Page 126 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 5
injury resulting into a chronic health condition that requires continued care for most patients. TBI should therefore be addressed as such by healthcare providers, researchers and policymakers. 45,46
Length of stay
Healthcare consumption in terms of length of stay and surgical intervention was substantial. However, when comparing our overall results to numbers for patients (age <65) from Canada, our mean LOS (days) was shorter for all patients (8 vs. 13), for patients with mild TBI (6 vs. 9) and severe TBI (15 vs. 22) but similar for moderate TBI (14 vs. 14). 47 Median LOS was also shorter for mild TBI (3 vs. 9), moderate TBI (7 vs. 11) and severe TBI (7 vs. 12) compared to recent numbers from England and Wales. 25 In a review on hospital costs for severe TBI patients, total LOS ranged between 10 and 36.8 days and ICU LOS between 7.9 and 25.8 days. 12 The large ranges are exemplary for the existing variation, that is primarily caused by patient case-mix and treatment-related factors. 48 Several factors that we found to be associated with an increased total LOS were also mentioned in literature: lower GCS, higher TBI severity and the presence of extracranial injury 47,49, ICP monitoring 50,51 and decompressive craniectomy. 52,53
There were several exceptions. For instance, the most severely injured TBI patients were sometimes admitted to the ward because of treatment limiting decisions shortly after presentation. 54 This could explain the lower LOS and lower in-hospital costs for very severe TBI patients and patients with two non-reacting pupils. Similarly, some mild TBI patients could have been admitted to the ICU because of (suspected) deterioration or over-triage or non-TBI related issues such as age, comorbidities, and concomitant extracranial injuries. 55,56
In-hospital costs
The median costs and interquartile range indicate that costs were skewed by a small group of patients with very high costs. The reported costs were generally similar to available literature. One Dutch study reported that the direct and indirect costs for all TBI patients were €18,030. 57 Costs were higher for Dutch patients with severe TBI (range €40,680 - €44,952), but these costs included rehabilitation and nursing home costs. 58 A recent systematic review reported median in-hospital costs per patient with severe TBI of €55,267 (range €2,130 to €401,808). 12 Mean hospital and healthcare charges for TBI in the USA were $36.075 and $67.224 respectively. 59,60 Differences between studies could be explained by variation, methodological heterogeneity, differences in case mix, but also by geographical location. For example, healthcare expenditures in
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