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Table of Contents    
ORIGINAL ARTICLE
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 305-314

A systematic review of quantitative research on traumatic brain injury in India


1 Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York; Program in Global Surgery and Social Change, Harvard Medical School, Boston; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA
2 Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India
3 Program in Global Surgery and Social Change, Harvard Medical School, Boston; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
4 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
5 Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India; Tata Institute of Social Sciences, School of Habitat, Mumbai, India; Health Systems and Policy, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
6 Health Systems and Policy, Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden

Date of Web Publication10-Mar-2017

Correspondence Address:
Benjamin B Massenburg
50 E 98th Street, New York - 10029
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_719_16

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 » Abstract 

Introduction: Over a quarter of the world's trauma deaths occur in India, with traumatic brain injury (TBI) as the leading cause of death and disability within trauma. With little known about TBI in India, we set out to do a systematic review to characterize the quantitative literature on TBI in India.
Materials and Methods: The following databases were searched from their inception to December 31, 2015: PubMed, Cochrane, Web of Science, and the World Health Organization's Global Health Library, using the keywords: neurotrauma, brain injury, traumatic brain injury, TBI, head injury, and India. Articles were screened by two independent reviewers, with disagreements arbitrated by discussion or a third reviewer.
Results: A total of 72 manuscripts were included, encapsulating 19962 patients over 27 years in 14 states of India. The sample-size-weighted mean age was 31.3 years, male-to-female ratio was 3.8:1, and sample-size-weighted mean in-hospital mortality was 24.6%. Age and mortality did not change significantly over time. Road traffic accidents (55.5%) and falls (29.2%) were the most commonly reported mechanisms of injury for TBI in India. The mean quality of reporting on TBI in India was 65.7%, according to the appropriate EQUATOR guideline score.
Conclusion: The quality of reporting of quantitative studies published on TBI in India is low, and future methodological excellence should be ensured. The demographics and outcomes identified can be used as an epidemiological baseline for future research on TBI in India. Future research can build upon this platform to develop and refine context-appropriate policy recommendations and treatment protocols.


Keywords: India, neurotrauma, TBI, traumatic Brain Injury
Key Messages:

  • High quality research on traumatic brain injury (TBI) in India is lacking but essential.
  • The implementation of certain checklists, like CONSORT for randomized-controlled trials, has led to significant improvements in reporting quality.
  • TBI is a complex disease process, but the results of this systematic review can be used as an epidemiological baseline for future research on TBI in India.


How to cite this article:
Massenburg BB, Veetil DK, Raykar NP, Agrawal A, Roy N, Gerdin M. A systematic review of quantitative research on traumatic brain injury in India. Neurol India 2017;65:305-14

How to cite this URL:
Massenburg BB, Veetil DK, Raykar NP, Agrawal A, Roy N, Gerdin M. A systematic review of quantitative research on traumatic brain injury in India. Neurol India [serial online] 2017 [cited 2017 Mar 26];65:305-14. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/305/201868


According to the most recent Global Burden of Disease study, over a quarter of the world's trauma deaths occur in India.[1],[2] In addition, traumatic brain injury (TBI) is the leading cause of death and disability within trauma, and the majority of this burden is experienced by low- and middle-income countries (LMICs).[3],[4] Maximizing prevention and optimizing treatment for TBI will be a critical strategy to address the growing number of deaths and disabilities from these injuries.

However, there are large gaps in research on TBI in countries with its highest burden.[4],[5],[6],[7] Furthermore, global research on neurotrauma must be performed in context because the transfer of evidence-based guidelines from a high-income setting do not apply to the injuries experienced in LMICs.[4],[8] Global health professionals from high-resource setting have been encouraged to partner equally with the clinicians and administration in LMICs to improve the quality of research and ultimately the delivery of care.[9] Pursuing this in neurotrauma research will ensure that local concerns are prioritized in order to more effectively use the shared resources of comparable global health movements.

