Variation in Neurosurgical Intervention for Severe TBI: The Challenge of Measuring Quality in Trauma Center Verification.

BACKGROUND Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the US by geography and institution. METHODS We identified all patients with a severe TBI (head AIS ≥3) from the 2016 Trauma Quality Improvement Program (TQIP) dataset. Patients who received surgical decompression or ICPm were identified via ICD codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with 1) craniotomy with or without ICPm or 2) ICPm alone. Data are presented as medians [IQR] and odds ratios [95%CI]. RESULTS We identified 75,690 patients (66.4% male, age 59 [36-77]) with a median ISS of 17 [11-25]. Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR 1.34 [1.20-1.50]) while Northeastern (OR 0.80 [0.72-0.89]), Southern (OR 0.84 [0.78-0.92]), and Western (OR 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSIONS Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe TBI. This suggests that non-patient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for ACS trauma center verification. LEVELS OF EVIDENCE AND STUDY TYPE Level III, retrospective cohort.