Temporal Trends in Healthcare Costs and Outcome Following ICU Admission After Traumatic Brain Injury

Intensive care unit caseload and workload and their association with outcomes in critically unwell patients: a large registry-based cohort analysis

BACKGROUND

Too high or too low patient volumes and work amounts may overwhelm health care professionals and obstruct processes or lead to inadequate personnel routine and process flow. We sought to evaluate, whether an association between current caseload, current workload, and outcomes exists in intensive care units (ICU).

METHODS

Retrospective cohort analysis of data from an Austrian ICU registry. Data on patients aged ≥ 18 years admitted to 144 Austrian ICUs between 2013 and 2022 were included. A Cox proportional hazards model with ICU mortality as the outcome of interest adjusted with patients' respective SAPS 3, current ICU caseload (measured by ICU occupancy rates), and current ICU workload (measured by median TISS-28 per ICU) as time-dependent covariables was constructed. Subgroup analyses were performed for types of ICUs, hospital care level, and pre-COVID or intra-COVID period.

RESULTS

415 584 patient admissions to 144 ICUs were analysed. Compared to ICU caseloads of 76 to 100%, there was no significant relationship between overuse of ICU capacity and risk of death [HR (95% CI) 1.06 (0.99-1.15), p = 0.110 for > 100%], but for lower utilisation [1.09 (1.02-1.16), p = 0.008 for ≤ 50% and 1.10 (1.05-1.15), p < 0.0001 for 51-75%]. Exceptions were significant associations for caseloads > 100% between 2020 and 2022 [1.18 (1.06-1.30), p = 0.001], i.e., the intra-COVID period. Compared to the reference category of median TISS-28 21-30, lower [0.88 (0.78-0.99), p = 0.049 for ≤ 20], but not higher workloads were significantly associated with risk of death. High workload may be associated with higher mortality in local hospitals [1.09 (1.01-1.19), p = 0.035 for 31-40, 1.28 (1.02-1.60), p = 0.033 for > 40].

CONCLUSIONS

In a system with comparably high intensive care resources and mandatory staffing levels, patients' survival chances are generally not affected by high intensive care unit caseload and workload. However, extraordinary circumstances, such as the COVID-19 pandemic, may lead to higher risk of death, if planned capacities are exceeded. High workload in ICUs in smaller hospitals with lower staffing levels may be associated with increased risk of death.

Variation in Severity-Adjusted Resource use and Outcome for Neurosurgical Emergencies in the Intensive Care Unit

BACKGROUND

The correlation between the standardized resource use ratio (SRUR) and standardized hospital mortality ratio (SMR) for neurosurgical emergencies is not known. We studied SRUR and SMR and the factors affecting these in patients with traumatic brain injury (TBI), nontraumatic intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH).

METHODS

We extracted data of patients treated in six university hospitals in three countries (2015-2017). Resource use was measured as SRUR based on purchasing power parity-adjusted direct costs and either intensive care unit (ICU) length of stay (costSRURlength of stay) or daily Therapeutic Intervention Scoring System scores (costSRURTherapeutic Intervention Scoring System). Five a priori defined variables reflecting differences in structure and organization between the ICUs were used as explanatory variables in bivariable models, separately for the included neurosurgical diseases.

RESULTS

Out of 28,363 emergency patients treated in six ICUs, 6,162 patients (22%) were admitted with a neurosurgical emergency (41% nontraumatic ICH, 23% SAH, 13% multitrauma TBI, and 23% isolated TBI). The mean costs for neurosurgical admissions were higher than for nonneurosurgical admissions, and the neurosurgical admissions corresponded to 23.6-26.0% of all direct costs related to ICU emergency admissions. A higher physician-to-bed ratio was associated with lower SMRs in the nonneurosurgical admissions but not in the neurosurgical admissions. In patients with nontraumatic ICH, lower costSRURs were associated with higher SMRs. In the bivariable models, independent organization of an ICU was associated with lower costSRURs in patients with nontraumatic ICH and isolated/multitrauma TBI but with higher SMRs in patients with nontraumatic ICH. A higher physician-to-bed ratio was associated with higher costSRURs for patients with SAH. Larger units had higher SMRs for patients with nontraumatic ICH and isolated TBI. None of the ICU-related factors were associated with costSRURs in nonneurosurgical emergency admissions.

