[Cost and Revenue Relationship in Orthopaedic and Trauma Surgery Patients in Relation to Body Mass Index]. / Kosten-Erlös-Verhältnis orthopädisch-unfallchirurgischer Patienten in Abhängigkeit vom Body-Mass-Index.

BACKGROUND: Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur. MATERIAL AND METHODS: Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests. RESULTS: Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI. CONCLUSION: To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients.

Partnerships between podiatrists and vascular surgeons in building effective wound care centers.

This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association and the Young Surgeons Committee of the Society for Vascular Surgery, is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an interprofessional partnership is crucial to provide the best possible care to this important population of patients.

Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: Opportunistic Screening for Sarcopenia and Osteopenia.

Importance: Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective: To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants: A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures: Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures: One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results: Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance: More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Cost-effectiveness of vitamin D supplementation and exercise in preventing injurious falls among older home-dwelling women: findings from an RCT.

UNLABELLED: This study assessed the cost-effectiveness of vitamin D supplementation and exercise, separately and combined, in preventing medically attended injurious falls among older home-dwelling Finnish women. Given a willingness to pay of €3,000 per injurious fall prevented, the exercise intervention had an 86 % probability of being cost-effective in this population. INTRODUCTION: The costs of falling in older persons are high, both to the individual and to society. Both vitamin D and exercise have been suggested to reduce the risk of falls. This study assessed the cost-effectiveness of vitamin D supplementation and exercise, separately and combined, in preventing medically attended injurious falls among older Finnish women. METHODS: Economic evaluation was based on the results of a previously published 2-year randomized controlled trial (RCT) where 409 community-dwelling women aged 70 to 80 years were recruited into four groups: (1) no exercise + placebo (D-Ex-), (2) no exercise + vitamin D 800 IU/day (D+Ex-), (3) exercise + placebo (D-Ex+), and (4) exercise + vitamin D 800 IU/day (D+Ex+). The outcomes were medically attended injurious falls and fall-related health care utilization costs over the intervention period, the latter evaluated from a societal perspective based on 2011 unit costs. Incremental cost-effectiveness ratios (ICER) were calculated for the number of injurious falls per person-year prevented and uncertainty estimated using bootstrapping. RESULTS: Incidence rate ratios (95 % CI) for medically attended injurious falls were lower in both Ex+ groups compared with D-Ex-: 0.46 (0.22 to 0.95) for D-Ex+, 0.38 (0.17 to 0.81) for D+Ex+. Step-wise calculation of ICERs resulted in exclusion of D+Ex- as more expensive and less effective. Recalculated ICERs were €221 for D-Ex-, €708 for D-Ex+, and €3,820 for D+Ex+; bootstrapping indicated 93 % probability that each injurious fall avoided by D-Ex+ per person year costs €708. At a willingness to pay €3,000 per injurious fall prevented, there was an 85.6 % chance of the exercise intervention being cost-effective in this population. CONCLUSIONS: Exercise was effective in reducing fall-related injuries among community-dwelling older women at a moderate cost. Vitamin D supplementation had marginal additional benefit. The results provide a firm basis for initiating feasible and cost-effective exercise interventions in this population.

Cost Effectiveness of Falls and Injury Prevention Strategies for Older Adults Living in Residential Aged Care Facilities.

OBJECTIVE: To evaluate the cost effectiveness of interventions designed to prevent falls and fall-related injuries among older people living in residential aged care facilities (RACFs) from an Australian health care perspective. METHODS: A decision analytic Markov model was developed that stratified individuals according to their risk of falling and accounted for the risk of injury following a fall. The effectiveness of the interventions was derived from two Cochrane reviews of randomized controlled trials for falls/fall-related injury prevention in RACFs. Interventions were considered effective if they reduced the risk of falling or reduced the risk of injury following a fall. The interventions that were modelled included vitamin D supplementation, annual medication review, multifactorial intervention (a combination of risk assessment, medication review, vision assessment and exercise) and hip protectors. The cost effectiveness was calculated as the incremental cost relative to the incremental benefit, in which the benefit was estimated using quality-adjusted life-years (QALYs). Uncertainty was explored using univariate and probabilistic sensitivity analysis. RESULTS: Vitamin D supplementation and medication review both dominated 'no intervention', as these interventions were both more effective and cost saving (because of healthcare costs avoided). Hip protectors are dominated (less effective and more costly) by vitamin D and medication review. The incremental cost-effectiveness ratio (ICER) for medication review relative to vitamin D supplementation is AU$2442 per QALY gained, and the ICER for multifactorial intervention relative to medication review is AU$1,112,500 per QALY gained. The model is most sensitive to the fear of falling and the cost of the interventions. CONCLUSION: The model suggests that vitamin D supplementation and medication review are cost-effective interventions that reduce falls, provide health benefits and reduce health care costs in older adults living in RACFs.

