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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 14-18

Retrospective study on cost accounting of trauma patients presenting to the Emergency Department in a tertiary care hospital in South India


1 Department of Emergency Medicine, Pacific International Hospital, Papua New Guinea
2 Department of Emergency Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission20-Nov-2019
Date of Decision14-Dec-2019
Date of Acceptance19-Dec-2019
Date of Web Publication03-Feb-2020

Correspondence Address:
Dr. Didla Gautam
Department of Emergency, Pacific International Hospital, Port Moresby
Papua New Guinea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_62_19

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  Abstract 

Background: Accelerated urbanization and industrialization have led to an alarming increase in the rates of trauma that eventually increases the financial burden of society. Understanding the direct medical costs associated with trauma provides a window for assessing the potential cost reductions with improved quality care in the Emergency department (ED).
Aim: The aim is to analyze the possibilities of minimizing the expenditure of trauma patients presenting to priority I and priority II of the emergency department (ED), without compromising care and treatment.
Materials and Methods: This is a retrospective study done in the ED of CMC Vellore in the month of January 2017. Multiple regression was used to categorize patients into major or minor trauma on the basis of Glasgow Coma Scale, hemodynamic stability, unstable abdominal/pelvic fractures, chest trauma (subcutaneous emphysema/open pneumothorax/penetrating chest injury), hypovolemic shock, and polytrauma. The costs of each type of trauma were then calculated after adjusting for differences in age, gender, mode of injury, influence of alcohol, and system(s) involvement.
Results: A total of 119 trauma patients who were admitted in priority I and II were studied in a period of 1 month, among which majority were male 97 (81.5%) patients. It was noted that the incidence of trauma was the highest in the adult age group, i.e., 91 (76.5%) patients. Road traffic accident was the most common mode of injury and seen in 83 (69.7%) patients. In injury profile, lower limb injuries were most commonly involved and contributed to 37 (31.1%) patients, followed by upper limb injuries in 21 (17.6%) patients and isolated head injuries in 15 (12.6%) patients. The average cost was more in patients suffering from major trauma (Rs. 10,983/-) in comparison to minor trauma (Rs. 6464/-), with the maximum expenditure in radiological investigation. In about 18 (15%) patients, blood tests and imaging were done without proper indication which led to additional expenditure. Among all these trauma patients, 40.3% of patients needed admission either in ICU or ward and underwent major surgical procedures, 44.5% of patients were discharged in a stable condition, 13.5% of patients were either discharged against medical advice or discharged at request after primary care and 1.7% of the patients died during their stay (primary Resuscitation) in the ED.
Conclusions: This study shows the cost-benefit analysis in major trauma while maintaining high quality care and treatment.

Keywords: Cost of trauma, financial burden in accidents, trauma


How to cite this article:
Gautam D, Hazra D, Nekkanti AC, Abhilash KP. Retrospective study on cost accounting of trauma patients presenting to the Emergency Department in a tertiary care hospital in South India. Curr Med Issues 2020;18:14-8

How to cite this URL:
Gautam D, Hazra D, Nekkanti AC, Abhilash KP. Retrospective study on cost accounting of trauma patients presenting to the Emergency Department in a tertiary care hospital in South India. Curr Med Issues [serial online] 2020 [cited 2020 Mar 29];18:14-8. Available from: http://www.cmijournal.org/text.asp?2020/18/1/14/277531




  Introduction Top


Trauma remains a common cause of permanent disability and death across all age groups worldwide, that eventually increases the financial burden on the society.[1],[2] The World Health Organization (WHO) estimates that approximately 5.8 million people die worldwide each year from injury, accounting for 11% of global mortality. The Global status report reflecting information from 180 countries, indicates that the total number of road traffic deaths has plateaued at 1.25 million per year worldwide.[2],[3],[4] Studies have demonstrated that the cumulative financial burden approximates to US$500 billion in developed countries and about US$60 billion in developing countries like ours.[5] In India, trauma was estimated as the seventh leading cause of mortality, where four-fifths of the deaths occur on the country's roads. Many families of these victims had to bear the financial burden of both short- and long-term medical care with additive loss of wages of the disabled family member. The WHO predicts that by 2020, road traffic accidents (RTAs) will account for nearly 550,000 deaths due to the ongoing and rapid socioeconomic and demographic transition coupled with growing urbanization in India.[5],[6],[7]

