title: The effect of specialist neurosciences care on outcome in adult severe head injury: a cohort study.
abstract: BACKGROUND
  Head injury is the leading cause of death in trauma. UK national guidelines have recommended that all patients with severe head injury (SHI) should be treated in neuroscience centers. The aim of this study was to investigate the effect of specialist neuroscience care on mortality after SHI.
  
  
  METHODS
  We conducted a cohort study using prospectively recorded data from the largest European trauma registry, for adult patients presenting with blunt trauma between 2003 and 2009. Mortality and unadjusted odds of death were compared for patients with SHI treated in neuroscience units (NSU) versus nonspecialist centers. To control for confounding, odds of death associated with non-NSU care were calculated using propensity score-adjusted multivariate logistic regression (explanatory covariates: age, Glasgow Coma Score, Injury Severity Score, treatment center). Sensitivity analyses were performed to study possible bias arising from selective enrollment, from loss to follow-up, and from hidden confounders.
  
  
  RESULTS
  5411 patients were identified with SHI between 2003 and 2009, with 1485 (27.4%) receiving treatment entirely in non-NSU centers. SHI management in a non-NSU was associated with a 11% increase in crude mortality (P<0.001) and 1.72-fold (95% confidence interval: 1.52-1.96) increase in odds of death. The case mix adjusted odds of death for patients treated in a non-NSU unit with SHI was 1.85 (95% confidence interval: 1.57-2.19). These results were not significantly changed in sensitivity analyses examining selective enrollment or loss to follow-up, and were robust to potential bias from unmeasured confounders.
  
  
  CONCLUSIONS
  Our data support current national guidelines and suggest that increasing transfer rates to NSUs represents an important strategy in improving outcomes in patients with SHI.
authors.affiliation: Trauma Audit and Research Network, Health Sciences Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Clinical Sciences Building, Salford Royal Hospital, Salford, UK. gordonwfuller@doctors.net.uk
authors.forename: Gordon
authors.initials: G
authors.lastname: Fuller
authors.forename: Omar
authors.initials: O
authors.lastname: Bouamra
authors.forename: Maralyn
authors.initials: M
authors.lastname: Woodford
authors.forename: Tom
authors.initials: T
authors.lastname: Jenks
authors.forename: Hirin
authors.initials: H
authors.lastname: Patel
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Coats
authors.forename: Peter
authors.initials: P
authors.lastname: Oakley
authors.forename: A David
authors.initials: AD
authors.lastname: Mendelow
authors.forename: Tim
authors.initials: T
authors.lastname: Pigott
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Hutchinson
authors.forename: Fiona
authors.initials: F
authors.lastname: Lecky
mesh_terms: D000328:Adult; D015331:Cohort Studies; D006259:Craniocerebral Trauma / Q000145:classification / Q000401:mortality / Q000628:therapy*; D005060:Europe; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009488:Neurosciences; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D013038:Specialization; D016019:Survival Analysis; D014193:Trauma Centers / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D055815:Young Adult