Economic Aspects of Trauma Care
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1 Economic Aspects of Trauma Care Maren Walgenbach, Carsten Mand, and Edmund A.M. Neugebauer 2 Contents 2.1 Introduction Economic Concepts Cost-Minimization Analysis (CMA) Cost-Effectiveness Analysis (CEA) Cost-Benefit Analysis (CBA) Cost-Utility Analysis (CUA) Cost of Illness (COI) Direct and Indirect Cost of Illness Road Traffic Accidents Prevention Polytrauma Osteoporosis DALY and QALY... 9 References Introduction Trauma and injury play a major role in today s health care. The fact that over 1.2 million people die each year in road traffic accidents alone and between 20 and 50 million are injured [1] by trauma is a major healthcare issue and also an important cost factor for most societies. According to the World Health Organization (WHO), trauma and injury account for 9.2% of all deaths worldwide and 10.9% of disability-adjusted life-years (DALYs see below). Over the last few decades, the understanding of injury has gone from being regarded as random and unpredictable accidents to being seen as possibly preventable events. The WHO estimates that in the year 2020, road traffic accidents will climb to rank 6th among the 15 leading causes of death, and 3rd in causes of DALYs lost [2]. In trauma it is important not only to consider immediate consequences such as mortality, but also to take into account that for every death there are many survivors who are left with permanently disabling injuries. Another special feature of trauma care is that injuries most often affect the working populace (see Fig. 2.1) so that death or disability decreases work and spending capacities. M. Walgenbach and E.A.M. Neugebauer (*) Institute for Research in Operative Medicine (IFOM), Private University Witten/Herdecke ggmbh, Ostmerheimer Str. 200, Köln, Germany maren.walgenbach@uni-wh.de; ifom-neugebauer-sek@uni-wh.de, edmund.neugebauer@uni-wh.de C. Mand Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg GmbH, Location Marburg, Baldingerstraße, D Marburg, Germany mand@med.uni-marburg.de 2.2 Economic Concepts It is simple to present mortality and morbidity statistics of health-care systems, but it is important for societies to consider the costs and values. Economic evaluation is required for good decision making in health-care systems, in order to choose medical alternatives with both reduced costs and a higher health benefit. The aim of economic evaluation is to calculate H.-C. Pape et al. (eds.), The Poly-Traumatized Patient with Fractures, DOI: / _2, Springer-Verlag Berlin Heidelberg
2 6 M. Walgenbach et al. No. of deaths (% of total) Age (years) the resource costs consumed versus the health benefits provided by the practice or technology in its diverse clinical uses [3]. There are a variety of cost analysis strategies, the appropriateness of which depends upon the purpose of an assessment, as well as the availability of data and other resources. There are also different types of costs and measurements in money terms, which are similar across most efficiency evaluations [4] (see Table 2.1). More difficult is the identification and quantification of all benefits and units, which may differ between evaluations. For example, in some evaluations the value cannot be measured in monetary units and are instead expressed in different units. The main types of cost analysis are discussed below Cost-Minimization Analysis (CMA) 80 Fig. 2.1 Age distribution of global injury-related mortality, 2000 (WHO The Injury Chart Book) Cost-minimization analysis does not consider value, and this is the structural weakness of this method. A CMA calculates the least cost of alternative technologies or interventions while assuming an equal health benefit among them. Therefore, the difference between alternatives is reduced to a comparison of costs in order to estimate the treatment with the lowest cost, which is the treatment of choice [5]. In practice, it is unlikely that two different alternatives will incur the same consequences. Medical or therapeutically alternatives often differ in the number or significance of adverse effects. If the outcomes are identical, often there is no difference between the techniques. Some authors (e.g., Drummond et al. [6]) argue that the CMA is not a complete form of economic evaluation and is only useful as an alternative for decision making [4, 5] when comparing two drugs of equal efficacy (e.g., with the same active ingredient) and equal tolerability Cost-Effectiveness Analysis (CEA) A cost-effectiveness analysis is a more complete form of economic evaluation, in which both the costs and consequences of the alternatives being compared are examined [4]. Costs are expressed in monetary units and value in natural units, so that costs are presented per unit of effect. The effect may be years of life gained, rescued human life, reduction in prevalence, reduced duration of disease, working days gained, and also other clinical parameters such as blood pressure or cholesterol level. Values differ for different types of issues. This is why a CEA can describe two different effects and Table 2.1 Measurement of costs and consequences in economic evaluation Type of study Measurement/valuation of costs in both alternatives Identification of consequences Cost analysis Monetary units None None Cost-effectiveness analysis Monetary units Single effect of interest, com - mon to both alternatives, but achieved to different degrees Cost-utility analysis Monetary units Single or multiple effects, not necessarily common to both alternatives Cost-benefit analysis Monetary units Single or multiple effects, not necessarily common to both alternatives Source: Methods for the Economic Evaluation of Health Care Programmes Measurement/valuation of consequences Natural units (e.g., life-years gained, disability-days saved, points of blood pressure reduction, etc.) Healthy years (typically measured as quality-adjusted life-years) Monetary units
