Arkansas — Targeted Issue

Description

Chapter in Economic Evaluation in Child Health in Economic Evaluation of Child Health (Wendy Ungar, Editor, Oxford University Press). Traumatic brain injury (TBI) is a major health problem worldwide and is often referred to as the ‘silent epidemic’. The uncertainty faced by clinicians in treating children with severe brain injuries is controversial with important clinical and social implications. This chapter weighs the costs and consequences of aggressive treatment of pediatric TBI. It is organized into three sections. First, the physiology and treatment of TBI in children is described. Second, a cost-effectiveness analysis evaluating technology improvement in the treatment of pediatric TBI is presented. This analysis incorporates quality-adjusted life years (QALYs) using published data on preference-weighted health outcomes for children with TBI. Finally, the implications and clinical policy relevance of the analysis are discussed and additional research that could inform clinical policy is outlined.

Author(s)/Presenter(s)

John M. Tilford, Mary E. Aitken, Allen C. Goodman, Debra H. Fiser, Jeffrey B. Killingsworth, Jerril W. Green, P. David Adelson

Abstract/Description

BACKGROUND: Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking.
OBJECTIVE: This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge.
SETTING/PATIENTS: Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation.
MAIN OUTCOME MEASURES: The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity.
METHODS: Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission.
RESULTS: A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores.
CONCLUSIONS: The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Author(s)/Presenter(s)

John M. Tilford, Allen C. Goodman, Mary E. Aitken, P. David Adelson

Abstract/Description

Substantial variation exists with respect to the management of traumatic brain injuries (TBI) in children. Centers that practice aggressive treatment of TBI may improve survival, but it is not clear that the outcomes can be justified using cost-effectiveness criteria. This study illustrates the use of cost-effectiveness analysis to assess interventions for improving outcomes in children by assessing the cost per quality-adjusted life year (QALY) gained from technological change in the treatment of TBI. Cost and survival data associated with technological change in the treatment of pediatric TBI was based on nationally representative hospital administrative data for all children <21 years with a TBI who required endotracheal intubation or mechanical ventilation. With QALYs of pediatric TBI survivors based on life expectancies ranging between 5 and 30 years and on an estimated preference score of approximately 0.5, the estimated incremental cost-effectiveness ratio ranges between $19,000 and $109,000 per QALY gained. Adding estimated rehabilitation costs increases the cost-effectiveness ratio to between $57,000 and $244,000 per QALY. Sensitivity analysis indicates that estimates of life years gained are critical to the estimated ratio. If TBI survivors live more than 5 years, then the estimated cost-effectiveness ratio seems favorable.

Author(s)/Presenter(s)

Lopez AM, Tilford JM, Anand KJ, Jo CH, Green JW, Aitken ME, Fiser DH

Abstract/Description

Context: The differential allocation of medical resources to adult patients according to characteristics such as race, gender, and insurance status raises the serious concern that such issues apply to critically ill children as well.

Objective: This study examined whether medical resources and outcomes for children admitted to pediatric intensive care units differed according to race, gender, or insurance status.

Design: An observational analysis was conducted with use of prospectively collected data from a multicenter cohort. Data were collected on 5,749 consecutive admissions for children from three pediatric intensive care units located in large urban children's hospitals.

Participants: Children aged </=18 years admitted over an 18-month period beginning in June 1996 formed the study sample.

Main outcome measures: Hospital mortality, length of hospital stay, and overall resource use were examined in relation to severity of illness. Standardized ratios were formed with generalized regression analyses that included the Pediatric Index of Mortality for risk adjustment.

Results: After adjustment for differences in illness severity, standardized mortality ratios and overall resource use were similar with regard to race, gender, and insurance status, but uninsured children had significantly shorter lengths of stay in the pediatric intensive care unit. Uninsured children also had significantly greater physiologic derangement on admission (mortality probability, 8.1%; 95% confidence interval [CI], 6.2-10.0) than did publicly insured (3.6%; 95% CI, 3.2-4.0) and commercially insured patients (3.7%; 95% CI, 3.3-4.1). Consistent with greater physiologic derangement, hospital mortality was higher among uninsured children than insured children.

Conclusions: Risk-adjusted mortality and resource use for critically ill children did not differ according to race, gender, or insurance status. Policies to expand health insurance to children appear more likely to affect physiologic derangement on admission rather than technical quality of care in the pediatric intensive care unit setting.

Author(s)/Presenter(s)

Folafoluwa O. Odetola, John M. Tilford, Matthew M. Davis

Abstract/Description

Objective: Our goal was to describe patient and hospital characteristics associated with the use of intracranial pressure monitors and outcomes in critically ill children with meningitis.

Methods: This was a retrospective cohort study of children 0 to 17 years of age hospitalized with meningitis and requiring mechanical ventilation using the 1997 and 2000 Kids' Inpatient Database. We generated national estimates of rates of intracranial pressure monitoring and in-hospital mortality by patient and hospital characteristics, and compared in-hospital mortality, hospital length of stay, and total charges for children who received an intracranial pressure monitor with those who did not.

Results: There were an estimated 1067 and 1170 hospitalizations nationally for childhood meningitis requiring mechanical ventilation in 1997 and 2000, respectively. Most (79%) of the hospitalizations involved infants. Overall, intracranial-pressure monitors were used in 7% of hospitalizations for meningitis, with the highest rates in children aged 5 to 17 years and lowest rates in children <1 year. In-hospital mortality was 19.6%, highest in children aged 5 to 17 years and in children with pneumococcal infections. In multivariate regression analyses, intracranial pressure monitor use was positively associated with age, patient volume, and hospitals located in the West census region. In-hospital mortality was associated with increasing age, hospitalization in the year 2000, self-pay/other insurance status, and pneumococcal meningitis. There was no difference in hospital mortality associated with use of intracranial pressure monitors, but both length of stay and log-transformed total hospital charges were significantly higher in the group that received an intracranial-pressure monitor.

Conclusion: Intracranial pressure monitoring for the treatment of critically ill children with meningitis varies by census region, the number of cases treated, and patient age. The use of intracranial pressure monitoring was not statistically associated with mortality in this national sample.

Author(s)/Presenter(s)

John M. Tilford, Mary E. Aitken, KJS Anand, Jerril Green, Allen C. Goodman, James Parker, Jeff Killingsworth, Debra Fiser, and David Adelson

Abstract/Description

Objective: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment.

Design: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals.

Setting: Hospital inpatient stays from all types of U.S. community hospitals.

Participants: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation.

Interventions: None.

Measurements and main results: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits.

Conclusions: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.