Quality indicators for patients with traumatic brain injury in European intensive care units: a CENTER-TBI study

Jilske A Huijben, Eveline J A Wiegers, Ari Ercole, Nicolette F de Keizer, Andrew I R Maas, Ewout W Steyerberg, Giuseppe Citerio, Lindsay Wilson, Suzanne Polinder, Daan Nieboer, David Menon, Hester F Lingsma, Mathieu van der Jagt, CENTER-TBI investigators and participants for the ICU stratum, Cecilia Åkerlund, Krisztina Amrein, Nada Andelic, Lasse Andreassen, Gérard Audibert, Philippe Azouvi, Maria Luisa Azzolini, Ronald Bartels, Ronny Beer, Bo-Michael Bellander, Habib Benali, Maurizio Berardino, Luigi Beretta, Erta Beqiri, Morten Blaabjerg, Stine Borgen Lund, Camilla Brorsson, Andras Buki, Manuel Cabeleira, Alessio Caccioppola, Emiliana Calappi, Maria Rosa Calvi, Peter Cameron, Guillermo Carbayo Lozano, Marco Carbonara, Ana M Castaño-León, Simona Cavallo, Giorgio Chevallard, Arturo Chieregato, Mark Coburn, Jonathan Coles, Jamie D Cooper, Marta Correia, Endre Czeiter, Marek Czosnyka, Claire Dahyot-Fizelier, Paul Dark, Véronique De Keyser, Vincent Degos, Francesco Della Corte, Hugo den Boogert, Bart Depreitere, Dula Dilvesi, Abhishek Dixit, Jens Dreier, Guy-Loup Dulière, Erzsébet Ezer, Martin Fabricius, Kelly Foks, Shirin Frisvold, Alex Furmanov, Damien Galanaud, Dashiell Gantner, Alexandre Ghuysen, Lelde Giga, Jagos Golubovic, Pedro A Gomez, Francesca Grossi, Deepak Gupta, Iain Haitsma, Raimund Helbok, Eirik Helseth, Peter J Hutchinson, Stefan Jankowski, Faye Johnson, Mladen Karan, Angelos G Kolias, Daniel Kondziella, Evgenios Koraropoulos, Lars-Owe Koskinen, Noémi Kovács, Ana Kowark, Alfonso Lagares, Steven Laureys, Fiona Lecky, Didier Ledoux, Aurelie Lejeune, Roger Lightfoot, Alex Manara, Costanza Martino, Hugues Maréchal, Julia Mattern, Catherine McMahon, Tomas Menovsky, Benoit Misset, Visakh Muraleedharan, Lynnette Murray, Ancuta Negru, David Nelson, Virginia Newcombe, József Nyirádi, Fabrizio Ortolano, Jean-François Payen, Vincent Perlbarg, Paolo Persona, Wilco Peul, Anna Piippo-Karjalainen, Horia Ples, Inigo Pomposo, Jussi P Posti, Louis Puybasset, Andreea Radoi, Arminas Ragauskas, Rahul Raj, Jonathan Rhodes, Sophie Richter, Saulius Rocka, Cecilie Roe, Olav Roise, Jeffrey V Rosenfeld, Christina Rosenlund, Guy Rosenthal, Rolf Rossaint, Sandra Rossi, Juan Sahuquillo, Oddrun Sandrød, Oliver Sakowitz, Renan Sanchez-Porras, Kari Schirmer-Mikalsen, Rico Frederik Schou, Peter Smielewski, Abayomi Sorinola, Emmanuel Stamatakis, Nino Stocchetti, Nina Sundström, Riikka Takala, Viktória Tamás, Tomas Tamosuitis, Olli Tenovuo, Matt Thomas, Dick Tibboel, Christos Tolias, Tony Trapani, Cristina Maria Tudora, Peter Vajkoczy, Shirley Vallance, Egils Valeinis, Zoltán Vámos, Gregory Van der Steen, Jeroen T J M van Dijck, Thomas A van Essen, Roel P J van Wijk, Alessia Vargiolu, Emmanuel Vega, Anne Vik, Rimantas Vilcinis, Victor Volovici, Daphne Voormolen, Petar Vulekovic, Guy Williams, Stefan Winzeck, Stefan Wolf, Alexander Younsi, Frederick A Zeiler, Agate Ziverte, Tommaso Zoerle, Hans