Page 84 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 3
As in literature, the identified in-hospital costs increase with higher TBI severity. 9,16,60,67 Costs increase because they primarily consist of costs related to LOS and surgical interventions and because the utilization of both is higher in more severely injured TBI patients. 68-71 After all, healthcare expenses are equal to utilization multiplied by associated prices. 62 Also in other studies, physician charges are another important contributor to in-hospital costs. 2,72 Length of stay results and its variability seemed to be in accordance with literature, but were difficult to compare due to this variation. 68,69 Like in previous research, extracranial injuries and overall injury severity contributed to higher healthcare consumption and in- hospital costs. 67,69,73-75 Distinguishing costs that are related to TBI or associated extracranial injuries is nearly impossible. Therefore, four studies explicitly investigated patients with isolated-TBI. 44,51,53,56 Motor vehicle accidents and gunshot wounds were reported to be related to higher costs, most likely because of higher injury severity and accompanying extracranial injuries. Although a higher age is often considered to be more expensive, only few studies mentioned this and comparison between the age groups did not show obvious differences in LOS or in-hospital costs. 15,63,67,73
Hospital and acute care costs were reported to be important constituents of total costs followed by in-patient rehabilitation. However, the limitations of a short follow-up period have been recognized before. 7 Although the in-hospital costs are obviously an important part, post-discharge rehabilitation and other long term care costs are also major contributors to the total costs after TBI. 12 When including the enormous long- term or lifetime costs and the loss of productivity, the share of in-hospital costs on the total burden significantly decreases. 12,14,76 A long-term follow up period would provide a better overview for two reasons. First, the assessment of patient outcome will be more accurate, because health problems might persist, improve or deteriorate several years after trauma. 77,78 Second, the cost analysis will be more comprehensive, since a changing health situation influences healthcare consumption and productivity for both patients and relatives. Therefore, especially for establishing the cost-effectiveness of treatments, a long-term follow-up should be included.
The identified most important reasons for (outcome) variation were probably all caused by different study objectives. Study objectives determined study methodology and consequently also the studied participants, interventions and outcome. Although most study objectives included costs research, the major differences between them likely caused the aforementioned methodological and clinical heterogeneity. Heterogeneity has earlier been reported for TBI cost studies and complicates study comparison and outcome interpretation. 7,10,59,60 Heterogeneity is not limited to TBI
82