Health Care Resource Utilization and Costs for Adults With Mild Traumatic Brain Injury With Chronic Vestibular Impairment.

OBJECTIVE: To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI). DESIGN: Retrospective matched cohort study. SETTING: IQVIA Integrated Data Warehouse. PARTICIPANTS: People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis. RESULTS: People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only. CONCLUSIONS: People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.

Pragmatic sedation strategies to prevent secondary brain injury in low-resource settings.

Traumatic brain injury is the alteration in brain function due to an external force. It is common and affects millions of people worldwide annually. The World Health Organization estimates that 90% of global deaths caused by injuries occur in low- and middle-income countries, with traumatic brain injury contributing up to half of these trauma-related deaths. Patients with traumatic brain injury in low- and middle-income countries have twice the odds of dying compared with their counterparts in high-income countries. Sedation is a key element of care in the management of traumatic brain injury, used for its neuroprotective effects and to prevent secondary brain injury. While sedatives have the potential to improve outcomes, they can be challenging to administer and have potentially dangerous complications. Sedation in low-resource settings should aim to be effective, safe, affordable and feasible. In this paper, we summarise the indications for sedation in traumatic brain injury, the choice of sedative drugs and the pragmatic management and monitoring of sedated traumatic brain injury patients in low-resource settings.

Costs of Nonfatal Traumatic Brain Injury in the United States, 2016.

BACKGROUND: Traumatic brain injury (TBI) is a serious public health problem in the United States. Each year, TBIs substantially contribute to health care costs, which vary by severity. This is important to consider given the variability in recovery time by severity. RESEARCH DESIGN: This study quantifies the annual incremental health care costs of nonfatal TBI in 2016 for the US population covered by a private health insurance, Medicaid, or Medicare health plan. This study uses MarketScan and defines severity with the abbreviated injury scale for the head and neck region. Nonfatal health care costs were compared by severity. RESULTS: The estimated 2016 overall health care cost attributable to nonfatal TBI among MarketScan enrollees was $40.6 billion. Total estimated annual health care cost attributable to TBI for low severity TBIs during the first year postinjury were substantially higher than costs for middle and high severity TBIs among those with private health insurance and Medicaid. CONCLUSIONS: This study presents economic burden estimates for TBI that underscore the importance of developing strategies to prevent TBIs, regardless of severity. Although middle and high severity TBIs were more costly at the individual level, low severity TBIs, and head injuries diagnosed as "head injury unspecified" resulted in higher total estimated annual health care costs attributable to TBI.

Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial).

BACKGROUND: The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation. METHODS: In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive. RESULTS: A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9). CONCLUSION: Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

A Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update.

OBJECTIVES: To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation. DATA SOURCES: Medline (PubMed), SCOPUS, Web of Science, and the gray literature were searched for relevant articles about amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury. STUDY SELECTION: Relevant articles (N=106) were included. DATA EXTRACTION: Two investigators independently reviewed articles and selected relevant articles for inclusion. Quality grading was performed using the Methodological Evaluation of Observational Research Checklist and Newcastle-Ottawa Quality Assessment Form. DATA SYNTHESIS: The prevalence of back pain in the past 3 months was 33.9% among community-dwelling adults, and patients with back pain contribute $365 billion in all-cause medical costs. Osteoarthritis is the next most prevalent condition (approximately 10.4%), and patients with this condition contribute $460 billion in all-cause medical costs. These 2 conditions are the most prevalent and costly (medically) of the illnesses explored in this study. Stroke follows these conditions in both prevalence (2.5%-3.7%) and medical costs ($28 billion). Other conditions may have a lower prevalence but are associated with relatively higher per capita effects. CONCLUSIONS: Consistent with previous findings, back pain and osteoarthritis are the most prevalent conditions with high aggregate medical costs. By contrast, other conditions have a lower prevalence or cost but relatively higher per capita costs and effects on activity and work. The data are extremely heterogeneous, which makes anything beyond broad comparisons challenging. Additional information is needed to determine the relative impact of each condition.

The CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative.

