Intramural healthcare consumption and costs after traumatic brain injury: a CENTER-TBI study.

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 the healthcare consumption and costs on a multinational scale. This study aimed to describe intramural healthcare consumption and costs across the full spectrum of TBI in Europe. The CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury) core study is a prospective observational study conducted in 18 countries across Europe and 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: prehospital 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 GDP-PPP adjustment. Mixed linear regression was used to identify between country-differences in length of stay, 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%) moderate, and 962 (22%) severe TBI. Hospitalization accounted for the largest part of the intramural consumption and costs (59%). In the total study population the mean length of stay at the ICU was 5.1 days and 6.4 days at the ward. For mild, moderate and severe TBI, mean length of stay was respectively 1.8, 8.8 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 (20%) 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-€112,400). The adjusted analysis showed that female patients had lower costs compared to male patients (OR 0.80 (CI 0.75-1.85). Increasing TBI severity was associated with higher costs, OR 1.46 (CI;1.31-1.63) and OR 1.67 (CI;1.52-1.84) for moderate and severe patients respectively. A worse premorbid overall health state, increasing age and more severe systemic trauma, expressed in 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, with age and male patients incurred higher costs. Reducing LOS could be targeted with advanced care planning in order to provide cost-effective care.