Acute Hospital By Ellen J. MacKenzie,
Costs of Pediatric Trauma in the United States: How Much and Who Pays? John A. Morris,
Jr, Gregory V. de Lissovoy,
Gordon Smith,
and Maureen
Fahey
Baltimore, Maryland and Nashville, Tennessee 9 National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sexspecific estimates of the numbers of hospital admissions and expenditures are reported for subgroups of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 286,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4.5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care. This analysis suggests that the designation of pediatric trauma centers would not appreciably affect the revenues of nontrauma centers because minor and moderate injuries representing 91% of total trauma admissions and 79% of total charges would remain in the domain of the nontrauma center hospital. o 1990 by W.B. Saunders Company.
injury problem. For every death there are an estimated 34 injuries resulting in hospitalization and 1,500 less severe injuries not requiring hospitalization but that result in 1 or more days of restricted activity.’ Comparatively little is known about the nature and severity of nonfatal injuries among children. Although there have been studies defining the magnitude of the problem, these have been limited to specific geographic regions and have not provided detailed information on the severity mix of trauma patients or costs associated with treatment.2-5 This paper provides national estimates of the incidence and initial treatment costs for traumatic injuries severe enough to require hospitalization. This information is then used to examine the impact of regionalized trauma care on the distribution of patients and dollars between trauma centers and nontrauma centers.
INDEX WORDS:
The primary data source used for the present analysis was the National Hospital Discharge Survey (NHDS).6 The NHDS consists of hospital discharge abstracts uniformly collected for a probability sample of approximately 200,000 patients discharged each year from nearly 600 short-stay, nonfederal hospitals located in the 50 states and the District of Columbia. Data abstracted for each hospital discharge include patient demographics, up to seven discharge diagnoses (coded using the Clinical Modification of the 9th Revision of the International Classification of Diseases [ICD9CM]), up to three procedures (ICD-9CM coded), length of stay, discharge status, and expected principal source of payment. Three years of NHDS data (1984 through 1986) were used to provide more accurate estimates by age, sex, and nature of injury. Annualized estimates for 1985 were obtained by averaging the estimates over the 3 years. Statewide hospital discharge abstract data from Maryland were used to supplement the information available from the NHDS on per diem charges and cause of injury? All 56 acute care, nonfederal hospitals in Maryland are mandated by law to submit uniform data
Pediatric
trauma,
MATERIALS
METHODS
Estimates of the number of acute hospital admissions, hospital charges, and source of payment were developed for children between the ages of 0 and 14. Separate estimates were developed for five categories of cause (falls, motor vehicles, firearms, fires/burns, other) and 21 categories describing the body region and severity of the principal or most severe injury sustained. Estimates reported are for 1985, the most recent year for which reliable data are available. The data sources and methods used to derive these estimates are described in detail elsewhere’; they are summarized below. Data Sources
cost.
T
RAUMA IS well recognized as the leading cause of death among children ages 0 to 14. However, mortality is only one indicator of the magnitude of the
From the Johns Hopkins University School of Hygiene and Public Health, Baltimore. MD, and Vanderbilt University School of Medicine, Nashville, TN. Supported in part by the National Highway Trajic Safety Administration (NHTSA) and Center for Disease Control (CDC) Grant No. DTNH22-88-Z-07144 and the National Center for Health Services Research and Health Technology Assessment Grant No. HSO5630-02. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois. October 21-23, 1989. Address reprint requests to Q 1990 by W.B. Saunders Company. 0022-3468/90/2509-0010$03.00/0
970
AND
on all discharges to the Health which is responsible for setting
Services Cost Review Commission, hospital rates under the State’s per
case payment system. The Maryland data base includes the NHDS
Journai of Pediatric Surgery,
Vol 25,
No 9
(September), 1990: pp
970-976
971
ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA
elements plus source of admission and total and component charges for each hospitalization. Also, the cause of injury is recorded for 61% of Maryland discharges as compared with 27% of the NHDS sample. The National Medical Care Utilization and Expenditure Survey (NMCUES) supplemented the source of payment information obtained from the NHDS.’ The NMCUES was a nationwide sample survey conducted in 1980 by the National Center for Health Statistics in which 10,000 households (17,000 individuals) were interviewed on five separate occasions at 3-month intervals. Data were collected on health conditions, services, charges, sources, and amounts of payment.
Estimating Number of Hospitalizations Included in the definition of an acute trauma hospitalization was any discharge with a principal diagnosis of an injury as defined by the ICD-9CM N-codes N800 through N959, excluding N958 (traumatic complications), N905 through N909 (late effects of injuries), and N930 through N939 (foreign bodies). Poisonings, near drownings, suffocations, and other nontraumatic injuries are excluded from the definition. National estimates of the number of hospital admissions were calculated by inflating the NHDS sample by the reciprocals of the probabilities of sample selection, adjusting for nonresponse. Estimates of less than 3,000 have a relative standard error that may exceed 30% and are generally considered unreliable. These figures are noted in the tables with an asterisk. Estimates of total trauma discharges were adjusted downward to exclude possible rehospitalization for follow-up care of a previous injury.’ All hospital discharges were classified into one of 21 categories defined by the body region and severity of the principal or most severe injury sustained. Injury severity was determined using a computerized mapping of ICD-9CM coded discharge diagnoses into Abbreviated Injury Scale (AIS) scores.9 The resulting severity scores, referred to as ICD/AIS scores, will on average, be slightly lower than AIS scores obtained by reviewing the entire medical record. Thus, the distribution of hospital discharges by severity will be conservative. A major limitation of the NHDS for estimating the number of hospital trauma episodes is the lack of uniform coding of the cause of injury. The percent of cases in the NHDS for which the cause of injury can be identified by an ICD E-code (External Cause of Injury Code) is low-approximately 25%. In Maryland, on the other hand, the percent of cases with information on cause is higher (61%). However, it has been shown that even in these more complete data bases, E-coding is not a random practice within or among hospitals, but is strongly correlated with the number and severity of injuries sustained; patients with multiple injuries or patients who develop complications during the hospitalization are less likely to be assigned E-codes.” To correct for this potential bias, the following procedure was used to estimate the number of trauma hospital episodes by major cause categories. Three years of discharges from the 56 acute care hospitals in Maryland for which E-codes were recorded were distributed by cause within two age groups, (0 to 4; 5 to 14) two sex groups, and 21 categories defining the body region and ICD/AIS severity of the principal injury. Based on the Maryland discharge data. the percent distributions of cause within each age, sex, and nature of injury category were then multiplied by the NHDS estimates of the total number of hospitalizations within each cell. Estimates of the number of hospital episodes were developed for five major cause categories: motor vehicle crashes, falls, firearms, fires/ burns, and other. Episodes were classified by cause regardless of intent.
