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Published on: August 16, 2019
Socioeconomic correlates of decompressive craniectomy outcomes for pediatric traumatic brain injury: a
Cesar Ramirez1, Ankitha Iyer2, Brandon Hoglund3
1Sam Houston State College of Osteopathic Medicine, Huntsville, TX, USA; Department of Neurosurgery, New York University, New York City, NY, USA.
Insights
Socioeconomic factors significantly impact pediatric decompressive craniectomy (DC) outcomes in low-resource settings. Higher population density and fewer hospital beds correlate with worse mortality rates for pediatric traumatic brain injury patients undergoing DC.
Area of Science:
- Neurosurgery
- Global Health
- Pediatric Traumatic Brain Injury
Background:
- Pediatric traumatic brain injury (TBI) is a significant concern in low- and middle-income countries (LMICs).
- Decompressive craniectomy (DC) is a critical intervention for severe TBI unresponsive to medical management.
- Existing guidelines for pediatric TBI lack comprehensive data on socioeconomic influences in resource-limited environments.
Purpose of the Study:
- To systematically review and analyze socioeconomic determinants affecting the success of DC in pediatric TBI patients.
- To identify barriers and factors influencing DC outcomes in resource-poor settings.
- To inform the modification of TBI guidelines for diverse global communities.
Main Methods:
- A PRISMA-adherent systematic review of four databases identified studies on pediatric DC outcomes.
- Data on mortality and functional status were extracted from 39 studies across 17 countries.
- Multivariable meta-regression analysis correlated epidemiological metrics (e.g., HDI, population density, hospital beds) with patient outcomes.
Main Results:
- Factors significantly correlated with increased mortality included higher population density, LMIC status, and higher rates of underweight children.
- Lower Human Development Index (HDI), lower school enrollment, and fewer hospital beds were also associated with worse outcomes.
- Postoperative Glasgow Outcome Scale (GOS) was not significantly associated with any evaluated epidemiological covariates.
Conclusions:
- Socioeconomic determinants are critical predictors of DC success in pediatric TBI.
- High population density and limited hospital beds in low-resource, high-volume settings are strongly linked to poorer patient outcomes.
- These findings underscore the need for context-specific TBI management strategies in LMICs.
Introduction:
Low- and middle-income countries experience high pediatric traumatic brain injury rates. A decompressive craniectomy (DC) is a viable option for patients who are unresponsive to medical management. In 2019, the AANS Joint Section for Neurotrauma developed guidelines for pediatric TBI; however, the literature regarding socioeconomic factors that influence the success rate of DC in resource-poor environments remains sparse. Identification of these barriers is important to modify appropriate guidelines for these communities.
Methods:
A PRISMA-adherent systematic review of four databases was performed to identify all primary articles investigating outcomes following DC in pediatric patients. Data were extracted for study features and primary outcomes including mortality and postoperative functional status. Socioeconomic epidemiological metrics, including poverty, population density, and health outcomes, were obtained from the United Nations and World Bank. A multivariable meta-regression analysis was performed to evaluate epidemiological factors influencing the pooled mortality and GOS estimates.
Results:
Data from 39 studies, spanning 17 unique countries were abstracted. The mean age of patients in LMIC undergoing DC was younger, mean 4.74 (sD = 2.76) vs. mean 9.37 (sD = 3.52). Factors correlated with mortality rate included Human Development Index (HDI) (B (SE) = -2.33 (1.02), p = 0.022), population density (0.798 (0.188), p < 0.001), percent of urban population (-0.02 (0.007), p = 0.006), percent of underweight population under 5 years of age (0.028 (0.011), p = 0.010), school enrollment (-0.018 (0.006), p = 0.006), LMIC status (0.83 (0.323), p = 0.010), and the number of hospital beds (-0.12 (0.039), p = 0.002). Post-operative GOS was not associated with any epidemiological covariates.
Conclusion:
Socioeconomic determinants predict the success rate of DC in pediatric traumatic brain injury. Population density and the number of hospital beds having the strongest correlation to mortality rate indicate that low-resource, high-volume communities suffer from worse outcomes post-DC.
