title: Is aggressive treatment of traumatic brain injury cost-effective?
abstract: OBJECTIVE
  The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.
  
  
  METHODS
  A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with "routine care," in which Brain Trauma Foundation guidelines are not followed. A "comfort care" category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.
  
  
  RESULTS
  For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.
  
  
  CONCLUSIONS
  When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.
authors.affiliation: Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. robert.whitmore@uphs.upenn.edu
authors.forename: Robert G
authors.initials: RG
authors.lastname: Whitmore
authors.forename: Jayesh P
authors.initials: JP
authors.lastname: Thawani
authors.forename: M Sean
authors.initials: MS
authors.lastname: Grady
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Levine
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Sanborn
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001930:Brain Injuries / Q000191:economics* / Q000601:surgery / Q000628:therapy*; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D003399:Craniotomy / Q000191:economics; D003627:Data Interpretation, Statistical; D056424:Decompressive Craniectomy; D005260:Female; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D006801:Humans; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D009010:Monte Carlo Method; D019635:Neurosurgical Procedures / Q000191:economics*; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome; D055815:Young Adult