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Pyne S, Barton G, Turner D, Mee H, Gregson BA, Kolias AG, Turner C, Adams H, Mohan M, Uff C, Hasan S, Wilson M, Bulters DO, Zolnourian A, McMahon C, Stovell MG, Al-Tamimi Y, Thomson S, Viaroli E, Belli A, King A, Helmy AE, Timofeev I, Menon D, Hutchinson PJ. Cost-effectiveness of craniotomy versus decompressive craniectomy for UK patients with traumatic acute subdural haematoma. BMJ Open 2024; 14:e085084. [PMID: 38885989 PMCID: PMC11184173 DOI: 10.1136/bmjopen-2024-085084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/08/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH). DESIGN Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial. SETTING UK secondary care. PARTICIPANTS 248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122). INTERVENTIONS Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery). MAIN OUTCOME MEASURES In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists. RESULTS In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be -£5520 (95% CI -£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be -£4536 (95% CI -£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE. CONCLUSIONS In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant). ETHICS Ethical approval for the trial was obtained from the North West-Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076). TRIAL REGISTRATION NUMBER ISRCTN87370545.
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Affiliation(s)
- Sarah Pyne
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Garry Barton
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Harry Mee
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Barbara A Gregson
- Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne, UK
| | - Angelos G Kolias
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Carole Turner
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Hadie Adams
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Midhun Mohan
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | | | | | - Mark Wilson
- Department of Neurosurgery, St Mary's Hospital, London, UK
| | | | | | - Catherine McMahon
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Matthew G Stovell
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Academic Directorate of Neurosciences, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Simon Thomson
- Department of Neurosurgery, Leeds General Infirmary, Leeds, UK
| | - Edoardo Viaroli
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Antonio Belli
- Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew King
- Department of Neurosurgery, Salford Royal Hospital Manchester Centre for Clinical Neurosciences, Salford, UK
| | - Adel E Helmy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Ivan Timofeev
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Peter John Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
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Ho KM, Rogers FB, Chamberlain J, Nasim S. Incremental cost of venous thromboembolism in trauma patients with contraindications to prophylactic anticoagulation: a prospective economic study. J Thromb Thrombolysis 2022; 54:115-122. [PMID: 34988869 DOI: 10.1007/s11239-021-02618-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/24/2022]
Abstract
Venous thromboembolism (VTE) is common in patients after major trauma. Attributable cost of VTE and whether this is related to the severity of injury have not been thoroughly investigated. We aimed to define the hospitalization costs of VTE and assess whether the costs were related to the severity of injury in this prospective economic study. Cost data of each patient enrolled in the da Vinci trial were drawn from hospital finance departments and standardized to 2020 Australian dollars (A$); and Injury Severity Score and Trauma Embolic Scoring System were used to quantify the severity of injury. Of the 223 patients who had complete financial cost data available until day-90 follow-up, 37 (16.6%) developed VTE, including upper limb (n = 3) and lower limb deep vein thrombosis (n = 25), pulmonary embolism (n = 7) and clots entrapped in a vena cava filter. The median total radiology (A$4307) as well as the hospitalization costs (A$138,526) of those who had VTE were significantly higher than those without VTE (A$1210; p < 0.001 and A$105,842; p = 0.023, respectively). The incremental hospitalization cost attributable to VTE was most apparent among those who had sustained extremely severe injuries, and estimated to be between A$43,292 (95% confidence interval [CI] 12,624-73,961, p = 0.006) and 41,680 (95%CI 7766-75,594, p = 0.016) after adjusted for Trauma Embolic Scoring System and Injury Severity Scores, respectively. VTE was common after major trauma and incurred a substantial incremental financial cost to the healthcare system, especially among those who had extremely severe injuries.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, 6000, Australia. .,Medical School, University of Western Australia, Perth, WA, 6000, Australia. .,School of Veterinary & Life Sciences, Murdoch University, Murdoch, WA, 6000, Australia.
| | - Frederick B Rogers
- Department of Surgery, University of Pennsylvania, Lancaster, PA, 17602, USA
| | - Jenny Chamberlain
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, 6000, Australia
| | - Sana Nasim
- State Trauma Unit, Royal Perth Hospital, Perth, WA, 6000, Australia
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3
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Behranwala R, Aojula N, Hagana A, Houbby N, de Preux DL. An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension. Brain Inj 2021; 35:444-452. [PMID: 33529095 DOI: 10.1080/02699052.2021.1878556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.
