Outcomes and costs of blunt trauma in England and Wales

Computed tomography benefits and cost in hemodynamically stable patients with blunt abdominal trauma at an Egyptian University Hospital

Background

Trauma is a significant cause of mortality, especially among individuals aged between 15 and 44 years, with a substantial burden falling on economically active populations. Low- and middle-income countries (LMICs) bear the burden of trauma-related deaths, accounting for over 90 % globally. In Egypt, trauma rates are increasing, primarily due to road traffic crashes (RTC), affecting males disproportionately. Blunt abdominal trauma, often caused by RTC, can lead to missed intra-abdominal injuries (IAIs) due to atypical symptoms. Computed Tomography (CT) offers high sensitivity and specificity in detecting IAIs, but concerns about cost and radiation exposure exist.

Methodology

This study investigates the roles of Focused Assessment with Sonography for Trauma (FAST) and CT in managing blunt abdominal trauma. A retrospective cohort study was conducted on hemodynamically stable patients. Data included patient demographics, trauma details, healthcare decisions, costs, and outcomes.

Results

Computed tomography significantly reduced unnecessary laparotomies (12.3% vs. 24.8 %, p = 0.001), shortened hospital stays (4.83±0.71 days vs. 6.15±1.28 days, p = 0.005), and reduced ICU admissions (8 vs. 32, p = 0.023) compared to FAST alone. Overall costs were lower in the CT & FAST Group ($2055.95 vs. $3488.7, p = 0.0001), with no significant difference in missed IAIs.

Conclusion

This study highlights the limitations of relying solely on FAST for IAIs and underscores the value of CT in guiding healthcare decisions. Incorporating CT led to reduced negative laparotomies, shorter hospital stays, and fewer ICU admissions. While CT incurs initial costs, its long-term benefits outweigh expenditures, particularly in LMICs. This study provides insights into optimizing diagnostic approaches for blunt abdominal trauma in low-resource settings.

Sport-related major trauma incidence in young people and adults in England and Wales: a national registry-based study

OBJECTIVES

Data on sport and physical activity (PA) injury risk can guide intervention and prevention efforts. However, there are limited national-level data, and no estimates for England or Wales. This study sought to estimate sport and PA-related major trauma incidence in England and Wales.

METHODS

Nationwide, hospital registry-based cohort study between January 2012 and December 2017. Following Trauma Audit and Research Network Registry Research Committee approval, data were extracted in April 2018 for people ≥16 years of age, admitted following sport or PA-related injury in England and Wales. The population-based Active Lives Survey was used to estimate national sport and PA participation (ie, running, cycling, fitness activities). The cumulative injury incidence rate was estimated for each activity. Injury severity was described by Injury Severity Score (ISS) >15.

RESULTS

11 702 trauma incidents occurred (mean age 41.2±16.2 years, 59.0% male), with an ISS >15 for 28.0% of cases, and 1.3% were fatal. The overall annual injury incidence rate was 5.40 injuries per 100 000 participants. The incidence rate was higher in men (6.44 per 100 000) than women (3.34 per 100 000), and for sporting activities (9.88 per 100 000) than cycling (2.81 per 100 000), fitness (0.21 per 100 000) or walking (0.03 per 100 000). The highest annual incidence rate activities were motorsports (532.31 per 100 000), equestrian (235.28 per 100 000) and gliding (190.81 per 100 000).

CONCLUSION

Injury incidence was higher in motorsports, equestrian activity and gliding. Targeted prevention in high-risk activities may reduce admissions and their associated burden, facilitating safer sport and PA participation.

Critical hypertension in trauma patients following prehospital emergency anaesthesia: a multi-centre retrospective observational study

BACKGROUND

Critical hypertension in major trauma patients is associated with increased mortality. Prehospital emergency anaesthesia (PHEA) is performed for 10% of the most seriously injured patients. Optimising oxygenation, ventilation, and cerebral perfusion, whilst avoiding extreme haemodynamic fluctuations are the cornerstones of reducing secondary brain injury. The aim of this study was to report the differential determinants of post-PHEA critical hypertension in a large regional dataset of trauma patients across three Helicopter Emergency Medical Service (HEMS) organisations.

METHODS

A multi-centre retrospective observational study of consecutive adult trauma patients undergoing PHEA across three HEMS in the United Kingdom; 2015-2022. Critical hypertension was defined as a new systolic blood pressure (SBP) > 180mmHg within 10 min of induction of anaesthesia, or > 10% increase if the baseline SBP was > 180mmHg prior to induction. Purposeful logistical regression was used to explore variables associated with post-PHEA critical hypertension in a multivariable model. Data are reported as number (percentage), and odds ratio (OR) with 95% confidence interval (95%CI).

RESULTS

30,744 patients were attended by HEMS during the study period; 2161 received PHEA and 1355 patients were included in the final analysis. 161 (11.9%) patients had one or more new episode(s) of critical hypertension ≤ 10 min post-PHEA. Increasing age (compared with 16-34 years): 35-54 years (OR 1.76, 95%CI 1.03-3.06); 55-74 years (OR 2.00, 95%CI 1.19-3.44); ≥75 years (OR 2.38, 95%CI 1.31-4.35), pre-PHEA Glasgow Coma Scale (GCS) motor score four (OR 2.17, 95%CI 1.19-4.01) and five (OR 2.82, 95%CI 1.60-7.09), patients with a pre-PHEA SBP > 140mmHg (OR 6.72, 95%CI 4.38-10.54), and more than one intubation attempt (OR 1.75, 95%CI 1.01-2.96) were associated with post-PHEA critical hypertension.

CONCLUSION

Delivery of PHEA to seriously injured trauma patients risks haemodynamic fluctuation. In adult trauma patients undergoing PHEA, 11.9% of patients experienced post-PHEA critical hypertension. Increasing age, pre-PHEA GCS motor score four and five, patients with a pre-PHEA SBP > 140mmHg, and more than intubation attempt were independently associated with post-PHEA critical hypertension.

Costs for Long-Term Health Care After a Police Shooting in Ontario, Canada

Importance

Police shootings can cause serious acute injury, and knowledge of subsequent health outcomes may inform interventions to improve care.

Objective

To analyze long-term health care costs among survivors of police shootings compared with those surviving nonfirearm police enforcement injuries using a retrospective design.

