The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: a systematic review.

INTRODUCTION: Although many articles report complications after pelvic ring and acetabular fracture surgery, a general overview of complication rates and potential risk factors is lacking. The current review provides a comprehensive summary of the complications after pelvic ring and acetabular fracture surgery in relation to the surgical approach. MATERIAL AND METHODS: Pubmed and Embase databases were systematically searched using the key words: pelvic fracture, acetabular fracture, fixation, surgical approaches, complications, and their synonyms. Extracted data included patient and fracture characteristics, surgical approaches, and post-operative complications; surgical site infections (SSI), implant-related complications, malunion and non-union. Study data were summarized using descriptive statistics. RESULTS: Twenty-two studies (twenty-one retrospective cohort studies, of which three comparative, and one randomized controlled trial) were included in this review. The overall complication rates reported for the included surgical approaches were: 17% for the (Modified) Stoppa approach, 11% for percutaneous fixation, 5% for the Kocher-Langenbeck approach, 7% for the ilioinguinal approach and 31% for external fixation. The most frequent complications were SSI (22%) and neurological (31%) complications, which were most often reported in patients treated with an external fixator. Re-operation rates were comparable for the surgical approaches (4-8%). Two studies reported on risk factors and identified concomitant traumatic injuries, prolonged ICU stay and high body mass index as risk factors for SSI. CONCLUSION: External fixation of pelvic fractures is associated with highest complications rates including SSI's and neurological complications. Although post-operative complications are frequently reported after pelvic fracture surgery, more studies are needed that identify potential risk factors. These will assist the surgeon in (pre)operative decision making and development of preventive strategies.

[Regulated market failure in healthcare; quality comparisons can improve competition in the Dutch healthcare market]. / Gereguleerd marktfalen in de zorg.

Competition in healthcare markets is controversial, as financial interests may negatively influence patient interests. In The Netherlands, public healthcare quality indicators are published annually, but no comparisons are made between hospitals and private healthcare facilities (PHF) operating in the Dutch healthcare market. Just nine such indicators could be compared, demonstrating an overall equivalence of success and complication rates. It is known that PHFs treat healthier patients, and as such their quality of care may in fact be lower. However, without casemix information, no conclusions on healthcare quality can be drawn from the Dutch experiment with regulated competition in the healthcare market. This lack of full, transparent information is a cause of market failure, but can be improved by implementing quality comparisons using routinely collected casemix variables.

Long-term outcome after severe traumatic brain injury: a systematic literature review.

BACKGROUND: Expectation of long-term outcome is an important factor in treatment decision-making after severe traumatic brain injury (sTBI). Conclusive long-term outcome data substantiating these decisions is nowadays lacking. This systematic review aimed to provide an overview of the scientific literature on long-term outcome after sTBI. METHODS: A systematic search was conducted using PubMed from 2008 to 2020. Studies were included when reporting long-term outcome ≥ 2 years after sTBI (GCS 3-8 or AIS head score ≥ 4), using standardized outcome measures. Study quality and risk of bias were assessed using the QUIPS tool. RESULTS: Twenty observational studies were included. Studies showed substantial variation in study objectives and study methodology. GOS-E (n = 12) and GOS (n = 8) were the most frequently used outcome measures. Mortality was reported in 46% of patients (range 18-75%). Unfavourable outcome rates ranged from 29 to 100% and full recovery was seen in 21-27% of patients. Most surviving patients reported SF-36 scores lower than the general population. CONCLUSION: Literature on long-term outcome after sTBI was limited and heterogeneous. Mortality and unfavourable outcome rates were high and persisting sequelae on multiple domains common. Nonetheless, a considerable proportion of survivors achieved favourable outcome. Future studies should incorporate standardized multidimensional and temporal long-term outcome measures to strengthen the evidence-base for acute and subacute decision-making. HIGHLIGHTS: 1. Expectation of long-term outcome is an important factor in treatment decision-making for patients with severe traumatic brain injury (sTBI). 2. Favourable outcome and full recovery after sTBI are possible, but mortality and unfavourable outcome rates are high. 3. sTBI survivors are likely to suffer from a wide range of long-term consequences, underscoring the need for long-term and multi-modality outcome assessment in future studies. 4. The quality of the scientific literature on long-term outcome after sTBI can and should be improved to advance treatment decision-making.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study.

BACKGROUND: The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI. METHODS: We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation. RESULTS: A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%). CONCLUSION: In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BACKGROUND: The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness. METHODS: This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation. RESULTS: Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580). CONCLUSIONS: Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.