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Affiliation(s)
| | - Nivaran Aojula
- Faculty of Medicine, Imperial College London, London, UK
| | - Arwa Hagana
- Faculty of Medicine, Imperial College London, London, UK
| | - Nour Houbby
- Faculty of Medicine, Imperial College London, London, UK
| | - Dr Laure de Preux
- Department of Economics and Public Policy, Imperial College London, Business School, London, UK
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4
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van Dijck JTJM, Mostert CQB, Greeven APA, Kompanje EJO, Peul WC, de Ruiter GCW, Polinder S. Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study. Acta Neurochir (Wien) 2020; 162:1607-1618. [PMID: 32410121 PMCID: PMC7295836 DOI: 10.1007/s00701-020-04384-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/29/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI. METHODS We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation. RESULTS A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%). CONCLUSION In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.
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Affiliation(s)
- Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands.
- LUMC, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Cassidy Q B Mostert
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | | | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, University Neurosurgical Center Holland, LUMC, HMC & Haga Teaching Hospital, Leiden, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Williamson T, Ryser MD, Abdelgadir J, Lemmon M, Barks MC, Zakare R, Ubel PA. Surgical decision making in the setting of severe traumatic brain injury: A survey of neurosurgeons. PLoS One 2020; 15:e0228947. [PMID: 32119677 PMCID: PMC7051065 DOI: 10.1371/journal.pone.0228947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/26/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Surgical decision-making in severe traumatic brain injury (TBI) is complex. Neurosurgeons weigh risks and benefits of interventions that have the potential to both maximize the chance of recovery and prolong suffering. Inaccurate prognostication can lead to over- or under-estimation of outcomes and influence treatment recommendations. OBJECTIVE To evaluate the impact of evidence-based risk estimates on neurosurgeon treatment recommendations and prognostic beliefs in severe TBI. METHODS In a survey-based randomized experiment, a total of 139 neurosurgeons were presented with two hypothetical patient with severe TBI and subdural hematoma; the intervention group received additional evidence-based risk estimates for each patient. The main outcome was neurosurgeon treatment recommendation of non-surgical management. Secondary outcomes included prediction of functional recovery at six months. RESULTS In the first patient scenario, 22% of neurosurgeons recommended non-surgical management and provision of evidence-based risk estimates increased the propensity to recommend non-surgical treatment (odds ratio [OR]: 2.81, 95% CI: 1.21-6.98; p = 0.02). Neurosurgeon prognostic beliefs of 6-month functional recovery were variable in both control (median 20%, IQR: 10%-40%) and intervention (30% IQR: 10%-50%) groups and neurosurgeons were less likely to recommend non-surgical management when they believed prognosis was favorable (odds ratio [OR] per percentage point increase in 6-month functional recovery: 0.97, 95% confidence interval [CI]: 0.95-0.99). The results for the second patient scenario were qualitatively similar. CONCLUSIONS Our findings show that the provision of evidence-based risk predictions can influence neurosurgeon treatment recommendations and prognostication, but the effect is modest and there remains large variability in neurosurgeon prognostication.
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Affiliation(s)
- Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Marc D. Ryser
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
- Department of Mathematics, Duke University, Durham, North Carolina, United States of America
| | - Jihad Abdelgadir
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Monica Lemmon
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke-Margolis Center for Health Policy, Durham, North Carolina, United States of America
| | - Mary Carol Barks
- The Fuqua School of Business, Duke University, Durham, North Carolina, United States of America
| | - Rasheedat Zakare
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
| | - Peter A. Ubel
- Duke School of Medicine, Duke University, Durham, North Carolina, United States of America
- The Fuqua School of Business, Duke University, Durham, North Carolina, United States of America
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6
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van Dijck JTJM, Dijkman MD, Ophuis RH, de Ruiter GCW, Peul WC, Polinder S. In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment. PLoS One 2019; 14:e0216743. [PMID: 31071199 PMCID: PMC6508680 DOI: 10.1371/journal.pone.0216743] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/28/2019] [Indexed: 12/19/2022] Open
Abstract
Background The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. Methods A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. Results Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. Conclusions Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.
