Medical and productivity costs after trauma

Health-Care Costs for Patients with a Lower-Extremity Fracture Have Increased Disproportionately Over the Past 10 Years: A Medical Expenditure Panel Survey Analysis of Total Expenditure and Out-of-Pocket Costs

BACKGROUND

Increasing U.S. health-care costs raise concerns regarding the sustainability of the U.S. health-care system, with the potential for negative effects on the mental and physical health of patients. Orthopaedic injuries often impose considerable financial burdens on patients and hospitals, but the trends in, and drivers of, costs remain unclear. This study evaluated the total expenditure and out-of-pocket (OOP) costs of patients with a lower-extremity (LE) fracture in the non-institutionalized U.S. population from 2010 to 2021.

METHODS

A total of 3,016 participants with an LE fracture from the Medical Expenditure Panel Survey (MEPS) were propensity score matched with 15,080 MEPS participants with no LE fracture. Patients with an LE fracture were predominantly between 40 and 64 years old (43.2%), female (66.0%), and White (78.8%). Total expenditure and OOP costs were compared between the groups. A multivariable regression analysis was performed to identify factors that were associated with costs. Outcomes were adjusted on the basis of the 2022 Consumer Price Index.

RESULTS

Patients with an LE fracture had greater total expenses than the control group ($20,230 [95% confidence interval (CI), $18,916 to $21,543] versus $10,678 [95% CI, $10,302 to $11,053]; p < 0.001) as well as greater OOP costs ($1,634 [95% CI, $1,516 to $1,753] versus $1,089 [95% CI, $1,050 to $1,128]; p < 0.001). Between 2010 and 2021, total expenses increased more for patients with an LE fracture than for the control group (101.2% versus 51.4%; p < 0.001), whereas OOP costs increased to a lesser degree in both groups (61.1% versus 44.5%; p = 0.17). In the LE fracture group, total expenditure was driven by inpatient care, office-based visits, and prescription costs, whereas OOP costs were driven by office-based visits, prescription costs, and "other" sources. Femoral fracture, hospitalization, and certain comorbidities were associated with higher total expenses. Hospitalization, uninsured status, and a higher income level were associated with increased OOP costs, whereas African American or Hispanic background and a lower educational level were associated with lower OOP costs.

CONCLUSIONS

An LE fracture was associated with considerable total expenditure and OOP costs, which increased disproportionately compared with general health-care costs over the past decade. Post-hospitalization care was the biggest driver of both total expenses and OOP costs. Due to limitations inherent to the MEPS database, the impact of financial burden on not only payers but also individuals and their medical decision-making remains unclear and requires further investigation.

LEVEL OF EVIDENCE

Economic Level III . See Instructions for Authors for a complete description of levels of evidence.

miR-21-5p Enriched Exosomes from Human Embryonic Stem Cells Promote Osteogenesis via YAP1 Modulation

Purpose

To investigate the osteogenic potential of human embryonic stem cell-derived exosomes (hESC-Exos) and their effects on the differentiation of human umbilical cord mesenchymal stem cells (hUCMSCs).

Methods

hESC-Exos were isolated and characterized using transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA), and Western blotting. hUCMSCs were cultured with hESC-Exos to assess osteogenic differentiation through alizarin red staining, quantitative PCR (qPCR), and Western blotting. miRNA profiling of hESC-Exos was performed using miRNA microarray analysis. In vivo bone regeneration was evaluated using an ovariectomized rat model with bone defects treated with exosome-loaded scaffolds.

Results

hESC-Exos significantly promoted the osteogenic differentiation of hUCMSCs, as evidenced by increased alizarin red staining and the upregulation of osteogenesis-related genes and proteins (ALP, RUNX2, OCN). miRNA analysis revealed that miR-21-5p is a key regulator that targets YAP1 and activates the Wnt/β-catenin signaling pathway. In vivo, hESC-Exos enhanced bone repair in ovariectomized rats, as demonstrated by increased bone mineral density and improved bone microarchitecture compared to those in controls.

Conclusion

hESC-Exos exhibit significant osteogenic potential by promoting the differentiation of hUCMSCs and enhancing bone regeneration in vivo. This study revealed that the miR-21-5p-YAP1/β-catenin axis is a critical pathway, suggesting that the use of hESC-Exos is a promising therapeutic strategy for bone regeneration and repair.

