Page 214 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 10
the second cohort consisted of 486 TBI patients that were regionally included in the CENTER-TBI study. Following the recommendations made in chapter 3, we used the Dutch guidelines for economic healthcare evaluations to ascertain the quality of costs calculation. Both studies reported high rates of mortality and unfavourable outcome, as defined by the Glasgow Outcome Scale score. These rates increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and need for surgical intervention. Despite high rates of mortality and unfavourable outcome, both studies also showed that patients with severe TBI could achieve favourable outcome. Even the most severely injured patients were able to achieve favourable outcome.
Both studies found substantial in-hospital healthcare consumption and generally high in-hospital costs, even in patients with mild TBI (Glasgow Coma Score 13-15). Average in-hospital costs were €7,800 for mild, €20,210 for moderate €26,600 for severe, and €26,350 for very severe TBI patients (chapter 5). Increase in healthcare consumption and costs was associated with several factors, including higher TBI severity (lower Glasgow Coma Score), presence of pupillary abnormalities, presence of major extracranial injury, presence of intracranial abnormalities on CT scan, use of intracranial pressure monitoring, and performed surgical interventions(s). In-hospital costs were primarily driven by costs related to admission and surgical intervention. This was in accordance with the results from chapter 3.
Chapter 6 was the result of multiple focus group sessions with medical professionals in the field of neurosurgery, intensive care medicine, rehabilitation, chronic care, anthropology and medical ethics. It described the process and reasoning of decision-making and proposed several reasons that could legitimize treatment-limiting decisions in patients with severe TBI (initial Glasgow Coma Score of 3-8). We also discussed the professional code of physicians, treatment-limiting decision, unacceptability of patient outcome, prognostic uncertainty, shared decision-making difficulties, healthcare costs, societal perspective, and importance of specialized rehabilitation and long-term care. Despite multiple efforts to improve care and outcome of TBI patients, it was concluded that decision-making remains highly complicated. The majority of uncertainty was caused by a lack of high-quality scientific evidence on treatment effectiveness and inaccurate outcome prediction. But there was also uncertainty on the acceptability of outcome, due to different societal and individual values.
Part II analysed procedural difficulties in TBI research efficiency by focussing on the process of institutional review board approval and the use of informed consent procedures in patients with TBI with an inability to provide informed consent.
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