JOURNAL CLUB JOURNAL CLUB
Response to Journal Club: National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury William C. Van Cleve, MD, MPH Monica S. Vavilala, MD Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington Correspondence: Monica S. Vavilala, MD, Departments of Anesthesiology & Pain Medicine, University of Washington and Harborview Injury Prevention and Research Center, Harborview Medical Center, 325 Ninth Avenue, Box 359724, Seattle, WA 98104. E-mail: [email protected] Copyright © 2014 by the Congress of Neurological Surgeons.
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e thank Dr Anderson and colleagues for their thorough Journal Club submission. We share their belief that an improved understanding of current national practices is a vital step towards planning and execution of research that can reliably guide the care for children with traumatic brain injury (TBI). We appreciate their thorough discussion of the methodological issues that must be considered when evaluating any observational study, particularly from large data sources such as the National Trauma Databank (NTDB). We have several specific responses to concerns raised in the authors’ Journal Club. First, they correctly point out the inferential issues that arise from our decision to limit our analysis to centers with 10 or more patients per year and to exclude patients transferred from other centers. When utilizing data sources such as the NTDB, ensuring external validity is a challenge, and our decision was made prior to conducting our analysis in order to manage concerns regarding data quality from small centers and because no identifier in NTDB links unique patients transferred between centers. A sensitivity analysis to examine the impact of these decisions might have improved readers’ confidence in our conclusions. Second, we wish to point out that the authors mistakenly state that we do not cite the updated
194 | VOLUME 75 | NUMBER 2 | AUGUST 2014
2012 Brain Trauma Foundation guidelines in our paper. Third, the authors express concern for the implications of familywise error on our conclusions. While we appreciate the statistical debate that exists regarding the management of these issues and share their concern for statistical “fishing trips,” we do not believe that all bivariate analyses require adjustment for multiple comparisons. Rather, the statistical summaries presented in Table 2 were meant to inform readers of the associations present linking our pre-specified covariates and outcomes prior to multivariate adjustment. In such a simplified initial analysis, confounding must be expected to exist, but the reader can still gain a sense of the integrity of the dataset. To fundamentally improve the care of children with brain injuries, the community of healthcare providers and researchers who study epidemiology and outcomes will need to make decisions about research priorities and mechanisms for collaboration in large-scale databases and clinical trials. We hope that our readers, informed by in-depth discussions such as that presented in this Journal Club, will be motivated to participate in such efforts. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
Response to Journal Club: National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury William C. Van Cleve, MD, MPH Monica S. Vavilala, MD Departments of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington Correspondence: Monica S. Vavilala, MD, Departments of Anesthesiology & Pain Medicine, University of Washington and Harborview Injury Prevention and Research Center, Harborview Medical Center, 325 Ninth Avenue, Box 359724, Seattle, WA 98104. E-mail: [email protected] Copyright © 2014 by the Congress of Neurological Surgeons.
W
e thank Dr Anderson and colleagues for their thorough Journal Club submission. We share their belief that an improved understanding of current national practices is a vital step towards planning and execution of research that can reliably guide the care for children with traumatic brain injury (TBI). We appreciate their thorough discussion of the methodological issues that must be considered when evaluating any observational study, particularly from large data sources such as the National Trauma Databank (NTDB). We have several specific responses to concerns raised in the authors’ Journal Club. First, they correctly point out the inferential issues that arise from our decision to limit our analysis to centers with 10 or more patients per year and to exclude patients transferred from other centers. When utilizing data sources such as the NTDB, ensuring external validity is a challenge, and our decision was made prior to conducting our analysis in order to manage concerns regarding data quality from small centers and because no identifier in NTDB links unique patients transferred between centers. A sensitivity analysis to examine the impact of these decisions might have improved readers’ confidence in our conclusions. Second, we wish to point out that the authors mistakenly state that we do not cite the updated
194 | VOLUME 75 | NUMBER 2 | AUGUST 2014
2012 Brain Trauma Foundation guidelines in our paper. Third, the authors express concern for the implications of familywise error on our conclusions. While we appreciate the statistical debate that exists regarding the management of these issues and share their concern for statistical “fishing trips,” we do not believe that all bivariate analyses require adjustment for multiple comparisons. Rather, the statistical summaries presented in Table 2 were meant to inform readers of the associations present linking our pre-specified covariates and outcomes prior to multivariate adjustment. In such a simplified initial analysis, confounding must be expected to exist, but the reader can still gain a sense of the integrity of the dataset. To fundamentally improve the care of children with brain injuries, the community of healthcare providers and researchers who study epidemiology and outcomes will need to make decisions about research priorities and mechanisms for collaboration in large-scale databases and clinical trials. We hope that our readers, informed by in-depth discussions such as that presented in this Journal Club, will be motivated to participate in such efforts. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
