Thromboembolism prophylaxis timing is associated with center mortality in traumatic brain injury: A Trauma Quality Improvement Program retrospective analysis.

Abstract

Background: Timing of venous thromboembolism chemoprophylaxis (VTEPPx) in traumatic brain injury (TBI) is complex given concerns for potential worsening of hemorrhage. While timing of VTEPPx for TBI patients is known to vary at the patient level, to our knowledge, variation at the hospital level and correlation with quality metrics have not been quantified in a cohort of nonneurosurgical patients.

Methods: This was a retrospective cohort study of the Trauma Quality Improvement database from 2018 to 2021. The primary outcome was variation in VTEPPx timing. This was ascertained by empirical Bayesian methodology using multilevel mixed-effects logistic regression. Secondary outcomes included the association of risk-adjusted VTEPPx timing and hospital characteristics such as volume and risk-adjusted mortality, which was assessed through Pearson's correlation coefficient ( r ). Risk-adjusted mortality was similarly calculated using multilevel mixed-effects modeling.

Results: Of 132,028 patients included in the current study, 38.7% received care at centers in the earliest quartile of VTEPPx timing, classified as Early (others labeled Delayed ). Patients receiving care at Early centers presented with severe TBI at a similar rate to Delayed (17.4% vs. 19.0%; absolute standardized mean difference, 0.04). Early center patients more commonly received unfractionated heparin as opposed to low-molecular-weight heparin compared with Delayed (40.5% vs. 27.6%; absolute standardized mean difference, 0.28). At the center level, 12% of observed variation in VTEPPx was attributable to differential hospital practices. Overall trauma volume ( r = -0.22, p < 0.001) and TBI volume ( r = -0.19, p < 0.001) were inversely associated with risk-adjusted VTEPPx timing. In addition, centers initiating VTEPPx earlier had lower overall ( r = 0.17, p < 0.001) and TBI-related mortality ( r = 0.17, p < 0.001).

Conclusion: There is significant center-level variation in timing of VTEPPx among TBI patients. Earlier VTEPPx was associated with improved center outcomes overall and among TBI patients, supporting usage of VTEPPx timing as a holistic measure of quality.

Level of evidence: Prognostic and Epidemiological; Level III.