Letters to the Editor: Severe traumatic brain injury

Michael D. Cusimano M.D., M.H.P.E., F.R.C.S.C., Ph.D., Katrina Zanetti B.Sc. and Conor Sheridan
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  • St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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To The Editor: We read with interest the article by Whitmore et al.4 (Whitmore RG, Thawani JP, Grady MS, et al: Is aggressive treatment of traumatic brain injury cost-effective? Clinical article. J Neurosurg 116:1106–1113, May 2012). This unique and nicely crafted research insightfully addressed the cost of more and less aggressive treatment approaches for traumatic brain injury (TBI) from the perspective of the patient and the health care system. The authors defined aggressive treatment as adhering to the Brain Trauma Foundation (BTF) guidelines in 50% or more of cases. However, such a definition may be problematic in really defining the differences inherent in aggressive and “traditional” or more “routine” or “palliative” care paradigms. For example, there would likely be very little difference in two hospitals, one of which followed BTF guidelines in 49% of cases and another that followed them in 51% of cases. The literature in fact suggests a cutoff in terms of adherence to BTF guidelines that is much higher than the value used in the article. The IRTC (Inova Regional Trauma Center) Neurotrauma Task Force considered 88% adherence to the same guidelines to be “high compliance.”2 Faul and associates regarded 80% adherence as fully compliant for the reason that a small subset of severely brain-injured patients will not be candidates for the guideline application due to comorbidities or extenuating circumstances.3 Faul et al. also recognize probable overestimation of benefits of adherence to guidelines due to low Glasgow Outcome Scale (GOS) scores in their sample.3 We wonder what would happen to the authors' conclusions had the more stringent definitions of “aggressive care” been used in the study? Would a range of percentage BTF guideline adherence that defines each category (for example, 70%–90% for aggressive and 10%–30% for traditional) perhaps be more effective in producing accurate distinctions between aggressive and traditional care? In this way, the “gray area” of compliance proportions that fall on the limits of two categories would be eliminated, thus removing the possibility of the treatments being analogous from a clinical perspective.

In addition, the authors estimate long-term quality of life (QOL) according to GOS outcomes at 6 months. In the calculations for cost-effectiveness, these QOL measurements were assumed to remain static for the remainder of the patient's life expectancy. However, there is considerable evidence to suggest that significant recovery after a TBI can continue beyond 6 months postinjury: at least 36% of patients with severe TBI were reported to have improved GOS scores during the period between 6 months and 1 year after the incident.1 To what degree would replacing the 6-month assumption with one that assumes static outcomes after 1 year affect the results of this study? Would the differences in results between comfort and routine care be reduced had this different assumption been used?

Given the huge global burden of TBI, Whitmore and collaborators have made an important contribution. In the future, to help resolve the issue of whether aggressive treatment is cost-effective for a 20-year-old or an 80-yearold with a severe TBI, we will need more studies and studies from other jurisdictions with vastly different cost estimates for patients with TBI. We also look forward to the development of simple tools that predict not only outcomes but also lifetime costs likely to be incurred, given a particular patient with a particular degree of injury, living in a particular jurisdiction.

Disclosure

The authors report no conflict of interest.

References

  • 1

    Corral L, , Ventura JL, , Herrero JI, , Monfort JL, , Juncadella M, & Gabarrós A, : Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury. Brain Inj 21:12251231, 2007

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  • 2

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

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  • 3

    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

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  • 4

    Whitmore RG, , Thawani JP, , Grady MS, , Levine JM, , Sanborn MR, & Stein SC: Is aggressive treatment of traumatic brain injury cost-effective? Clinical article. J Neurosurg 116:11061113, 2012

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  • Hospital of the University of Pennsylvania, Philadelphia, PA
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Response

We would like to thank Cusimano and colleagues for their interest in our paper and their thoughtful commentary. Specifically, they raise two broad questions regarding our methodology: 1) the threshold of adherence to BTF guidelines that we used to distinguish aggressive from traditional (routine) treatment; 2) the 6-month cutoff we used for GOS scores to calculate Quality Adjusted Life-Years (QALYs) created by the treatment paradigm.

We defined aggressive care as adherence to BTF guidelines in more than 50% of cases. This threshold follows previous definitions by our group2 and other literature, including the study by Faul et al.,1 which depicts an increasing linear relationship between improved BTF compliance and patient lives saved. In practice, most modern centers do adhere to the BTF guidelines in considerably more (or less) than half their cases. Adopting a more stringent definition of aggressive care in this study would likely change the proportion of patients in each GOS category at 6 months (see Table 1 in original article) such that a greater percentage would have GOS higher than 3 in aggressive care and lower than 3 in routine care. As Dr. Cusimano and colleagues note, this would accentuate the benefit of adherence to BTF guidelines between the two categories of treatment.

When selecting our methodology, we made conscious choices to avoid bias in favor of aggressive treatment. Adopting a definition of aggressive care as greater than 70% BTF guideline compliance not only biases the analysis in favor of aggressive treatment, but also risks introducing other sources of bias, such as temporal covariates. The same holds true for using GOS scores greater than 6 months. Even if adequate numbers of cases with longer-term follow-up data were available, they are likely to favor the aggressively treated group. It could be argued that patients saved by aggressive care who would have died under routine treatment are more likely to continue to improve after 6 months. On the other hand, if late recovery rates are the same in the two groups, changes in cost and QALYs will also be the same. Thus the incremental cost-effectiveness ratio should change little, if at all. The question of continued recovery may indeed influence the comparison between the routine and comfort care groups. However, as stated above, this latter comparison is not a practical one, nor do we seriously promote comfort care as a therapeutic alternative, except in selected cases.

Finally, we heartily agree with the writers that prospective studies of diverse populations and development of predictive models applicable to individual cases would aid clinicians greatly in making complex treatment decisions.

References

  • 1

    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

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    • Export Citation
  • 2

    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

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Contributor Notes

Please include this information when citing this paper: published online July 26, 2013; DOI: 10.3171/2012.11.JNS121419.

  • 1

    Corral L, , Ventura JL, , Herrero JI, , Monfort JL, , Juncadella M, & Gabarrós A, : Improvement in GOS and GOSE scores 6 and 12 months after severe traumatic brain injury. Brain Inj 21:12251231, 2007

    • Search Google Scholar
    • Export Citation
  • 2

    Fakhry SM, , Trask AL, , Waller MA, & Watts DD: IRTC Neurotrauma Task Force: 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
  • 3

    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
  • 4

    Whitmore RG, , Thawani JP, , Grady MS, , Levine JM, , Sanborn MR, & Stein SC: Is aggressive treatment of traumatic brain injury cost-effective? Clinical article. J Neurosurg 116:11061113, 2012

    • Search Google Scholar
    • Export Citation
  • 1

    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
  • 2

    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

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