Long-term PTSD prevalence and associated adverse psychological, functional, and economic outcomes: a 12-15 year follow-up of adults with suspected serious injury

Background: An increasing number of longitudinal studies investigates long-term PTSD, related outcomes and potential gender differences herein. However, a knowledge gap exists when it comes to studies following individual civilian trauma beyond a decade post-trauma.Objective: To investigate the long-term PTSD prevalence, associated adverse psychological, functional and economic outcomes related to (suspected) serious injury of 12-15 years ago in Dutch adults, as well as potential gender differences herein.Method: N = 194 trauma-exposed adults (34% women) admitted to an emergency department following suspected serious injury completed a follow-up assessment 12-15 years (M = 14.30, SD = 1.00) post-trauma. Participants completed assessments of clinician-rated PTSD symptom severity, as well as self-report questionnaires on psychological, functional and economic outcomes.Results: Nine participants (4.8%) fulfilled the DSM-5 diagnostic criteria for PTSD related to the index trauma of 12-15 years ago. Results showed that PTSD symptom severity (CAPS-5) was significantly associated with more severe symptoms of anxiety (HADS) and depression (QIDS), lower well-being (WHO-5) and (health-related) quality of life (WHOQOL; EQ-5D-5L), but not with alcohol use (AUDIT), productivity loss at work (iPCQ) and health care use (iMCQ). No significant gender differences in the long-term PTSD prevalence nor in its related psychological, functional and economic outcomes were found.Conclusions: Our findings underscore the long-term presence of PTSD and associated adverse psychological and functional outcomes in a proportion of adults who experienced (suspected) serious injury over a decade ago. PTSD is already widely recognized for its substantial impact in the aftermath of a trauma. The current study emphasizes the potential long-term consequences of individual civilian trauma, highlighting the importance of accurate screening and prevention for PTSD.

Cost-Benefit Analysis of the CT of the Face in the Evaluation of Traumatic Facial Fractures in an Appalachian Tri-state Geriatric Population

OBJECTIVE

This study aimed to evaluate the cost vs. benefits of the CT face imaging study in the trauma workup of those over the age of 65.

METHODS

We performed a retrospective chart review of 169 trauma patients in our trauma database aged 65 years or older who underwent a CT of the head, a CT of the face, or a CT of the head and CT of the face that resulted in findings of a facial fracture from 2017-2022. Injuries and the treatment they received were documented. If a patient underwent both a CT of the face and a CT of the head, then the author first viewed the CT of the head, documented any injury, and then recorded treatment based on the CT of the head. The CT of the face was then viewed, injuries were recorded, and treatment based on the CT of the face was documented. Statistical analysis was then performed using the paired T-test, McNemar test, and number needed to harm analysis.

RESULTS

Of the 169 patients sampled, 159 underwent both CT of the head and the face. There were no patients who underwent a CT of the face exclusively, and only 10 patients underwent a CT of the head exclusively. Of the 159 that had both a CT of the head and the face, the average number of injuries noted on CT of the head + CT of the face vs. CT of the head was 2.42 vs. 1.36, P<.0.0001. The number needed to avoid missing a surgical facial fracture when only a CT of the head was obtained was 14.68.

CONCLUSION

The risks of missing a surgical facial fracture outweigh the monetary, radiation, and patient-desired necessity benefits of only performing a CT of the head. A CT of the face should be included in the trauma workup for those over the age of 65 when facial fractures are suspected.

Barriers and facilitators associated with the upscaling of the Transmural Trauma Care Model: a qualitative study

BACKGROUND

To assess the barriers and facilitators associated with upscaling the Transmural Trauma Care Model (TTCM), a multidisciplinary and patient-centred transmural rehabilitation care model.

METHODS

Semi-structured interviews were conducted with eight trauma surgeons, eight hospital-based physiotherapists, eight trauma patients, and eight primary care physiotherapists who were part of a trauma rehabilitation network. Audio recordings of the interviews were made and transcribed verbatim. Data were analysed using a framework method based on the "constellation approach". Identified barriers and facilitators were grouped into categories related to structure, culture, and practice.