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Affiliation(s)
- Jeroen T. J. M. van Dijck
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
- * E-mail:
| | - Mark D. Dijkman
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Robbin H. Ophuis
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Godard C. W. de Ruiter
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Neurosurgical Center Holland, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haaglanden Medical Center, The Hague, The Netherlands
- Department of Neurosurgery, Neurosurgical Center Holland, Haga Teaching Hospital, The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
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7
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van Dijck JTJM, van Essen TA, Dijkman MD, Mostert CQB, Polinder S, Peul WC, de Ruiter GCW. Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox? Acta Neurochir (Wien) 2019; 161:875-884. [PMID: 30923919 PMCID: PMC6483942 DOI: 10.1007/s00701-019-03878-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness. METHODS This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation. RESULTS Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580). CONCLUSIONS Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.
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Affiliation(s)
- Jeroen T J M van Dijck
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands.
| | - Thomas A van Essen
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Mark D Dijkman
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Cassidy Q B Mostert
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, University Neurosurgical Center Holland (UNCH), Leiden University Medical Center & Haaglanden Medical Center & Haga Teaching Hospital, Leiden/The Hague, The Netherlands
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Sun H, Wang H, Diao Y, Tu Y, Li X, Zhao W, Ren J, Zhang S. Large retrospective study of artificial dura substitute in patients with traumatic brain injury undergo decompressive craniectomy. Brain Behav 2018; 8:e00907. [PMID: 29761002 PMCID: PMC5943738 DOI: 10.1002/brb3.907] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/26/2017] [Accepted: 11/09/2017] [Indexed: 12/16/2022] Open
Abstract
Background Decompressive craniectomy is widely used for treating patients with traumatic brain injury (TBI). Usually patients have dura mater defect due to surgery or injury itself. The defective area may left open or repaired by artificial dura substitutes. A variety of artificial dura substitutes have been used for this purpose. Objective This study aimed to evaluate bovine-derived pericardium membrane as artificial dural material for patients with decompressive craniectomy. Methods Totally 387 patients with severe TBI in our hospital were included in this study. Among them, 192 patients were treated with standard decompressive craniectomy without dura repair (control group). One hundred and ninety-five TBI patients were treated with dura repair by artificial dura materials (ADM). Nonlyophilized bovine pericardium membranes were used as artificial dura material. The postoperative complications were compared in both groups, including infection, seizure, and cerebrospinal fluid (CSF) leakage. Results Patients in control group have higher complication rates than patients in ADM group, including subcutaneous hematoma (13.02% in control vs. 4.01% in ADM group, p = .004), infection (12.5% in control vs. 5.64% in ADM group, p = .021), CSF leakage (13.02% in control vs. 5.13% in ADM group, p = .012), and seizure (10.42% in control vs. 3.08% in ADM group, p = .007). Patients in ADM group are only associated with higher incidence of foreign body reaction (6 of 195 patients in ADM vs. none from control group). Conclusion Bovine-derived pericardium membranes are successfully used as artificial dural substitutes for decompressive craniectomy. Patients with ADM have better clinical outcome than control group.
