Determinants of hospital costs associated with traumatic brain injury in England and Wales*
|
|
- Thomas Barber
- 5 years ago
- Views:
Transcription
1 Anaesthesia, 2008, 63, pages doi: /j x Determinants of hospital costs associated with traumatic brain injury in England and Wales* S. Morris, 1 S. Ridley, 2 F. E. Lecky, 3 V. Munro 4 and M. C. Christensen 5 1 Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UB8 3PH, UK 2 Glan Clwyd Hospital, Rhyl, Denbighshire, LL18 5UJ, UK 3 Trauma Audit and Research Network, University of Manchester, Eccles Old Road, Salford M6 8HD, UK 4 Novo Nordisk Ltd, Broadfield Park, Brighton Road, Crawley, West Sussex RH11 9RT, UK 5 Global Development, Novo Nordisk A S, Krogshøjvej 55, DK-2880 Bagsværd, Denmark Summary Using data from the Trauma Audit Research Network, we investigated the costs of acute care in patients 18 years of age hospitalised for traumatic brain injury between January 2000 and December 2005 in England and Wales. Traumatic brain injury patients were defined and stratified using the Abbreviated Injury Scale. A total of 6484 traumatic brain injury patients were identified; 22.3% had an Abbreviated Injury Scale score of three, 38.0% of four and 39.7% of five. Median age (IQR) was 42 years (28 59) and 76.7% were men. Primary cause of injury was motor vehicle collisions (42.4%) followed by falls (38.0%). In total 23.7% of the patients died before discharge. Hospitalisation costs averaged (SD ). Costs varied significantly by age, Glasgow Coma Score, Injury Severity Score, coexisting injuries of the thorax, spine and lower limb, hospital mortality, availability of neurosurgical services, and specialty of attendants seen in the Accident and Emergency department.... Correspondence to: Dr Stephen Morris stephen.morris@brunel.ac.uk *Presented in part at the European Association for Trauma and Emergency Surgery European Trauma Society Congress, Graz, May Accepted: 4 December 2007 At least one million patients present in hospitals in the United Kingdom (UK) each year with head injuries, representing 10% of all patients attending Accident and Emergency (A&E) departments [1]. About 90% of these patients have minor or mild head injuries, with the remainder having moderate to severe head injuries. Approximately 20% require admission for observation but fewer than 5% are transferred to specialised neurosurgical care. About one third of all adult patients admitted to an intensive care unit (ICU) for head injury die while in hospital [2]. Despite the clinical importance of head injury current treatment patterns for severe injuries are not well described in the literature. Furthermore, the costs of treatment for severe head injury have not been examined. A recent study from the Intensive Care National Audit and Research Centre (ICNARC) examined the case mix and outcome among patients admitted to the ICU with head injuries between 1995 and 2005 in the UK [2]. Mortality in the ICU was 23%, while total hospital mortality was 33.5%. The Trauma Audit and Research Network (TARN) recently compared hospitalised trauma patients with and without significant head injury and demonstrated a 10-fold higher mortality rate within the head injury cohort [3]. One-third of those with head injuries were not treated in neurosurgical centres, which was associated with a 2.15-fold increase in the odds of death. While a significant reduction in case fatality after head trauma was observed between 1989 and 2003, most of the reduction seems to have occurred before These findings are supported by results from an earlier nationally representative study on acute survival after blunt trauma from 1989 to 2000 [4]. In light of these findings, it has been recommended that public health efforts in trauma care are focussed on improving the treatment of severe head injury as this Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 499
2 S. Morris et al. Æ Cost of TBI Anaesthesia, 2008, 63, pages appears to be the best strategy for further reduction in case fatality among hospitalised blunt trauma patients [3]. In particular, it has been recommended that neurosurgical and neurocritical care interventions play a key role in such health care improvement. The National Institute for Health and Clinical Excellence (NICE) recently published a clinical guideline on the early management of head injury [5]. The guideline covers optimal pre-hospital care including assessment, airway management and ventilation, cervical spine protection and appropriate transfer, indications for referral to hospital from pre-hospital care, secondary care with the aim of early detection of intracranial complications and appropriate transfers to neurosurgical units. The guideline is currently under revision to further update recommendations regarding pre-hospital management, selection of patients for computerised tomography (CT) scanning, pain management and use of neuroscience units. The NICE guideline follows an earlier report by the Royal College of Surgeons recommending that all patients with severe head injuries are treated in a neurosurgical centre [6]. The aims of this study were to estimate the hospital costs associated with traumatic brain injury (TBI) in England and Wales and to identify their most important predictors. The analysis will be useful for evaluating how current treatment adheres to proposed clinical guidelines and for guiding decision-makers towards an optimal use of health care resources. Methods Data source and variables Data for this study were taken from the Trauma Audit Research Network (TARN). Data from TARN have been used in a number of studies investigating, inter alia, trends in trauma care [4], the effect of neurosurgical care on head injury outcome [3], and outcome prediction in trauma [7]. This is the first study to use this dataset to investigate the acute treatment costs of TBI. TARN includes data from 50% of all hospitals receiving trauma patients in England and Wales. It collects data from participating hospitals on patients who sustain injuries resulting in immediate admission to hospital for 3 days, admission to ICU or high dependency unit (HDU), or death within 93 days. Data for the study were obtained from the TARN database. The authors did not have access to individual patient records. TARN is supported by the Healthcare Commission. Specific informed patient consent or ethical approval is not required because no patient identifiers are retained by TARN either electronically or on paper. TARN has Section 60 Patient Information Advisory Group approval. As this study involves the secondary analysis of TARN and other published data, ethical approval was not sought. We included all patients hospitalised for TBI in TARN hospitals between 1 January 2000 and 31 December Hospitals completed a data entry sheet for each patient with information on age, gender, cause and type of injuries, severity of the injuries, treatment provided at the scene of accident, en route to hospital or in A&E, and any other care received at the hospital, including diagnostic tests, surgical procedures and length of stay (LOS). TARN classifies injuries according to the 1998 revision of the Abbreviated Injury Scale (AIS), which has been widely adopted for use in studies of acute injury, including TBI [6]. TBI was defined using six-digit AIS codes beginning 14****. Each AIS injury code is allocated an AIS score ranging from one (minor injury) to six (virtually unsurvivable injury). In our study, severity of TBI was assessed for each subject by calculating the maximum AIS score of any brain injuryrelated diagnosis recorded for that patient during hospitalisation. In addition, we utilised data on gender, age, mechanism of injury, earliest recorded Glasgow Coma Score (GCS), Injury Severity Score (ISS), co-existing injuries with an AIS score of three or more by body region, discharge status and year of admission. We also report data on the specific treatment provided, including mode of arrival at A&E, time from emergency call to arrival at A&E, time spent in A&E, grade of doctor seen in A&E, specialty of doctors seen in A&E, diagnostic tests performed, TBI-related surgical interventions, admission to critical care (ICU, neurocritical units or HDU), LOS in critical care and total LOS. Finally, we used data on whether or not the treating hospital had a neurosurgical unit. We excluded from the analysis patients younger than 18 years of age at the time of injury. Measuring costs Treatment costs were estimated from the perspective of the National Health Service (NHS) in England and Wales and restricted to those for TBI. We calculated treatment costs for each patient based on the following components: transportation to the hospital, hospital stay (A&E, critical care, regular ward), and TBI-related surgical procedures. Resource use for every component was measured for each TBI patient in the TARN database. Other treatment costs were included where a clear distinction between TBI-related care and unrelated care could not be made, e.g. mode of transportation to the hospital with more than one injury. We then assigned unit costs from external sources to each item (see the Appendix for further details on the data used and methodology applied). 500 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