Clusmann, Jilske A Huijben, Eveline J A Wiegers, Ari Ercole, Nicolette F de Keizer, Andrew I R Maas, Ewout W Steyerberg, Giuseppe Citerio, Lindsay Wilson, Suzanne Polinder, Daan Nieboer, David Menon, Hester F Lingsma, Mathieu van der Jagt, CENTER-TBI investigators and participants for the ICU stratum, Cecilia Åkerlund, Krisztina Amrein, Nada Andelic, Lasse Andreassen, Gérard Audibert, Philippe Azouvi, Maria Luisa Azzolini, Ronald Bartels, Ronny Beer, Bo-Michael Bellander, Habib Benali, Maurizio Berardino, Luigi Beretta, Erta Beqiri, Morten Blaabjerg, Stine Borgen Lund, Camilla Brorsson, Andras Buki, Manuel Cabeleira, Alessio Caccioppola, Emiliana Calappi, Maria Rosa Calvi, Peter Cameron, Guillermo Carbayo Lozano, Marco Carbonara, Ana M Castaño-León, Simona Cavallo, Giorgio Chevallard, Arturo Chieregato, Mark Coburn, Jonathan Coles, Jamie D Cooper, Marta Correia, Endre Czeiter, Marek Czosnyka, Claire Dahyot-Fizelier, Paul Dark, Véronique De Keyser, Vincent Degos, Francesco Della Corte, Hugo den Boogert, Bart Depreitere, Dula Dilvesi, Abhishek Dixit, Jens Dreier, Guy-Loup Dulière, Erzsébet Ezer, Martin Fabricius, Kelly Foks, Shirin Frisvold, Alex Furmanov, Damien Galanaud, Dashiell Gantner, Alexandre Ghuysen, Lelde Giga, Jagos Golubovic, Pedro A Gomez, Francesca Grossi, Deepak Gupta, Iain Haitsma, Raimund Helbok, Eirik Helseth, Peter J Hutchinson, Stefan Jankowski, Faye Johnson, Mladen Karan, Angelos G Kolias, Daniel Kondziella, Evgenios Koraropoulos, Lars-Owe Koskinen, Noémi Kovács, Ana Kowark, Alfonso Lagares, Steven Laureys, Fiona Lecky, Didier Ledoux, Aurelie Lejeune, Roger Lightfoot, Alex Manara, Costanza Martino, Hugues Maréchal, Julia Mattern, Catherine McMahon, Tomas Menovsky, Benoit Misset, Visakh Muraleedharan, Lynnette Murray, Ancuta Negru, David Nelson, Virginia Newcombe, József Nyirádi, Fabrizio Ortolano, Jean-François Payen, Vincent Perlbarg, Paolo Persona, Wilco Peul, Anna Piippo-Karjalainen, Horia Ples, Inigo Pomposo, Jussi P Posti, Louis Puybasset, Andreea Radoi, Arminas Ragauskas, Rahul Raj, Jonathan Rhodes, Sophie Richter, Saulius Rocka, Cecilie Roe, Olav Roise, Jeffrey V Rosenfeld, Christina Rosenlund, Guy Rosenthal, Rolf Rossaint, Sandra Rossi, Juan Sahuquillo, Oddrun Sandrød, Oliver Sakowitz, Renan Sanchez-Porras, Kari Schirmer-Mikalsen, Rico Frederik Schou, Peter Smielewski, Abayomi Sorinola, Emmanuel Stamatakis, Nino Stocchetti, Nina Sundström, Riikka Takala, Viktória Tamás, Tomas Tamosuitis, Olli Tenovuo, Matt Thomas, Dick Tibboel, Christos Tolias, Tony Trapani, Cristina Maria Tudora, Peter Vajkoczy, Shirley Vallance, Egils Valeinis, Zoltán Vámos, Gregory Van der Steen, Jeroen T J M van Dijck, Thomas A van Essen, Roel P J van Wijk, Alessia Vargiolu, Emmanuel Vega, Anne Vik, Rimantas Vilcinis, Victor Volovici, Daphne Voormolen, Petar Vulekovic, Guy Williams, Stefan Winzeck, Stefan Wolf, Alexander Younsi, Frederick A Zeiler, Agate Ziverte, Tommaso Zoerle, Hans Clusmann

Abstract

Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measurement and improvement.

