International Journal of Injury Control and Safety Promotion
ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy Francesco Chini, Sara Farchi, Laura Camilloni, Maria Letizia Giarrizzo & Paolo Giorgi Rossi To cite this article: Francesco Chini, Sara Farchi, Laura Camilloni, Maria Letizia Giarrizzo & Paolo Giorgi Rossi (2014): Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.942324 To link to this article: http://dx.doi.org/10.1080/17457300.2014.942324
Published online: 29 Sep 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=nics20 Download by: [University of Lethbridge]
Date: 12 November 2015, At: 02:40
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.942324
Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy Francesco Chinia*, Sara Farchia, Laura Camillonia, Maria Letizia Giarrizzoa and Paolo Giorgi Rossib a
Agency of Public Health, Lazio Region, via di S. Costanza 53, 00198 Rome, Italy; bServizio Interaziendale di Epidemiologia, AUSL Reggio Emilia, Rome, Italy
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
(Received 6 September 2013; accepted 3 July 2014) The economic consequences of road traffic injuries (RTIs) are very important in terms of health care costs. The aim of this study is to provide estimates of health care costs of non-fatal RTIs and to estimate functional outcomes using in-hospital rehabilitation data. We identified all emergency department (ED) visits related to RTI during 2008 and then linked them with hospital discharges and rehabilitation admissions, health care costs following RTI were estimated from the integrated database. We performed an epidemiological evaluation of RTI with a comprehensive description of functional outcomes at 6 months. Health care costs have been estimated at about €80 million with a per person cost of €522. About 18% of the total cost was due to rehabilitation treatments. In multivariate analysis the variables that correlated better with higher total health care costs were: older age, injury severity, presence of spinal lesion. Patients requiring rehabilitation were: the elderly, patients suffering from a spinal cord injury and leg injuries. This study provides consistent health care cost estimates of RTI using administrative databases and it shows a picture of functional outcomes after RTI. Further research is needed for the estimation of other components of the total cost of RTI. Keywords: road traffic injuries; health care costs; functional outcomes
Introduction Road traffic injuries (RTIs) represent a relevant public health problem. According to the WHO, RTIs account for almost 1.2 million deaths a year around the world, and for 50 million injuries or disabilities (Peden et al., 2004). In addition to the impact of RTIs on public health, they represent a relevant source of health care costs and use. Priorities for injury prevention depend on the burden of injury mortality and morbidity. In a health technology assessment approach the estimation of economic cost of RTIs is important in order to observe effectiveness of prevention programmes. The economic consequences of RTIs (including lost productivity, human cost, property damage, service and health care costs) are very important and their estimate is approximately 1% of the gross national product in low-income countries, 1.5% in middle-income countries and 2% in high-income countries (Peden et al., 2004). In Italy, the economic costs of RTI have been estimated at €30 billion in 2008, 4% of which was health care cost (Automobile Club d’Italia [ACI], 2008); however, a detailed analysis of health care costs is lacking, because the estimation is often based on RTI reported by police forces, which suffers from underreporting of RTI injuries and their severity (Chini, Farchi, Giorgi Rossi, Camilloni, & Borgia, 2010; Giorgi Rossi et al., 2005).
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
In the Lazio region of Italy, since 2000, a surveillance system of the RTI based on the integration of data from emergency facilities with other health-related information (hospital admission and mortality data) has been established to define the extent of the problem in terms of its health consequences (Giorgi Rossi et al., 2005; Petridou & Alexe, 2004). To date, few studies used rehabilitation treatment data to estimate recovery outcomes and costs of which some studies were based on a sample of injured persons followed up through interviews (Clay, Fitzharris, Kerr, McClure, & Watson, 2012) and other studies were focused on specific types of lesion (Bragge et al., 2011). In general, studies analysing long-term post-traumatic outcomes have used different populations, different data collection methods, or follow-up strategies. Nevertheless, all these studies show that injured patients are not fully recovered 1218 months post injury (Holbrook, Anderson, Sieber, Browner, & Hoyt, 1998, 1999; Michaels et al., 2000), even less severely injured patients (Mayou & Bryant, 2001). One study in 2011 on short-term recovery outcome of injured patients shows that few socio-demographic factors are associated with adverse outcomes, the most important is gender. Females had adverse outcomes compared with males. Admission to hospital and trouble accessing health services were consistently associated with
2
F. Chini et al.
adverse outcomes (Langley, Derrett, Davie, Ameratunga, & Wyeth, 2011). The aims of this study are to provide an estimate of the health care use and costs of non-fatal RTIs that occurred in 2008 in the Lazio region through data derived from the surveillance system implemented and to estimate functional outcomes using in-hospital rehabilitation data.
