title: Cost-effectiveness of decompressive craniectomy as a lifesaving rescue procedure for patients with severe traumatic brain injury.
abstract: BACKGROUND
  Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after severe traumatic brain injury (TBI), but its cost-effectiveness remains uncertain.
  
  
  METHODS
  Using data on length of stay in hospital, rehabilitation facility, procedural costs, and Glasgow Outcome Scale (GOS) up to 18 months after surgery, the average total hospital costs per life-year and quality-adjusted life-year (QALY) were calculated for patients who had decompressive craniectomy for TBI between 2004 and 2010 in Western Australia. The Corticosteroid Randomisation After Significant Head Injury prediction model was used to quantify the severity of TBI.
  
  
  RESULTS
  Of the 168 patients who had 18-month follow-up data available after the procedure, 70 (42%) achieved a good outcome (GOS-5), 27 (16%) had moderate disability (GOS-4), 34 (20%) had severe disability (GOS-3), 5 (3%) were in vegetative state (GOS-2), and 32 (19%) died (GOS-1). The hospital costs increased with the severity of TBI and peaked when the predicted risk of an unfavorable outcome was about 80%. The average cost per life-year gained (US$671,000 per life-year) and QALY (US$682,000 per QALY) increased substantially and became much more than the usual acceptable cost-effective limit (US$100,000 per QALY) when the predicted risk of an unfavorable outcome was >80%. Changing different underlying assumptions of the analysis did not change the results significantly.
  
  
  CONCLUSIONS
  Severity of TBI had an important effect on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy was not cost-effective for patients with extremely severe TBI.
authors.affiliation: Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia. kwok.ho@health.wa.gov.au
authors.forename: Kwok M
authors.initials: KM
authors.lastname: Ho
authors.forename: Stephen
authors.initials: S
authors.lastname: Honeybul
authors.forename: Christopher R P
authors.initials: CR
authors.lastname: Lind
authors.forename: Grant R
authors.initials: GR
authors.lastname: Gillett
authors.forename: Edward
authors.initials: E
authors.lastname: Litton
mesh_terms: D000293:Adolescent; D000328:Adult; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D056424:Decompressive Craniectomy / Q000191:economics* / Q000379:methods; D005260:Female; D015600:Glasgow Coma Scale; D017721:Hospital Costs; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D015601:Injury Severity Score; D008020:Life Support Care / Q000191:economics / Q000379:methods; D008297:Male; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014904:Western Australia; D055815:Young Adult