Design, Setting, and Participants

This population-based cohort analysis identified adults (age ≥16 years) who were injured by police and required emergency medical care between April 1, 2002, and March 31, 2022, in Ontario, Canada.

Exposure

Police shootings compared with other mechanisms of injury involving police.

Main Outcomes and Measures

Long-term health care costs determined using a validated costing algorithm. Secondary outcomes included short-term mortality, acute care treatments, and rates of subsequent disability.

Results

Over the study, 13 545 adults were injured from police enforcement (mean [SD] age, 35 [12] years; 11 637 males [86%]). A total of 13 520 individuals survived acute injury, and 8755 had long-term financial data available (88 surviving firearm injury, 8667 surviving nonfirearm injury). Patients surviving firearm injury had 3 times greater health care costs per year (CAD$16 223 vs CAD$5412; mean increase, CAD$9967; 95% CI, 6697-13 237; US $11 982 vs US $3997; mean increase, US $7361; 95% CI, 4946-9776; P < .001). Greater costs after a firearm injury were not explained by baseline costs and primarily reflected increased psychiatric care. Other characteristics associated with increased long-term health care costs included prior mental illness and a substance use diagnosis.

Conclusions and Relevance

In this longitudinal cohort study of long-term health care costs, patients surviving a police shooting had substantial health care costs compared with those injured from other forms of police enforcement. Costs primarily reflected psychiatric care and suggest the need to prioritize early recognition and prevention.

Evaluation of Missing Prehospital Physiological Values in Injured Children and Adolescents

INTRODUCTION

Prehospital vital signs and the Glasgow Coma Scale score are often missing in clinical practice and not recorded in trauma databases. Our study aimed to identify factors associated with missing prehospital physiological values, including systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, and Glasgow Coma Scale.

METHODS

We used our hospital trauma registry to obtain patient, injury, resuscitation, and transportation characteristics for injured children and adolescents (age <15 y). We evaluated the association of missing documentation of prehospital values with other patient, injury, transportation, and resuscitation characteristics using multivariable regression. We standardized vital sign values using age-adjusted z-scores.

RESULTS

The odds of a missing physiological value decreased with age (odds ratio [OR] = 0.9, 95% confidence interval [CI] = 0.9, 0.9) and were higher when prehospital cardiopulmonary resuscitation was required (OR = 3.3, 95% CI = 1.9, 5.7). Among the physiological values considered, we observed the highest odds of missingness of systolic blood pressure, respiratory rate, and oxygen saturation. The odds of observing normal emergency department physiological values were lower when prehospital physiological values were missing (OR = 0.9, 95% CI = 0.9, 1.0; P = 0.04).

CONCLUSIONS

Missing prehospital physiological values were associated with younger age and cardiopulmonary resuscitation among the injured children treated at our hospital. Measurement and documentation of physiological variables of patients with these characteristics should be targeted.

An economic evaluation of triage tools for patients with suspected severe injuries in England

BACKGROUND

Many health care systems triage injured patients to major trauma centres (MTCs) or local hospitals by using triage tools and paramedic judgement. Triage tools are typically assessed by whether patients with an Injury Severity Score (ISS) ≥ 16 go to an MTC and whether patients with an ISS < 16 are sent to their local hospital. There is a trade-off between sensitivity and specificity of triage tools, with the optimal balance being unknown. We conducted an economic evaluation of major trauma triage tools to identify which tool would be considered cost-effective by UK decision makers.

METHODS

A patient-level, probabilistic, mathematical model of a UK major trauma system was developed. Patients with an ISS ≥ 16 who were only treated at local hospitals had worse outcomes compared to being treated in an MTC. Nine empirically derived triage tools, from a previous study, were examined so we assessed triage tools with realistic trade-offs between triage tool sensitivity and specificity. Lifetime costs, lifetime quality adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each tool and compared to maximum acceptable ICERs (MAICERs) in England.

RESULTS

Four tools had ICERs within the normal range of MAICERs used by English decision makers (£20,000 to £30,000 per QALY gained). A low sensitivity (28.4%) and high specificity (88.6%) would be cost-effective at the lower end of this range while higher sensitivity (87.5%) and lower specificity (62.8%) was cost-effective towards the upper end of this range. These results were sensitive to the cost of MTC admissions and whether MTCs had a benefit for patients with an ISS between 9 and 15.

CONCLUSIONS

The cost-effective triage tool depends on the English decision maker's MAICER for this health problem. In the usual range of MAICERs, cost-effective prehospital trauma triage involves clinically suboptimal sensitivity, with a proportion of seriously injured patients (at least 10%) being initially transported to local hospitals. High sensitivity trauma triage requires development of more accurate decision rules; research to establish if patients with an ISS between 9 and 15 benefit from MTCs; or, inefficient use of health care resources to manage patients with less serious injuries at MTCs.

The economic costs of child maltreatment in UK

Child maltreatment is a major public health problem with significant consequences for individual victims and for society. In this paper, we quantify for the first time the economic costs of fatal and nonfatal child maltreatment in the UK in relation to several short-, medium-, and long-term outcomes ranging from physical and mental health problems to labor market outcomes and welfare use. We combine novel regression analysis of rich data from the National Child Development Study and the English Longitudinal Study of Aging with secondary evidence to produce an incidence-based estimate of the lifetime costs of child maltreatment from a societal perspective. The discounted average lifetime incidence cost of nonfatal child maltreatment by a primary caregiver is estimated at £89,390 (95% uncertainty interval £44,896 to £145,508); the largest contributors to this are costs from social care, short-term health, and long-term labor market outcomes. The discounted lifetime cost per death from child maltreatment is estimated at £940,758, comprising health care and lost productivity costs. Our estimates provide the first comprehensive benchmark to quantify the costs of child maltreatment in the UK and the benefits of interventions aimed at reducing or preventing it.

Cost-Effectiveness of Multifactorial Interventions in Preventing Falls among Elderly Population: A Systematic Review

Objective:

To review the cost-effectiveness of multifactorial interventions to prevent falls in elderly people.

Methods:

In this systematic review, the databases including PubMed via MEDLINE, Web of Science, Embase, Scopus, Cochrane Library and Google Scholar (from 1st January 2000 to 30^th February) were used. All pre-reviewed articles related to cost-effectiveness analysis of multifactorial interventions to prevent falls in elderly were included in this paper and congresses abstracts were excluded. Descriptive statistics were used for quantitative data and content-analysis method to analyze qualitative data.

