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Published on: July 5, 2011
Cost-effectiveness of decompressive craniectomy in non-traumatic neurological emergencies
K Malmivaara1, J Ohman, R Kivisaari
1Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland.
Insights
Decompressive craniectomy for non-traumatic brain swelling has high mortality but survivors often live at home. The cost per quality-adjusted life year (QALY) is acceptable for these emergency neurosurgical procedures.
Area of Science:
- Neurosurgery
- Critical Care Medicine
- Health Economics
Background:
- Decompressive craniectomy is standard for traumatic brain injury and malignant stroke.
- Its efficacy for other non-traumatic brain swelling causes remains unclear.
Purpose of the Study:
- To evaluate outcomes and costs of decompressive craniectomy for non-traumatic neurological emergencies.
- To assess health-related quality of life (HRQoL) and cost-effectiveness.
Main Methods:
- Retrospective analysis of emergency decompressive craniectomies (2000-2006).
- Exclusion of traumatic brain injury and malignant middle cerebral artery infarction.
- Evaluation using Euroqol (EQ-5D) for HRQoL and calculation of cost per quality-adjusted life year (QALY).
Main Results:
- High 3-year mortality: 62% for subarachnoid hemorrhage (SAH) and 31% for other emergencies.
- Survivors had poor median EQ-5D index (0.15 for SAH, 0.62 for others), but most lived at home (73%-89%).
- Cost per QALY was €11,000 for SAH and €2,000 for other emergencies.
Conclusions:
- Decompressive craniectomy for non-traumatic emergencies has high mortality.
- Survivors achieve a reasonable quality of life, often living independently.
- The cost-effectiveness of this neurosurgical intervention is acceptable.
Background:
Decompressive craniectomy is used regularly in traumatic brain injury (TBI) and malignant middle cerebral artery infarction. Its benefits for other causes of non-traumatic brain swelling, if any, are unclear, especially after a devastating primary event.
Methods:
We evaluated the outcomes as well as treatment costs of all emergency decompressive craniectomies performed between the 2000 and 2006 in a single institution to lower intractable intracranial pressure, excluding the standard indications TBI and malignant middle cerebral infarction. The health-related quality of life (HRQoL) was evaluated on the Euroqol (EQ-5D) scale, and cost of a quality-adjusted life year (QALY) calculated.
Results:
The overall 3-year mortality rate was 62% for subarachnoid haemorrhage (SAH, 29 patients) and 31% for other neurological emergencies (13 patients). Patients with SAH were on average 13 years older than the other indications mean. Of the non-survivors, 45% died within a month and 95% within 1 year. Median EQ-5D index values were poor (0.15 for SAH and 0.62 for the other emergencies, versus 0.85 for the normal population), but of the survivors, 73% and 89% were able to live at home. The cost of neurosurgical treatment for one QALY was 11,000 € for SAH and 2000 € for other emergencies.
Conclusion:
Mortality after non-traumatic neurological emergencies leading to decompressive craniectomy was high, and the HRQoL index of the survivors was poor. Most survivors were, however, able to live at home, and the cost of neurosurgical treatment for a QALY gained was acceptable.