In order to address a growing TBI pandemic, high quality research is necessary to drive policy decisions on trauma prevention and treatment guidelines. Little is known, however, regarding the basic characteristics of TBI in India. Previous studies have estimated the mortality rate for TBI in various areas in India to be approximately 14.7%, but this has not been systematically assessed nationwide.[7],[10],[11] Similarly, little is known about the demographics and mechanisms of injury for TBI in India, or the quantity and quality of academic literature published on this topic. We set out to do a systematic review to characterize the quantitative literature on TBI in India.


 » Materials and Methods Top


Search strategy and selection criteria

We performed a systematic review of the following databases: PubMed (January 1, 1946 to December 31, 2015), Cochrane (January 1, 1898 to December 31, 2015), Web of Science (January 1, 1864 to December 31, 2015) and the World Health Organization (WHO) Global Health Library (January 1, 1947 to December 31, 2015). We searched using appropriate combinations of keywords and MeSH terms including neurotrauma, brain injury, traumatic brain injury, TBI, head injury, and India [Appendix 1] [Additional file 1]. We checked the reference list of all included articles for additional studies. The inclusion criteria were case series, case-control studies, cohort studies, randomized studies, systematic reviews, and meta-analyses in English language including 50 or greater human patients of any age who experienced TBI in India. Patient data was required to have originated from India. Neonatal and birth trauma studies were excluded. Case reports, comments, editorials, and letters to the editor, as well as any study with a sample size less than 50, animal studies, and articles without full-text available online were excluded. TBI included any definition provided by the authors of the reviewed studies. Prior to beginning the systematic review, the search protocol was registered with PROSPERO, the international prospective register of systematic reviews (no. 35578).

Outcomes of interest and quality assessment

Outcomes of interest in the quantitative portion of this study include quality of reporting, patient age, patient gender, Mechanisms of injury, and in-hospital mortality. Mechanism of injury included assault, burn, fall, railway accident, road traffic accident, and others. A quality score was created by calculating the percentage of completion of the appropriate reporting guideline: Randomized trials were assessed with the CONSORT guidelines, observational studies were assessed with the STROBE guidelines, and systematic reviews and meta-analyses were assessed with the PRISMA guidelines.

Data extraction

Two investigators (BBM and DKV) independently determined study eligibility, first by title, then abstract, and then full-text, and independently extracted data from the full-text of the articles using a standardized extraction form in Qualtrics. Disagreements in study eligibility during the title review were resolved by including the article for further review. Disagreements in abstract review and data extraction were resolved through systematic discussion or data extraction by a senior investigator (MG or NPR). Disagreements in quality scores for each article were averaged if the score from each investigator differed by less than 15%. If the quality score differed by 15% or greater, the quality was assessed by a senior investigator.

Statistical analysis

We tabulated the characteristics and results of all included studies; the analysis was quantitative. Patient demographics and mortality were calculated from all studies that provided this data using weighted averaging. Weights were based on the sample size of the study. Linear regressions were performed on patient age, mortality, and quality scores over time. All statistical analyses were performed using R and geographic mapping using QGIS.

Role of the funding source

There was no funding source for this study. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.


 » Results Top


Searching PubMed, Cochrane, Web of Science, and the WHO Global Health Library Report databases from their inception to December 31, 2015 resulted in 1508 manuscripts. After inclusion and exclusion criteria were applied by two unique reviewers (BBM and DKV), disagreements were arbitrated by discussion or a third reviewer (MG or NPR), and the references of the articles were reviewed for any missing manuscripts.

