Intramural Healthcare Consumption and Costs After Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Abstract

Traumatic brain injury (TBI) is a global public health problem and a leading cause of mortality, morbidity, and disability. The increasing incidence combined with the heterogeneity and complexity of TBI will inevitably place a substantial burden on health systems. These findings emphasize the importance of obtaining accurate and timely insights into healthcare consumption and costs on a multi-national scale. This study aimed to describe intramural healthcare consumption and costs across the full spectrum of TBI in Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective observational study conducted in 18 countries across Europe and in Israel. The baseline Glasgow Coma Scale (GCS) was used to differentiate patients by brain injury severity in mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS ≤8) TBI. We analyzed seven main cost categories: pre-hospital care, hospital admission, surgical interventions, imaging, laboratory, blood products, and rehabilitation. Costs were estimated based on Dutch reference prices and converted to country-specific unit prices using gross domestic product (GDP)-purchasing power parity (PPP) adjustment. Mixed linear regression was used to identify between-country differences in length of stay (LOS), as a parameter of healthcare consumption. Mixed generalized linear models with gamma distribution and log link function quantified associations of patient characteristics with higher total costs. We included 4349 patients, of whom 2854 (66%) had mild, 371 (9%) had moderate, and 962 (22%) had severe TBI. Hospitalization accounted for the largest part of the intramural consumption and costs (60%). In the total study population, the mean LOS was 5.1 days at the intensive care unit (ICU) and 6.3 days at the ward. For mild, moderate, and severe TBI, mean LOS was, respectively, 1.8, 8.9, and 13.5 days at the ICU and 4.5, 10.1, and 10.3 days at the ward. Other large contributors to the total costs were rehabilitation (19%) and intracranial surgeries (8%). Total costs increased with higher age and greater trauma severity (mild; €3,800 [IQR €1,400-14,000], moderate; €37,800 [IQR €14,900-€74,200], severe; €60,400 [IQR €24,400-€112,700]). The adjusted analysis showed that female patients had lower costs than male patients (odds ratio (OR) 0.80 [CI 0.75-1.85]). Increasing TBI severity was associated with higher costs, OR 1.46 (confidence interval [CI] 1.31-1.63) and OR 1.67 [CI 1.52-1.84] for moderate and severe patients, respectively. A worse pre-morbid overall health state, increasing age and more severe systemic trauma, expressed in the Injury Severity Score (ISS), were also significantly associated with higher costs. Intramural costs of TBI are significant and are profoundly driven by hospitalization. Costs increased with trauma severity and age, and male patients incurred higher costs. Reducing LOS could be targeted with advanced care planning, in order to provide cost-effective care.

Keywords: healthcare consumption; healthcare costs; hospital costs; traumatic brain injury;.

FIG. 1.

Proportion of mean total intramural costs per cost- category according to severity of traumatic brain injury (TBI). The proportion of the total intramural costs from each cost category are plotted in a histogram for each TBI severity level separately. The exact percentage for each cost category (including pre-hospital costs, intensive care unit and ward admission costs, intra- and extracranial surgery costs, laboratory costs, imaging costs, blood products costs, and rehabilitation costs) are presented in the table below the figure. For example, of the total costs within the mild TBI category, 7% of the expenses were from pre-hospital costs.

FIG. 2.

The median total intramural costs for male and female patients are plotted according to injury severity and age category. The injury severity was determined using the baseline systemic Injury Severity Score (ISS) and was categorized into three groups: ISS ≤16 (minor injury); ISS 17–25 (major injury); ISS >25 (critical injury). The four panels represent the four different age categories: (A) 16–25 years, (B) 26–40 years, (C) 41–64 years, and (D) ≥ 65 years.

FIG. 3.

This panel shows forest plots reporting the random country effect (random intercept estimate and 95% confidence intervals) on the length of stay at the ICU and ward for mild (A–B), moderate (C–D) and severe (E–F) TBI patients. Countries including fewer than five patients per severity group were excluded from this analysis. The models included adjustment according to the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic model. The median β reflects the between-country variation; a median β equal to 0 represents no variation, the larger the median β, the larger the variation.