RESULTS

Various barriers and facilitators to upscaling were identified. Under structure, barriers and facilitators belonged to one of five themes: "financial structure", "communication structure", "physical structures and resources", "rules and regulations", and "organisation of the network". Under culture, the five themes were "commitment", "job satisfaction", "acting as a team", "quality and efficiency of care", and "patients' experience". Under practice, the two themes were "practical issues at the outpatient clinic" and "knowledge gained".

CONCLUSION

The success of upscaling the TTCM differed across hospitals and settings. The most important prerequisites for successfully upscaling the TTCM were adequate financial support and presence of "key actors" within an organisation who felt a sense of urgency for change and/or expected the intervention to increase their job satisfaction.

TRIAL REGISTRATION

NL8163 The Netherlands National Trial Register, date of registration 16-11-2019.

Barriers to accessing follow up care in post-hospitalized trauma patients in Moshi, Tanzania: A mixed methods study

Disproportionately high injury rates in Sub-Saharan Africa combined with limited access to care in both the acute injury phase and for injury patients requiring continued care after hospital discharge remains a challenge. We aimed to characterize barriers to transportation and access to care in a cohort of post-hospitalized injury patients in Moshi, Tanzania. This was a mixed-methods study of a prospective cohort of trauma registry patients presenting to Kilimanjaro Christian Medical Center between August 2018 and January 2020. We conducted standardized patient/family surveys and in-depth interviews at a 2-week follow up visit after hospital discharge, and focus groups with healthcare providers. Quantitative results were analyzed using descriptive statistics and multivariable logistic regression using R statistical software. Qualitative results were analyzed using thematic analysis through an iterative process using NVivo software. A total of 1,365 patients were enrolled in the trauma registry, with 169 patients followed up at 2 weeks. Over half of patients at follow-up, 101 (59.8%), reported challenges in traveling. The majority of patients were male (80.3%). Difficulty in traveling since injury was associated with female gender (aOR 5.85 [95% CI 1.20-33.59]) and a need for non-family members escorts for travel (aOR 7.10 [95% CI 1.43-41.66]). Those who reported assault or fall as the mechanism of injury as compared to road traffic injury and had health insurance were less likely to report challenges in traveling (aOR 0.19 [95% CI 0.03-0.90]), 0.11 [95% CI 0.01-0.61], 0.14 [95% 0.02-0.80]). Transportation barriers that emerged from qualitative data included inability to use regular means of transportation, financial challenges, physical barriers, rigid compliance to physician orders, access to healthcare, and social support barriers. Our findings demonstrate several areas to address transportation barriers for post-injury patients in Tanzania. Educational interventions such as clarification of doctors' orders of strict bedrest, provision of vouchers to support financial challenges and alternate means of transportation given physical barriers and reliance on social support may address some of these barriers.

Parenting-related trauma exposure among parents of children with intellectual and developmental disorders: Development and validation of the Parenting Trauma Checklist

Parents of children with intellectual and developmental disorders (IDDs) often encounter parenting-related traumatic events. Trauma exposure is a risk factor for mental health problems, including posttraumatic stress disorder (PTSD). Little is known regarding the types of traumatic events that parents commonly experience and how to best assess parenting-related trauma exposure. To address this gap, we developed the Parenting Trauma Checklist (PTC) and tested its psychometric properties. The PTC was created based on an extensive literature review and consultation with stakeholders, which led to the creation of a 17-item instrument. Participants (N = 424) were Canadian parents of children with IDDs who completed an online test battery that included the PTC and several questionnaires to assess PTSD symptoms, global mental and physical health, lifetime trauma exposure, and functional impairment, which were included to test the validity of the new instrument. The PTC demonstrated good construct validity. Ninety four percent of the sample reported parenting-related trauma exposure. Parents reported having experienced an average of 5.79 parenting-related traumatic events, with seeing their child undergo a medical procedure the most frequently endorsed event (68.6%). Experiencing more parenting-related traumatic events was positively associated with higher PTSD symptom levels, r = .35, p < .001. The PTC is a promising instrument that can be used to examine parenting-related trauma exposure. The measure can be used as a screening tool to detect parents' risk of traumatic stress disorders, evaluate traumatic experiences, and assess whether trauma-focused treatment is warranted.