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Affiliation(s)
- Hongtao Sun
- Sixth Department of Neurosurgery, Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Hongda Wang
- Division of Clinical MedicineChongqing Medical UniversityChongqingChina
| | - Yunfeng Diao
- Sixth Department of Neurosurgery, Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Yue Tu
- Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Xiaohong Li
- Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Wanyong Zhao
- Sixth Department of Neurosurgery, Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Jibin Ren
- Sixth Department of Neurosurgery, Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
| | - Sai Zhang
- Brain CenterAffiliated Hospital of Logistics University of People's Armed Police ForceTianjinChina
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Moran D, Shrime MG, Nang S, Vycheth I, Vuthy D, Hong R, Padula WV, Park KB. Cost-Effectiveness of Craniotomy for Epidural Hematomas at a Major Government Hospital in Cambodia. World J Surg 2018; 41:2215-2223. [PMID: 28444463 DOI: 10.1007/s00268-017-4022-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Epidural hematoma (EDH) is a common and potentially deadly occurrence following a severe traumatic brain injury. Our aim was to determine whether craniotomy is cost-effective when indicated for the treatment of EDH when a trained neurosurgeon is available. METHODS A decision tree was used to model the cost-effectiveness of craniotomy available versus craniotomy unavailable for the management of traumatic EDH from a Cambodian societal and provider perspective. Costs and effectiveness parameters were obtained from patient data at a large government hospital in Cambodia. Outcomes were measured in quality-adjusted life years (QALYs). Incremental cost per QALY and budget impact were calculated for each intervention at a willingness-to-pay (WTP) threshold of $9787.80/QALY (3× GDP per capita PPP). The time horizon reflected full life span, and costs and QALYs were discounted at 3%. Sensitivity analysis was also conducted. RESULTS Compared to craniotomy unavailable for EDH ($945.80; 11.78 QALYs), craniotomy available came at a higher cost and greater effectiveness ($1520.73; 12.78 QALYs), resulting in an incremental cost-effectiveness ratio (ICER) of $574.93. One-way analysis demonstrated that craniotomy unavailable became more cost-effective than craniotomy available when the percent chance of having a GOS of 4 or 5 was 60% for patients with an EDH where craniotomy was indicated but not performed. Probabilistic sensitivity analysis revealed that craniotomy available was more cost-effective than conservative management in 84.4% of simulations at the WTP threshold. CONCLUSIONS Craniotomy is a cost-effective treatment for patients with a traumatic EDH who meet criteria for operation when trained neurosurgeons are available onsite.
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Affiliation(s)
- Dane Moran
- Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD, 21205, USA.,Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
| | - Sam Nang
- Department of Neurosurgery, Preah Kossamak Hospital, Street 271, Phnom Penh, Cambodia
| | - Iv Vycheth
- Department of Neurosurgery, Preah Kossamak Hospital, Street 271, Phnom Penh, Cambodia
| | - Din Vuthy
- Department of Neurosurgery, Preah Kossamak Hospital, Street 271, Phnom Penh, Cambodia
| | - Raksmey Hong
- Department of Neurosurgery, Preah Kossamak Hospital, Street 271, Phnom Penh, Cambodia
| | - William V Padula
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Kee B Park
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA. .,Department of Neurosurgery, Preah Kossamak Hospital, Street 271, Phnom Penh, Cambodia. .,Department of Neurosurgery, Preah Kossamak Hospital, St 265, Phnom Penh, Cambodia.
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10
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Abstract
Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.
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11
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Carter EL, Hutchinson PJA, Kolias AG, Menon DK. Predicting the outcome for individual patients with traumatic brain injury: a case-based review. Br J Neurosurg 2016; 30:227-32. [PMID: 26853860 DOI: 10.3109/02688697.2016.1139048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Traumatic brain injuries result in significant morbidity and mortality. Accurate prediction of prognosis is desirable to inform treatment decisions and counsel family members. Objective To review the currently available prognostic tools for use in traumatic brain injury (TBI), to analyse their value in individual patient management and to appraise ongoing research on prognostic modelling. METHODS AND RESULTS We present two patients who sustained a TBI in 2011-2012 and evaluate whether prognostic models could accurately predict their outcome. The methodology and validity of current prognostic models are analysed and current research that might contribute to improved individual patient prognostication is evaluated. CONCLUSION Predicting prognosis in the acute phase after TBI is complex and existing prognostic models are not suitable for use at the individual patient level. Data derived from these models should only be used as an adjunct to clinical judgement and should not be used to set limits for acute care interventions. Information from neuroimaging, physiological monitoring and analysis of biomarkers or genetic polymorphisms may be used in the future to improve accuracy of individual patient prognostication. Clinicians should consider offering full supportive treatment to patients in the early phase after injury whilst the outcome is unclear.
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Affiliation(s)
- Eleanor L Carter
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK ;,b Department of Anaesthesia , National Hospital for Neurology and Neurosurgery , London , UK
| | - Peter J A Hutchinson
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - David K Menon
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
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12
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Alali AS, Burton K, Fowler RA, Naimark DMJ, Scales DC, Mainprize TG, Nathens AB. Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:721-734. [PMID: 26297101 DOI: 10.1016/j.jval.2015.04.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 03/23/2015] [Accepted: 04/12/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Economic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial. OBJECTIVE The objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI. METHODS Two reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively. RESULTS Of 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers. CONCLUSIONS Threshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.