3 Anaesthesia, 2008, 63, pages S. Morris et al. Æ Cost of TBI Data analysis We examined the study population and treatment patterns stratified by AIS score. We estimated treatment costs per patient and calculated mean treatment costs by patient characteristics, treatment patterns and AIS score. We also undertook multivariate analyses of treatment costs using regression analysis to identify important predictors of costs. We estimated a full model including the full range of subject characteristics and treatment variables, and a reduced model including only those variables that had a statistically significant association with costs. These variables were identified using forwards stepwise and backwards stepwise selection procedures where the significance level for removal from the model was p 0.01, and significance level for addition was p < Robust standard errors were used to control for clustering within individuals. The models were estimated using least squares and the coefficients are marginal effects. Some of the data collected by TARN and used in the analysis are missing in a number of patients. The main variables where this occurs are the time from emergency call to arrival at A&E, whether or not the patient had a CT scan, and whether or not they had surgical procedures. The first item is available for patients who travelled to hospital by ambulance. The last item may be missing because the relevant section on the data entry sheet is completed by free text and may have been left blank. We report the numbers of observations used to calculate every statistic reported. When we calculated the acute care costs for each patient we only did so using patients with complete data. If data for one or more of the cost components were missing for a patient then we assigned a missing code to the total costs incurred by that patient and did not include the patient in the cost calculation. Results Sample characteristics We identified 6484 patients with TBI in the study period. Head injuries with AIS scores of one or two do not include brain injury; all TBI patients have an AIS score of three or more. Hence patients with an AIS score of one or two did not meet the study inclusion criteria. Only 10 patients with an AIS score of six were identified, and were as a consequence excluded from further analysis. Of the remaining 6474 patients, 1441 (22.3%) had an AIS score of three (serious TBI), 2460 (38.0%) an AIS score of four (severe TBI) and 2573 (39.7%) an AIS score of five (critical TBI). The patients demographic and clinical characteristics are detailed in Table 1. Seventy-seven percent of the Table 1 Sample characteristics of patients hospitalised for TBI, by severity. TBI AIS score All Total number Male; % Age; years Median (IQR) 38 (26 55) 42 (29 60) 43 (29 60) 42 (28 59) Cause of injury; % Vehicle incident collision Fall more than 2 m Fall less than 2 m Blow(s) Other Glasgow Coma Score Median (IQR) 12 (7 15) 12 (6 14) 7 (3 13) 10 (5 14) n Injury Severity Score Median (IQR) 14 (10 25) 17 (16 25) 26 (25 35) 25 (17 29) n Coexisting injuries by body region; %* Head (excluding TBI) or face Thorax Abdomen Spine Upper or lower limb Any Alive at hospital discharge; % The sample size is equal to the total number other than where indicated by n. *Injuries with an AIS score of 3 or more. TBI, traumatic brain injury. Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 501
4 S. Morris et al. Æ Cost of TBI Anaesthesia, 2008, 63, pages subjects were male, and the median age (IQR) was 42 years (28 59). There was little variation in age and gender by AIS score. The predominant cause of injury was motor vehicle collisions (42.4%), followed by falls (38.0%) and blows (12.7%). Median (IQR) GCS was 10 (5 14) and median (IQR) ISS was 25 (17 29). The most frequent co-existing injuries with an AIS score of three or more were other injuries to the head (excluding TBI) or face (36.9%), thoracic injuries (20.8%) and injuries to the upper or lower limbs (17.2%). Twenty-four percent of patients died in hospital, with the highest proportion of deaths in the group with an AIS score of five (37.7%). Among those who died, the mean (SD) time to death was 6.4 days (15.8) from the date of arrival at the hospital. It was 6.3 days (10.6) for patients with an AIS score of 3, 10.8 days (25.4) for those with an AIS score of 4, and 4.8 days (10.9) for those with an AIS score of 5. There was a reasonably uniform distribution of patients in each year over the 6-year study period: the percentage of the total sample from each year ranged from 14.1% in 2005 to 20.6% in Management patterns Treatments received while in hospital are shown in Table 2. Eighty-six percent and 11% of patients arrived at the hospital by ambulance and helicopter, respectively. Helicopter transport is usually reserved for the most seriously injured patients, which includes those with TBI. TARN includes London s Air Ambulance Service, which covers all TBI patients in London. The median (IQR) time from emergency call to arrival at A&E by ambulance was 48 min (34 78), and the median (IQR) time in A&E was 70 min (0 209). Forty-two percent of patients had missing data on whether or not they had a CT scan for their head injury. Among those with a documented CT scan, 70% of these had the scan within 2 h of arrival at A&E. Twenty-nine percent of patients had TBI related surgery; the most common surgical procedures were evacuation of epidural haematoma subdural haematoma (EDH SDH) (13.5%) craniotomy (9.3%), and intracranial pressure monitoring (9.2%). Each of these procedures was more common in patients with more severe TBI. Approximately two-thirds of patients were admitted to critical care, with a median (IQR) LOS of 5 days (2 13). The median (IQR) total hospital LOS was 11 days (5 27). Patients with an AIS score of five were more likely to be admitted to critical care than less severely injured patients, but the length of stay in critical care among those who were admitted, and total length of stay was similar across the different AIS groups. Around 70% of all TBI patients were taken or transferred to a hospital with on site neurosurgery. The proportion of patients treated in a hospital with these facilities who died in the hospital was 0.227, compared with for patients treated in a hospital without these facilities (mean difference 0.033, standard error (SE) 0.012, 95% confidence interval (CI) , p = 0.005). Twenty-five percent of patients saw a consultant in A&E and around 60% saw a middle grade doctor (defined as senior registrar, registrar, specialist registrar with up to 5 years of experience, staff grade, associate specialist and research fellow). Over 50% of TBI patients were seen by a doctor with a speciality in emergency medicine; specialists in neurosurgery, anaesthesia, orthopaedics and general surgery were also common. Treatment costs The mean total cost per patient was (SD ) (Table 3). Mean costs per patient were highest in those with an AIS score of five. Length of stay in critical care accounted for 51% of mean total costs. The next most important component was length of stay on a regular ward (38%), followed by travel costs to the A&E department (5%) and TBI related surgery (4%). These proportions were similar for every AIS group. Across age groups, patients aged years incurred the highest costs. This was due to the longer mean stay in critical care and the longer mean total length of stay in this age group. There was little variation in costs by gender. Across mechanism of injury and severity of injury, costs were highest among those injured in motor vehicle collisions, those with a lower GCS (3 8) and those with a higher ISS (35 75). The higher costs for motor vehicle collisions were due to the more severe injuries sustained in this group (median GCS and ISS were 8 and 26 compared to 12 and 24 among those injured in other ways). Co-existing injuries had a positive effect on treatment costs, especially injuries to the neck, thorax, abdomen and spine, while mortality had a negative effect on costs. Costs also varied substantially by mode of arrival to the hospital, by time from emergency call to arrival at A&E (this was positively correlated with costs) (Table 4). Injuries requiring surgical interventions were generally associated with higher treatment costs. Notable exceptions were burrhole of the cranium and repair of dura, which were associated with lower costs due to less severe injuries among patients undergoing these procedures (median GCS and ISS were 14 and 25 for burrhole of cranium and 14 and 17 for repair of dura, compared with values of 10 and 25 for the whole sample). As expected, costs were positively correlated with longer lengths of stay in critical care and overall LOS. Mean treatment costs for TBI in hospitals with neurosurgical units were higher than in hospitals without neurosurgical units. 502 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
