title: An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury.
abstract: BACKGROUND
  For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre.
  
  
  METHODS
  The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses.
  
  
  RESULTS
  Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000.
  
  
  CONCLUSIONS
  For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.
authors.affiliation: a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK ;
authors.forename: R
authors.initials: R
authors.lastname: Grieve
authors.affiliation: a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK ;
authors.forename: Z
authors.initials: Z
authors.lastname: Sadique
authors.affiliation: a Department of Health Services Research and Policy , London School of Hygiene and Tropical Medicine , London , UK ;
authors.forename: M
authors.initials: M
authors.lastname: Gomes
authors.affiliation: b National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust , London , UK ;
authors.forename: M
authors.initials: M
authors.lastname: Smith
authors.affiliation: c School of Health and Related Research, University of Sheffield , Sheffield , UK ;
authors.forename: F E
authors.initials: FE
authors.lastname: Lecky
authors.affiliation: d School of Clinical Medicine, University of Cambridge , Cambridge , UK ;
authors.forename: P J A
authors.initials: PJ
authors.lastname: Hutchinson
authors.affiliation: d School of Clinical Medicine, University of Cambridge , Cambridge , UK ;
authors.forename: D K
authors.initials: DK
authors.lastname: Menon
authors.affiliation: e Clinical Trials Unit, Intensive Care National Audit and Research Centre , London , UK.
authors.forename: K M
authors.initials: KM
authors.lastname: Rowan
authors.affiliation: e Clinical Trials Unit, Intensive Care National Audit and Research Centre , London , UK.
authors.forename: D A
authors.initials: DA
authors.lastname: Harrison
mesh_terms: D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000191:economics / Q000628:therapy; D000070642:Brain Injuries, Traumatic / Q000191:economics* / Q000628:therapy*; D003362:Cost-Benefit Analysis / Q000379:methods; D016638:Critical Illness / Q000191:economics* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011788:Quality of Life; D019057:Quality-Adjusted Life Years
keywords: Cost-effectiveness analysis; neurocritical care; traumatic brain injury