The injury profile and acute treatment costs of major trauma in older people in New South Wales

Original Article: The impacts of DRG payment system on financial balance of multiple trauma: Experiences of three trauma centers in Taiwan

INTRODUCTION

There are concerns regarding the adequacy of applying the diagnosis-related groups (DRG) payment system for multiple traumas (i.e., major diagnostic category 24, MDC-24) patients in Taiwan. Therefore, this study used a multi-center dataset to assess the influence of the DRG payment system on the cost and outcome of multiple trauma care.

MATERIALS AND METHODS

We collected data of all multiple trauma patients from the Trauma Registry of three hospitals from 2014 - 2017. Next, we selected patients who met the criteria of MDC-24 and calculated the corresponding DRG payment. Subsequently, we combined the clinical care information with health insurance information to analyze the problems of applying the DRG payment system to multiple trauma care.

RESULTS

Overall, of 465 cases, 367 met the criteria of MDC-24, and the mean injury severity score (ISS) was high (average 20.1). The total deficit of the polytrauma DRG cases amounted to 131,445 USD, and the average deficit in each case was 397 USD. In the multivariable analysis, higher revised trauma score and specific lower abbreviated Injury Scale (AIS) scores in certain body regions resulted in profits, while increased length of stay in intensive care units, longer operative time, and higher AIS score in the thorax were significantly correlated with deficits in medical costs.

CONCLUSION

Our study revealed that the current DRG payment system results in financial losses for hospitals. Further, the payment grouping of MDC-24 should consider adding more disease severity factors to reduce the financial constraints faced by trauma centers.

Variability drivers of treatment costs in hospitals: A systematic review

OBJECTIVES

Studies on variability drivers of treatment costs in hospitals can provide the necessary information for policymakers and healthcare providers seeking to redesign reimbursement schemes and improve the outcomes-over-cost ratio, respectively. This systematic literature review, focusing on the hospital perspective, provides an overview of studies focusing on variability in treatment cost, an outline of their study characteristics and cost drivers, and suggestions on future research methodology.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Handbook for Systematic Reviews of Interventions. We searched PubMED/MEDLINE, Web of Science, EMBASE, Scopus, CINAHL, Science direct, OvidSP and Cochrane library. Two investigators extracted and appraised data for citation until October 2020.

RESULTS

90 eligible articles were included. Patient, treatment and disease characteristics and, to a lesser extent, outcome and institutional characteristics were identified as significant variables explaining cost variability. In one-third of the studies, the costing method was classified as unclear due to the limited explanation provided by the authors.

CONCLUSION

Various patient, treatment and disease characteristics were identified to explain hospital cost variability. The limited transparency on how hospital costs are defined is a remarkable observation for studies wherein cost variability is the main focus. Recommendations relating to variables, costs, and statistical methods to consider when designing and conducting cost variability studies were provided.

Complications, burden and in-hospital death among hospital treated injury patients in Victoria, Australia: a data linkage study

Background

A wide range of outcome measures can be calculated for hospital-treated injury patients. These include mortality, use of critical care services, complications, length of stay, treatment costs, readmission and nursing care after discharge. Each address different aspects and phases of injury recovery and can yield vastly different results. This study aims to: (1) measure and report this range of outcomes in hospital-treated injury patients in a defined population; and (2) describe the associations between injury characteristics, socio-demographics and comorbidities and the various outcomes.

Methods

A retrospective analysis was conducted of injury-related hospital admissions from July 2012 to June 2014 (152,835 patients) in Victoria, Australia. The admission records were linked within the dataset, enabling follow-up, to assess the outcomes of in-hospital death, burden, complications and 30-day readmissions. Associations between factors and outcomes were determined using univariate regression analysis.

Results

The proportion of patients who died in hospital was 0.9%, while 26.8% needed post-discharge care. On average patients had 2.4 complications (confidence interval (CI) 2.4–2.5) related to their initial injury, the mean cost of treating a patient was Australian dollars 7013 (CI 6929–7096) and the median length of stay was one day (inter quartile range 1–3). Intensive-care-unit-stay was recorded in 3% of the patients. All-cause 30-day readmissions occurred in 12.3%, non-planned 30-day readmissions in 7.9%, while potentially avoidable 30-day readmissions were observed in 3.2% of the patients. Increasing age was associated with all outcomes. The need for care post-discharge from hospital was highest among children and the oldest age group (85 years and over). Injury severity was associated with all adverse outcomes. Increasing number of comorbidities increased the likelihood of all outcomes. Overall, outcomes are shown to differ by age, gender, comorbidities, body region injured, injury type and injury severity, and to a lesser extent by socio-economic areas.

Conclusions

Outcomes and risk factors differ depending on the outcome measured, and the method used for measuring the outcome. Similar outcomes measured in different ways produces varying results. Data linkage has provided a valuable platform for a comprehensive overview of outcomes, which can help design and target secondary and tertiary preventive measures.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7080-y) contains supplementary material, which is available to authorized users.