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
Methods Setting Lazio is a region of central Italy with a population of around 5,600,000 (including Rome) as of 2008 (Italian National Institute of Statistics, 2011a). Like all other Italian regions, it provides its citizens with universal health care coverage. All outpatient/inpatient treatments and procedures are recorded in the health information system. Data sources The Emergency Information System (EIS): collects information on all visits to emergency departments (EDs) in the Lazio region. The information collected includes the patients’ demographics, procedures, diagnoses and outcome. In case of trauma, the type or location of the accident is also reported (intentional violence, road, work, home, other). In the EIS an urgency scale is used called ‘triage’, commonly used in crowded EDs to determine treatment priority. Triage involves colour codes based on priority with red D urgent, yellow D critical, green D deferrable and white D not appropriate for ED. The Hospital Discharge Information System (HDIS): gathers and manages data from all hospital admissions from both public and private hospitals in the Lazio region and collects the patients’ demographics, procedures, diagnoses and final disposition. Rehabilitation Information System (RIS): manages rehabilitation admissions at both public and private hospitals and collects demographic data of patients, diagnoses, the rehabilitation treatments received, final disposition and the Barthel index (admission and discharge) used to measure performance in basic activities of daily living for patients older than 17 without previous coma status and spinal cord injury. Selection and linkage procedure We selected all emergency visits with at least one diagnosis of trauma (ICD9-CM 800959) that listed ‘road’ as the place of accident. Emergency visits by the same
person within 48 hours were considered as stemming from the same accident. For each case, through deterministic record linkage, we looked for subsequent hospital admissions in the HDIS that occurred within 24 hours of the accident. A more detailed description of HDIS linkage procedures is reported elsewhere (Giorgi Rossi et al., 2005). The EIS-HDIS integrated database was linked to the RIS to identify in-hospital rehabilitation treatments performed within 6 months of the emergency visit. We considered only the rehabilitation treatments related to acute events with or without a hospital admission and excluded V code 43.64 (hip joint replacement) and those that did not report a diagnosis of trauma, whereas the late effects (ICD9-CM 905909) were included. All linkage procedures were performed according to privacy laws, through the use of indirect pseudonym identifiers. Health care costs From the integrated database, health care costs following RTI were estimated assuming the National Health Service (NHS) perspective. The estimated costs of emergency visits comprehensive of ambulance costs (ambulance transport D 175€, helicopter transport D 5675€) were performed and applied a reimbursement tariff based of triage codes (red D 1032.91€, yellow D 309.87€, green D 154.94€ and white D 41.32€). Hospital admission costs and rehabilitation ones were estimated using diagnosisrelated groups (DRGs) prices adopted by NHS. By definition, DRGs classify patients according to the following variables: principal and secondary diagnoses, patient age and sex, the presence of co-morbidities and complications and the procedures performed. Patients with a specific DRG have homogenous resource consumption pattern and, at the same time, DRGs are clinically meaningful. Thus, cases within the same DRG are economically and medically similar. In formula, total health care cost D emergency cost C emergency transport cost C hospital discharge cost (if any) C rehabilitation cost (if any). Analysis A general epidemiological evaluation of RTI that occurred during 2008 was performed with a comprehensive description of rehabilitation treatments. Health care costs were estimated separately for emergency visits, hospital admissions and rehabilitation and were stratified by sex, age, triage code, length of stay (LOS) in hospital, Barthel index score and DRGs (grouped in the major diagnostic category). Trauma diagnoses were classified according to the Barell matrix (Barell et al., 2002) into 12 types of injuries and seven body regions. If more than one body region or
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
International Journal of Injury Control and Safety Promotion type of injury was present, the case was classified as a multiple injury. We calculated the rates of emergency visits for body region and type of injury and compared them with their health care costs estimated using the DRG approach described above. The rates were calculated using the number of emergency room visits as the numerator, and the resident population of the region of Lazio during the study period as the denominator (Rooney, Warner, & Fingerhut, 2000). A multivariate linear regression model was run to describe the variability of average total health care costs. Furthermore, a separate model was built for rehabilitation treatment costs. The variables included in the model were: gender, age group, triage code, hospital admission, Barthel index score, body region and type of injuries; the choice of the variables was made a priori. Since costs had a skewed distribution, logarithmic transformation was used to sufficiently approximate a normal distribution. All analyses were performed using SAS V 9.2 statistical package (SAS Institute Inc., 2005).
