Cost-effectiveness of immediate total-body CT in patients with severe trauma (REACT-2 trial).

BACKGROUND: The effect of immediate total-body CT (iTBCT) on health economic aspects in patients with severe trauma is an underreported issue. This study determined the cost-effectiveness of iTBCT compared with conventional radiological imaging with selective CT (standard work-up (STWU)) during the initial trauma evaluation. METHODS: In this multicentre RCT, adult patients with a high suspicion of severe injury were randomized in-hospital to iTBCT or STWU. Hospital healthcare costs were determined for the first 6 months after the injury. The probability of iTBCT being cost-effective was calculated for various levels of willingness-to-pay per extra patient alive. RESULTS: A total of 928 Dutch patients with complete clinical follow-up were included. Mean costs of hospital care were €25 809 (95 per cent bias-corrected and accelerated (bca) c.i. €22 617 to €29 137) for the iTBCT group and €26 155 (€23 050 to €29 344) for the STWU group, a difference per patient in favour of iTBCT of €346 (€4987 to €4328) (P = 0.876). Proportions of patients alive at 6 months were not different. The proportion of patients alive without serious morbidity was 61.6 per cent in the iTBCT group versus 66.7 per cent in the STWU group (difference -5.1 per cent; P = 0.104). The probability of iTBCT being cost-effective in keeping patients alive remained below 0.56 for the whole group, but was higher in patients with multiple trauma (0.8-0.9) and in those with traumatic brain injury (more than 0.9). CONCLUSION: Economically, from a hospital healthcare provider perspective, iTBCT should be the diagnostic strategy of first choice in patients with multiple trauma or traumatic brain injury.

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]. / Kosten und Erlöse von über den Schockraum eingelieferten Patienten mit leichtem Schädel-Hirn-Trauma.

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2­day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

Nurse Practitioners' Role in Improving Service for Elderly Trauma Patients.

Preexisting conditions and decreased physiological reserve in the elderly frequently complicate the provision of health care in this population. A Level 1 trauma center expanded its nurse practitioner (NP) model to facilitate admission of low-acuity patients, including the elderly, to trauma services. This model enabled NPs to initiate admissions and coordinate day-to-day care for low-acuity patients under the supervision of a trauma attending. The complexity of elderly trauma care and the need to evaluate the efficacy of management provided by NPs led to the development of the current study. Accordingly, this study endeavored to compare outcomes in elderly patients whose care was coordinated by trauma NP (TNP) versus nontrauma NP (NTNP) services. Patients under the care of TNPs had a 1.22-day shorter duration of hospitalization compared with that of the NTNP cohort (4.38 ± 3.54 vs. 5.60 ± 3.98, p = .048). Decreased length of stay in the TNP cohort resulted in an average decrease in hospital charges of $13,000 per admission ($38,053 ± $29,640.76 vs. $51,317.79 ± $34,756.83, p = .016). A significantly higher percentage of patients admitted to the TNP service were discharged home (67.1% vs. 36.0%, p = .002), and a significantly lower percentage of patients were discharged to skilled nursing facilities (25.7% vs. 51.9%, p = .040). These clinical and economic outcomes have proven beneficial in substantiating the care provided by TNPs at the study institution. Future research will focus on examining the association of positive outcomes with specific care elements routinely performed by the TNPs in the current practice model.

[Medical information system (PMSI) does not adequately identify severe trauma]. / La codification PMSI identifie mal les traumatismes graves.

BACKGROUND: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. METHODS: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. RESULTS: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). CONCLUSION: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

Living status, economic hardship and sleep disturbance were associated with subjective shoulder pain in survivors of the Great East Japan Earthquake: A cross sectional study.

