Long-term Follow-up Following Traumatic Brain Injury: Contextual Understanding and Technology-led Solutions

Traumatic brain injury (TBI) is a global health concern and remains a prominent cause of death and disability. Collecting outcome data at follow-up is crucial for both the clinical management of patients, and for wider research efforts. This data helps to decrease the number of deaths and disabilities caused by injuries worldwide. However, outcome data are generally not reliably or consistently recorded in low- and middle-income countries (LMICs), where 85% of the world’s population lives. Thus, the full picture of outcomes post-TBI in these settings remains largely unknown. This thesis was conducted under the National Institute for Health Research Global Health Research Group on Neurotrauma, a multi-disciplinary global group focused on improving care for those with traumatic brain injury. In this respect, this thesis addresses two key questions: what is the state of play of current long-term follow-up and outcome data collection practices following TBI in LMIC settings? And: What roles might technology-led solutions have in enhancing existing, or establishing new, follow-up and outcome data collection efforts? This thesis employed an exploratory mixed methods design, comprised of three core projects. These projects were encapsulated in the ‘Double Diamond’ design process model, which sought to provide an additional, pragmatic structure underpinning the schedule of works. First, a reflexive thematic analysis of semi-structured interviews was conducted with 18 LMIC neurosurgeons to investigate the current state of play of long-term TBI follow-up in LMICs, the contextual challenges associated with it, and potential technology-led solutions to improve the delivery of services. This led to the second project, a comprehensive scoping exercise to map the current evidence base for follow-up technologies used globally in the monitoring of outcomes following TBI. The third and final project was informed by the findings of the earlier studies, which led to the design, development, and evaluation of a novel, SMS-based follow-up technology (FUT) implemented through a local service evaluation project. Qualitative findings derived from project one identified the many different stakeholders with distinct vested interests in long-term follow-up following TBI. The study also showed that clinical case-volume and patient-facing barriers of geography and poverty act as key agents in LMIC follow-up attrition. Findings from the scoping review identified FUTs, particularly those built upon “common denominator” technologies such as text-messaging and telephony, as feasible ways of maintaining remote contact with and clinical oversight of patients post-discharge. The service evaluation project, which piloted a novel FUT in a high-income country (HIC) setting, proved efficacious, demonstrating good concurrent validity between the traditional, clinician-delivered Extended Glasgow Outcome Scale (GOS-E) and a short-form equivalent delivered autonomously through SMS. In conclusion, long-term follow-up for TBI remains a multifaceted challenge. Though currently in their infancy, novel technologies may have an increasing role in bridging communication gaps between traditional outpatient appointments in the future. Such novel technologies offer a new medium to both assess and monitor patient status, independence, and societal reintegration following injury. Such surveillance may alleviate clinical burden through service transformation and improve patient outcomes. However, in all cases where there are technological solutions to care delivery, due diligence must be exercised so that gaps in service access are bridged rather than further exacerbated.

Name dc:type.qualificationname

Doctor of Philosophy (PhD)

Level dc:type.qualificationlevel

Doctoral

Grantor dc:publisher.institution

University of Cambridge

Year dc:date.issued

2023

Author dc:creator

• Smith, Brandon

Advisors dc:contributor.advisor

• Hutchinson, Peter
• Kolias, Angelos

• Design process models
• Follow-up
• Global health
• Mixed methods
• Neurosurgery
• Qualitative
• Traumatic brain injury

Licence

• https://apollo8-f-pro.lib.cam.ac.uk/bitstreams/032fb582-9335-447b-a592-48d078d8ac41/download
• https://creativecommons.org/licenses/by/4.0/

Language dc:language

eng

Author Identifier

0000-0001-8471-1368

OAI identifier oai:identifier

oai:www.repository.cam.ac.uk:1810/355721