Estimating Total Hospital Charges Charges associated with each trauma hospitalization were estimated using the following procedures. First, Maryland discharge data were used to determine the mean per diem charge for subgroups of the population defined by age (0 to 4; 5 to 14) and the 21 groups defining the nature and severity of the injury. These means were then multiplied by the corresponding length of stay as reported in the NHDS. These estimates were deflated by a factor of .9572, which is the ratio of the United States average per diem hospital charge to the Maryland average per diem hospital charge based on the 1985 Annual Survey of the American Hospital Association.” The resulting estimates of hospital charges were inflated by 25% to account for professional fees.‘* Maryland per diem charges were used because they are computerized for all acute care discharges and because hospital charges are regulated by the State’s Health Services Cost Review Commission and have a known relationship to costs. All third-party payers pay full charges less a small discount (6%) for timely payment. Therefore, per diem hospital charges in Maryland represent a good proxy for costs and will not vary across payers.
Distributing Patients and Hospital Charges by Level of Care To determine the impact of regionalization on the distribution of patients and hospital revenues, trauma admissions and total charges were distributed according to the lowest level of care (ie, trauma center or nontrauma center hospital) that is appropriate based on the nature and ICD/AIS severity of injuries sustained and the age of the patient. These criteria were developed for retrospective evaluation of the performance of regionalized trauma systems. They indicate how patients should be treated under an idealized set of circumstances when full knowledge of the type and severity of injuries is available. As such, the criteria are based on the type and severity of injuries as ultimately described by discharge diagnoses and autopsy results. Criteria for classifying the appropriate level of care were developed by a committee of nationally recognized experts in the treatment of trauma. According to the criteria, all patients with injuries to three or more body systems or patients with at least one injury of AIS 4 or greater, require trauma center care. Patients with minor (AIS = 1 or 2) injuries to one or two body systems can be treated at a nontrauma center. All other patients are classified according to the precise nature of the injuries sustained and age of the patient (0 to 4; 5 to 14). A detailed description of the criteria can be found elsewhere.?
Estimating Source of Payment The NHDS was used to distribute acute hospitalizations for trauma by expected principal source of payment. When hospital charges were covered by several sources, the NMCUES data were used to distribute the total payment to the various payers, conditioned on the identity of the primary payer as determined from the NHDS. RESULTS
In 1985 an estimated 266,248 children aged 0 to 14 (or 51.3 per 10,000 population) were hospitalized for acute treatment of a traumatic injury. Of these, less than 1% (0.52%) died prior to discharge. Two thirds of all hospitalizations were among boys. Preschool children (ages 0 to 4) accounted for 29% of total hospitalizations (42 hospitalizations per 10,000 population), early school children (ages 5 to 9) for 32% (51 per
972
MACKENZIE ET AL
lO,OOO),and preadolescents (ages 10 to 14) for 39% (61 per 10,000) (Table 1). Hospital charges for acute hospitalizations among all children ages 0 to 14 totaled $946 million in 1985 or over $1 billion in 1988 dollars. Incidence and Charges by External Cause
Falls constitute the leading cause of trauma-related hospitalizations among children and are also the major contributor to hospital charges (Fig 1). In 1985, falls accounted for 36% of all acute hospitalizations (94,689) and 30% of total hospital charges ($286 million). Falls were most prevalent among preschool-aged children, accounting for nearly one half (46%) of all hospitalizations in this age group. Among early school and preadolescents, falls accounted for 32% of all acute trauma hospitalizations. Motor vehicle injuries ranked second in admissions and economic toll, accounting for 19% of total pediatric trauma hospitalizations among children (n = 51,759) and 24% of total charges ($229 million). Fires and burns accounted for an additional 6% of hospitalizations (n = 17,110) and 11% of total charges ($101 million). Injuries categorized as other included a variety of causes; together they accounted for 38% of all hospitalizations for acute trauma care and 33% of total charges. Some of the more common causes categorized as other included bicycle injuries, being struck by an object in play or sports and being injured by a cutting or piercing instrument or object. Incidence and Charges by Nature and Severity of the Principal Injury
In Table 2, total hospitalizations and associated charges are distributed by the body region and ICD/ AIS severity of the principal or most severe injury sustained. Overall, 2% of hospitalizations were for serious and severe injuries (ICD/AIS = 4 and 5); these injuries accounted for 8% of total charges. Moderately severe injuries (ICD/AIS = 3) accounted for an additional 18% of the hospitalizations and 31% of charges (Fig 2). Head injuries accounted for 29% of hospitalizations (78,168) and 29% associated charges ($270 million). Table 1. Acute Hospitalizations for Traumatic Injury (United States. 1985) BOYS
Total
Girls
@late)
NO.
vim)
NO.
mate)
0 to 4
45,387
(49.3)
30,948
(35.2)
76,337
(42.4)
5 to 9
58,545
(68.0)
27,238
(33.2)
85,780
(51.0)
10 to 14
72,077
(82.3)
32,052
(38.4)
104,131
(60.9)
All ages
176,009
(66.2)
90,238
(35.6)
266,248
151.3)
NOTE. Rate is per 10,000 population.
Distribution of Admissions and Costs by Appropriate Level of Care
When the appropriateness criteria were applied to the preceding estimates by nature and severity of the injury and age of the patient, an estimated 8.6% of all hospitalizations were classified as requiring treatment at a trauma center (Fig 3). Because these hospitalizations by definition involve the most severe injuries, they represented a disproportionate share of the total hospital charges. Charges accrued by patients who, according to the criteria, should optimally be treated at a trauma center represented 21.2% of total hospital charges. Source of Payment
In 1985 the majority of hospital care (63%) for acute treatment of traumatic injury among children was paid for by private sources, primarily private health insurance (Table 3). An additional 28% of acute hospital charges were covered by public sources, primarily Medicaid (23%). The federal government paid for approximately 15% of the acute hospital charges, state and local governments, the remaining 13%. Uninsured care represents 9% of total hospital charges. This category includes direct out-of-pocket expenditures for copayments and uncovered services as well as an unknown amount of uncompensated care. DISCUSSION
NO.
Age ~yearsl
Although the majority (81%) of hospitalized head injuries were relatively minor, an estiamted 14,497 children sustained a moderately severe (ICD/AIS = 3) or severe (ICD/AIS = 4 and 5) head injury in 1985. Hospitalization for these more severe head injuries, only representing 5% of all trauma hospitalizations, accounted for 14% of the total bill for acute hospital trauma care. Injuries to the lower extremities were also a common cause of hospitalization, accounting for 17% of all hospitalizations (n = 44,611) and 24% of all charges ($227 million). An additional 21% of hospitalizations were for injuries to the upper extremities (n = 54,965), accounting for 14% of the total cost for acute hospital trauma care ($134 million). Burns accounted for 7% of all acute trauma hospitalizations (n = 18,953) and 11% of associated charges in 1985 ($101 million).