In traumatic brain injury (TBI), future integration of multimodal monitoring of cerebral physiology and high-frequency signal processing techniques, with advanced neuroimaging, proteomic and genomic analysis, provides an opportunity to explore the molecular pathways involved in various aspects of cerebral physiologic dysfunction in vivo. The main issue with early and rapid discovery in this field of personalized medicine is the expertise and complexity of data involved. This brief communication highlights the CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative, which has been formed from centers with specific expertise in the area of high-frequency physiologic monitoring/processing, and outlines its objectives.

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

The Incremental Hospitalization Cost of Significant Transport-Related Traumatic Brain Injury.

AIM: This study aims to determine the incremental cost of acute hospitalization for traumatic brain injury (TBI) compared with matched controls. A second purpose is to identify the factors contributing to this hospital costs. METHODOLOGY: Analyses were performed on administrative data for injured patients, hospitalized in Belgium between 2009 and 2011 following a road traffic accident. Cases were matched to a control with similar injuries but without TBI. The incremental hospitalization cost of TBI and the factors contributing to the hospital costs were determined using multivariable regression modeling with gamma distribution and log link. RESULTS: A descriptive comparison of cases and controls shows clear differences in healthcare utilization and costs. The presence of a TBI increases the cost by a factor between 1.66 (95% confidence interval: 1.52-1.82) and 2.08 (95% confidence interval: 1.72-2.51). Regarding healthcare utilization, the most important determinants of hospital costs are surgical complexity, use of magnetic resonance imaging, intensive care unit admission, and mechanical ventilation. DISCUSSION: To our knowledge, this is the first matched-control study calculating the incremental hospitalization cost of TBI. The insights provided by this study are relevant in the context of prospective payments and can be an incentive for investments in prevention policies and extramural care.

Cost-effectiveness of mandatory bicycle helmet use to prevent traumatic brain injuries and death.

BACKGROUND: Traumatic brain injury (TBI) is the main cause of mortality and severe morbidity in cyclists admitted to Dutch emergency departments (EDs). Although the use of bicycle helmets is an effective way of preventing TBI, this is uncommon in the Netherlands. An option to increase its use is through a legal enforcement. However, little is known about the cost-effectiveness of such mandatory use of helmets in the Dutch context. The current study aimed to assess the cost-effectiveness of a law that enforces helmet use to reduce TBI and TBI-related mortality. METHODS: The cost-effectiveness was estimated through decision tree modelling. In this study, wearing bicycle helmets enforced by law was compared with the current situation of infrequent voluntary helmet use. The total Dutch cycling population, consisting of 13.5 million people, was included in the model. Model data and parameters were obtained from Statistics Netherlands, the National Road Traffic Database, Dutch Injury Surveillance System, and literature. Effects included were numbers of TBI, death, and disability-adjusted life years (DALY). Costs included were healthcare costs, costs of productivity losses, and helmet costs. Sensitivity analysis was performed to assess which parameter had the largest influence on the incremental cost-effectiveness ratio (ICER). RESULTS: The intervention would lead to an estimated reduction of 2942 cases of TBI and 46 deaths. Overall, the incremental costs per 1) death averted, 2) per TBI averted, and 3) per DALY averted were estimated at 1) € 2,002,766, 2) € 31,028 and 3) € 28,465, respectively. Most favorable were the incremental costs per DALY in the 65+ age group: € 17,775. CONCLUSIONS: The overall costs per DALY averted surpassed the Dutch willingness to pay threshold value of € 20,000 for cost-effectiveness of preventive interventions. However, the cost per DALY averted for the elderly was below this threshold, indicating that in this age group largest effects can be reached. If the price of a helmet would reduce by 20%, which is non-hypothetical in a situation of large-scale purchases and use of these helmets, the introduction of this regulation would result in an intervention that is almost cost-effective in all age groups.

Workers' compensation claims for traumatic brain injuries among private employers-Ohio, 2001-2011.