The main aim of this project is to calculate the expenses of providing hospital care (ED) with the highest standard of treatment and thereby managing it more efficiently in future. This study will analyze the average treatment cost in trauma patients, outcome from the emergency department (ED) and hospital and possibilities of minimizing the expenditure of patients without compromising on the level of care.


  Materials and Methods Top


Methodology

Design

This study was a retrospective study conducted in the ED of Christian Medical College Hospital, Vellore.

Setting

This study was conducted in the ED, which is a tertiary medical care center. The ED is a 50-bed department and receives an average of 500 trauma patients in 1 month.

Participants

All trauma patients who presented to priority I and II of ED in the month of January 2017 were inncluded. Patients were categorized into major and minor trauma. Major trauma included patients with Glasgow Coma Scale (GCS) <9, penetrating ocular trauma, hemodynamically unstable abdominal and pelvic fractures, limb injuries with vascular compromise, open long bone fractures, chest trauma with SpO2<90%, subcutaneous emphysema, open pneumothorax, penetrating chest or neck wound, hypovolemic shock or polytrauma. Minor trauma included patients with GCS 9 and above, all dislocations, all long bone closed fractures with no vascular compromise, hemodynamically stable abdominal and pelvic injuries.

Variables

Data of the patients were obtained from the electronic hospital records and the details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: Age, place of incident/demography, mechanism of injury, alcohol consumption at the time of incident, individual's injury profile, costs involved in major and minor trauma, investigations done without indications, and the ED and hospital outcome.

Outcome Variable

Cost accounting in major trauma.

Bias

This is a retrospective study, and therefore, we could not control exposure or outcome assessment, and instead relied on others for accurate recordkeeping. History, physical examination, and decision to send investigations completely depended on the ED registrar. The cost details of procedures done in ED were not available for patients getting admitted and had to be calculated manually for each patient, which might not be the true picture. For some discharged patients, charges like bed and treatment, professional or suturing charges were not entered and hence led to bias. The study was done in 2017; hence, costs are subject to change. Our institute being a tertiary referral care hospital, this data may not represent the exact scenario in the community.

Study size

All patients with trauma presenting to Priority 1 and priority II of the ED, in the month of January 2017.

Laboratory test

The injuries of the patients were noted. All patients had routine blood investigations including alcohol levels and relevant radiological tests based on the initial primary and secondary surveys.

Statistical analysis

All categorical variables were expressed as frequencies and percentages. The data were extracted from ED triage software and Clinical Workstation and entered into SPSS software (SPSS Inc., Released 2007. SPSS for Windows, version 16.0, Chicago, IL, USA) Data were summarized using mean with standard deviation for continuous variables and frequencies with percentages.

Ethical considerations

This study was approved by the Institutional Review Board Prior to the commencement of the study, approval from the Institutional Review Board Ethical Committee was obtained (IRB Min no: 12387 dated November 20, 2019). Patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.