Results:

Out of the 456 articles, 19 were finally included in the study. Eighteen articles were conducted in High-Income Countries (HICs) and 16 were at the community level. Medical visits consultation and education were the most common interventions. Most studies were cost-effectiveness and using the Randomized Control Trial (RCT) methods. A fall of prevention costs ranged from $ 272 to $ 987. Incremental Cost-Effectiveness Ratio (ICER) interventions also ranged from the US $ 120,667 to the US $ 4280.9.

Conclusion:

The results show that despite the high effectiveness of multifactorial interventions to prevent elderly falls, the cost of the interventions are high and they are not very cost-effective. It would be better to design and implement multifactorial interventions with low cost and high effectiveness that are appropriate for each country.

Improving rib fracture management in Morriston hospital: using QI to develop an erector spinae plane catheter service

Introduction

Trauma audit research network (TARN) data for 2018 indicated that we admitted 100 patients with chest wall injuries in our District General Hospital (DGH). Our own retrospective audit of pain team referrals confirmed long length of stay (median 14 days), with 59% requiring level 2/3 care and 11% mortality risk. We noticed that Regional anaesthesia was offered to less than 25% of patients despite 63% reporting severe pain and decided to introduce an erector spinae plane (ESP) catheter service for rib fractures. Our aims were to reduce length of stay and pain scores.

Methods

We set up an email alert system, where TARN data collectors notified us when patients were admitted through the emergency department with rib fractures. Using a secure social media app (Whatsapp), we organised a group of regional anaesthetists who were willing to provide an ESP service. Process mapping and driver diagrams helped to streamline the service.

Results

Mean length of hospital stay was reduced from 10 to 7 days after introduction of the service with significant reduction in variability. Mean pain scores improved from 8.9/10 to 5/10 with an average improvement of pain score of 2.78 points on a numerical scale out of 10. (n=9)

Conclusions

This service improvement relied on a team of hospital clinicians who agreed to provide an extra pain service for patients with rib fracture. The reduction in LOS may be explained by improved respiratory physiology with ESP catheter placement. The ability to deep breathe, cough and engage in physiotherapy treatment are important factors in recovering from rib fractures. The small reduction in pain scores may be explained by the presence of other injuries. Ongoing improvements in training should improve reliability of catheter placement and reduce practitioner variation.

Patient experiences of rehabilitation following traumatic complex musculoskeletal injury – A mixed methods pilot study

Introduction

The aim of this pilot study was to measure patient reported outcomes and evaluate their rehabilitation experience following traumatic complex musculoskeletal (CMSK) injury.

Methods

A mixed methods prospective observational study was undertaken between December 2015 and March 2018 to explore patient reported outcomes following CMSK injury sustained as a result of major trauma and perception of their rehabilitation and its impact on their recovery. The participants were asked to complete a series of outcome measures at 18-months post-injury. The data was anonymised and analysed by the lead researcher.

Results

Thirty patients were recruited into the study (19 males, 11 females) between 23 and 76 years of age (median 52 years). Their injury profile was split between open fractures 30%, pelvic fractures 23%, multiple fractures 27% and polytrauma 20%. The majority (60%) reported moderate disability at 18-months post injury with 50% returning to full time employment. Patients with multiple or open fractures reported the worst outcomes. There was no relationship between frequency, quantity or duration of physiotherapy and outcome. However, 77% reported supplementing their NHS rehabilitation with other interventions such as gym membership, hydrotherapy and psychological therapies. The thematic analysis showed that patients considered intensity, quality and coordinated timely access to rehabilitation as the most important factors.

Conclusion

From a patient perspective, the current NHS rehabilitation provision does not appear to meet their complex needs. In addition to physical and vocational rehabilitation, patients wanted effective pain management and psychological support. Strengthening current therapy services and involving other sectors (e.g. Citizen’s Advice) could help achieve this. Early access to an intensive multidisciplinary rehabilitation programme was perceived to have positive benefits and improve outcomes.

[Emergency room and major trauma treatment is a "loss-making business" : A Swiss trauma center experience with current DRG reimbursement]

Hintergrund

Es galt herauszufinden, wie kostendeckend die Versorgung potenziell Schwerverletzter in einem Schweizer Traumazentrum ist, und inwieweit Spitalgewinne bzw. -verluste mit patientenbezogenen Unfall‑, Behandlungs- oder Outcome-Daten korrelieren.

Methodik

Analyse aller 2018 im Schockraum (SR) bzw. mit Verletzungsschwere New Injury Severity Score (NISS) ≥8 notfallmäßig stationär behandelter Patienten eines Schwerverletztenzentrums der Schweiz (uni- und multivariate Analyse; p < 0,05).

Ergebnisse

Für das Studienkollektiv (n = 513; Ø NISS = 18) resultierte gemäß Spitalkostenträgerrechnung ein Defizit von 1,8 Mio. CHF. Bei einem Gesamtdeckungsgrad von 86 % waren 66 % aller Fälle defizitär (71 % der Allgemein- vs. 42 % der Zusatzversicherten; p < 0,001). Im Mittel betrug das Defizit 3493.- pro Patient (allg. Versicherte, Verlust 4545.-, Zusatzversicherte, Gewinn 1318.-; p < 0,001). Auch „in“- und „underlier“ waren in 63 % defizitär. SR-Fälle machten häufiger Verlust als Nicht-SR-Fälle (73 vs. 58 %; p = 0,002) wie auch Traumatologie- vs. Neurochirurgiefälle (72 vs. 55 %; p < 0,001). In der multivariaten Analyse ließen sich 43 % der Varianz erhaltener Erlöse mit den untersuchten Variablen erklären. Hingegen war der ermittelte Deckungsgrad nur zu 11 % (korr. R²) durch die Variablen SR, chirurgisches Fachgebiet, Intensivaufenthalt, Thoraxverletzungsstärke und Spitalletalität zu beschreiben. Case-Mix-Index gemäß aktuellen Diagnosis Related Groups (DRG) und Versicherungsklasse addierten weitere 13 % zu insgesamt 24 % erklärter Varianz.