Results Epidemiological findings and functional outcomes In the Lazio region in Italy during 2008 there were 153,232 emergency visits for non-fatal RTIs of which 9643 required hospital care, with an emergency visit rate of 2755/100,000 inhabitants and a hospitalisation rate of 173/100,000 inhabitants. The 1534 years old group and those who were males had a higher risk of being visited by the emergency room and of being admitted to the hospital after RTI; hospitalised patients had median length of stay (including possible stay in resuscitation unit) equal to 6 days (interquartile range D 8 days). Patients requiring rehabilitation (Table 1) were the 0.8% of the entire cohort, with no difference by gender. Stratification by age showed that elderly people were more likely to be admitted to rehabilitation treatment than younger. Traumatic brain injury, lower extremity injury and fractures were more likely to be referred to the rehabilitation unit. 26.8% of the patients stayed in the rehabilitation unit for more than 60 days. Among patients admitted to the rehabilitation programmes, 50.4% had a Barthel index score below 50 at admission, but after the rehabilitation treatment the Barthel index (average) passed from 50.4 to 84.1 (p < 0.001). After the hospitalisation and rehabilitation care, 68 patients (5.6% of those admitted to rehabilitation programmes) had a Barthel index below 50 and 362 subjects (30% of those admitted to rehabilitation programmes) needed prosthesis, in particular older patients and those with low Barthel index scores. Among patients younger
3
than 18 years old (76 cases), the main pathology object of rehabilitation treatments was fractures of lower extremities (38% of young patients) and almost one-third of them needed prosthesis (mainly device to aid ambulation) at discharge at home.
Health care costs Health care direct costs have been estimated in about €80 million (expenditure per person of €522) (Table 2), and about 18% of the total cost was due to rehabilitation treatments. The cost of ambulance/helicopter transportation to EDs has been estimated at about €7 million (9% of total health care cost); of these costs almost 40% was attributable to red and yellow triage codes and 45% to the 1534 year old patients. The analysis of direct health care costs, stratified for socio-demographic and clinical factors showed that higher unit costs were observed in males, elderly patients, severely injured, in particular with spinal cord injury (3075€), blood vessel injury (2688€) and traumatic brain injury (1504€). Higher costs were observed also in patients with a Barthel index score at admission below 50. Large unit cost was observed in case of patients with multiple trauma, with emergency visit cost equal to 1063€, hospital admission cost equal to 11,084€ and rehabilitation treatment cost equal to 17,132€. Rehabilitation costs were very different according to the pathology object of rehabilitation, length of stay and outcome (Table 3). In all, almost half of the costs was due to rehabilitation of fracture (upper and lower extremities), and the rehabilitation treatments longer than 60 days represented more than one-third of rehabilitation costs. Relevant in terms of both percentage (15%) and unit cost (39,662€) is the rehabilitation of quadriplegia and paraplegia. Figure 1 showed that incidence of RTI visits and direct costs had similar patterns until 64 years of age; after that age, females corresponded to higher costs. Relevant costs were seen for elderly people although the incidence of RTI visits was low. Comparison among emergency visit rates and health care costs in different body regions showed that the traumatic brain injuries, spinal lesions and fractures had higher cost/incidence ratios than other body regions did (Figure 2). A multivariate linear regression analysis of total health care costs (Table 4) showed that the variables better correlated with higher total health care costs were the same found in descriptive analysis: older age, injury severity (triage code red or hospitalised patients), low Barthel index score, presence of spinal injury or fracture. If we included only rehabilitation costs, the model showed
4
F. Chini et al.
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
Table 1. Characteristics of subject undergoing rehabilitation treatments and Barthel index score at discharge. Lazio region of Italy 2008. % Barthel index score at discharge 60 days
215 530 273
21.0 52.1 26.8
14.0 5.9 2.6
ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy Francesco Chini, Sara Farchi, Laura Camilloni, Maria Letizia Giarrizzo & Paolo Giorgi Rossi To cite this article: Francesco Chini, Sara Farchi, Laura Camilloni, Maria Letizia Giarrizzo & Paolo Giorgi Rossi (2014): Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy, International Journal of Injury Control and Safety Promotion, DOI: 10.1080/17457300.2014.942324 To link to this article: http://dx.doi.org/10.1080/17457300.2014.942324
Published online: 29 Sep 2014.
