Is aggressive treatment of traumatic brain injury cost-effective?

Cost-effectiveness of craniotomy versus decompressive craniectomy for UK patients with traumatic acute subdural haematoma

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.

Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups

Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.

Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care

In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design

BACKGROUND

The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024.

DISCUSSION

The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered.

TRIAL REGISTRATION

Nederlands Trial Register (NTR), Trial NL9012 .

CLINICALTRIALS

gov, Trial NCT04648436 .

Incidence of emergency neurosurgical TBI procedures: a population-based study

BACKGROUND

The rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures.

METHODS

Oslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry - Neurosurgery over a five-year period (2015-2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures.

RESULTS

A total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability.

CONCLUSIONS

The incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.

Financial Risk Protection for Neurosurgical Care in Indonesia and the Philippines: A Primer on Health Financing for the Global Neurosurgeon

Which conditions treated by neurosurgeons cause the worst economic hardship in low middle-income in countries? How can public health financing be responsive to the inequities in the delivery of neurosurgical care? This review article frames the objectives of equity, quality, and efficiency in health financing to the goals of global neurosurgery. In order to glean provider perspectives on the affordability of neurosurgical care in low-resource settings, we did a survey of neurosurgeons from Indonesia and the Philippines and identified that the care of socioeconomically disadvantaged patients with malignant intracranial tumors were found to incur the highest out-of-pocket expenses. Additionally, the surveyed neurosurgeons also observed that treatment of traumatic brain injury may have to require greater financial subsidies. It is therefore imperative to frame health financing alongside the goals of equity, efficiency, and quality of neurosurgical care for the impoverished. Using principles and perspectives from managerial economics and public health, we conceptualize an implementation framework that addresses both the supply and demand sides of healthcare provision as applied to neurosurgery. For the supply side, strategic purchasing enables a systematic and contractual management of payment arrangements that provide performance-based economic incentives for providers. For the demand side, conditional cash transfers similarly leverages on financial incentives on the part of patients to reward certain health-seeking behaviors that significantly influence clinical outcomes. These health financing strategies are formulated in order to ultimately build neurosurgical capacity in LMICs, improve access to care for patients, and ensure financial risk protection.

Health-Related Quality-of-Life and Cost Utility Analyses in Critical Care: A Systematic Review

OBJECTIVES

Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured.

DESIGN

Systematic review.

DATA SOURCES

We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020.

SETTING

Adult ICUs.

PATIENTS

Adult critically ill patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies.

CONCLUSIONS

We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care.

An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension

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.

Evidence-practice gaps in initial neuro-protective nursing care: A mixed methods study of Thai patients with moderate or severe traumatic brain injury

AIMS

This paper aims to identify the frequency and nature of evidence-practice gaps in the initial neuro-protective nursing care of patients with moderate or severe traumatic brain injury provided by Thai trauma nurses.

BACKGROUND

Little is known about how Thai trauma nurses use evidence-based practice when providing initial neuro-protective nursing care to patients with moderate or severe traumatic brain injury.

DESIGN

A mixed methods design was used to conduct this study.

METHODS

Data were collected from January to March 2017 using observations and audits of the clinical care of 22 patients by 35 nurses during the first 4 h of admission to trauma ward. The study site was a regional hospital in Southern Thailand.

RESULTS

The major evidence-practice gaps identified were related to oxygen and carbon dioxide monitoring and targets, mean arterial pressure and systolic blood pressure targets and management of increased intracranial pressure through patient positioning and pain and agitation management.

CONCLUSION

There were evidence-practice gaps in initial neuro-protective nursing care provided by Thai trauma nurses that need to be addressed to improve the safety and quality of care for Thai patients with moderate or severe traumatic brain injury.

Effect of hyperglycemia on all-cause mortality from pediatric brain injury: A systematic review and meta-analysis

BACKGROUND

This study aimed to assess the effect of hyperglycemia on all-cause mortality in pediatric patients with brain injury, based on currently available evidence.

