神经外科干预严重创伤性脑损伤的变化：创伤中心验证中衡量质量的挑战。
Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.
机构信息
From the Department of Surgery (E.I.T., S.P.S., B.S.D., E.S.T., J.J.C., V.P.H.) MetroHealth Medical Center; Department of Population and Quantitative Health Sciences (V.P.H.), Case Western Reserve University School of Medicine; Department of Neurological Surgery, MetroHealth Medical Center, Cleveland, Ohio (M.L.K.).
出版信息
J Trauma Acute Care Surg. 2021 Jul 1;91(1):114-120. doi: 10.1097/TA.0000000000003114.
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.
背景
颅内压监测 (ICPm) 程序率是美国外科医师学院创伤中心验证的一项质量指标。然而，ICPm 程序率可能无法准确反映 TBI 的护理质量。我们假设，严重 TBI 的 ICPm 和开颅术/去骨瓣减压术的程序率因地理位置和机构而异。
方法
我们从 2016 年创伤质量改进计划数据集中确定了所有严重创伤性脑损伤（头部损伤严重程度评分，≥3）的患者。通过国际疾病分类代码识别接受手术减压或 ICPm 的患者。医院因素包括神经外科医生小组的规模、地理位置、教学状态和创伤中心级别。进行了两项多因素逻辑回归模型，以确定与 (1) 开颅术加或不加 ICPm 或 (2) 单独 ICPm 相关的因素。数据以中位数（四分位距）和比值比 (OR)（95%置信区间）表示。
结果
我们确定了 75690 名患者（66.4%为男性；年龄，59 [36-77] 岁），损伤严重程度评分中位数为 17（11-25）。总体而言，6.1%的患者接受了手术减压，4.8%的患者接受了 ICPm 放置。逻辑回归分析表明，国家的地理位置与手术类型显著相关：西部地区的医院更有可能使用 ICPm（OR，1.34 [1.20-1.50]），而东北地区（OR，0.80 [0.72-0.89]）、南部（OR，0.84 [0.78-0.92]）和西部（OR，0.88 [0.80-0.96]）医院则不太可能进行手术减压。神经外科医生人数较少（<3 人）的医院更有可能进行手术干预。社区医院与更高的手术减压几率相关，但 ICPm 放置的几率较低。
结论
地理位置差异和医院特征都是严重创伤性脑损伤手术干预的独立预测因素。这表明非患者因素驱动手术决策，表明 ICPm 率不是美国外科医师学院创伤中心验证的理想质量指标。
证据水平
流行病学，III 级；护理管理/治疗，III 级。
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