Economic Optimization Through Adherence to Best Practice Guidelines: A Decision Analysis of Traumatic Spinal Cord Injury Care Pathways in Australia

Traumatic spinal cord injuries (TSCIs) have significant health, economic, and social effects on individuals, families, and society. In this economic analysis modeling study, we used record-linked administrative patient data from New South Wales, Australia, to construct a decision tree model to compare the economic cost of acute care for patients with TSCI under current clinical pathways with an optimal care (consensus guidelines-informed) modeled pathway. The optimal care pathway included direct transfer to a specialist SCI Unit (SCIU) or indirect transfer to SCIU within 24 h of injury, surgical intervention within 12 h of injury, and subsequent inpatient rehabilitation. Propensity score matching with inverse probability of treatment weighting (IPTW) was used to reduce potential confounding from baseline differences in patient characteristics. A generalized linear model regression with gamma distribution and log link, weighted with IPTW scores, was used for cost and length of stay (LoS) estimations to reduce any residual bias. Sensitivity analyses quantified the sensitivity of the findings to key model parameters. From the healthcare payer perspective, our economic analysis found acute TSCI care at an SCIU was more expensive, with delayed patient transfer pathways, surgery, and timing of surgery driving higher per-patient costs ($14,322 at specialist centers). Probabilistic sensitivity analysis (PSA) using 10,000 Monte Carlo iterations showed the modeled optimal pathway as the expensive option in the majority (86%) of stimulations. However, the modeled direct transfer care pathway demonstrated economic improvements compared to current care pathways, despite a higher upfront cost ($25,428 per patient), the modeled pathway reduced the episode LoS by 5 days (23 days vs. 28 days) on average, generating system-level savings of $20,628 per patient. In PSA, increasing the proportion of patients directly transferred to SCIU by 25%, the optimized pathway was preferred in 28.3% of the simulations. Furthermore, adopting this pathway lowered the incremental per patient cost to $17,157 while preserving a 5-day LoS benefit compared to current pathways (22 days vs. 27 days), which could generate potential savings of $3,471 per patient. Our findings show that guideline-based acute care management is initially resource-intensive but efficient in terms of patient LoS, with a higher proportion of direct transfers resulting in cost savings of $3,471 per patient, which represent system-level benefits from adopting the modeled pathway, rather than episode-level savings. Following consensus guidelines for acute care can provide an economically sustainable approach to resource-intensive patient needs while improving outcomes, as demonstrated in previous studies. In summary, while more intensive, adhering to clinical guidelines of direct transfer to SCIU demonstrates value for patients and health systems. Standardization to optimize time to surgery can achieve improved outcomes through earlier access to rehabilitation and substantial care efficiencies. These findings highlight the economic case for adherence to best practice care guidelines at the healthcare system level to inform future healthcare planning for patients with TSCI.