BACKGROUND: The Great East Japan Earthquake and devastating Tsunami hit hard everything on the northeastern coast of Japan. This study aimed to determine socio-psychological factors for "subjective shoulder pain" of the survivors at 2 years evaluated by a self-report questionnaire. METHODS: Between November 2012 to February 2013, survivors replied to the self-report questionnaire, and 2275 people consented to join this study. Living status was divided into 5 categories (1. same house as before the earthquake (reference group), 2. temporary small house, 3. apartment, 4. house of relatives or acquaintance, 5. new house) and economic hardship was divided into 4 categories (1. normal (reference group), 2. a little bit hard, 3. hard, 4. very hard). Gender, age, body mass index, living areas, smoking and drinking habits, complications of diabetes mellitus and cerebral stroke, working status, and walking time were considered as the confounding factors. Kessler Psychological Distress Scale of ≥10/24 and Athens Insomnia Scale of ≥6/24 points were defined as a presence of psychological distress and sleep disturbance, respectively. We used multiple logistic regression analysis to examine the association of shoulder pain with living environment, economic hardship, psychological distress, and sleep disturbance at 2 years after the earthquake. RESULTS: There were significant differences in the risk of having shoulder pain in those with "apartment" (OR = 1.74, 95% CI = 1.03-2.96), "house of relatives or acquaintance" (OR = 2.98, 95% CI = 1.42-6.25), economic hardship of "hard" (OR = 1.71, 95% CI = 1.08-2.7) and "very hard" (OR = 2.51, 95% CI = 1.47-4.29), and sleep disturbance (OR = 2.96, 95% CI = 2.05-4.27). CONCLUSIONS: Living status of "apartment" and "house of relatives or acquaintance", economic hardship of "hard" and "very hard", and "sleep disturbance" were significantly associated with shoulder pain.

[The cost estimator in the TraumaRegister DGU]. / Der Kostenschätzer im TraumaRegister DGU®.

BACKGROUND AND OBJECTIVES: Estimated treatment costs of severely injured patients were often added to registry-based analyses. In the past, the TraumaRegister DGU® used a modular cost estimator for this purpose. A recent research project initiated by the German Trauma Society (DGU) evaluated the reimbursement of severely injured patients in the German DRG system. This project also allowed the generation of an improved update of the registry's cost estimator. METHODS: Detailed cost data for the acute therapy of severely injured patients were available from 10 hospitals that also participate in the TraumaRegister DGU®. Cost and registry data were matched using hospital code, date of admission, age, sex, and length of stay. A multivariate regression analysis with hospital costs as dependent variable included patients with an injury severity score (ISS) ≥ 9 points who stayed in hospital at least three days. All injuries were coded using the abbreviated injury scale (AIS). A total of 1002 patients treated in 2007 and 2008 were successfully matched. Cost data was collected for each case according to the method of calculation provided by the German DRG Institute (InEK). RESULTS: The mean age was 44 years and 73 % were males; the mean ISS was 27 points. The following aspects were significantly associated with the overall hospital costs: length of stay on the intensive care unit (ICU) (1152 € per day); length on intubation/ventilation (568 € per day); length of stay on normal ward (531 € per day); number of blood products (packed red blood cells; fresh frozen plasma) transfused until ICU admission (258 € per unit); a serious abdominal injury (AIS ≥3; 2849 €); an instable pelvic fracture with relevant blood loss (AIS 5; 7505 €); and a serious injury of the extremities (AIS 3-4; 2418 €). The estimated overall treatment costs calculated by the above mentioned formula averaged 22,138 € per case. The deviation from the measured real costs (21,546 € per case) was less than 3 %. CONCLUSION: Using only key data available for all patients in the registry, a valid cost estimator for acute care costs is now available in the TraumaRegister DGU®.

[The new treatment procedures of the DGUV from the perspective of an injury type procedure (VAV) clinic]. / Die neuen Heilverfahren der DGUV aus der Sicht einer VAV-Klinik.