Cost-minimization analysis of two fluid products for resuscitation of critically injured trauma patients.

PURPOSE: Results of a study to determine potential cost benefits of substituting an alternative electrolyte solution for 0.9% sodium chloride injection for the initial fluid resuscitation of trauma patients are presented. METHODS: Using data from a randomized clinical trial that compared 24-hour fluid resuscitation outcomes in critically injured trauma patients treated with 0.9% sodium chloride injection and those who received a balanced electrolyte solution (Plasma-Lyte A, Baxter Healthcare), a cost-minimization analysis was performed at a large medical center. The outcomes evaluated included fluid and drug acquisition costs, materials and nurse labor costs, and costs associated with electrolyte replacement. RESULTS: The use of Plasma-Lyte A was associated with a relatively higher fluid acquisition cost but a reduced need for magnesium replacement. During the first 24 hours of hospitalization, 4 of 24 patients (17%) treated with 0.9% sodium chloride injection and none of the patients who received the comparator product (n = 22) required supplemental magnesium. Patients treated with 0.9% sodium chloride injection received a median of 4 g of magnesium (interquartile range [IQR], 2.5-4.0 g), compared with a median of 0 g (IQR 0-2 g) in the comparator group. Taking into account the costs of consumable supplies and nursing labor, the cost-minimization analysis indicated a 24-hour cost differential of $12.35 in favor of Plasma-Lyte A. CONCLUSION: Substitution of Plasma-Lyte A for 0.9% sodium chloride injection for fluid resuscitation during the first 24 hours after traumatic injury was associated with decreased magnesium replacement requirements and a net cost benefit to the institution.

Chronic diseases and injuries in India.

Chronic diseases (eg, cardiovascular diseases, mental health disorders, diabetes, and cancer) and injuries are the leading causes of death and disability in India, and we project pronounced increases in their contribution to the burden of disease during the next 25 years. Most chronic diseases are equally prevalent in poor and rural populations and often occur together. Although a wide range of cost-effective primary and secondary prevention strategies are available, their coverage is generally low, especially in poor and rural populations. Much of the care for chronic diseases and injuries is provided in the private sector and can be very expensive. Sufficient evidence exists to warrant immediate action to scale up interventions for chronic diseases and injuries through private and public sectors; improved public health and primary health-care systems are essential for the implementation of cost-effective interventions. We strongly advocate the need to strengthen social and policy frameworks to enable the implementation of interventions such as taxation on bidis (small hand-rolled cigarettes), smokeless tobacco, and locally brewed alcohols. We also advocate the integration of national programmes for various chronic diseases and injuries with one another and with national health agendas. India has already passed the early stages of a chronic disease and injury epidemic; in view of the implications for future disease burden and the demographic transition that is in progress in India, the rate at which effective prevention and control is implemented should be substantially increased. The emerging agenda of chronic diseases and injuries should be a political priority and central to national consciousness, if universal health care is to be achieved.

Evaluating antimicrobial efficacy and cost of 3 dressings containing silver versus a novel antimicrobial hydrogel impregnated gauze dressing containing Oakin, an oak extract.