Methods: Our analysis was based on 2006 adult patients admitted to 54 ICUs between 2014 and 2018, enrolled in the CENTER-TBI study. Indicator scores were calculated as percentage adherence for structure and process indicators and as event rates or median scores for outcome indicators. Feasibility was quantified by the completeness of the variables. Discriminability was determined by the between-centre variation, estimated with a random effect regression model adjusted for case-mix severity and quantified by the median odds ratio (MOR). Statistical uncertainty of outcome indicators was determined by the median number of events per centre, using a cut-off of 10.

Results: A total of 26/42 indicators could be calculated from the CENTER-TBI database. Most quality indicators proved feasible to obtain with more than 70% completeness. Sub-optimal adherence was found for most quality indicators, ranging from 26 to 93% and 20 to 99% for structure and process indicators. Significant (p < 0.001) between-centre variation was found in seven process and five outcome indicators with MORs ranging from 1.51 to 4.14. Statistical uncertainty of outcome indicators was generally high; five out of seven had less than 10 events per centre.

Conclusions: Overall, nine structures, five processes, but none of the outcome indicators showed potential for quality improvement purposes for TBI patients in the ICU. Future research should focus on implementation efforts and continuous reevaluation of quality indicators.

Trial registration: The core study was registered with ClinicalTrials.gov, number NCT02210221, registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582).

Keywords: Benchmarking; Intensive care units; Quality indicators; Quality of health care; Traumatic brain injuries.

Conflict of interest statement

AIRM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DKM reports grants from the UK National Institute for Health Research, during the conduct of the study; grants, personal fees, and non-financial support from GlaxoSmithKline; and personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Adjusted random effect estimates per centre for process indicators. This figure shows the between-centre differences for the process indicators (beware of different x-axes). Quality indicator definitions can be found in Additional file 3. On the y-axis, each dot represents a centre. A centre with an average indicator score has log odds 0 (a positive log odds indicates higher indicator scores and a negative log odds lower indicator scores). The between-centre differences are represented by the shape of the caterpillar plots; the variation in the log odds for individual centres and the corresponding confidence intervals (uncertainty). For example, the use of ICP monitoring shows large variation between centres with small confidence intervals, so there is high variation with low statistical uncertainty. While for use of low molecular weight heparin, the variation is large, but the statistical uncertainty is high as well (due to high adherence rates for most centres). The caterpillars were based on non-missing data (after imputation). ‘Use of Low Molecular Weight Heparin’ reflects the indicator ‘Number of patients that receive pharmaceutical prophylaxis with low molecular weight heparins/ total number of TBI patients admitted to the ICU’. ‘Surgery within 4 hours’ reflects the indicator ‘Median door-to-operation time for acute operation of SDH and EDH with surgical indication’. DVT deep venous thrombosis, EDH epidural hematoma, ICU intensive care unit, MOR median odds ratio, SDH subdural hematoma
Fig. 2
Fig. 2
Adjusted random effect estimates per centre for outcome indicators. This figure shows the between-centre differences for the outcome indicators. Quality indicator definitions can be found in Additional file 4. On the y-axis, each dot represents a centre. A centre with an average indicator score has log odds 0 (a positive log odds indicates higher indicator scores and a negative log odds a lower indicator scores). Outcome indicator scores were adjusted for case-mix and ‘statistical uncertainty’ (variation by chance) by using a random effects logistic regression model. The MOR (median odds ratio) represents the between-centre variation: the higher the MOR, the larger the between-centre variation (a MOR equal to 1 reflects no variation). The confidence intervals represent the statistical uncertainty. The caterpillars were based on non-missing data (after imputation). Outcome incidence for decubitus and hypoglycemia was too low to reliably show between-centre variation (high confidence intervals). Impaired SF-36v2 (PCS or MCS) score ≤ 40. CI confidence interval, GOSE Glasgow Outcome Scale Extended, ICU intensive care unit, MOR median odds ratio

