Pragmatic sedation strategies to prevent secondary brain injury in low-resource settings.

Traumatic brain injury is the alteration in brain function due to an external force. It is common and affects millions of people worldwide annually. The World Health Organization estimates that 90% of global deaths caused by injuries occur in low- and middle-income countries, with traumatic brain injury contributing up to half of these trauma-related deaths. Patients with traumatic brain injury in low- and middle-income countries have twice the odds of dying compared with their counterparts in high-income countries. Sedation is a key element of care in the management of traumatic brain injury, used for its neuroprotective effects and to prevent secondary brain injury. While sedatives have the potential to improve outcomes, they can be challenging to administer and have potentially dangerous complications. Sedation in low-resource settings should aim to be effective, safe, affordable and feasible. In this paper, we summarise the indications for sedation in traumatic brain injury, the choice of sedative drugs and the pragmatic management and monitoring of sedated traumatic brain injury patients in low-resource settings.

Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment.

OBJECTIVE: To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI). DESIGN: Retrospective matched cohort study. SETTING: IQVIA Integrated Data Warehouse. PARTICIPANTS: People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis. RESULTS: People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only. CONCLUSIONS: People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.

The Burden of Traumatic Brain Injury in Sub-Saharan Africa: A Scoping Review.

BACKGROUND: Despite the growing incidence of traumatic brain injury (TBI) in Sub-Saharan Africa, there is yet to be a study to map the current burden of the disease on the continent. This scoping review aims to outline the literature on TBI. METHODS: This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews. A search string was developed to identify studies relating to TBI epidemiology, management, and outcomes. The search was applied to Medline, Embase, and Global Medicus Index. RESULTS: In total, 107 studies were included in the final analysis. More than one half originated from South Africa. Seventy-five studies were published in 2013 or later. Studies recruited a median of 115 patients: 83.5 male and 31 female. TBI affected all age groups (range = 0-105 years) and sexes but was more common among young males aged 20-40. Road traffic accidents caused TBI in a median of 71 patients. Other major causes included assault (median = 39.5) and falls (median = 12.5). Craniectomies were the most commonly reported surgical treatment (18.7%) followed by burr holes (7.5%). Four studies (3.7%) reported delays in seeking neurotrauma care, with delays in reaching a neurotrauma facility and delays in receiving care being reported in 15 studies (14%) each. Glasgow Outcome Scale score was reported in 28 (26.1%) studies, whereas quality of life measures were reported in 2 (1%). Younger age was associated with favorable outcomes. CONCLUSIONS: There is an increased need for TBI research, education, and training in Sub-Saharan Africa. This will aid stakeholders in optimizing patient management and outcome.

Assessing the Cost Burden of Pediatric Neurosurgery in Kaduna, Nigeria.

BACKGROUND: Few studies have evaluated the cost burden borne by neurosurgical patients in the developing world and their potential implications for efficient and effective delivery of care. This study aims to assess the cost associated with obtaining pediatric neurosurgical care in a hospital in Kaduna. METHODS: All patients younger than 15 years who had a neurosurgical operation from July to December 2019 were included in the study. The characteristics of the patients were obtained using a proforma while the cost data were retrieved from the accounts unit of the hospital. The direct cost was obtained from the billing records of the hospital. Indirect cost was obtained using a questionnaire. The data obtained were analyzed using SPSS version 25 for Windows. RESULTS: A total of 27 patients were included in the study with a mean age of 7.2 years and a standard deviation of 4.95 years. The 2 most common procedures done were craniotomy for trauma and ventriculoperitoneal shunt insertion for hydrocephalus. The mean total cost of a neurosurgical procedure was $895.99. Intensive care unit length of stay was found to have a significant influence on the direct cost. The cost of surgery and investigation were the main contributors to the total cost of care with a mean of $618.3 and a standard deviation of $248.67. CONCLUSIONS: The mean cost of pediatric neurosurgical procedures in our setting is $895.99, which is 40.18% of our gross domestic product per capita. The main drivers of cost are the cost of operation, investigations, and intensive care unit length of stay.

Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial).

BACKGROUND: The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation. METHODS: In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive. RESULTS: A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9). CONCLUSION: Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

Costs of Nonfatal Traumatic Brain Injury in the United States, 2016.

