Page 227 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Humans have suffered from the consequences of traumatic brain injuries (TBI) from the beginning of mankind and will continue to do so in the future. For ages, people have attempted to minimize the consequences of TBI by examining and treating affected individuals. 1 Extensive experience and improvements in medical treatments from the last century resulted in substantial progress in the survival and outcome of severe TBI (s-TBI) patients (Glasgow Coma Score (GCS) of 3 – 8). 2-5
Patients with s-TBI (29% – 40%) 6,7 and vs-TBI (GCS 3 – 5; 19.6% – 23%) 6,7 are nowadays able to achieve so-called ‘favourable’ outcome. 8,9 Most s-TBI patients (40% – 65%) 6,7 however still die or survive with long-term disabilities 2,3,8-11, which also negatively affects the quality of life of most proxies. 12-14 Outcome is usually worse in patients with higher TBI severity (i.e. lower GCS, pupillary abnormalities), intracranial abnormalities on first CT scan, extracranial injuries and need for surgical intervention. 3,6,7,15-17 Despite all available patient outcome data, it remains challenging to interpret, generalize, valuate, and use this data for acute treatment decision-making.
Acute treatment decisions are poorly supported by high- or even moderate quality evidence and accurate prognostic algorithms, leaving ample room for uncertainty.18-23,47 Also, available guidelines do not cover all relevant topics due to a lack of supporting evidence. 18 Non-adherence to guidelines and treatment variation seem understandable in light of such lack of certainty. 24-27 It even remains unclear how specific factors substantiate the acute treatment decision-making process. 28-31 As a result, the decision to initiate acute treatment or not in s-TBI patients or discontinue critical care in the subacute period poses major medical and ethical dilemmas to physicians.
This general discussion elaborates on the role of patient outcome and in-hospital costs in the acute treatment decision-making process in s-TBI patients.
Main findings and interpretation
Patient outcome
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General discussion and future perspectives
Providing healthcare is about doing ‘right’ for individual patients and about better health for populations. 32 Physicians have a responsibility to customize treatment strategies to achieve best possible patient outcome that is respectful of and responsive
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