The Economic Burden of Brain Disability in Korea, 2008-2011.

This study estimated the economic burden of people with brain disability in Korea during 2008-2011 using nationally representative data and was conducted to use the results as an evidence for determining the resources allocation of people with brain disability. We used a prevalence-based approach to estimate the economic burden, classified by direct costs (medical costs and nonmedical costs) and indirect costs (productivity loss of morbidity and premature death). Data from the National Health Insurance Service, the National Disability Registry, the National survey on persons with disabilities, the Korea National Statistical Office's records of causes of death, and the Labor Statistics were used to calculate direct and indirect costs. The treated prevalence of brain disability increased from 0.26% (2008) to 0.35% (2011). Total economic burden of brain-related diseases was US$1.88 billion in 2008 and increased to US$2.90 billion in 2011, with a 54% rate of increase. The economic burden of all diseases, which was 1.2 to 1.4 times higher than that of brain-related diseases, accounted for US$2.61 billion in 2008 and US$3.62 billion in 2011, increasing by 39%. Owing to the growing occurrence of brain disability, the annual prevalence and related costs are increasing. Health management programs are necessary to reduce the economic burden of brain disability in Korea.

[Quality of life after multiple trauma]. / Lebensqualität nach Polytrauma.

BACKGROUND: Multiple trauma is an independent injury pattern which, because of its complexity, is responsible for 25 % of the costs for the treatment of all injured patients. Because of the often long-lasting physical impairment and the high incidence of residual permanent handicaps, it is apparent that multiple trauma can lead to a reduction in patient quality of life. OBJECTIVES: The aim of this study was to give an overview of the known data concerning the change in quality of life for multiple trauma patients. Furthermore, predictors for the reduction of quality of life after multiple trauma will be identified. MATERIALS AND METHODS: A MedLine search was performed to identify studies dealing with the outcome after multiple trauma. RESULTS: In addition to functional outcome parameters, the term quality of life has become more important in recent years when it comes to evaluating the outcome following injury. While the mortality after multiple trauma could be significantly reduced over the years, there is no comparable effect on the quality of life. Predictors for a worse quality of life after multiple trauma are female gender, high age, low social status, concomitant head injuries and injury to the lower extremities. CONCLUSION: The fact that mortality after multiple trauma has decreased but not impairment of the quality of life makes it clear that in addition to the acute medical treatment, a follow-up treatment including not only physiotherapy but also psychotherapy is crucial for multiple trauma patients.

Risk Adjustment In Neurocritical care (RAIN)--prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study.

OBJECTIVES: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. DESIGN: Cohort study. SETTING: Sixty-seven adult critical care units. PARTICIPANTS: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. INTERVENTIONS: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. MAIN OUTCOME MEASURES: Mortality, Glasgow Outcome Scale - Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. RESULTS: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the 'early' (within 18 hours of presentation) and 'no or late' (after 24 hours) transfer groups. After adjustment, the 'early' transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. CONCLUSIONS: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

[Interest and costs of neurorehabilitation of brain injury patients]. / Intérêt et coût de la réadaptation neurologique des patients cérébrolésés.

The severity of the initial deficit and the improvement in the first weeks are the strongest indicators for a favorable outcome after stroke. Meta-analyses attempt to evaluate the efficacy of neurorehabilitation, but the results are unconclusive due to the heterogeinity of the groups of patients and therapies. However, there is sufficient data to conclude that repetitive, high intensity, task orientated training is efficacious. New approaches (mental imagery, robotics, virtual therapies...) are also useful but are not better than physiotherapy. It is as important to individualize the approach in a multidisciplinary well organised and communicative setting and to treat early complications. Cerebral plasticity is an individualized process and limited in time, so therapy should be regularly adapted and stopped if the deficit remains stable.

Treatment paths and costs for young adults with acquired brain injury in the United Kingdom.

PRIMARY OBJECTIVES: To identify the health and social care services used by young adults aged 18-25 years with acquired brain injury (ABI) and the costs of these supports. RESEARCH METHODS: A review of existing literature and databases and contact with academics and stakeholders working with people with ABI. MAIN OUTCOMES AND RESULTS: The likely care pathways of young adults with ABI were mapped over a notional 1-year period after presentation at hospital accident and emergency departments. Most young adults with ABI will use minimal health and social care support following injury but those with subsequent disabilities may cost the health and social care budget in excess of pound47.2 million per year. CONCLUSION: Lack of available data mean the service use and cost estimates draw from a range of sources. However, the costs may under-estimate the true impact on budgets as incidence rates may be higher than identified and conservative values were selected for unit costs. The model estimates the cost of treatment and support as provided today, but high levels of unmet need remain.

Indications for CT scanning in mild traumatic brain injury: A cost-effectiveness study.

BACKGROUND: There is considerable uncertainty about the indications for cranial computed tomography (CT) scanning in patient with minor traumatic brain injury (TBI). This analysis involves an evidence-based comparison of several strategies for selecting patients for CT with regard to effectiveness and cost. METHODS: We performed a structured literature review of mild traumatic brain injury and constructed a cost-effectiveness model. The model estimated the impact of missed intracranial lesions on longevity, quality of life and costs. Using a 20-year-old patient for primary analysis, we compared the following strategies to screen for the need to perform a CT scan: observation in the emergency department or hospital floor, skull radiography, Selective CT based on the presence of additional risk factors and scanning all. RESULTS: Outcome measures for each strategy included average years of life, quality of life and costs. Selective CT and the CT All policy performed significantly better than the alternatives with respect to outcome. They were also less expensive in terms of total direct health care costs, although the differences did not reach statistical significance. The model yielded similar, but smaller, differences between the selective imaging and other strategies when run for older patients. CONCLUSIONS: Although the incidence of intracranial lesions, especially those that require surgery, is low in mild TBI, the consequences of delayed diagnosis are forbidding. Adverse outcome of an intracranial hematoma is so costly that it more than balances the expense of CT scans. In our cost-effectiveness model, the liberal use of CT scanning in mild TBI appears justified.