Admission Lymphopenia is Associated With Discharge Disposition in Blunt Chest Wall Trauma Patients

BACKGROUND

Lymphopenia contributes to the immune suppression observed in critical illness. However, its role in the immunologic response to trauma remains unclear. Herein, we assessed whether admission lymphopenia is associated with poor outcomes in patients with blunt chest wall trauma (BCWT).

METHODS

All adult patients with a Chest Abbreviated Injury Score (CAIS) ≥2 admitted to our Level I Trauma center between May 2009 and December 2018 were identified in our institution Trauma Registry. Patients with absolute lymphocyte counts (ALC) collected within 24 H of admission were included. Patients who died within 24 H of admission, had bowel perforation on admission, penetrating trauma, and burns were excluded. Demographics, injury characteristics, comorbidities, ALC, complications, and outcomes were collected. Lymphopenia was defined as an ALC ≤1000/µL. Association between lymphopenia and clinical outcomes of BCWT was assessed using multivariate analyses. P < 0.05 was considered significant.

RESULTS

A total of 1394 patients were included; 69.7% were male; 44.3% were lymphopenic. On univariate analysis, lymphopenia was associated with longer in-hospital stay (11.6±10.2 versus 10.1±11.4, P = 0.009), in-hospital death (9.7% versus 5.8%, P = 0.006), and discharge to a healthcare facility (60.9% versus 46.4%, P < 0.001). Controlling for Injury Severity Score, age, gender, and comorbidities, the association between lymphopenia and discharge to another facility (SNF/rehabilitation facility/ACH) (OR = 1.380 [1.041-1.830], P = 0.025) remained significant.

CONCLUSIONS

Lymphopenia on admission is associated with discharge requiring increased healthcare support. Routine lymphocyte count monitoring on admission may provide important prognostic information for BCWT patients.

Association between the initial serum phosphate level and 30-day mortality in blunt trauma patients

BACKGROUND

Studies on patients with cardiac arrest or sepsis have reported that high initial phosphate levels are associated with poor outcomes. However, no previous study has investigated the association between initial phosphate levels and outcomes in blunt trauma patients.

METHODS

This study was a retrospective observational study conducted on blunt trauma patients who had been treated at the single regional trauma center between January 2016 and December 2017. Patients' demographic data, initial vital signs, trauma scores, and laboratory parameters including phosphate levels were collected from the trauma registry. The primary outcome was set to 30-day mortality. The secondary outcomes were the total volume of blood transfused, 30-day hospital-free days, and 30-day intensive care unit-free days.

RESULTS

Of the 1,907 included patients, 1,836 were in the survival group, and 71 were in the nonsurvival group. The nonsurvival group had a significantly higher phosphate level than the survival group. Patients in the hyperphosphatemia group had a higher 30-day mortality, fewer 30-day intensive care unit-free days, and higher transfusion volume than those in the other groups. In multivariable logistic regression analysis, hyperphosphatemia was independently associated with 30-day mortality. The receiver operating characteristic curve analysis showed that the area under the curve with the inclusion of phosphate in addition to Injury Severity Score, Revised Trauma Score, and age was 0.911. Area under the curve was also increased when phosphate was simply added to Injury Severity Score and Revised Trauma Score.

CONCLUSION

In blunt trauma patients, hyperphosphatemia was associated with an increased 30-day mortality.

LEVEL OF EVIDENCE

Prognostic, level III.

Long-term medical and productivity costs of severe trauma: Results from a prospective cohort study

Background

Through improvements in trauma care there has been a decline in injury mortality, as more people survive severe trauma. Patients who survive severe trauma are at risk of long-term disabilities which may place a high economic burden on society. The purpose of this study was to estimate the health care and productivity costs of severe trauma patients up to 24 months after sustaining the injury. Furthermore, we investigated the impact of injury severity level on health care utilization and costs and determined predictors for health care and productivity costs.

Methods

This prospective cohort study included adult trauma patients with severe injury (ISS≥16). Data on in-hospital health care use, 24-month post-hospital health care use and productivity loss were obtained from hospital registry data and collected with the iMTA Medical Consumption and Productivity Cost Questionnaire. The questionnaires were completed 1 week and 1, 3, 6, 12 and 24 months after injury. Log-linked gamma generalized linear models were used to investigate the drivers of health care and productivity costs.

