Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury
Authors: Giugni Aimone , Gamberini Lorenzo , Carrara Greta , Antiga Luca , Brissy Obou , Buldini Virginia , Calamai Italo , Csomos Akos , De Luca Alessandra , Ferri Enrico , Fleming Joanne M. , Gradisek Primoz , Kaps Rafael , Kyprianou Theodoros , Lagomarsino Silvia , Lazar Isaac , Martino Costanza , Mikaszewska-Sokolewicz Malgorzata , Montis Andrea , Nardai Gabor , Nattino Giovanni , Nattino Giuseppe , Paci Giulia , Portolani Laila , Xirouchaki Nektaria , Chieregato Arturo , Bertolini Guido ,   for The CREACTIVE consortium, Ágnes Sárkány , Agostini Fulvio , Ajmone-Cat Claudio , Bassi Giovanni , Bekos Vasileios , Bellin Marzia , Bocci Maria Grazia , Bonato Valeria , Bonato Alfeo , Bonizzoli Manuela , Bonucci Paola , Bottazzi Andrea , Calicchio Giuseppe , Carlin Fabrizia , Casagli Sergio , Castioni Carlo Alberto , Ciceri Rita , Cocciolo Francesco , Crestan Ezio , Cseplo Peter , Csomos Akos , Curto Francesco , Dąbrowski Wojciech , De Cristofaro Anna , De Luca Alessandra , Duda Izabela , Duek Or , Bakó Blanka Emoke , Fagoni Nazzareno , Fassini Paola , Ferri Enrico , Filekovic Suada , Fiore Gilberto , Gamberini Emiliano , Gattari Diego , Gianni Massimo , Dessena Maria Giovanna , Giuntini Romano , Guido Stefania , Gyulai Rita , Hadash Amir , Hribar Renata , Ilia Stavroula , Novak Jankovič Vesna , Jurekovic Vlado , Jereb Mateja , Kapias Maciej , Karadzic Dragica , Kasnik Darja , Kioulpalis Anastasios , Szaszi Adrienn Kitti , Kompan Janez , Kyriakides Eraclis , Lamborghini Sara , Livigni Sergio , Malacarne Paolo , Martelli Maria , Martin Marina Alessandra , Marudi Andrea , Melis Martina , Mengoli Francesca , Mirkovic Tomislav , Mizak Wiktoria , Munari Marina , Nascimben Ennio , Natalini Giuseppe , Negro Giancarlo , Nemes Csaba , Bernasconi Mara Olga , Pagani Michele , Parrini Vieri , Partala Panagio , Pastorelli Mauro , Pellicioli Isabella , Bert Paolo Perino , Petrucci Nicola , Piva Simone , Poole Daniele , Radrizzani Danilo , Rekas Anna , Robak Paweł , Rosano Antonio , Ruggeri Patrizia , Sacchi Marco , Skoti Mara , Skrt Alja , Spagarino Ermanno , Sulkowski Wiktor , Szedlák Balázs , Terzitta Marina , Tinturini Rebecca , Tofani Rossella , Tselioti Paraskevi , Vecchiarelli Ada , Venturini Elisabetta , Visconti Salvatore , Xirouchaki Nektaria , Zompanti Valeria , Zoppellari Roberto 
Published: November 2021

Abstract
Background
We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH).

Methods
The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality.

Results
A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk.

Conclusions
In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs.