Neighborhood Deprivation is Associated With Hospital Length of Stay, Discharge Disposition, and Readmission Rates for Patients Who Survive Hospitalization With Traumatic Brain Injury.

BACKGROUND AND OBJECTIVES: Traumatic brain injury (TBI) is a leading cause of disability in the United States. Limited research exists on the influence of area-level socioeconomic status and outcomes after TBI. This study investigated the correlation between the Area Deprivation Index (ADI) and (1) 90-day hospital readmission rates, (2) facility discharge, and (3) prolonged (≥5 days) hospital length of stay (LOS). METHODS: Single-center retrospective review of adult (18 years or older) patients who were admitted for TBI during 2018 was performed. Patients were excluded if they were admitted for management of a chronic or subacute hematoma. We extracted relevant clinical and demographic data including sex, comorbidities, age, body mass index, smoking status, TBI mechanism, and national ADI. We categorized national ADI rankings into quartiles for analysis. Univariate, multivariate, and area under the receiver operating characteristic curve (AUROC) analyses were performed to assess the relationship between ADI and 90-day readmission, hospital LOS, and discharge disposition. RESULTS: A total of 523 patients were included in final analysis. Patients from neighborhoods in the fourth ADI quartile were more likely to be Black (P = .007), have a body mass index ≥30 kg/m2 (P = .03), have a Charlson Comorbidity Index ≥5 (P = .004), and have sustained a penetrating TBI (P = .01). After controlling for confounders in multivariate analyses, being from a neighborhood in the fourth ADI quartile was independently predictive of 90-day hospital readmission (odds ratio [OR]: 1.35 [1.12-1.91], P = .011) (model AUROC: 0.82), discharge to a facility (OR: 1.46 [1.09-1.78], P = .03) (model AUROC: 0.79), and prolonged hospital LOS (OR: 1.95 [1.29-2.43], P = .015) (model AUROC: 0.85). CONCLUSION: After adjusting for confounders, including comorbidities, TBI mechanism/severity, and age, higher ADI was independently predictive of longer hospital LOS, increased risk of 90-day readmission, and nonhome discharge. These results may help establish targeted interventions to identify at-risk patients after TBI.

Impact of preoperative mental health diagnosis on postoperative opioid use patterns in spine fusion surgery: A systematic literature review.

Opioids are frequently prescribed for patients undergoing procedures such as spinal fusion surgery for the management of chronic back pain. However, the association between a preoperative mental health illness, such as depression or anxiety, and opioid use patterns after spinal fusion surgery remain unclear. Therefore, we performed a systematic literature review in accordance with PRISMA guidelines to identify articles from the PubMed Database that analyzed the relationship between preoperative mental health illness and postoperative opioid usage after spinal fusion surgery on June 1, 2023. The Methodological Index for Nonrandomized Studies (MINORS) was utilized to evaluate the quality of included articles. Seven studies with 139,580 patients and a mean MINORS score of 18 ± 0.5 were included in qualitative synthesis. The most common spine surgery performed was lumbar fusion (59 %) and the mean age across studies ranged from 50 to 62 years. The range of postoperative opioid usage patterns analyzed ranged from 1 to 24 months. The majority of studies (6/7; 86 %) reported that a preoperative diagnosis of mental health illness was associated with increased opioid dependence after spinal fusion surgery. Preoperative use of opioids for protracted periods was shown to be associated with postoperative chronic opioid dependence. Consensus findings suggest that having a preoperative diagnosis of a mental health illness such as depression or anxiety is associated with increased postoperative opioid use after spinal fusion surgery. Patient comorbidities, including diagnoses of mental health illness, must be considered by the spine surgeon in order to reduce rates of postoperative opioid dependence.

Incidence of Sacroiliac Joint Pain Following Lumbar Fractures: A Retrospective-Cohort Study.