3 2 Economic Aspects of Trauma Care decisions. Although the chosen alternatives are similar, one effect might be measured in terms of life-years gained and the other in gained workdays. Depending on the focus, analysis of these effects may result in two different alternatives. burden on a social system incurred by a specific disease, and distribute resources for preventing associated treatment costs (e.g., medication to prevent osteoporosis) [6] Cost-Benefit Analysis (CBA) The cost-benefit analysis measures costs and benefits in common monetary units. The alternative to the medical or therapeutic treatment being evaluated is a donothing alternative entailing no costs and no benefits. Only in cases in which the benefit is at least similar to the costs leads to an economical result and the decision in favor of the new medical or therapeutic treatment. The challenge of this analysis is estimating an appropriate amount of money for the do-nothing alternative Cost-Utility Analysis (CUA) A cost-utility analysis focuses on the quality of health, measures costs in monetary terms and, like the CEA, measures utility in non-monetary terms. It is different from CEA in that CEA utilizes a natural or direct measurement. The CUA measures its outcomes in terms of their utility, quality-adjusted life-years (QALYs), disability-adjusted life-years (DALYs), or a specific level of health status. This can be measured in terms of individuals or society. The results are expressed as cost per QALY gained. A CEA can only compare technologies whose outcomes are measured in the same units. Utility is expressed on a 0 1 scale, in which 0 means death and 1 means entirely healthy. There are many questionnaires and rating scales designed to measure the health related quality of life (hrqol), which is needed in order to estimate the QALY (see Sect. 2.6) Cost of Illness (COI) This economic evaluation considers all costs of an individual disease with two approaches: prevalence cost or incidence cost. While COI does not take different alternatives into account, this evaluation should help to estimate the 2.3 Direct and Indirect Cost of Illness Every injury results in direct and indirect health-care costs. Direct costs include the immediate costs that follow an injury, such as hospital treatment, medications, prostheses, rehabilitation, and all consequential treatment and nursing costs (e.g., home care, outpatient care, and visits to health professionals). Indirect costs consist of each individual s lost productivity and ability to work, and are therefore losses in societal productivity. Other factors that potentially add to indirect costs include social isolation, economic dependence, pain, and suffering. The latter are almost impossible to quantify, but should be considered nonetheless in the calculation of indirect costs rather than underestimating the real expenses. Because trauma and injury mainly affect the working populace, indirect costs play an important role and may equal the direct costs. Example Canada: Total direct costs from injuries in Canada in the year 2004 amounted to $10,716 million and indirect costs were $9,065 million [7]. According to the 1998 publication The Economic Burden of Illness in Canada, the indirect mortality cost due to injuries ranked 3rd after cancer and cardiovascular diseases, and as shown in Fig. 2.2, adults aged years of age accounted for 91.6% of the costs [8]. 2.4 Road Traffic Accidents In 2009, the Commission for Global Road Safety from the World Health Organization issued a call for a Decade of Action for Road Safety. Nearly 90% of deaths after road traffic accidents occur in low- and middle-income countries where less than half of the world s motor vehicles are registered. Among young people (aged 5 44 years), road traffic accidents are one of the three leading causes for death, and it has been predicted that unless immediate action is taken road traffic accidents will become the fifth leading cause of death for all ages. Especially due to young
4 8 M. Walgenbach et al. Fig. 2.2 Mortality costs by most costly diagnostic categories and age group in Canada, 1998 (The Economic Burden of Illness in Canada, 1998) 34.7% 49.8% 4.5% 45.6% 61.9% 35.0% 40.9% 60.1% 47.2% 46.0% 32.4% 59.2% 48.9% 4.5% 0.7% 2.6% 0.4% 3.9% 4.3% 1.5% 4.4% 1.5% 7.8% 2.5% Cancer Cardiovascular Injuries Respiratory Digestive Endocrine/related $10.6 billion $8.3 billion $5.9 billion $1.6 billion $1.1 billion $1.0 billion 0 14 years years years 65 years and over people dying in road traffic accidents, the economic consequences are enormous and estimates range from 1% to 3% of a country s Gross National Product (GNP), or in total about $500 billion a year. 2.5 Prevention Injuries fall into one of two main categories: 1. Intentional injuries such as self-inflicted injuries (e.g., suicide), acts of violence, and war-related injuries 2. Unintentional injuries that including but not limited to road traffic accidents, poisoning, falls, fires, and drowning Unintentional injuries are very