Submit your article to this journal
Article views: 20
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=nics20 Download by: [University of Lethbridge]
Date: 12 November 2015, At: 02:40
International Journal of Injury Control and Safety Promotion, 2014 http://dx.doi.org/10.1080/17457300.2014.942324
Health care costs and functional outcomes of road traffic injuries in the Lazio region of Italy Francesco Chinia*, Sara Farchia, Laura Camillonia, Maria Letizia Giarrizzoa and Paolo Giorgi Rossib a
Agency of Public Health, Lazio Region, via di S. Costanza 53, 00198 Rome, Italy; bServizio Interaziendale di Epidemiologia, AUSL Reggio Emilia, Rome, Italy
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
(Received 6 September 2013; accepted 3 July 2014) The economic consequences of road traffic injuries (RTIs) are very important in terms of health care costs. The aim of this study is to provide estimates of health care costs of non-fatal RTIs and to estimate functional outcomes using in-hospital rehabilitation data. We identified all emergency department (ED) visits related to RTI during 2008 and then linked them with hospital discharges and rehabilitation admissions, health care costs following RTI were estimated from the integrated database. We performed an epidemiological evaluation of RTI with a comprehensive description of functional outcomes at 6 months. Health care costs have been estimated at about €80 million with a per person cost of €522. About 18% of the total cost was due to rehabilitation treatments. In multivariate analysis the variables that correlated better with higher total health care costs were: older age, injury severity, presence of spinal lesion. Patients requiring rehabilitation were: the elderly, patients suffering from a spinal cord injury and leg injuries. This study provides consistent health care cost estimates of RTI using administrative databases and it shows a picture of functional outcomes after RTI. Further research is needed for the estimation of other components of the total cost of RTI. Keywords: road traffic injuries; health care costs; functional outcomes
Introduction Road traffic injuries (RTIs) represent a relevant public health problem. According to the WHO, RTIs account for almost 1.2 million deaths a year around the world, and for 50 million injuries or disabilities (Peden et al., 2004). In addition to the impact of RTIs on public health, they represent a relevant source of health care costs and use. Priorities for injury prevention depend on the burden of injury mortality and morbidity. In a health technology assessment approach the estimation of economic cost of RTIs is important in order to observe effectiveness of prevention programmes. The economic consequences of RTIs (including lost productivity, human cost, property damage, service and health care costs) are very important and their estimate is approximately 1% of the gross national product in low-income countries, 1.5% in middle-income countries and 2% in high-income countries (Peden et al., 2004). In Italy, the economic costs of RTI have been estimated at €30 billion in 2008, 4% of which was health care cost (Automobile Club d’Italia [ACI], 2008); however, a detailed analysis of health care costs is lacking, because the estimation is often based on RTI reported by police forces, which suffers from underreporting of RTI injuries and their severity (Chini, Farchi, Giorgi Rossi, Camilloni, & Borgia, 2010; Giorgi Rossi et al., 2005).
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
In the Lazio region of Italy, since 2000, a surveillance system of the RTI based on the integration of data from emergency facilities with other health-related information (hospital admission and mortality data) has been established to define the extent of the problem in terms of its health consequences (Giorgi Rossi et al., 2005; Petridou & Alexe, 2004). To date, few studies used rehabilitation treatment data to estimate recovery outcomes and costs of which some studies were based on a sample of injured persons followed up through interviews (Clay, Fitzharris, Kerr, McClure, & Watson, 2012) and other studies were focused on specific types of lesion (Bragge et al., 2011). In general, studies analysing long-term post-traumatic outcomes have used different populations, different data collection methods, or follow-up strategies. Nevertheless, all these studies show that injured patients are not fully recovered 1218 months post injury (Holbrook, Anderson, Sieber, Browner, & Hoyt, 1998, 1999; Michaels et al., 2000), even less severely injured patients (Mayou & Bryant, 2001). One study in 2011 on short-term recovery outcome of injured patients shows that few socio-demographic factors are associated with adverse outcomes, the most important is gender. Females had adverse outcomes compared with males. Admission to hospital and trouble accessing health services were consistently associated with
2
F. Chini et al.
adverse outcomes (Langley, Derrett, Davie, Ameratunga, & Wyeth, 2011). The aims of this study are to provide an estimate of the health care use and costs of non-fatal RTIs that occurred in 2008 in the Lazio region through data derived from the surveillance system implemented and to estimate functional outcomes using in-hospital rehabilitation data.
