What’s To Gain From Aggressive Treatment Of Severe TBI?
It’s not always clear that aggressive treatment of severe traumatic brain injury (TBI) , including invasive monitoring of intracranial pressure and decompressive craniectomy, is worth the cost, especially in light of questions about the patient’s prognosis and the high costs. That especially can be a concern when the patient is elderly. A new study finally offers some answers to those questions...
An ambulance brings a patient with severe traumatic brain injury to your ED. What happens over the next few minutes sets the course of treatment—and, quite possibly, the patient’s life. As some recent studies have indicated that aggressive treatment may not be effective in reducing mortality, should you proceed with decompressive craniectomy and invasive monitoring of intracranial pressure? A new study in the Journal of Neurosurgery says, “Yes.”
Using a decision-analytical model to compare aggressive treatment (following the Brain Trauma Foundation Guidelines) to “routine care” and “comfort care” (1 day in the ICU followed by routine floor care), researchers at the University of Pennsylvania found that aggressive care produces better outcomes for individuals of any age. While the difference in effectiveness between aggressive care and routine care diminishes as patient age increases, aggressive care is cost effective for all age groups, according to the study.
Up to the age of 80, total costs for aggressive treatment are also significantly less costly than lifetime costs associated with routine care. Across the board, comfort care produces significantly worse outcomes and higher costs for all groups except the oldest and should be reserved for situations where assessment indicates treatment would be futile or more aggressive approaches have been tried and failed, said the authors.
The study defined severe TBI as a score of 8 or less on the Glasgow Coma Scale. Probabilities obtained from literature that each treatment type would result in various Glasgow Outcome Scale (GOS) scores were converted into quality-adjusted life years (QALYs) based on life expectancy and quality of life associated with those scores. Societal costs for direct medical care and loss of productivity were calculated. and all data was put through a Monte Carlo simulation of 1000 trials, each with 1000 patients, to estimate QALYs for patients at 20, 40, 60, and 80 years of age.
While aggressive care is associated with the highest direct costs, the lower associated mortality rate and higher rate of good outcomes keep down lifetime costs associated with long-term nursing care and lost productivity. As a result, total societal costs are lowest for those who receive aggressive treatment, beginning in the ED. In the case of elderly patients, researchers calculated that each additional QALY costs society $88,000 compared to routine care. Using the $100,000 value suggested by recent research as the threshold for cost-effectiveness, aggressive treatment even of 80-year-olds is cost-effective.
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