METHODS

We systematically searched the PubMed, Embase, and Cochrane Library databases with the keywords "hyperglycemia", "brain injury", and "pediatrics". The retrieved records were screened by title, abstract, and full-text to include original articles assessing the effects of hyperglycemia on pediatric brain injury. The extracted data were assessed by a fixed-effects model. The risk of bias in the eligible studies was evaluated with the Newcastle-Ottawa Scale. Publication bias was visually examined with a funnel plot. Begg and Egger tests, respectively, were used to identify small-study effects. Sensitivity analysis was performed to evaluate the robustness of the original effect size.

RESULTS

Nine observational studies were identified from 1439 primary hits. A total of 970 pediatric patients, including 304 with hyperglycemia and brain injury, were included for meta-analysis. Hyperglycemia was strongly associated with a higher risk of all-cause mortality in pediatric patients (odds ratio = 11.60, 95% confidence interval [CI] 7.88-17.08; I = 0%). The overall quality of eligible studies was low, but the funnel plot indicated no publication bias.

CONCLUSIONS

Hyperglycemia is significantly associated with high all-cause mortality in pediatric patients with brain injury. However, the relationship should be confirmed by larger-scale observational studies and randomized controlled trials.

Traumatic brain injury-the effects of patient age on treatment intensity and mortality

Background

Ageing is associated with worse treatment outcome after traumatic brain injury (TBI). This association may lead to a self-fulfilling prophecy that affects treatment efficacy. The aim of the current study was to evaluate the role of treatment bias in patient outcomes by studying the intensity of diagnostic procedures, treatment, and overall 30-day mortality in different age groups of patients with TBI.

Methods

Included in this study was consecutively admitted patients with TBI, aged ≥ 15 years, with a cerebral CT showing intracranial signs of trauma, during the time-period between 2015–2018. Data were extracted from our prospective quality control registry for admitted TBI patients. As a measure of management intensity in different age groups, we made a composite score, where placement of intracranial pressure monitor, ventilator treatment, and evacuation of intracranial mass lesion each gave one point. Uni- and multivariate survival analyses were performed using logistic multinomial regression.

Results

A total of 1,571 patients with TBI fulfilled the inclusion criteria. The median age was 58 years (range 15–98), 70% were men, and 39% were ≥ 65 years. Head injury severity was mild in 706 patients (45%), moderate in 437 (28%), and severe in 428 (27%). Increasing age was associated with less management intensity, as measured using the composite score, irrespective of head injury severity. Multivariate analyses showed that the following parameters had a significant association with an increased risk of death within 30 days of trauma: increasing age, severe comorbidities, severe TBI, Rotterdam CT-score ≥ 3, and low management intensity.

Conclusion

The present study indicates that the management intensity of hospitalised patients with TBI decreased with advanced age and that low management intensity was associated with an increased risk of 30-day mortality. This suggests that the high mortality among elderly TBI patients may have an element of treatment bias and could in the future be limited with a more aggressive management regime.

Characteristics of traumatic brain injury patients with abnormal neuroimaging in Southeast Norway

Background

The vast majority of hospital admitted patients with traumatic brain injury (TBI) will have intracranial injury identified by neuroimaging, requiring qualified staff and hospital beds. Moreover, increased pressure in health care services is expected because of an aging population. Thus, a regular evaluation of characteristics of hospital admitted patients with TBI is needed. Oslo TBI Registry – Neurosurgery prospectively register all patients with TBI identified by neuroimaging admitted to a trauma center for southeast part of Norway. The purpose of this study is to describe this patient population with respect to case load, time of admission, age, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival.

Methods

Data for 5 years was extracted from Oslo TBI Registry – Neurosurgery. Case load, time of admission, age, sex, comorbidity, injury mechanism, injury characteristics, length of stay, and 30-days survival was compiled and compared.

