Secondary Logo

Institutional members access full text with Ovid®

Causes and Consequences of Treatment Variation in Moderate and Severe Traumatic Brain Injury: A Multicenter Study

Cnossen, Maryse C. MSc; Polinder, Suzanne PhD; Andriessen, Teuntje M. MSc; van der Naalt, Joukje MD, PhD; Haitsma, Iain MD, PhD; Horn, Janneke MD, PhD; Franschman, Gaby MD, PhD; Vos, Pieter E. MD, PhD; Steyerberg, Ewout W. PhD; Lingsma, Hester PhD

doi: 10.1097/CCM.0000000000002263
Neurologic Critical Care

Objectives: Although guidelines have been developed to standardize care in traumatic brain injury, between-center variation in treatment approach has been frequently reported. We examined variation in treatment for traumatic brain injury by assessing factors influencing treatment and the association between treatment and patient outcome.

Design: Secondary analysis of prospectively collected data.

Setting: Five level I trauma centers in the Netherlands (2008–2009).

Patients: Five hundred three patients with moderate or severe traumatic brain injury (Glasgow Coma Scale, 3–13).

Interventions: We examined variation in seven treatment parameters: direct transfer, involvement of mobile medical team, mechanical ventilation, intracranial pressure monitoring, vasopressors, acute neurosurgical intervention, and extracranial operation.

Measurements and Main Results: Data were collected on patient characteristics, treatment, and 6-month Glasgow Outcome Scale-Extended. Multivariable logistic regression models were used to assess the extent to which treatment was determined by patient characteristics. To examine whether there were between-center differences in treatment, we used unadjusted and adjusted random effect models with the seven treatment parameters as dependent variables. The influence of treatment approach in a center (defined as aggressive and nonaggressive based on the frequency intracranial pressure monitoring) on outcome was assessed using multivariable random effect proportional odds regression models in those patients with an indication for intracranial pressure monitoring. Sensitivity analyses were performed to test alternative definitions of aggressiveness. Treatment was modestly related to patient characteristics (Nagelkerke R2 range, 0.12–0.52) and varied widely among centers, even after case-mix correction. Outcome was more favorable in patients treated in aggressive centers than those treated in nonaggressive centers (OR, 1.73; 95% CI, 1.05–3.15). Sensitivity analyses, however, illustrated that the aggressiveness-outcome association was dependent on the definition used.

Conclusions: The considerable between-center variation in treatment for patients with brain injury can only partly be explained by differences in patient characteristics. An aggressive treatment approach may imply better outcome although further confirmation is required.

Supplemental Digital Content is available in the text.

1Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.

2Department of psychology, RIVAS Healthcare Group, Gorinchem, The Netherlands.

3Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands.

4Department of Neurosurgery, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.

5Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

6Department of Anesthesiology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands.

7Department of neurology, Slingeland Hospital, Doetinchem, The Netherlands.

The POCON study was performed in the Radboud University Hospital Nijmegen, University Medical Center Groningen, Erasmus Medical Center Rotterdam, Academic Medical Center Amsterdam, and the VU University Medical Center Amsterdam.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

The POCON study is funded by the Dutch Brain Foundation (Hersenstichting—HSN-07-01).

Dr. Cnossen received support for article research from The European Union FP 7th Framework program (grant 602150)—CENTER-TBI. Dr. Andriessen’s institution received funding from Dutch brain foundation (Hersenstichting). Dr. Haitsma’s institution received funding from University Medical Center Nijmegen, Department of Neurology. Dr. Vos’ institution received funding from Dutch Brain Foundation (Hersenstichting), and he received funding from Ever Neuropharma (consultancy). Dr. Steyerberg’s institution received funding from EU FP7 programme. Dr. Lingsma received support for article research from European Union (FP7). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail:

Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.