Departments of Public Health and.
J Neurosurg. 2013 Dec;119(6):1583-90. doi: 10.3171/2013.8.JNS13276. Epub 2013 Oct 8.
In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines.
The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers.
From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p < 0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p < 0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p < 0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p < 0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001).
There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.
尽管有证据表明，使用《颅脑创伤基金会严重颅脑创伤管理指南》（Guidelines）将显著降低发病率和死亡率，但这些指南在各创伤中心的应用仍存在差异。作者分析了 2001 年至 2009 年纽约州严重颅脑创伤（TBI）的两周死亡率，并研究了指南应用的变化趋势。
作者计算了 2001 年 1 月 1 日至 2009 年 12 月 31 日期间对指南的遵循情况和年龄调整后两周死亡率的变化趋势。采用单变量和多变量逻辑回归分析来评估时间段对病死率的影响。采用两水平分层模型对颅内压（ICP）监测仪插入进行建模，采用广义线性混合效应来允许不同中心的聚类。
2001 年至 2009 年，病死率从 22%降至 13%（p < 0.0001），调整了独立预测死亡率的因素后，这一变化仍然显著（调整后的 OR 0.52，95%CI 0.39-0.70；p < 0.0001）。指南的遵循率增加，ICP 监测的患者比例从 56%增加到 75%（p < 0.0001）。脑灌注压治疗阈值的遵循率从 15%增加到 48%（p < 0.0001）。ICP 升高超过 25mmHg 的患者比例从 42%降至 29%（p = 0.0001）。
纽约州 2001 年至 2009 年 TBI 死亡率显著降低。指南的应用增加与 2 周死亡率显著下降和颅内高血压发生率下降同时发生，提示指南应用与结局改善之间存在因果关系。我们的研究结果值得进一步研究，以确定增加和维持对循证指南建议的遵循的方法。