Results

From January 1st, 2015 to December 31st, 2019, 2153 consecutive patients with TBI identified by neuroimaging were registered. The admission rate of TBI of all severities has been stable year-round since 2015. Mean age was 52 years (standard deviation 25, range 0–99), and 68% were males. Comorbidities were common; 28% with pre-injury ASA score of ≥3 and 25% used antithrombotic medication. The dominating cause of injury in all ages was falls (55%) but increased with age. Upon admission, the head injury was classified as mild TBI in 46%, moderate in 28%, and severe (Glasgow coma score ≤ 8) in 26%. Case load was stable without seasonal variation. Majority of patients (68%) were admitted during evening, night or weekend. 68% was admitted to intensive care unit. Length of hospital stay was 4 days (median, interquartile range 3–9). 30-day survival for mild, moderate and severe TBI was 98, 94 and 69%, respectively.

Conclusions

The typical TBI patients admitted to hospital with abnormal neuroimaging were aged 50–79 years, often with significant comorbidity, and admitted outside ordinary working hours. This suggests the necessity for all-hour presence of competent health care professionals.

The Evolution of the Role of External Ventricular Drainage in Traumatic Brain Injury

External ventricular drains (EVDs) are commonly used in neurosurgery in different conditions but frequently in the management of traumatic brain injury (TBI) to monitor and/or control intracranial pressure (ICP) by diverting cerebrospinal fluid (CSF). Their clinical effectiveness, when used as a therapeutic ICP-lowering procedure in contemporary practice, remains unclear. No consensus has been reached regarding the drainage strategy and optimal timing of insertion. We review the literature on EVDs in the setting of TBI, discussing its clinical indications, surgical technique, complications, clinical outcomes, and economic considerations.

In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment

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.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

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.

Cost-Effectiveness of Biomarker Screening for Traumatic Brain Injury

Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.

[Intracranial pressure monitoring in polytrauma patients with traumatic brain injury]

BACKGROUND

The monitoring of intracranial pressure (ICP) represents a cornerstone in the intensive care of patients with traumatic brain injury (TBI) and the industry provides various technical solutions to this end. Decompressive craniectomy can be an option if conservative measures fail to reduce excessive ICP.

OBJECTIVE

To examine the pathophysiology of ICP in trauma, the management of polytrauma involving TBI, and the indications for decompressive craniectomy; and to compare the different monitoring systems and their complications.

MATERIAL AND METHODS

A retrospective analysis of TBI patients between 2010 and 2016 was performed. Relevant publications are discussed, particularly those relating to the indications for monitoring and its influence on polytrauma management.

RESULTS

Between 2010 and 2016, 106 patients with closed TBI and a mean age of 65.9 years received a total of 120 ICP monitors, most of which were parenchyma devices (111/120), followed by intraventricular catheters (8/120), and one combined system (1/120). Of these patients, 27.4% had sustained polytrauma, whilst 33% regularly used anticoagulants. ICP monitors were removed after 8.5 days on an average and the mean ICU stay was 20 days. Probe insertion was combined with craniectomy in 69.8% patients. Probe-related complications, most commonly involving malfunction, were seen in 6.6%. The duration of monitoring was significantly related to polytrauma (p ≤ 0.001) and age <60 (p = 0.03). ICU stay was also significantly related to polytrauma (p = 0.02) and monitoring complications (p ≤ 0.001). Mortality was related to anticoagulant medication (p = 0.01) and age <60 (p = 0.03).

CONCLUSIONS

ICP monitoring is one of the most important tools in TBI treatment. The course and outcome of these severe injuries is affected by polytrauma, age, and the use of anticoagulants.

Transfusion practices in traumatic brain injury

Purpose of review

The aim of this review is to summarize the recent studies looking at the effects of anemia and red blood cell transfusion in critically-ill patients with traumatic brain injury (TBI), describe the transfusion practice variations observed worldwide, and outline the ongoing trials evaluating restrictive versus liberal transfusion strategies for TBI.

Recent findings

Anemia is common among critically-ill patients with TBI, it is also thought to exacerbate secondary brain injury, and is associated with an increased risk of poor outcome. Conversely, allogenic red blood cell transfusion carries its own risks and complications, and has been associated with worse outcomes. Globally, there are large reported differences in the hemoglobin threshold used for transfusion after TBI. Observational studies have shown differential results for improvements in cerebral oxygenation and metabolism after red blood cell transfusion in TBI.