Diskussion

Die notfallmäßige Versorgung potenziell Schwerverletzter an einem Schweizer Traumazentrum erweist sich nur in einem Drittel der Fälle als zumindest kostendeckend, dies v. a. bei Zusatzversicherten, Patienten mit einem hohen Case-Mix-Index oder einer IPS- bzw. kombinierten Polytrauma- und Schädel-Hirn-Trauma-DRG-Abrechnungsmöglichkeit.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00113-020-00937-w) enthält weitere Tabellen und Abbildungen (s. Verweise „Zusatzmaterial online: Abb.“ bzw. „Zusatzmaterial online: Tab.“ im Text). Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Epidemiology of penetrating injury in an urban versus rural level 1 trauma center in the Netherlands

Background:

Penetrating injury can encompass a large spectrum of injuries dependent on the penetrating object, the location of entry, and the trajectory of the object through the human body. Therefore, the management of penetrating injuries can be challenging and often requires rapid assessment and intervention. No universal definition of penetrating injury exists in the literature and little is known about the demographics and outcome of penetrating injury in the Netherlands.

Objective:

A research was carried out to ascertain the size and outcome of penetrating injuries in two level-one trauma centers in the Netherlands.

Methods:

Using the trauma registry of the Radboud University Medical Center in Nijmegen and VU University Medical Center in Amsterdam, all patients with penetrating injury were identified who were admitted to these level 1 trauma centers in the period between January 1, 2009, and January 1, 2014. Penetrating injury was defined as an injury that caused disruption of the body surface and extended into the underlying tissue or into a body cavity. Data concerning age, gender, mechanism of injury, Glasgow Coma Scale, number of injuries, type of injury, and Injury Severity Score were collected and analyzed. Patient results were stratified by Injury Severity Score.

Results:

In total, 354 patients were identified, making up around 2% of all admitted trauma patients 3.1% (VU Medical Center) and 1.6% (Radboud Medical Center). Patients were overwhelmingly male (83.1%) and median age was 36 years (range = 1–88 years). Most injuries were caused by stabbings (51.1%) followed by shootings (26.3%). Admission to the intensive care unit occurred in 41.1% of all patients. Median stay in the intensive care unit was 5.1 days (range = 1–96 days) and median total hospital stay was 8 days (range = 1–95 days). Mortality among these patients was 7.1%, ranging from 0% among patients with Injury Severity Score 1–8 to 100% in patients with Injury Severity Score > 34. High mortality figures were associated with injuries caused by firearms (19.4%), injuries to the head (27.9%), and alleged assaults (10.9%). Differences in demographics between the two centers were not significant.

Conclusion:

Penetrating injury is a relative rare occurrence in the Netherlands compared with other countries. It is associated with high mortality and substantial hospital costs. The incidence of penetrating injuries is higher in metropolitan areas than in rural areas. A universal definition of penetrating trauma should be agreed upon in order to ensure that future studies remain free of bias, and also to ensure that data remain homogeneous.

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

Purpose

Swiss and German (pre-)hospital systems, distribution and organization of trauma centres differ from each other. It is unclear if outcome in trauma patients differs as well. Therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both German-speaking countries.

Methods

The TraumaRegister DGU^® (TR-DGU) was used. Patients with Injury Severity Score ≥ 9 admitted to a level 1 trauma centre between 01/2009 and 12/2017 were included if they required ICU care or died. Trauma pattern, pre-hospital procedures and outcome were compared between Swiss (CH, n = 4768) and German (DE, n = 66,908) groups.

Results

Swiss patients were older than German patients (53 vs. 50 years). ISS did not differ between groups (CH 23.8 vs. DE 23.0 points). There were more low falls < 3 m (34% vs. 21%) at the expense of less traffic accidents (37% vs. 52%) in the Swiss population. In Switzerland 30% of allocations were done without physician involvement, whereas this occurred in 4% of German cases. Despite a comparable number of patients with a GCS ≤ 8 (CH 29.6%; DE 26.4%), differences in pre-hospital intubation rates occurred (CH 31% vs. DE 40%). Severe traumatic brain injuries were diagnosed most frequently in Switzerland (CH 62% vs. DE 49%). Admission vital signs were similar, and standardized mortality ratios were close to one in both countries.

Conclusion

This study demonstrates that patients’ age, trauma patterns and pre-hospital care differ between Germany and Switzerland. However, adjusted mortality was almost similar. Further benchmarking studies are indicated to optimize trauma care in both German-speaking countries.

Blunt versus penetrating trauma: Is there a resource intensity discrepancy?

BACKGROUND

The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries.

METHODS

This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant.

RESULTS

4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges.

CONCLUSIONS

Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution.

Patient-level resource use for injury admissions in Canada: A multicentre retrospective cohort study

BACKGROUND

Variations in adjusted costs have been observed among trauma centres in the United States but patient outcomes were not better in centres with higher costs. Attempts to improve injury care efficiency are hampered by insufficient patient-level information on resource use and on the drivers of resource use intensity.

OBJECTIVES

To estimate patient-level resource use for injury admissions, identify determinants of resource use intensity, and evaluate inter-hospital variations in resource use.

METHODS

We conducted a retrospective cohort study including ≥16-year-olds admitted to adult trauma centres in a mature, inclusive Canadian trauma system between 2014 and 2016. We extracted data from the trauma registry and hospital financial reports. We estimated resource use with activity-based costs, identified determinants of resource use intensity using a multilevel linear model and assessed the relative importance of each determinant with Cohen's f². We evaluated inter-provider variations with intraclass correlation coefficients (ICC) and 95% confidence intervals.

RESULTS

We included 32,411 patients. Median costs per admission were $4857 (Quartiles 1 and 3 2961-8448). The most important contributors to total resource use were the medical ward (57%), followed by the operating room (OR; 23%) and the intensive care unit (13%). The strongest determinant of resource use intensity was discharge destination (Cohen's f² = 7%). The most resource intense patient group was spinal cord injuries with $11,193 (7115-17,606) per admission. While resource use increased with increasing age for the medical ward, it decreased with increasing age for the OR. Resource use was 18% higher in level I centres compared to level IV centres and we observed significant variations in resource use across centres (ICC = 5% [4-6]), particularly for the OR (28% [20-40]).