BACKGROUND: Sacroiliac joint (SIJ) pain commonly affects patients with low back pain and can arise from traumatic and degenerative causes. However, the incidence of SIJ pain following lumbar fractures is not well understood. METHODS: TriNetX, a national network of deidentified patient records, was retrospectively queried. The lumbar fracture cohort included 239,199 adults, while the no lumbar fracture group included 6,975,046 adults. Following a propensity-score match based on demographics and risk factors for SIJ, there were 239,197 patients in each cohort. The incidence of SIJ pain and clinical outcomes were analyzed from 1 day to 1 year following the index event. Moreover, the location and type of single-level lumbar fractures were reported. The incidence of SIJ pain for single-level fractures was compared using a χ2 goodness-of-fit. RESULTS: The lumbar fracture cohort was more likely to develop SIJ pain at 3 months (odds ratio [OR]: 5.3, 95% confidence interval [CI]: 4.8-5.9), 6 months (OR: 4.4, 95% CI: 4.1-4.8), and 1 year (OR: 3.9, 95% CI: 3.6-4.2) postfracture. Among single-level lumbar fractures, the incidence of SIJ pain at 1 month (P = 0.005), 6 months (P = 0.010), and 1 year (P = 0.003) varied significantly, with the highest incidence in the L5 cohort. CONCLUSIONS: Our findings suggest that lumbar fractures are a risk factor for developing SIJ pain. Moreover, the incidence of SIJ pain is greater following an L5 fracture than an L1 fracture. Further investigation is warranted to determine how the type and treatment of lumbar fractures affects the incidence of SIJ pain.

Outcomes After the Surgical Evacuation of Traumatic Acute Subdural Hematomas: The tASDH Risk Score.

BACKGROUND: Acute subdural hematoma (ASDH) is a common pathology following traumatic brain injury (TBI). There is sparse data on the prediction of clinical outcomes following traumatic ASDH (tASDH) evacuation. We investigated prognosticators of outcome following evacuation of tASDHs, with subset analysis in a cohort of octogenarians. We developed a scoring system for stratifying the risk of in-hospital mortality for patients undergoing tASDH evacuation. METHODS: A retrospective chart review was performed to identify all patients who underwent tASDH evacuation. Baseline clinical and demographic data including age, traumatic brain injury mechanism, admission Glasgow Coma Scale (GCS), and Rotterdam computed tomography Scale (RCS) were collected. In-hospital outcomes such as mortality and discharge disposition were collected. A scoring system (tASDH Score) which incorporates RCS (1-2 points), admissions GCS (0-1 points), and age (0-1 point) was created to predict the risk of in-hospital mortality following tASDH evacuation. RESULTS: Being an octogenarian (OR = 6.91 [2.20-21.71], P = 0.0009), having a GCS of 9-12 (OR = 1.58 [1.32-4.12], P = 0.027) or 3-8 (OR = 2.07 [1.41-10.38], P = 0.018), and having an RCS of 4-6 (OR = 3.49 [1.45-8.44], P = 0.0055) were independently predictive of in-hospital mortality. The in-hospital mortality rate was lower for those with a tASDH score of 1 (10%), compared to those with a score of 2 (12%), 3 (42%), and 4 (100%). CONCLUSIONS: Octogenarians with an RCS of 4-6 and an admission GCS <13 have a high risk of mortality following tASDH evacuation. Knowledge of which patients are unlikely to survive ASDH evacuation may help guide neurosurgeons in prognostication and goals of care discussions.

Diffuse Axonal Injury Pattern Predicts Timing of In-Hospital Neurologic Recovery: A Retrospective Case Series.

BACKGROUND: Diffuse axonal injury (DAI) is a devastating traumatic neurologic injury with variable prognosis. Although outcomes such as mortality have been described, the time course of neurologic progression is poorly understood. We investigated the association between DAI neuroanatomic injury pattern and neurologic recovery timing. METHODS: A retrospective review of our institution's trauma registry identified patients diagnosed with DAI from 2017-2021. The neuroradiologist's review of a head computed tomography scan was used to score DAI severity. In-hospital neurologic examinations were reviewed, and the Glasgow Coma Scale (GCS) was calculated for all patients throughout the hospital stay. Categorical variables were analyzed using the Fisher exact test, and continuous variables were analyzed using the Kruskal-Wallis test. RESULTS: Nineteen DAI patients (grade 1 = 8; grade 2 = 1; grade 3 = 10) were included (mean age 31 years, 79% male). Mean Rotterdam computed tomography score, Injury Severity Scale, and admission GCS were comparable across DAI grades. Mean time in days to follow commands was shorter for those with grade 1 DAI (9.3) compared with grade 2 (17 days) or grade 3 (19 days) DAI (P = 0.02). Throughout hospitalization, patients with grade 1 DAI had higher motor (P = 0.006), eye (P = 0.001), and total GCS (P = 0.011) scores compared with those with grade 2 or 3 DAI. At the time of discharge, total GCS and the frequency of command following was similar across DAI grades. CONCLUSIONS: Patients with grade 1 DAI demonstrated the fastest short-term neurologic recovery, although final discharge neurologic examination was comparable across DAI grades. DAI classification can provide useful short-term prognostic information regarding in-hospital neurologic improvement.

