Page 213 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Humans have sustained traumatic brain injuries (TBI) from the beginning of their existence and will most likely be confronted with this devastating disease until their extinction. Even after thousands of years of experience in treating patients with TBI, decisions regarding the optimal treatment strategy remain difficult for both healthcare workers as policy makers. In this thesis, consisting of two parts, we aimed to describe and improve the acute treatment decision-making process and research practice in patients with TBI.
Part I investigated the challenges of the treatment decision-making process in patients with (severe) TBI and focussed on three factors considered to be important in this process: patient outcome, in-hospital healthcare consumption, and in-hospital costs.
Chapter 2 was a literature review of acute neurosurgical management in patient with very severe TBI (Glasgow Coma Scale 3-5). It showed major variation in treatment strategies between forty-five included studies. Mortality rates were high, and the chance to reach a so called ‘favourable outcome’ was low. Some studies however, did report favourable outcome rates for specific patient groups (lower age, lower TBI severity and absence of pupillary abnormalities). In addition to patient and injury related factors, also the type and timing of an intervention appeared to be related with outcome. It was not possible to establish causality due to the high variation between studies and due to the methodological limitations of individual studies.
Chapter 3 was a systematic review that investigated the in-hospital costs of patients after sustaining severe TBI (Glasgow Coma Scale 3-8). The twenty-five included articles showed generally high in-hospital healthcare costs (median €44,660; range €1,720 – €324,660; mean €70,810). The in-hospital costs were primarily driven by costs related to both general ward (12% – 38%) and ICU (51% – 79%) length of stay and surgical interventions (4% – 8%). The length of stay (LOS) in the ICU ranged from 8 to 26 days and hospital LOS ranged from 10 to 37 days. Consumption and costs increased with higher TBI severity. Drawing firm conclusions was difficult, due to the inadequate quality of the included studies and variation of study results, caused by methodological and clinical heterogeneity. It was concluded that future economic evaluations could improve their quality, accuracy of cost calculation, and reporting of costs, by using guideline recommendations and common data elements.
Chapter 4 and chapter 5 reported on patient outcome and on in-hospital healthcare consumption and in-hospital costs of two different patient cohorts. The first cohort consisted of 108 consecutive patients with a traumatic acute subdural hematoma and
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