CONCLUSIONS

Resource use for acute injury care in Quebec is not solely due to the clinical status of patients. We identified determinants of resource use that can be used to establish evidence-based resource allocations and improve injury care efficiency. The method we developed for estimating patient-level, in-hospital resource use for injury admissions and identifying related determinants could be reproduced using local trauma registry data and our unit costs or unit costs specific to each setting.

Variability in the evalution of pediatric blunt abdominal trauma

PURPOSE

To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT).

METHODS

Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed.

RESULTS

2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use.

CONCLUSIONS

Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma.

LEVEL OF EVIDENCE

Level II.

Surgical intervention in pediatric trauma at a level 1 trauma hospital: a retrospective cohort study and report of cost data

BACKGROUND

Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario.

METHODS

All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group.

RESULTS

Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group.

CONCLUSION

One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.

Assessment of clinical parameters of the polytraumatized patient as predictors of hospital expenditure and of its distribution

INTRODUCTION

Traumatic pathology continues to represent an important socio-health problem. The aim of the study was to assess the clinical predictors of total expenditure, as well as to analyze which components of the cost are modified with each clinical parameter of the polytraumatized patient.

MATERIAL AND METHODS

Retrospective study of 131 polytrauma patients registered prospectively. A statistical analysis was carried out to assess the relationship between clinical parameters, the total cost and the cost of various treatment components.

RESULTS

The total cost of hospital admission was 3,791,879 euros. The average cost per patient was € 28,945. Age and gender were not predictors of cost. The scales ISS, NISS and PS were predictors of the total cost and of multiple treatment components. The AIS of Skull and Thorax predicted a higher cost of admission to ICU and Total Cost. The AIS of lower limbs was associated with greater spending on facets of treatment related to surgical activity.

DISCUSSION

There are clinical parameters that are predictors of the treatment cost of the polytraumatized patient. The study describes how the type of trauma that the patient suffers modifies the type of expenses that will present in their hospital admission.

CONCLUSIONS

Polytraumatized patients with severe multisystem injury present increased costs in multiple components of the treatment cost. Patients with TBI or chest trauma present a higher cost for admission to ICU and those with orthopaedic trauma are associated with greater expenditure on surgical activity.

Incidence of traumatic carotid and vertebral artery dissections: results of cervical vessel computed tomography angiogram as a mandatory scan component in severely injured patients

Purpose

The aim of this study was to evaluate the true incidence of cervical artery dissections (CeADs) in trauma patients with an Injury Severity Score (ISS) of ≥16, since head-and-neck computed tomography angiogram (CTA) is not a compulsory component of whole-body trauma computed tomography (CT) protocols.

Patients and methods

A total of 230 consecutive trauma patients with an ISS of ≥16 admitted to our Level I trauma center during a 24-month period were prospectively included. Standardized whole-body CT in a 256-detector row scanner included a head-and-neck CTA. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed retrospectively in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD).

Results

Of the 230 patients included, 6.5% had a CeAD, 5.2% had a CAD, and 1.7% had a VAD. One patient had both CAD and VAD. For both, CAD and VAD, mortality is 25%. One death was caused by fatal cerebral ischemia due to high-grade CAD. A total of 41.6% of the patients with traumatic CAD and 25% of the patients with VAD had neurological sequelae.

Conclusion

Mandatory head-and-neck CTA yields higher CeAD incidence than reported before. We highly recommend the compulsory inclusion of a head-and-neck CTA to whole-body CT routines for severely injured patients.

Differential effects of the Glasgow Coma Scale Score and its Components: An analysis of 54,069 patients with traumatic brain injury

INTRODUCTION

The Glasgow Coma Scale (GCS) is widely used in the assessment of clinical severity and prediction of outcome after traumatic brain injury (TBI). The sum score is frequently applied, but the differential influence of the components infrequently addressed. We aimed to investigate the contribution of the GCS components to the sum score, floor and ceiling effects of the components, and their prognostic effects.

METHODS

Data on adult TBI patients were gathered from three data repositories: TARN (n=50,064), VSTR (n=14,062), and CRASH (n=9,941). Data on initial hospital GCS-assessment and discharge mortality were extracted. A descriptive analysis was performed to identify floor and ceiling effects. The relation between GCS and outcome was studied by comparing case fatality rates (CFR) between different component-profiles adding up to identical sum scores using Chi²-tests, and by quantifying the prognostic value of each component and sum score with Nagelkerke's R² derived from logistic regression analyses across TBI severities.

RESULTS

In the range 3-7, the sum score is primarily determined by the motor component, as the verbal and eye components show floor-effects at sum scores 7 and 8, respectively. In the range 8-12, the effect of the motor component attenuates and the verbal and eye components become more relevant. The motor, eye and verbal scores reach their ceiling-effects at sum 13, 14 and 15, respectively. Significant variations were exposed in CFR between different component-profiles despite identical sum scores, except in sum scores 6 and 7. Regression analysis showed that the motor score had highest R² values in severe TBI patients, whereas the other components were more relevant at higher sum scores. The prognostic value of the three components combined was consistently higher than that of the sum score alone.

CONCLUSION

The GCS-components contribute differentially across the spectrum of consciousness to the sum score, each having floor and ceiling effects. The specific component-profile is related to outcome and the three components combined contain higher prognostic value than the sum score across different TBI severities. We, therefore, recommend a multidimensional use of the three-component GCS both in clinical practice, and in prognostic studies.

Regionalisation of trauma care in England

AIMS

We aimed to determine whether there is evidence of improved patient outcomes in Major Trauma Centres following the regionalisation of trauma care in England.

PATIENTS AND METHODS

An observational study was undertaken using the Trauma Audit and Research Network (TARN), Hospital Episode Statistics (HES) and national death registrations. The outcome measures were indicators of the quality of trauma care, such as treatment by a senior doctor and clinical outcomes, such as mortality in hospital.

RESULTS AND CONCLUSION

A total of 20 181 major trauma cases were reported to TARN during the study period, which was 270 days before and after each hospital became a Major Trauma Centre. Following regionalisation of trauma services, all indicators of the quality of care improved, fewer patients required secondary transfer between hospitals and a greater proportion were discharged with a Glasgow Outcome Score of "good recovery". In this early post-implementation analysis, there were a number of apparent process improvements (e.g. time to CT) but no differences in either crude or adjusted mortality. The overall number of deaths following trauma in England did not change following the national reconfiguration of trauma services. Evidence from other countries that have regionalised trauma services suggests that further benefits may become apparent after a period of maturing of the trauma system. Cite this article: Bone Joint J 2016;98-B:1253-61.