CONCLUSIONS

Neurosurgical emergencies constitute a major proportion of all emergency ICU admissions. A lower SRUR was associated with higher SMR in patients with nontraumatic ICH but not for the other diagnoses. Different organizational and structural factors seemed to affect resource use for the neurosurgical patients compared with nonneurosurgical patients. This emphasizes the importance of case-mix adjustment when benchmarking resource use and outcomes.

Effect of antiplatelet and anticoagulant medication use on injury severity and mortality in patients with traumatic brain injury treated in the intensive care unit

BACKGROUND

Antiplatelet and anticoagulant medication are increasingly common and can increase the risks of morbidity and mortality in traumatic brain injury (TBI) patients. Our study aimed to quantify the association of antiplatelet or anticoagulant use in intensive care unit (ICU)-treated TBI patients with 1-year mortality and head CT findings.

METHOD

We conducted a retrospective, multicenter observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted to four university hospital ICUs during 2003-2013. The patients were followed up until the end of 2016. The national drug reimbursement database provided information on prescribed medication for our study. We used multivariable logistic regression models to assess the association between TBI severity, prescribed antiplatelet and anticoagulant medication, and their association with 1-year mortality.

RESULTS

Of 3031 patients, 128 (4%) had antiplatelet and 342 (11%) anticoagulant medication before their TBI. Clopidogrel (2%) and warfarin (9%) were the most common antiplatelets and anticoagulants. Three patients had direct oral anticoagulant (DOAC) medication. The median age was higher among antiplatelet/anticoagulant users than in non-users (70 years vs. 52 years, p < 0.001), and their head CT findings were more severe (median Helsinki CT score 3 vs. 2, p < 0.05). In multivariable analysis, antiplatelets (OR 1.62, 95% CI 1.02-2.58) and anticoagulants (OR 1.43, 95% CI 1.06-1.94) were independently associated with higher odds of 1-year mortality. In a sensitivity analysis including only patients over 70, antiplatelets (OR 2.28, 95% CI 1.16-4.22) and anticoagulants (1.50, 95% CI 0.97-2.32) were associated with an increased risk of 1-year mortality.

CONCLUSIONS

Both antiplatelet and anticoagulant use before TBI were risk factors in our study for 1-year mortality. Antiplatelet and anticoagulation medication users had a higher radiological intracranial injury burden than non-users defined by the Helsinki CT score. Further investigation on the effect of DOACs on mortality should be done in ICU-treated TBI patients.

Epidemiology and disease burden of patients requiring neurocritical care: a Brazilian multicentre cohort study

Acute neurological emergencies are highly prevalent in intensive care units (ICUs) and impose a substantial burden on patients. This study aims to describe the epidemiology of patients requiring neurocritical care in Brazil, and their differences based on primary acute neurological diagnoses and to identify predictors of mortality and unfavourable outcomes, along with the disease burden of each condition at intensive care unit admission. This prospective cohort study included patients requiring neurocritical care admitted to 36 ICUs in four Brazilian regions who were followed for 30 days or until ICU discharge (Aug-Sep in 2018, 1 month). Of 4245 patients admitted to the participating ICUs, 1194 (28.1%) were patients with acute neurological disorders requiring neurocritical care and were included. Patients requiring neurocritical care had a mean mortality rate 1.7 times higher than ICU patients not requiring neurocritical care (17.21% versus 10.1%, respectively). Older age, emergency admission, higher number of potential secondary injuries, and worse APACHE II, SAPS III, SOFA, and Glasgow coma scale scores on ICU admission are independent predictors of mortality and poor outcome among patients with acute neurological diagnoses. The estimated total DALYs were 4482.94 in the overall cohort, and the diagnosis with the highest DALYs was traumatic brain injury (1634.42). Clinical, epidemiological, treatment, and ICU outcome characteristics vary according to the primary neurologic diagnosis. Advanced age, a lower GCS score and a higher number of potential secondary injuries are independent predictors of mortality and unfavourable outcomes in patients requiring neurocritical care. The findings of this study are essential to guide education policies, prevention, and treatment of severe acute neurocritical diseases.

The effect of recombinant erythropoietin on long-term outcome after moderate-to-severe traumatic brain injury

PURPOSE

Recombinant erythropoietin (EPO) administered for traumatic brain injury (TBI) may increase short-term survival, but the long-term effect is unknown.