BACKGROUND: Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity. RESEARCH DESIGN: This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity. RESULTS: The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid. CONCLUSIONS: This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.

Predicting the Individual Treatment Effect of Neurosurgery for Patients with Traumatic Brain Injury in the Low-Resource Setting: A Machine Learning Approach in Uganda.

Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). In these low-resource settings, effective triage of patients with TBI-including the decision of whether or not to perform neurosurgery-is critical in optimizing patient outcomes and healthcare resource utilization. Machine learning may allow for effective predictions of patient outcomes both with and without surgery. Data from patients with TBI was collected prospectively at Mulago National Referral Hospital in Kampala, Uganda, from 2016 to 2019. One linear and six non-linear machine learning models were designed to predict good versus poor outcome near hospital discharge and internally validated using nested five-fold cross-validation. The 13 predictors included clinical variables easily acquired on admission and whether or not the patient received surgery. Using an elastic-net regularized logistic regression model (GLMnet), with predictions calibrated using Platt scaling, the probability of poor outcome was calculated for each patient both with and without surgery (with the difference quantifying the "individual treatment effect," ITE). Relative ITE represents the percent reduction in chance of poor outcome, equaling this ITE divided by the probability of poor outcome with no surgery. Ultimately, 1766 patients were included. Areas under the receiver operating characteristic curve (AUROCs) ranged from 83.1% (single C5.0 ruleset) to 88.5% (random forest), with the GLMnet at 87.5%. The two variables promoting good outcomes in the GLMnet model were high Glasgow Coma Scale score and receiving surgery. For the subgroup not receiving surgery, the median relative ITE was 42.9% (interquartile range [IQR], 32.7% to 53.5%); similarly, in those receiving surgery, it was 43.2% (IQR, 32.9% to 54.3%). We provide the first machine learning-based model to predict TBI outcomes with and without surgery in LMICs, thus enabling more effective surgical decision making in the resource-limited setting. Predicted ITE similarity between surgical and non-surgical groups suggests that, currently, patients are not being chosen optimally for neurosurgical intervention. Our clinical decision aid has the potential to improve outcomes.

A Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update.

OBJECTIVES: To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation. DATA SOURCES: Medline (PubMed), SCOPUS, Web of Science, and the gray literature were searched for relevant articles about amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury. STUDY SELECTION: Relevant articles (N=106) were included. DATA EXTRACTION: Two investigators independently reviewed articles and selected relevant articles for inclusion. Quality grading was performed using the Methodological Evaluation of Observational Research Checklist and Newcastle-Ottawa Quality Assessment Form. DATA SYNTHESIS: The prevalence of back pain in the past 3 months was 33.9% among community-dwelling adults, and patients with back pain contribute $365 billion in all-cause medical costs. Osteoarthritis is the next most prevalent condition (approximately 10.4%), and patients with this condition contribute $460 billion in all-cause medical costs. These 2 conditions are the most prevalent and costly (medically) of the illnesses explored in this study. Stroke follows these conditions in both prevalence (2.5%-3.7%) and medical costs ($28 billion). Other conditions may have a lower prevalence but are associated with relatively higher per capita effects. CONCLUSIONS: Consistent with previous findings, back pain and osteoarthritis are the most prevalent conditions with high aggregate medical costs. By contrast, other conditions have a lower prevalence or cost but relatively higher per capita costs and effects on activity and work. The data are extremely heterogeneous, which makes anything beyond broad comparisons challenging. Additional information is needed to determine the relative impact of each condition.

A population-based sex-stratified study to understand how health status preceding traumatic brain injury affects direct medical cost.