Quantifying the healthcare costs of treating severely bleeding major trauma patients: a national study for England

INTRODUCTION

Severely bleeding trauma patients are a small proportion of the major trauma population but account for 40% of all trauma deaths. Healthcare resource use and costs are likely to be substantial but have not been fully quantified. Knowledge of costs is essential for developing targeted cost reduction strategies, informing health policy, and ensuring the cost-effectiveness of interventions.

METHODS

In collaboration with the Trauma Audit Research Network (TARN) detailed patient-level data on in-hospital resource use, extended care at hospital discharge, and readmissions up to 12 months post-injury were collected on 441 consecutive adult major trauma patients with severe bleeding presenting at 22 hospitals (21 in England and one in Wales). Resource use data were costed using national unit costs and mean costs estimated for the cohort and for clinically relevant subgroups. Using nationally available data on trauma presentations in England, patient-level cost estimates were up-scaled to a national level.

RESULTS

The mean (95% confidence interval) total cost of initial hospital inpatient care was £19,770 (£18,177 to £21,364) per patient, of which 62% was attributable to ventilation, intensive care, and ward stays, 16% to surgery, and 12% to blood component transfusion. Nursing home and rehabilitation unit care and re-admissions to hospital increased the cost to £20,591 (£18,924 to £22,257). Costs were significantly higher for more severely injured trauma patients (Injury Severity Score ≥15) and those with blunt injuries. Cost estimates for England were £148,300,000, with over a third of this cost attributable to patients aged 65 years and over.

CONCLUSIONS

Severely bleeding major trauma patients are a high cost subgroup of all major trauma patients, and the cost burden is projected to rise further as a consequence of an aging population and as evidence continues to emerge on the benefits of early and simultaneous administration of blood products in pre-specified ratios. The findings from this study provide a previously unreported baseline from which the potential impact of changes to service provision and/or treatment practice can begin to be evaluated. Further studies are still required to determine the full costs of post-discharge care requirements, which are also likely to be substantial.

Hemodynamic optimization in severe trauma: a systematic review and meta-analysis

Objective

Severe trauma can be associated with significant hemorrhagic shock and impaired organ perfusion. We hypothesized that goal-directed therapy would confer morbidity and mortality benefits in major trauma.

Methods

The MedLine, Embase and Cochrane Controlled Clinical Trials Register databases were systematically searched for randomized, controlled trials of goal-directed therapy in severe trauma patients. Mortality was the primary outcome of this review. Secondary outcomes included complication rates, length of hospital and intensive care unit stay, and the volume of fluid and blood administered. Meta-analysis was performed using RevMan software, and the data presented are as odds ratios for dichotomous outcomes and as mean differences (MDs) and standard MDs for continuous outcomes.

Results

Four randomized, controlled trials including 419 patients were analyzed. Mortality risk was significantly reduced in goal-directed therapy-treated patients, compared to the control group (OR=0.56, 95%CI: 0.34-0.92). Intensive care (MD: 3.7 days 95%CI: 1.06-6.5) and hospital length of stay (MD: 3.5 days, 95%CI: 2.75-4.25) were significantly shorter in the protocol group patients. There were no differences in reported total fluid volume or blood transfusions administered. Heterogeneity in reporting among the studies prevented quantitative analysis of complications.

Conclusion

Following severe trauma, early goal-directed therapy was associated with lower mortality and shorter durations of intensive care unit and hospital stays. The findings of this analysis should be interpreted with caution due to the presence of significant heterogeneity and the small number of the randomized, controlled trials included.

Augmented renal clearance in the ICU: results of a multicenter observational study of renal function in critically ill patients with normal plasma creatinine concentrations*

OBJECTIVE

To describe the prevalence and natural history of augmented renal clearance in a cohort of recently admitted critically ill patients with normal plasma creatinine concentrations.

DESIGN

Multicenter, prospective, observational study.

SETTING

Four, tertiary-level, university-affiliated, ICUs in Australia, Singapore, Hong Kong, and Portugal.

PATIENTS

Study participants had to have an expected ICU length of stay more than 24 hours, no evidence of absolute renal impairment (admission plasma creatinine < 120 µmol/L), and no history of prior renal replacement therapy or chronic kidney disease. Convenience sampling was used at each participating site.

INTERVENTIONS

Eight-hour urinary creatinine clearances were collected daily, as the primary method of measuring renal function. Augmented renal clearance was defined by a creatinine clearance more than or equal to 130 mL/min/1.73 m. Additional demographic, physiological, therapeutic, and outcome data were recorded prospectively.

MEASUREMENTS AND MAIN RESULTS

Nine hundred thirty-two patients were admitted to the participating ICUs over the study period, and 281 of which were recruited into the study, contributing 1,660 individual creatinine clearance measures. The mean age (95% CI) was 54.4 years (52.5-56.4 yr), Acute Physiology and Chronic Health Evaluation II score was 16 (15.2-16.7), and ICU mortality was 8.5%. Overall, 65.1% manifested augmented renal clearance on at least one occasion during the first seven study days; the majority (74%) of whom did so on more than or equal to 50% of their creatinine clearance measures. Using a mixed-effects model, the presence of augmented renal clearance on study day 1 strongly predicted (p = 0.019) sustained elevation of creatinine clearance in these patients over the first week in ICU.

CONCLUSIONS

Augmented renal clearance appears to be a common finding in this patient group, with sustained elevation of creatinine clearance throughout the first week in ICU. Future studies should focus on the implications for accurate dosing of renally eliminated pharmaceuticals in patients with augmented renal clearance, in addition to the potential impact on individual clinical outcomes.

Acute costs and predictors of higher treatment costs of trauma in New South Wales, Australia

BACKGROUND

Accurate economic data are fundamental for improving current funding models and ultimately in promoting the efficient delivery of services. The financial burden of a high trauma casemix to designated trauma centres in Australia has not been previously determined, and there is some evidence that the episode funding model used in Australia results in the underfunding of trauma.

AIM

To describe the costs of acute trauma admissions in trauma centres, identify predictors of higher treatment costs and cost variance in New South Wales (NSW), Australia.

