Is aggressive treatment of traumatic brain injury cost-effective?

Clinical article

View More View Less
  • 1 Departments of Neurosurgery,
  • 2 Neurology, and
  • 3 Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.

Methods

A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with “routine care,” in which Brain Trauma Foundation guidelines are not followed. A “comfort care” category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.

Results

For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.

Conclusions

When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

Abbreviations used in this paper:GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICER = incremental cost-effectiveness ratio; ICP = intracranial pressure; QALY = quality-adjusted life year; QOL = quality of life; TBI = traumatic brain injury.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Robert G. Whitmore, M.D., Hospital of the University of Pennsylvania, Department of Neurosurgery, 3rd Floor Silverstein, 3400 Spruce Street, Philadelphia, Pennsylvania 19104. email: robert.whitmore@uphs.upenn.edu.

Please include this information when citing this paper: published online March 6, 2012; DOI: 10.3171/2012.1.JNS11962.

  • 1

    Akopian G, , Gaspard DJ, & Alexander M: Outcomes of blunt head trauma without intracranial pressure monitoring. Am Surg 73:447450, 2007

  • 2

    Aoki N, , Kitahara T, , Fukui T, , Beck JR, , Soma K, & Yamamoto W, : Management of unruptured intracranial aneurysm in Japan: a Markovian decision analysis with utility measurements based on the Glasgow Outcome Scale. Med Decis Making 18:357364, 1998

    • Search Google Scholar
    • Export Citation
  • 3

    Arias E: United States life tables, 2001. Natl Vital Stat Rep 52:138, 2004

  • 4

    Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS: Guidelines for the management of severe traumatic brain injury. J Neurotrauma 24:Suppl 1 S1S106, 2007

    • Search Google Scholar
    • Export Citation
  • 5

    Braithwaite RS, , Meltzer DO, , King JT Jr, , Leslie D, & Roberts MS: What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?. Med Care 46:349356, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Bratton SL, , Chestnut RM, , Ghajar J, , McConnell Hammond FF, , Harris OA, & Hartl R, : Guidelines for the management of severe traumatic brain injury. VII. Intracranial pressure monitoring technology. J Neurotrauma 24:Suppl 1 S45S54, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Brown AW, , Leibson CL, , Malec JF, , Perkins PK, , Diehl NN, & Larson DR: Long-term survival after traumatic brain injury: a population-based analysis. NeuroRehabilitation 19:3743, 2004

    • Search Google Scholar
    • Export Citation
  • 8

    Centers for Medicare and Medicaid Services: Acute Inpatient Prospective Payment System. Data Files for Final Notice for Fiscal Year 2010 (http://www.cms.gov/PhysicianFeeSched/) [Accessed January 26, 2012]

    • Search Google Scholar
    • Export Citation
  • 9

    Chesnut RM, , Marshall LF, , Klauber MR, , Blunt BA, , Baldwin N, & Eisenberg HM, : The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216222, 1993

    • Search Google Scholar
    • Export Citation
  • 10

    Clifton GL, , Hayes RL, , Levin HS, , Michel ME, & Choi SC: Outcome measures for clinical trials involving traumatically brain-injured patients: report of a conference. Neurosurgery 31:975978, 1992

    • Search Google Scholar
    • Export Citation
  • 11

    Cooper DJ, , Rosenfeld JV, , Murray L, , Arabi YM, , Davies AR, & D'Urso P, : Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:14931502, 2011

    • Search Google Scholar
    • Export Citation
  • 12

    Fakhry SM, , Trask AL, , Waller MA, & Watts DD: Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma 56:492500, 2004

    • Search Google Scholar
    • Export Citation
  • 13

    Faul M, , Wald MM, , Rutland-Brown W, , Sullivent EE, & Sattin RW: Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma 63:12711278, 2007

    • Search Google Scholar
    • Export Citation
  • 14

    Finkelstein EA, , Corso PS, & Miller TR: The Incidence and Economic Burden of Injuries in the United States New York, Oxford University Press, 2006