METHODS

We conducted a pre-planned long-term follow-up of patients in the multicentre erythropoietin in TBI trial (2010-2015). We invited survivors to follow-up and evaluated survival and functional outcome with the Glasgow Outcome Scale-Extended (GOSE) (categories 5-8 = good outcome), and secondly, with good outcome determined relative to baseline function (sliding scale). We used survival analysis to assess time to death and absolute risk differences (ARD) to assess favorable outcomes. We categorized TBI severity with the International Mission for Prognosis and Analysis of Clinical Trials in TBI model. Heterogeneity of treatment effects were assessed with interaction p-values based on the following a priori defined subgroups, the severity of TBI, and the presence of an intracranial mass lesion and multi-trauma in addition to TBI.

RESULTS

Of 603 patients in the original trial, 487 patients had survival data; 356 were included in the follow-up at a median of 6 years from injury. There was no difference between treatment groups for patient survival [EPO vs placebo hazard ratio (HR) (95% confidence interval (CI) 0.73 (0.47-1.14) p = 0.17]. Good outcome rates were 110/175 (63%) in the EPO group vs 100/181 (55%) in the placebo group (ARD 8%, 95% CI [Formula: see text] 3 to 18%, p = 0.14). When good outcome was determined relative to baseline risk, the EPO groups had better GOSE (sliding scale ARD 12%, 95% CI 2-22%, p = 0.02). When considering long-term patient survival, there was no evidence for heterogeneity of treatment effect (HTE) according to severity of TBI (p = 0.85), presence of an intracranial mass lesion (p = 0.48), or whether the patient had multi-trauma in addition to TBI (p = 0.08). Similarly, no evidence of treatment heterogeneity was seen for the effect of EPO on functional outcome.

CONCLUSION

EPO neither decreased overall long-term mortality nor improved functional outcome in moderate or severe TBI patients treated in the intensive care unit (ICU). The limited sample size makes it difficult to make final conclusions about the use of EPO in TBI.

Safety and Cost Savings Associated with Reduced Inpatient Hospitalization for Microvascular Decompression

OBJECTIVES

Microvascular decompression (MVD) has grown as a first-line surgical intervention for severe facial pain from trigeminal neuralgia and/or hemifacial spasm. We sought to examine the safety and cost-benefits of discharging patients with MVD within 1 day of admission.

METHODS

We retrospectively reviewed patients undergoing MVD at our institution from 2008 to 2020. Patients were sorted by 1 day, 2 days, or >2 days until discharge and by year from 2008 to 2013, 2014 to 2018, or 2019 to 2020. Patient presenting characteristics, intraoperative measures, and complications were documented. Statistical differences were calculated by one-way analysis of variance and χ2 analyses.

RESULTS

Our cohort included 976 patients undergoing MVD, with 231 (23.6%) between 2008 and 2013, 517 (52.9%) between 2014 and 2018, and 228 (23.3%) between 2019 and 2020. Over time, postoperative admission rates to the critical care unit, total inpatient hospital admission times, and Barrow Neurological Institute scores at first follow-up decreased. Postoperative complications, including cerebrospinal fluid leak, decreased significantly. In addition, patients discharged within 1 day of admission incurred a total hospital cost of $26,689, which was $3588 lower than patients discharged within more than 1 day of admission, P < 0.0001. Discharging carefully selected patients who are appropriate for discharge within 1 day of admission could translate to a potential cost-savings of $255,346 per year in our clinical practice.

CONCLUSIONS

In our experience, MVDs are a safe, elective intervention. Our findings suggest that postoperative day 1 discharge in patients with an uncomplicated postoperative course may be safe while improving hospital resource use.

One-year healthcare costs of patients with spontaneous intracerebral hemorrhage treated in the intensive care unit

Background

Spontaneous intracerebral hemorrhage (ICH) entails significant mortality and morbidity. Severely ill ICH patients are treated in intensive care units (ICUs), but data on 1-year healthcare costs and patient care cost-effectiveness are lacking.

Methods

Retrospective multi-center study of 959 adult patients treated for spontaneous ICH from 2003 to 2013. The primary outcomes were 12-month mortality or permanent disability, defined as being granted a permanent disability allowance or pension by the Social Insurance Institution by 2016. Total healthcare costs were hospital, rehabilitation, and social security costs within 12 months. A multivariable linear regression of log transformed cost data, adjusting for case mix, was used to assess independent factors associated with costs.