Results

In total, 174 severe injury patients were included in this study. The median age of participants was 55 years and the majority were male (66.1%). The mean hospital stay was 14.2 (SD = 13.5) days. Patients with paid employment returned to work 21 weeks after injury. In total, the mean costs per patient were €24,760 with in-hospital costs of €11,930, post-hospital costs of €7,770 and productivity costs of €8,800. Having an ISS ≥25 and lower health status were predictors of high health care costs and male sex was associated with higher productivity costs.

Conclusions

Both health care and productivity costs increased with injury severity, although large differences were observed between patients. It is important for decision-makers to consider not only in-hospital health care utilization but also the long-term consequences and associated costs related to rehabilitation and productivity loss.

Effectiveness and cost-effectiveness of the Transmural Trauma Care Model investigated in a multicenter trial with a controlled before-and-after design: A study protocol

OBJECTIVE

The rehabilitation of trauma patients in primary care is challenging, and there are no guidelines for optimal treatment. Also, the organization of care is not well-structured. The Transmural Trauma Care Model (TTCM) has been developed in the Netherlands, aiming to improve patient outcomes by optimizing the organization and the quality of the rehabilitation process in primary care. A recent feasibility study showed that implementation of the TTCM at a Dutch Level 1 trauma center was feasible, patient outcomes were improved, and costs were reduced. This study aims to assess the effectiveness and cost-effectiveness of the TTCM compared to the usual care in a multicenter trial.

METHODS

A multicenter trial with a controlled before-and-after design will be performed at 10 hospitals in the Netherlands. First, participating hospitals will include 322 patients in the control group, receiving usual care as provided in these specific hospitals. Subsequently, the TTCM will be implemented in all participating hospitals, and hospitals will include an additional 322 patients in the intervention group. The TTCM consists of a multidisciplinary team at the outpatient clinic (trauma surgeon and hospital-based physical therapist), an educated and trained network of primary care trauma physical therapists, and structural communication between them. Co-primary outcomes will investigate generic and disease-specific, health-related quality of life. Secondary outcomes will include pain, patient satisfaction, perceived recovery, and patient-reported physical functioning. For the economic evaluation, societal and healthcare costs will be measured. Measurements will take place at baseline and after 6 weeks, 3, 6, and 9 months. Analyses will be based on the intention-to-treat principle. Missing data will be handled using longitudinal data analyses in the effect analyses and by multivariate imputation in the economic evaluation.

CONCLUSION

This trial with a controlled before-and-after design will give insight into the effectiveness and cost-effectiveness of the TTCM in a multicenter trial.

Health care costs of injury in the older population: a prospective multicentre cohort study in the Netherlands

Background

With the ageing population, the number of older trauma patients has increased. The aim of this study was to assess non-surgical health care costs of older trauma patients and to identify which characteristics of older trauma patients were associated with high health care costs.

Methods

Trauma patients aged ≥65 years who were admitted to a hospital in Noord-Brabant, the Netherlands, were included in the Brabant Injury Outcome Surveillance (BIOS) study. Non-surgical in-hospital and up to 24- months post-hospital health care use were obtained from hospital registration data and collected with the iMTA Medical Consumption Questionnaire which patients completed 1 week and 1, 3, 6, 12 and 24 months after injury. Log-linked gamma generalized linear models were used to identify cost-driving factors.

Results

A total of 1910 patients were included in the study. Mean total health care costs per patient were €12,190 ranging from €8390 for 65–69 year-olds to €15,550 for those older than 90 years. Main cost drivers were the post-hospital costs due to home care and stay at an institution. Falls (72%) and traffic injury (15%) contributed most to the total health care costs, although costs of cause of trauma varied with age and sex. In-hospital costs were especially high in patients with high injury severity, frailty and comorbidities. Age, female sex, injury severity, frailty, having comorbidities and having a hip fracture were independently associated with higher post-hospital health care costs.

Conclusions

In-hospital health care costs were chiefly associated with high injury severity. Several patient and injury characteristics including age, high injury severity, frailty and comorbidity were associated with post-hospital health care costs. Both fall-related injuries and traffic-related injuries are important areas for prevention of injury in the older population.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12877-020-01825-z.

