Page 239 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Another method to answer research questions related to point 1 and 4 is called “Comparative Effectiveness Research” (CER). With this method, the effectiveness of (surgical and critical care) treatment is investigated by comparing variation between local practices. This method is used in recent TBI research initiatives like CENTER- TBI, TRACK-TBI and Net-QuRe. 119,135,136 CER is a well-known and promising method to assess treatment effectiveness in TBI, but there are also some important limitations. 137 Studies are generally expensive because many centres and participants must be included to reach sufficient statistical power. Also, effect estimates largely depend on the used analytical method. When a RCT or CER design is not possible, the focus should be on patient cohorts, surgical treatments and outcome measures that are as equal as possible. It is highly recommended to use the well-known common data elements. 138 This will improve comparability and generalizability of study results and allow data analyses in large meta-analyses. Point 2 is basically fundamental research and point 3 and 5 require a more humanistic approach to the topic.
CONCLUSION
Decision-making dilemmas in the acute treatment of s-TBI patients are common. They are caused by insufficient evidence and by uncertainties in outcome prediction and outcome valuation. To decrease uncertainty and improve decision-making, treatment-limiting decisions in a selection of s-TBI patients should be delayed to after at least 72 hours after injury. These patients will receive optimal acute treatment. Although the feasibility and cost-effectiveness of the proposed strategy requires further investigation, it prevents premature treatment-limiting decisions and allows the collection of essential information to improve the identification of patients that will benefit from specific treatment strategies. At the same time, it could prevent ‘unacceptable’ patient outcome and inefficient use of limited healthcare resources in threatened healthcare systems. Including an economic perspective in decision-making is reasonable and essential, but the individual aspects of care and the social utility of caring for those most in need should not be disregarded. Although it is unlikely that all uncertainty will ever be resolved, researchers and ethicists should continue to try to reduce uncertainty in decision-making by improving the scientific quality of evidence.
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General discussion and future perspectives
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