BACKGROUND: The purpose of this analysis was to identify and prioritize high-risk industry groups for traumatic brain injury (TBI) prevention efforts. METHODS: Workers with TBI from 2001 to 2011 were identified from the Ohio Bureau of Workers' Compensation data. To prioritize industry groups by claim type (lost-time (≥8 days away from work) and total claims) and injury event categories, we used a prevention index (PI) that averaged TBI counts and rate ranks (PI = (count rank + rate rank)/2). TBI rates per 10 000 estimated full-time equivalent (FTE = 2000 h/y) workers were calculated. RESULTS: From 2001 to 2011, 12 891 TBIs were identified among private employers, resulting in a rate of 5.1 TBIs per 10 000 FTEs. Of these, 40% (n = 5171) were lost-time TBIs, at a rate of 2.0 per 10 000 FTEs. Spectator Sports had the highest lost-time TBI rate (13.5 per 10 000 FTEs), whereas General Freight Trucking had the greatest number of lost-time TBIs (n = 293). Based on PIs, General Freight Trucking ranked first for lost-time TBIs for all injury events combined. Several industry groups within Construction, General and Specialized Freight Trucking, Services to Building and Dwellings, Employment Services, and Restaurants and Other Eating Places ranked high across multiple injury event categories for lost-time TBIs. CONCLUSIONS: The high-ranking industry groups identified from our study can be used to effectively direct occupational TBI prevention efforts.

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study.

BACKGROUND: The high occurrence and acute and chronic sequelae of traumatic brain injury (TBI) cause major healthcare and socioeconomic challenges. This study aimed to describe outcome, in-hospital healthcare consumption and in-hospital costs of patients with TBI. METHODS: We used data from hospitalised TBI patients that were included in the prospective observational CENTER-TBI study in three Dutch Level I Trauma Centres from 2015 to 2017. Clinical data was completed with data on in-hospital healthcare consumption and costs. TBI severity was classified using the Glasgow Coma Score (GCS). Patient outcome was measured by in-hospital mortality and Glasgow Outcome Score-Extended (GOSE) at 6 months. In-hospital costs were calculated following the Dutch guidelines for cost calculation. RESULTS: A total of 486 TBI patients were included. Mean age was 56.1 ± 22.4 years and mean GCS was 12.7 ± 3.8. Six-month mortality (4.2%-66.7%), unfavourable outcome (GOSE ≤ 4) (14.6%-80.4%) and full recovery (GOSE = 8) (32.5%-5.9%) rates varied from patients with mild TBI (GCS13-15) to very severe TBI (GCS3-5). Length of stay (8 ± 13 days) and in-hospital costs (€11,920) were substantial and increased with higher TBI severity, presence of intracranial abnormalities, extracranial injury and surgical intervention. Costs were primarily driven by admission (66%) and surgery (13%). CONCLUSION: In-hospital mortality and unfavourable outcome rates were rather high, but many patients also achieved full recovery. Hospitalised TBI patients show substantial in-hospital healthcare consumption and costs, even in patients with mild TBI. Because these costs are likely to be an underestimation of the actual total costs, more research is required to investigate the actual costs-effectiveness of TBI care.

The effect of socioeconomic deprivation on 12 month Traumatic Brain Injury (TBI) outcome.

Objectives: To assess the impact of social deprivation on Traumatic Brain Injury (TBI) global outcome.Design: The study was a prospective observational study conducted using consecutive admissions with TBI.Subjects: 1322 consecutive adult patients with TBI were recruited into the study between 2010 and 2015.Methods: All patients were assessed by the TBI rehabilitation team at both six weeks and 12 months following TBI. Details of the injury and demographic data was collated at six weeks. This included age, gender and ZIP Code. Social deprivation was measured by the Indices of Multiple Deprivation (IMD) Score. The outcome measure used was the Extended Glasgow Outcome Score (GOSE) at 12 months. Univariate analysis was followed by a Multi-Ordinal Regression to evaluate predictor variables.Results: With regard to the representation of IMD deciles, the study population approximated to the general Sheffield population (p = .139). Within the univariate analysis, statistically significant relationships were noted between IMD and GOSE (p = <.001). The Ordinal Regression revealed a significant relationship between worse GOSE and IMD (p = .002), age (p = .001), GCS (p < .001), alcohol intoxication (p < .001) and Medical Comorbidity (p = .041).Conclusion: Increasing social deprivation is associated with poorer global TBI outcomes at 12 months.

Estimated Life-Time Savings in the Cost of Ongoing Care Following Specialist Rehabilitation for Severe Traumatic Brain Injury in the United Kingdom.