Fatal injuries and economic development in the population sample of Central and Eastern European Countries: the perspective of adolescents

Objectives

Researches consider the young generation (adolescents) to be the population group whose mortality from injury has the lowest effect on economic growth. The objective was to evaluate the relations between economic indicators and preventable injury mortality in Central and Eastern European Countries (CEECs), with a primary focus on adolescents.

Methods

The analyses included health indicators of preventable injury mortality and economic indicators that represent human development and economic growth in the CEECs from 1990 to 2016. The analytical process involved a population group divided by age (0–14 years: children, 15–24 years: adolescents, 25–74 years: adults) and gender. Descriptive analysis, cluster analysis and primarily panel regression analysis were used.

Results

Significant effects of economic indicators on drowning were found in all analysed relations. In the group of adolescents, significant effects of fatal falls were found. Overall, it can be concluded that the effects of fatal injuries are not homogenous between age and gender groups.

Conclusions

The effects of years and individual countries should be taken into account in the cross-sectional analyses. In terms of economic growth, public policies should focus on drowning in children, on falls in adolescents and on transport accidents, fire injuries and poisoning in adults.

Does the EQ-5D-5L benefit from extension with a cognitive domain: Testing a multi-criteria psychometric strategy in trauma patients

Purpose

This study investigated the psychometric yield of extension of the EQ-5D-5L with a cognitive domain (EQ-5D+C) in a mixed cohort of trauma patients with repeated data.

Methods

A stratified sample of patients that presented at the emergency department filled out a follow-up survey 6 and 12 months after trauma. The surveys included the EQ-5D-5L+C, EQ-VAS, and the impact of events scale-revised (IES-R), a validated post-traumatic stress disorder (PTSD) self-assessment scale. Generally, results of the EQ-5D and EQ-5D+C were compared. Psychometrics included the following: distributional features (ceiling/floor effects), discriminatory performance, convergent validity with the EQ-VAS as reference, and responsiveness to change. Psychometric properties were compared between predefined subgroups based on conditions with cognitive impact (Traumatic Brain Injury (TBI)/PTSD).

Results

In total, 1799 trauma patients responded 6 and 12 months after trauma, including 107 respondents with PTSD, and 273 with TBI. Six months post-trauma, ceiling of the EQ-5D (26.3%) was reduced with 2.2% with the additional cognitive domain. Using EQ-VAS as reference, convergent validity increased slightly with the addition of the cognitive domain: correlation increasing from 0.651 to 0.664. Cognitive level was found to slightly improve over time in TBI (delta: 0.04) and PTSD patients (delta: 0.05), while (almost) no change was found in patients without TBI and PTSD.

Conclusion

Adding a cognitive domain to the EQ-5D-5L slightly improved measurement properties and better captured change in health status for trauma patients with TBI and PTSD. Inclusion of the cognitive domain in the EQ-5D-5L when measuring in populations with cognitive problems should be considered.

Prognostic factors for medical and productivity costs, and return to work after trauma

AIM

The aim of this study was to determine prognostic factors for medical and productivity costs, and return to work (RTW) during the first two years after trauma in a clinical trauma population.

METHODS

This prospective multicentre observational study followed all adult trauma patients (≥18 years) admitted to a hospital in Noord-Brabant, the Netherlands from August 2015 through November 2016. Health care consumption, productivity loss and return to work were measured in questionnaires at 1 week, 1, 3, 6, 12 and 24 months after injury. Data was linked with hospital registries. Prognostic factors for medical costs and productivity costs were analysed with log-linked gamma generalized linear models. Prognostic factors for RTW were assessed with Cox proportional hazards model. The predictive ability of the models was assessed with McFadden R2 (explained variance) and c-statistics (discrimination).

RESULTS

A total of 3785 trauma patients (39% of total study population) responded to at least one follow-up questionnaire. Mean medical costs per patient (€9,710) and mean productivity costs per patient (€9,000) varied widely. Prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. Productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the ICU. Prognostic factors for RTW were high educational level, male gender, low injury severity, shorter length of stay at the hospital and absence of comorbidity.

CONCLUSIONS

Productivity costs and RTW should be considered when assessing the economic impact of injury in addition to medical costs. Prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increasing RTW rates.