This study provides national estimates of the number of acute hospitalizations for traumatic injury among children and documents the cost of these hospitalizations. In 1985 over 266,000 children aged 0 to 14 sustained an injury severe enough to result in
973
ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA Falls
Falls
Motor Motor
Vehicles 19%
Vehicles 24%
\
\
Fires/Burns 0% Firearms 2%
Fires/Burns 11%
,-
Other 33%
Other 3am
266,248 Fig 1.
$946
Hospitalizations
Million
Distribution of pediatric trauma by cause of injury (United States, 1985).
Table 2. Number of Acute Hospitalizations and Total Hospital Charges by Body Region and Severity of Principal Injury (United States, 198% Ages 0 to 14) HospitalCharges
HospitalEpisodes Als Head
23.9
138,254
11.244
4.2
70,385
7.4
1.0
25,360
2.7
l-2
10,116
1,121.
3.8 28.6
3.8
24,060
l
570
3.9
24,638
2.6
0.7
3,175
0.3
0.4
8,322
0.9
1.1
11,497
1.2
0.1
4.071
0.4 0.6
529.
0.2
5,592
926.
0.3
9,663
1.0
8,609
3.2
32,966
3.5
1.424*
0.5
7,875
0.8
524*
0.2
5,303
0.6
Total
10,557
4.0
46,144
4.9
l-2
51,951
19.5
121,713
12.9
3-5
3,014
1.1
11,991
1.3
133,704
14.1
Total
54,965
20.6
l-2
24.080
9.0
60,161
6.4
3-5
20.53 1
7.7
167.249
17.7
Total
44,611
16.8
227.410
24.1
l-2
11,024
4.1
43.018
4.6
0.3
12,228
1.3
2.7
45.620
3-5 Unknown Total
700s 7,229 18,953
7.1
100.866
4.8 10.7
44,810
16.8
121,678
12.9
266,248
100.0
945,657
Abbreviation: AIS, abbreviated injury scale. *Estimates of less than 3,000
2.5 0.1
4-5
3
Total
3974
36,053 270,052
Total
4-5
Other and unknown (total)
1,830. 2,951
0.2 29.4 0.1
10,307
4
l-2
Burns
191.
Total 3
Lower extremities
618. 78,168
1-2
Upper extremities
2,635.
Total
Total
Abdomen, thorax, neck
14.6
63,671
3-5
Spinal cord
% Distribution
3 5
Vertebrae
NO.
Amount (Thousand$I
l-2 4
Face
% Distribution
have a relative standard errs that may exceed 30% and are generally considered unreliable.
974
MACKENZIE ET AL ICD/AIS
80%
l-2
ICDIAIS
l-2
61%
ICD/AIS
4-5 ICD/AIS
8%
ICD/AIS 31% Fig 2.
Distribution of pediatric trauma by ICD/AIS
hospitalization. The resulting incidence figure of 51 hospitalizations per 10,000 children is comparable to previously reported estimates for Massachusetts (54 per 10,000) and North Carolina (59 per 10,000).2” Charges associated with these hospitalizations (adjusted to 1988 dollars) exceeded $1 billion. Falls are the leading cause of hospitalizations for traumatic injury among children and constitute the leading contribution to hospital costs. Motor vehicles, although the leading cause of trauma deaths in this age group, rank second as a contributor to hospital admissions and costs. Although several studies have addressed the risk factors associated with falls among infants and children, further work is needed to identify effective prevention strategies and to ensure their implementation.‘4 The importance of head injury among children is underscored in this analysis. Each year over 78,000 children sustain a head injury serious enough to result in hospitalization. Head injuries account for almost one third of all acute hospitalizations for pediatric trauma and cost $270 million in acute hospital treat-
226,246 Patients
4-5
3
of principal injury (United States, 1996).
ment alone. The significant physical, neuropsychological, and neurobehavioral consequences of severe head injury in children have been documented in the literature.” Less is known about the consequences of minor and moderately severe head injury in children, although there is increasing evidence to suggest that they can result in significant social limitations and behavioral problems.16 Acute hospital costs for treating lower extremity injuries among children are also high ($227 million). Each year over 44,000 children are hospitalized with a principal diagnosis of a lower extremity injury; nearly one half of these are for severe fractures that require long hospital stays and often result in significant disability.17 An important implication of the present analysis is that regionalization of trauma care, including designation of specialty referral centers for pediatric trauma care, should not appreciably affect traditional patterns of hospital use or the distribution of hospital revenues among trauma centers and nontrauma center hospitals. This concern is thought to be a major impediment to a universal approach to the regionalization of trauma care in the US.‘* This study suggests that these concerns are unfounded. Applying optimal treatment Table 3. Distribution of Acute Hospitalization Charges by Source
$1 Billion Hospital Costs
of Payment (United States, 1995; Ages 0 to 14) $
Source of Payment Total public Federal Medicaid Other
15.4 12.3 3.1 32.7
Medicaid
10.4
Total private Health insurance Other Hospitalizations for pediatric trauma (United States.
28.1
State and local Other
Fig 3. 1996).
