Page 95 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Outcome versus in-hospital costs: a neurosurgical paradox?
INTRODUCTION
Traumatic brain injury (TBI) is accompanied by an acute subdural hematoma (t-ASDH)
in around 10-20% of admitted TBI patients. 1 Despite neurosurgical treatment, the
mortality rate is high (40-60%) and outcome often unfavourable (up to 70%). 1-4
This frequently poses an ethical dilemma for neurosurgeons, especially in the more
severe cases. Neurosurgical evacuation of the hematoma, sometimes with additional decompressive craniectomy (DC), can save patients’ lives by decreasing intracranial
pressure and preventing secondary edema, ischaemia and inflammatory cell death, 4 but at the same time, it may result in the survival of severely disabled patients. 5,6 Alternatively, early treatment limiting decisions (TLD) reduce any chance of recovery
and normally result in death. 7,8 To assist physicians in these difficult life-or-death decisions, experts in the field have provided statements and guidelines on the preferred treatment strategies in these patients. 1,9 However, the overall adherence to these guidelines is low, probably because the general conception is that outcome for these patients is rather “unfavourable”. 10-12
Unfortunately, in the literature there is little information on the health-related quality of life (HRQoL) after surgical treatment of patients with a t-ASDH. Until recently researchers used functional indicators like the Glasgow Outcome Scale (GOS) or generic HRQoL instruments because a TBI-specific HRQoL instrument was not available. 13,14 These methods however lacked the perspective of subjective well-being and were considered to be less sensitive. 15 To overcome these limitations, the Quality Of Life after Brain Injury questionnaire (QOLIBRI) was developed. 15 This TBI-specific HRQoL measure covers six dimensions typically affected after TBI and provides more precise information on quality of life. 15 It has been validated in multiple study settings, but has not been used frequently to measure outcome after t-ASDH in clinical studies. 16 Therefore, the TBI-specific HRQoL was investigated in addition to functional outcome (GOS) after the surgical treatment of patients with a t-ASDH.
Furthermore, we analyzed the in-hospital costs associated with both conservative and different surgical treatments in patients with a diagnosed t-ASDH. Costs for the treatment of TBI are high and annually increasing. In the US for example the national hospital costs for all subdural hematomas were estimated to be $US1.6 billion in 2007, a 60% increase compared to 1998. 17 There is an increasing pressure from governments, insurance companies and healthcare providers to control healthcare costs. 18 The demand for high quality evidence regarding the cost-effectiveness of treatments is
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