High Variability Found in Mortality from Traumatic Brain Injuries

The mortality rates of traumatic brain injuries (TBI) could vary greatly depending on where the individual is treated.

A team, led by Guoyi Gao, MD, Department of Neurosurgery, Renji Hospital, School of Medicine, described the existing standard care procedures for patients with traumatic brain injuries and the ultimate outcomes in China.

Currently, large-scale studies are required to better characterize traumatic brain injuries and identify the most effective treatment approaches.

The prospective, multicenter, longitudinal, observational study dubbed the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) was conducted in 56 neurosurgical centers in China.

The investigators gathered data of patients who were admitted to the hospital with a clinical TBI diagnosis and an indication for CT. The researchers excluded patients who were discharged directly from the emergency room.

The investigators sought primary endpoints of survival on discharge. They applied prognostic analyses to identify predictors of mortality.

Variations in mortality were compared between different centers and provinces within China and mortality was compared with expected mortality, using estimates derived by the CRASH basic model.

Between December 2014 and August 2017, the investigators enrolled 13,627 patients with a traumatic brain injury in the registry. Ultimately, they analyzed data from 13,138 patients from 52 hospitals in 22 provinces.

The majority of patients—9782 (74%)—were male, with a median age of 48 years old.

The median Glasgow Coma Scale (GCS) score was 13. In addition, the leading cause of injury was road-traffic incident (n = 6548; 50%).

A total of 637 individuals (5%) in the study died, including 552 patients (20%) suffering from a severe traumatic brain injury.

The investigators identified age, GCS score, injury severity score, pupillary light reflex, CT findings (compressed basal cistern and midline shift ≥5 mm), presence of hypoxia, systemic hypotension, altitude higher than >500 m, and GDP per capita as factors significantly tied to survival in all patients with TBI.

However, they found variation in mortality in different centers and region. Overall, the expected 14-day mortality was 1116 (13%), but there were 544 (7%) deaths observed within 14 days (observed to expected ratio, 0.49; 95% CI, 0.45-0.53).

Earlier this year, researchers found repetitive head injuries during a professional football player’s career is linked to an increased risk of all-cause mortality.

Among the 13,912 players included in the pfCHII analysis, the median score was 32.63 (interquartile range, 13.71-66.12). A 1-log increase in pfCHII was linked to significant increases in hazard of death for the 1969-2017 seasons (HR, 2.02; 95% CI, 1.21-3.37; P = 0.01) after adjustment.

The quadratic pfCHII was also statistically significant (HR, 0.91; 95% CI, 0.85-0.98; P ­= 0.01).

This indicates the hazard of death increased at a decreasing rate while the pfCHII increased.

Ultimately, the take home point of the study based in China was that there is a lot of variability amongst the mortality rate of TBI patients depending on where they are hospitalized.

“The results show differences in mortality between centers and regions across China, which indicates potential for identifying best practices through comparative effectiveness research,” the authors wrote. “The risk factors identified in prognostic analyses might contribute to developing benchmarks for assessing quality of care.”

The study, “Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicenter, longitudinal, observational study,” was published online in The Lancet Neurology.