Summary

Currently, there is insufficient evidence to make strong recommendations regarding which hemoglobin threshold to use as a transfusion trigger in critically-ill patients with TBI. There is also uncertainty whether the restrictive transfusion strategy used in general critical care can be extrapolated to acutely brain injured patients. Ultimately, the consequences of anemia-induced cerebral injury need to be weighed up against the risks and complications associated with red blood cell transfusion.

Analysis of direct costs of decompressive craniectomy in victims of traumatic brain injury

ABSTRACT Background: Decompressive craniectomy is a procedure required in some cases of traumatic brain injury (TBI). This manuscript evaluates the direct costs and outcomes of decompressive craniectomy for TBI in a developing country and describes the epidemiological profile. Methods: A retrospective study was performed using a five-year neurosurgical database, taking a sample of patients with TBI who underwent decompressive craniectomy. Several variables were considered and a formula was developed for calculating the total cost. Results: Most patients had multiple brain lesions and the majority (69.0%) developed an infectious complication. The general mortality index was 68.8%. The total cost was R$ 2,116,960.22 (US$ 661,550.06) and the mean patient cost was R$ 66,155.00 (US$ 20,673.44). Conclusions: Decompressive craniectomy for TBI is an expensive procedure that is also associated with high morbidity and mortality. This was the first study performed in a developing country that aimed to evaluate the direct costs. Prevention measures should be a priority.

Cost-Effectiveness of Craniotomy for Epidural Hematomas at a Major Government Hospital in Cambodia

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.

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator

Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT’s prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.

Impact of tranexamic acid on coagulation and inflammation in murine models of traumatic brain injury and hemorrhage

BACKGROUND

Posttraumatic coagulopathy and inflammation can exacerbate secondary cerebral damage after traumatic brain injury (TBI). Tranexamic acid (TXA) has been shown clinically to reduce mortality in hemorrhaging and head-injured trauma patients and has the potential to mitigate secondary brain injury with its reported antifibrinolytic and antiinflammatory properties. We hypothesized that TXA would improve posttraumatic coagulation and inflammation in a murine model of TBI alone and in a combined injury model of TBI and hemorrhage (TBI/H).

METHODS

An established murine weight drop model was used to induce a moderate TBI. Mice were administered intraperitoneal injections of 10 mg/kg TXA or equivalent volume of saline 10 min after injury. An additional group of mice was subjected to TBI followed by hemorrhagic shock using a pressure-controlled model. TBI/H mice were given intraperitoneal injections of TXA or saline during resuscitation. Blood was collected at intervals after injury to assess coagulation by rotational thromboelastometry (ROTEM) and inflammation by Multiplex cytokine analysis. Soluble P-selectin, a biomarker of platelet activation, and serum neuron-specific enolase, a biomarker of cerebral injury, were measured at intervals. Brain homogenates were analyzed for inflammatory changes by Multiplex enzyme-linked immunosorbent assay, and splenic tissue was collected for splenic cell population assessment by flow cytometry.

RESULTS

There were no coagulation, serum or cerebral cytokine, P-selectin, or neuron-specific enolase differences between mice treated with TXA or saline after TBI. After the addition of hemorrhagic shock and resuscitation to TBI, TXA administration still did not affect coagulation parameters, systemic or cerebral inflammation, or platelet activation, as compared with saline alone. At 24 hours after TBI, mice given TXA demonstrated lower splenic total cell counts central memory CD8, effector CD8, B cell, and increased naive CD4 cell populations. By contrast, TXA did not affect splenic leukocyte populations after combined TBI/H.

CONCLUSIONS

Despite clinical data suggesting a mortality benefit, TXA did not modulate coagulation, inflammation, or biomarker generation in either the TBI or TBI/H murine models. Administration of TXA after TBI altered splenic leukocyte populations, which may contribute to a change in posttraumatic immune status. Future studies should be done to investigate the role of TXA in the development of posttraumatic immunosuppression and risk of nosocomial infections.

