Page 86 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 3
would have compromised comparability and interpretation of study results. In addition, the used TBI severity criteria have their limitations. The GCS has been criticized for its general applicability although it shows adequate reliability in a recent review. 24,83 A patient can be scored ‘false-low’ due to intubation and sedation overestimating injury severity, while the severity of patients who quickly deteriorate after admission will be underestimated. Also, a decreased GCS is not always caused by TBI and could also be caused by extracranial injury alone. 84 Last, patients could be at the lower or the higher end of the spectrum within the GCS 3-8 group. This could have substantial impact on study results, because severity is related to costs. Regarding AIS, the classification system changed over time and the 2005 version codes similar injuries with a lower severity score compared to the 1998 version. 85 Also, some researchers suggest using AIS≥5 as severe, instead of AIS≥4. 86 Despite this, using both criteria is very relevant because they are the most widely used criteria for s-TBI. 24 Limiting the selection to patients with s-TBI improves comparability, but fails to assess the financial burden caused by minor and/ or moderate TBI. Although individual costs are lower for these injuries, the total burden on society is much higher because of their more frequent occurrence. 16 Although the distinction is clearly made throughout, including hospital charges and hospital costs may have compromised comparability of study results. Since both are frequently reported, it did however make a comprehensive review of in-hospital expenses possible and points out the difficulty of cost research. Last, the focus on in-hospital costs, dramatically underestimated the total financial burden caused by s-TBI. 12,14,76
Future research
Because a righteous and ethical distribution of limited healthcare resources is essential to secure the future existence of successful healthcare systems around the world, policymakers increasingly request high quality evidence regarding the cost effectiveness of treatments. 3 To improve the future quality of TBI cost research, investigators should equalize methodological and clinical heterogeneity by using specific methodological guidelines and common data elements. 27,87 As seen in this systematic review, one of the biggest challenges in TBI cost research is heterogeneity. Checklists could be helpful, but the development of international guidelines on economical evaluations for TBI patients is preferred. Patient outcome should be investigated along with the financial burden of treatments. Therefore, cost-effectiveness analysis should be included in upcoming trials investigating TBI treatment strategies. Patients from all ages should be investigated because all are confronted with the consequences of TBI. Because TBI related consequences and associated costs are variable over time, economic evaluations should include a long-term or even lifetime horizon. 6 All associated costs
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