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Cost-Effectiveness of the Transmural Trauma Care Model (TTCM) for the Rehabilitation of Trauma Patients

  • Suzanne H Wiertsema (a1), Johanna M van Dongen (a2), Edwin Geleijn (a3), Rosalie J Huijsmans (a3), Frank W Bloemers (a4), Vincent de Groot (a1) and Raymond WJG Ostelo (a5)...



To assess the societal cost-effectiveness of the Transmural Trauma Care Model (TTCM), a multidisciplinary transmural rehabilitation model for trauma patients, compared with regular care.


The economic evaluation was performed alongside a before-and-after study, with a convenience control group measured only afterward, and a 9-month follow-up. Control group patients received regular care and were measured before implementation of the TTCM. Intervention group patients received the TTCM and were measured after its implementation. The primary outcome was generic health-related quality of life (HR-QOL). Secondary outcomes included disease-specific HR-QOL, pain, functional status, and perceived recovery.


Eighty-three trauma patients were included in the intervention group and fifty-seven in the control group. Total societal costs were lower in the intervention group than in the control group, but not statistically significantly so (EUR-267; 95 percent confidence interval [CI], EUR-4,175–3011). At 9 months, there was no statistically significant between-group differences in generic HR-QOL (0.05;95 percent CI, −0.02–0.12) and perceived recovery (0.09;95 percent CI, −0.09–0.28). However, mean between-group differences were statistically significantly in favor of the intervention group for disease-specific HR-QOL (−8.2;95 percent CI, −15.0–−1.4), pain (−0.84;95CI, −1.42–−0.26), and functional status (−20.1;95 percent CI, −29.6–−10.7). Cost-effectiveness acceptability curves indicated that if decision makers are not willing to pay anything per unit of effect gained, the TTCM has a 0.54–0.58 probability of being cost-effective compared with regular care. For all outcomes, this probability increased with increasing values of willingness-to-pay.


The TTCM may be cost-effective compared with regular care, depending on the decision-makers willingness to pay and the probability of cost-effectiveness that they perceive as acceptable.


Corresponding author

Author for correspondence: Suzanne Wiertsema, Email:


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Ethics approval and consent to participate: The medical ethics committee of the VUmc assessed the present study, and decided the Dutch Medical Research Involving Human Subjects Act (WMO) was not applicable (registered under number 2013.454). All participants gave informed consent. The trial is registered at the Dutch Trial Register (NTR5474). Authors’ contributions: S.H.W. has been involved in the development of the TTCM, the design of the study, the implementation of the TTCM, the data collection, the data analysis and writing the manuscript. JMD was closely involved in the design of the study, was responsible for the economic evaluation and involved in writing the manuscript. EG and RJH were substantially involved in development of the TTCM and negotiated a model for reimbursement with hospital managers, policy makers and insurers. F.W.B., V.G., and R.W.O. were involved in the overall design of the study and were critically reading the manuscript for important intellectual content. All authors read and approved the final manuscript. Acknowledgements: We thank all trauma patients who participated in the study. Furthermore, we thank Frank Duijff and Sander Assendelft from FysioRoadmap for their ongoing support and technical assistance during the project. Finally we thank Milou Rossenaar for her help with the cost-effectiveness analyses as a part of her graduation thesis. Financial support: This project is partly funded by “Zilveren Kruis Health Insurer” (grant number Z516).