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Affiliation(s)
- Aziz S Alali
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada.
| | - Kirsteen Burton
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Robert A Fowler
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - David M J Naimark
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - Todd G Mainprize
- Division of Neurosurgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - Avery B Nathens
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
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13
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Fletcher JJ, Kotagal V, Mammoser A, Peterson M, Morgenstern LB, Burke JF. Cost-effectiveness of transfers to centers with neurological intensive care units after intracerebral hemorrhage. Stroke 2014; 46:58-64. [PMID: 25477220 DOI: 10.1161/strokeaha.114.006653] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to estimate the cost-effectiveness of transferring patients with intracerebral hemorrhage from centers without specialized neurological intensive care units (neuro-ICUs) to centers with neuro-ICUs. METHODS Decision analytic models were developed for the lifetime horizons. Model inputs were derived from the best available data, informed by a variety of previous cost-effectiveness models of stroke. The effect of neuro-ICU care on functional outcomes was modeled in 3 scenarios. A favorable outcomes scenario was modeled based on the best observational data and compared with moderately favorable and least-favorable outcomes scenarios. Health benefits were measured in quality-adjusted life years (QALYs), and costs were estimated from a societal perspective. Costs were combined with QALYs gained to generate incremental cost-effectiveness ratios. One-way sensitivity analysis and Monte Carlo simulations were performed to test robustness of the model assumptions. RESULTS Transferring patients to centers with neuro-ICUs yielded an incremental cost-effectiveness ratio for the lifetime horizon of $47,431 per QALY, $91,674 per QALY, and $380,358 per QALY for favorable, moderately favorable, and least-favorable scenarios, respectively. Models were robust at a willingness-to-pay threshold of $100,000 per QALY, with 95.5%, 75.0%, and 2.1% of simulations below the threshold for favorable, moderately favorable, and least-favorable scenarios, respectively. CONCLUSIONS Transferring patients with intracerebral hemorrhage to centers with specialized neuro-ICUs is cost-effective if observational estimates of the neuro-ICU-based functional outcome distribution are accurate. If future work confirms these functional outcome distributions, then a strong societal rationale exists to build systems of care designed to transfer intracerebral hemorrhage patients to specialized neuro-ICUs.
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Affiliation(s)
- Jeffrey J Fletcher
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.).
| | - Vikas Kotagal
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Aaron Mammoser
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Mark Peterson
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - Lewis B Morgenstern
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
| | - James F Burke
- From the Departments of Neurosurgery (J.J.F., L.B.M.), Neurology (V.K., A.M.), Biostatistics (L.B.M.), Physical Medicine and Rehabilitation (M.P.), and the Stroke Program (L.B.M., J.F.B.), University of Michigan, Ann Arbor; and Department of Neurology, Bronson Methodist Hospital, Kalamazoo, MI (J.J.F.)
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14
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Economic evaluation of decompressive craniectomy versus barbiturate coma for refractory intracranial hypertension following traumatic brain injury. Crit Care Med 2014; 42:2235-43. [PMID: 25054675 DOI: 10.1097/ccm.0000000000000500] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Decompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context. DESIGN We performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research. SETTING Trauma centers in the United States. SUBJECTS Base case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury. INTERVENTIONS We compared two treatment strategies: decompressive craniectomy and barbiturate coma. MEASUREMENTS AND MAIN RESULTS Decompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of $9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is $50,000/quality-adjusted life year and 82% of cases at a threshold of $100,000/quality-adjusted life year. At older age, decompressive craniectomy continued to increase survival but at higher cost (incremental cost-effectiveness ratio = $197,906/quality-adjusted life year at mean age = 85 yr). CONCLUSIONS Based on available evidence, decompressive craniectomy for the treatment of refractory intracranial hypertension following traumatic brain injury provides better value in terms of costs and health gains than barbiturate coma. However, decompressive craniectomy might be less economically attractive for older patients. Further research, particularly on natural history of severe traumatic brain injury patients, is needed to make more informed treatment decisions.