The new treatment procedures of the German Statutory Accident Insurance (DGUV) have ramifications for the injury type procedure clinics (VAV) from medical, economic and structural aspects. Whereas the latter can be assessed as positive, the medical and economical aspects are perceived as being negative. Problems arise from the partially unclear formulation of the injury type catalogue, which results in unpleasant negotiations with the occupational insurance associations with respect to financial remuneration for services rendered. Furthermore, the medical competence of the VAV clinics will be reduced by the preset specifications of the VAV catalogue, which opens up an additional field of tension between medical treatment, fulfillment of the obligatory training and acquisition of personnel as well as the continually increasing economic pressure. From the perspective of the author, the relinquence of medical competence imposed by the regulations of the new VAV catalogue is "throwing the baby out with the bathwater" because many VAV clinics nationwide also partially have competence in the severe injury type procedure (SAV). A concrete "competence-based approval" for the individual areas of the VAV procedure would be sensible and would maintain the comprehensive care of insured persons and also increase or strengthen the willingness of participating VAV hospitals for unconditional implementation of the new VAV procedure.

Differences in perceived fairness and health outcomes in two injury compensation systems: a comparative study.

BACKGROUND: Involvement in a compensation process following a motor vehicle collision is consistently associated with worse health status but the reasons underlying this are unclear. Some compensation systems are hypothesised to be more stressful than others. In particular, fault-based compensation systems are considered to be more adversarial than no-fault systems and associated with poorer recovery. This study compares the perceived fairness and recovery of claimants in the fault-based compensation system in New South Wales (NSW) to the no-fault system in Victoria, Australia. METHODS: One hundred eighty two participants were recruited via claims databases of the compensation system regulators in Victoria and NSW. Participants were > 18 years old and involved in a transport injury compensation process. The crash occurred 12 months (n = 95) or 24 months ago (n = 87). Perceived fairness about the compensation process was measured by items derived from a validated organisational justice questionnaire. Health outcome was measured by the initial question of the Short Form Health Survey. RESULTS: In Victoria, 84 % of the participants considered the claims process fair, compared to 46 % of NSW participants (χ(2) = 28.54; p < .001). Lawyer involvement and medical assessments were significantly associated with poorer perceived fairness. Overall perceived fairness was positively associated with health outcome after adjusting for demographic and injury variables (Adjusted Odds Ratio = 2.8, 95 % CI = 1.4 - 5.7, p = .004). CONCLUSION: The study shows large differences in perceived fairness between two different compensation systems and an association between fairness and health. These findings are politically important because compensation processes are designed to improve recovery. Lower perceived fairness in NSW may have been caused by potential adversarial aspects of the scheme, such as liability assessment, medical assessments, dealing with a third party for-profit insurance agency, or financial insecurity due to lump sum payments at settlement. This study should encourage an evidence informed discussion about how to reduce anti-therapeutic aspects in the compensation process in order to improve the injured person's health.

[Long-term outcome following multiple trauma in working age : A prospective study in a Swiss trauma center]. / Langzeitoutcome nach Polytrauma im erwerbsfähigen Alter : Eine prospektive Datenerhebung an einem Schweizer Traumazentrum.

BACKGROUND: Given the lack of data in the available literature, we were interested in the disability rate and corresponding insurance costs following multiple trauma in Switzerland. The possible impact of demographic, traumatic and hospital process factors as well as subjective and objective longer-term outcome variables on insurance data acquired were examined. MATERIAL AND METHODS: Following multiple trauma the clinical and socioeconomic parameters in 145 survivors of working age were investigated over 2 and 4 years post-injury at a Swiss trauma center (University Hospital Basel). The correlation with the corresponding data provided by the largest Swiss accident insurance company (Suva, n = 63) was tested by univariate and multivariate analysis and patients insured at Suva were compared with those insured elsewhere (n = 82). RESULTS: The mean level of disability in this cohort of multiple trauma patients insured at Suva was 43 %. The insurer expected costs of more than 1 million Swiss Francs per multiply injured patient. In univariate analysis, only discrete correlations (maximum r = 0.37) were found with resulting disability, but significant correlations were found in subsequent multivariate testing most of all for age and the sequential organ failure assessment (SOFA 11 % and 15 % predictive capacity, p = 0.001; corrected R2 = 0.26). Among variables of longer-term outcome the Euro Quality of Life Group health-related quality of life in five dimensions (EQ-5D) correlated almost as highly with the objective extent of disability as did the reduced capacity to work declared by the patients (0.64 and 0.7, respectively). CONCLUSION: The estimation of long-term disability following multiple trauma based on primary data following injury appears to be possible only to a limited extent. Given the clinical and socioeconomic relevance, comparable analyses are necessary by including all insurance providers involved.