Intraventricular intracranial pressure monitoring improves the outcome of older adults with severe traumatic brain injury: an observational, prospective study

BACKGROUND

Intracranial pressure (ICP) monitoring is widely used in the management of patients with severe traumatic brain injury (TBI). However, there is limited evidence about the efficacy of ICP monitoring in older subjects (aged ≥65 years). This study evaluated the effect of intraventricular ICP monitoring on the outcome of older adults suffering from a severe TBI.

METHODS

This prospective, observational study included 166 older TBI patients (aged ≥65 years) with Glasgow Coma scale (GCS) scores lower than 9 at admission. The study cohort was divided into two groups, intraventricular ICP monitoring and non-ICP monitoring. The primary outcome was in-hospital mortality. The secondary outcomes included the Glasgow Outcome Scale (GOS) score 6 months after injury, the ICU and total hospital lengths of stay, and mechanical ventilation days.

RESULTS

There were 80 patients in the intraventricular ICP monitoring group and 86 patients in non-ICP monitoring group. There was no statistical difference between groups in demographics and severity of head injury. Patients treated with intraventricular ICP monitoring had lower in-hospital mortality (33.8 % vs 51.2 %, P < 0.05), a higher 6-month GOS score (3.0 ± 1.4 vs 2.5 ± 1.2 P < 0.05), and a lower dosage (514 ± 246 g vs 840 ± 323 g, P < 0.0001) and shorter duration (7.2 ± 3.6 days vs 8.4 ± 4.3 days, P < 0.01) of mannitol use. However, the ICU length of stay (14.3 ± 6.4 days vs 11.6 ± 5.8 days, P < 0.01) and mechanical ventilation days (6.7 ± 3.5 days vs 5.6 ± 2.4 days, P < 0.05) were longer in the ICP monitoring group. The total length of hospital stay did not differ between the two groups (28.5 ± 12.1 days vs 26.1 ± 13.5 days, P = 0.23).

CONCLUSIONS

Intraventricular ICP monitoring may have beneficial effects on the decreased in-hospital mortality and improved 6-month outcome of older patients with severe TBI. However, given that this was an observational study conducted in a single institution, further well-designed randomized control trials are needed to evaluate the effect of intraventricular ICP monitoring on the outcome of older severe TBI patients.

Consensus statement from the 2014 International Microdialysis Forum

Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.

Predicting the outcome for individual patients with traumatic brain injury: a case-based review

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.

Multimodality monitoring consensus statement: monitoring in emerging economies

The burden of disease and so the need for care is often greater at hospitals in emerging economies. This is compounded by frequent restrictions in the delivery of good quality clinical care due to resource limitations. However, there is substantial heterogeneity in this economically defined group, such that advanced brain monitoring is routinely practiced at certain centers that have an interest in neurocritical care. It also must be recognized that significant heterogeneity in the delivery of neurocritical care exists even within individual high-income countries (HICs), determined by costs and level of interest. Direct comparisons of data between HICs and the group of low- and middle-income countries (LAMICs) are made difficult by differences in patient demographics, selection for ICU admission, therapies administered, and outcome assessment. Evidence suggests that potential benefits of multimodality monitoring depend on an appropriate environment and clinical expertise. There is no evidence to suggest that patients in LAMICs where such resources exist should be treated any differently to patients from HICs. The potential for outcome benefits in LAMICs is arguably greater in absolute terms because of the large burden of disease; however, the relative cost/benefit ratio of such monitoring in this setting must be viewed in context of the overall priorities in delivering health care at individual institutions.

Intracranial pressure monitoring: fundamental considerations and rationale for monitoring

Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.

Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality

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.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Trends and outcome predictors after traumatic brain injury surgery: a nationwide population-based study in Taiwan

OBJECT

The authors sought to analyze trends in hospital resource utilization and mortality rates in a population of patients who had received traumatic brain injury (TBI) surgery.

METHODS

This nationwide population-based cohort study retrospectively analyzed 18,286 patients who had received surgical treatment for TBI between 1998 and 2010. The multiple linear regression model and Cox proportional hazards model were used for multivariate assessment of outcome predictors.