5 Anaesthesia, 2008, 63, pages S. Morris et al. Æ Cost of TBI Table 2 Treatment patterns for patients hospitalised for TBI, by severity. TBI AIS score All Mode of arrival; % Ambulance Helicopter Car Aircraft Walking n Time from emergency call to arrival at A&E; min* Median (IQR) 47 (33 75) 47 (34 73) 51 (35 89) 48 (34 78) n Time in A&E; min Median (IQR) 106 (0 229) 65 (0 222) 54 (0 183) 70 (0 209) n Time to CT scan after arrival at Emergency Department; min Median (IQR) 70 (47 119) 76 (47 128) 72 (46 106) 74 (47 117) n TBI-related surgery; % Evacuation of EDH SDH Craniotomy Intracranial pressure monitor Elevation of depressed fracture of cranium Burrhole of cranium Drainage of EDH SDH Any TBI-related surgery n Admitted to critical care; % n LOS in critical care; days Median (IQR) 5 (2 11) 6 (2 13) 6 (2 13) 5 (2 13) n Total length of stay; days Median (IQR) 12 (6 28) 11 (5 26) 10 (4 27) 11 (5 27) n Hospital has a neurosurgical centre; % Grade of most senior doctor seen in A&E; % Consultant Middle grade SHO n Specialty of doctors seen in A&E; % Emergency medicine Neurosurgery Anaesthesia Orthopaedics Other *Among those arriving by ambulance. Among those having a CT scan. The figures pertain only to those patients who were admitted to critical care. Including LOS in critical care. The figures pertain both to those who were admitted to critical care and those who were not. Among those with an ISS > 15. TBI, traumatic brain injury; AIS, Abbreviated Injury Scale; A&E, Accident and Emergency; CT, computerised tomography; EDH SDH, epidural haematoma subdural haematoma; LOS, length of stay. Mean treatment costs were higher if the patient was seen by a consultant, and if the patient was seen by a doctor from the specialties of anaesthesia, orthopaedics and general surgery. Note that the unit costs used in the analysis (see Appendix) did not vary by the grade or specialty of the doctors seen in A&E. Therefore, the variation in costs by doctor is a function of variations in surgery and length of stay, which in turn is affected by injury severity. Patients with missing cost data had similar severity of injuries to those with non-missing cost data (median (IQR) ISS 25 (17 29) versus 25 (17 29)). Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 503
6 S. Morris et al. Æ Cost of TBI Anaesthesia, 2008, 63, pages Table 3 Mean treatment costs for patients hospitalised for TBI, by severity and demographic and clinical characteristics. TBI AIS score All Total cost; Mean (SD) (16 725) (16 896) (16 815) (16 844) Median (IQR) 8330 ( ) 7551 ( ) 9997 ( ) 8735 ( ) n Mean total cost; By gender Male Female By age group years years years years years By cause of injury Vehicle incident collision Fall more than 2 m Fall less than 2 m Blow(s) Other By Injury Severity Score group Coexisting injuries by body region* Neck Thorax Abdomen Spine Upper limb Lower limb Any By discharge status Alive Dead *Injuries with an AIS score of 3 or more. TBI, traumatic brain injury; AIS, Abbreviated Injury Scale. Multivariate analysis The results of the multivariate analysis are in Table 5. In the reduced model, the statistically significant cost drivers were age (those between 65 and 74 years incurred the highest cost), GCS (a lower level of consciousness was positively correlated with costs), ISS (greater severity had a positive impact on costs), co-existing injuries with an AIS score of three or more of the thorax, spine and lower limb (all of which were positively correlated with costs), and mortality (negatively correlated). Treatment costs were significantly lower in Being treated in a hospital with a neurosurgical centre had a positive impact on treatment cost, and being seen in A&E by a doctor from the specialties of anaesthesia or general surgery was also associated with higher in treatment costs. Conditional on these variables, the other patient and treatment characteristics were not statistically significant predictors of total hospital costs. Discussion This study provides a detailed description of the demographic and clinical characteristics of TBI patients in England and Wales, their causes of injury, acute treatment provided, and outcomes observed. It focuses specifically on NHS hospital costs and is the first study to provide a detailed assessment of the NHS hospital costs associated with TBI in England and Wales. The typical TBI patient was male, 45 years old, involved in a motor vehicle accident, with a moderate head injury (GCS 10) and polytraumatised (ISS 25). The most frequent co-existing injuries were other head injury, thoracic injury and 504 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
7 Anaesthesia, 2008, 63, pages S. Morris et al. Æ Cost of TBI Table 4 Mean treatment costs, by treatment patterns. TBI AIS score Mean total cost; By mode of arrival Ambulance Helicopter Car Walking By time from emergency call to arrival at A&E; h* By TBI-related surgery Evacuation of EDH SDH Craniotomy Intracranial pressure monitoring Burrhole of cranium Drainage of EDH SDH Any TBI-related surgery By LOS in critical care; days By total length of stay; days By whether hospital has a neurosurgical centre No Yes By grade of most senior doctor seen in A&E Consultant Middle grade SHO By specialty of doctors seen in A&E Emergency medicine Neurosurgery Anaesthesia Orthopaedics General surgery Other *Among those arriving by ambulance. Including LOS in critical care. The figures pertain both to those who were admitted to critical care and those who were not. AIS, Abbreviated Injury Scale; A&E, Accident and Emergency; TBI, traumatic brain injury; EDH SDH, epidural haematoma subdural haematoma; LOS, length of stay. damage to the upper and lower limbs. About 70% of all TBI patients were admitted to critical care for median LOS of 5 days. Median total LOS was 11 days and 23.0% of the patients died before hospital discharge. The mean cost of acute treatment to the NHS was per patient. All The observed mortality among TBI patients across the 6-year period of our study was 23.7%. It fell from 28.8% in 2000, to 23.3% in 2001, 25.2% in 2002, 22.8% in 2003, 21.5% in 2004 and 21.1% in 2005 (after controlling for injury severity in terms of AIS scores, GCS, ISS, plus age, gender, cause of injury, and coexisting injuries there was no statistically significant variation in mortality across the study period). The crude mortality rate in our study is similar to that found in other studies. For example, Patel et al. [3] reported an overall mortality rate of 25% among TBI patients treated in TARN hospitals between 1983 and In the ICNARC study of TBI patients admitted to ICU, Hyam et al. [2] reported an ICU mortality of 23.0% and in-hospital mortality of 33.5%. Our findings on the demographic and clinical characteristics of TBI in England and Wales are also consistent with findings in other European countries; about twothirds of all severe TBIs occur in men, in their early to mid-40s, with motor vehicle collisions and falls as the most common causes of injury [8]. In the United States, McGarry et al. [9] reported a detailed study on the acute treatment, outcomes and costs among 8717 patients with moderate to critical TBI. While there were no marked differences in the cause of injury by AIS, the average LOS ranged from 9.7 days for AIS 3 to 17.5 days for AIS 5, and total hospital mortality varied from 5.7% for AIS 3 to 52.0% for AIS 5. About 45% and 54% with AIS 4 and AIS 5, respectively, underwent some form of TBI related surgery compared to 26% and 42% in our study, though underreporting of surgery in the TARN database may explain at least part of this difference. No previous studies have examined the cost of acute treatment for TBI in the UK, and little is known about the cost of acute treatment in Europe [10]. A recent literature review identified only two studies, in Germany [11] and Spain [12], containing TBI related cost data, and presented new costs estimates for acute TBI treatment in Sweden [10]. Differences in costing methodology prevent a detailed comparison, but the reported average inpatient costs for patients with severe brain injury, ranging from 5622 ( 3830) in Spain to 8951 ( 6097) in Sweden, appear significantly lower than those observed in our study. Identification of substantial differences in hospital costs by specific patient characteristics generate knowledge useful for a more rational budgeting process of health care expenditures, and allow for a much better estimation of the cost-effectiveness of new public health interventions. In our multivariate analysis, we identified age, GCS, ISS, co-existing injuries of the thorax, spine and lower limb, mortality, year of admission, hospital specialisation and specialty of doctor as significant predictors of hospital Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 505
8 S. Morris et al. Æ Cost of TBI Anaesthesia, 2008, 63, pages Full model Reduced model Table 5 Multivariate analysis of mean treatment costs for TBI. Coefficient t-statistic p-value Coefficient t-statistic p-value TBI AIS score* 4 )434.6 ) ) ) Gender; female )277.7 ) Age years years < < years < < years < Cause of injury Fall more than 2 m )650.1 ) Fall less than 2 m ) ) Blow(s) ) )3.8 < ) )3.9 < Other ) ) Glasgow Coma Score 6 8 )752.1 ) ) )6.4 < ) )7.0 < ) )13.4 < ) )16.2 < Injury Severity Score < < Coexisting injuries by body region** Head (excluding TBI) )295.7 ) Face Neck Thorax Abdomen Spine < < Upper limb Lower limb < Discharge status; dead ) )14.6 < ) )15.3 < Year of admission ) ) ) ) Hospital has a neurosurgical centre; yes < < Grade of most senior doctor seen in A&E Consultant Middle grade Specialty of doctors seen in A&E Emergency medicine )394.0 ) Neurosurgery Anaesthesia < < Orthopaedics General surgery Other Constant < < Observations Adjusted R *The omitted category in the full model is 3. The omitted category is years. The omitted category is vehicle incident collision. The omitted category is 3 5. The omitted category is **Injuries with an AIS score of three or more. The omitted category is The omitted category is SHO. TBI, traumatic brain injury; AIS, Abbreviated Injury Scale. costs. In the univariate analysis, mean treatment costs also varied by other patient and treatment characteristics (e.g. cause of injury, other coexisting injuries), yet this was due to the correlation between these characteristics and injury severity, and they were insignificant in the multivariate model. This highlights the importance of undertaking 506 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
