Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

Michael C. Jin BS 1 , Bina Kakusa BS 1 , Seul Ku MS 1 , Silvia D. Vaca MD 2 , Linda W. Xu MD 3 , Juliet Nalwanga MBChB, MMed Surg 4 , Joel Kiryabwire MBChB, MMed Surg 4 , Hussein Ssenyonjo MBChB, MMed Surg 4 , John Mukasa MBChB, MMed Surg 4 , Michael Muhumuza MBChB, MMed Surg 4 , Anthony T. Fuller MD, MSc-GH 5 , 6 , Michael M. Haglund MD, PhD, MACM 5 , 6 and Gerald A. Grant MD 2
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  • 1 School of Medicine and
  • 2 Department of Neurosurgery, Stanford University, Palo Alto, California;
  • 3 Department of Neurosurgery, Allegheny Medical Group, Pittsburgh, Pennsylvania;
  • 4 Department of Neurosurgery, Mulago National Referral Hospital, Kampala, Uganda;
  • 5 Department of Neurosurgery, Duke University, Durham, North Carolina; and
  • 6 Duke Global Neurosurgery and Neurology, Durham, North Carolina
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OBJECTIVE

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.

METHODS

A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.

RESULTS

A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128–0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53–0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05–16.7) and older age (continuous HR 1.03, 95% CI 1.009–1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.

CONCLUSIONS

Inpatient and postdischarge mortality remain high following admission to Uganda’s main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

ABBREVIATIONS GCS = Glasgow Coma Scale; GOSE = Extended Glasgow Outcome Scale; HICs = high-income countries; IPQ-9 = Brief Illness Perception Questionnaire; LMICs = low- and middle-income countries; LOS = length of stay; MNRH = Mulago National Referral Hospital; PHQ-9 = Patient Health Questionnaire-9; PTE = posttraumatic epilepsy; RTA = road traffic accident; SF-12 = 12-Item Short-Form Health Survey; TBI = traumatic brain injury.

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Contributor Notes

Correspondence Gerald A. Grant: Stanford University, Stanford, CA. ggrant2@stanford.edu.

INCLUDE WHEN CITING Published online July 3, 2020; DOI:10.3171/2020.4.JNS193092.

M.C.J. and B.K. contributed equally to this work.

Disclosures Dr. Haglund reports clinical or research support for this study from Nuva and LifeNet, support of non–study-related clinical or research effort from UCB Pharma, and being a consultant to Nuva.

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