Musing: Severe Brain Injury Warrants Bold Moves

Dean Reinke
Deans’ Stroke Musing

Wednesday, March 7, 2012

And just think, there is nothing similar for stroke or its well hidden -- Severe Brain Injury Warrants Bold Moves.

Early, aggressive treatment of patients with severe traumatic brain injury appears to be cost-effective compared with less aggressive approaches, an analytical model showed.

Compared with a routine strategy, an aggressive approach resulted in a greater gain in quality-adjusted life years (QALYs) for the average 20-year-old patient (11.7 versus 10, P<0.001), according to Robert Whitmore, MD, of the University of Pennsylvania in Philadelphia, and colleagues.

The difference lessened with increasing age, but remained significantly better for the aggressive approach even in 80-year-olds, the researchers reported online in the Journal of Neurosurgery.

Total direct and indirect lifetime costs were lower for the aggressive approach for patients up to age 60, making it the dominant strategy compared with routine care. And even for 80-year-olds, the aggressive approach would likely be cost-effective, even though it carried higher costs.

A third approach -- comfort care -- yielded the worst outcomes and higher costs that the other two strategies for most age groups.

"Despite higher initial costs for an aggressive management strategy of traumatic brain injury, the substantial improvements in patient outcome cause the total lifetime costs to be the lowest of the three treatment paradigms," Whitmore and colleagues wrote.

Although early and aggressive treatment has been associated with improved outcomes in patients with traumatic brain injury in some studies, other research has pointed to possible harm accompanied by higher costs.

To explore the cost-effectiveness of various approaches, the researchers created a decision analytical model to compare three treatment strategies for patients with severe traumatic brain injury:

• Aggressive: The Brain Trauma Foundation guidelines are followed in at least half of the patients. That includes invasive monitoring of intracranial pressure until the Glasgow Coma Scale score rises above 8 or patients follow commands, and decompressive craniectomy as indicated.
• Routine: The Brain Trauma Foundation guidelines are followed in fewer than half of the patients.
• Comfort: Patients spend a single day in the intensive care unit (but do not undergo invasive intracranial monitoring or decompressive craniectomy), which is followed by routine floor care.

Data were pooled from other studies. All care before and after hospitalization was assumed to be the same in the three groups, with differences present only in acute hospital management.

The researchers assessed outcomes based on the Glasgow Outcome Scale score at six months. The scale runs from 1 (dead), 2 (vegetative state), 3 (severely disabled), 4 (moderately disabled), and 5 (good recovery).

Compared with routine care, aggressive care resulted in a higher proportion of patients with a good recovery (28% versus 23.3%) and a lower percentage of patients who died (28% versus 41%).

In addition to resulting in better outcomes, aggressive care required lower total costs than routine care ($1,264,000 versus $1,361,000 for the average 20-year-old), a result of lower costs associated with long-term nursing care and lost productivity.

Outcomes and costs favored the aggressive approach for patients up to age 60, making it the dominant strategy, according to the researchers.

The aggressive approach was more costly than routine care for 80-year-old patients, resulting in an additional cost of $88,507 per QALY, which may or may not be considered cost-effective.

"Although the threshold [for cost-effectiveness] has long been thought to be $50,000 per QALY, recent research suggests a number considerably more than $100,000," the authors wrote. "If one uses this latter threshold, aggressive care can be considered the most cost-effective strategy for all age groups."

Comfort care was associated with the worst outcomes for all age groups and higher costs for all groups except for the 80-year-olds. That approach "should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile," Whitmore and colleagues wrote.

The authors acknowledged that the analysis was limited by the large number of assumptions that were made and by the lack of age-specific outcomes in patients treated aggressively for severe traumatic brain injury. They also noted that one paper from which they derived much of their data on outcomes did not include any randomized clinical trials.

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Severe Brain Injury Warrants Bold Moves

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