Percentof Total Charges
Uninsured Total
2.3 62.8 60.6 2.0 9.1 100.0
975
ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA
criteria indicates that less than 9% of total patients and 2 1% of hospital charges would accrue at trauma center hospitals. Since the appropriateness criteria were developed for retrospective evaluation of trauma systems, they classify where patients should be treated under an idealized set of circumstances when full knowledge of the type and severities of injuries is known. Clearly, some patients who are classified as not needing a trauma center based on their final diagnoses will be treated at a trauma center either appropriately because of the uncertainty regarding the extent and severity of injury at the time of triage or inappropriately because of inefficiencies in the system. Although this overtriage might affect the number of patients being transferred to trauma centers, these patients should only marginally increase the trauma center revenues. Even though major trauma cases requiring trauma center care represent a disproportionate share of hospital charges for trauma care, over three quarters of the total hospital revenues, or over $745 million dollars, would still be generated from the less severe injuries that can be appropriately treated at community hospitals. The analysis of hospital charges by source of payment indicates that the burden of hospital trauma costs is borne by all sectors of society, although private health insurance covers the majority of the costs. However, these figures should be interpreted with caution, due to the limitations of the data sources used in the analysis. One reporting problem in the NHDS concerns the identity of the principal source of payment; the payer identified at the time of discharge from the hospital may not represent the ultimate source of coverage. For example, a person injured in an automo-
bile crash may be covered under a private health insurance plan. However, the hospitalization may ultimately be paid by the insurance company of the person held liable for the crash. Therefore, the contribution of other private sources may be underestimated. Uninsured care comprises 9% of total hospital charges for pediatric trauma care, representing an estimated total amount per year of $86 million. A substantial portion of uninsured care for acute hospitalization represents bad debt for the provider. Bad debt is ultimately shifted to the charges paid by both public and private payers. Therefore, the source of payment labeled as “uninsured care” embodies a degree of uncertainty as to the true source of payment. The high cost of acute hospital care for trauma represents only a fraction of the total economic cost of hospitalized traumatic injury among children.] The 1,384 children who died prior to discharge from the hospital represent a loss to society of over 88 thousand life-years and an estimated $332 million in lost productivity. Lifetime costs associated with hospitalized children who survive their injury total an estimated $8.4 billion. Over one third ($3 billion) of these costs are for direct expenditures related to medical care and rehabilitation received during a lifetime following injury. The remaining two thirds ($5.4 billion) comprise the amount of reduced productivity due to temporary and permanent disabilities. These high costs underscore the importance of pediatric trauma as a major public health concern. Greater resources are needed to develop and implement effective prevention strategies and to ensure that optimal acute care and rehabilitation are available and accessible for those injuries that are not prevented.
REFERENCES I. Rice DP, MacKenzie EJ, Max W, et al: Cost of injury in the United States: A report to Congress. Institute for Health and Aging, University of California and Injury Prevention Center, The Johns Hopkins University, 1989 2. Gallagher SS, Finison K, Guyer B, et al: The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-81 statewide childhood injury prevention program surveillance system. Am J Public Health 74: 1340-1347, 1984 3. Runyan CW, Ketch JB, Margolis LH, et al: Childhood injuries in North Carolina: A statewide analysis of hospitalizations and deaths. Am J Public Health 75~1429-1431, 1985 4. Fife D, Barancik JI, Chatterjee BF: Northeastern Ohio trauma study: II. Injury rates by age, sex and cause. Am J Public Health 741473-478, 1984 5. Tiret L, Garros B, Havrette P, et al: Incidence, causes and severity of injuries in Aquitane, France: A community-based study of hospital admissions and deaths. Am J Public Health 79:316-321, 1989 6. US National Center for Health Statistics: 1984, 1985. 1986 National Hospital Discharge Survey (public use tapes) 7. Maryland
Health
Services
Cost Review Commission
(HSCc):
1984, 1985, 1986 Hospital Discharge Abstract Data (public usedata tapes) 8. US National Center for Health Statistics: 1980 National Medical Utilization and Expenditure Survey (public use tape) 9. MacKenzie EJ, Steinwachs DM, Shankar B: Classifying trauma severity based on hospital discharge diagnoses: Validation of an ICD-9CM to AIS ‘85 conversion table. Med Care 17:412-422. 1989 10. MacKenzie EJ, Steinwachs DM, Shankar B: Utility of uniform hospital discharge data in trauma research and evaluation. in 32nd Proc Assoc Advance Automotive Med, Des Plaines, IL, 1988 11. American Hospital Association (AHA): 1985 Annual Survey. Chicago, IL, AHA, 1986 12. MacKenzie EJ, Shapiro S, Siegel JH: The economic impact of traumatic injuries. JAMA 260:3048-3050, 1988 13. Mackenzie EJ, Steinwachs DM, Ramzey AI, et al: Evaluating compliance with a statewide regionalized system of trauma care. Presented at the Annual Meeting of the Eastern Association for the Surgery of Trauma, Naples, FL, January 1990 14. National Committee for Injury Prevention and Control: Injury prevention: Meeting the challenge. Am J Prevent Med 5:150-154, 1989 (suppl)
976
MACKENZIE ET AL
15. Levin HS, Eisenberg HM: Neuropsychological outcome of closed head injury in children and adolescents. Child Brain 5:281292,1979 16. Casey R, Ludwig S, McCormick MC: Morbidity following minor head trauma in children. Pediatrics 78:497-502, 1986
17. Wesson DE, Williams JI, Spence LJ, et al: Functional outcome in pediatric trauma. J Trauma 19:589-592, 1988 18. Aprahamian C, Wolferth CC, Darin JC, et al: Status of trauma center designations. J Trauma 29:566-570, 1989
Discussion C. Turner (Winston-Salem, NC): In the competitive atmosphere of the hospitals in urban areas, will we work out among ourselves which patients go to which trauma centers or are we going to have to go to the bureaucracy of Washington to get an answer? E. MacKenzie (response): I would think that the trauma community needs to answer that question in terms of defining better triage guidelines and making sure that the right patient gets the right level of care. I’d hate to see it going to the level of the bureaucracy. B. Harris (Boston, MA): Without intending the customary puffery of congratulating the author, I want those of you who don’t know Dr MacKenzie to be aware of her distinguished credentials in public health and trauma epidemiology. She is one of only two nonphysician members of the Eastern Association for the Surgery of Trauma (EAST), and her presence at our meetings is most welcome. Pediatric surgeons need to become missionaries to pediatric trauma centers. We are living in a time when the adult trauma centers,
which a few years ago were fighting to get designated, are now closing because they are losing money. And it’s happening all over the country. That situation need not be true in pediatric trauma, and it would be wonderful if all of you at this meeting could ‘go home and make two points. The first is that the adult trauma center must be saved-the loss is a social problem, not a medical one. The second is that pediatric trauma centers should not be painted with the same brush. In our experience in Boston, the free care and bed debt percentage for pediatric trauma patients has been minuscule-2% in a hospital where all free care and bed debt runs 12%-and the reason is that the mechanism of injury in pediatric trauma patients almost always involves some form of insurance. Those of you who work in hospitals where there are adult trauma patients must forcefully convince the governing bodies that a pediatric trauma program is essential in a society where injury is the number one child health problem.