    • Search Google Scholar
    • Export Citation
  • 15

    Ghajar J: Traumatic brain injury. Lancet 356:923929, 2000

  • 16

    Gold MR, , Siegel JE, & Russell LB, : Cost-Effectiveness in Health and Medicine New York, Oxford University Press, 1996

  • 17

    Harris OA, , Bruce CA, , Reid M, , Cheeks R, , Easley K, & Surles MC, : Examination of the management of traumatic brain injury in the developing and developed world: focus on resource utilization, protocols, and practices that alter outcome. J Neurosurg 109:433438, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Harrison-Felix C, , Whiteneck G, , DeVivo M, , Hammond FM, & Jha A: Mortality following rehabilitation in the Traumatic Brain Injury Model Systems of Care. NeuroRehabilitation 19:4554, 2004

    • Search Google Scholar
    • Export Citation
  • 19

    Hesdorffer DC, & Ghajar J: Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers. J Trauma 63:841848, 2007

    • Search Google Scholar
    • Export Citation
  • 20

    Hutchinson PJ, , Corteen E, , Czonsnyka M, , Mendelow AD, , Menon DK, & Mitchell P, : Decompressive craniectomy in traumatic brain injury: the randomized multicenter RESCUEicp study (www.RESCUEicpcom). Acta Neurochir Suppl 96:1720, 2006

    • Search Google Scholar
    • Export Citation
  • 21

    Ibrahim MI, , Abdullah M, , Naing L, , Abdullah JM, , Idris Z, & Aljunid SM: Cost effectiveness analysis of using multiple neuromodalities in treating severe traumatic brain injury in a developing country like Malaysia. Asian J Surg 30:261266, 2007

    • Search Google Scholar
    • Export Citation
  • 22

    Jennett B, , Teasdale G, , Galbraith S, , Pickard J, , Grant H, & Braakman R, : Severe head injuries in three countries. J Neurol Neurosurg Psychiatry 40:291298, 1977

    • Search Google Scholar
    • Export Citation
  • 23

    Kumar R, , West CG, , Quirke C, , Hall L, & Taylor R: Do children with severe head injury benefit from intensive care?. Childs Nerv Syst 7:299304, 1991

    • Search Google Scholar
    • Export Citation
  • 24

    Langfitt TW: Measuring the outcome from head injuries. J Neurosurg 48:673678, 1978

  • 25

    Le QA, & Hay JW: Cost-effectiveness analysis of lapatinib in HER-2-positive advanced breast cancer. Cancer 115:489498, 2009

  • 26

    Lipscomb J, , Yabroff KR, , Brown ML, , Lawrence W, & Barnett PG: Health care costing: data, methods, current applications. Med Care 47:7 Suppl 1 S1S6, 2009

    • Search Google Scholar
    • Export Citation
  • 27

    Maas AI, , Roozenbeek B, & Manley GT: Clinical trials in traumatic brain injury: past experience and current developments. Neurotherapeutics 7:115126, 2010

    • Search Google Scholar
    • Export Citation
  • 28

    Malmivaara K, , Kivisaari R, , Hernesniemi J, & Siironen J: Costeffectiveness of decompressive craniectomy in traumatic brain injuries. Eur J Neurol 18:656662, 2011

    • Search Google Scholar
    • Export Citation
  • 29

    Marion DW: Traumatic Brain Injury New York, Thieme, 1998

  • 30

    Marshall LF: Head injury: recent past, present, and future. Neurosurgery 47:546561, 2000

  • 31

    McGarry LJ, , Thompson D, , Millham FH, , Cowell L, , Snyder PJ, & Lenderking WR, : Outcomes and costs of acute treatment of traumatic brain injury. J Trauma 53:11521159, 2002

    • Search Google Scholar
    • Export Citation
  • 32

    McHugh GS, , Butcher I, , Steyerberg EW, , Marmarou A, , Lu J, & Lingsma HF, : A simulation study evaluating approaches to the analysis of ordinal outcome data in randomized controlled trials in traumatic brain injury: results from the IMPACT Project. Clin Trials 7:4457, 2010