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1.World Health Organisation (2002) The World Health Report 2002 - Reducing risks, promoting healthy life. Geneva: WHO.
2.Lozano, R, Naghavi, M, Foreman, K, et al. (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859), 20952128.
3.Murray, CJ, Vos, T, Lozano, R, et al. (2012) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859), 21972223.
4.Kotagal, M, Agarwal-Harding, KJ, Mock, C, et al. (2014) Health and economic benefits of improved injury prevention and trauma care worldwide. PLoS One 9, e91862
5.den Hertog, P, Stam, C, Valkenberg, H (2013) Rapport Letsels en letselpreventie [Trauma and trauma prevention]. Amsterdam: VeiligheidNL.
6.Lansink, KW, Leenen, LP (2007) Do designated trauma systems improve outcome? Curr Opin Crit Care 13, 686690.
7.MacKenzie, EJ, Rivara, FP, Jurkovich, GJ, et al. (2006) A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 354, 366378.
8.Haas, B, Jurkovich, GJ, Wang, J, et al. (2009) Survival advantage in trauma centers: Expeditious intervention or experience? J Am Coll Surg 208, 2836.
9.Celso, B, Tepas, J, Langland-Orban, B, et al. (2006) A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 60, 371378; discussion 378.
10.Wiertsema, SH, van Dongen, JM, Geleijn, E, et al. (2017) Evaluation of a new Transmural Trauma Care Model (TTCM) for the rehabilitation of trauma patients: A study protocol. BMC Health Serv Res 17, 99.
11.Drummond, MF, Sculpher, MJ, Torrance, GW, O'Brien, BJ, Stoddart, GL (2005) Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford University Press.
12.Seguin, J, Garber, BG, Coyle, D, Hebert, PC (1999) An economic evaluation of trauma care in a Canadian lead trauma hospital. J Trauma 47(3 Suppl), S99-S103.
13.Durham, R, Pracht, E, Orban, B, et al. (2006) Evaluation of a mature trauma system. Ann Surg 243, 775783; discussion 783–785.
14.MacKenzie, EJ, Weir, S, Rivara, FP, et al. (2010) The value of trauma center care. J Trauma 69, 110.
15.Higgins, JTP, Green, S (2011) Cochrane handbook for systematic reviews of interventions. Version 5.1.0. [Updated March 2011]. The Cochrane Collaboration; 2011.
16.van Dongen, JM, van Wier, MF, Tompa, E, et al. (2014) Trial-based economic evaluations in occupational health: Principles, methods, and recommendations. J Occup Environ Med 56, 563572.
17.Netwerk Traumarevalidatie VUmc [Trauma rehabilitation network VUmc].
18.Lamers, L, Stalmeier, P, McDonnell, J, Krabbe, P, van Busschbach, J (2006) The Dutch tariff: Results and arguments for an effective design for national EQ-5D valuation studies. Health Econ 15(10), 11211132.
19.Hudak, PL, Amadio, PC, Bombardier, C (1996) Development of an upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 29, 602608.
20.Veehof, MM, Sleegers, EJ, van Veldhoven, NH, Schuurman, AH, van Meeteren, NL (2002) Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-DLV). J Hand Ther 15, 347354.
21.Binkley, JM, Stratford, PW, Lott, SA, Riddle, DL (1999) The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. Phys Ther 79, 371–83.
22.Hoogeboom, TJ, de Bie, RA, den Broeder, AA, van den Ende, CH (2012) The Dutch Lower Extremity Functional Scale was highly reliable, valid and responsive in individuals with hip/knee osteoarthritis: A validation study. BMC Musculoskelet Disord 13, 117.
23.Roland, M, Morris, R (1983) A study of the natural history of back pain. Part I: Development of a reliable and sensitive measure of disability in low-back pain. Spine (Phila Pa 1976) 8, 141144.
24.Brouwer, S, Kuijer, W, Dijkstra, PU, et al. (2004) Reliability and stability of the Roland Morris Disability Questionnaire: Intra class correlation and limits of agreement. Disabil Rehabil 26, 162165.
25.Kempen, GI, Miedema, I, Ormel, J, Molenaar, W (1996) The assessment of disability with the Groningen Activity Restriction Scale. Conceptual framework and psychometric properties. Soc Sci Med 43(11), 16011610.
26.Von Korff, M, Jensen, MP, Karoly, P (2000) Assessing global pain severity by self-report in clinical and health services research. Spine (Phila Pa 1976) 25(24), 31403151.