Canal narrowing in adult patients with cervical spinal cord injury without computed tomography evidence of trauma.

PURPOSE: Cervical spinal cord injury can be a particularly devastating sequela of trauma. The purpose of this study was to describe the imaging findings of adult patients with cervical spinal cord injury without computed tomography evidence of trauma (SCIWOCTET). METHODS: All adult patients (≥18 years) treated for acute cervical SCIWOCTET at a single Level I adult trauma center over an eight-year period were retrospectively identified. CT imaging was evaluated for degenerative changes narrowing the midsagittal canal diameter (SCD) of the cervical spine and relative congenital cervical stenosis (CCS; congenital narrowing of the SCD <13 mm). Magnetic resonance imaging (MRI) scans were evaluated for signal intensity change (SIC) suspicious for cord edema/contusion as well as ligamentous injury, hemorrhage, and epidural hematoma. RESULTS: Ninety-six patients with cervical SCIWOCTET met inclusion criteria. The most common mechanism of injury was fall from standing (47.9%). On CT, 86 patients (89.6%) had CCS. Degenerative changes were present in 95 patients (99.0%). In 98/99 patients (99.0%), the point of narrowest cervical SCD was ≤8 mm. On MRI, 79 patients (82.3%) demonstrated signal intensity change (SIC) indicative of cord edema/contusion, while 16 (16.7%) had ligamentous injury. Intramedullary cord hemorrhage was seen in two patients (2.1%) and epidural hematoma in three (3.1%). CONCLUSION: Degenerative changes or CCS may narrow the minimum cervical SCD beyond the threshold at which low-energy trauma results in C-SCI. Adult patients with cervical spinal stenosis, whether congenital and/or degenerative, and neurologic findings referable to the cervical spine should be assessed for C-SCI.

Percutaneous vertebral augmentation for acute traumatic vertebral Fractures: A TQIP database study.

Patients with vertebral fractures may be treated with percutaneous vertebroplasty (VP) and kyphoplasty (KP) for pain relief. Few studies examine the use of VP and KP in the setting of an acute trauma. In this study, we describe the current use of VP/KP in patients with acute traumatic vertebral fractures. All patients in the ACS Trauma Quality Improvement Program (TQIP) 2016 National Trauma Databank with severe spine injury (spine AIS ≥ 3) met inclusion criteria, including patients who underwent PVA. Logistic regression was used to assess patient and hospital factors associated with PVA; odds ratios and 95 % confidence intervals are reported. 20,769 patients met inclusion criteria and 406 patients received PVA. Patients aged 50 or older were up to 6.73 (2.45 - 27.88) times more likely to receive PVA compared to younger age groups and women compared to men (1.55 [1.23-1.95]). Hospitals with a Level II trauma center and with 401-600 beds were more likely to perform PVA (2.07 [1.51-2.83]) and (1.82 [1.04-3.34]) respectively. African American patients (0.41 [0.19-0.77]), isolated trauma (0.64 [0.42-0.96]), neurosurgeon group size > 6 (0.47 [0.30-0.74]), orthopedic group size > 10, and hospitals in the Northeastern and Western regions of the U.S. (0.33 [0.21-0.51] and 0.46 [0.32-0.64]) were less likely to be associated with PVA. Vertebroplasty and kyphoplasty use for acute traumatic vertebral fractures significantly varied across major trauma centers in the United States by multiple patient, hospital, and surgeon demographics. Regional and institutional practice patterns play an important role in the use of these procedures.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Novel application of the Rotterdam CT score in the prediction of intracranial hypertension following severe traumatic brain injury.

