Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study
Objectives: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. Design: Cohort study. Setting: Sixty-seven adult critical care units. Participants: Adult patients...
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| Format: | Article |
| Language: | English |
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NIHR Journals Library
2013-06-01
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| Series: | Health Technology Assessment |
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| Online Access: | https://doi.org/10.3310/hta17230 |
| _version_ | 1818478277991333888 |
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| author | DA Harrison G Prabhu R Grieve SE Harvey MZ Sadique M Gomes KA Griggs E Walmsley M Smith P Yeoman FE Lecky PJA Hutchinson DK Menon KM Rowan |
| author_facet | DA Harrison G Prabhu R Grieve SE Harvey MZ Sadique M Gomes KA Griggs E Walmsley M Smith P Yeoman FE Lecky PJA Hutchinson DK Menon KM Rowan |
| author_sort | DA Harrison |
| collection | DOAJ |
| description | Objectives: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. Design: Cohort study. Setting: Sixty-seven adult critical care units. Participants: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. Interventions: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. Main outcome measures: Mortality, Glasgow Outcome Scale – Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. Results: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the ‘early’ (within 18 hours of presentation) and ‘no or late’ (after 24 hours) transfer groups. After adjustment, the ‘early’ transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. Conclusions: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. Funding: The National Institute for Health Research Health Technology Assessment programme. |
| first_indexed | 2024-12-10T09:45:54Z |
| format | Article |
| id | doaj.art-3201c637d27344a59428379f8611545b |
| institution | Directory Open Access Journal |
| issn | 1366-5278 2046-4924 |
| language | English |
| last_indexed | 2024-12-10T09:45:54Z |
| publishDate | 2013-06-01 |
| publisher | NIHR Journals Library |
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| series | Health Technology Assessment |
| spelling | doaj.art-3201c637d27344a59428379f8611545b2022-12-22T01:53:50ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242013-06-01172310.3310/hta1723007/37/29Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort studyDA Harrison0G Prabhu1R Grieve2SE Harvey3MZ Sadique4M Gomes5KA Griggs6E Walmsley7M Smith8P Yeoman9FE Lecky10PJA Hutchinson11DK Menon12KM Rowan13Intensive Care National Audit and Research Centre, London, UKIntensive Care National Audit and Research Centre, London, UKDepartment of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UKIntensive Care National Audit and Research Centre, London, UKDepartment of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UKDepartment of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UKIntensive Care National Audit and Research Centre, London, UKIntensive Care National Audit and Research Centre, London, UKNational Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UKQueen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UKSchool of Health and Related Research, University of Sheffield, Sheffield, UKUniversity of Cambridge, Cambridge, UKUniversity of Cambridge, Cambridge, UKIntensive Care National Audit and Research Centre, London, UKObjectives: To validate risk prediction models for acute traumatic brain injury (TBI) and to use the best model to evaluate the optimum location and comparative costs of neurocritical care in the NHS. Design: Cohort study. Setting: Sixty-seven adult critical care units. Participants: Adult patients admitted to critical care following actual/suspected TBI with a Glasgow Coma Scale (GCS) score of < 15. Interventions: Critical care delivered in a dedicated neurocritical care unit, a combined neuro/general critical care unit within a neuroscience centre or a general critical care unit outside a neuroscience centre. Main outcome measures: Mortality, Glasgow Outcome Scale – Extended (GOSE) questionnaire and European Quality of Life-5 Dimensions, 3-level version (EQ-5D-3L) questionnaire at 6 months following TBI. Results: The final Risk Adjustment In Neurocritical care (RAIN) study data set contained 3626 admissions. After exclusions, 3210 patients with acute TBI were included. Overall follow-up rate at 6 months was 81%. Of 3210 patients, 101 (3.1%) had no GCS score recorded and 134 (4.2%) had a last pre-sedation GCS score of 15, resulting in 2975 patients for analysis. The most common causes of TBI were road traffic accidents (RTAs) (33%), falls (47%) and assault (12%). Patients were predominantly young (mean age 45 years overall) and male (76% overall). Six-month mortality was 22% for RTAs, 32% for falls and 17% for assault. Of survivors at 6 months with a known GOSE category, 44% had severe disability, 30% moderate disability and 26% made a good recovery. Overall, 61% of patients with known outcome had an unfavourable outcome (death or severe disability) at 6 months. Between 35% and 70% of survivors reported problems across the five domains of the EQ-5D-3L. Of the 10 risk models selected for validation, the best discrimination overall was from the International Mission for Prognosis and Analysis of Clinical Trials in TBI Lab model (IMPACT) (c-index 0.779 for mortality, 0.713 for unfavourable outcome). The model was well calibrated for 6-month mortality but substantially underpredicted the risk of unfavourable outcome at 6 months. Baseline patient characteristics were similar between dedicated neurocritical care units and combined neuro/general critical care units. In lifetime cost-effectiveness analysis, dedicated neurocritical care units had higher mean lifetime quality-adjusted life-years (QALYs) at small additional mean costs with an incremental cost-effectiveness ratio (ICER) of £14,000 per QALY and incremental net monetary benefit (INB) of £17,000. The cost-effectiveness acceptability curve suggested that the probability that dedicated compared with combined neurocritical care units are cost-effective is around 60%. There were substantial differences in case mix between the ‘early’ (within 18 hours of presentation) and ‘no or late’ (after 24 hours) transfer groups. After adjustment, the ‘early’ transfer group reported higher lifetime QALYs at an additional cost with an ICER of £11,000 and INB of £17,000. Conclusions: The risk models demonstrated sufficient statistical performance to support their use in research but fell below the level required to guide individual patient decision-making. The results suggest that management in a dedicated neurocritical care unit may be cost-effective compared with a combined neuro/general critical care unit (although there is considerable statistical uncertainty) and support current recommendations that all patients with severe TBI would benefit from transfer to a neurosciences centre, regardless of the need for surgery. We recommend further research to improve risk prediction models; consider alternative approaches for handling unobserved confounding; better understand long-term outcomes and alternative pathways of care; and explore equity of access to postcritical care support for patients following acute TBI. Funding: The National Institute for Health Research Health Technology Assessment programme.https://doi.org/10.3310/hta17230risk prediction modeltraumatic brain injuryneurocritical carecohort studyglasgow coma scaleeuropean quality of life-5 dimensions3-level version (eq-5d-3l)cost-effectiveness |
| spellingShingle | DA Harrison G Prabhu R Grieve SE Harvey MZ Sadique M Gomes KA Griggs E Walmsley M Smith P Yeoman FE Lecky PJA Hutchinson DK Menon KM Rowan Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study Health Technology Assessment risk prediction model traumatic brain injury neurocritical care cohort study glasgow coma scale european quality of life-5 dimensions 3-level version (eq-5d-3l) cost-effectiveness |
| title | Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study |
| title_full | Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study |
| title_fullStr | Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study |
| title_full_unstemmed | Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study |
| title_short | Risk Adjustment In Neurocritical care (RAIN) – prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study |
| title_sort | risk adjustment in neurocritical care rain prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care a cohort study |
| topic | risk prediction model traumatic brain injury neurocritical care cohort study glasgow coma scale european quality of life-5 dimensions 3-level version (eq-5d-3l) cost-effectiveness |
| url | https://doi.org/10.3310/hta17230 |
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