1
|
Schenck HE, Joackim P, Lazaro A, Wu X, Gerber LM, Stieg PE, Härtl R, Shabani H, Mangat HS. Affordability impacts therapeutic intensity of acute management of severe traumatic brain injury patients: An exploratory study in Tanzania. BRAIN & SPINE 2023; 3:101738. [PMID: 37383438 PMCID: PMC10293321 DOI: 10.1016/j.bas.2023.101738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 06/30/2023]
Abstract
Introduction Quality health care in low and middle-income countries (LMICs) is constrained by financing of care. Research question What is the effect of ability to pay on critical care management of patients with severe traumatic brain injury (sTBI)? Material and Methods Data on sTBI patients admitted to a tertiary referral hospital in Dar-es-Salaam, Tanzania, were collected between 2016 and 2018, and included payor mechanisms for hospitalization costs. Patients were grouped as those who could afford care and those who were unable to pay. Results Sixty-seven patients with sTBI were included. Of those enrolled, 44 (65.7%) were able to pay and 15 (22.3%) were unable to pay costs of care upfront. Eight (11.9%) patients did not have a documented source of payment (unknown identity or excluded from further analysis). Overall mechanical ventilation rates were 81% (n=36) in the affordable group and 100% (n=15) in the unaffordable group (p=0.08). Computed tomography (CT) rates were 71.6% (n=48) overall, 100% (n=44) and 0% respectively (p<0.01); Surgical rates were 16.4% (n=11) overall, 18.2% (n=8) vs. 13.3% (n=2) (p=0.67) respectively. Two-week mortality was 59.7% overall (n=40), 47.7% (n=21) in the affordable group and 73.3% (n=11) in the unaffordable group (p=0.09) (adjusted OR 0.4; 95% CI: 0.07-2.41, p=0.32). Discussion and Conclusion Ability to pay appears to have a strong association with the use of head CT and a weak association with mechanical ventilation in the management of sTBI. Inability to pay increases redundant or sub-optimal care, and imposes a financial burden on patients and their relatives.
Collapse
Affiliation(s)
| | - Pascal Joackim
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Xian Wu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA
| | - Linda M. Gerber
- Department of Population Health Sciences, Weill Cornell Medicine, New York, USA
| | - Philip E. Stieg
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
| | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
| | - Hamisi Shabani
- Department of Neurosurgery, Muhimbili Orthopedic Institute, Muhimbili National Hospital, Dar-es-Salaam, Tanzania
| | - Halinder S. Mangat
- Department of Neurosurgery, Weill Cornell Brain & Spine Institute, USA
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
2
|
Allen BC, Cummer E, Sarma AK. Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature. J Neurotrauma 2023; 40:602-619. [PMID: 36424896 DOI: 10.1089/neu.2022.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.
Collapse
Affiliation(s)
- Beddome C Allen
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elaina Cummer
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anand K Sarma
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Neurology, Division of Neurocritical Care, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
| |
Collapse
|
3
|
Whitaker J, Harling G, Sie A, Bountogo M, Hirschhorn LR, Manne-Goehler J, Bärnighausen T, Davies J. Non-fatal injuries in rural Burkina Faso amongst older adults, disease burden and health system responsiveness: a cross-sectional household survey. BMJ Open 2021; 11:e045621. [PMID: 34049913 PMCID: PMC8166610 DOI: 10.1136/bmjopen-2020-045621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the epidemiology of injury as well as patient-reported health system responsiveness following injury and how this compares with non-injured patient experience, in older individuals in rural Burkina Faso. DESIGN Cross-sectional household survey. Secondary analysis of the CRSN Heidelberg Ageing Study dataset. SETTING Rural Burkina Faso. PARTICIPANTS 3028 adults, over 40, from multiple ethnic groups, were randomly sampled from the 2015 Nouna Health and Demographic Surveillance Site census. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was incidence of injury. Secondary outcomes were incidence of injury related disability and patient-reported health system responsiveness following injury. RESULTS 7.7% (232/3028) of the population reported injury in the preceding 12 months. In multivariable analyses, younger age, male sex, highest wealth quintile, an abnormal Generalised Anxiety Disorder score and lower Quality of Life score were all associated with injury. The most common mechanism of injury was being struck or hit by an object, 32.8%. In multivariable analysis, only education was significantly negatively associated with odds of disability (OR 0.407, 95% CI 0.17 to 0.997). Across all survey participants, 3.9% (119/3028) reported their most recent care seeking episode was following injury, rather than for another condition. Positive experience and satisfaction with care were reported following injury, with shorter median wait times (10 vs 20 min, p=0.002) and longer consultation times (20 vs 15 min, p=0.002) than care for another reason. Injured patients were also asked to return to health facilities more often than those seeking care for another reason, 81.4% (95% CI 73.1% to 87.9%) vs 54.8% (95% CI 49.9% to 53.6%). CONCLUSIONS Injury is an important disease burden in this older adult rural low-income and middle-income country population. Further research could inform preventative strategies, including safer rural farming methods, explore the association between adverse mental health and injury, and strengthen health system readiness to provide quality care.
Collapse
Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Guy Harling
- Institute for Global Health, University College London, London, UK
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Lisa R Hirschhorn
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospitals, University of Heidelberg, Heidelberg, Germany
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| |
Collapse
|
4
|
Mangat HS, Wu X, Gerber LM, Shabani HK, Lazaro A, Leidinger A, Santos MM, McClelland PH, Schenck H, Joackim P, Ngerageza JG, Schmidt F, Stieg PE, Hartl R. Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort. J Neurosurg 2021; 135:1190-1202. [PMID: 33482641 PMCID: PMC8295409 DOI: 10.3171/2020.8.jns201243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania. METHODS A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model. RESULTS In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model. CONCLUSIONS The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.
Collapse
Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Linda M. Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Hamisi K. Shabani
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Andreas Leidinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Maria M. Santos
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Paul H. McClelland
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | | | - Pascal Joackim
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Japhet G. Ngerageza
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Franziska Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Philip E. Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| |
Collapse
|
5
|
Dixon J, Comstock G, Whitfield J, Richards D, Burkholder TW, Leifer N, Mould-Millman NK, Calvello Hynes EJ. Emergency department management of traumatic brain injuries: A resource tiered review. Afr J Emerg Med 2020; 10:159-166. [PMID: 32923328 PMCID: PMC7474234 DOI: 10.1016/j.afjem.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/20/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. Objectives Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. Methods A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. Key recommendations Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.
Collapse
|