    • Search Google Scholar
    • Export Citation
  • 33

    Murray CJL, & Lopez AD: The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability From Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020 Geneva, The Harvard School of Public Health, 1996

    • Search Google Scholar
    • Export Citation
  • 34

    Palmer S, , Bader MK, , Qureshi A, , Palmer J, , Shaver T, & Borzatta M, : The impact on outcomes in a community hospital setting of using the AANS traumatic brain injury guidelines. J Trauma 50:657664, 2001

    • Search Google Scholar
    • Export Citation
  • 35

    Patel HC, , Bouamra O, , Woodford M, , Yates DW, & Lecky FE: Clinical article: mortality associated with severe head injury in the elderly. Acta Neurochir (Wien) 152:13531357, 2010

    • Search Google Scholar
    • Export Citation
  • 36

    Saul TG, & Ducker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:498503, 1982

    • Search Google Scholar
    • Export Citation
  • 37

    Shafi S, , Diaz-Arrastia R, , Madden C, & Gentilello L: Intracranial pressure monitoring in brain-injured patients is associated with worsening of survival. J Trauma 64:335340, 2008

    • Search Google Scholar
    • Export Citation
  • 38

    Shavelle RM, , Strauss D, , Whyte J, , Day SM, & Yu YL: Long-term causes of death after traumatic brain injury. Am J Phys Med Rehabil 80:510519, 2001

    • Search Google Scholar
    • Export Citation
  • 39

    Shiroiwa T, , Motoo Y, & Tsutani K: Cost-effectiveness analysis of KRAS testing and cetuximab as last-line therapy for colorectal cancer. Mol Diagn Ther 14:375384, 2010

    • Search Google Scholar
    • Export Citation
  • 40

    Sosin DM, , Sniezek JE, & Thurman DJ: Incidence of mild and moderate brain injury in the United States, 1991. Brain Inj 10:4754, 1996

  • 41

    Sosin DM, , Sniezek JE, & Waxweiler RJ: Trends in death associated with traumatic brain injury, 1979 through 1992. Success and failure. JAMA 273:17781780, 1995

    • Search Google Scholar
    • Export Citation
  • 42

    Spiotta AM, , Stiefel MF, , Gracias VH, , Garuffe AM, , Kofke WA, & Maloney-Wilensky E, : Brain tissue oxygen-directed management and outcome in patients with severe traumatic brain injury. Clinical article. J Neurosurg 113:571580, 2010

    • Search Google Scholar
    • Export Citation
  • 43

    Stein SC, , Georgoff P, , Meghan S, , Mirza KL, & El Falaky OM: Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury. Clinical article. J Neurosurg 112:11051112, 2010

    • Search Google Scholar
    • Export Citation
  • 44

    Stein SC, , Georgoff P, , Meghan S, , Mizra K, & Sonnad SS: 150 years of treating severe traumatic brain injury: a systematic review of progress in mortality. J Neurotrauma 27:13431353, 2010

    • Search Google Scholar
    • Export Citation
  • 45

    Strauss DJ, , Shavelle RM, & Ashwal S: Life expectancy and median survival time in the permanent vegetative state. Pediatr Neurol 21:626631, 1999

    • Search Google Scholar
    • Export Citation
  • 46

    Tilford JM, , Aitken ME, , Goodman AC, & Adelson PD: Measuring the cost-effectiveness of technologic change in the treatment of pediatric traumatic brain injury. J Trauma 63:6 Suppl S113S121, 2007

    • Search Google Scholar
    • Export Citation
  • 47

    Tosteson AN, , Lurie JD, , Tosteson TD, , Skinner JS, , Herkowitz H, & Albert T, : Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 149:845853, 2008

    • Search Google Scholar
    • Export Citation
  • 48

    US Department of Labor, Bureau of Labor Statistics: CPI Inflation Calculator (http://data.bls.gov/cgi-bin/cpicalc.pl) [Accessed January 26, 2012]