PURPOSE: Antimicrobial wound dressings are becoming more popular and are routinely used in the treatment of chronic and problematic wounds. Despite the ever-growing number and types of these antimicrobial products, many practitioners often do not report significant clinical differences between various common antimicrobial wound dressings despite wide variations in cost. Although these dressings use different active ingredients or different presentations of a particular active ingredient, all attempt to protect the wound from bacterial colonization and promote wound repair. With so many topical antimicrobial dressings to choose from in the clinical setting (many having already fallen into disfavor due to their cytotoxic characteristics) it was of prime interest to determine if there was a substantial difference between some of the more commonly used antimicrobial dressings, with silver versus an antimicrobial wound dressing using Oakin (oak extract [Amerx Health Care Corporation, Clearwater, Florida]) as the active ingredient. METHODS: This article compares the antimicrobial efficacy of 4 commonly used wound dressings in vitro, utilizing a corrected zone of inhibition test followed by a cost analysis. RESULTS: In vitro testing demonstrated that there were no substantial differences in the corrected zone of inhibition measurements between the silver wound dressings and the less expensive Oakin-impregnated gauze dressing. CONCLUSION: Despite obvious limitations of this study, these results suggest that the biggest differences between many antimicrobial dressings on the market may be more in cost than in antimicrobial efficacy. The differences in cost are due to variances in cost per application and frequency of applications per week.

Skin and wound care excellence: integrating best-practice evidence.

North York General Hospital (NYGH), in collaboration with Nursing Practice Solutions, Smith & Nephew and the Central Community Care Access Centre, implemented a program in skin and wound care that has made best-practice, evidenced-based wound care management possible, affordable and sustainable. Focused action using advanced wound care products and proven clinical approaches has dramatically improved the identification, protection and support of skin integrity. Wound prevention and management are among the most direct and cost-effective measures a healthcare organization can take to improve patient safety and quality of life, and they allow for the reduction of expenditures and re-allocation of funds into other important areas. The Skin and Wound Care Program was designed to create and maintain resources within NYGH to ensure the delivery of consistent, best-practice wound prevention and management. The program has successfully sustained a significant reduction in the prevalence of pressure ulcers. Benefits of the program include improved patient safety, health and quality of life. The Skin and Wound Care Program has seen the transfer of knowledge and evidence-based best practices to both the bedside and the community. Extending the collaborative effort beyond the walls of NYGH has helped the hospital gain further insight into and experience with our community partners to spread skin and wound best practices across the healthcare continuum. Lessons learned have been shared with other healthcare organizations in forums such as the Congress of the World Union of Wound Healing Societies, thus contributing to the advancement of continuous improvement in healthcare.

Using existing case-mix methods to fund trauma cases.

Policymakers frequently face the need to increase funding in isolated and frequently heterogeneous (clinically and in terms of resource consumption) patient subpopulations. This article presents a methodologic solution for testing the appropriateness of using existing grouping and weighting methodologies for funding subsets of patients in the scenario where a case-mix approach is preferable to a flat-rate based payment system. Using as an example the subpopulation of trauma cases of Ontario lead trauma hospitals, the statistical techniques of linear and nonlinear regression models, regression trees, and spline models were applied to examine the fit of the existing case-mix groups and reference weights for the trauma cases. The analyses demonstrated that for funding Ontario trauma cases, the existing case-mix systems can form the basis for rational and equitable hospital funding, decreasing the need to develop a different grouper for this subset of patients. This study confirmed that Injury Severity Score is a poor predictor of costs for trauma patients. Although our analysis used the Canadian case-mix classification system and cost weights, the demonstrated concept of using existing case-mix systems to develop funding rates for specific subsets of patient populations may be applicable internationally.

[Development of trauma surgery in the next 20 years]. / Entwicklung der Unfallchirurgie in den nächsten 20 Jahren.

During the last century trauma surgery became established as an independent and academically accepted surgical specialty and significant progress was achieved. A high international reputation was also gained. Nowadays health care in Germany is under increased economical pressure mostly caused by a loss of resources as a sign of decreased public appreciation of excellent trauma care. Thus it becomes more and more necessary to find new structures for delivery of trauma care as well as for development of staff, especially in times of feminization in medicine. It is beyond any doubt that the demand for musculoskeletal surgery will rise during the next 20 years especially for the elder generation but it is uncertain how excellent trauma care should be delivered without massive spending and financing of health care including research and innovative forms of trauma treatment.