responsive to prevention, and some governments have not only recognized injury as a major threat to human health and their health-care system, but have specifically founded institutions for injury prevention (e.g., the United States National Center for Injury Prevention and Control). It has also been suggested that higher income countries should turn their focus to injury prevention rather than the marginal improvement of initial trauma care, as more than half of deaths caused by unintentional injuries might be preventable with pre-injury behavioral changes [9]. Roadsafety interventions (e.g., seat belts) used and established in high-income countries can be successfully translated to low- and middle-income countries where road traffic mortality and morbidity is constantly rising [10] Polytrauma As the most severely injured subgroup of trauma patients with injuries to more than one body region of which at least one or more in combination is lifethreatening, polytrauma patients require complex and multidisciplinary management and still have a significantly higher mortality and morbidity than other trauma patients. The costs for this care and the provision of personnel and materials are immense, and reimbursement to hospitals among different health systems, primarily due to lack of data for an accurate cost estimation, shows a negative balance of % [11]. In the Federal Republic of Germany, a model to calculate the actual costs that a severely injured patient produces has been presented based on data derived from the national trauma registry (TraumaRegister DGU TR-DGU). Currently a nation-wide Trauma Network is forming, and hopefully due to mandatory participation in the TR-DGU, the network will soon encompass all severely injured patients and a more correct estimation of the actual costs due to trauma will be possible [12] Osteoporosis With medical care improving people have longer life expectancies and consequently higher risk of osteoporosis. Though osteoporosis affects one-third of postmenopausal women and one-fifth of men over the age
5 2 Economic Aspects of Trauma Care Women Men reflects the severity of the disease. The number of deaths at each age multiplied by a global standard life expectancy for the age at which death occurs is the YLL. While DALYs include death, injury, and physical disability, they are limited in that they do not include all the health consequences (e.g., mental health) and the economic consequences stemming from a health condition. Fig. 2.3 Projected costs of osteoporosis in Europe in billion euros (Osteoporosis in Europe: Indicators of Progress) of 50, its relevance for health-care systems is widely underestimated. Often the first symptom is a fracture after an inadequate trauma, and once a fracture has occurred, the risk of a second fracture is doubled within the year. The projected costs of osteoporosis in Europe can be seen in Fig The acute hospital costs (as a part of the direct costs) of a hip fracture in Europe range from 1,000 in Estonia to 30,000 in Austria, and data suggest that total costs following a hip fracture could be 2.5 times greater. Medical treatment of established osteoporosis has proven to be cost-effective irrespective of age. However, a major problem of this silent epidemic is poor compliance with drug therapies that effectively reduce the risk of fractures, and thereby also reduce the overall costs and QALYs (see below) lost. 2.6 DALY and QALY A QALY is not a measure of lost utility, but of one lost year of healthy life. DALYs are calculated by adding a society s years of life lost due to premature mortality (YLL) in the population and years of life lost due to disability (YLD) for incident cases of the health condition [13]. The latter is estimated by multiplying the number of incident cases in a given period by the average duration of the disease and a weight factor that References 1. Anonymous. Global status report on road safety: time for action. In: World Health Organization, Geneva int/violence_injury_prevention/road_safety_status/ Peden M, Mcgee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva: World Health Organization; Weinstein MC. Economic assessments of medical practices and technologies. Med Decis Making. 1981;1: Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. Oxford/New York: Oxford University Press; Briggs AH, O brien BJ. The death of cost-minimization analysis? Health Econ. 2001;10: Drummond M. Cost-of-illness studies: a major headache? Pharmacoeconomics. 1992;2: SMARTRISK. The economic burden of injury in Canada Anonymous. The economic burden of illness in Canada Stewart RM, Myers JG, Dent DL, et al. Seven hundred fiftythree consecutive deaths in a level I trauma center: the argument for injury prevention. J Trauma. 2003;54:66 70; discussion Stevenson M, Yu J, Hendrie D, et al. Reducing the burden of road traffic injury: translating high-income country interventions to middle-income and low-income countries. Inj Prev. 2008;14: Giannoudis PV, Kanakaris NK. The unresolved issue of health economics and polytrauma: the UK perspective. Injury. 2008;39: Pape HC, Grotz M, Schwermann T, et al. The development of a model to calculate the cost of care for the severely injured an initiative of the Trauma Register of the DGU. Unfallchirurg. 2003;106: Anonymous. The global burden of disease. In: World Health Organization, Geneva. Update healthinfo/global_burden_disease/gbd_report_2004update_ full.pdf.
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