OBJECTIVE: Severe traumatic brain injury (TBI) is associated with intracranial hypertension (ICHTN). The Rotterdam CT score (RS) can predict clinical outcomes following TBI, but the relationship between the RS and ICHTN is unknown. The purpose of this study was to investigate clinical and radiological factors that predict ICHTN in patients with severe TBI. METHODS: The authors performed a single-center retrospective review of patients who, between 2018 and 2021, had an intracranial pressure (ICP) monitor placed following TBI. Radiological and clinical characteristics related to the TBI and ICP monitoring were collected. The main outcome of interest was ICHTN, which was a dichotomous outcome (yes or no) defined on a per-patient basis as an ICP > 22 mm Hg that persisted for at least 5 minutes and required an escalation of treatment. ICHTN included both elevated opening pressure on initial monitor placement and ICP elevations later during hospitalization. Multivariate logistic regression was performed to determine variables associated with ICHTN. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC). RESULTS: Seventy patients with severe TBI and an ICP monitor were included in this study. There was a predominance of male patients (94.0%), and the mean patient age was 40 years old. Most patients (67%) had an intraparenchymal catheter placed, whereas 33% of patients had a ventriculostomy catheter placed. In the multivariate logistic regression analysis, the RS was an independent predictor of ICHTN (OR 2.0, 95% CI 1.2-3.5, p = 0.014). No instances of ICHTN were observed in patients with an RS of 2 or less and no sulcal effacement. The AUROC of the RS and sulcal effacement was higher than the AUROC of the RS alone for predicting ICHTN (0.76 vs 0.71, p = 0.003, z-test). CONCLUSIONS: The RS was predictive of ICHTN in patients with severe TBI, and the diagnostic accuracy of the model was improved with the inclusion of sulcal effacement at the vertex on CT of the head. Patients with a low RS and no sulcal effacement are likely at low risk for the development of ICHTN.

Feasibility of gabapentin as an intervention for neurorecovery after an acute spinal cord injury: Protocol.

Introduction: This protocol is describing the first ever prospective, mock-efficacy, dose exploration trial design testing the feasibility of administering gabapentin in the acute setting as an intervention for neurorecovery. Gabapentin is an FDA-approved medication for treating seizures and postherpetic neuralgia and is used broadly off-label for neuropathic pain management for many conditions, including spinal cord injury. Emerging data suggests that when given early after spinal cord injury onset and in low-medium doses, gabapentin may have properties that promote recovery of neurological function. The objective of this trial is to assess the feasibility of conducting an efficacy trial in which gabapentin is started early after injury, is restricted in its dose, and is not used for pain management. Methods and analysis: Forty-two people aged 18 years or older with any level and any severity of spinal cord injury induced by a trauma will be enrolled, randomized, and have the first dose of study medication by 120 h post-injury onset. Participants will be randomly assigned to one of three groups: 600, 1,800 mg/day gabapentin, or placebo. Study medication will be given for a 90-day duration. Blinded assessments will be obtained at 7 days post-injury (baseline), 30 days post-injury (interim), after the 90-day treatment duration/approximately 3 months post-injury (end of treatment), and at 6 months post-injury (end of study). The key analysis parameters will evaluate feasibility of recruitment of target population, delivery of drug treatment protocol, maintenance of blinding, and retention of participants. Discussion: Outputs from this trial will inform research and clinical practice on the effects of manipulating gabapentin for non-pain management purposes in the acute setting and will guide the development of a properly powered efficacy trial of gabapentin as an intervention for neurorecovery in spinal cord injury. Ethics and dissemination: The study was approved by the MetroHealth Institutional Review Board (IRB21-00609) and registered at clinicaltrials.gov prior to enrolling any participants. Dissemination will include peer-reviewed publications, presentations at professional conferences and in the community, and through other healthcare and public venues. Clinical trial registration: www.ClinicalTrials.gov, identifier: NCT05302999; protocol version 1.1 approved 05/23/2022. Trial funding: National Institute on Disability, Independent Living and Rehabilitation Research.

Failure of Conservatively Managed Traumatic Vertebral Compression Fractures: A Systematic Review.