Musculoskeletal training for orthopaedists and nonorthopaedists in China.

No diploma for orthopaedic surgery is available in the current medical education and licensing system in China. The orthopaedist generally receives on-the-job training in a clinical practice after getting a license to practice surgery. There are multiple training pathways to and opportunities in orthopaedic surgery, and these vary from hospital to hospital and from region to region. These include on-the-job training, academic visits, rotation through different departments based on local medical needs, fellowship training in large general or teaching hospitals (locally, regionally, nationally, or internationally), English language training, postgraduate diploma training, and Internet CME. Due to the current training system, orthopaedic techniques and skill levels vary greatly from hospital to hospital.

Topics in global public health.

Deficiencies in the delivery of musculoskeletal trauma care in low- and middle-income countries can be attributed to a variety of causes, all of which can be linked to failure of the health system to deliver the necessary services to prevent death and disability. As such, a "systems" approach will be required to improve the delivery of services. The goal of this review is to familiarize the orthopaedic surgeon with selected topics in public health, including health systems, burden of disease, disability adjusted life year (DALY), cost-effective analysis, and related concepts (eg, met versus unmet need, access, utilization, effective coverage).

Musculoskeletal training for orthopaedists and nonorthopaedists: experiences in India.

In India, health policies, services, health indices, and medical education are improving despite the country's enormous population and limited resources. Orthopaedic training in India should be geared to serve the predominantly rural population (72% of total population) living in some 550,000 villages, but unless the basic amenities improve in villages and towns, orthopaedists will remain averse to serving in these areas. Traditional practitioners play an important role in musculoskeletal trauma care in villages and even some town and city areas, and hence cannot be ignored. We suggest a stratified system of orthopaedic training for medical graduates, postgraduates, and paramedics with a well-defined need-based curriculum, and a clear cut division of labor, terms, and conditions to suit the stratified social and demographic structure of India. This stratified system is intended to provide appropriate musculoskeletal trauma care services to the rural population, reduce neglected and mismanaged trauma, consequently avoiding subsequent orthopaedic disability, and reduce the financial burden of managing these cases. This system also intends to prevent overloading of teaching hospitals and apex institutes and ensure availability of subspecialized orthopaedic services in the country at designated centers. Traditional practitioners shall be periodically educated regarding safe orthopaedic practices, which are anticipated to yield improved trauma care services.

Update on road traffic crashes: progress in the Middle East.

Road traffic injuries comprise the major share of all injuries globally. Traffic injuries kill 1.2 million people annually and injure 40 times as many, leaving a subsequent number totally disabled. Globally we spend approximately US $500 billion annually. The Middle East encompasses West Asia and North Africa and is very diverse economically, culturally and socially. Prevention and management of road traffic crashes and injuries is difficult. Comparative data are not readily available and therefore developing unified policies is a mammoth task. Implementation of best practices is not uniformly advocated due to socioeconomic and cultural differences. Enforcement of endorsed legislation on road traffic safety is not uniform in the region. Professional staff to combat this pandemic are scarce and it is important that capacity building, knowledge sharing, and increased political will becomes a priority in the region. This paper discusses the problems encountered in the prevention and management of road traffic injuries from the site of injury to rehabilitation and social reintegration. The role of Oman and that of the Bone and Joint Decade in the United Nations on Global Road Safety and its update is highlighted.

Managing the injury burden in Nepal.

Nepal loses about 530,000 disability adjusted life years (DALYs) per year to injury, predominantly due to falls. It takes 30,000 Nepali rupees (NR), or approximately US$430 at 70 rupees per $US saved per DALY to achieve primary prevention and 6000 NR per DALY if we invest in hospitals, versus 1000 NR invested in prehospital care, because simpler less expensive actions performed early have a greater impact on outcome than more complex measures later. A system for prehospital services was planned for medical emergencies at a national level meeting at the Medical University of Nepal to promote healthcare to victims in inaccessible regions by empowered or enlightened citizens. Feasible actions for common emergencies were defined and a tutorial required to help the majority of such victims was created and packaged. The knowledge and attitude component of the tutorial will be delivered through a web site to citizens motivated to learn and help with emergencies. The knowledge will be tested through a net-based Multiple Choice Questions (MCQ) test. Practical training in medical triage skills will be provided to those who qualify for the test at the University or its designated affiliates. A mobile phone-based information system will be created and used to make these enlightened citizens available to the victim at the site/time of the emergency.

