• Aziz S Alali, David M J Naimark, Jefferson R Wilson, Robert A Fowler, Damon C Scales, Eyal Golan, Todd G Mainprize, Joel G Ray, and Avery B Nathens.
• 1Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, ON, Canada. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. 3Division of Neurosurgery, University of Ottawa, Ottawa, ON, Canada. 4Department of Medicine, University of Toronto, Toronto, ON, Canada. 5Division of Neurosurgery, University of Toronto, Toronto, ON, Canada. 6Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada. 7Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. 8Keenan Research Centre of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 9Department of Surgery, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada.
• Crit. Care Med.. 2014 Oct 1;42(10):2235-43.

ObjectivesDecompressive craniectomy and barbiturate coma are often used as second-tier strategies when intracranial hypertension following severe traumatic brain injury is refractory to first-line treatments. Uncertainty surrounds the decision to choose either treatment option. We investigated which strategy is more economically attractive in this context.DesignWe performed a cost-utility analysis. A Markov Monte Carlo microsimulation model with a life-long time horizon was created to compare quality-adjusted survival and cost of the two treatment strategies, from the perspective of healthcare payer. Model parameters were estimated from the literature. Two-dimensional simulation was used to incorporate parameter uncertainty into the model. Value of information analysis was conducted to identify major drivers of decision uncertainty and focus future research.SettingTrauma centers in the United States.SubjectsBase case was a population of patients (mean age = 25 yr) who developed refractory intracranial hypertension following traumatic brain injury.InterventionsWe compared two treatment strategies: decompressive craniectomy and barbiturate coma.Measurements And Main ResultsDecompressive craniectomy was associated with an average gain of 1.5 quality-adjusted life years relative to barbiturate coma, with an incremental cost-effectiveness ratio of $9,565/quality-adjusted life year gained. Decompressive craniectomy resulted in a greater quality-adjusted life expectancy 86% of the time and was more cost-effective than barbiturate coma in 78% of cases if our willingness-to-pay threshold is $50,000/quality-adjusted life year and 82% of cases at a threshold of $100,000/quality-adjusted life year. At older age, decompressive craniectomy continued to increase survival but at higher cost (incremental cost-effectiveness ratio = $197,906/quality-adjusted life year at mean age = 85 yr).ConclusionsBased on available evidence, decompressive craniectomy for the treatment of refractory intracranial hypertension following traumatic brain injury provides better value in terms of costs and health gains than barbiturate coma. However, decompressive craniectomy might be less economically attractive for older patients. Further research, particularly on natural history of severe traumatic brain injury patients, is needed to make more informed treatment decisions.

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