Hidden burdens of orthopedic injury care: the lost providers.

BACKGROUND: There are no previously known studies on the effects of orthopedic trauma on informal caregivers despite rich literature in other areas of caregiving. In this prospective study, we characterize personal and socioeconomic impact on orthopedic trauma caregivers. METHODS: Ninety-nine subjects were given the Caregiver Burden Scale and an original survey measuring emotional, employment, and socioeconomic burden. Demographic, patient injury, and treatment data were also collected. RESULTS: Seventy percent of caregivers were female family members of the patient. Fifty-four percent experienced substantial disruption to social life and emotional stress. Fifty-one percent spent more than 21 hrs/wk caregiving postinjury. Before/after injury time spent caring for the patient was statistically significant (p < 0.01). Many caregivers experienced employment stress; 8% quit their jobs. Before/after injury employment stress was statistically significant (p < 0.01). Caregivers also expressed considerable financial stress. CONCLUSIONS: Socioeconomic impacts related to caregiving experiences extend beyond the clinical care of the patient with caregivers facing extensive stress, financial drain, and employment difficulties. Understanding the complex nature of caring for orthopedic patients may assist in connecting patients and caregivers to the appropriate services and further improve patient outcomes.

United States level I trauma centers are not created equal - a concern for patient safety?

BACKGROUND: The American College of Surgeons delineates 108 requirements for level I trauma centers. Some of these requirements include: minimum of 1,200 trauma admissions per year; an average of 35 major trauma patients per surgeon; residency training programs; and 10 peer-reviewed journal submissions every three years. This study examines the variation in services provided among U.S. level I trauma centers. METHODS: 218 facilities identified as level I trauma centers in 2005 were contacted for participation. 136 centers in 37 states completed the questionnaire. Surveys queried variances in trauma, neurosurgery, plastics, and orthopaedic surgery with regard to type of center, type of accreditation, number and training of participating physicians, number of beds, dedicated OR support (staff/rooms), call pay, and research. RESULTS: Of the level I centers surveyed, 66% are university-affiliated facilities that employ more surgeons and staffing across trauma and all subspecialties compared to community-based or public centers. However, the community and public centers have more surgeons per capita (44% of the university-affiliated hospitals have six or more trauma surgeons on staff compared to 59% of the community and 70% of the public facilities). University-affiliated centers also provide more in-house subspecialty services (orthopaedic, neurosurgery, and plastics). Thirty-nine percent do not have ACS accreditation and are designated trauma facilities by state or local governments. Only 49% of trauma centers provide on-call pay to trauma surgeons, and these percentages decline for all subspecialties. Dedicated operating rooms and research programs are also lacking among all subspecialties. CONCLUSION: Based on our findings, we conclude that there are no homogeneous criteria for being accredited as a level I trauma center. Reliable resources should be offered at any facility that claims a level I trauma designation. We do not know if such diversity of services truly impacts care or how it can be measured; nevertheless, it would be logical to presume that at some point services that fall below a minimum threshold would potentially adversely affect the quality of care. In order to develop appropriate policy to decrease possible disparities, differentiation in services between trauma centers must be further researched and described.

Economic value of orthopaedic trauma: the (second to) bottom line.

OBJECTIVES: We evaluated the economic aspects of an orthopaedic trauma section at a regional Level I, semi-academic community hospital. This study analyzes the economics of a dedicated hospital-based orthopaedic trauma program. METHODS: Institutional financial reports were analyzed for 2 time periods. In the pre-program (PRE) period (2 years), we estimated the amount of forsaken revenue resulting from cases transferred to other institutions. In the post-program (POST) period (2 years), we analyzed financial reports to evaluate fiscal solvency. Health Care Cost and Utilization Project National Inpatient Sample (HCUP-NIS) data, International Classification of Diseases, 9th Revision (ICD-90 codes, and Eclipsys software were used. Standard accounting definitions for gross revenue, net revenue, direct costs, contribution margin, indirect costs, and net profit/loss were used. RESULTS: In the PRE-program period 88 patients were transferred; forsaken charges were about $1.25 million/year. Based on historic collection rates, there was about $450,000/year of actual lost revenue. In the POST-program period net revenue was about $7 million with a $1.5 million contribution margin, which increased 9%-11% in year 2. With inclusion of indirect costs, there was a net loss of nearly $5 million/year, but the financial software uses the direct cost expense as a major determinant of indirect costs. Based on the definition of indirect costs (overhead for lights, maintenance, etc) and with such expenses being used prior to the program, we felt that indirect cost was not an accurate variable and contribution margin is the better measure of economic value. CONCLUSION: We found that orthopaedic trauma is a financially viable program. Understanding the determination and interpretation of financial data is essential for any such analysis.