OBJECTIVES: To evaluate cost-efficiency of rehabilitation following severe traumatic brain injury (TBI) and estimate the life-time savings in costs of care. SETTING/PARTICIPANTS: TBI patients (n = 3578/6043) admitted to all 75 specialist rehabilitation services in England 2010-2018. DESIGN: A multicenter cohort analysis of prospectively collated clinical data from the UK Rehabilitation Outcomes Collaborative national clinical database. MAIN MEASURES: Primary outcomes: (a) reduction in dependency (UK Functional Assessment Measure), (b) cost-efficiency, measured in time taken to offset rehabilitation costs by savings in costs of ongoing care estimated by the Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA), and (c) estimated life-time savings. RESULTS: The mean age was 49 years (74% males). Including patients who remained in persistent vegetative state on discharge, the mean episode cost of rehabilitation was £42 894 (95% CI: £41 512, £44 235), which was offset within 18.2 months by NPCNA-estimated savings in ongoing care costs. The mean period life expectancy adjusted for TBI severity was 21.6 years, giving mean net life-time savings in care costs of £679 776/patient (95% CI: £635 972, £722 786). CONCLUSIONS: Specialist rehabilitation proved highly cost-efficient for severely disabled patients with TBI, despite their reduced life-span, potentially generating over £4 billion savings in the cost of ongoing care for this 8-year national cohort.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial.

OBJECTIVE: To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury. DESIGN: Multicentre, pragmatic, observer-blinded, randomized controlled trial in England. SETTING: Community. PARTICIPANTS: People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent. INTERVENTIONS: A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control). MAIN MEASURES: The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization. RESULTS: We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised. CONCLUSION: This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

Practitioners' opinions on traumatic brain injury care pathways in Finland and France: different organizations, common issues.

OBJECTIVE: In traumatic brain injury (TBI), differences in health-care contexts have profound effects on care pathways. Objectives were to compare TBI pathways of care and practitioners' views on quality of care issues in two large European areas: Varsinais-Suomi, Finland and Ile-de-France, France. METHODS: Thematic analysis of semi-structured interviews was conducted with TBI practitioners (n = 10) from all stages of TBI care. Interviews addressed organization and financing of care, decision-making on care transitions, and perceived issues. The structure-process-outcome model of Donabedian was used to classify findings related to quality of care issues. RESULTS: Main differences in organization of care pathways for people with TBI were related to financing modalities, number of pathway alternatives, inpatient versus outpatient rehabilitation, and indirect versus direct referrals to rehabilitation. Similar categories of issues were raised in the two settings. Issues in structures involved availability of services, financial access, and heterogeneity of expertise. Issues in processes involved diagnosis and follow-up, training regarding cognitive impairments, decision-making for referrals, transition delays, and care pathways of very severely affected patients. CONCLUSIONS: These findings provide clues to address care pathways in further comparative studies. Determinants of care pathway quality could be classified as direct or indirect, binding or adaptive organizational factors.

The risk factors, outcomes, and costs associated with venous thromboembolism after traumatic brain injury: a nationwide analysis.

Objective: We sought to identify risk factors for VTE following traumatic brain injury (TBI) and determine how venous thromboembolism (VTE) affects outcomes and costs using a national database.Methods: The Nationwide Inpatient Sample (NIS) was used to identify patients with TBI between 2002 and 2014. VTE was identified as any occurrence of deep venous thrombosis or pulmonary embolism. We investigated putative risk factors for VTE and determined the effect of VTE on outcomes including mortality and disposition.Results: 424,929 patients met the inclusion criteria. There were 16,690 (3.9%) patients who developed a VTE. The annual incidence of VTE increased from 2.2% in 2002 to 5.4% in 2014 (R2 = 0.992, p < .001). Older age, increasing number of comorbidities, craniotomy or craniectomy, and more severe injuries were associated with increased odds of developing VTE (p < .001 for all). Patients with VTE had decreased odds of in-hospital mortality (OR 0.53; 95% CI 0.50-0.57) and increased odds of non-routine disposition (OR 2.05; 95% CI 1.97-2.14), tracheostomy, and gastrostomy.Conclusion: To our knowledge, we provide the largest analysis of VTE in TBI. This entity appears to be increasing in frequency, which may merit new strategies for prevention.

The incremental cost of traumatic brain injury during the first year after a road traffic accident.