Costs of Pediatric Trauma in the United States: How Much and Who Pays? John A. Morris,
Jr, Gregory V. de Lissovoy,
Gordon Smith,
and Maureen
Fahey
Baltimore, Maryland and Nashville, Tennessee 9 National estimates of the numbers and expenditures associated with hospitalization due to injury among children (aged 0 to 14) were derived using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys (NHDS) and the 1980 National Medical Care Utilization and Expenditures Study (NMCUES). In this report, age- and sexspecific estimates of the numbers of hospital admissions and expenditures are reported for subgroups of patients defined by external cause of the injury and by nature and severity of the injury. In 1985, over 286,000 children sustained a traumatic injury resulting in hospitalization (rate of 51 per 10,000 children). Expenditures totaled nearly $1 billion. Over 80% of the hospitalizations and two thirds of total expenditures were for minor (Maximum AIS = 1.2) trauma. Moderate (Maximum AIS = 3) and severe (Maximum AIS = 4.5) trauma accounted for 18% and 2% of admissions and 31% and 8% of expenditures, respectively. Falls ranked first in expenditures and admissions (36% of the total). Motor vehicle-related injuries accounted for 19% of trauma admissions and 24% of expenditures. Other less common causes included bicycle injuries, penetrating injuries and injuries caused by the child being hit by an object or person. An estimated 28% of the total hospital charges were paid for by public sources (15% from federal government programs, 13% from state and local programs). An additional 63% of total expenditures were paid for by private sources, with the remaining 9% considered uninsured care. This analysis suggests that the designation of pediatric trauma centers would not appreciably affect the revenues of nontrauma centers because minor and moderate injuries representing 91% of total trauma admissions and 79% of total charges would remain in the domain of the nontrauma center hospital. o 1990 by W.B. Saunders Company.
injury problem. For every death there are an estimated 34 injuries resulting in hospitalization and 1,500 less severe injuries not requiring hospitalization but that result in 1 or more days of restricted activity.’ Comparatively little is known about the nature and severity of nonfatal injuries among children. Although there have been studies defining the magnitude of the problem, these have been limited to specific geographic regions and have not provided detailed information on the severity mix of trauma patients or costs associated with treatment.2-5 This paper provides national estimates of the incidence and initial treatment costs for traumatic injuries severe enough to require hospitalization. This information is then used to examine the impact of regionalized trauma care on the distribution of patients and dollars between trauma centers and nontrauma centers.
INDEX WORDS:
The primary data source used for the present analysis was the National Hospital Discharge Survey (NHDS).6 The NHDS consists of hospital discharge abstracts uniformly collected for a probability sample of approximately 200,000 patients discharged each year from nearly 600 short-stay, nonfederal hospitals located in the 50 states and the District of Columbia. Data abstracted for each hospital discharge include patient demographics, up to seven discharge diagnoses (coded using the Clinical Modification of the 9th Revision of the International Classification of Diseases [ICD9CM]), up to three procedures (ICD-9CM coded), length of stay, discharge status, and expected principal source of payment. Three years of NHDS data (1984 through 1986) were used to provide more accurate estimates by age, sex, and nature of injury. Annualized estimates for 1985 were obtained by averaging the estimates over the 3 years. Statewide hospital discharge abstract data from Maryland were used to supplement the information available from the NHDS on per diem charges and cause of injury? All 56 acute care, nonfederal hospitals in Maryland are mandated by law to submit uniform data
Pediatric
trauma,
MATERIALS
METHODS
Estimates of the number of acute hospital admissions, hospital charges, and source of payment were developed for children between the ages of 0 and 14. Separate estimates were developed for five categories of cause (falls, motor vehicles, firearms, fires/burns, other) and 21 categories describing the body region and severity of the principal or most severe injury sustained. Estimates reported are for 1985, the most recent year for which reliable data are available. The data sources and methods used to derive these estimates are described in detail elsewhere’; they are summarized below. Data Sources
cost.
T
RAUMA IS well recognized as the leading cause of death among children ages 0 to 14. However, mortality is only one indicator of the magnitude of the
From the Johns Hopkins University School of Hygiene and Public Health, Baltimore. MD, and Vanderbilt University School of Medicine, Nashville, TN. Supported in part by the National Highway Trajic Safety Administration (NHTSA) and Center for Disease Control (CDC) Grant No. DTNH22-88-Z-07144 and the National Center for Health Services Research and Health Technology Assessment Grant No. HSO5630-02. Presented at the 38th Annual Meeting of the Surgical Section of the American Academy of Pediatrics, Chicago, Illinois. October 21-23, 1989. Address reprint requests to Q 1990 by W.B. Saunders Company. 0022-3468/90/2509-0010$03.00/0
970
AND
on all discharges to the Health which is responsible for setting
Services Cost Review Commission, hospital rates under the State’s per
case payment system. The Maryland data base includes the NHDS
Journai of Pediatric Surgery,
Vol 25,
No 9
(September), 1990: pp
970-976
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ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA
elements plus source of admission and total and component charges for each hospitalization. Also, the cause of injury is recorded for 61% of Maryland discharges as compared with 27% of the NHDS sample. The National Medical Care Utilization and Expenditure Survey (NMCUES) supplemented the source of payment information obtained from the NHDS.’ The NMCUES was a nationwide sample survey conducted in 1980 by the National Center for Health Statistics in which 10,000 households (17,000 individuals) were interviewed on five separate occasions at 3-month intervals. Data were collected on health conditions, services, charges, sources, and amounts of payment.
Estimating Number of Hospitalizations Included in the definition of an acute trauma hospitalization was any discharge with a principal diagnosis of an injury as defined by the ICD-9CM N-codes N800 through N959, excluding N958 (traumatic complications), N905 through N909 (late effects of injuries), and N930 through N939 (foreign bodies). Poisonings, near drownings, suffocations, and other nontraumatic injuries are excluded from the definition. National estimates of the number of hospital admissions were calculated by inflating the NHDS sample by the reciprocals of the probabilities of sample selection, adjusting for nonresponse. Estimates of less than 3,000 have a relative standard error that may exceed 30% and are generally considered unreliable. These figures are noted in the tables with an asterisk. Estimates of total trauma discharges were adjusted downward to exclude possible rehospitalization for follow-up care of a previous injury.’ All hospital discharges were classified into one of 21 categories defined by the body region and severity of the principal or most severe injury sustained. Injury severity was determined using a computerized mapping of ICD-9CM coded discharge diagnoses into Abbreviated Injury Scale (AIS) scores.9 The resulting severity scores, referred to as ICD/AIS scores, will on average, be slightly lower than AIS scores obtained by reviewing the entire medical record. Thus, the distribution of hospital discharges by severity will be conservative. A major limitation of the NHDS for estimating the number of hospital trauma episodes is the lack of uniform coding of the cause of injury. The percent of cases in the NHDS for which the cause of injury can be identified by an ICD E-code (External Cause of Injury Code) is low-approximately 25%. In Maryland, on the other hand, the percent of cases with information on cause is higher (61%). However, it has been shown that even in these more complete data bases, E-coding is not a random practice within or among hospitals, but is strongly correlated with the number and severity of injuries sustained; patients with multiple injuries or patients who develop complications during the hospitalization are less likely to be assigned E-codes.” To correct for this potential bias, the following procedure was used to estimate the number of trauma hospital episodes by major cause categories. Three years of discharges from the 56 acute care hospitals in Maryland for which E-codes were recorded were distributed by cause within two age groups, (0 to 4; 5 to 14) two sex groups, and 21 categories defining the body region and ICD/AIS severity of the principal injury. Based on the Maryland discharge data. the percent distributions of cause within each age, sex, and nature of injury category were then multiplied by the NHDS estimates of the total number of hospitalizations within each cell. Estimates of the number of hospital episodes were developed for five major cause categories: motor vehicle crashes, falls, firearms, fires/ burns, and other. Episodes were classified by cause regardless of intent.
