Quality of life in patients with traumatic brain injury: A single tertiary center experience

Introduction Traumatic brain injury (TBI) is the main cause of death in motor-vehicle accidents. Investigation on the quality of life in patients with TBI would provide essential information for the society and policy makers in seeking the optimum ways to manage this devastating injury. Methods A total 178 of patients were involved in this study, consists of 97 patients with TBI and 81 non-TBI patients. The patients’ quality of life was evaluated by using Euroqol 5D (EQ-5D) up to 3 months of follow up. Then, the results of EQ-5D were analyzed.


Introduction
Traumatic brain injury (TBI) is the main cause of mortality and morbidity in young adults, particularly in motor-vehicle accidents. Several factors such as high mobility and lack of road safety awareness contribute to the high prevalence of TBI in those group. An estimated about more than 50% of mortality in tra c accidents is due to TBI. Approximately about 50-60 million people suffered from head injuries worldwide annually, with mortality rate of 4% and morbidity rate of 5%. 1,2,3 TBI is de ned as non-degenerative and non-congenital trauma that occurs as a result of external mechanical force causing head to experience temporary or permanent psychological, cognitive and psychological disorders. 4 TBI is commonly observed in male than female with ratio of 3:2. 1,2,3 The common causes of TBI in adulthood are motor vehicle accidents and violence, while falling is frequent in elderly patients.. 5 related to the underlying disease, success of the surgery and postoperative rehabilitation. Hence, an appropriate management planning is needed to optimize the quality of life of each patient. 6 Despite of any complex efforts in the management of patients with TBI, mortality and morbidity among these patients remained high. 7,8 Thus, any information regarding their quality of life after treatment is important as the basic foundation for delivering informed consent for patients and their families. This study aimed to assess the quality of life in patients with TBI after their hospitalization. In order to objectively compare the role of TBI in the prognosis of TBI patients, the results from TBI patients were then compared to the results from non-TBI patients.

Methods
The ethical clearance was obtained from the Ethical Committee of the Faculty of Medicine, Universitas Padjadjaran and Hasan Sadikin General Hospital. All TBI patients who were ≥ 18 years old and treated at Hasan Sadikin Hospital in between October 2015 and March 2016 were included in this study. In the non-TBI group, all non-TBI patients who were of the same age group with TBI patients, and treated at the same neurosurgical center in the same period of times were included. Quality of life in both groups were assessed by using Euroqol-5D (EQ-5D) 7 at the time of discharge and 3 months after being discharged from the hospital. This study was a prospective cohort study, all data were analyzed then described by using tables and graphs. After discharge, the patients were then evaluated by ling in the questionnare at 3 months post hospitalization.
The data was analyzed with Graph Pad Prism 8.0 and p < 0.05 was considered as statistically signi cant.

Results
A total of 178 patients were included in this study, consisting 97 patients with TBI and 81 non-TBI patients. There was no difference in term of social and demographic baseline between two groups ( Table   1, p<0.05). All patients were evaluated at each time point and 37 patients were died during hospitalization Twenty patients with TBI and 17 non-TBI patients were died during hospitalization. Patients with TBI who died during hospitalization (39.21 ± 10.39 years old) tend to be younger than non-TBI patients (43.87 ± 13.21 years old), however this tendency was not signi cant (p=0.2379). Majority of mortality occurred in patients with low GCS (3-8) in both groups. Majority of mortality occurred in male, but there was no signi cant different in both groups ( Table 2).
Of the remaining surviving patients (77 patients with TBI and 64 non-TBI patients), were subjected for the evaluation for the quality of life. At 3 months post hospitalization, severe impairment of mobility and selfcare were commonly observed in patients with TBI than patients without TBI (p<0.05, Table 3). There was no difference in term of proportion of patients with severe problem of daily routine activity, pain, and anxiety or depression (p>0.05). discharged, in all 5 parameters of EQ-5D (mobility, self-care, routine activity, pain, anxiety or depression, p<0.05), however this trend did not reach statistically signi cant (p>0.05, Table 4)..

Discussion
TBI, remains a growing public health concern and represents the major contributor to death and disability globally among all trauma-related injuries and also known as the silent epidemic. 1,2,3 According to estimates based on literature reported numbers 1,2,3 , about 50-60 million individuals are affected by TBI each year, and it is predicted that close to 50% of the world's population will sustain a TBI in their lifetime. 9 Patients with mild, moderate or severe brain injuries suffer from physical, cognitive, behavioural, emotional and social problems, however speci c instruments or objective assessment to evaluate quality of life in patients with TBI is scarce. 10 In Indonesia particularly, the information regarding the quality of life in patients with TBI is severely lacking, hence creating a gap for policy making and public health intervention.
In this study, we investigated the quality of patients with TBI and compared the ndings with similar clinical characteristics from non-TBI patients. We found that patients with TBI had a tendency to die at a younger age than non-TBI patients, although it did not reach statistical signi cance. This nding re ect the condition in our region that majority of patients with TBI were young adults and male. These population are at high risk for having TBI due to highly mobile and lack of road safety awareness. 11,12 In this study, we found that mortality commonly observed in patients with lower GCS either in patients with TBI and non-TBI. This nding in accordance to literatures, suggesting initial GCS value re ects the state of brain damaged or neurological insults. Low GCS value is associated with dismal prognosis. 13,14 We found that at 3 months of follow up, patients with TBI were more frequent to have impairment in mobility and self-care than non-TBI patients. This nding indicate that the social burden of TBI might be underestimated. Impairment in mobility and self-care in patients with TBI, particularly in young adults signi cantly decrease the productivity, hence creating a socioeconomic burden for the society. 15 Previous study in European community, indicated the quality of life of patients with TBI is better than non-TBI, as indicated by better performance in cognitive function and daily tasks. 16 On this matter, cultural differences might have in uenced the ndings, 17 in our society the attention regarding TBI is severely lacking, hence public awareness of its sequel is low. 13,14 . Nevertheless, there was a trend of quality of life improvement in patients with TBI during the follow-up. Appropriate managed-care could enhance the recovery and promote better quality of life hence reducing socioeconomic burden for the society.
This nding in this study could be used for the reference for the policy making and health care intervention in Indonesia. Further study involving more participants and nationwide would be pivotal to con rm the ndings in this study.

Conclusions
There were signi cant differences in mobility and self-care between patients with TBI and non-TBI patients. Patients with TBI had worse quality of life than non-TBI patients.

Declarations
Ethics approval and consent to participate The ethical clearance was obtained from the Ethical Committee of the Faculty of Medicine, Universitas Padjadjaran and Hasan Sadikin General Hospital.

Consent for publication
Not applicable

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.