Page 104 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 4
DISCUSSION
“Favourable” outcome with a good HRQoL was achieved in an important quarter proportion of the seemingly most severely injured patients. This retrospective cohort study, however, also shows high rates of mortality and so called “unfavourable” outcome in patients with a t-ASDH and relatively high healthcare consumption and in- hospital costs. These costs increased with higher injury severity scores and in patients with a surgical intervention. The majority of costs were related to (ICU) admission and surgical intervention. According to the investigators, this study shows a trend that surgical treatment of t-ASDH can realize favourable outcome in s-TBI at for society acceptable in-hospital costs.
Patient outcome
Accurate comparison of the reported patient outcome results with literature is challenging because outcome in TBI is highly variable and dependent on patient characteristics, circumstances, social context and treatment. 2-4,12,28 Nonetheless, the important result that even the most severely injured TBI patients can, although a small number, achieve favourable outcome (GOS) and good quality of life (QOLIBRI) is supported by recent literature. 29,30
Our QOLIBRI results are not applicable to study patients with a cognitive dysfunction and/or impaired self-awareness that is too severe to complete the questionnaire. The unmeasured HRQoL of these patients might have negatively influenced the reported HRQoL per TBI severity group. The applicability of the QOLIBRI for all patients with TBI remains unclear since it has only been validated in patients without substantial post- traumatic cognitive restraints. 16 Proxy completion is impossible for many QOLIBRI items and misses the essence of measuring the ‘self-perceived’ HRQoL. It also remains unclear whether the cut-off point of 60 is satisfying for quantifying a good HRQoL. 23 Therefore, validity should be confirmed for patients with TBI associated persisting cognitive restraints or suitable new (HRQoL) measurement options need to be developed.
In contrast to earlier published reports on t-ASDH, the mean cohort age of 65 years was relatively high, but in accordance with changing TBI epidemiology. 31 Also, a large number of patients had an initial low GCS and/or pupillary abnormalities. These three factors are known to negatively influence outcome and sometimes these patients are
102