Impact of Geographic Distance and Prehospital Delay on Mortality and Functional Outcomes in Severe Traumatic Brain Injury in a Low-Resource Setting.

Abstract

Background: Traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs), where prehospital delays and geographic barriers may adversely impact outcomes.

Methods: This retrospective study included 1068 consecutive patients with severe TBI (admission Glasgow Coma Scale [GCS] < 9) admitted to Lady Reading Hospital, Peshawar, in 2024. Variables were incident-to-presentation delay, distance, in-hospital timings to surgery, severity markers, mortality, and discharge Glasgow Outcome Scale (GOS). Patients were stratified by urban or rural area according to the place of incident. Statistical analyses included the Mann-Whitney U test, chi-square test, and multivariable logistic regression.

Results: The In-hospital mortality was 12.2%, and poor outcomes (GOS ≤ 3) were observed in 95.9%. The median delay before presentation was 6 h (IQR 3-9), with a median distance of 70 km (IQR 6-210). Delays were significantly longer in rural patients (median 9 vs. 3 h in urban areas, p < 0.001), and distances to presentation were also greater (median 180 km vs. 40 km, p < 0.001), with rural patients accounting for 72%. The median in-hospital intervention time was 42 min. No significant differences in mortality were found between the high-delay and high-distance groups (13.1% vs. 11.3%, p = 0.41; 12.8% vs. 11.6%, p = 0.62) or between rural and urban patients (12.5% vs. 11.4%, p = 0.69). Multivariable analysis demonstrated no independent association between geographic factors and mortality after adjustment for injury severity.

Conclusions: Significant disparities in prehospital access were observed; however, no independent association between geographic factors and in-hospital mortality among admitted patients was identified. Functional outcomes remained poor.