Response to Letter to Editor: “Costs associated with ‘determinants of adherence’: Essential for evaluation of cost effectiveness of any guideline-driven care?”

We read with interest the letter to the editor by Dr. Ganesan. In this letter, Dr. Ganesan questions whether we were able to determine the true cost of guideline adherence in severe traumatic brain injury based on our use of the HCUP cost to charge ratios (1). Dr. Ganesan argues correctly that our prior work showing reducing barrier domains associated with poor adherence incurs some cost that would not be captured by HCUP data (2). We also agree with Dr. Ganesan that implementation of systems and resources needed to achieve high guideline adherence would require examination of monies actually spent, specifically for guideline adherence. Examples of these costs could include additional staff time used for guideline education or incentives given for guideline adherence.

Consideration of costs is a relatively recent phenomenon in medical care and one that is important to consider, especially since the majority of the TBI burden is borne by low-middle income countries. There may be some elements of guideline adherence that depend more on organization of care and communication between teams, whereas adherence to other key performance indicators, such as consistent use of intracranial pressure monitors, may be associated with significant costs, given the need for higher intensity of care and monitoring. Further study is needed to examine which aspects of guideline adherence are truly cost effective. Furthermore, each society may need to decide on a willingness to pay model for children with severe TBI. Our study was a secondary analysis of data and provides incremental information - the first step in the right direction towards understanding the relationship between costs and guideline adherence.