MATERIALS AND METHODS

Data linkage of admitted trauma patient and financial data provided by 12 Level 1 NSW trauma centres for the 08/09 financial year was performed. Demographic, injury details and injury scores were obtained from trauma registries. Individual patient general ledger costs (actual trauma patient costs), Australian Refined Diagnostic Related Groups (AR-DRG) and state-wide average costs (which form the basis of funding) were obtained. The actual costs incurred by the hospital were then compared with the state-wide AR-DRG average costs. Multivariable multiple linear regression was used for identifying predictors of costs.

RESULTS

There were 17,522 patients, the average per patient cost was $10,603 and the median was $4628 (interquartile range: $2179-10,148). The actual costs incurred by trauma centres were on average $134 per bed day above AR-DRG costs-determined costs. Falls, road trauma and violence were the highest causes of total cost. Motor cyclists and pedestrians had higher median costs than motor vehicle occupants. As a result of greater numbers, patients with minor injury had comparable total costs with those generated by patients with severe injury. However the median cost of severely injured patients was nearly four times greater. The count of body regions injured, sex, length of stay, serious traumatic brain injury and admission to the Intensive Care Unit were significantly associated with increased costs (p<0.001).

CONCLUSION

This multicentre trauma costing study demonstrated the feasibility of trauma registry and financial data linkage. Discrepancies between the observed costs of care in these 12 trauma centres and the NSW average AR-DRG costs suggest that trauma care is currently underfunded in NSW.

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996-2010). A population cross-sectional survey study

BACKGROUND

Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma.

INTRODUCTION

The evaluation of their influence on mortality during the last 15 years can lead to further improvements.

METHODS

In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996-2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value.

RESULTS

Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p < 0.01). Mean GCS (10.2) increased during the period (test trend p < 0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p < 0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p < 0.05). Significant predictors of mortality in the whole group were year of admission (p < 0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p < 0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p < 0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p = 0.06).

CONCLUSION

Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.

Early computed tomography scanning in multisystem trauma: The evidence

The utility of computed tomography as a radiological investigation following multisystem trauma is already well established in current practice. This article examines the existing evidence and rationale behind the use of early computed tomography scanning in the management of the multisystem trauma patient, with a particular emphasis on the use of ‘whole body’ computed tomography scanning as a component of their initial management in the Emergency Department.

The use of computed tomography has been shown to be superior to plain radiography for the detection of injuries in important body regions including the spine, thorax, abdomen and pelvis. Computed tomography scan of the head and cervical spine is also well established as the first investigation of choice for significant traumatic brain injury. The potential benefits of whole body computed tomography include reduced time to diagnosis and intervention, as well as significant improvements in clinical outcome and survival. Concerns regarding a whole body computed tomography approach relate to the increased ionising radiation dosage that patients will be exposed to, and perceived risks of the secondary transfer and scanning room environment itself. Potential barriers to the use of whole body computed tomography are also explored and discussed.

This article also presents a proposed clinical algorithm derived from the results of a recent Delphi study into whole body computed tomography following blunt multitrauma, along with conclusions and recommendations from the subject matter panel review process.

The variation of acute treatment costs of trauma in high-income countries

BACKGROUND

In order to assist health service planning, understanding factors that influence higher trauma treatment costs is essential. The majority of trauma costing research reports the cost of trauma from the perspective of the receiving hospital. There has been no comprehensive synthesis and little assessment of the drivers of cost variation, such as country, trauma, subgroups and methods. The aim of this review is to provide a synthesis of research reporting the trauma treatment costs and factors associated with higher treatment costs in high income countries.

METHODS

A systematic search for articles relating to the cost of acute trauma care was performed and included studies reporting injury severity scores (ISS), per patient cost/charge estimates; and costing methods. Cost and charge values were indexed to 2011 cost equivalents and converted to US dollars using purchasing power parities.

RESULTS

A total of twenty-seven studies were reviewed. Eighty-one percent of these studies were conducted in high income countries including USA, Australia, Europe and UK. Studies either reported a cost (74.1%) or charge estimate (25.9%) for the acute treatment of trauma. Across studies, the median per patient cost of acute trauma treatment was $22,448 (IQR: $11,819-$33,701). However, there was variability in costing methods used with 18% of studies providing comprehensive cost methods. Sixty-three percent of studies reported cost or charge items incorporated in their cost analysis and 52% reported items excluded in their analysis. In all publications reviewed, predictors of cost included Injury Severity Score (ISS), surgical intervention, hospital and intensive care, length of stay, polytrauma and age.

CONCLUSION

The acute treatment cost of trauma is higher than other disease groups. Research has been largely conducted in high income countries and variability exists in reporting costing methods as well as the actual costs. Patient populations studied and the cost methods employed are the primary drivers for the treatment costs. Targeted research into the costs of trauma care is required to facilitate informed health service planning.

Relationship between types of head injury and age of pedestrian

This paper explores the relationship between age and the different types of head injury received by pedestrians in traffic accidents with cars. The analysis is based on information collected by hospitals in England, and is supported by in-depth case examples. The principle result is that the risk of intracranial injury increases with age, whilst the risk of fracture to the head or facial bones remains relatively constant. This agrees with previous findings for other groups of casualties, which have reported that that the decrease in brain size leads to an increase in the relative motion of the skull and brain in an impact, with a corresponding increase in the risk of traumatic brain injury. Intracranial injuries have also been found to place the greatest burden on hospitals, which may have implications on automotive design if prevention of these injuries is to be prioritised over fractures of the skull.

Evaluating the validity of multiple imputation for missing physiological data in the national trauma data bank

Background:

The National Trauma Data Bank (NTDB) is plagued by the problem of missing physiological data. The Glasgow Coma Scale score, Respiratory Rate and Systolic Blood Pressure are an essential part of risk adjustment strategies for trauma system evaluation and clinical research. Missing data on these variables may compromise the feasibility and the validity of trauma group comparisons.

Aims:

To evaluate the validity of Multiple Imputation (MI) for completing missing physiological data in the National Trauma Data Bank (NTDB), by assessing the impact of MI on 1) frequency distributions, 2) associations with mortality, and 3) risk adjustment.

Methods:

Analyses were based on 170,956 NTDB observations with complete physiological data (observed data set). Missing physiological data were artificially imposed on this data set and then imputed using MI (MI data set). To assess the impact of MI on risk adjustment, 100 pairs of hospitals were randomly selected with replacement and compared using adjusted Odds Ratios (OR) of mortality. OR generated by the observed data set were then compared to those generated by the MI data set.