Estimating Total Hospital Charges Charges associated with each trauma hospitalization were estimated using the following procedures. First, Maryland discharge data were used to determine the mean per diem charge for subgroups of the population defined by age (0 to 4; 5 to 14) and the 21 groups defining the nature and severity of the injury. These means were then multiplied by the corresponding length of stay as reported in the NHDS. These estimates were deflated by a factor of .9572, which is the ratio of the United States average per diem hospital charge to the Maryland average per diem hospital charge based on the 1985 Annual Survey of the American Hospital Association.” The resulting estimates of hospital charges were inflated by 25% to account for professional fees.‘* Maryland per diem charges were used because they are computerized for all acute care discharges and because hospital charges are regulated by the State’s Health Services Cost Review Commission and have a known relationship to costs. All third-party payers pay full charges less a small discount (6%) for timely payment. Therefore, per diem hospital charges in Maryland represent a good proxy for costs and will not vary across payers.
Distributing Patients and Hospital Charges by Level of Care To determine the impact of regionalization on the distribution of patients and hospital revenues, trauma admissions and total charges were distributed according to the lowest level of care (ie, trauma center or nontrauma center hospital) that is appropriate based on the nature and ICD/AIS severity of injuries sustained and the age of the patient. These criteria were developed for retrospective evaluation of the performance of regionalized trauma systems. They indicate how patients should be treated under an idealized set of circumstances when full knowledge of the type and severity of injuries is available. As such, the criteria are based on the type and severity of injuries as ultimately described by discharge diagnoses and autopsy results. Criteria for classifying the appropriate level of care were developed by a committee of nationally recognized experts in the treatment of trauma. According to the criteria, all patients with injuries to three or more body systems or patients with at least one injury of AIS 4 or greater, require trauma center care. Patients with minor (AIS = 1 or 2) injuries to one or two body systems can be treated at a nontrauma center. All other patients are classified according to the precise nature of the injuries sustained and age of the patient (0 to 4; 5 to 14). A detailed description of the criteria can be found elsewhere.?
Estimating Source of Payment The NHDS was used to distribute acute hospitalizations for trauma by expected principal source of payment. When hospital charges were covered by several sources, the NMCUES data were used to distribute the total payment to the various payers, conditioned on the identity of the primary payer as determined from the NHDS. RESULTS
In 1985 an estimated 266,248 children aged 0 to 14 (or 51.3 per 10,000 population) were hospitalized for acute treatment of a traumatic injury. Of these, less than 1% (0.52%) died prior to discharge. Two thirds of all hospitalizations were among boys. Preschool children (ages 0 to 4) accounted for 29% of total hospitalizations (42 hospitalizations per 10,000 population), early school children (ages 5 to 9) for 32% (51 per
972
MACKENZIE ET AL
lO,OOO),and preadolescents (ages 10 to 14) for 39% (61 per 10,000) (Table 1). Hospital charges for acute hospitalizations among all children ages 0 to 14 totaled $946 million in 1985 or over $1 billion in 1988 dollars. Incidence and Charges by External Cause
Falls constitute the leading cause of trauma-related hospitalizations among children and are also the major contributor to hospital charges (Fig 1). In 1985, falls accounted for 36% of all acute hospitalizations (94,689) and 30% of total hospital charges ($286 million). Falls were most prevalent among preschool-aged children, accounting for nearly one half (46%) of all hospitalizations in this age group. Among early school and preadolescents, falls accounted for 32% of all acute trauma hospitalizations. Motor vehicle injuries ranked second in admissions and economic toll, accounting for 19% of total pediatric trauma hospitalizations among children (n = 51,759) and 24% of total charges ($229 million). Fires and burns accounted for an additional 6% of hospitalizations (n = 17,110) and 11% of total charges ($101 million). Injuries categorized as other included a variety of causes; together they accounted for 38% of all hospitalizations for acute trauma care and 33% of total charges. Some of the more common causes categorized as other included bicycle injuries, being struck by an object in play or sports and being injured by a cutting or piercing instrument or object. Incidence and Charges by Nature and Severity of the Principal Injury
In Table 2, total hospitalizations and associated charges are distributed by the body region and ICD/ AIS severity of the principal or most severe injury sustained. Overall, 2% of hospitalizations were for serious and severe injuries (ICD/AIS = 4 and 5); these injuries accounted for 8% of total charges. Moderately severe injuries (ICD/AIS = 3) accounted for an additional 18% of the hospitalizations and 31% of charges (Fig 2). Head injuries accounted for 29% of hospitalizations (78,168) and 29% associated charges ($270 million). Table 1. Acute Hospitalizations for Traumatic Injury (United States. 1985) BOYS
Total
Girls
@late)
NO.
vim)
NO.
mate)
0 to 4
45,387
(49.3)
30,948
(35.2)
76,337
(42.4)
5 to 9
58,545
(68.0)
27,238
(33.2)
85,780
(51.0)
10 to 14
72,077
(82.3)
32,052
(38.4)
104,131
(60.9)
All ages
176,009
(66.2)
90,238
(35.6)
266,248
151.3)
NOTE. Rate is per 10,000 population.
Distribution of Admissions and Costs by Appropriate Level of Care
When the appropriateness criteria were applied to the preceding estimates by nature and severity of the injury and age of the patient, an estimated 8.6% of all hospitalizations were classified as requiring treatment at a trauma center (Fig 3). Because these hospitalizations by definition involve the most severe injuries, they represented a disproportionate share of the total hospital charges. Charges accrued by patients who, according to the criteria, should optimally be treated at a trauma center represented 21.2% of total hospital charges. Source of Payment
In 1985 the majority of hospital care (63%) for acute treatment of traumatic injury among children was paid for by private sources, primarily private health insurance (Table 3). An additional 28% of acute hospital charges were covered by public sources, primarily Medicaid (23%). The federal government paid for approximately 15% of the acute hospital charges, state and local governments, the remaining 13%. Uninsured care represents 9% of total hospital charges. This category includes direct out-of-pocket expenditures for copayments and uncovered services as well as an unknown amount of uncompensated care. DISCUSSION
NO.