References

    1. Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Buki A, Chesnut RM, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987–1048. doi: 10.1016/S1474-4422(17)30371-X.
    1. Haider AH, Hashmi ZG, Gupta S, Zafar SN, David JS, Efron DT, Stevens KA, Zafar H, Schneider EB, Voiglio E, et al. Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB) World J Surg. 2014;38(8):1882–1891. doi: 10.1007/s00268-014-2629-5.
    1. Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Chiche JD, Eddleston J, Endacott R, Ferdinande P, Flaatten H, Guidet B, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM) Intensive Care Med. 2012;38(4):598–605. doi: 10.1007/s00134-011-2462-3.
    1. O'Reilly GM, Cameron PA, Joshipura M. Global trauma registry mapping: a scoping review. Injury. 2012;43(7):1148–1153. doi: 10.1016/j.injury.2012.03.003.
    1. Salluh JIF, Soares M, Keegan MT. Understanding intensive care unit benchmarking. Intensive Care Med. 2017;43(11):1703–1707. doi: 10.1007/s00134-017-4760-x.
    1. Coleman MP, Forman D, Bryant H, Butler J, Rachet B, Maringe C, Nur U, Tracey E, Coory M, Hatcher J, et al. Cancer survival in Australia, Canada, Denmark, Norway, Sweden, and the UK, 1995-2007 (the International Cancer Benchmarking Partnership): an analysis of population-based cancer registry data. Lancet. 2011;377(9760):127–138. doi: 10.1016/S0140-6736(10)62231-3.
    1. Fox KA, Fitzgerald G, Puymirat E, Huang W, Carruthers K, Simon T, Coste P, Monsegu J, Gabriel Steg P, Danchin N, et al. Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open. 2014;4(2):e004425. doi: 10.1136/bmjopen-2013-004425.
    1. Padman R, McColley SA, Miller DP, Konstan MW, Morgan WJ, Schechter MS, Ren CL, Wagener JS, Investigators, Coordinators of the Epidemiologic Study of Cystic F Infant care patterns at epidemiologic study of cystic fibrosis sites that achieve superior childhood lung function. Pediatrics. 2007;119(3):e531–e537. doi: 10.1542/peds.2006-1414.
    1. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–1748. doi: 10.1001/jama.1988.03410120089033.
    1. Volovici V, Ercole A, Citerio G, Stocchetti N, Haitsma IK, Huijben JA, Dirven CMF, van der Jagt M, Steyerberg EW, Nelson D, et al. Intensive care admission criteria for traumatic brain injury patients across Europe. J Crit Care. 2019;49:158–161. doi: 10.1016/j.jcrc.2018.11.002.
    1. Maas AI, Menon DK, Steyerberg EW, Citerio G, Lecky F, Manley GT, Hill S, Legrand V, Sorgner A, Participants C-T, et al. Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study. Neurosurgery. 2015;76(1):67–80. doi: 10.1227/NEU.0000000000000575.
    1. Steyerberg EW et al. Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet neurol. 2019;18(10):923-34.
    1. Cnossen MC, Polinder S, Lingsma HF, Maas AI, Menon D, Steyerberg EW, Investigators C-T, Participants Variation in structure and process of care in traumatic brain injury: provider profiles of European Neurotrauma Centers participating in the CENTER-TBI study. PLoS One. 2016;11(8):e0161367. doi: 10.1371/journal.pone.0161367.
    1. Fischer C. Quality indcators for hospital care. 2015.
    1. Arts DG, De Keizer NF, Scheffer GJ. Defining and improving data quality in medical registries: a literature review, case study, and generic framework. J Am Med Inform Assoc. 2002;9(6):600–611. doi: 10.1197/jamia.M1087.
    1. van Dishoeck AM, Looman CW, van der Wilden-van Lier EC, Mackenbach JP, Steyerberg EW. Displaying random variation in comparing hospital performance. BMJ Qual Saf. 2011;20(8):651–657. doi: 10.1136/bmjqs.2009.035881.
