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Associations Between Care Pathways and Outcome 1 Year After Severe Traumatic Brain Injury

Godbolt, Alison K. MD, MBChB; Stenberg, Maud MD; Lindgren, Marie MD; Ulfarsson, Trandur MD; Lannsjö, Marianne MD, PhD; Stålnacke, Britt-Marie MD, PhD; Borg, Jörgen MD, PhD; DeBoussard, Catharina Nygren MD, PhD

Journal of Head Trauma Rehabilitation: May/June 2015 - Volume 30 - Issue 3 - p E41–E51
doi: 10.1097/HTR.0000000000000050
Original Articles

Objective: To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year.

Setting and Design: Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals.

Participants: Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury.

Main Measures: Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post–acute complications. Logistic regression analyses were performed.

Results: A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post–acute complications (0.058 [0.006-0.60], 0.017).

Conclusions: Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.

Department of Clinical Sciences, Karolinska Institute, and University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital, Stockholm, Sweden (Drs Godbolt, Borg, and DeBoussard); Department of Community Medicine and Rehabilitation, Rehabilitation Medicine, Umeå University, Umeå, Sweden (Drs Stenberg and Stålnacke); Department of Clinical Rehabilitation Medicine, County Council, Linköping, Sweden (Dr Lindgren); Department of Rehabilitation Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden (Dr Ulfarsson); and Department of Neuroscience, Uppsala University, Uppsala, and Department of Rehabilitation Medicine, Gävle and Sandviken Hospital, Sandviken, Sweden (Dr Lannsjö). Dr Godbolt was previously with Department of Rehabilitation Medicine, University Hosptial Uppsala and Uppsala University, Uppsala Sweden, during the intial stages of the study.

Corresponding Author: Alison Kate Godbolt, MD, MBChB, Department of Clinical Sciences, Karolinska Institute, and University Department of Rehabilitation Medicine Stockholm, Danderyd Hospital Stockholm, hus 39, plan 3, Danderyds sjukhus, SE-182 88 Stockholm, Sweden (

Drs Godbolt and Nygren DeBoussard contributed equally to this work.

This study was supported by grant 060833 from AFA insurance. Dr Godbolt has received support from ALF grants from Uppsala University Hospital and Danderyd Hospital. Drs Stenberg and Stålnacke received ALF grants from Umeå University Hospital. The authors thank the patients and their relatives, the PROBRAIN collaborators, the clinical staff of their units, and their neurosurgical colleagues for allowing recruitment of their patients. The authors also thank Dr Anna Tölli, Danderyd Hospital and Karolinska Institute, Dr Kristina Lindgren, Karlstad Hospital, Dr Björn Johansson, University Hospital Uppsala, and Dr Christer Tengvar, University Hospital Uppsala, who assisted in the assessment of patients. Paramedical staff contributing to the study included Stina Gunnarsson and Marina Byström Odhe (Linköping), Anna-Lisa Nilsson (Umeå), Marie Sandgren (Stockholm), Staffan Stenson (Uppsala), and Siv Svensson (Gothenburg). Seija Lund was nurse coordinator in Stockholm and Ingrid Morberg in Gothenburg. Lisbet Broman gave advice on statistical aspects.

The funders had no access to data and no input to study design or data analysis.

PROBRAIN collaborators: The authors together with Dr Gudrun Karlsdottir, Department of Rehabilitation Medicine, Landspitalinn, University Hospital, Reykjavik, Iceland.

The authors declare no conflicts of interest.

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