Age ~yearsl
Although the majority (81%) of hospitalized head injuries were relatively minor, an estiamted 14,497 children sustained a moderately severe (ICD/AIS = 3) or severe (ICD/AIS = 4 and 5) head injury in 1985. Hospitalization for these more severe head injuries, only representing 5% of all trauma hospitalizations, accounted for 14% of the total bill for acute hospital trauma care. Injuries to the lower extremities were also a common cause of hospitalization, accounting for 17% of all hospitalizations (n = 44,611) and 24% of all charges ($227 million). An additional 21% of hospitalizations were for injuries to the upper extremities (n = 54,965), accounting for 14% of the total cost for acute hospital trauma care ($134 million). Burns accounted for 7% of all acute trauma hospitalizations (n = 18,953) and 11% of associated charges in 1985 ($101 million).
This study provides national estimates of the number of acute hospitalizations for traumatic injury among children and documents the cost of these hospitalizations. In 1985 over 266,000 children aged 0 to 14 sustained an injury severe enough to result in
973
ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA Falls
Falls
Motor Motor
Vehicles 19%
Vehicles 24%
\
\
Fires/Burns 0% Firearms 2%
Fires/Burns 11%
,-
Other 33%
Other 3am
266,248 Fig 1.
$946
Hospitalizations
Million
Distribution of pediatric trauma by cause of injury (United States, 1985).
Table 2. Number of Acute Hospitalizations and Total Hospital Charges by Body Region and Severity of Principal Injury (United States, 198% Ages 0 to 14) HospitalCharges
HospitalEpisodes Als Head
23.9
138,254
11.244
4.2
70,385
7.4
1.0
25,360
2.7
l-2
10,116
1,121.
3.8 28.6
3.8
24,060
l
570
3.9
24,638
2.6
0.7
3,175
0.3
0.4
8,322
0.9
1.1
11,497
1.2
0.1
4.071
0.4 0.6
529.
0.2
5,592
926.
0.3
9,663
1.0
8,609
3.2
32,966
3.5
1.424*
0.5
7,875
0.8
524*
0.2
5,303
0.6
Total
10,557
4.0
46,144
4.9
l-2
51,951
19.5
121,713
12.9
3-5
3,014
1.1
11,991
1.3
133,704
14.1
Total
54,965
20.6
l-2
24.080
9.0
60,161
6.4
3-5
20.53 1
7.7
167.249
17.7
Total
44,611
16.8
227.410
24.1
l-2
11,024
4.1
43.018
4.6
0.3
12,228
1.3
2.7
45.620
3-5 Unknown Total
700s 7,229 18,953
7.1
100.866
4.8 10.7
44,810
16.8
121,678
12.9
266,248
100.0
945,657
Abbreviation: AIS, abbreviated injury scale. *Estimates of less than 3,000
2.5 0.1
4-5
3
Total
3974
36,053 270,052
Total
4-5
Other and unknown (total)
1,830. 2,951
0.2 29.4 0.1
10,307
4
l-2
Burns
191.
Total 3
Lower extremities
618. 78,168
1-2
Upper extremities
2,635.
Total
Total
Abdomen, thorax, neck
14.6
63,671
3-5
Spinal cord
% Distribution
3 5
Vertebrae
NO.
Amount (Thousand$I
l-2 4
Face
% Distribution
have a relative standard errs that may exceed 30% and are generally considered unreliable.
974
MACKENZIE ET AL ICD/AIS
80%
l-2
ICDIAIS
l-2
61%
ICD/AIS
4-5 ICD/AIS
8%
ICD/AIS 31% Fig 2.
Distribution of pediatric trauma by ICD/AIS
hospitalization. The resulting incidence figure of 51 hospitalizations per 10,000 children is comparable to previously reported estimates for Massachusetts (54 per 10,000) and North Carolina (59 per 10,000).2” Charges associated with these hospitalizations (adjusted to 1988 dollars) exceeded $1 billion. Falls are the leading cause of hospitalizations for traumatic injury among children and constitute the leading contribution to hospital costs. Motor vehicles, although the leading cause of trauma deaths in this age group, rank second as a contributor to hospital admissions and costs. Although several studies have addressed the risk factors associated with falls among infants and children, further work is needed to identify effective prevention strategies and to ensure their implementation.‘4 The importance of head injury among children is underscored in this analysis. Each year over 78,000 children sustain a head injury serious enough to result in hospitalization. Head injuries account for almost one third of all acute hospitalizations for pediatric trauma and cost $270 million in acute hospital treat-
226,246 Patients
4-5
3
of principal injury (United States, 1996).
ment alone. The significant physical, neuropsychological, and neurobehavioral consequences of severe head injury in children have been documented in the literature.” Less is known about the consequences of minor and moderately severe head injury in children, although there is increasing evidence to suggest that they can result in significant social limitations and behavioral problems.16 Acute hospital costs for treating lower extremity injuries among children are also high ($227 million). Each year over 44,000 children are hospitalized with a principal diagnosis of a lower extremity injury; nearly one half of these are for severe fractures that require long hospital stays and often result in significant disability.17 An important implication of the present analysis is that regionalization of trauma care, including designation of specialty referral centers for pediatric trauma care, should not appreciably affect traditional patterns of hospital use or the distribution of hospital revenues among trauma centers and nontrauma center hospitals. This concern is thought to be a major impediment to a universal approach to the regionalization of trauma care in the US.‘* This study suggests that these concerns are unfounded. Applying optimal treatment Table 3. Distribution of Acute Hospitalization Charges by Source
$1 Billion Hospital Costs
of Payment (United States, 1995; Ages 0 to 14) $
Source of Payment Total public Federal Medicaid Other
15.4 12.3 3.1 32.7
Medicaid
10.4
Total private Health insurance Other Hospitalizations for pediatric trauma (United States.
28.1
State and local Other
Fig 3. 1996).
