Outlining the global variation in resources for traumatic brain injury care: site-level data from the Global Neurotrauma Outcomes Study (GNOS)

INTRODUCTION: Traumatic brain injury (TBI), a leading cause of global morbidity and mortality, has notably poorer outcomes in resource-poor settings. Managing TBI effectively requires functional integration of several interdependent phases of care which, in resource-poor settings, may be both individually fragile and poorly coordinated. However, there is a paucity of global data quantifying systemic deficiencies in TBI care across varying resource settings which hinders targeted improvement. To address this, we present an analysis of site surveys from centres contributing to the Global Neurotrauma Outcomes Study, to illustrate the global variation in health system performance with respect to TBI management. METHODS: The GNOS was a prospective, international, multicentre cohort study conducted between 1 November 2018 and 31 January 2020 across 159 centres that perform emergency surgery for TBI. Participating centres completed a 50-point site survey, assessing local resource availability and guideline usage across the TBI care pathway, including prehospital, intraoperative and rehabilitative care. Responses were stratified by each country's Human Development Index (HDI). RESULTS: The site survey was completed by 153/159 (96%) centres. Variation in resource availability across HDI strata was least prevalent within operating theatres, whereas the biggest disparities were observed in prehospital and rehabilitation care. Resource-poor settings reported deficiencies in both the capital resources and skilled human resources needed to deliver TBI care. Overall, participants most commonly suggested that improvements in prehospital care would have the greatest impact on patient outcomes in TBI (53/153, 35%), although participants from the more resource-poor settings more commonly suggested improvements in intensive care management (6/14, 43%). CONCLUSION: There are profound HDI-associated disparities in the resources for TBI care, which likely account for the global variation in patient mortality. Our study suggests improving the provision of non-operative interventions within TBI care pathways may offer the most successful approach to improve patient outcomes. TRIAL REGISTRATION NUMBER: NCT04212754.