Results

Twelve-month mortality was 45% and 51% of the survivors were disabled at the end of follow-up. The mean 12-month total cost was €49,754, of which rehabilitation, tertiary hospital and social security costs accounted for 45%, 39%, and 16%, respectively. The highest effective cost per independent survivor (ECPIS) was noted among patients aged >70 years with brainstem ICHs, low Glasgow Coma Scale (GCS) scores, larger hematoma volumes, intraventricular hemorrhages, and ICH scores of 3. In multivariable analysis, age, GCS score, and severity of illness were associated independently with 1-year healthcare costs.

Conclusions

Costs associated with ICHs vary between patient groups, and the ECPIS appears highest among patients older than 70 years and those with brainstem ICHs and higher ICH scores. One-third of financial resources were used for patients with favorable outcomes. Further detailed cost-analysis studies for patients with an ICH are required.

Temporal trends of medical cost and cost-effectiveness in sepsis patients: a Japanese nationwide medical claims database

Background

Sepsis is the leading cause of death worldwide. Although the mortality of sepsis patients has been decreasing over the past decade, the trend of medical costs and cost-effectiveness for sepsis treatment remains insufficiently determined.

Methods

We conducted a retrospective study using the nationwide medical claims database of sepsis patients in Japan between 2010 and 2017. After selecting sepsis patients with a combined diagnosis of presumed serious infection and organ failure, patients over the age of 20 were included in this study. We investigated the annual trend of medical costs during the study period. The primary outcome was the annual trend of the effective cost per survivor, calculated from the gross medical cost and number of survivors per year. Subsequently, we performed subgroup and multiple regression analyses to evaluate the association between the annual trend and medical costs.

Results

Among 50,490,128 adult patients with claims, a total of 1,276,678 patients with sepsis were selected from the database. Yearly gross medical costs to treat sepsis gradually increased over the decade from $3.04 billion in 2010 to $4.38 billion in 2017, whereas the total medical cost per hospitalization declined (rate = − $1075/year, p < 0.0001). While the survival rate of sepsis patients improved during the study period, the effective cost per survivor significantly decreased (rate = − $1806/year [95% CI − $2432 to − $1179], p = 0.001). In the subgroup analysis, the trend of decreasing medical cost per hospitalization remained consistent among the subpopulation of age, sex, and site of infection. After adjusting for age, sex (male), number of chronic diseases, site of infection, intensive care unit (ICU) admission, surgery, and length of hospital stay, the admission year was significantly associated with reduced medical costs.

Conclusions

We demonstrated an improvement in annual cost-effectiveness in patients with sepsis between 2010 and 2017. The annual trend of reduced costs was consistent after adjustment with the confounders altering hospital expenses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-022-00624-5.

Decompressive craniectomy practice following traumatic brain injury, in comparison with randomized trials

High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized CENTER-TBI and OzENTER-TBI Core study datasets. These include patients admitted to ICUs in Europe, the United Kingdom and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI, and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8.9%) of those matching DECRA enrolment, and in 30/224 (13.4%) of those matching RESCUEicp. Of patients who underwent DC 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to be potentially harmful, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.

Craniotomies following acute traumatic brain injury in Finland-a national study between 1997 and 2018

Background

A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.

Methods

The data were collected retrospectively from the Finnish Care Register for Health Care (1997–2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.

Results

The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18–39 years = 84% men, 40–69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.

Conclusions

The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

Cost of healthcare rehabilitation services following road traffic injuries: Results from a Level-I trauma center in Saudi Arabia

BACKGROUND

Road traffic injuries (RTIs) are the second leading cause of mortality in Saudi Arabia. The high rate of RTIs puts a strain on rehabilitation services. Yet, little is known of the economic burden of nonfatal RTIs and rehabilitation services. This study, therefore, aims to describe the annual rehabilitation costs associated with RTIs at a local trauma center.

MATERIALS AND METHODS

This study was conducted among all the 17 years or older patients hospitalized at King Abdulaziz Medical City in Riyadh following RTIs and required rehabilitation care. We included 299 patients who met the inclusion criteria and were followed for one year after discharge from the index hospital. The data was abstracted through retrospective review of patients' medical records. All rehabilitative services utilized by the healthcare system were recorded. To describe the economic burden, the mean, median, standard deviation, and interquartile range (IQR) were calculated. Total costs were aggregated for all patients to estimate overall costs.

