Guest post from Kimon Bekelis, MD
Section of Neurosurgery, Dartmouth-Hitchcock Medical Center
Value reigns supreme in the world of healthcare delivery today. Value has been defined easily as:
COST/QUALITY
A recent landmark study tackles the difficult question on the value of expensive helicopter transport in the care of traumatic brain injury (TBI) patients. To fully appreciate the results of this work, it is necessary to grasp the scope of TBI in the U.S. today.
- TBI contributes to a substantial number of deaths and cases of permanent disability in the U.S.;
- 1.7 million TBIs occur annually;
- Estimated direct medical costs is $31.7 billion;
- Estimated global cost is $48.3 billion; and
- Often impact during prime years (ages 16-30).
Significant improvements in survival for this patient population have been achieved through widespread use of evidence-based guidelines, centralization of care and advances in neurocritical care. Other important factors — which allow patients to capitalize on the aforementioned developments — are improvements in emergency medical services (EMS) and timely transport to specialized trauma centers, capable of providing life-saving interventions.
Frontal cerebral contusions secondary to a motor vehicle accident
Within this setting, helicopter utilization and its value — based on the effect on outcomes of TBI — remains a hotly debated issue. Helicopter transport is one of the most expensive interventions in modern emergency medicine, with annual cost ranging from $114,777 to $4.5 million per institution. Other studies have suggested there is no value in using helicopter transport for patient with TBI. However, all of these studies had limited generalizability given their focus on single center or regional analyses.
A historic study recently published in the Annals of Surgery1 has demonstrated that helicopter transport is associated with increased survival (Table 1) in comparison to ground EMS — using the National Trauma Data Bank, the largest trauma registry in the country. The analysis was based on national level data, and addressed methodologic limitations of prior studies, controlling for confounders (including the neurologic status and injury severity of the patient), and producing robust results through several analytic iterations, including a propensity score matched cohort.
Table 1. Models demonstrating the association of helicopter transport with survival of TBI patients
| OR (95% CI) | P-value | ARR, % (95% CI) | |||
| Level I Trauma Centers | |||||
| Logistic regression | |||||
| Standard | 1.95 (1.81-2.10) | <0.001 | 6.37 (5.89-6.85) | ||
| Incorporating propensity score matching | 1.88 (1.74-2.03) | <0.001 | 5.93 (5.46-6.40) | ||
| Level II Trauma Centers | |||||
| Logistic regression | |||||
| Standard | 1.81 (1.64-2.00) | <0.001 | 5.17 (4.55-5.79) | ||
| Incorporating propensity score matching | 1.73 (1.55-1.94) | <0.001 | 4.69 (4.08-5.31) | ||
Abbreviations: OR: Odds Ratio, ARR: Absolute Risk Reduction
For all trauma patients, in order to save one life you would need to transport 65 patients with a helicopter.2 The present study1 revealed this effect is more pronounced for patients with TBI, with only 17 patients needed transport to save one life. A recent analysis3 concluded that helicopter transport needs to provide a minimum of 17 percent relative reduction in mortality (1.6 lives saved every 100 patients) to be cost-effective. These data are compatible with the number of TBI patients which needed transport in order to save one life, supporting the cost effectiveness of helicopter transport for this population.
Patients with TBI are some of the most severely injured trauma patients, in need of timely, efficient and specialized care. The value equation for care delivery requires both cost and quality be optimized. Recent evidence allows patients to be first priority, through use of helicopter utilization to improve access of this population in specialized trauma centers. To this end, the impact helicopter transport has to increase survival rates among neuro-trauma patients should be taken into account by policy makers and payors.
References
1. K. Bekelis, S. Missios, T.A. MacKenzie. Pre-hospital helicopter transportation and survival of patients with traumatic brain injury. Annals of Surgery, 2015 Mar;261(3):579-85
2. Galvagno SMJ, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA 2012; 307(15):1602-1610
3. Delgado MK, Staudenmayer KL, Wang NE, et al. Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States. Ann Emerg Med 2013;63(4):411.