A total of 72 manuscripts were found suitable and were included to represent the quantitative research published on TBI in India [[Figure 1], Appendix 2] [Additional file 2].[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81] Six manuscripts (8.3%) were randomized controlled trials and 66 (91.7%) were observational studies. No systematic reviews were identified that met the inclusion and exclusion criteria. The quantity of published articles on TBI in India increased over time [Figure 2], as only one article was included from the inception of the medical databases to 1990 and 11 articles were included from 2015 alone.
Figure 1: PRISMA flow chart displaying inclusion and exclusion criteria applied throughout the systematic review

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Figure 2: Quality of reporting (y-axis) and sample size (size of circle) of randomized controlled trials (RCT, blue) and observational studies (pink) on traumatic brain injury in India over time (x-axis)

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There were a total 19962 patients over 27 years in 14 states of India in the included studies [Figure 3]. Gender was reported in 53 (73.6%) studies, with a male-to-female ratio of 3.8:1, from 11018 (79.2%) male and 2897 (20.8%) female patients.
Figure 3: State map of India displaying where the 19962 patients identified in this study were treated

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The mean age was reported in 32 (44.4%) studies, and the sample-size-weighted mean across these studies was 31.3 years of age, ranging from mean ages of 1.6 years to 56.76 years of age. The age of patients experiencing TBI did not change significantly over time (slope = 0.099 years of age/year, P = 0.722) [Figure 4].
Figure 4: Age of patients who experienced traumatic brain injury in India over time

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In-hospital mortality was reported in 25 (34.7%) studies, with a sample-size-weighted mean mortality of 24.6% for patients presenting with TBI in India. Reported in-hospital mortality for TBI in India varied by state. Mortality of TBI in India did not change significantly over time (slope = −0.46% mortality/year, P = 0.442) [Figure 5].
Figure 5: Reported mortality of traumatic brain injury in India over time

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Mechanism of injury was reported in 28 (38.8%) studies, with road traffic accidents (55.5%) and falls (29.2%) as the most commonly reported mechanism of injury for TBI in India [Appendix 3].[Additional file 3]

All 72 studies were assessed for reporting quality. Randomized trials scored an average of 55.0% using the CONSORT guidelines. Observational studies scored an average of 66.7% using the STROBE guidelines. In total, the mean quality of reporting on TBI in India was 65.7% and varied greatly by state [Figure 6]. The quality of reporting did not change significantly over time (slope = 0.28% score/year, P = 0.301) [Figure 2].
Figure 6: Quality of reporting on traumatic brain injury by state in India

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 » Discussion Top


This study represents the first systematic review of quantitative research on TBI in India, pooling data from nearly 2000 patients, over 27 years, across 14 states, in 72 manuscripts. Almost 4 in 5 (79.2%) patients in the included studies were males, the mean age was 31.3 years, and the mean reported in-hospital mortality was 24.6%. The most common mechanisms of injury were road traffic accidents and falls, which together made up more than 80% of the reported patients experiencing TBI in India. The mean age and reported mortality did not significantly change over the past 27 years.

This compares well to data on TBI from other LMICs, The mean gender ratio of 3.8 males per female is similar to the reported ratios of 3.5 males per female in Brazil [82] and 3.2 in China.[83] However, it is significantly different from that in the United States, where the gender ratio is 1.4 males to females.[84] The age of patients in high-income countries has also been reported to be increasing over time, whereas it remains younger in LMICs and remained unchanged over our study period in India.[85] The age distribution from the included studies on India was similar to the age distribution in Brazil and China,[82],[83] but younger than the age distribution in the United States or Europe.[84],[86]

Similarly, the reported mechanisms of injury for TBI in India compares well to data from other LMICs. Road traffic accidents have been reported to cause over half of the cases of TBI in China [83] and have been reported as the most common cause of TBI in many African countries.[87],[88],[89] However, in the United States, the most common cause of TBI is a fall.[84] The differences in gender and age profiles of patients experiencing TBI in India and other LMICs compared to high-income countries are most likely influenced by the differing mechanisms of injury in these settings. With a growing elderly population in the United States, and equal propensity to fall between both genders, the age and gender distribution of TBI in the United States is understandably older and more equally divided between males and females. Similarly, in other countries with high rates of road traffic accidents, the male predominance in trauma is estimated to be due to a relatively higher number of male drivers, despite recent increases in the number of female drivers.[90]