9 Anaesthesia, 2008, 63, pages S. Morris et al. Æ Cost of TBI multivariate analysis when investigating the determinants of treatment costs. In our study we observed that 72% of patients were admitted to hospitals with neurosurgical expertise (neurosurgical centres). These have previously been associated with better outcomes for the severely head injured regardless of whether they actually received neurosurgery [3]. In our multivariate analysis, the conditional incremental costs of admission to a hospital with neurosurgical expertise were approximately This cost estimate can be compared to the incremental survival benefit observed in hospitals with compared to those without neurosurgical expertise to evaluate the cost-effectiveness of neurosurgical centres in treating TBI. With an incremental survival of 26% identified by Patel et al. [3], we estimate the incremental cost per hospital death averted in patients with TBI treated at a hospital with neurosurgical expertise to be approximately This study has a number of limitations. First, we were not always able to make a clear distinction between TBI related costs and costs related to other co-existing injuries; this means that the initial hospital costs of TBI may be overestimated. Second, we did not include treatment costs incurred after the initial hospitalisation period, such as the cost of rehabilitation, home care support and any subsequent hospitalisations related to TBI. Third, the retrospective nature of the study implies reliance on the quality and completeness of the data reported to TARN. We observed incomplete data on a number of treatment parameters, particularly whether or not the patient had a CT scan, and whether or not they had surgical procedures. This may mean that the costs of TBI are underestimated. Whether or not the patient had a CT scan was missing in 42% of patients. According to NHS Reference Costs [13] the mean cost per CT scan is around 100; it is therefore unlikely that the addition of these costs would have increased the total mean costs computed in this study noticeably. Given the format in which surgical procedures were recorded it was not possible to identify whether data on surgical procedures was missing or incomplete, but potentially the number of surgical procedures is higher than the figures reported in our study. Fourth, the indirect costs related to lost productivity and time spent away from other activities, as well as the costs associated with the pain and suffering by victims and relatives were not included. However, the cost of follow up care and the indirect costs can be substantial, and in fact represent the majority of the lifetime societal costs of TBI [14, 15]. In summary, our study provides the most detailed information to date on the costs of TBI in the acute care setting in England and Wales. Our findings indicate that the initial hospital costs associated with TBI vary by injury severity. Public health initiatives that aim to reduce the incidence of TBI and the severity of head injury are therefore likely to produce significant savings in acute trauma care. These data will also be important for any planned reconfiguration of trauma centres in England and Wales. Acknowledgements This study was funded by Novo Nordisk A S. S. Morris received consultancy fees and S. Ridley has received honoraria relating to lectures and other work from Novo Nordisk. M. C. Christensen and V. Munro are employees of Novo Nordisk. The authors would like to thank Omar Bouamra and Tom Jenks at TARN for providing the data used in this study and gratefully acknowledge the huge effort made by individual clinicians and hospitals in collecting and submitting raw data to the TARN database. TARN is funded by its participating hospitals. Finally, the authors would also like to thank Tina G. Nielsen, Novo Nordisk A S, for her very helpful comments relating to the statistical analyses. References 1 Kay A, Teasdale G. Head injury in the United Kingdom. World Journal of Surgery 2001; 25: Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes, and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICN- ARC Case Mix Programme Database. Critical Care 2006; 10: S2. 3 Patel HC, Bouamra O, Woodford M, King AT, Yates DM, Lecky FE. Trends in head injury outcome from 1998 to 2003 and the effect of neurosurgical care: an observational study. Lancet 2005; 366: Lecky FE, Woodford M, Bouamra O, Yates DW. Lack of change in trauma care in England and Wales since Emergency Medical Journal 2002; 19: National Institute for Health and Clinical Excellence. Head injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. (Clinical Guideline 4), London, UK: NICE, Royal College of Surgeons. Report of the Working Party on the Management of Patients with Head Injury. London, UK: The Royal College of Surgeons, Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. A new approach to outcome prediction in trauma: a comparison with the TRISS model. Journal of Trauma 2006; 61: Tagliaferri F, Compagnone C, Korsic M, Servadei F, Kraus J. A systematic review of brain injury epidemiology in Europe. Acta Neurochirurgica 2006; 148: Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland 507
10 S. Morris et al. Æ Cost of TBI Anaesthesia, 2008, 63, pages McGarry LJ, Thompson D, Millham FH, et al. Outcomes and costs of acute treatment of traumatic brain injury. Journal of Trauma 2002; 53: Berg J, Tagliaferri F, Servadei F. Cost of trauma in Europe. European Journal of Neurology 2005; 12 (Suppl. 1): Firsching R, Woischneck D. Present status of neurosurgical trauma in Germany. World Journal of Surgery 2001; 25: Brell M, Ibanez J. Manejo del Traumaismo Craneoencefalico Leve en España. Encuesta Multicentrica Nacional Neurocirurgia 2001; 12: Department of Health. NHS Reference Costs Appendix SRC1 NHS Trust reference cost index. London: Department of Health, Dikman SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to 5 years after moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2003; 84: Boake C, McCauley SR, Pedroza C, Levin HS, Brown SA, Brundage SI. Lost productive work time after mild to moderate traumatic brain injury with and without hospitalization. Neurosurgery 2005; 56: Curtis L, Netten A. Unit Costs of Health and Social Care Canterbury: University of Kent, London s Air Ambulance Service. londonsairambulance.com/ (accessed 23 June 2007). 18 National Institute for Health and Clinical Excellence. Technology Appraisal Guidance 83. Laparoscopic surgery for inguinal hernia repair. London: NICE, 2004: Morris S, Ridley S, Munro V, Christensen MC, on behalf of the NovoSeven Trauma Study Group. Cost effectiveness of recombinant activated factor VII for the control of bleeding in patients with severe blunt trauma injuries in the United Kingdom. Anaesthesia 2007; 62: Appendix Unit costs. Cost component Unit Unit cost ( ) Source and notes Mode of arrival at hospital Ambulance Cost per minute 5.50 Curtis and Netten [16] (p.112); cost per minute of emergency ambulance service Helicopter Mean cost per patient journey 1650 London Air Ambulance website [17]; mean cost per mission Hospital stay Emergency Department Mean cost per attender 278 NHS reference costs 2004 [13]; mean cost per attender across all A&E Healthcare Resource Groups Regular ward Mean cost per day 281 NHS reference costs 2004 [13]; mean national average unit cost per day for Healthcare Resource Group A31 (Head injury with brain injury) Critical Care Unit Mean cost per day 1328 NHS reference costs 2004 [13]; mean cost per day in Intensive Care Unit Intensive Therapy Unit Surgical procedures Duration; min Intracranial pressure monitor TARN; NICE [18]; the duration in minutes for each procedure was computed internally using the TARN database. The unit costs were then computed by multiplying the duration by the variable cost per minute from NICE [18] and adding a fixed cost per procedure also from NICE [18].* Elevation of depressed fracture of cranium Evacuation of EDH SDH Craniotomy Bur hole of cranium Drainage of EDH SDH *This method has been used in previous UK cost analyses of trauma care [19]. EDH SDH, epidural haematoma subdural haematoma. 508 Journal compilation Ó 2008 The Association of Anaesthetists of Great Britain and Ireland
Major Trauma Service in England - TARN s supporting role
The Trauma Audit & Research Network Major Trauma Service in England - TARN s supporting role Scottish Trauma Audit Group National Meeting 11 th November 2016 Major Trauma Services in England - TARN s supporting
More informationEngland & Wales 2 YEARS OF SEVERE INJURY IN CHILDREN
England & Wales 2 YEARS OF SEVERE INJURY IN CHILDREN January 2013-December 2014 THE TRAUMA AUDIT AND RESEARCH NETWORK The TARNlet Committee Mr Ross Fisher Co-chairman of TARNlet Consultant in Paediatric
More informationEngland & Wales SEVERE INJURY IN CHILDREN
England & Wales SEVERE INJURY IN CHILDREN January 215 December 216 Contents Members of the Working Group... 4 Introduction... 5 Summary... 6 Data completeness... 7 Demographics... 8 Injury mechanism...