    1. van Overveld LFJ, Takes RP, Braspenning JCC, Baatenburg de Jong RJ, de Boer JP, Brouns JJA, Bun RJ, Dik EA, van Dijk BAC, van Es RJJ. Variation in integrated head and neck cancer care: impact of patient and hospital characteristics. J Natl Compr Cancer Netw. 2018;16(12):1491–8.
    1. Lingsma HF, Steyerberg EW, Eijkemans MJ, Dippel DW, Scholte Op Reimer WJ, Van Houwelingen HC, Netherlands Stroke Survey I Comparing and ranking hospitals based on outcome: results from The Netherlands Stroke Survey. QJM. 2010;103(2):99–108. doi: 10.1093/qjmed/hcp169.
    1. van Dishoeck AM, Lingsma HF, Mackenbach JP, Steyerberg EW. Random variation and rankability of hospitals using outcome indicators. BMJ Qual Saf. 2011;20(10):869–874. doi: 10.1136/bmjqs.2010.048058.
    1. Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P, Rastam L, Larsen K. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290–297. doi: 10.1136/jech.2004.029454.
    1. Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5(8):e165. doi: 10.1371/journal.pmed.0050165.
    1. Stram DO, Lee JW. Variance components testing in the longitudinal mixed effects model. Biometrics. 1994;50(4):1171–1177. doi: 10.2307/2533455.
    1. Buuren S. van, Groothuis-Oudshoorn K. Mice: Multivariate Imputation by Chained Equations in R. J Stat Software 45. 2011. p. 1-68.
    1. Cnossen MC, Polinder S, Andriessen TM, van der Naalt J, Haitsma I, Horn J, Franschman G, Vos PE, Steyerberg EW, Lingsma H. Causes and consequences of treatment variation in moderate and severe traumatic brain injury: a multicenter study. Crit Care Med. 2017;45(4):660–669. doi: 10.1097/CCM.0000000000002263.
    1. Bulger EM, Nathens AB, Rivara FP, Moore M, MacKenzie EJ, Jurkovich GJ, Brain Trauma Foundation. Management of severe head injury: institutional variations in care and effect on outcome. Crit Care Med. 2002;30(8):1870–6.
    1. Alali AS, Fowler RA, Mainprize TG, Scales DC, Kiss A, de Mestral C, Ray JG, Nathens AB. Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program. J Neurotrauma. 2013;30(20):1737–1746. doi: 10.1089/neu.2012.2802.
    1. Vavilala MS, Kernic MA, Wang J, Kannan N, Mink RB, Wainwright MS, Groner JI, Bell MJ, Giza CC, Zatzick DF, et al. Acute care clinical indicators associated with discharge outcomes in children with severe traumatic brain injury. Crit Care Med. 2014;42(10):2258–2266. doi: 10.1097/CCM.0000000000000507.
    1. de Carvalho AGR, de Moraes APP, Tanaka LMS, Gomes RV, da Silva AAM. Quality in intensive care units: proposal of an assessment instrument. BMC Res Notes. 2017;10(1):222. doi: 10.1186/s13104-017-2563-3.
    1. Najjar-Pellet J, Jonquet O, Jambou P, Fabry J. Quality assessment in intensive care units: proposal for a scoring system in terms of structure and process. Intensive Care Med. 2008;34(2):278–285. doi: 10.1007/s00134-007-0883-9.
    1. Cai L, Zhu Y. The challenges of data quality and data quality assessment in the big data era. Data Sci J. 2015;14:2. doi: 10.5334/dsj-2015-002.
    1. Stocchetti N, Penny KI, Dearden M, Braakman R, Cohadon F, Iannotti F, Lapierre F, Karimi A, Maas A, Jr, Murray GD, et al. Intensive care management of head-injured patients in Europe: a survey from the European brain injury consortium. Intensive Care Med. 2001;27(2):400–406. doi: 10.1007/s001340000825.
    1. Ethical approval in CENTER-TBI; , 397. Accessed 24 Oct 2019.

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