Percentof Total Charges
Uninsured Total
2.3 62.8 60.6 2.0 9.1 100.0
975
ACUTE HOSPITAL COSTS OF PEDIATRIC TRAUMA
criteria indicates that less than 9% of total patients and 2 1% of hospital charges would accrue at trauma center hospitals. Since the appropriateness criteria were developed for retrospective evaluation of trauma systems, they classify where patients should be treated under an idealized set of circumstances when full knowledge of the type and severities of injuries is known. Clearly, some patients who are classified as not needing a trauma center based on their final diagnoses will be treated at a trauma center either appropriately because of the uncertainty regarding the extent and severity of injury at the time of triage or inappropriately because of inefficiencies in the system. Although this overtriage might affect the number of patients being transferred to trauma centers, these patients should only marginally increase the trauma center revenues. Even though major trauma cases requiring trauma center care represent a disproportionate share of hospital charges for trauma care, over three quarters of the total hospital revenues, or over $745 million dollars, would still be generated from the less severe injuries that can be appropriately treated at community hospitals. The analysis of hospital charges by source of payment indicates that the burden of hospital trauma costs is borne by all sectors of society, although private health insurance covers the majority of the costs. However, these figures should be interpreted with caution, due to the limitations of the data sources used in the analysis. One reporting problem in the NHDS concerns the identity of the principal source of payment; the payer identified at the time of discharge from the hospital may not represent the ultimate source of coverage. For example, a person injured in an automo-
bile crash may be covered under a private health insurance plan. However, the hospitalization may ultimately be paid by the insurance company of the person held liable for the crash. Therefore, the contribution of other private sources may be underestimated. Uninsured care comprises 9% of total hospital charges for pediatric trauma care, representing an estimated total amount per year of $86 million. A substantial portion of uninsured care for acute hospitalization represents bad debt for the provider. Bad debt is ultimately shifted to the charges paid by both public and private payers. Therefore, the source of payment labeled as “uninsured care” embodies a degree of uncertainty as to the true source of payment. The high cost of acute hospital care for trauma represents only a fraction of the total economic cost of hospitalized traumatic injury among children.] The 1,384 children who died prior to discharge from the hospital represent a loss to society of over 88 thousand life-years and an estimated $332 million in lost productivity. Lifetime costs associated with hospitalized children who survive their injury total an estimated $8.4 billion. Over one third ($3 billion) of these costs are for direct expenditures related to medical care and rehabilitation received during a lifetime following injury. The remaining two thirds ($5.4 billion) comprise the amount of reduced productivity due to temporary and permanent disabilities. These high costs underscore the importance of pediatric trauma as a major public health concern. Greater resources are needed to develop and implement effective prevention strategies and to ensure that optimal acute care and rehabilitation are available and accessible for those injuries that are not prevented.
REFERENCES I. Rice DP, MacKenzie EJ, Max W, et al: Cost of injury in the United States: A report to Congress. Institute for Health and Aging, University of California and Injury Prevention Center, The Johns Hopkins University, 1989 2. Gallagher SS, Finison K, Guyer B, et al: The incidence of injuries among 87,000 Massachusetts children and adolescents: Results of the 1980-81 statewide childhood injury prevention program surveillance system. Am J Public Health 74: 1340-1347, 1984 3. Runyan CW, Ketch JB, Margolis LH, et al: Childhood injuries in North Carolina: A statewide analysis of hospitalizations and deaths. Am J Public Health 75~1429-1431, 1985 4. Fife D, Barancik JI, Chatterjee BF: Northeastern Ohio trauma study: II. Injury rates by age, sex and cause. Am J Public Health 741473-478, 1984 5. Tiret L, Garros B, Havrette P, et al: Incidence, causes and severity of injuries in Aquitane, France: A community-based study of hospital admissions and deaths. Am J Public Health 79:316-321, 1989 6. US National Center for Health Statistics: 1984, 1985. 1986 National Hospital Discharge Survey (public use tapes) 7. Maryland
Health
Services
Cost Review Commission
(HSCc):
1984, 1985, 1986 Hospital Discharge Abstract Data (public usedata tapes) 8. US National Center for Health Statistics: 1980 National Medical Utilization and Expenditure Survey (public use tape) 9. MacKenzie EJ, Steinwachs DM, Shankar B: Classifying trauma severity based on hospital discharge diagnoses: Validation of an ICD-9CM to AIS ‘85 conversion table. Med Care 17:412-422. 1989 10. MacKenzie EJ, Steinwachs DM, Shankar B: Utility of uniform hospital discharge data in trauma research and evaluation. in 32nd Proc Assoc Advance Automotive Med, Des Plaines, IL, 1988 11. American Hospital Association (AHA): 1985 Annual Survey. Chicago, IL, AHA, 1986 12. MacKenzie EJ, Shapiro S, Siegel JH: The economic impact of traumatic injuries. JAMA 260:3048-3050, 1988 13. Mackenzie EJ, Steinwachs DM, Ramzey AI, et al: Evaluating compliance with a statewide regionalized system of trauma care. Presented at the Annual Meeting of the Eastern Association for the Surgery of Trauma, Naples, FL, January 1990 14. National Committee for Injury Prevention and Control: Injury prevention: Meeting the challenge. Am J Prevent Med 5:150-154, 1989 (suppl)
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15. Levin HS, Eisenberg HM: Neuropsychological outcome of closed head injury in children and adolescents. Child Brain 5:281292,1979 16. Casey R, Ludwig S, McCormick MC: Morbidity following minor head trauma in children. Pediatrics 78:497-502, 1986
17. Wesson DE, Williams JI, Spence LJ, et al: Functional outcome in pediatric trauma. J Trauma 19:589-592, 1988 18. Aprahamian C, Wolferth CC, Darin JC, et al: Status of trauma center designations. J Trauma 29:566-570, 1989
Discussion C. Turner (Winston-Salem, NC): In the competitive atmosphere of the hospitals in urban areas, will we work out among ourselves which patients go to which trauma centers or are we going to have to go to the bureaucracy of Washington to get an answer? E. MacKenzie (response): I would think that the trauma community needs to answer that question in terms of defining better triage guidelines and making sure that the right patient gets the right level of care. I’d hate to see it going to the level of the bureaucracy. B. Harris (Boston, MA): Without intending the customary puffery of congratulating the author, I want those of you who don’t know Dr MacKenzie to be aware of her distinguished credentials in public health and trauma epidemiology. She is one of only two nonphysician members of the Eastern Association for the Surgery of Trauma (EAST), and her presence at our meetings is most welcome. Pediatric surgeons need to become missionaries to pediatric trauma centers. We are living in a time when the adult trauma centers,
which a few years ago were fighting to get designated, are now closing because they are losing money. And it’s happening all over the country. That situation need not be true in pediatric trauma, and it would be wonderful if all of you at this meeting could ‘go home and make two points. The first is that the adult trauma center must be saved-the loss is a social problem, not a medical one. The second is that pediatric trauma centers should not be painted with the same brush. In our experience in Boston, the free care and bed debt percentage for pediatric trauma patients has been minuscule-2% in a hospital where all free care and bed debt runs 12%-and the reason is that the mechanism of injury in pediatric trauma patients almost always involves some form of insurance. Those of you who work in hospitals where there are adult trauma patients must forcefully convince the governing bodies that a pediatric trauma program is essential in a society where injury is the number one child health problem.