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15
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McLaughlin N, Ong MK, Tabbush V, Hagigi F, Martin NA. Contemporary health care economics: an overview. Neurosurg Focus 2014; 37:E2. [DOI: 10.3171/2014.8.focus14455] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Economic evaluations provide a decision-making framework in which outcomes (benefits) and costs are assessed for various alternative options. Although the interest in complete and partial economic evaluations has increased over the past 2 decades, the quality of studies has been marginal due to methodological challenges or incomplete cost determination. This paper provides an overview of the main types of complete and partial economic evaluations, reviews key methodological elements to be considered for any economic evaluation, and reviews concepts of cost determination. The goal is to provide the clinician neurosurgeon with the knowledge and tools needed to appraise published economic evaluations and to direct high-quality health economic evaluations.
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Affiliation(s)
| | - Michael K. Ong
- 2Internal Medicine, David Geffen School of Medicine at UCLA; and
| | - Victor Tabbush
- 3UCLA Anderson School of Management, Los Angeles, California
| | - Farhad Hagigi
- 3UCLA Anderson School of Management, Los Angeles, California
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16
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Andelic N, Ye J, Tornas S, Roe C, Lu J, Bautz-Holter E, Moger T, Sigurdardottir S, Schanke AK, Aas E. Cost-Effectiveness Analysis of an Early-Initiated, Continuous Chain of Rehabilitation after Severe Traumatic Brain Injury. J Neurotrauma 2014; 31:1313-20. [DOI: 10.1089/neu.2013.3292] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nada Andelic
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Jiajia Ye
- Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | | | - Cecilie Roe
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Juan Lu
- Department of Family Medicine and Population Health, Division of Epidemiology, Virginia Commonwealth University, Richmond, Virginia
| | - Erik Bautz-Holter
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Tron Moger
- Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Solrun Sigurdardottir
- Institute of Health and Society, Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
- Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway
| | | | - Eline Aas
- Institute of Health and Society, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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17
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Algattas H, Huang JH. Traumatic Brain Injury pathophysiology and treatments: early, intermediate, and late phases post-injury. Int J Mol Sci 2013; 15:309-41. [PMID: 24381049 PMCID: PMC3907812 DOI: 10.3390/ijms15010309] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/02/2013] [Accepted: 12/20/2013] [Indexed: 12/25/2022] Open
Abstract
Traumatic Brain Injury (TBI) affects a large proportion and extensive array of individuals in the population. While precise pathological mechanisms are lacking, the growing base of knowledge concerning TBI has put increased emphasis on its understanding and treatment. Most treatments of TBI are aimed at ameliorating secondary insults arising from the injury; these insults can be characterized with respect to time post-injury, including early, intermediate, and late pathological changes. Early pathological responses are due to energy depletion and cell death secondary to excitotoxicity, the intermediate phase is characterized by neuroinflammation and the late stage by increased susceptibility to seizures and epilepsy. Current treatments of TBI have been tailored to these distinct pathological stages with some overlap. Many prophylactic, pharmacologic, and surgical treatments are used post-TBI to halt the progression of these pathologic reactions. In the present review, we discuss the mechanisms of the pathological hallmarks of TBI and both current and novel treatments which target the respective pathways.
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Affiliation(s)
- Hanna Algattas
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 441, Rochester, NY 14642, USA.
| | - Jason H Huang
- School of Medicine and Dentistry, University of Rochester Medical Center, 601 Elmwood Ave, Box 441, Rochester, NY 14642, USA.
