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

R Raj, S Bendel, M Reinikainen, S Hoppu, R Laitio, T Ala-Kokko, S Curtze, M B Skrifvars, R Raj, S Bendel, M Reinikainen, S Hoppu, R Laitio, T Ala-Kokko, S Curtze, M B Skrifvars

Abstract

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.

Keywords: Acute ischemic stroke; Finland; Intracerebral hemorrhage; Neurocritical care; neurointensive care; costs; Outcome; cost-effectiveness; Subarachnoid hemorrhage; Traumatic brain injury.

Conflict of interest statement

Ethics approval and consent to participate

The research committee of the of Helsinki University Hospital (HUS/26/2018 §37), the Finnish National Institute for Health and Welfare (THL/2034/5.05.00/2017), Statistics Finland (TK-53-1047-14), the Social Insurance Institution (Kela 23/522/2018), the Office of the Data Protection Ombudsman (2794/402/2015) and all of the participating university hospitals’ ethics committees approved this study and waived the need for informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow chart. Abbreviations: TBI, traumatic brain injury; ICH, intracerebral hemorrhage; SAH, subarachnoid hemorrhage; AIS, acute ischemic stroke; FICC, Finnish Intensive Care Consortium; GCS, Glasgow Coma Scale
Fig. 2
Fig. 2
Changes in mean probability of one-year mortality (with 95% confidence intervals), reflecting patient severity of illness. Probabilities are calculated by logistic regression analysis, adjusting for age, Glasgow Coma Scale score, significant comorbidity, pre-admission functional status and the modified Simplified Acute Physiology Score II. The y-axis scale extends from 0 to 0.4, where 0 indicates that the probability is 0% and 0.4 that the probability is 40%. Severity of illness decreased markedly from 2007 to 2009, where after it remained largely the same
Fig. 3
Fig. 3
Left panel, changes in mean costs per patient during the study period (with 95% confidence intervals (CI)]). A trend towards lower mean costs per patient is noted. Mean cost per patient was €50,162 (95% CI €43,783–€56,541) in 2003 and €38,872 (95% CI €36,236–€41,508) in 2013. Right panel, changes in the sum of costs (blue bars) and absolute number of patients per year (connected boxes). The sum of costs increased by 76% from 2003 to 2013 (€18.6 million in 2003 and €32.8 million in 2013). The total number of patients increased by 227% from 370 patients in 2003 to 840 patients in 2013
Fig. 4
Fig. 4
Effective cost per survivor (ECPS) in blue and effective cost per independent survivor (ECPIS) in red

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