BACKGROUND: Most vertebral compression fractures (VCFs) are successfully managed conservatively; however, some patients fail conservative management and require further surgical treatment. We sought to identify significant variables that contribute to progressive vertebral collapse in nonoperative treatment of traumatic VCFs. METHODS: A systematic review identified original research articles of conservatively managed VCFs secondary to trauma from inception to September 2021. Articles with patients treated with initial nonoperative therapy, AO type A0, A1, and A2 fractures, risk factor analysis, >10 patients, and vertebral fracture secondary to trauma were included. Articles with pediatric patients, burst fractures or AO type A3 and A4 fractures, vertebral fractures secondary to neoplasm or infectious disease, and operative versus nonoperative treatment comparations were excluded. Failure of nonoperative treatment was defined as salvage surgery/vertebral augmentation, progressive kyphosis, chronic pain, or functional disability. RESULTS: Of 3877 articles identified, 6 articles were included with 582 patients with conservatively managed thoracolumbar VCFs. Treatment failure was reported in 102 (17.5%) patients. Of 102 treatment failures, 37 (36.3%) were due to subsequent VCF, 33 (32.4%) were due to back pain or functional disability at follow-up, and 32 (31.4%) were due to increased compression rate or kyphotic deformity at follow-up. Prior VCF was a significant variable in 2 (33.3%) of 6 studies. Age, lumbar bone mineral density, segmental Cobb angle, and vertebral height loss were each described as a significant factor in 1 (16.7%) of the 6 studies. CONCLUSIONS: Identifying patients who are at risk for treatment failure may help select patients who would benefit from close clinical follow-up or early surgical/procedural intervention.

Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study.

Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.

Energy conservation characterizes sleep in sharks.

Sharks represent the earliest group of jawed vertebrates and as such, they may provide original insight for understanding the evolution of sleep in more derived animals. Unfortunately, beyond a single behavioural investigation, very little is known about sleep in these ancient predators. As such, recordings of physiological indicators of sleep in sharks have never been reported. Reduced energy expenditure arising from sustained restfulness and lowered metabolic rate during sleep have given rise to the hypothesis that sleep plays an important role for energy conservation. To determine whether this idea applies also to sharks, we compared metabolic rates of draughtsboard sharks (Cephaloscyllium isabellum) during periods ostensibly thought to be sleep, along with restful and actively swimming sharks across a 24 h period. We also investigated behaviours that often characterize sleep in other animals, including eye closure and postural recumbency, to establish relationships between physiology and behaviour. Overall, lower metabolic rate and a flat body posture reflect sleep in draughtsboard sharks, whereas eye closure is a poorer indication of sleep. Our results support the idea for the conservation of energy as a function of sleep in these basal vertebrates.

Viscoelastic Hemostatic Assays and Outcomes in Traumatic Brain Injury: A Systematic Literature Review.

BACKGROUND: Coagulopathy in traumatic brain injury (TBI) occurs frequently and is associated with poor outcomes. Conventional coagulation assays (CCA) traditionally used to diagnose coagulopathy are often not time sensitive and do not assess complete hemostatic function. Viscoelastic hemostatic assays (VHAs) including thromboelastography and rotational thromboelastography provide a useful rapid and comprehensive point-of-care alternative for identifying coagulopathy, which is of significant consequence in patients with TBI with intracranial hemorrhage. METHODS: A systematic review was performed in accordance with PRISMA guidelines to identify studies comparing VHA with CCA in adult patients with TBI. The following differences in outcomes were assessed based on ability to diagnose coagulopathy: mortality, need for neurosurgical intervention, and progression of traumatic intracranial hemorrhage (tICH). RESULTS: Abnormal reaction time (R time), maximum amplitude, and K value were associated with increased mortality in certain studies but not all studies. This association was reflected across studies using different statistical parameters with different outcome definitions. An abnormal R time was the only VHA parameter found to be associated with the need for neurosurgical intervention in 1 study. An abnormal R time was also the only VHA parameter associated with progression of tICH. Overall, many studies also reported abnormal CCAs, mainly activated partial thromboplastin time, to be associated with poor outcomes. CONCLUSIONS: Given the heterogenous nature of the available evidence including methodology and study outcomes, the comparative difference between VHA and CCA in predicting rates of neurosurgical intervention, tICH progression, or mortality in patients with TBI remains inconclusive.

Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures. CONCLUSIONS: Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States.

BACKGROUND: Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. METHODS: All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. RESULTS: 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. CONCLUSIONS: Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.

BACKGROUND: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. METHODS: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). RESULTS: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSION: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. LEVEL OF EVIDENCE: Epidemiological, level III; Care management/Therapeutic level III.