RESULTS

The study population was relatively young (31 years ± 14.4). The total annual rehabilitation cost of patients was Saudi Riyals (SAR) 6,113,781 (IQR: 20,589.3 - 3,125 = 17,464.3), and the average for each patient was SAR 20,447 (median = 7875). Patients aged 40-59 years and ≥60 years accounted for the highest average rehabilitation cost of SAR 31,563.99 and 32,639.21, respectively. Rehabilitation visits incurred the highest cost (mean SAR 1,494,124), followed by bed utilization which cost SAR 1,311,972 and radiology examination at SAR 1,032,261. The cost of motorcycle injuries was relatively higher (SAR 44,441.0) than other injury mechanisms.

CONCLUSION

This study underlines the economic burden of rehabilitation services resulting from RTIs. Public health interventions are needed to reduce the burden of RTIs by dealing with their preventable causes and improving road safety measures. These findings may be useful to policymakers and researchers to support and improve rehabilitation services in Saudi Arabia.

Early thrombocytopenia is associated with an increased risk of mortality in patients with traumatic brain injury treated in the intensive care unit: a Finnish Intensive Care Consortium study

BACKGROUND

Coagulopathy after traumatic brain injury (TBI) is associated with poor prognosis.

PURPOSE

To assess the prevalence and association with outcomes of early thrombocytopenia in patients with TBI treated in the intensive care unit (ICU).

METHODS

This is a retrospective multicenter study of adult TBI patients admitted to ICUs during 2003-2019. Thrombocytopenia was defined as a platelet count < 100 × 10⁹/L during the first day. The association between thrombocytopenia and hospital and 12-month mortality was tested using multivariable logistic regression, adjusting for markers of injury severity.

RESULTS

Of 4419 patients, 530 (12%) had early thrombocytopenia. In patients with thrombocytopenia, hospital and 12-month mortality were 26% and 48%, respectively; in patients with a platelet count > 100 × 10⁹/L, they were 9% and 22%, respectively. After adjusting for injury severity, a higher platelet count was associated with decreased odds of hospital mortality (OR 0.998 per unit, 95% CI 0.996-0.999) and 12-month mortality (OR 0.998 per unit, 95% CI 0.997-0.999) in patients with moderate-to-severe TBI. Compared to patients with a normal platelet count, patients with thrombocytopenia not receiving platelet transfusion had an increased risk of 12-month mortality (OR 2.2, 95% CI 1.6-3.0), whereas patients with thrombocytopenia receiving platelet transfusion did not (OR 1.0, 95% CI 0.6-1.7).

CONCLUSION

Early thrombocytopenia occurs in approximately one-tenth of patients with TBI treated in the ICU, and it is an independent risk factor for mortality in patients with moderate-to-severe TBI. Further research is necessary to determine whether this is modifiable by platelet transfusion.

Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019: a Finnish Intensive Care Consortium study

Background

Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland.

Methods

We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003–2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality.

Results

A total of 4535 patients were included. Between 2003–2007 and 2016–2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged ≥ 70 years.

Conclusion

A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-05034-4.

Psychotropic medication use among patients with a traumatic brain injury treated in the intensive care unit: a multi-centre observational study

BACKGROUND

Psychiatric sequelae after traumatic brain injury (TBI) are common and may impede recovery. We aimed to assess the occurrence and risk factors of post-injury psychotropic medication use in intensive care unit (ICU)-treated patients with TBI and its association with late mortality.

METHODS

We conducted a retrospective multi-centre observational study using the Finnish Intensive Care Consortium database. We included adult TBI patients admitted in four university hospital ICUs during 2003-2013 that were alive at 1 year after injury. Patients were followed-up until end of 2016. We obtained data regarding psychotropic medication use through the national drug reimbursement database. We used multivariable logistic regression models to assess the association between TBI severity, treatment-related variables and the odds of psychotropic medication use and its association with late all-cause mortality (more than 1 year after TBI).

RESULTS

Of 3061 patients, 2305 (75%) were alive at 1 year. Of these, 400 (17%) became new psychotropic medication users. The most common medication types were antidepressants (61%), antipsychotics (35%) and anxiolytics (26%). A higher Glasgow Coma Scale (GCS) score was associated with lower odds (OR 0.93, 95% CI 0.90-0.96) and a diffuse injury with midline shift was associated with higher odds (OR 3.4, 95% CI 1.3-9.0) of new psychotropic medication use. After adjusting for injury severity, new psychotropic medication use was associated with increased odds of late mortality (OR 1.19, 95% CI 1.19-2.17, median follow-up time 6.4 years).

