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Published on: March 26, 2019
Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic
Aaron J Dawes1, Greg D Sacks2, H Gill Cryer3
1Department of Surgery, David Geffen School of Medicine, UCLA (University of California, Los Angeles)2Robert Wood Johnson Clinical Scholars Program, UCLA3Department of Surgery, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.
Insights
Hospital adherence to traumatic brain injury (TBI) guidelines for intracranial pressure monitoring and craniotomy showed no association with patient mortality. Current compliance metrics may not accurately reflect hospital quality for severe TBI care.
Area of Science:
- Neurosurgery
- Healthcare Quality Improvement
- Trauma Care
Background:
- Evidence-based guidelines aim to standardize care for severe traumatic brain injury (TBI).
- Hospital compliance with guidelines like those from the Brain Trauma Foundation is proposed as a quality marker.
- The relationship between adherence to TBI guidelines and actual patient outcomes is not well understood.
Purpose of the Study:
- To determine if hospital-level compliance with guidelines for intracranial pressure monitoring and craniotomy is linked to risk-adjusted mortality in severe TBI patients.
- To evaluate the utility of guideline compliance as a quality indicator in TBI care.
Main Methods:
- A study analyzed data from 734 adult patients with severe TBI across 14 hospitals between 2009 and 2010.
- Hierarchical mixed-effects models were used to assess the association between hospital compliance rates and mortality.
- Adjustments were made for patient demographics, injury severity, and TBI-specific clinical factors.
Main Results:
- Hospital compliance with guidelines for intracranial pressure monitoring (46.1%) and craniotomy (45.6%) varied significantly.
- No statistically significant association was found between hospital-level guideline compliance rates and risk-adjusted mortality.
- Compliance rates ranged widely, from 9.6% to 65.2% for ICP monitoring and 6.7% to 76.2% for craniotomy.
Conclusions:
- Hospital adherence to severe TBI guidelines for ICP monitoring and craniotomy shows minimal association with patient outcomes.
- Using guideline compliance as a sole quality metric for TBI care may be misleading.
- Outcomes-based measures, potentially including functional recovery, may offer a more accurate assessment of hospital quality in TBI management.
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.