Musculoskeletal training for orthopaedists and nonorthopaedists: experiences in Nepal.

Orthopaedic surgical training in Nepal began in 1998, and four major centers now produce between 15 and 20 graduates annually. The duration of the training is four years in one center and three years in the remaining centers. Trainees have adequate trauma exposure. The major challenges include: tailoring training to suit local needs, avoiding the dangers of market driven orthopaedic surgery, adequately emphasizing and implementing time honored methods of closed fracture treatment, and ensuring uniformity of exposure to the various musculoskeletal problems. Training in research methods needs to be implemented more effectively. The evaluation process needs to be more uniform and all training programs need to complement one another and avoid unhealthy competition. Training for nonorthopaedists providing musculoskeletal care is virtually nonexistent in Nepal. Medical graduates have scant exposure to trauma and musculoskeletal diseases during their training. General surgeons provide the majority of trauma care and in the rural areas, health assistants, auxiliary health workers and physiotherapy assistants provide much needed basic services, but all lack formal training. Traditional "bone setters" in Nepal often cater to certain faithful clientele with sprains, minor fractures etc. A large vacuum exists in Nepal for trained nonorthopaedists leading to deficiencies in prehospital care, safe transport and basic, primary emergency care. The great challenges are yet to be addressed.

Musculoskeletal trauma services in Serbia.

Serbia, a middle-income country, is located in southeastern Europe, with territory of 88,361 km(2) and 9,400,000 inhabitants. Average month salary is US$542 and the registered unemployment rate is 22%. The country is administratively divided into 30 districts (193 municipalities). The healthcare system is territorially organized. In the state capital there are five clinical hospitals with musculoskeletal traumatology departments, as well as one in each of the four university centers. In addition, there are orthopaedic departments in 40 smaller hospitals throughout the country and in three military hospitals, along with several pediatric surgical departments involved in managing musculoskeletal trauma. There are 524 orthopaedic trauma surgeons (1:18,000 people), with a minor number of additionally trained general and pediatric surgeons who care for musculoskeletal problems. Bonesetters are neither recognized nor included in the healthcare system. Orthopaedic traumatology services are well organized, with variable accessibility depending on the distance between injury site and nearest medical facility. Preventive strategies are well developed and mainly consider agricultural, industrial, and traffic injuries. Distribution of medical institutions is satisfactory. Future activities should include continuing medical education of specialists, exclusion of inappropriate specialists, improvement of preventive strategies and medical transport facilities, as well as standardization of medical equipment, diagnostics, and treatment protocols.

Musculoskeletal trauma service in Thailand.

Trauma is becoming a leading cause of death in most of the low-income and middle-income countries worldwide. The growing number of motor vehicles far surpasses the development and upkeep of the road and highway networks, traffic laws, and driver training and licensing. In Thailand, road traffic injuries have become the second leading cause of death and morbidity overall since 1990. The lack of improvement to existing roadways, implementation of traffic safety and ridership laws including seatbelt regulations, and poor emergency medical assistance support systems all contribute to these statistics. An insufficient number and inequitable distribution of healthcare professionals is also a national problem, especially at the district level. Prehospital care of trauma patients remains insufficient and improvements at the national level are suggested.

Musculoskeletal trauma services in China.

China is a developing country with a population over 1.3 billion with the second largest group of people in poverty next to India. There are about 159 million motor vehicles, with 163,887,372 drivers. From 2001 to 2004 over 100,000 people died each year in traffic accidents. With law enforcement and public education, traffic accidents have decreased, and the death rate is now less than 100,000 each year.