CONCLUSIONS

Psychotropic medication use is common in TBI survivors. Higher TBI severity is associated with increased odds of psychotropic medication use. New use of psychotropic medications after TBI was associated with increased odds of late mortality. Our results highlight the need for early identification of potential psychiatric sequelae and psychiatric evaluation in TBI survivors.

Intensive care-treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

Background

Cardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.

Methods

This single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.

Results

This study included a total of 1,285 patients, of which 212 (16 %) were \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).

Conclusions

The elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00923-0.

Long-Term Healthcare Expenditures Following Combat-Related Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is one of the most common injuries resulting from U.S. Military engagements since 2001. Long-term consequences in terms of healthcare utilization are unknown. We sought to evaluate healthcare expenditures among U.S. military service members with TBI, as compared to a matched cohort of uninjured individuals.

METHODS

We identified service members who were treated for an isolated combat-related TBI between 2007 and 2011. Controls consisted of hospitalized active duty service members, without any history of combat-related injury, matched by age, biologic sex, year of hospitalization, and duration of follow-up. Median total healthcare expenditures over the entire surveillance period represented our primary outcome. Expenditures in the first year (365 days) following injury (hospitalization for controls) and for subsequent years (366th day to last healthcare encounter) were considered secondarily. Negative binomial regression was used to identify the adjusted influence of TBI.

RESULTS

The TBI cohort consisted of 634 individuals, and there were 1,268 controls. Healthcare expenditures among those with moderate/severe TBI (median $154,335; interquartile range [IQR] $88,088-$360,977) were significantly higher as compared to individuals with mild TBI (median $113,951; IQR $66,663-$210,014) and controls (median $43,077; IQR $24,403-$83,590; P < .001). Most expenditures were incurred during the first year following injury.

CONCLUSION

This investigation represents the first continuous observation of healthcare utilization among individuals with combat-related TBI. Our findings speak to continued consumption of health care well beyond the immediate postinjury period, resulting in total expenditures approximately six to seven times higher than those of service members hospitalized for noncombat-related reasons.

A Post Hoc Analysis of Osmotherapy Use in the Erythropoietin in Traumatic Brain Injury Study-Associations With Acute Kidney Injury and Mortality

OBJECTIVES

Mannitol and hypertonic saline are used to treat raised intracerebral pressure in patients with traumatic brain injury, but their possible effects on kidney function and mortality are unknown.

DESIGN

A post hoc analysis of the erythropoietin trial in traumatic brain injury (ClinicalTrials.gov NCT00987454) including daily data on mannitol and hypertonic saline use.

SETTING

Twenty-nine university-affiliated teaching hospitals in seven countries.

PATIENTS

A total of 568 patients treated in the ICU for 48 hours without acute kidney injury of whom 43 (7%) received mannitol and 170 (29%) hypertonic saline.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We categorized acute kidney injury stage according to the Kidney Disease Improving Global Outcome classification and defined acute kidney injury as any Kidney Disease Improving Global Outcome stage-based changes from the admission creatinine. We tested associations between early (first 2 d) mannitol and hypertonic saline and time to acute kidney injury up to ICU discharge and death up to 180 days with Cox regression analysis. Subsequently, acute kidney injury developed more often in patients receiving mannitol (35% vs 10%; p < 0.001) and hypertonic saline (23% vs 10%; p < 0.001). On competing risk analysis including factors associated with acute kidney injury, mannitol (hazard ratio, 2.3; 95% CI, 1.2-4.3; p = 0.01), but not hypertonic saline (hazard ratio, 1.6; 95% CI, 0.9-2.8; p = 0.08), was independently associated with time to acute kidney injury. In a Cox model for predicting time to death, both the use of mannitol (hazard ratio, 2.1; 95% CI, 1.1-4.1; p = 0.03) and hypertonic saline (hazard ratio, 1.8; 95% CI, 1.02-3.2; p = 0.04) were associated with time to death.

CONCLUSIONS

In this post hoc analysis of a randomized controlled trial, the early use of mannitol, but not hypertonic saline, was independently associated with an increase in acute kidney injury. Our findings suggest the need to further evaluate the use and choice of osmotherapy in traumatic brain injury.