Clinical and economic effects of selective radiological evaluation of high-energy trauma patients: a prospective experience of a level 1 busy trauma centre.

INTRODUCTION: Cervical spine, thoracic and pelvic fractures are the main causes of devastation in patients who have suffered blunt trauma. Radiographic imaging plays an important role in diagnosing such injuries. Nevertheless, the present dominant approach, the routine use of X-ray studies, seems to have no cost-benefit justification for healthcare systems. METHODS: This prospective cross-sectional study was performed over a 3-month period. During the determined time frame, all haemodynamically stable, high-energy blunt trauma patients were included. Based on the predefined criteria, selective radiographic images of the neck, chest and pelvis were obtained. Patients were followed during their hospital stay and for a 2-week period after discharge. RESULTS: 1002 cases were included in the final survey. 247/1002 (24.6%) cervical radiographic images, 500/1002 (49.9%) CXRs and 171/1002 (17%) pelvic radiographic images of the patients were taken on the first day of hospital admission. New X-ray images required during the patients' hospital stay resulted in 5/1002 (0.4%) cervical, 4/1002 (0.3%) chest and 8/1002 (0.7%) pelvic radiographies. In the 2-week period after discharge, 4/1002 cases (0.3%) needed to repeat neck radiography. Overall, 697.44 mSv X-ray radiation was potentially prevented and US$426,450 were potentially saved. CONCLUSIONS: Selective radiographic imaging of the neck, chest and pelvis together with a precise history-taking and physical examination in cases of high-energy blunt trauma could eliminate unnecessary costs to patients and healthcare systems, and significantly save resources.

[Cost analysis of emergency room patients in the German diagnosis-related groups system. A practice relevant depiction subject to clinical parameters]. / Kostenanalyse von Schockraumpatienten im DRG-System. Eine praxisnahe Abbildung in Abhängigkeit klinischer Parameter.

BACKGROUND: Since the implementation of the diagnosis-related system there has been a continuous lack of finances in the treatment of multiple injured patients. The current investigation summarizes consecutive patients from a level I trauma centre and tests the hypothesis that an injury severity score (ISS) based reimbursement would be an improvement in the cost-effectiveness of this patient population. METHODS: The study is based on multiple injured patients admitted to the emergency department in 2009. The ISS, intensive care unit (ICU) stay and cost data were recorded for every patient and two subgroups were formed: group I ISS < 16 and group II ISS ≥ 16. RESULTS: A total of 442 patients with an average age of 40.5 ± 9.1 years (ISS 12) were included. The average amount of coverage during an average length of stay of 13.15 ± 6.3 was -2,752 per patient. Patients in group I (n = 296, ISS 6.3) showed a value of -1,163 with an average length of stay of 8 ± 4.6 days. In group II (n = 146, ISS 23.6) the average amount of coverage was -5,973 during an average hospital stay of 23 ± 8.7 days. CONCLUSION: Improvements have been made with the recent adjustment of the reimbursement within the last year. Nevertheless, several factors identified in this study require additional adjustment: the ISS, the requirement of blood transfusion and the presence of additional chest trauma should be weighted in the calculation of reimbursement.

Health-related quality of life and rehabilitation cost following intensive care unit stay in multiple trauma patients.