  Results Top


Data were collected in 119 trauma patients in the month of January 2017. Among these, majority were male with 97 (81.5%) patients. These cases were categorized into major and minor trauma. Minor trauma contributed to 92 (77.3%) cases [Figure 1]. The highest incidence of trauma was noted in the young adult age group, i.e., 91 (76.5%) patients, followed by the pediatric age group, i.e., 18 (15.1%) patients and then the geriatric age group, i.e., 10 (8.4%) patients. Most of these trauma patients presenting to our ED were from Vellore itself, i.e., 70 (58.8%) patients, followed by Tiruvannamalai with 15 (12.6%) patients and Chittoor with 13 (10.9%) patients [Figure 1]. RTAs were the most common mode of injury noted and comprised 83 (69.7%) patients followed by slip and fall seen in 15 (12.6%) patients [Figure 2]. Among the whole study population, 21 (17.6%) trauma patients had significant levels of alcohol in their blood, 83 (69.7%) tested negative, and the test were not performed in 15 (12.7%) patients. In injury profile, lower limbs were the most commonly injured body part and was seen in 37 (31.1%) patients, followed by upper limb in 21 (17.6%) and head injury in 15 (12.6%). It was noted that 19 (15.9%) cases had 2 or more systems involved which were either major or minor traumas [Table 1]. The mean cost (S. D) of treatment was Rs. 10,983/-(SD Rs. 5164/-) in major trauma patients and 6464 (3086) in minor trauma patients. The amount spent on radiological investigations (X-rays, Focused Assessment with Sonography in Trauma and computed tomography scans) was the highest cost factor with a mean of Rs. 3983/-(SD Rs. 3053/-) in major trauma patients and Rs. 2285/-(SD Rs. 2457/-) in minor trauma patients. The mean cost of blood and blood products in major trauma patients was Rs. 3306/-(SD Rs. 2393/-), whereas there were no blood or blood products used in any minor trauma patients. Medication charges for major trauma patients was Rs. 1452 (SD Rs. 729/-), and minor trauma patients was Rs. 969/-(SD Rs. 514/-). The other cost factors were procedural charges (washing, POP fixation, minor wound debridement, wiring, ventilation, catheterization, etc.) done in the ED, bed charges, professional fees and these amounted to a mean of Rs. 1792 (SD Rs. 815/-) in major trauma patients and Rs. 1100 (SD Rs. 447/-) in minor trauma patients [Figure 3] and [Figure 4]. In about 18 (15%) patients of the study population, few investigations (chest X-ray, cervical spine X-ray, pelvis X-ray, complete blood count, and liver function tests) were done individually or in combination without any indication and added an extra amount of Rs. 701/-(SD Rs. 312/-). In 8 (6.73%) patients, few charges were not added; however, this number might be higher as some charts did not have proper documentation and some charts were not scanned.
Figure 1: Place of inicdent and categorization

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Figure 2: Mode of injury

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Table 1: Injury profile (n=119)

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Figure 3: Expenses in major trauma

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Figure 4: Expenses in minor trauma

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Among all these trauma patients, 48 (40.3%) patients needed admission either in ICU or ward and underwent major surgical procedures, 53 (44.5%) patients were discharged in a stable condition, 16 (13.5%) patients were either discharged against medical advice or discharged at request after primary care and 2 (1.7%) patients with polytrauma died during primary resuscitation in the ED.


  Discussion Top


Trauma is a common presentation in the ED globally. While the human suffering and death caused by injury is well recognized, these injuries have a significant economic impact that must be considered when public policy regarding trauma centers is debated or discussed.[7],[8],[9] Both the human and economic costs must be considered when assessing the value of quality trauma care and a regionalized trauma system. While it is becoming widely recognized that trauma centers save lives, effective trauma systems should address the economic impact of injury including the substantial costs resulting from lost wages and productivity.[5],[10],[11],[12] Policy makers must also understand that rehabilitation, job retraining, and injury prevention plays an important role in dealing with the tremendous economic impact of this public health issue.[13],[14] To our knowledge, this is the first retrospective study done in Tamil Nadu, that focuses on the direct cost analysis of trauma patients presenting to ED.