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18
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Lu J, Roe C, Aas E, Lapane KL, Niemeier J, Arango-Lasprilla JC, Andelic N. Traumatic brain injury: methodological approaches to estimate health and economic outcomes. J Neurotrauma 2013; 30:1925-33. [PMID: 23879599 DOI: 10.1089/neu.2013.2891] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effort to standardize the methodology and adherence to recommended principles for all economic evaluations has been emphasized in medical literature. The objective of this review is to examine whether economic evaluations in traumatic brain injury (TBI) research have been compliant with existing guidelines. Medline search was performed between January 1, 1995 and August 11, 2012. All original TBI-related full economic evaluations were included in the study. Two authors independently rated each study's methodology and data presentation to determine compliance to the 10 methodological principles recommended by Blackmore et al. Descriptive analysis was used to summarize the data. Inter-rater reliability was assessed with Kappa statistics. A total of 28 studies met the inclusion criteria. Eighteen of these studies described cost-effectiveness, seven cost-benefit, and three cost-utility analyses. The results showed a rapid growth in the number of published articles on the economic impact of TBI since 2000 and an improvement in their methodological quality. However, overall compliance with recommended methodological principles of TBI-related economic evaluation has been deficient. On average, about six of the 10 criteria were followed in these publications, and only two articles met all 10 criteria. These findings call for an increased awareness of the methodological standards that should be followed by investigators both in performance of economic evaluation and in reviews of evaluation reports prior to publication. The results also suggest that all economic evaluations should be made by following the guidelines within a conceptual framework, in order to facilitate evidence-based practices in the field of TBI.
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Affiliation(s)
- Juan Lu
- 1 Department of Family Medicine and Population Health, Division of Epidemiology, Virginia Commonwealth University , Richmond, Virginia
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19
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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20
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Honeybul S, Ho KM, Lind CRP, Gillett GR. Letter to the editor: decompressive craniectomy for acute subdural hematoma. Acta Neurochir (Wien) 2013; 155:185-6. [PMID: 23104583 DOI: 10.1007/s00701-012-1530-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 10/12/2012] [Indexed: 11/28/2022]
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21
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Abstract
Total joint arthroplasty (TJA) continues to be one of the most successful surgical interventions in medicine. Demand is growing rapidly, placing an increasingly heavy cost burden on national health systems. Despite the popularity of these surgeries, high-quality cost-effectiveness studies evaluating TJA are few in number. This article summarizes the current literature on value in arthroplasty, identifying the various factors affecting costs and outcomes, and suggesting how policy makers can influence utilization of TJA to further improve value to society.
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22
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Ho KM, Geelhoed E, Gope M, Burrell M, Rao S. An injury awareness education program on outcomes of juvenile justice offenders in Western Australia: an economic analysis. BMC Health Serv Res 2012; 12:279. [PMID: 22929004 PMCID: PMC3470939 DOI: 10.1186/1472-6963-12-279] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 08/22/2012] [Indexed: 11/10/2022] Open
Abstract
Background Injury is a major cause of mortality and morbidity of young people and the cost-effectiveness of many injury prevention programs remains uncertain. This study aimed to analyze the costs and benefits of an injury awareness education program, the P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) program, for juvenile justice offenders in Western Australia. Methods Costs and benefits analysis based on effectiveness data from a linked-data cohort study on 225 juvenile justice offenders who were referred to the education program and 3434 who were not referred to the program between 2006 and 2011. Results During the study period, there were 8869 hospitalizations and 113 deaths due to violence or traffic-related injuries among those aged between 14 and 21 in Western Australia. The mean length of hospital stay was 4.6 days, a total of 320 patients (3.6%) needed an intensive care admission with an average length of stay of 6 days. The annual cost saved due to serious injury was $3,765 and the annual net cost of running this program was $33,735. The estimated cost per offence prevented, cost per serious injury avoided, and cost per undiscounted and discounted life year gained were $3,124, $42,169, $8,268 and $17,910, respectively. Increasing the frequency of the program from once per month to once per week would increase its cost-effectiveness substantially. Conclusions The P.A.R.T.Y. injury education program involving real-life trauma scenarios was cost-effective in reducing subsequent risk of committing violence or traffic-related offences, injuries, and death for juvenile justice offenders in Western Australia.
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Affiliation(s)
- Kwok M Ho
- University of Western Australia, Perth, Australia.
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23
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Honeybul S, Ho K, O'Hanlon S. Access to reliable information about long-term prognosis influences clinical opinion on use of lifesaving intervention. PLoS One 2012; 7:e32375. [PMID: 22384231 PMCID: PMC3285690 DOI: 10.1371/journal.pone.0032375] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 01/28/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI. METHOD A two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios. RESULTS Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] -1.5, 95% confidence interval -1.3 to -1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants. CONCLUSIONS Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Perth, Western Australia, Australia.
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