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
Methods Setting Lazio is a region of central Italy with a population of around 5,600,000 (including Rome) as of 2008 (Italian National Institute of Statistics, 2011a). Like all other Italian regions, it provides its citizens with universal health care coverage. All outpatient/inpatient treatments and procedures are recorded in the health information system. Data sources The Emergency Information System (EIS): collects information on all visits to emergency departments (EDs) in the Lazio region. The information collected includes the patients’ demographics, procedures, diagnoses and outcome. In case of trauma, the type or location of the accident is also reported (intentional violence, road, work, home, other). In the EIS an urgency scale is used called ‘triage’, commonly used in crowded EDs to determine treatment priority. Triage involves colour codes based on priority with red D urgent, yellow D critical, green D deferrable and white D not appropriate for ED. The Hospital Discharge Information System (HDIS): gathers and manages data from all hospital admissions from both public and private hospitals in the Lazio region and collects the patients’ demographics, procedures, diagnoses and final disposition. Rehabilitation Information System (RIS): manages rehabilitation admissions at both public and private hospitals and collects demographic data of patients, diagnoses, the rehabilitation treatments received, final disposition and the Barthel index (admission and discharge) used to measure performance in basic activities of daily living for patients older than 17 without previous coma status and spinal cord injury. Selection and linkage procedure We selected all emergency visits with at least one diagnosis of trauma (ICD9-CM 800959) that listed ‘road’ as the place of accident. Emergency visits by the same
person within 48 hours were considered as stemming from the same accident. For each case, through deterministic record linkage, we looked for subsequent hospital admissions in the HDIS that occurred within 24 hours of the accident. A more detailed description of HDIS linkage procedures is reported elsewhere (Giorgi Rossi et al., 2005). The EIS-HDIS integrated database was linked to the RIS to identify in-hospital rehabilitation treatments performed within 6 months of the emergency visit. We considered only the rehabilitation treatments related to acute events with or without a hospital admission and excluded V code 43.64 (hip joint replacement) and those that did not report a diagnosis of trauma, whereas the late effects (ICD9-CM 905909) were included. All linkage procedures were performed according to privacy laws, through the use of indirect pseudonym identifiers. Health care costs From the integrated database, health care costs following RTI were estimated assuming the National Health Service (NHS) perspective. The estimated costs of emergency visits comprehensive of ambulance costs (ambulance transport D 175€, helicopter transport D 5675€) were performed and applied a reimbursement tariff based of triage codes (red D 1032.91€, yellow D 309.87€, green D 154.94€ and white D 41.32€). Hospital admission costs and rehabilitation ones were estimated using diagnosisrelated groups (DRGs) prices adopted by NHS. By definition, DRGs classify patients according to the following variables: principal and secondary diagnoses, patient age and sex, the presence of co-morbidities and complications and the procedures performed. Patients with a specific DRG have homogenous resource consumption pattern and, at the same time, DRGs are clinically meaningful. Thus, cases within the same DRG are economically and medically similar. In formula, total health care cost D emergency cost C emergency transport cost C hospital discharge cost (if any) C rehabilitation cost (if any). Analysis A general epidemiological evaluation of RTI that occurred during 2008 was performed with a comprehensive description of rehabilitation treatments. Health care costs were estimated separately for emergency visits, hospital admissions and rehabilitation and were stratified by sex, age, triage code, length of stay (LOS) in hospital, Barthel index score and DRGs (grouped in the major diagnostic category). Trauma diagnoses were classified according to the Barell matrix (Barell et al., 2002) into 12 types of injuries and seven body regions. If more than one body region or
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
International Journal of Injury Control and Safety Promotion type of injury was present, the case was classified as a multiple injury. We calculated the rates of emergency visits for body region and type of injury and compared them with their health care costs estimated using the DRG approach described above. The rates were calculated using the number of emergency room visits as the numerator, and the resident population of the region of Lazio during the study period as the denominator (Rooney, Warner, & Fingerhut, 2000). A multivariate linear regression model was run to describe the variability of average total health care costs. Furthermore, a separate model was built for rehabilitation treatment costs. The variables included in the model were: gender, age group, triage code, hospital admission, Barthel index score, body region and type of injuries; the choice of the variables was made a priori. Since costs had a skewed distribution, logarithmic transformation was used to sufficiently approximate a normal distribution. All analyses were performed using SAS V 9.2 statistical package (SAS Institute Inc., 2005).