The Association Between Arterial Oxygen Level and Outcome in Neurocritically Ill Patients is not Affected by Blood Pressure

Background

In neurocritically ill patients, one early mechanism behind secondary brain injury is low systemic blood pressure resulting in inadequate cerebral perfusion and consequent hypoxia. Intuitively, higher partial pressures of arterial oxygen (PaO₂) could be protective in case of inadequate cerebral circulation related to hemodynamic instability.

Study purpose

We examined whether the association between PaO₂ and mortality is different in patients with low compared to normal and high mean arterial pressure (MAP) in patients after various types of brain injury.

Methods

We screened the Finnish Intensive Care Consortium database for mechanically ventilated adult (≥ 18) brain injury patients treated in several tertiary intensive care units (ICUs) between 2003 and 2013. Admission diagnoses included traumatic brain injury, cardiac arrest, subarachnoid and intracranial hemorrhage, and acute ischemic stroke. The primary exposures of interest were PaO₂ (recorded in connection with the lowest measured PaO₂/fraction of inspired oxygen ratio) and the lowest MAP, recorded during the first 24 h in the ICU. PaO₂ was grouped as follows: hypoxemia (< 8.2 kPa, the lowest 10th percentile), normoxemia (8.2–18.3 kPa), and hyperoxemia (> 18.3 kPa, the highest 10th percentile), and MAP was divided into equally sized tertiles (< 60, 60–68, and > 68 mmHg). The primary outcome was 1-year mortality. We tested the association between hyperoxemia, MAP, and mortality with a multivariable logistic regression model, including the PaO₂, MAP, and interaction of PaO₂*MAP, adjusting for age, admission diagnosis, premorbid physical performance, vasoactive use, intracranial pressure monitoring use, and disease severity. The relationship between predicted 1-year mortality and PaO₂ was visualized with locally weighted scatterplot smoothing curves (Loess) for different MAP levels.

Results

From a total of 8290 patients, 3912 (47%) were dead at 1 year. PaO₂ was not an independent predictor of mortality: the odds ratio (OR) for hyperoxemia was 1.16 (95% CI 0.85–1.59) and for hypoxemia 1.24 (95% CI 0.96–1.61) compared to normoxemia. Higher MAP predicted lower mortality: OR for MAP 60–68 mmHg was 0.73 (95% CI 0.64–0.84) and for MAP > 68 mmHg 0.80 (95% CI 0.69–0.92) compared to MAP < 60 mmHg. The interaction term PaO₂*MAP was nonsignificant. In Loess visualization, the relationship between PaO₂ and predicted mortality appeared similar in all MAP tertiles.

Conclusions

During the first 24 h of ICU treatment in mechanically ventilated brain injured patients, the association between PaO₂ and mortality was not different in patients with low compared to normal MAP.

Supplementary Information

The online version of this article (10.1007/s12028-020-01178-w) contains supplementary material, which is available to authorized users.

One-year costs of intensive care in pediatric patients with traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of death and disability in the pediatric population. The authors assessed 1-year costs of intensive care in pediatric TBI patients.

METHODS

In this retrospective multicenter cohort study of four academic ICUs in Finland, the authors used the Finnish Intensive Care Consortium database to identify children aged 0-17 years treated for TBI in ICUs between 2003 and 2013. The authors reviewed all patient health records and head CT scans for admission, treatment, and follow-up data. Patient outcomes included functional outcome (favorable outcome defined as a Glasgow Outcome Scale score of 4-5) and death within 6 months. Costs included those for the index hospitalization, rehabilitation, and social security up to 1 year after injury. To assess costs, the authors calculated the effective cost per favorable outcome (ECPFO).

RESULTS

In total, 293 patients were included, of whom 61% had moderate to severe TBI (Glasgow Coma Scale [GCS] score 3-12) and 40% were ≥ 13 years of age. Of all patients, 82% had a favorable outcome and 9% died within 6 months of injury. The mean cost per patient was €48,719 ($54,557) (95% CI €41,326-€56,112). The index hospitalization accounted for 66%, rehabilitation costs for 27%, and social security costs for 7% of total healthcare costs. The ECPFO was €59,727 ($66,884) (95% CI €52,335-€67,120). A higher ECPFO was observed among patients with clinical and treatment-related variables indicative of parenchymal swelling and high intracranial pressure. Lower ECPFO was observed among patients with higher admission GCS scores and those who had epidural hematomas.

