An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis

• Published in: Neurosurgical focus Vol. 47; no. 5; p. E6
• Main Authors: Elahi, Cyrus, Rocha, Thiago Augusto Hernandes, da Silva, Núbia Cristina, Sakita, Francis M, Ndebea, Ansbert Sweetbert, Fuller, Anthony, Haglund, Michael M, Mmbaga, Blandina T, Nickenig Vissoci, João Ricardo, Staton, Catherine A
• Format: Journal Article
• Language: English
• Published: United States 01.11.2019
• Subjects: IQR = interquartile range; critical care outcomes; TBI = traumatic brain injury; CoxPH = Cox proportional hazard model; MOI = mechanism of injury; KM = Kaplan-Meier; GOSE = Glasgow Outcome Scale–Extended; HIC = high-income country; RTI = road traffic injury; GOS = Glasgow Outcome Scale; LMIC = low- and middle-income country; SSA = sub-Saharan Africa; survival analysis; brain injuries; developing countries; GCS = Glasgow Coma Scale; HD = hospital day; HR = hazard ratio; KCMC = Kilimanjaro Christian Medical Center
• DOI: 10.3171/2019.7.FOCUS19316
• ISSN: 1092-0684

The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury. The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania. Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI. Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.