Process of Care and Outcome of Critically Ill Patients with Traumatic Brain Injury
This thesis used clinical epidemiology methods to examine the relationship between process of care and outcome of critically ill patients with traumatic brain injury (TBI). First, I evaluated the association between intracranial pressure (ICP) monitoring use and mortality after severe TBI at the patient-level and at the hospital-level. ICP monitoring use was associated with lower mortality at the patient-level [adjusted odds ratio (OR) was 0.44; 95% confidence interval (CI): 0.31-0.63] and at the hospital-level (adjusted OR for death in the quartile of hospitals with highest use compared to the lowest was 0.52; 95% CI: 0.35-0.78). The main implication is that wider utilization of ICP monitoring in managing severe TBI appears warranted pending further studies. Second, I evaluated whether decompressive craniectomy or barbiturate coma provides better value, in terms of health effects and costs, for the management of refractory intracranial hypertension following TBI. Decompressive craniectomy resulted in greater quality-adjusted life expectancy relative to barbiturate coma [average gain was 1.5 quality-adjusted life years (QALYs)] but at higher costs (incremental cost-effectiveness ratio was $9,565/QALY gained). The main implication is that decompressive craniectomy, for this indication, is a more attractive strategy relative to barbiturate coma at commonly accepted willingness-to-pay thresholds. Third, I examined the relationship between tracheostomy timing and outcomes of TBI patients. Early tracheostomy (
Critical Care, Epidemiology, Traumatic Brain Injury
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