OBJECTIVE: To understand how pre-injury health status present five-years preceding traumatic brain injury (TBI) affects direct medical cost two years post-injury. METHODS: Patients age ≥19 years in the emergency department (ED) or acute care for a TBI between April 1, 2007 and March 31, 2014 in Ontario, Canada (N = 55,669) were identified from population-based health administrative data. Forty-three factors of pre-injury health status (i.e., comorbidities and personal, social, and environmental factors) that were internally validated for the TBI population were assessed in this study. The outcome of interest was direct medical cost within two years of discharge. Sex-specific multivariable linear regressions were conducted to understand the associations between direct medical cost within two years of discharge and pre-injury health status. RESULTS: Patients who received care in the ED (81.9% of total sample) incurred a median cost of $2,492/male patient (average $12,342/patient) and $3,508/female patient (average $65,285/patient) within two years of injury; 37 pre-injury factors were significantly associated with increased direct medical costs. Patients who first received care for their TBI in acute care (18.1%) incurred a median cost of $25,081/male patient (average $63,060/patient) and $30,277/female patient (average $65,285/patient) within two years of injury; 21 factors were significantly associated with increased direct medical costs. Among more prevalent factors, those associated with increased medical cost by at least 50% included mental health disorders, substance abuse, disorders or medical conditions frequently observed among the elderly, cardiovascular disorders, stroke and emergencies involving the brain, metabolic disorders and abdominal symptoms, conditions and symptoms of abdomen and pelvis, genitourinary disorders and disorders of prostate, and pulmonary abdominal and other emergencies. CONCLUSIONS: Direct medical costs two years post-TBI differed significantly between patients with and without adverse pre-existing health status. Interdisciplinary teams to promote early identification of pre-existing health conditions and appropriate management and integration of these conditions in TBI care across the continuum of healthcare may be opportunities to reduce direct medical costs post-injury.

One-year costs of intensive care in pediatric patients with traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is a major cause of death and disability in the pediatric population. The authors assessed 1-year costs of intensive care in pediatric TBI patients. METHODS: In this retrospective multicenter cohort study of four academic ICUs in Finland, the authors used the Finnish Intensive Care Consortium database to identify children aged 0-17 years treated for TBI in ICUs between 2003 and 2013. The authors reviewed all patient health records and head CT scans for admission, treatment, and follow-up data. Patient outcomes included functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4-5) and death within 6 months. Costs included those for the index hospitalization, rehabilitation, and social security up to 1 year after injury. To assess costs, the authors calculated the effective cost per favorable outcome (ECPFO). RESULTS: In total, 293 patients were included, of whom 61% had moderate to severe TBI (Glasgow Coma Scale [GCS] score 3-12) and 40% were ≥ 13 years of age. Of all patients, 82% had a favorable outcome and 9% died within 6 months of injury. The mean cost per patient was €48,719 ($54,557) (95% CI €41,326-€56,112). The index hospitalization accounted for 66%, rehabilitation costs for 27%, and social security costs for 7% of total healthcare costs. The ECPFO was €59,727 ($66,884) (95% CI €52,335-€67,120). A higher ECPFO was observed among patients with clinical and treatment-related variables indicative of parenchymal swelling and high intracranial pressure. Lower ECPFO was observed among patients with higher admission GCS scores and those who had epidural hematomas. CONCLUSIONS: Greater injury severity increases ECPFO and is associated with higher postdischarge costs in pediatric TBI patients. In this pediatric cohort, over two-thirds of all resources were spent on patients with favorable functional outcome, indicating appropriate resource allocation.

Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines.

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI-subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.

Traumatismo cranioencefálico no Brasil: análise epidemiológica / Cranioencephalic traumatism in Brazil: epidemiological analysis

Introdução: O traumatismo cranioencefálico (TCE) é definido por agressão de ordem traumática, que pode ser classificado como leve, moderado e grave, pela Escala de Coma de Glasgow (ECG). No Brasil, o traumatismo tem grande importância pela alta incidência e morbimortalidade. Objetivo: Analisar o perfil epidemiológico dos pacientes internados devido à TCE no Brasil. Método: Trata-se de estudo descritivo, cujos dados foram obtidos através de abordagem documental do Departamento de Informática do Sistema Único de Saúde (DATASUS). Para o estudo epidemiológico foram utilizados dados da prevalência da morbidade no Brasil, no período de 2010 a 2019. Resultados: O número de internações foi predominante no sexo masculino (76,23%), na faixa etária entre 20 e 29 anos (17,65%); em relação à permanência hospitalar, foi obtido uma média de 6,2 dias de internação; os índices de mortalidade foram maiores no sexo masculino (10,06%), assim como o valor gasto com os pacientes, com 81,39% para esse sexo. Conclusão: A partir do presente estudo foi possível observar que no Brasil os jovens do sexo masculino, vítimas de TCE, são os que mais internam e geram custos à saúde, permitindo evidenciar essa parcela populacional como grupo de risco. Os pacientes, vítimas de TCE, tem prognóstico relacionado a fatores como a idade, gravidade do trauma, tipo de lesão, dentre outros fatores que possam estar associados. Desse modo, torna-se fundamental a análise do perfil epidemiológico do TCE para uma melhor intervenção, buscando cuidados constantes, evitando-se complicações, permitindo uma conduta mais adequada e resolutiva e, consequentemente, um melhor prognóstico