More informationEngland & Wales MAJOR TRAUMA IN OLDER PEOPLE
England & Wales MAJOR TRAUMA IN OLDER PEOPLE 2017 THE TRAUMA AUDIT AND RESEARCH NETWORK 2 THE TRAUMA AUDIT AND RESEARCH NETWORK 2 Contents Members of the Working Group... 4 Foreword... 5 Executive summary...
More informationCORE STANDARDS STANDARDS USED IN TARN REPORTS
CORE STANDARDS Time to CT Scan BEST PRACTICE TARIFF SECTION 4.10 MAJOR TRAUMA 7 If the patient is admitted directly to the MTC or transferred as an emergency, the patient must be received by a trauma team
More informationNICE Guidelines for C-Spine Imaging: Real Life Impact
NICE Guidelines for C-Spine Imaging: Real Life Impact Poster No.: C-1367 Congress: ECR 2017 Type: Scientific Exhibit Authors: D. Weinberg, I. Djoukhadar, G. Potter; Salford/UK Keywords: Trauma, Audit and
More informationCan we abolish skull x-rays for head injury?
ADC Online First, published on April 25, 2005 as 10.1136/adc.2004.053603 Can we abolish skull x-rays for head injury? Matthew J Reed, Jen G Browning, A. Graham Wilkinson & Tom Beattie Corresponding author:
More informationTrauma: Service delivery
National Clinical Guideline Centre DRAFT FOR CONSULTATION Trauma: Service delivery Major trauma services: service delivery for major trauma Service delivery guidance Appendices K P August 05 Draft for
More informationAnalysis of pediatric head injury from falls
Neurosurg Focus 8 (1):Article 3, 2000 Analysis of pediatric head injury from falls K. ANTHONY KIM, MICHAEL Y. WANG, M.D., PAMELA M. GRIFFITH, R.N.C., SUSAN SUMMERS, R.N., AND MICHAEL L. LEVY, M.D. Division
More informationHip Fracture (HFR) Measures Document
Hip Fracture (HFR) Measures Document HFR Version: 2 - covering patients discharged between 01/10/2017 and present. Programme Lead: Sam Doddridge Clinical Leads: Ms Phil Thorpe Dr John Tsang Number of Measures
More informationTrauma scoring systems and databases
British Journal of Anaesthesia 113 (2): 286 94 (2014) doi:10.1093/bja/aeu242 Trauma scoring systems and databases F. Lecky 1,2 *, M. Woodford 2, A. Edwards 2, O. Bouamra 2 and T. Coats 3 1 EMRiS Group,
More informationO ne million patients are treated annually in United
859 ORIGIAL ARTICLE Can we abolish skull x rays for head injury? M J Reed, J G Browning, A G Wilkinson, T Beattie... See end of article for authors affiliations... Correspondence to: Matthew J Reed, Accident
More informationA bout million patients present to UK hospitals
420 ORIGINAL ARTICLE Application of the Canadian CT head rules in managing minor head injuries in a UK emergency department: implications for the implementation of the NICE guidelines H Y Sultan, A Boyle,
More informationMajor Trauma Dashboard Measures. SUPPORT DOCUMENT April 2016 TO BE READ IN CONJUNCTION WITH THE MT DASHBOARD
Major Trauma Dashboard Measures SUPPORT DOCUMENT April 2016 TO BE READ IN CONJUNCTION WITH THE MT DASHBOARD Introduction This document addresses key questions relevant to the Major Trauma Dashboard and
More informationARE STROKE UNITS COST EFFECTIVE? EVIDENCE FROM A NEW ZEALAND STROKE INCIDENCE AND POPULATION-BASED STUDY
ARE STROKE UNITS COST EFFECTIVE? EVIDENCE FROM A NEW ZEALAND STROKE INCIDENCE AND POPULATION-BASED STUDY Braden Te Ao, Ph.D. Centre for Health Services Research & Policy, University of Auckland, National
More informationChapter 2 Triage. Introduction. The Trauma Team
Chapter 2 Triage Chapter 2 Triage Introduction Existing trauma courses focus on a vertical or horizontal approach to the ABCDE assessment of an injured patient: A - Airway B - Breathing C - Circulation
More informationPROPOSAL FOR MULTI-INSTITUTIONAL IMPLEMENTATION OF THE BRAIN INJURY GUIDELINES
PROPOSAL FOR MULTI-INSTITUTIONAL IMPLEMENTATION OF THE BRAIN INJURY GUIDELINES INTRODUCTION: Traumatic Brain Injury (TBI) is an important clinical entity in acute care surgery without well-defined guidelines
More informationWAHT-T&O-006 It is the responsibility of every individual to check that this is the latest version/copy of this document.
