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Randomized Controlled Trial
. 2021 Apr 5;108(3):277-285.
doi: 10.1093/bjs/znaa091.

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

K Treskes  1 , J C Sierink  1 , M J R Edwards  2 , B J A Beuker  3 , E M M Van Lieshout  4 , J Hohmann  5 , T P Saltzherr  6 , M W Hollmann  7 , S Van Dieren  8 , J C Goslings  1   9 , M G W Dijkgraaf  10 ; REACT-2 study group
Collaborators, Affiliations
Randomized Controlled Trial

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

K Treskes et al. Br J Surg. .

Abstract
in English, Spanish

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.

Antecedentes: El efecto de la tomografía computarizada inmediata de todo el cuerpo (immediate total-body CT, iTBCT) sobre los aspectos económicos de la salud en pacientes con traumatismos graves es un tema con información limitada. Este estudio determinó el coste-efectividad de la exploración iTBCT en comparación con las imágenes radiológicas convencionales y la CT selectiva (evaluación estándar, standard work-up, STWU) durante la evaluación inicial del trauma.

Métodos: En este ensayo clínico aleatorizado y multicéntrico, los pacientes adultos con una alta sospecha de lesiones graves, una vez ingresados en el hospital, se asignaron al azar a una exploración iTBCT o STWU. Los costes de atención médica hospitalaria se determinaron durante los primeros seis meses posteriores al trauma. La probabilidad de que iTBCT fuera coste-efectiva se calculó para varios niveles de disposición a pagar por cada paciente adicional vivo.

Resultados: Se incluyeron un total de 928 pacientes holandeses con seguimiento clínico completo. Los costes medios de la atención hospitalaria fueron 25.809€ (95% bcaCI: 22.617€ a 29.137€) para el grupo iTBCT y 26.155€ (95% bcaCI: 23.050€ a 29.344€) para el grupo STWU, una diferencia de 346€ por paciente en favor de iTBCT (95% bcaCI: 4.987€ a 4.328€; P = 0,876). El porcentaje de pacientes vivos a los seis meses no fue diferente. La diferencia en el porcentaje de pacientes vivos sin morbilidad grave fue del 61,6% en el grupo iTBCT versus 66,7% en el grupo STWU (-5,1%, P = 0,104). La probabilidad de que iTBCT fuese costo-eficiente para mantener a los pacientes en vida se mantuvo por debajo de 0,56 en todo el grupo, sin embargo, fue mayor en pacientes politraumatizados (0,8-0,9) y en pacientes con lesión cerebral traumática (más de 0,9).

Conclusión: Desde la perspectiva económica del proveedor de atención médica hospitalaria, la tomografía computarizada inmediata de todo el cuerpo debería ser la estrategia diagnóstica de primera elección en pacientes con traumatismos múltiples o traumatismos craneoencefálicos.

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Figures

Fig. 1
Fig. 1
Selected patients from the REACT-2 multicentre RCT Of the 541 patients in the immediate total-body CT (iTBCT) group, 62 Swiss patients were excluded and a further 23 Dutch patients had no known health status at 6 months, leaving 456 patients available for cost-effectiveness analysis. Of the 542 patients in the standard work-up group, 54 Swiss patients were excluded and the health status of 16 Dutch patients was unknown, leaving 472 patients available for cost-effectiveness analysis.
Fig. 2
Fig. 2
Cost-effectiveness of immediate total-body CT versus standard work-up for all patients a,c Cost-effectiveness plane based on 5000 bootstrap resamples showing differences in hospital healthcare costs and proportions of patients alive at 6 months with or without serious morbidity (a) and without serious morbidity (c) between immediate total-body CT (iTBCT) and standard workup. Larger dots represent higher bootstrap counts (scale legend). iTBCT may be more costly and more effective (upper right quadrant), more costly and less effective (upper left), cheaper and less effective (lower left), or cheaper and more effective (lower right). b,d Cost-effectiveness acceptability curve showing the probability of iTBCT being cost-effective for different values of willingness to pay up to €500 000 per patient alive at 6 months with or without serious morbidity (b) and without serious morbidity (d).
Fig. 3
Fig. 3
Cost-effectiveness of immediate total-body CT versus standard work-up in patients with multiple injury a,c Cost-effectiveness plane based on 5000 bootstrap resamples showing differences in hospital healthcare costs and proportions of patients alive at 6 months with or without serious morbidity (a) and without serious morbidity (c) between immediate total-body CT (iTBCT) and standard workup. Larger dots represent higher bootstrap counts (scale legend). iTBCT may be more costly and more effective (upper right quadrant), more costly and less effective (upper left), cheaper and less effective (lower left), or cheaper and more effective (lower right). b,d Cost-effectiveness acceptability curve showing the probability of iTBCT being cost-effective for different values of willingness to pay up to €500 000 per patient alive at 6 months with or without serious morbidity (b) and without serious morbidity (d).
Fig. 4
Fig. 4
Cost-effectiveness of immediate total-body CT versus standard work-up in patients with traumatic brain injury a,c Cost-effectiveness plane based on 5000 bootstrap resamples showing differences in hospital healthcare costs and proportions of patients alive at 6 months with or without serious morbidity (a) and without serious morbidity (c) between immediate total-body CT (iTBCT) and standard workup. Larger dots represent higher bootstrap counts (scale legend). iTBCT may be more costly and more effective (upper right quadrant), more costly and less effective (upper left), cheaper and less effective (lower left), or cheaper and more effective (lower right). b,d Cost-effectiveness acceptability curve showing the probability of iTBCT being cost-effective for different values of willingness to pay up to €500 000 per patient alive at 6 months with or without serious morbidity (b) and without serious morbidity (d). The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study (REACT-2) determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT during the initial trauma evaluation. 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.
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References

    1. Sierink JC, Treskes K, Edwards MJ, Beuker BJ, den Hartog D, Hohmann J et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 2016;388:673–683 - PubMed
    1. Sierink JC, Saltzherr TP, Beenen LF, Luitse JS, Hollmann MW, Reitsma JB et al. A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC Emerg Med 2012;12:4. - PMC - PubMed
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