Ho Kwok M, Honeybul Stephen, Lind Christopher R P, Gillett Grant R, Litton Edward
Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.
J Trauma. 2011 Dec;71(6):1637-44; discussion 1644. doi: 10.1097/TA.0b013e31823a08f1.
Decompressive craniectomy has been traditionally used as a lifesaving rescue procedure for patients with refractory intracranial hypertension after severe traumatic brain injury (TBI), but its cost-effectiveness remains uncertain.
Using data on length of stay in hospital, rehabilitation facility, procedural costs, and Glasgow Outcome Scale (GOS) up to 18 months after surgery, the average total hospital costs per life-year and quality-adjusted life-year (QALY) were calculated for patients who had decompressive craniectomy for TBI between 2004 and 2010 in Western Australia. The Corticosteroid Randomisation After Significant Head Injury prediction model was used to quantify the severity of TBI.
Of the 168 patients who had 18-month follow-up data available after the procedure, 70 (42%) achieved a good outcome (GOS-5), 27 (16%) had moderate disability (GOS-4), 34 (20%) had severe disability (GOS-3), 5 (3%) were in vegetative state (GOS-2), and 32 (19%) died (GOS-1). The hospital costs increased with the severity of TBI and peaked when the predicted risk of an unfavorable outcome was about 80%. The average cost per life-year gained (US$671,000 per life-year) and QALY (US$682,000 per QALY) increased substantially and became much more than the usual acceptable cost-effective limit (US$100,000 per QALY) when the predicted risk of an unfavorable outcome was >80%. Changing different underlying assumptions of the analysis did not change the results significantly.
Severity of TBI had an important effect on cost-effectiveness of decompressive craniectomy. As a lifesaving procedure, decompressive craniectomy was not cost-effective for patients with extremely severe TBI.
传统上，去骨瓣减压术一直被用作重度创伤性脑损伤（TBI）后难治性颅内高压患者的一种挽救生命的急救手术，但其成本效益仍不确定。
利用2004年至2010年在西澳大利亚州接受TBI去骨瓣减压术患者的住院时间、康复机构、手术成本以及术后18个月的格拉斯哥预后量表（GOS）数据，计算每个生命年和质量调整生命年（QALY）的平均总住院成本。使用重度颅脑损伤后皮质类固醇随机化预测模型来量化TBI的严重程度。
在术后有18个月随访数据的168例患者中，70例（42%）获得良好预后（GOS-5），27例（16%）有中度残疾（GOS-4），34例（20%）有重度残疾（GOS-3），5例（3%）处于植物人状态（GOS-2），32例（19%）死亡（GOS-1）。住院成本随着TBI严重程度的增加而增加，当预测不良预后风险约为80%时达到峰值。当预测不良预后风险>80%时，每获得一个生命年的平均成本（每生命年671,000美元）和QALY（每QALY 682,000美元）大幅增加，远超通常可接受的成本效益极限（每QALY 100,000美元）。改变分析的不同基础假设并未显著改变结果。
TBI的严重程度对去骨瓣减压术的成本效益有重要影响。作为一种挽救生命的手术，去骨瓣减压术对极重度TBI患者不具有成本效益。