OPERATIONAL GUIDELINES FOR OCCUPATIONAL THERAPY ASSESSMENT AND TREATMENT OF ADULTS WITH TRAUMATIC HEAD INJURY ADMITTED/TRANSFERRED OR ATTENDING A&E AT WORCESTERSHIRE ROYAL HOSPITAL This guidance does t
More informationThe risk of a bleed after delayed head injury presentation to the ED: systematic review protocol. Correspondence to:
The risk of a bleed after delayed head injury presentation to the ED: systematic review protocol. Carl Marincowitz, Christopher M. Smith, William Townend Emergency Department, Hull Royal, Hull, UK Correspondence
More informationManagement of Severe Traumatic Brain Injury
Guideline for North Bristol Trust Management of Severe Traumatic Brain Injury This guideline describes the following: Initial assessment and management of the patient with head injury Indications for CT
More informationMassive Transfusion in Pediatric Trauma: Analysis of the National Trauma Databank
Massive Transfusion in Pediatric Trauma: Analysis of the National Trauma Databank Michelle Shroyer, MPH, Russell Griffin, PhD, Vincent Mortellaro, MD, and Rob Russell MD, MPH Introduction Hemorrhage is
More informationHow to make changes in the NHS
How to make changes in the NHS Keith Willett Prof of Orthopaedic Trauma Surgery University of Oxford prev. National Clinical Director for Trauma Care ATOCP Conference Oxford 2016 Medical Director for Acute
More informationLondon School of Hygiene and Tropical Medicine, Keppel Street, London, UK 2
CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) intracranial bleeding study: the effect of tranexamic acid in traumatic brain injury a nested, randomised, placebo-controlled
More informationEAST MULTICENTER STUDY DATA DICTIONARY
EAST MULTICENTER STUDY DATA DICTIONARY Does the Addition of Daily Aspirin to Standard Deep Venous Thrombosis Prophylaxis Reduce the Rate of Venous Thromboembolic Events? Data Entry Points and appropriate
More informationTITLE: Optimal Oxygen Saturation Range for Adults Suffering from Traumatic Brain Injury: A Review of Patient Benefit, Harms, and Guidelines
TITLE: Optimal Oxygen Saturation Range for Adults Suffering from Traumatic Brain Injury: A Review of Patient Benefit, Harms, and Guidelines DATE: 11 April 2014 CONTEXT AND POLICY ISSUES Traumatic brain
More informationChildren diagnosed with skull fractures are often. Transfer of children with isolated linear skull fractures: is it worth the cost?
clinical article J Neurosurg Pediatr 17:602 606, 2016 Transfer of children with isolated linear skull fractures: is it worth the cost? Ian K. White, MD, 1 Ecaterina Pestereva, BS, 1 Kashif A. Shaikh, MD,
More informationPredictors of Post-injury Mortality in Elderly Patients with Trauma: A Master's Thesis
University of Massachusetts Medical School escholarship@umms GSBS Dissertations and Theses Graduate School of Biomedical Sciences 7-21-2016 Predictors of Post-injury Mortality in Elderly Patients with
More informationSurvival Trends after Surgery for Acute Subdural Hematoma in Adults over a 20-Year Period
Survival Trends after Surgery for Acute Subdural Hematoma in Adults over a 20-Year Period Original study - observational Authors: Daniel M Fountain BSc 1* Angelos G Kolias MRCS 1* Fiona E Lecky PhD 2,5
More informationOutcome Evaluation of Chronic Subdural Hematoma Using Glasgow Outcome Score
Outcome Evaluation of Chronic Subdural Hematoma Using Glasgow Outcome Score Mehdi Abouzari, Marjan Asadollahi, Hamideh Aleali Amir-Alam Hospital, Medical Sciences/University of Tehran, Tehran, Iran Introduction
More informationThe AHEAD Study: Managing anticoagulatedpatients who suffer head injury
AHEAD Study The AHEAD Study: Managing anticoagulatedpatients who suffer head injury Suzanne Mason 1,2, Maxine Kuczawski 1, Matthew Stevenson 1, Dawn Teare 1, Michael Holmes 1, ShammiRamlakhan 1, Steve
More informationOsteoporosis: fragility fracture risk. Costing report. Implementing NICE guidance
Osteoporosis: fragility fracture risk Costing report Implementing NICE guidance August 2012 NICE clinical guideline 146 1 of 15 This costing report accompanies the clinical guideline: Osteoporosis: assessing
More informationSevere trauma presenting to the resuscitation room of a Hong Kong emergency department
Hong Kong Journal of Emergency Medicine Severe trauma presenting to the resuscitation room of a Hong Kong emergency department TH Rainer, SY Chan, K Kwok, DTK Suen, W Lam, RA Cocks Background: Little is
More informationCorrespondence should be addressed to Sorayouth Chumnanvej;
Neurology Research International Volume 2016, Article ID 2737028, 7 pages http://dx.doi.org/10.1155/2016/2737028 Research Article Assessment and Predicting Factors of Repeated Brain Computed Tomography
More informationNational Bowel Cancer Audit Supplementary Report 2011
National Bowel Cancer Audit Supplementary Report 2011 This Supplementary Report contains data from the 2009/2010 reporting period which covers patients in England with a diagnosis date from 1 August 2009
More informationTechnology appraisal guidance Published: 26 September 2012 nice.org.uk/guidance/ta264
Alteplase for treating acute ischaemic stroke Technology appraisal guidance Published: 26 September 2012 nice.org.uk/guidance/ta264 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
More informationCritical care resources are often provided to the too well and as well as. to the too sick. The former include the patients admitted to an ICU
Literature Review Critical care resources are often provided to the too well and as well as to the too sick. The former include the patients admitted to an ICU following major elective surgery for overnight
More informationPEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM)
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Network Organisation Measures (T13-1C-1) - 2013/14 Peer Review Visit Date 29th April 2014 Compliance
More informationSupplementary Online Content
Supplementary Online Content Cooper DJ, Nichol A, Bailey M, et al. Effect of early sustained prophylactic hypothermia on neurologic outcomes among patients with severe traumatic brain injury: the POLAR
More informationReport of the Welsh Neuroscience External Expert Review Group. All Wales Recommendations
Report of the Welsh Neuroscience External Expert Review Group All Wales Recommendations Main Recommendations 1. The workforce delivering all aspects of care to people with acute and long term neurological
More informationEndovascular or open repair for ruptured abdominal aortic aneurysm: 30-day outcomes from
Web supplement for Endovascular or open repair for ruptured abdominal aortic aneurysm: 30-day outcomes from the IMPROVE trial IMPROVE trial investigators Containing: page Risk differences for mortality
More informationThe Royal College of Anaesthetists THE STRUCTURE OF A STANDARD
ROYAL COLLEGE OF ANAESTHETISTS ACCREDITATION The Royal College of Anaesthetists THE STRUCTURE OF A STANDARD Page 1 of 10 The ACSA standard has 5 DOMAINS: 1. The Care Pathway 2. Equipment, Facilities and
More informationRisk Factors Predicting Mortality in Spinal Cord Injury in Nigeria
Article ID: WMC00807 ISSN 2046690 Risk Factors Predicting Mortality in Spinal Cord Injury in Nigeria Corresponding Author: Dr. Ahidjo Kawu, Consultant Surgeon, Dept of Orthopaedics, UATH, Gwagwalada Abuja
More informationS pinal injury in the paediatric trauma patient can have
860 ORIGINAL ARTICLE Patterns and risks in spinal trauma B W Martin, E Dykes, F E Lecky... See end of article for authors affiliations... Correspondence to: Dr B W Martin, Hope Hospital, Stott Lane, Salford
More informationA protocol for the development of a prediction model in mild traumatic brain injury with CT scan abnormality: which patients are safe for discharge?
Marincowitz et al. Diagnostic and Prognostic Research (2018) 2:6 https://doi.org/10.1186/s41512-018-0027-4 Diagnostic and Prognostic Research PROTOCOL A protocol for the development of a prediction model
More informationAugust 2009 Ceri J. Phillips and Andrew Bloodworth
Cost of smoking to the NHS in Wales August 2009 Ceri J. Phillips and Andrew Bloodworth Key Findings Smoking cost NHS Wales an estimated 386 million in 2007/08; equivalent to 129 per head and 7% of total
More information*Corresponding Author:
Audit of venous thromboembolism prophylaxis administered to general surgical patients undergoing elective and emergency operations at National Hospital, Sri Lanka *Migara Seneviratne 1, Asanka Hemachandra
More informationSetting The setting was secondary care. The study was carried out in the UK, with emphasis on Scottish data.
