James
AU - Navarrete, Sixta
AU - Demetriades, Demetrios
N1 - Publisher Copyright:
Copyright 2015 American Medical Association. All rights reserved.
Copyright:
Copyright 2015 Elsevier B.V., All rights reserved.
PY - 2015/10
Y1 - 2015/10
N2 - 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). MAINOUTCOMESAND 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.
AB - 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). MAINOUTCOMESAND 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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U2 - 10.1001/jamasurg.2015.1678
DO - 10.1001/jamasurg.2015.1678
M3 - Article
C2 - 26200744
AN - SCOPUS:84944735232
VL - 150
SP - 965
EP - 972
JO - JAMA Surgery
JF - JAMA Surgery
SN - 2168-6254
IS - 10
ER -