Introduction: The traumatic brain injury is defined by traumatic aggression, which can be classified as mild, moderate and severe, by the Glasgow Coma Scale. In Brazil, trauma is of great importance due to its high incidence and morbidity and mortality. Objective: To analyze the epidemiological profile of hospitalized patients due to traumatic brain injury in Brazil. Method: This is a descriptive study, whose data were obtained through a documentary approach by the Department of Informatics of the Unified Health System. For the epidemiological study, data on the prevalence of morbidity in Brazil, from 2010 to 2019 were used. Results: The number of hospitalizations was predominant in the male gender (76.23%) and in the age group between 20 and 29 years old (17.65%); in relation to hospital stay, an average of 6.2 days was obtained; mortality rates were higher in males (10.06%); and the amount spent on patients, were significantly higher in males (81.39%). Conclusion: The present study made it possible to observe that, in Brazil, young men are the ones who intern the most and generate health costs through the traumatic brain injury, allowing to show this population as a risk group. Patients, victims of this injury, have a prognosis related to factors such as age, trauma severity, type of injury, among other factors that may be associated, it is essential to analyze the epidemiological profile for intervention seeking constant care to avoid complications , allow appropriate and resolutive conduct and consequently seek a better prognosis

Socioeconomic Consequences of Traumatic Brain Injury: A Danish Nationwide Register-Based Study.

This study examined if acquiring a traumatic brain injury (TBI) increases utilization of health care costs, increases risk of job loss for the patient and the closest relatives, and increases the risk of divorce 1 to 5 years following the injury. The study was conducted as a Danish national population-based register study with follow-up. Participants included a cohort of patients with TBI (n = 18,328) admitted to a hospital or treated in an emergency room (ER) and a matching control group (n = 89,155). For both the TBI group and the matching controls, relatives were identified, using national registers (TBI relatives: n = 25,708 and control relatives: n = 135,325). The outcome measures were utilization of health care costs (including hospital services, use of general practitioner and practicing specialists, and prescribed medication), risk of job loss, and risk of divorce among the TBI group and the control group and their relatives. Patients with TBI had significantly increased health care costs at baseline (i.e., the year before the injury) and during the following 4 years. Further, TBI relatives had a significantly higher utilization of health care costs the first and the third year after injury. The TBI group had a significant increased risk of job loss (odds ratio [OR] = 2.88; confidence interval [CI]: 2.70-3.07) and divorce (OR = 1.44; CI: 1.27-1.64) during the first 3 years following injury. In conclusion, the TBI group had significantly higher utilization of health care costs, both pre-morbidly and post-injury. Further, increased risk of job loss and divorce were found, emphasizing that the socioeconomic consequences of TBI last for years post-injury.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study.

BACKGROUND: The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI. METHODS: We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation. RESULTS: A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%). CONCLUSION: In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Cost-effectiveness of mandatory bicycle helmet use to prevent traumatic brain injuries and death.