Cost-effectiveness of thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke assessed by a model based on UK NHS costs Sandercock P, Berge E, Dennis M, Forbes J, Hand P, Kwan
More informationGUIDELINES FOR THE MANAGEMENT OF HEAD INJURIES IN REMOTE AND RURAL ALASKA
GUIDELINES FOR THE MANAGEMENT OF HEAD INJURIES IN REMOTE AND RURAL ALASKA Approximately 800 patients with head injuries die or are hospitalized in the state of Alaska each year 1. In addition, thousands
More informationDeterminants of Health: Effects of Funding on Quality of Care for Patients with severe TBI
Determinants of Health: Effects of Funding on Quality of Care for Patients with severe TBI Facts about traumatic brain injury Definitions & Outcomes Methods Results Conclusions Facts about TBI TBI (traumatic
More informationQuality Surveillance Team. Major Trauma Services Quality Indicators
Quality Surveillance Team Major Trauma Services Quality Indicators 1 MAJOR TRAUMA QUALITY INDICATORS Introduction These quality indicators have been commissioned by the National Clinical Director for Major
More informationFactors associated with Outcome in Patients Admitted with Traumatic Brain Injury at the University Teaching Hospital, Lusaka, Zambia
ORIGINAL ARTICLE Factors associated with Outcome in Patients Admitted with Traumatic Brain Injury at the University Teaching Hospital, Lusaka, Zambia K. Mwala, J.C Munthali, L. Chikoya Department of Surgery,
More informationCHEST WALL TRAUMA SCREEN
CHEST WALL TRAUMA SCREEN April 2016 SPECIALIST SCREEN GUIDANCE Overview Over twenty-five years, the Trauma Audit & Research Network (TARN) has accumulated a huge database of injured patients with process
More informationprivate patients centre Royal Brompton Heart Risk Clinic
private patients centre Royal Brompton Heart Risk Clinic Trust our experts to detect the early signs of heart disease Royal Brompton and Harefield Contents 3 Introduction to the Heart Risk Clinic 3 What
More informationWhat to do with missing data in clinical registry analysis?
Melbourne 2011; Registry Special Interest Group What to do with missing data in clinical registry analysis? Rory Wolfe Acknowledgements: James Carpenter, Gerard O Reilly Department of Epidemiology & Preventive
More informationMidlands Silver Trauma Group.
Midlands Silver Trauma Group. The Silver Safety Net A Proposal for a Regional Trauma Desk Response to Triage Older People with Injuries Raven D, Hall R, Chamberlain H, Roberts S, Littleson S, Graham S
More informationSpinal injury. Structure of the spine
Spinal injury Structure of the spine Some understanding of the structure of the spine (spinal column) and the spinal cord is important as it helps your Neurosurgeon explain about the part of the spine
More informationBritish Geriatrics Society
Healthcare professional group/clinical specialist statement Thank you for agreeing to give us a statement on your organisation s view of the technology and the way it should be used in the NHS. Healthcare
More informationIntroduction to Neurosurgical Subspecialties:
Introduction to Neurosurgical Subspecialties: Trauma and Critical Care Neurosurgery Brian L. Hoh, MD 1, Gregory J. Zipfel, MD 2 and Stacey Q. Wolfe, MD 3 1 University of Florida, 2 Washington University,
More informationProgress in improving cancer services and outcomes in England. Report. Department of Health, NHS England and Public Health England
Report by the Comptroller and Auditor General Department of Health, NHS England and Public Health England Progress in improving cancer services and outcomes in England HC 949 SESSION 2014-15 15 JANUARY
More informationThe audit is managed by the Royal College of Psychiatrists in partnership with:
Background The National Audit of Dementia (NAD) care in general hospitals is commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England and the Welsh Government, as part of
More informationMethod Hannah Shotton
#asah Method Hannah Shotton 2 Introduction SAH Rupturing aneurysm Poor outlook Intervention Secure the aneurysm: clipping or coiling Recommended 48 hours Regional Specialist NSC Conservative management
More informationResource impact report: Eating disorders: recognition and treatment (NG69)
Resource impact report: Eating disorders: recognition and treatment (NG69) Published: May 2017 Summary This report looks at the resource impact of implementing NICE s guideline on eating disorders: recognition
More informationThe Glasgow UK Experiment: What a Working System Can Deliver
ASBMR Symposium Systems Approaches to Secondary Fracture Prevention: Doing Something that Actually Works The Glasgow UK Experiment: What a Working System Can Deliver Alastair R. McLellan MD, FRCP Western
More informationOutlook for intracerebral haemorrhage after a MISTIE spell
Outlook for intracerebral haemorrhage after a MISTIE spell David J Werring PhD FRCP Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital
More informationNATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Medical technologies guidance SCOPE CardioQ-ODM oesophageal Doppler monitor for patients undergoing major or high-risk surgery and patients in critical
More informationThe Nottingham Head Injury Register: a survey of 1,276 adult cases of moderate and severe traumatic brain injury in a British neurosurgery centre
The Intensive Care Society 2011 Audits and surveys The Nottingham Head Injury Register: a survey of 1,276 adult cases of moderate and severe traumatic brain injury in a British neurosurgery centre G Fuller,
More informationUse of CT in minor traumatic brain injury. Lisa Ayoub-Rodriguez, MD Bert Johansson, MD Michael Lee, MD
Use of CT in minor traumatic brain injury Lisa Ayoub-Rodriguez, MD Bert Johansson, MD Michael Lee, MD No financial or other conflicts of interest Epidemiology of traumatic brain injury (TBI) Risks associated
More informationEffect of post-intubation hypotension on outcomes in major trauma patients
Effect of post-intubation hypotension on outcomes in major trauma patients Dr. Robert S. Green Professor, Emergency Medicine and Critical Care Dalhousie University Medical Director, Trauma Nova Scotia
More informationEfficacy of the Motor Component of the Glasgow Coma Scale in Trauma Triage
Page 1 of 7 Journals A-Z > Journal of Trauma-Injury... > 45(1) July 1998 > Efficacy of the... The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 45(1), July 1998, pp 42-44 Copyright:
More informationFalling down a flight of stairs: The impact of age and intoxication on injury pattern and severity
Original Article Falling down a flight of stairs: The impact of age and intoxication on injury pattern and severity TRAUMA Trauma 0(0) 1 6! The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalspermissions.nav
More informationResource Utilization in Helicopter Transport of Head-Injured Children
Resource Utilization in Helicopter Transport of Head-Injured Children Clay M. Elswick MD, Deidre Wyrick MD, Lori Gurien MD, Mallik Rettiganti PhD, Marie Saylors MS, Ambre Pownall APRN, Diaa Bahgat MD,
More informationThe effect of emergency medical services response on outcome of trauma laparotomy at a Level 1 Trauma Centre in South Africa
The effect of emergency medical services response on outcome of trauma laparotomy at a Level 1 Trauma Centre in South Africa S Chowdhury, 1 P H Navsaria, 2 S Edu, 3 A J Nicol 4 TRAUMA 1 Department of Surgery,
More informationThe significance of traumatic haematoma in the
Journal of Neurology, Neurosurgery, and Psychiatry 1986;49:29-34 The significance of traumatic haematoma in the region of the basal ganglia P MACPHERSON, E TEASDALE, S DHAKER, G ALLERDYCE, S GALBRAITH
More informationCorrelation of D-Dimer level with outcome in traumatic brain injury
2014; 17 (1) Original Article Correlation of D-Dimer level with outcome in traumatic brain injury Pradip Prasad Subedi 1, Sushil Krishna Shilpakar 2 Email: Abstract Introduction immense. The major determinant
More informationMedical technologies guidance Published: 2 October 2018 nice.org.uk/guidance/mtg39
ifuse for treating chronic sacroiliac joint pain Medical technologies guidance Published: 2 October 2018 nice.org.uk/guidance/mtg39 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).