This study aims to determine the incremental cost of TBI during the first year after a traffic accident, compared to other patients with similar non-TBI injuries. Secondly, identification of factors associated with medical costs of TBI is pursued. Analyses were performed on administrative data for traffic victims hospitalised in Belgium between 2009 and 2011. Medical costs attributable to the accident are estimated over one year post-injury. Cases with TBI were matched to controls with similar non-TBI injuries to determine the incremental cost of TBI. Both aims of this research were assessed using regression analysis. The incremental cost of TBI is estimated to range between € 10 042 (95%CI [€8198; €11 887]) and €21 715 (95%CI [€13 5889; €29 540]). Age, problems with self-reliance, survival status, the occurrence of acute events and severity of TBI are significant predictors of medical costs. As to healthcare utilisation, MRI usage, inpatient rehabilitation facilities, nursing homes and readmissions to acute hospital stand out as having most influence on costs. This study reveals a considerable incremental cost of TBI. Policy-making bodies should be made aware of this phenomenon and a diversified policy should be considered when financing programs are discussed.

Temporal Trends in Healthcare Costs and Outcome Following ICU Admission After Traumatic Brain Injury.

OBJECTIVE: To assess temporal trends in 1-year healthcare costs and outcome of intensive care for traumatic brain injury in Finland. DESIGN: Retrospective observational cohort study. SETTING: Multicenter study including four tertiary ICUs. PATIENTS: Three thousand fifty-one adult patients (≥ 18 yr) with significant traumatic brain injury treated in a tertiary ICU during 2003-2013. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Total 1-year healthcare costs included the index hospitalization costs, rehabilitation unit costs, and social security reimbursements. All costs are reported as 2013 U.S. dollars ($). Outcomes were 1-year mortality and permanent disability. Multivariate regression models, adjusting for case-mix, were used to assess temporal trends in costs and outcome in predefined Glasgow Coma Scale (3-8, 9-12, and 13-15) and age (18-40, 41-64, and ≥ 65 yr) subgroups. Overall 1-year survival was 76% (n = 2,304), and of 1-year survivors, 37% (n = 850) were permanently disabled. Mean unadjusted 1-year healthcare cost was $39,809 (95% CI, $38,144-$41,473) per patient. Adjusted healthcare costs decreased only in the Glasgow Coma Scale 13-15 and 65 years and older subgroups, due to lower rehabilitation costs. Adjusted 1-year mortality did not change in any subgroup (p < 0.05 for all subgroups). Adjusted risk of permanent disability decreased significantly in all subgroups (p < 0.05). CONCLUSION: During the last decade, healthcare costs of ICU-admitted traumatic brain injury patients have remained largely the same in Finland. No change in mortality was noted, but the risk for permanent disability decreased significantly. Thus, our results suggest that cost-effectiveness of traumatic brain injury care has improved during the past decade in Finland.

Lack of Health Insurance Associated With Lower Probability of Head Computed Tomography Among United States Traumatic Brain Injury Patients.

BACKGROUND: Uninsured traumatic brain injury (TBI) patients have higher mortality than their insured counterparts. One possible reason is disparities in receipt of appropriate diagnostic imaging. OBJECTIVE: Examine the association between lack of insurance and use of diagnostic imaging. RESEARCH DESIGN: This is a retrospective cohort study. SUBJECTS: All adult patients admitted with severe (AIS>4 and GCS<15) TBI, in the National Trauma Data Bank 2010-2015. MEASURES: Primary outcome was receipt of head computed tomography (CT) and number of CT scans received. Secondary outcomes included head x-ray, angiography, or magnetic resonance imaging. Patients were classified as uninsured if their payment method was self-pay or not billed. RESULTS: Of 59,540 patients meeting inclusion criteria, 18.9% were uninsured. After adjusting for demographic, clinical, and facility characteristics, compared with patients with any insurance, 4.47 per 100 (95% confidence interval, 1.60-7.34) fewer uninsured patients had a head CT, with uninsured patients receiving 13% (95% confidence interval, 3-21) fewer head CTs. There were no differences in x-ray, angiography, or magnetic resonance imaging receipt. CONCLUSIONS: Findings suggest lower receipt of guideline-indicated head CT among uninsured TBI patients. Mechanisms could include unconscious provider bias or institutional financial constraints. Further research is warranted to elucidate mechanisms and assess mediation by diagnostic imaging use of the insurance-mortality association.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study.

BACKGROUND: Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU). METHODS: We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate. RESULTS: In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071). CONCLUSION: Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.