BACKGROUND: Traumatic brain injury (TBI) is the main cause of mortality and severe morbidity in cyclists admitted to Dutch emergency departments (EDs). Although the use of bicycle helmets is an effective way of preventing TBI, this is uncommon in the Netherlands. An option to increase its use is through a legal enforcement. However, little is known about the cost-effectiveness of such mandatory use of helmets in the Dutch context. The current study aimed to assess the cost-effectiveness of a law that enforces helmet use to reduce TBI and TBI-related mortality. METHODS: The cost-effectiveness was estimated through decision tree modelling. In this study, wearing bicycle helmets enforced by law was compared with the current situation of infrequent voluntary helmet use. The total Dutch cycling population, consisting of 13.5 million people, was included in the model. Model data and parameters were obtained from Statistics Netherlands, the National Road Traffic Database, Dutch Injury Surveillance System, and literature. Effects included were numbers of TBI, death, and disability-adjusted life years (DALY). Costs included were healthcare costs, costs of productivity losses, and helmet costs. Sensitivity analysis was performed to assess which parameter had the largest influence on the incremental cost-effectiveness ratio (ICER). RESULTS: The intervention would lead to an estimated reduction of 2942 cases of TBI and 46 deaths. Overall, the incremental costs per 1) death averted, 2) per TBI averted, and 3) per DALY averted were estimated at 1) € 2,002,766, 2) € 31,028 and 3) € 28,465, respectively. Most favorable were the incremental costs per DALY in the 65+ age group: € 17,775. CONCLUSIONS: The overall costs per DALY averted surpassed the Dutch willingness to pay threshold value of € 20,000 for cost-effectiveness of preventive interventions. However, the cost per DALY averted for the elderly was below this threshold, indicating that in this age group largest effects can be reached. If the price of a helmet would reduce by 20%, which is non-hypothetical in a situation of large-scale purchases and use of these helmets, the introduction of this regulation would result in an intervention that is almost cost-effective in all age groups.

The CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative.

In traumatic brain injury (TBI), future integration of multimodal monitoring of cerebral physiology and high-frequency signal processing techniques, with advanced neuroimaging, proteomic and genomic analysis, provides an opportunity to explore the molecular pathways involved in various aspects of cerebral physiologic dysfunction in vivo. The main issue with early and rapid discovery in this field of personalized medicine is the expertise and complexity of data involved. This brief communication highlights the CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative, which has been formed from centers with specific expertise in the area of high-frequency physiologic monitoring/processing, and outlines its objectives.

The effect of socioeconomic deprivation on 12 month Traumatic Brain Injury (TBI) outcome.

Objectives: To assess the impact of social deprivation on Traumatic Brain Injury (TBI) global outcome.Design: The study was a prospective observational study conducted using consecutive admissions with TBI.Subjects: 1322 consecutive adult patients with TBI were recruited into the study between 2010 and 2015.Methods: All patients were assessed by the TBI rehabilitation team at both six weeks and 12 months following TBI. Details of the injury and demographic data was collated at six weeks. This included age, gender and ZIP Code. Social deprivation was measured by the Indices of Multiple Deprivation (IMD) Score. The outcome measure used was the Extended Glasgow Outcome Score (GOSE) at 12 months. Univariate analysis was followed by a Multi-Ordinal Regression to evaluate predictor variables.Results: With regard to the representation of IMD deciles, the study population approximated to the general Sheffield population (p = .139). Within the univariate analysis, statistically significant relationships were noted between IMD and GOSE (p = <.001). The Ordinal Regression revealed a significant relationship between worse GOSE and IMD (p = .002), age (p = .001), GCS (p < .001), alcohol intoxication (p < .001) and Medical Comorbidity (p = .041).Conclusion: Increasing social deprivation is associated with poorer global TBI outcomes at 12 months.

The Incremental Hospitalization Cost of Significant Transport-Related Traumatic Brain Injury.

AIM: This study aims to determine the incremental cost of acute hospitalization for traumatic brain injury (TBI) compared with matched controls. A second purpose is to identify the factors contributing to this hospital costs. METHODOLOGY: Analyses were performed on administrative data for injured patients, hospitalized in Belgium between 2009 and 2011 following a road traffic accident. Cases were matched to a control with similar injuries but without TBI. The incremental hospitalization cost of TBI and the factors contributing to the hospital costs were determined using multivariable regression modeling with gamma distribution and log link. RESULTS: A descriptive comparison of cases and controls shows clear differences in healthcare utilization and costs. The presence of a TBI increases the cost by a factor between 1.66 (95% confidence interval: 1.52-1.82) and 2.08 (95% confidence interval: 1.72-2.51). Regarding healthcare utilization, the most important determinants of hospital costs are surgical complexity, use of magnetic resonance imaging, intensive care unit admission, and mechanical ventilation. DISCUSSION: To our knowledge, this is the first matched-control study calculating the incremental hospitalization cost of TBI. The insights provided by this study are relevant in the context of prospective payments and can be an incentive for investments in prevention policies and extramural care.

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.