High quality research will be important to formulate recommendations to drive policy change in the area of neurotrauma prevention and treatment. In the included studies, there was wide variation in the quality of reporting, with studies scoring as low as 32% and as high as 100%, with a median of 68.2% on the appropriate quality checklist. There was no significant change in the quality of reporting in neurotrauma research during the study period. This may be due to limited resources for research because of clinical burden, language barriers for publishing in English journals, small sample sizes, or lack of information management systems to facilitate data collection and research.[7] In Europe, a need for improved methodological quality and standardization of reporting has similarly been identified.[86] However, there have been significant improvements in the quality of surgical research in the United States over a similar time period.[91] International medical journals have also noted that the implementation of certain checklists, such as CONSORT for randomized-controlled trials, has led to significant improvements in reporting quality.[92]

In India, however, low quantity and poor quality of reporting in medical publications is not isolated to research on TBI. Over half of all medical teaching institutions in India did not produce an identifiable publication between 2005 and 2014.[93] The authors of that study concluded that Indian medical education needs a reform, similar to the Flexner reform in the early 20th century United States.[93],[94] Without high quality studies, recommendations for policy changes will not have strong clinical and empirical evidence. Research should be incentivized from the undergraduate and medical school level. In Norway, the implementation of a medical student research program increased the recruitment of medical graduates to a career in medical research.[95] Though the quality of reporting in studies published on TBI in India is not significantly improving over time, a current and future push to ensure high quality study design should improve this trend.

Our study has important limitations. We were only able to compile and analyze the reported data on TBI in India. Non-academic and rural medical centers were significantly under-represented in our dataset. Given that much of the data were from academic centers in urban areas, and two-thirds of the Indian population in India lives in rural areas,[96] this data does not necessarily represent the experience of all patients who experience TBI and physicians who treat TBI in India. For instance, the reported in-hospital mortality of this review may be falsely low if hospital referral systems and ambulances function better in the urban, higher-resource settings that publish their data than in the rural areas. Partnerships between urban centers with greater research capability and rural centers should be encouraged in order to better characterize the experience of TBI across India. In addition, trend analyses were done using linear regression without adjusting for potential autocorrelation of the error terms. Therefore, results of significance tests should be interpreted conservatively. Finally, TBI is a complex disease process, making it difficult to generalize across heterogeneous studies.[4],[8] No distinction was made between mild, moderate, and severe TBI during data collection, so it was not possible to distinguish variance in these mortality rates. Thus, the results and discussion in this paper should be interpreted and applied carefully.

Most of the evidence driving the policies and recommendations for the care of a patient who has experienced TBI come from high-resource settings.[4] The implementation and adherence to treatment guidelines for TBI in high-income settings has been associated with a significant reduction in TBI mortality,[97] though the reported TBI mortality in India has not changed. These high-income recommendations are best applied in well-equipped settings with similar resources. For areas that are vastly different, new policies and recommendations should be developed. If this is not feasible, caution should be exercised when transferring guidelines and policies between different contexts. A baseline of care should be measured for lower resource settings, similar to this study characterizing the quality of reporting, the demographics, and the outcomes of patients who experienced TBI in India. This certainly warrants future investigation to develop context-appropriate guidelines and recommendations.


 » Conclusions Top


The quality of reporting of quantitative studies published on traumatic brain injury in India is low, and future methodological excellence should be ensured. Patients from the included quantitative studies on traumatic brain injury in India are young and largely male. Road traffic accidents are the most commonly reported mechanisms of injury for traumatic brain injury in India. The demographics and outcomes identified in this study can be used as an epidemiological baseline for future research on TBI in India. Future research can build upon this platform to develop and refine context-appropriate policy recommendations and treatment protocols.

Author disclosure statement

I, Benjamin Massenburg, on behalf of all the authors (Benjamin B. Massenburg, Deepa Kizhakke Veetil, Nakul P. Raykar, Amit Agrawal, Nobhojit Roy, Martin Gerdin), declare that there are no conflicts of interest that need to be reported and that ethical guidelines have been adhered to in the preparation of this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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