OBJECTIVES: The objective of this study was to assess changes in health-related quality of life (HRQOL) in multiple trauma patients due to motor vehicle crashes during a follow-up period of 2 years after discharge from an intensive care unit (ICU) and the effect of income and financial cost of rehabilitation in HRQOL. METHODS: The study was a prospective observational study of multiple trauma patients from January 2009 to January 2011 who were hospitalized in a general, medical, and surgical ICU of a district hospital in Athens, Greece. Eighty-five patients with multiple traumas due to motor vehicle crashes and with an ICU stay of more than 24 hours were included in the study. HRQOL was assessed by a general questionnaire, the EuroQol 5D. RESULTS: Increased monthly household income and absence of traumatic brain injuries were associated with an improved EQ-VAS score. The frequency of severe problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression decreased over time. The financial cost of rehabilitation was initially high but decreased over time. CONCLUSIONS: Severely injured victims of motor vehicle crashes suffer from serious problems in terms of HRQOL which is gradually improved even 2 years after hospital discharge. In addition, HRQOL is significantly related to income. Resources used for rehabilitation decrease over time, but even at 24 months, the patients still use half of the amount as compared with the cost of the first 6 months after trauma.

[Is polytrauma affordable these days? G-DRG system vs per diem charge based on 1,030 patients with multiple injuries]. / Ist ein Polytrauma heutzutage noch bezahlbar? G-DRG-System vs. Tagessätze anhand 1030 polytraumatisierter Patienten.

UNLABELLED: The introduction of diagnosis-related groups (DRG) in Germany comprises the risk of a non-cost-effective reimbursement in complex medical treatments. The aim of this study was to compare the reimbursement between the DRG system and the system of hospital per diem charge in effect until now. MATERIAL AND METHODS: The G-DRG (Version 2004) reimbursement was calculated for 1,030 polytrauma patients (average ISS 26.4) treated at the BGU Murnau from 2000 to 2004, using a base value of 2900 euros, and compared to the reimbursement of hospital per diem charge. RESULTS: Just half of all polytrauma patients are classified as a polytrauma according to the DRG (18.7%) or as requiring artificial respiration based on the DRG (29.1%). The average G-DRG reimbursement was 27,157 euros vs 36,387 euros (74.6%). Patients with minor trauma, increasing age, high GCS, ICU stay without artificial respiration, trauma of the upper extremity and patients who survived show the greatest discrepancy. CONCLUSION: A revision of the G-DRG definition of polytrauma is necessary to ensure adequate reimbursement for management of patients with multiple injuries. The severity of a trauma has to be considered in the DRG system.

[Cost-analysis of treating patients with multiple injuries in a reference hospital in Spain]. / Análisis del coste del tratamiento del paciente politraumatizado en un hospital de referencia en España.

INTRODUCTION: The aim of this study is to analyse the costs of the treatment of a group of patients with severe injuries. The distribution of the costs between the different departments involved in the management of these patients is also investigated. MATERIAL AND METHOD: The data from patients who suffered severe injuries, and recorded in the Traumasur data base, were prospectively gathered to be used in the study. The data from a total of 131 patients treated in the year 2008 were collected. Data obtained from the hospital finance office were also used, providing the overall cost as well as the separate costs of each of the departments involved in the treatment. RESULTS: The injury severity score (ISS) and the new injury severity score (NISS) mean values were 31.8 and 39.4, respectively. The mortality rate was 17.5%. The overall costs of the patients was 3,791,879.3 €, with a mean cost per patient of 28,945 €. The mean percentage of the overall costs of the treatment incurred by the ICU and the ward was 62% and 12.7%, respectively. The cost of the ICU admission increased up to 68.4% in patients with an ISS>40. Although the patients who died had more serious injuries, they had a lower cost in all areas. CONCLUSION: Patients with multiple injuries represent a significant health cost, with the greater percentage being due to the hospital stay, particularly that in ICU. Other cost areas involve a lower percentage of the cost.

What are the true costs of major trauma?