More informationUtilisation of an embedded specialist nurse and collaborative care pathway increases potential organ donor referrals in the emergency department
1 Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK 2 NHS Blood and Transplant, Addenbrookes Hospital, Cambridge, UK Correspondence to Dr Julian Garside, Emergency Medicine Registrar,
More informationBACKGROUND AND SCIENTIFIC RATIONALE. Protocol Code: ISRCTN V 1.0 date 30 Jan 2012
BACKGROUND AND SCIENTIFIC RATIONALE Protocol Code: ISRCTN15088122 V 1.0 date 30 Jan 2012 Traumatic Brain Injury 10 million killed or hospitalised every year 90% in low and middle income countries Mostly
More informationhad non-continuous enrolment in Medicare Part A or Part B during the year following initial admission;
Effectiveness and cost-effectiveness of implantable cardioverter defibrillators in the treatment of ventricular arrhythmias among Medicare beneficiaries Weiss J P, Saynina O, McDonald K M, McClellan M
More informationThe costs of traumatic brain injury. Michael Parsonage February 2017
The costs of traumatic brain injury Michael Parsonage February 2017 Coverage Definition and scale of TBI Consequences Costs What is traumatic brain injury? TBI is any injury to the brain caused by impact
More informationAN AUDIT: THROMBOPROPHYLAXIS FOR TOTAL HIP REPLACEMENT PATIENTS AT NORTHWICK PARK AND CENTRAL MIDDLESEX HOSPITALS
The West London Medical Journal 2010 Vol 2 No 4 pp 19-24 AN AUDIT: THROMBOPROPHYLAXIS FOR TOTAL HIP REPLACEMENT PATIENTS AT NORTHWICK PARK AND CENTRAL MIDDLESEX HOSPITALS Soneji ND Agni NR Acharya MN Anjari
More information(i) This FAQ does not deal with clinical issues (eg What is the definition of a stroke unit? or
STROKE INTEGRATED PERFORMANCE MEASURE RETURN (IPMR) FREQUENTLY ASKED QUESTIONS (FAQ) Prepared by NHS North West, Lancashire & Cumbria Cardiac & Stroke Network, Cheshire and Merseyside Clinical Networks
More informationCost of trauma in Europe
European Journal of Neurology 2005, 12 (Suppl. 1): 85 90 ORIGINAL ARTICLE Cost of trauma in Europe J. Berg a, F. Tagliaferri b and F. Servadei b a Stockholm Health Economics, Stockholm, Stockholm, Sweden;
More informationCosting Report: atrial fibrillation Implementing the NICE guideline on atrial fibrillation (CG180)
Putting NICE guidance into practice Costing Report: atrial fibrillation Implementing the NICE guideline on atrial fibrillation (CG180) Published: June 2014 This costing report accompanies the clinical
More informationSelective Dorsal Rhizotomy (SDR) Scotland Service Pathway
Selective Dorsal Rhizotomy (SDR) Scotland Service Pathway This pathway should to be read in conjunction with the attached notes. The number in each text box refers to the note that relates to the specific
More informationSouth East Coast Operational Delivery Network. Critical Care Rehabilitation
South East Coast Operational Delivery Networks Hosted by Medway Foundation Trust South East Coast Operational Delivery Network Background Critical Care Rehabilitation The optimisation of recovery from
More informationOriginal Article. Emergency Department Evaluation of Ventricular Shunt Malfunction. Is the Shunt Series Really Necessary? Raymond Pitetti, MD, MPH
Original Article Emergency Department Evaluation of Ventricular Shunt Malfunction Is the Shunt Series Really Necessary? Raymond Pitetti, MD, MPH Objective: The malfunction of a ventricular shunt is one
More informationMy hip fracture care: 12 questions to ask A guide for patients, their families and carers
My hip fracture care: 12 questions to ask A guide for patients, their families and carers About this guide This guide is aimed at patients who have a hip fracture, and their families and carers. It explains
More informationAn Overview of Health Economics Data and Expertise in Cancer
An Overview of Health Economics Data and Expertise in Cancer Peter Smith, (Professor of Health Policy, Imperial College London) Mauro Laudicella (Research Fellow, Imperial College London) Source: A. Maynard
More informationNHS RightCare scenario: Getting the dementia pathway right
NHS RightCare scenario: Getting the dementia pathway right Tom and Barbara s story: Dementia Appendix 1: Summary slide pack April 2017 Tom s story This is the story of Tom s experience of a dementia care
More informationMeeting the Future Challenge of Stroke
Meeting the Future Challenge of Stroke Stroke Medicine Consultant Workforce Requirements 2011 201 Dr Christopher Price BASP Training and Education Committee Stroke Medicine Specialist Advisory Committee
More informationCLINICAL AUDIT 2017/2018 Fractured Neck of Femur Clinical Audit Information
CLINICAL AUDIT 2017/2018 Fractured Neck of Femur Clinical Audit Information INTRODUCTION AND BACKGROUND... 2 Aims and objectives... 2 METHODOLOGY... 3 Inclusion criteria... 3 Exclusion criteria... 3 Search
More informationEconomic Analysis of Interventions for Smoking Cessation Aimed at Pregnant Women
Y O R K Health Economics C O N S O R T I U M NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Economic Analysis of Interventions for Smoking Cessation Aimed at Pregnant Women Supplementary Report
More informationPhenytoin versus Levetiracetam for Prevention of Early Posttraumatic Seizures: A Prospective Comparative Study
136 Original Article Phenytoin versus Levetiracetam for Prevention of Early Posttraumatic Seizures: A Prospective Comparative Study Kairav S. Shah 1 Jayun Shah 1 Ponraj K. Sundaram 1 1 Department of Neurosurgery,
More informationSAFE HIP FRACTURES. Dr Karthik Kayan MD FRCP Consultant Physician and Orthogeriatrician Stockport NHS Foundation Trust
SAFE HIP FRACTURES Dr Karthik Kayan MD FRCP Consultant Physician and Orthogeriatrician Stockport NHS Foundation Trust Why hip fracture? Common in older adult (~84 years) UK current incidence : 70000 (Stockport
More informationrecommendations of the Royal College of
Archives of Emergency Medicine, 1993, 10, 138-144 Skull X-ray after head injury: the recommendations of the Royal College of Surgeons Working Party Report in practice R. E. MACLAREN, H. I. GHOORAHOO &
More informationEffect of Mobility on Community Participation at 1 year Post-Injury in Individuals with Traumatic Brain Injury (TBI)
Effect of Mobility on Community Participation at 1 year Post-Injury in Individuals with Traumatic Brain Injury (TBI) Irene Ward, PT, DPT, NCS Brain Injury Clinical Research Coordinator Kessler Institute
More informationNumber of records submitted: 14,750 Number of participants: Part 1 = 146 hospitals (120 trusts); Part 2 = 140 hospitals (119 trusts)
British Thoracic Society Smoking Cessation Audit Report Smoking cessation policy and practice in NHS hospitals National Audit Period: 1 April 31 May 2016 Dr Sanjay Agrawal and Dr Zaheer Mangera Number
More informationCost-effectiveness of brief intervention and referral for smoking cessation
Cost-effectiveness of brief intervention and referral for smoking cessation Revised Draft 20 th January 2006. Steve Parrott Christine Godfrey Paul Kind Centre for Health Economics on behalf of PHRC 1 Contents
More informationFractures of the Thoracic and Lumbar Spine
A spinal fracture is a serious injury. Nader M. Hebela, MD Fellow of the American Academy of Orthopaedic Surgeons http://orthodoc.aaos.org/hebela Cleveland Clinic Abu Dhabi Cleveland Clinic Abu Dhabi Neurological
More informationPEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM)
PEER REVIEW VISIT REPORT (MULTI-DISCIPLINARY TEAM) Regional Trauma Network Trauma Centre Trauma Service RMTN Manchester Collaborative MTC Greater Manchester Major Trauma Centre Collaborative Network Organisation
More information