27.Chatman, AB, Hyams, SP, Neel, JM, et al. (1997) The Patient-Specific Functional Scale: Measurement properties in patients with knee dysfunction. Phys Ther 77, 820879.
28.Beurskens, AJ, de Vet, HC, Koke, AJ, et al. (1999) A patient-specific approach for measuring functional status in low back pain. J Manipulative Physiol Ther 22, 144148.
29.Kamper, SJ, Ostelo, RW, Knol, DL, et al. (2010) Global Perceived Effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status. J Clin Epidemiol 63, 760766.
30.Frick, FD (2009) Microcosting quantity data collection methods. Med Care 47(7 Suppl 1), S76-S81.
31.Tan, SS, Bouwmans, CA, Rutten, FF, Hakkaart-van Roijen, L (2012) Update of the Dutch Manual for Costing in Economic Evaluations. Int J Technol Assess Health Care 28, 152158.
32.G-Standard (2006) The Hague, The Netherlands: Z-Index BV.
33.Koopmanschap, MA (2005) PRODISQ: A modular questionnaire on productivity and disease for economic evaluation studies. Expert Rev Pharmacoecon Outcomes Res 5, 2328.
34.Kessler, RC, Ames, M, Hymel, PA, et al. (2004) Using the World Health Organization Health and Work Performance Questionnaire (HPQ) to evaluate the indirect workplace costs of illness. J Occup Environ Med 46, S23-S37.
35.Azur, MJ, Stuart, EA, Frangakis, C, Leaf, PJ (2011) Multiple imputation by chained equations: What is it and how does it work? Int J Methods Psychiatr Res 20, 4049.
36.White, IR, Royston, P, Wood, AM (2011) Multiple imputation using chained equations: Issues and guidance for practice. Stat Med 30, 377399.
37.Black, WC (1990) The CE plane: A graphic representation of cost-effectiveness. Med Decis Making 10, 212214.
38.Fenwick, E, O'Brien, BJ, Briggs, A (2004) Cost-effectiveness acceptability curves-facts, fallacies and frequently asked questions. Health Econ 13, 405415.
39.Holbrook, TL, Anderson, JP, Sieber, WJ, Browner, D, Hoyt, DB (1999) Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project. J Trauma 46, 765771; discussion 771–773.
40.Willenberg, L, Curtis, K, Taylor, C, et al. (2012) The variation of acute treatment costs of trauma in high-income countries. BMC Health Serv Res 12, 267.
41.Wu, J, Faux, SG, Harris, I, Poulos, CJ (2016) Integration of trauma and rehabilitation services is the answer to more cost-effective care. ANZ J Surg 86(11), 900904.
42.Bouman, AI, Hemmen, B, Evers, SM, et al. (2017) Effects of an integrated ‘fast track’ rehabilitation service for multi-trauma patients: A non-randomized clinical trial in the Netherlands. PLoS One 2, e0170047.
43.Lahtinen, A, Leppilahti, J, Vahanikkila, H, et al. (2017) Costs after hip fracture in independently living patients: A randomised comparison of three rehabilitation modalities. Clin Rehabil 31, 672685.
44.Gabbe, BJ, Sutherland, AM, Hart, MJ, Cameron, PA (2010) Population-based capture of long-term functional and quality of life outcomes after major trauma: The experiences of the Victorian State Trauma Registry. J Trauma 69, 532536; discussion 536.
45.Holtslag, HR, Post, MW, Lindeman, E, Van der Werken, C (2007) Long-term functional health status of severely injured patients. Injury 38, 280289.
46.Lindsay, R, Burge, RT, Strauss, DM (2005) One year outcomes and costs following a vertebral fracture. Osteoporos Int 16, 7885.
47.Ho, AM, Phelan, R, Mizubuti, GB, et al. (2018) Bias in before-after studies: Narrative overview for anesthesiologists. Anesth Analg 126, 17551762.
48.Petrou, S, Gray, A (2011) Economic evaluation alongside randomised controlled trials: Design, conduct, analysis, and reporting. BMJ 342, d1548.


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Cost-Effectiveness of the Transmural Trauma Care Model (TTCM) for the Rehabilitation of Trauma Patients

  • Suzanne H Wiertsema (a1), Johanna M van Dongen (a2), Edwin Geleijn (a3), Rosalie J Huijsmans (a3), Frank W Bloemers (a4), Vincent de Groot (a1) and Raymond WJG Ostelo (a5)...


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