RESULTS

The prevalence rate of surgical treatment for patients with TBI gradually but significantly (p < 0.001) increased by 47.6% from 5.0 per 100,000 persons in 1998 to 7.4 per 100,000 persons in 2010. Age, sex, Deyo-Charlson comorbidity index score, hospital volume, and surgeon volume were significantly associated with TBI surgery outcomes (p < 0.05). Over the 12-year period analyzed, the estimated mean hospital treatment cost increased 19.06%, whereas the in-hospital mortality rate decreased 10.9%. The estimated mean time of overall survival after TBI surgery (± SD) was 83.0 ± 4.2 months, and the overall in-hospital and 1-, 3-, and 5-year survival rates were 74.5%, 67.3%, 61.1%, and 57.8%, respectively.

CONCLUSIONS

These data reveal an increased prevalence of TBI, especially in older patients, and an increased hospital treatment cost but a decreased in-hospital mortality rate. Health care providers and patients should recognize that attributes of the patient and of the hospital may affect hospital resource utilization and the mortality rate. These results are relevant not only to other countries with similar population sizes but also to countries with larger populations.

Traumatic Brain Injury: Patient Characteristics, Hospital Costs and Trends Over Time

Background: Traumatic brain injury (TBI) is an increasingly diagnosed condition, but the trends in TBI visits and the cost of which have not been quantified from the hospital perspective. Objectives: To quantify the costs of TBI stratified by inpatient and outpatient visits and to examine trends in TBI incidence over time. Methods: This descriptive study utilized data for 2007-2012 from the Premier hospital database, which includes clinical and utilization information from hospitals across the United States. TBI was identified through International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Descriptive data were obtained to identify the TBI costs, visit costs, patient characteristics, and intertemporal trends in TBI rates. Results: TBI patients were treated on an outpatient basis 88% of the time. Nearly 45% (44.3%) of TBI patients requiring inpatient admissions were age 65 or over, and 20% of TBI patients treated as an outpatient were age 75 or over. Children aged 4 or younger accounted for nearly 14% of TBI cases treated on an outpatient basis. TBI patients treated in the inpatient setting incurred fairly long hospital visits (mean 4.8 days; median 3.0 days) and substantial hospital costs (mean $12,717; median $8,176). The rate of TBI visits have risen substantially over time, especially among children under age 18 years and patients in the Northeast US Census Region. Conclusion: TBI is a serious medical condition that appears to be on the rise. Large differences exist between the hospital costs associated with TBIs treated in the inpatient and outpatient settings. Further research to understand factors affecting the costs and clinical outcomes of TBI can help refine treatment strategies to enhance patient outcomes while providing cost effective care.

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine

Neurocritical care depends, in part, on careful patient monitoring but as yet there are little data on what processes are the most important to monitor, how these should be monitored, and whether monitoring these processes is cost-effective and impacts outcome. At the same time, bioinformatics is a rapidly emerging field in critical care but as yet there is little agreement or standardization on what information is important and how it should be displayed and analyzed. The Neurocritical Care Society in collaboration with the European Society of Intensive Care Medicine, the Society for Critical Care Medicine, and the Latin America Brain Injury Consortium organized an international, multidisciplinary consensus conference to begin to address these needs. International experts from neurosurgery, neurocritical care, neurology, critical care, neuroanesthesiology, nursing, pharmacy, and informatics were recruited on the basis of their research, publication record, and expertise. They undertook a systematic literature review to develop recommendations about specific topics on physiologic processes important to the care of patients with disorders that require neurocritical care. This review does not make recommendations about treatment, imaging, and intraoperative monitoring. A multidisciplinary jury, selected for their expertise in clinical investigation and development of practice guidelines, guided this process. The GRADE system was used to develop recommendations based on literature review, discussion, integrating the literature with the participants' collective experience, and critical review by an impartial jury. Emphasis was placed on the principle that recommendations should be based on both data quality and on trade-offs and translation into clinical practice. Strong consideration was given to providing pragmatic guidance and recommendations for bedside neuromonitoring, even in the absence of high quality data.