Results Epidemiological findings and functional outcomes In the Lazio region in Italy during 2008 there were 153,232 emergency visits for non-fatal RTIs of which 9643 required hospital care, with an emergency visit rate of 2755/100,000 inhabitants and a hospitalisation rate of 173/100,000 inhabitants. The 1534 years old group and those who were males had a higher risk of being visited by the emergency room and of being admitted to the hospital after RTI; hospitalised patients had median length of stay (including possible stay in resuscitation unit) equal to 6 days (interquartile range D 8 days). Patients requiring rehabilitation (Table 1) were the 0.8% of the entire cohort, with no difference by gender. Stratification by age showed that elderly people were more likely to be admitted to rehabilitation treatment than younger. Traumatic brain injury, lower extremity injury and fractures were more likely to be referred to the rehabilitation unit. 26.8% of the patients stayed in the rehabilitation unit for more than 60 days. Among patients admitted to the rehabilitation programmes, 50.4% had a Barthel index score below 50 at admission, but after the rehabilitation treatment the Barthel index (average) passed from 50.4 to 84.1 (p < 0.001). After the hospitalisation and rehabilitation care, 68 patients (5.6% of those admitted to rehabilitation programmes) had a Barthel index below 50 and 362 subjects (30% of those admitted to rehabilitation programmes) needed prosthesis, in particular older patients and those with low Barthel index scores. Among patients younger
3
than 18 years old (76 cases), the main pathology object of rehabilitation treatments was fractures of lower extremities (38% of young patients) and almost one-third of them needed prosthesis (mainly device to aid ambulation) at discharge at home.
Health care costs Health care direct costs have been estimated in about €80 million (expenditure per person of €522) (Table 2), and about 18% of the total cost was due to rehabilitation treatments. The cost of ambulance/helicopter transportation to EDs has been estimated at about €7 million (9% of total health care cost); of these costs almost 40% was attributable to red and yellow triage codes and 45% to the 1534 year old patients. The analysis of direct health care costs, stratified for socio-demographic and clinical factors showed that higher unit costs were observed in males, elderly patients, severely injured, in particular with spinal cord injury (3075€), blood vessel injury (2688€) and traumatic brain injury (1504€). Higher costs were observed also in patients with a Barthel index score at admission below 50. Large unit cost was observed in case of patients with multiple trauma, with emergency visit cost equal to 1063€, hospital admission cost equal to 11,084€ and rehabilitation treatment cost equal to 17,132€. Rehabilitation costs were very different according to the pathology object of rehabilitation, length of stay and outcome (Table 3). In all, almost half of the costs was due to rehabilitation of fracture (upper and lower extremities), and the rehabilitation treatments longer than 60 days represented more than one-third of rehabilitation costs. Relevant in terms of both percentage (15%) and unit cost (39,662€) is the rehabilitation of quadriplegia and paraplegia. Figure 1 showed that incidence of RTI visits and direct costs had similar patterns until 64 years of age; after that age, females corresponded to higher costs. Relevant costs were seen for elderly people although the incidence of RTI visits was low. Comparison among emergency visit rates and health care costs in different body regions showed that the traumatic brain injuries, spinal lesions and fractures had higher cost/incidence ratios than other body regions did (Figure 2). A multivariate linear regression analysis of total health care costs (Table 4) showed that the variables better correlated with higher total health care costs were the same found in descriptive analysis: older age, injury severity (triage code red or hospitalised patients), low Barthel index score, presence of spinal injury or fracture. If we included only rehabilitation costs, the model showed
4
F. Chini et al.
Downloaded by [University of Lethbridge] at 02:40 12 November 2015
Table 1. Characteristics of subject undergoing rehabilitation treatments and Barthel index score at discharge. Lazio region of Italy 2008. % Barthel index score at discharge 60 days
215 530 273
21.0 52.1 26.8
14.0 5.9 2.6