Ageing population has changed the nature of major thoracic injury

Introduction

An increasing proportion of the major trauma population are older persons. The pattern of injury is different in this age group and serious chest injuries represent a significant subgroup, with implications for trauma system design. The aim of this study was to examine trends in thoracic injuries among major trauma patients in an inclusive trauma system.

Methods

This was a retrospective review of all adult cases of major trauma with thoracic injuries of Abbreviated Injury Scale score of 3 or more, using data from the Victorian State Trauma Registry from 2007 to 2016. Prevalence and pattern of thoracic injury was compared between patients with multitrauma and patients with isolated thoracic injury. Poisson regression was used to determine whether population-based incidence had changed over the study period.

Results

There were 8805 cases of hospitalised major trauma with serious thoracic injuries. Over a 10-year period, the population-adjusted incidence of thoracic injury increased by 8% per year (incidence rate ratio [IRR] 1.08, 95% CI 1.07 to 1.09). This trend was observed across all age groups and mechanisms of injury. The greatest increase in incidence of thoracic injuries, 14% per year, was observed in people aged 85 years and older (IRR 1.14, 95% CI 1.09 to 1.18).

Conclusions

Admissions for thoracic injuries in the major trauma population are increasing. Older patients are contributing to an increase in major thoracic trauma. This is likely to have important implications for trauma system design, as well as morbidity, mortality and use of healthcare resources.

Treatment Charges for Traumatic Brain Injury Among Older Adults at a Trauma Center

OBJECTIVE

To provide charge estimates of treatment for traumatic brain injury (TBI), including both hospital and physician charges, among adults 65 years and older treated at a trauma center.

METHODS

We identified older adults treated for TBI during 2008-2012 (n = 1843) at Maryland's Primary Adult Resource Center and obtained hospital and physician charges separately. Analyses were stratified by sex and all charges were inflated to 2012 dollars. Total TBI charges were modeled as a function of covariates using a generalized linear model.

RESULTS

Women comprised 48% of the sample. The mean unadjusted total TBI hospitalization charge for adults 65 years and older was $36 075 (standard deviation, $63 073). Physician charges comprised 15% of total charges. Adjusted mean charges were lower in women than in men (adjusted difference, -$894; 95% confidence interval, -$277 to -$1512). Length of hospital and intensive care unit stay were associated with the highest charges.

CONCLUSIONS

This study provides the first estimates of hospital and physician charges associated with hospitalization for TBI among older adults at a trauma center that will aid in resource allocation, triage decisions, and healthcare policy.

Effectiveness of trauma team on medical resource utilization and quality of care for patients with major trauma

BACKGROUND

Trauma is one of the leading causes of death in Taiwan, and its medical expenditure escalated drastically. This study aimed to explore the effectiveness of trauma team, which was established in September 2010, on medical resource utilization and quality of care among major trauma patients.

METHODS

This was a retrospective study, using trauma registry data bank and inpatient medical service charge databases. Study subjects were major trauma patients admitted to a medical center in Tainan during 2009 and 2013, and was divided into case group (from January, 2011 to August, 2013) and comparison group (from January, 2009 to August, 2010).

RESULTS

Significant reductions in several items of medical resource utilization were identified after the establishment of trauma team. In the sub-group of patients who survived to discharge, examination, radiology and operation charges declined significantly. The radiation and examination charges reduced significantly in the subcategories of ISS = 16 ~ 24 and ISS > 24 respectively. However, no significant effectiveness on quality of care was identified.

CONCLUSIONS

The establishment of trauma team is effective in containing medical resource utilization. In order to verify the effectiveness on quality of care, extended time frame and extra study subjects are needed.

Profile of fall injury in the New South Wales older adult population

BACKGROUND

A previous report from the New South Wales (NSW) Trauma Registry identified falls and increasing age of severely injured patients as highly prevalent, but detailed injury and demographic profiles, outcomes and their predictors are poorly reported. This study describes the fall-injury profile in the older adult major trauma patient in NSW.

METHODS

A retrospective registry based study between 2010 and 2014 on patients aged 55 years and over who sustained a moderate to critical injury from a fall, examining mortality and length of stay using regression analyses.

RESULTS

There were 4263 major trauma falls between 2010 and 2014, most occurring at home (55.4%), on the same level (46.7%) and resulting in head injury (63.2%). Significant predictors for mortality following a fall were increased age, male gender, falls in residential care institutions, isolated head injuries and injury classified as critical (ISS 41-75).

CONCLUSIONS

The outcomes of falls in the older adult are very poor and a focused prospective study is required to identify areas for intervention and prevention. The predictors of mortality following a fall identified in this study can be used with existing research to develop tools and design care pathways for implementation in the emergency context to improve patient care and outcomes.