Cost-Effectiveness of Decompressive Craniectomy in Severe Traumatic Brain Injury Patients: A Systematic Review of Economic Studies.

OBJECTIVE: This systematic review aimed to assess the cost-effectiveness of decompressive craniectomy (DC) in severe traumatic brain injury (TBI) patients by analyzing relevant economic studies. METHODS: The authors conducted a comprehensive search across multiple databases and included economic evaluation studies, clinical trials, observational studies, or modeling studies that focused on patients who underwent DC for severe TBI. The quality of included studies was assessed using the Drummond checklist, and potential publication bias was examined. Data on total hospital costs, quality-adjusted life years (QALY), cost per QALY, and patient demographics were extracted and analyzed. RESULTS: The included studies were of moderate to high quality. Total hospital costs increased with a higher likelihood of unfavorable outcomes. A cost-utility analysis demonstrated that DC led to a higher expected QALY gain compared to medical management. At 12 months, though, DC was the costlier option. In the Finnish cohort, the estimated cost of continued care ran to several times that of the initial admission, which raised the all-in cost per QALY well above the figure for neurosurgical treatment alone. Cost-effectiveness varied with the severity of TBI. CONCLUSIONS: DC may be cost-effective in the management of severe TBI in selected patients, particularly those at lower risk of an unfavorable outcome, although the available evidence is limited and heterogeneous. That value falls as injury severity rises, and at the extreme end of severity the procedure is no longer cost-effective. Decisions about DC in severe TBI therefore turn on both the expected clinical benefit and the cost, not on either alone. Longer follow-up would help, since much of both the cost and the recovery in these patients accrues years after surgery.