Page 16 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 1
The many problems with the availability of high-quality evidence results in a lack of consensus, decision-making difficulties, and an inability to practice evidence-based medicine. This enables treatment variation, which is reported in nearly all fields of TBI management, including the use and implementation of guidelines in European neurotrauma centers 32, structures and processes of TBI care 33, monitoring and treatment policies in patients with TBI and intracranial hypertension 34, general supportive and preventive measures at ICUs 35, and neurosurgical strategies or management. 36,37
Future research is needed to improve the quality and completeness of evidence on the treatment of TBI patients. Reliable information on patient outcome and treatment effectiveness is likely to substantially improve the treatment decision-making process for physicians.
Patient outcome
The effectiveness of treatments can be assessed by measuring achieved patient
outcome, because the main goal of providing healthcare is to achieve best possible
patient outcome. Despite available treatment interventions, TBI patients still show
high rates of mortality and unfavourable outcome, especially in patients with s-TBI. In
a recent meta-analysis, the in-hospital mortality for moderate TBI and s-TBI patients
was 57.2% and the ‘all time point’ mortality was 65.3% for s-TBI, 34.3% for moderate
TBI and 12.3% for mild TBI patients. 38 Other studies reported lower mortality rates of
0.45% to 8% for mild TBI 39, 0.9% to 8% for moderate TBI 40 and 39% - 40.4% for s-TBI. 41,42
In addition to mortality rates many investigators report functional patient outcome by using the Glasgow Outcome Score - Extended. 43 (Table 1) A so called ‘favourable outcome’ (GOSE 5-8), indicating independency in daily life, was achieved by 29% - 40% of s-TBI patients, 55.3% - 87% of moderate TBI patients, and 85.4% of mild TBI patients. 40,41,44 Unfortunately, outcome rates are difficult to generalize because they depend on multiple factors such as age, injury severity, initial neurologic condition and TBI severity (i.e defined by GCS). 38,45
Besides short term outcome, many studies report long-term sustained healthcare problems, which are not limited to s-TBI patients, but also reported after mild TBI. 10,11,46-51 Several authors therefore consider TBI to be a chronic health condition and suggest that it should be addressed as such by healthcare providers, researchers and policymakers. 52,53
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