BACKGROUND: This economic evaluation reports the results of a detailed study of the cost of major trauma treated at Princess Alexandra Hospital (PAH), Australia. METHODS: A bottom-up approach was used to collect and aggregate the direct and indirect costs generated by a sample of 30 inpatients treated for major trauma at PAH in 2004. Major trauma was defined as an admission for Multiple Significant Trauma with an Injury Severity Score>15. Direct and indirect costs were amalgamated from three sources, (1) PAH inpatient costs, (2) Medicare Australia, and (3) a survey instrument. Inpatient costs included the initial episode of inpatient care including clinical and outpatient services and any subsequent representations for ongoing-related medical treatment. Medicare Australia provided an itemized list of pharmaceutical and ambulatory goods and services. The survey instrument collected out-of-pocket expenses and opportunity cost of employment forgone. Inpatient data obtained from a publically funded trauma registry were used to control for any potential bias in our sample. Costs are reported in Australian dollars for 2004 and 2008. RESULTS: The average direct and indirect costs of major trauma incurred up to 1-year postdischarge were estimated to be A$78,577 and A$24,273, respectively. The aggregate costs, for the State of Queensland, were estimated to range from A$86.1 million to $106.4 million in 2004 and from A$135 million to A$166.4 million in 2008. CONCLUSIONS: These results demonstrate that (1) the costs of major trauma are significantly higher than previously reported estimates and (2) the cost of readmissions increased inpatient costs by 38.1%.

[Examples of erroneous coding in trauma surgery]. / Beispiele für fehlerhafte Kodierung in der Unfallchirurgie.

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.

Diagnostic accuracy, biohazard safety, and cost effectiveness-the Lodox/Statscan provides a beneficial alternative for the primary evaluation of patients with multiple injuries.

BACKGROUND: Lodox/Statscan is a new digital X-ray machine with a low dose of radiation exposure that provides rapid, whole-body scans. In the setting of acute trauma management, the importance of image study is well recognized. Here, we report the accuracy of diagnoses made using Lodox/Statscan in patients with multiple injuries. We analyze the cost effectiveness, biohazard safety, and detection rate for treatment using the Lodox/Statscan and evaluate whether it is a viable alternative to the conventional trauma X-ray. METHODS: We retrospectively reviewed patients who received a Lodox/Statscan between November 2007 and January 2009. All patients who had received both a Lodox/Statscan and a computed tomographic (CT) scan were enrolled. The CT scan was used to make the final diagnosis. The detection rate for treatment, sensitivity, and specificity of the Lodox/Statscan in diagnosis was analyzed. RESULTS: One hundred eighty-four patients were eligible for the study during the 15-month study period. The detection rates for treatment using the Lodox/Statscan for pneumothorax, pelvic fracture, cervical spine injury, and thoracic-lumbar spine injury were 95%, 96.0%, and 57.1%, and 100%, respectively. CONCLUSION: In our series, the Lodox/Statscan provided similar quality images and conventional series to the CT scans. Although the Lodox/Statscan missed some injuries, most of the subsequent treatments were not changed. Overall, there were several advantages to using this system, including the short interval of study, low-radiation exposure, and low cost. The Lodox/Statscan could therefore be used as an alternative to the traditional trauma X-ray for evaluation of acute trauma patients.

[Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: benefit and costs]. / Early Total Care (ETC) im Vergleich zu Damage Control Orthopedics (DCO) bei der Behandlung polytraumatisierter Patienten mit Femurschaftfrakturen: Nutzen und Kosten.

INTRODUCTION: Femoral fractures are common injuries in multiple trauma patients. The treatment concept of damage control orthopedics (DCO) is in competition with the concept of early total care (ETC). PATIENTS AND METHODS: In a retrospective study (2003-2007) 73 multiple trauma patients with femoral shaft fractures were included. The cohort was subdivided according to the Injury Severity Score (ISS) (16-24, 25-39 and more than 40) and treatment strategy (ETC versus DCO). Patients were analyzed for outcome and cost aspects. RESULTS: In the patient group with an ISS 16-24 ventilation time and intensive care treatment were longer after DCO treatment, overall costs and deficient cost cover were higher in the DCO group. In the patient group with an ISS 25-39 cost aspects showed a higher cover deficient in the DCO group. CONCLUSION: From an economic point of view the cost deficits for the ETC group were lower than in the DCO group. The treatment strategy should be selected by the pattern of injuries. The costs should be addressed by the Institute for the Hospital Remuneration System (INEK).