The Ministry of Health and FW started a pilot project in 1999, during the ninth 5-year plan to augment and upgrade the accidents and emergency services in selected state government hospitals that are in the most accident-prone areas. It was proposed to design and develop a network of trauma care centers that would in the first phase cover the entire golden quadrilateral connecting Delhi-Kolkata-Chennai-Mumbai-Delhi or the North-South-East-West corridors.[6],[11] However, in 2016, Tamil Nadu topped the country in road accidents and counted more than 17,000 fatalities. An audit by the health department revealed that more than 70% of the accidents happened on the roads, particularly the highways, and the deaths happened because these trauma victims were not able to reach the hospital for basic first aid.[6],[11],[15]

In our study, it was noted that the young adult population in the working age group formed the major bulk of trauma patients. This is an alarming number because most of the Indian population falls in this age group. Trauma was more predominant in males, probably due to more involvement in high risk jobs. We found that RTAs were the most common mode of trauma accounting to about 70% of cases, similar to other studies from Tamil Nadu.[16],[17] Significant levels of plasma alcohol were seen in approximately one-fifth of the total study population, though this might be an underestimation since plasma alcohol levels were not sent in about 15% of RTA patients. This was most likely due to denied consent or occasionally due to the unavailability of serum alcohol collection tubes in our ED. In injury profile, lower limbs were the most commonly injured body part which can partly be explained by the fact that most of these incidents were 2-wheeler related, correlating with data from our other study.[17] We categorized this study population group into major and minor trauma patients. The average cost for minor trauma cases in ED was Rs. 6464/-and for major trauma cases was Rs. 10983/-. In studies done on motor vehicle trauma in the University of Arizona Health Science center, Tucson, hospital stay averaged 11 days, and patients were charged an average of $16000. However, ours is a study done in the ED alone and therefore admission stay charges/surgical charges were not included.

It was observed that the amount spent on radiological imaging was the highest cost factor in both major and minor trauma cases. In our study population, about 15% of cases had imaging done (amounting to an average of about Rs. 700/-per person) without any indication. Similarly, a small fraction of them had somewhat unnecessary blood tests done such as complete blood count and liver function test. This could be attributed to the inexperience of the registrar attending the patient and lack of proper guidelines. Medication charges in ED for major and minor trauma cases was Rs. 1452/-and Rs. 969/, respectively. In all cases, procedural charges in ED are usually marked in the billing sheet by the staff nurse and sent for billing at the time of discharge. However, it was seen that in few of these cases some procedural charges were not entered either due to a busy shift or change of duty between the nurses with inadequate communication. This could have been avoided with an alternate billing system.[14]

The true economic burden of injuries is greater than that of these estimates. Expenses associated with lost patient and caregiver time, nonmedical expenditures incurred by those having to deal with injury and disability, insurance costs, property damage costs are not included in these estimates. In addition, while it is difficult to quantify, the value of life lost to premature mortality, decreased quality of life, or diminished functional capacity should also be included in estimates of economic impact of trauma.[9],[10],[11],[12]


  Conclusions Top


Most of the study population was found to be in the young adult age group and serum alcohol levels were positive in one fifth of them. The mean cost of treatment in ED for major and minor trauma cases was Rs. 10,983/-and Rs. 6464/-, respectively. About 15% of cases were found to be over investigated with a mean cost of Rs. 701/-, which could be prevented by judicious use of resources and the establishment of proper guidelines. This study shows the cost-benefit analysis in major trauma while maintaining high quality care and treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board / Ethics Committee review, and the corresponding protocol / approval number is IRB Min no: 12387 dated November 20, 2019. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.



 
  References Top

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Pathak A, Desania NL, Verma R. Profile of road traffic accidents and head injury in Jaipur (Rajasthan). J Indian Acad Forensic Med 2008;30:6-9.  Back to cited text no. 13
    
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Jacobs G, Aeron-Thomas A, Astrop A. Estimating Global Road Fatalities, TRL Report 445. London: Transport Research Laboratory, Berkshire and Department for International Development; 2000. p. 1.  Back to cited text no. 15
    
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Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.  Back to cited text no. 16
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Dkhar I, Hazra D, Madhiyazhagan M, Joseph JV, Abhilash KP. A retrospective study on the profile of long bone injuries in trauma patients presenting to emergency department. Curr Med Issues 2019;17:60-5.  Back to cited text no. 17
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