Results:

Frequency distributions and associations with mortality were preserved following MI. The median absolute difference between adjusted OR of mortality generated by the observed data set and by the MI data set was 3.6% (inter-quartile range: 2.4%-6.1%).

Conclusions:

This study suggests that, provided it is implemented with care, MI of missing physiological data in the NTDB leads to valid frequency distributions, preserves associations with mortality, and does not compromise risk adjustment in inter-hospital comparisons of mortality.

Probability of survival, early critical care process, and resource use in trauma patients

BACKGROUND

Trauma Injury Severity Score is a frequently used prediction model for mortality. However, few studies have assessed the probability of survival (Ps) and early resource use after trauma. We studied the impact of Ps on early critical care or costs to test its applicability to efficient trauma care.

METHODS

The relationship between Ps in 8207 trauma patients and patients' demographics, organ injured, comorbidities, use of critical care, and total charges during the initial 48 hours was analyzed using multiple regression analyses.

RESULTS

Significant differences were observed among study variables across different Ps. A large variability in total charges was observed and explained by critical care, which Ps was significantly associated with.

CONCLUSIONS

Trauma Injury Severity Score offers a tool for estimating resource use and might improve monitoring of early trauma care quality. Measuring the combined effect of Trauma Injury Severity Score and injured organs would refine the methodology for evaluating the trauma care system.

Injury severity score, resource use, and outcome for trauma patients within a Japanese administrative database

BACKGROUND

Injury Severity Score (ISS) is commonly used in prediction models and risk adjustment for mortality. However, few studies have assessed the relationship of ISS to outcomes such as resource use. To test the utility of ISS for investigation of the quality of trauma care, we evaluated the impact of ISS on resource utilization and mortality.

METHODS

Of 1,895,249 cases from a Japanese administrative database in 2006, 13,627 trauma patients with ISS were analyzed. Variables included demographics, ISS, number and locations of injured organs, comorbidities, diagnostic and therapeutic procedures recorded during hospitalization, and hospital type. Dependent variables were length of stay (LOS), total charges (TC), initial 48-hour TC, high outliers of LOS or TC, and mortality. Multivariate analyses were used to measure the impact of ISS.

RESULTS

ISS 1 to 9 was most frequent (85.5%) and blunt injury occurred in 93.7% of patients. With increasing ISS, the mortality rate rose to 27.2% at ISS >or=36. LOS was higher at ISS >or=36 whereas TC was higher at 25 to 35. After controlling for study variables, rehabilitation was most strongly associated with LOS, TC, and LOS outliers. ISS 25 to 35 affected initial 48-hour TC most, while ventilation affected mortality most. "Abdomen, pelvic organs" and ISS 25 to 35 or >or=36 were more strongly associated with outcomes.

CONCLUSIONS

Specific ISS and injured organs may be used to estimate resource use or mortality for monitoring quality of trauma care. To integrate a more efficient system of trauma care, variations in resource input among hospitals should be investigated.

Health and economic burden of traumatic brain injury: Missouri, 2001-2005

OBJECTIVE

We examined the financial and social costs resulting from traumatic brain injury (TBI) in Missouri.

METHODS

We computed mortality rates from death certificates, the direct cost of TBI from hospital and emergency department (ED) visit charges, the social cost in terms of years of potential life lost (YPLL) using an abridged Missouri life table, and the indirect financial cost in terms of lost productivity due to premature death for all TBI and four major causes of TBI in Missouri.

RESULTS

During 2001-2005, a mean of 1358 lives were lost due to TBI in Missouri. Four major causes-unintentional falls, motor vehicle traffic crashes, motorcycle crashes, and firearms-accounted for 88% of all TBI deaths. We estimated the annual direct medical cost of TBI at $95 million, or about $1.67 million per 100,000 Missourians. This cost increased by about 60% between 2001 and 2005. The four major causes of TBI accounted for 68% of all direct medical costs of TBI. We estimated the cost per hospitalization and ED visit at $6948 and the indirect social cost at 48,501 YPLL. During this period, the mean age of TBI fatality was 44 years. We determined the lost productivity due to TBI mortality--$1.1 billion, or about $18.8 million per 100,000 Missourians--to be three times as high for males as for females.

CONCLUSIONS

The types of costs covered in this study underestimated the total cost of TBI in Missouri, as we did not include outpatient care, rehabilitation, and drug costs. Nevertheless, we found the health and economic burden from medical care and mortality related to TBI to be substantial in Missouri.

A review of injury epidemiology in the UK and Europe: some methodological considerations in constructing rates

BACKGROUND

Serious injuries have been stated as a public health priority in the UK. However, there appears to be a lack of information on population-based rates of serious injury (as defined by a recognised taxonomy of injury severity) at national level from either official statistics or research papers. We aim to address this through a search and review of literature primarily focused within the UK and Europe.

METHODS

The review summarizes research papers on the subject of population based injury epidemiology published from 1970 to 2008. We examined critically methodological approaches in measuring injury incident rates including data sources, description of the injury pyramid, matching numerator and denominator populations as well as the relationship between injury and socioeconomic status.

RESULTS

National representative rates come from research papers using official statistics sources, often focusing on mortality data alone. Few studies present data from the perspective of an injury pyramid or using a standardized measure of injury severity, i.e. Injury Severity Score (ISS). The population movement that may result in a possible numerator - denominator mismatch has been acknowledged in five research studies and in official statistics. The epidemiological profile shows over the past decades in UK and Europe a decrease in injury death rates. No major trauma population based rates are available within well defined populations across UK over recent time periods. Both fatal and non-fatal injury rates occurred more frequently in males than females with higher rates in males up to 65 years, then in females over 65 years. Road traffic crashes and falls are predominant injury mechanisms. Whereas a straightforward inverse association between injury death rates and socio-economic status has been observed, the evidence of socioeconomic inequalities in non-fatal injuries rates has not been wholly consistent.

CONCLUSION

New methodological approaches should be developed to deal with the study design inconsistencies and the knowledge gaps identified across this review. Trauma registries contain injury data from hospitals within larger regions and code injury by Abbreviated Injury Scale enabling information on severity; these may be reliable data sources to improve understanding of injury epidemiology.