Commitment to COT verification improves patient outcomes and financial performance.

BACKGROUND: After an unsuccessful American College of Surgery Committee on Trauma visit, our level I trauma center initiated an improvement program that included (1) hiring new personnel (trauma director and surgeons, nurse coordinator, orthopedic trauma surgeon, and registry staff), (2) correcting deficiencies in trauma quality assurance and process improvement programs, and (3) development of an outreach program. Subsequently, our trauma center had two successful verifications. We examined the longitudinal effects of these efforts on volume, patient outcomes and finances. METHODS: The Trauma Registry was used to derive data for all trauma patients evaluated in the emergency department from 2001 to 2007. Clinical data analyzed included number of admissions, interfacility transfers, injury severity scores (ISS), length of stay, and mortality for 2001 to 2007. Financial performance was assessed for fiscal years 2001 to 2007. Data were divided into patients discharged from the emergency department and those admitted to the hospital. RESULTS: Admissions increased 30%, representing a 7.6% annual increase (p = 0.004), mostly due to a nearly fivefold increase in interfacility transfers. Severe trauma patients (ISS >24) increased 106% and mortality rate for ISS >24 decreased by 47% to almost half the average of the National Trauma Database. There was a 78% increase in revenue and a sustained increase in hospital profitability. CONCLUSION: A major hospital commitment to Committee on Trauma verification had several salient outcomes; increased admissions, interfacility transfers, and acuity. Despite more seriously injured patients, there has been a major, sustained reduction in mortality and a trend toward decreased intensive care unit length of stay. This resulted in a substantial increase in contribution to margin (CTM), net profit, and revenues. With a high level of commitment and favorable payer mix, trauma center verification improves outcomes for both patients and the hospital.

[Classification of severely injured patients in the G-DRG System 2008]. / Abbildung des schwer verletzten Patienten im G-DRG-System 2008.

BACKGROUND: Since the introduction of a per-case reimbursement system in Germany (German Diagnosis-Related Groups, G-DRG), the correct reimbursement for the treatment of severely injured patients has been much debated. While the classification of a patient in a polytrauma DRG follows different rules than the usual clinical definition, leading to a high number of patients not grouped as severely injured by the system, the system was also criticized in 2005 for its shortcomings in financing the treatment of severely injured patients. The development of financial reimbursement will be discussed in this paper. METHOD: 167 patients treated in 2006 and 2007 due to a severe injury at the University-Hospital Münster and grouped into a polytrauma-DRG were included in this study. For each patient, cost-equivalents were estimated. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK cost-calculation method. The reimbursement was calculated using the G-DRG-Systems of 2007, 2008 and 2009. Cost-equivalents/costs and clinical parameters were correlated. RESULTS: A total of 167 patients treated in 2006 and 2007 for a severe injury at the Münster University Hospital and grouped into a polytrauma DRG were included in this study. Cost equivalents were estimated for each patient. For those patients treated in 2007 (n=110), exact costs were calculated following the InEK (Institute for the Hospital Remuneration System) cost calculation method. Reimbursement was calculated using the G-DRG systems of 2007, 2008 and 2009. Cost equivalents/costs and clinical parameters were correlated. DISCUSSION: With the ongoing development of the G-DRG system, reimbursement for the treatment of severely injured patient has improved, but the amount of underfinancing remains substantial. As treatment of severely injured patients must be reimbursed using the G-DRG system, this system must be further adapted to better meet the needs of severely injured patients. Parameters such as total surgery time, injury severity score (ISS) and LOS in ICU could be used for this purpose. In future, data obtained in trauma networks can help optimize reimbursement for the treatment of these patients.