From the Division of Neurosurgery (A.K.M., H.S., R.H.J., A.E., F.M., E.Y.Y., C.D.W., J.R.W.), Unity Health; Li Ka Shing Knowledge Institute (A.K.M., H.S., F.M., C.D.W., J.R.W.); Institute for Health Policy, Management and Evaluation (A.K.M., A.B.N., H.S., R.H.J., K.T., A.V.K., C.D.W., J.R.W.), University of Toronto; Department of Surgery (A.B.N.), Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; Division of Orthopedics (A.E.), Department of Surgery, Shamir Medical Center (Assaf Harofeh), Zerifin; Faculty of Medicine (A.E.), Tel Aviv University, Israel; Interdepartmental Division of Critical Care Medicine (F.M.), Unity Health; Division of Spine Surgery (J.H.B.), Sunnybrook Health Sciences Center; and Division of Neurosurgery (A.V.K.), Hospital for Sick Children, Toronto, Ontario, Canada.
Neurology. 2024 Oct 22;103(8):e209904. doi: 10.1212/WNL.0000000000209904. Epub 2024 Sep 16.
Administrative data are invaluable for assessing outcomes at the population level. However, there are few validated patient-centered outcome measures that capture morbidity following traumatic brain injury (TBI) using these data. We sought to characterize and validate days at home (DAH) as a measure to quantify population-level outcomes after moderate to severe TBI. We additionally assessed the earliest feasible outcome assessment period for patients with TBI using this outcome measure.
This multicenter retrospective cohort study used linked health administrative data sources to identify adults with moderate to severe TBI presenting to trauma centers in Ontario, Canada, between 2009 and 2021. DAH at 180 days (DAH) reflects the total number of days spent alive and at home excluding the days spent institutionalized across care settings. Construct validity was determined using hierarchical quantile regression to assess the associations between clinical and injury covariates with DAH. Predictive validity was assessed using Spearman rank correlation. We estimated minimally important difference (MID) in DAH to aid with outcome measure interpretability.
There were 6,340 patients who met inclusion criteria. Median DAH was 70 days (interquartile range 0-144). Mortality occurred in 2,162 (34.1%) patients within 90 days following injury. Patients in the lower DAH group were more commonly older (absolute standardized difference [ASD] = 0.68) with higher preinjury health resource utilization (ASD = 0.36) and greater injury severity (ASD = 0.81). Increased baseline health resource utilization (-10.1 days, 95% CI -17.4 to -2.8, = 0.0041), older age (-4.6 days, 95% CI -5.7 to -3.4, < 0.001), higher cranial injury severity (-84.6 days, 95% CI -98.3 to -71.0, < 0.001), and major extracranial injuries (-14.2 days, 95% CI -19.5 to -8.93, < 0.001) were significantly associated with fewer DAH. DAH was positively correlated with DAH at up to 3 years ( = 0.91, 95% CI 0.90-0.92) and negatively correlated with direct health care expenditure ( = -0.89, 95% CI -0.88 to -0.90). The average MID estimated from anchor-based and distribution-based methods was 18 days.
We validate DAH as a potentially useful outcome measure with construct, predictive, and face validity in a population with moderate to severe TBI. Given the intensity of acute care requirements for patients with TBI, our work highlights DAH as a feasible and sufficiently responsive outcome measure.
行政数据对于评估人群水平的结局至关重要。然而，使用这些数据来评估创伤性脑损伤（TBI）后发病率的患者为中心的结局测量方法却很少得到验证。我们旨在将居家天数（DAH）作为一种测量方法进行特征描述和验证，以量化中度至重度 TBI 后的人群水平结局。我们还评估了使用该结局测量方法评估 TBI 患者的最早可行的结局评估时间。
这项多中心回顾性队列研究使用了链接的健康行政数据源，以确定 2009 年至 2021 年期间在加拿大安大略省创伤中心就诊的中度至重度 TBI 成人患者。180 天居家天数（DAH）反映了在整个医疗保健环境中居家生活的总天数，不包括在机构中度过的天数。使用分层分位数回归来评估临床和损伤协变量与 DAH 之间的关联，以确定构效关系。使用 Spearman 秩相关评估预测效度。我们估计了 DAH 的最小临床重要差异（MID），以帮助解释结局测量。
共纳入 6340 例符合条件的患者。中位数 DAH 为 70 天（四分位距 0-144）。伤后 90 天内有 2162 例（34.1%）患者死亡。DAH 较低的患者更常见于年龄较大（绝对标准化差异 [ASD] = 0.68），且术前健康资源利用率更高（ASD = 0.36）和损伤严重程度更高（ASD = 0.81）。基线健康资源利用率的增加（-10.1 天，95%CI-17.4 至-2.8， = 0.0041）、年龄的增加（-4.6 天，95%CI-5.7 至-3.4， < 0.001）、颅损伤严重程度的增加（-84.6 天，95%CI-98.3 至-71.0， < 0.001）和主要的颅外损伤（-14.2 天，95%CI-19.5 至-8.93， < 0.001）与 DAH 较少显著相关。DAH 与高达 3 年的 DAH 呈正相关（ = 0.91，95%CI 0.90-0.92），与直接医疗保健支出呈负相关（ = -0.89，95%CI-0.88 至-0.90）。基于锚定和基于分布的方法估计的平均 MID 为 18 天。
我们验证了 DAH 作为一种潜在有用的结局测量方法，在中度至重度 TBI 人群中具有构效、预测和表面效度。鉴于 TBI 患者急性护理需求的强度，我们的工作强调了 DAH 作为一种可行且具有足够反应性的结局测量方法。
