Impact of Initial Care at a Neurosurgery-Capable Facility on Mortality Among Patients with Moderate-to-Severe Traumatic Brain Injury in South Africa

OBJECTIVE: Moderate-to-severe traumatic brain injury (msTBI) disproportionately affects populations in low- and middle-income countries. This study examines how initial care at a neurosurgery-capable facility (NCF) affects survival. METHODS: This is a secondary analysis of data collected in the EpiC study from the Western Cape of South Africa. The study period was January 2022 to October 2024 and included adult patients with msTBI who survived to hospital arrival. The study compares in-hospital TBI-associated mortality among NCF and non-NCF groups using inverse probability of treatment weighted logistic regression models. RESULTS: A total of 620 patients with msTBI were included (210 NCF and 410 non-NCF, including 291 who were later transferred to the NCF), with mean age 34 years, 89% male, and 78% blunt injury. NCF group had lower Glasgow Coma Scale (median 4 vs. 9, p < 0.01), worse injury severity (median New Injury Severity Score [NISS] 34 vs. 27, p < 0.01), and greater likelihood of ambulance transport (94% vs. 51%, p < 0.01). NCF group received head computed tomography (CT) earlier (median 6 h vs. 15 h, p < 0.01). Neurosurgical procedures occurred faster for NCF compared with non-NCF patients (median 12 h vs. 23 h, p = 0.13). Almost one-third (29%) of the cohort experienced TBI-associated mortality (37% vs. 25%, p < 0.01). After adjustment for confounders and effect modifiers such as age, sex, EMS arrival, intubation within 24 h of injury, NISS, initial GCS, polytrauma, hypotension, and blood product administration, NCF was associated with lower odds of TBI-associated mortality (adjusted OR 0.51, CI 0.34-0.75, p < 0.01). CONCLUSIONS: Direct transport to NCF was associated with improved survival for patients with msTBI in South Africa.