    • Search Google Scholar
    • Export Citation
  • 49

    Weiner GM, , Lacey MR, , Mackenzie L, , Shah DP, , Frangos SG, & Grady MS, : Decompressive craniectomy for elevated intracranial pressure and its effect on the cumulative ischemic burden and therapeutic intensity levels after severe traumatic brain injury. Neurosurgery 66:11111119, 2010

    • Search Google Scholar
    • Export Citation
  • 1

    Aoki N, , Kitahara T, , Fukui T, , Beck JR, , Soma K, & Yamamoto W, : Management of unruptured intracranial aneurysm in Japan: a Markovian decision analysis with utility measurements based on the Glasgow Outcome Scale. Med Decis Making 18:357364, 1998

    • Search Google Scholar
    • Export Citation
  • 2

    Arias E: United States life tables, 2001. Natl Vital Stat Rep 52:138, 2004

  • 3

    Braithwaite RS, , Meltzer DO, , King JT Jr, , Leslie D, & Roberts MS: What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?. Med Care 46:349356, 2008

    • Search Google Scholar
    • Export Citation
  • 4

    Brown AW, , Leibson CL, , Malec JF, , Perkins PK, , Diehl NN, & Larson DR: Long-term survival after traumatic brain injury: a population-based analysis. NeuroRehabilitation 19:3743, 2004

    • Search Google Scholar
    • Export Citation
  • 5

    Centers for Medicare and Medicaid Services: Acute Inpatient Prospective Payment System. Data Files for Final Notice for Fiscal Year 2010 (http://www.cms.gov/PhysicianFeeSched/) [Accessed January 26, 2012]

    • Search Google Scholar
    • Export Citation
  • 6

    Faul M, , Wald MM, , Rutland-Brown W, , Sullivent EE, & Sattin RW: Using a cost-benefit analysis to estimate outcomes of a clinical treatment guideline: testing the Brain Trauma Foundation guidelines for the treatment of severe traumatic brain injury. J Trauma 63:12711278, 2007

    • Search Google Scholar
    • Export Citation
  • 7

    Finkelstein EA, , Corso PS, & Miller TR: The Incidence and Economic Burden of Injuries in the United States New York, Oxford University Press, 2006

    • Search Google Scholar
    • Export Citation
  • 8

    Gold MR, , Siegel JE, & Russell LB, : Cost-Effectiveness in Health and Medicine New York, Oxford University Press, 1996

  • 9

    Halpern NA, , Pastores SM, & Greenstein RJ: Critical care medicine in the United States 1985–2000: an analysis of bed numbers, use, and costs. Criti Care Med 32:12541259, 2004

    • Search Google Scholar
    • Export Citation
  • 10

    Harrison-Felix C, , Whiteneck G, , DeVivo M, , Hammond FM, & Jha A: Mortality following rehabilitation in the Traumatic Brain Injury Model Systems of Care. NeuroRehabilitation 19:4554, 2004

    • Search Google Scholar
    • Export Citation
  • 11

    Shavelle RM, , Strauss D, , Whyte J, , Day SM, & Yu YL: Long-term causes of death after traumatic brain injury. Am J Phys Med Rehabil 80:510519, 2001

    • Search Google Scholar
    • Export Citation
  • 12

    Stein SC, , Burnett MG, & Glick HA: Indications for CT scanning in mild traumatic brain injury: a cost-effectiveness study. J Trauma 61:558566, 2006

    • Search Google Scholar
    • Export Citation
  • 13

    Strauss DJ, , Shavelle RM, & Ashwal S: Life expectancy and median survival time in the permanent vegetative state. Pediatr Neurol 21:626631, 1999

    • Search Google Scholar
    • Export Citation
  • 14

    van der Sluis CK, , Klasen HJ, , Eisma WH, & ten Duis HJ: Major trauma in young and old: what is the difference?. J Trauma 40:7882, 1996

  • 15

    Zasler ND, , Katz DI, & Zafonte RD: Brain Injury Medicine: Principles and Practice New York, Demos Medical Publishing, 2007

Metrics

All Time Past Year Past 30 Days
Abstract Views 1078 282 31
Full Text Views 385 47 1
PDF Downloads 253 33 1
EPUB Downloads 0 0 0