Traumatic Brain Injury: Evidence, Guidelines and Treatment Variation

Traumatic Brain Injury (TBI) is a heterogeneous disease with a high incidence, morbidity and mortality. Good treatment modalities are, especially for severe traumas, few and for most of them there is little to no evidence available in the literature. This thesis aims to analyze and improve the evidence generation process and its translation to guidelines. From our analyses we conclude that the recommendations in the past were unjustly highly graded. Moreover, the chance that a certain recommendation still appears in a subsequent edition of the guidelines (“survival”) is around 30 percent. However, methodologically sound evidence is being published and the quality of research in TBI is improving, but very high quality evidence to guide care is still lacking.We also show that despite the improvement in evidence base, the number of recommendation decreases. This leads to highly significant variation in clinical practice, which means the guidelines suffer from low adherence and the treatment a patient receives in one city is very different than the treatment the same patient would receive in a city just 50 km further. To illustrate new evidence generation methods we used a "comparative effectiveness research" approach, in which we used these differences in patient care in an attempt to determine what the best way is to monitor intracranial pressure after severe head trauma. We have shown that choosing one of these monitors is associated with less need for surgery.

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