Neurologic disorders, in-hospital deaths, and years of potential life lost in the USA, 1988-2011

Premature mortality is a public health concern that can be quantified as years of potential life lost (YPLL). Studying premature mortality can help guide hospital initiatives and resource allocation. We investigated the categories of neurologic and neurosurgical conditions associated with in-hospital deaths that account for the highest YPLL and their trends over time. Using the Nationwide Inpatient Sample (NIS), we calculated YPLL for patients hospitalized in the USA from 1988 to 2011. Hospitalizations were categorized by related neurologic principal diagnoses. An estimated 2,355,673 in-hospital deaths accounted for an estimated 25,598,566 YPLL. The traumatic brain injury (TBI) category accounted for the highest annual mean YPLL at 361,748 (33.9% of total neurologic YPLL). Intracerebral hemorrhage, cerebral ischemia, subarachnoid hemorrhage, and anoxic brain damage completed the group of five diagnoses with the highest YPLL. TBI accounted for 12.1% of all inflation adjusted neurologic hospital charges and 22.4% of inflation adjusted charges among neurologic deaths. The in-hospital mortality rate has been stable or decreasing for all of these diagnoses except TBI, which rose from 5.1% in 1988 to 7.8% in 2011. Using YPLL, we provide a framework to compare the burden of premature in-hospital mortality on patients with neurologic disorders, which may prove useful for informing decisions related to allocation of health resources or research funding. Considering premature mortality alone, increased efforts should be focused on TBI, particularly in and related to the hospital setting.

Traumatic Brain Injury pathophysiology and treatments: early, intermediate, and late phases post-injury

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.

Traumatic brain injury: methodological approaches to estimate health and economic outcomes

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.

Decompressive craniectomy: past, present and future

Decompressive craniectomy (DC)--a surgical procedure that involves removal of part of the skull to accommodate brain swelling--has been used for many years in the management of patients with brain oedema and/or intracranial hypertension, but its place in contemporary practice remains controversial. Results from a recent trial showed that early (neuroprotective) DC was not superior to medical management in patients with diffuse traumatic brain injury. An ongoing trial is investigating the clinical and cost effectiveness of secondary DC as a last-tier therapy for post-traumatic refractory intracranial hypertension. With regard to ischaemic stroke (malignant middle cerebral artery infarction), a recent Cochrane review concluded that DC improves survival compared with medical management, but that a higher proportion of DC survivors experience moderately severe or severe disability. Although many patients have a good outcome, the issue of DC-related disability raises important ethical issues. As DC and subsequent cranioplasty are associated with a number of complications, indiscriminate use of this surgery is not appropriate. Here, we review the evidence and present considerations regarding surgical technique, ethics and cost-effectiveness of DC. Prospective clinical trials and cohort studies are essential to enable optimization of patient care and outcomes.

Traumatic brain injury: A case-based review

BACKGROUND

Traumatic brain injuries are common and costly to hospital systems. Most of the guidelines on management of traumatic brain injuries are taken from the Brain Trauma Foundation Guidelines. This is a review of the current literature discussing the evolving practice of traumatic brain injury.

DATA SOURCES

A literature search using multiple databases was performed for articles published through September 2012 with concentration on meta-analyses, systematic reviews, and randomized controlled trials.

RESULTS

The focus of care should be to minimize secondary brain injury by surgically decompressing certain hematomas, maintain systolic blood pressure above 90 mmHg, oxygen saturations above 93%, euthermia, intracranial pressures below 20 mmHg, and cerebral perfusion pressure between 60-80 mmHg.

CONCLUSION

Much is still unknown about the management of traumatic brain injury. The current practice guidelines have not yet been sufficiently validated, however equipoise is a major issue when conducting randomized control trials among patients with traumatic brain injury.

The value of critical care

The primary focus of this review is on the cost-effectiveness of critical care. The rapid growth in health care expenditures has engendered careful scrutiny of the practice of medicine with regard not only to effectiveness but also to efficiency. This shift necessitates that physicians understand the effectiveness of their interventions and the cost at which this effectiveness is obtained. Cost-effectiveness and cost-utility analyses have become crucial evaluative tools in medicine. Explicit articulation of comparative cost-effectiveness facilitates the allocation of limited resources. Physicians and policy-makers must evaluate such studies with caution, skepticism, and attention to the methods used.