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.

Long-term disability and survival in traumatic brain injury: results from the National Institute on Disability and Rehabilitation Research Model Systems.

OBJECTIVES: To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality. DESIGN: Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression. SETTING: Postdischarge from rehabilitation units. PARTICIPANTS: Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Survival. RESULTS: Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9-2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05). CONCLUSIONS: Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml).

Rating the raters: evaluating the predictions from a life expectancy rating service.

There is a growing market for the resale of life insurance policies to third party investors. A key factor in the valuation of a policy is how long the insured is likely to live. Various commercial rating services offer to provide estimates of individuals' likely longevity, but the reliability of their estimates has rarely been correctly evaluated. The question is how to compare the estimates provided for a large group of policy-holders with the observed "truth data"--the actual mortality experience observed during follow-up. Various approaches to this have been used in practice, some of them quite wrong. The correct method does not seem to be practiced or widely known in the life settlement industry. It is based on a comparison of observed and expected deaths computed on the basis of person-years of exposure rather than of individual persons. The method is explained in detail here and illustrated with the results from a large portfolio of policies.

Economic factors and longevity in spinal cord injury: a reappraisal.

OBJECTIVE: To review and reassess the findings of Krause and colleagues on the effect of economic and other risk factors on life expectancy after spinal cord injury, using an expanded and updated database. DESIGN: Pooled person-year analysis. SETTING: Model Spinal Cord Injury Systems hospitals. PARTICIPANTS: A total of 7331 persons injured since 1973 who were enrolled in the National Spinal Cord Injury Database and received an evaluation between November 1995 and December 2005. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mortality, determined by routine follow-up supplemented by information from the Social Security Death Index. Logistic regression models based on the predictor variables were developed to estimate the chance of dying in a given year. RESULTS: As in the Krause study, life expectancies of persons with the greatest handicap in economic self-sufficiency were substantially shorter than average. However, the positive effect of favorable economics was much less than previously reported, largely because having health insurance coverage through workers' compensation was no longer a powerful (or statistically significant) predictor of survival. CONCLUSIONS: The beneficial effect of favorable economics appears to be much less than previously reported. Further, the interpretation of the effects of modifiable factors (such as economics and social integration) is complicated by questions of cause and effect.

Smoking habit and mortality: a meta-analysis.

Cigarette smoking leads to excess mortality risk. Although it is well known that the risk increases with the number of pack-years of smoking--that is, how much a person smokes, or "habit"--there is apparently no published studies that organize and synthesize the evidence on this topic. This paper provides a meta-analysis of the latest published findings relating to cigarette smoking habit and excess mortality. A combined estimate of the relative risk (RR) of death for smokers, stratified by habit (light, medium, or heavy smoking), compared with non-smokers is provided.

Underwriting the presidents.

The United States has had 43 presidents. We examined whether they survive significantly longer or shorter than their contemporaries. We found that survival was better for presidents elected in the 1789-1841 and 1933-2001 periods (SMRs of 0.7 and 0.6, respectively), but worse for those elected in 1845-1929 (SMR = 2.9). We also found increased mortality during the years lived in office (SMR = 1.4), but no increase in mortality after leaving office (SMR = 1.0).

Worklife after traumatic spinal cord injury.

OBJECTIVE: To develop predictive models to estimate worklife expectancy after spinal cord injury (SCI). DESIGN: Inception cohort study. SETTING: Model SCI Care Systems throughout the United States. PARTICIPANTS: 20,143 persons enrolled in the National Spinal Cord Injury Statistical Center database since 1973. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: Postinjury employment rates and worklife expectancy. RESULTS: Using logistic regression, we found a greater likelihood of being employed in any given year to be significantly associated with younger age, white race, higher education level, being married, having a nonviolent cause of injury, paraplegia, ASIA D injury, longer time postinjury, being employed at injury and during the previous postinjury year, higher general population employment rate, lower level of Social Security Disability Insurance benefits, and calendar years after the passage of the Americans with Disabilities Act. CONCLUSIONS: The likelihood of postinjury employment varies substantially among persons with SCI. Given favorable patient characteristics, worklife should be considerably higher than previous estimates.

Excess mortality in remote symptomatic epilepsy.

BACKGROUND: Published estimates of excess mortality associated with epilepsy vary greatly. How much, if any, of the excess is attributable to the seizures themselves as opposed to an underlying condition causing the epilepsy is not clear from the literature. This article offers evidence that epilepsy per se is associated with excess mortality. The excess varies according to severity and frequency of seizures. MATERIALS AND METHODS: The authors studied mortality rates of developmentally disabled persons in California with and without epilepsy. In order to focus on the effect on mortality risk of epilepsy per se, they included only persons with good motor function (able to walk and climb stairs) and at worst moderate mental retardation (MR). The data were 506,204 person-years and 1523 deaths among 80,682 California subjects of age 5 to 65 years during the 1988-1999 study period. Mortality rates for persons with epilepsy were compared to rates for persons with no history of epilepsy. RESULTS: Mortality rates were higher for persons with epilepsy than for those without. Excess death rates (EDRs) varied according to type and frequency of seizures. Combined EDRs were 6 (deaths per 1000 person-years) for persons with recent (< 12 months) history of status epilepticus, 5 for recent history of generalized tonic-clonic (GTC) seizures, 3 for recent history of seizures but no recent GTC seizures, and less than 1 for a history of seizures but no recent events. CONCLUSIONS: The data presented here are evidence that epilepsy per se is associated with increased mortality. The EDRs reported here may be better measures of excess mortality due to epilepsy than previously published estimates.