CONCLUSIONS

Greater injury severity increases ECPFO and is associated with higher postdischarge costs in pediatric TBI patients. In this pediatric cohort, over two-thirds of all resources were spent on patients with favorable functional outcome, indicating appropriate resource allocation.

Early surgery for superficial supratentorial spontaneous intracerebral hemorrhage: a Finnish Intensive Care Consortium study

BACKGROUND

The benefits of early surgery in cases of superficial supratentorial spontaneous intracerebral hemorrhage (ICH) are unclear. This study aimed to assess the association between early ICH surgery and outcome, as well as the cost-effectiveness of early ICH surgery.

METHODS

We conducted a retrospective, register-based multicenter study that included all patients who had been treated for supratentorial spontaneous ICH in four tertiary intensive care units in Finland between 2003 and 2013. To be included, patients needed to have experienced supratentorial ICHs that were 10-100 cm³ and located within 10 mm of the cortex. We used a multivariable analysis, adjusting for the severity of the illness and the probability of surgical treatment, to assess the independent association between early ICH surgery (≤ 1 day), 12-month mortality rates, and the probability of survival without permanent disability. In addition, we assessed the cost-effectiveness of ICH surgery by examining the effective cost per 1-year survivor (ECPS) and per independent survivor (ECPIS).

RESULTS

Of 254 patients, 27% were in the early surgery group. Overall 12-month mortality was 39%, while 29% survived without a permanent disability. According to our multivariable analysis, early ICH surgery was associated with lower 12-month mortality rates (odds ratio [OR] 0.22, 95% confidence intervals [CI] 0.10-0.51), but not with a higher probability of survival without permanent disability (OR 1.23, 95% CI 0.59-2.56). For the early surgical group, the ECPS and ECPIS were €111,409 and €334,227, respectively. For the non-surgical cohort, the ECPS and ECPIS were €76,074 and €141,471, respectively.

CONCLUSIONS

Early surgery for superficial ICH is associated with a lower 12-month mortality risk but not with a higher probability of survival without a permanent disability. Further, costs were higher and cost-effectiveness was, thus, worse for the early surgical cohort.

Erythropoietin in traumatic brain injury associated acute kidney injury: A randomized controlled trial

BACKGROUND

Acute kidney injury (AKI) in traumatic brain injury (TBI) is poorly understood and it is unknown if it can be attenuated using erythropoietin (EPO).

METHODS

Pre-planned analysis of patients included in the EPO-TBI (ClinicalTrials.gov NCT00987454) trial who were randomized to weekly EPO (40 000 units) or placebo (0.9% sodium chloride) subcutaneously up to three doses or until intensive care unit (ICU) discharge. Creatinine levels and urinary output (up to 7 days) were categorized according to the Kidney Disease Improving Global Outcome (KDIGO) classification. Severity of TBI was categorized with the International Mission for Prognosis and Analysis of Clinical Trials in TBI.

RESULTS

Of 3348 screened patients, 606 were randomized and 603 were analyzed. Of these, 82 (14%) patients developed AKI according to KDIGO (60 [10%] with KDIGO 1, 11 [2%] patients with KDIGO 2, and 11 [2%] patients with KDIGO 3). Male gender (hazard ratio [HR] 4.0 95% confidence interval [CI] 1.4-11.2, P = 0.008) and severity of TBI (HR 1.3 95% CI 1.1-1.4, P < 0.001 for each 10% increase in risk of poor 6 month outcome) predicted time to AKI. KDIGO stage 1 (HR 8.8 95% CI 4.5-17, P < 0.001), KDIGO stage 2 (HR 13.2 95% CI 3.9-45.2, P < 0.001) and KDIGO stage 3 (HR 11.7 95% CI 3.5-39.7, P < 0.005) predicted time to mortality. EPO did not influence time to AKI (HR 1.08 95% CI 0.7-1.67, P = 0.73) or creatinine levels during ICU stay (P = 0.09).

CONCLUSIONS

Acute kidney injury is more common in male patients and those with severe compared to moderate TBI and appears associated with worse outcome. EPO does not prevent AKI after TBI.

Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre

BACKGROUND

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades.

METHODS

We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury.

RESULTS

Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients).

CONCLUSIONS

During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study

BACKGROUND

Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU).

METHODS

We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate.

RESULTS

In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071).

CONCLUSION

Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.