International variation in clinical injury incidence: exploring the performance of indicators based on health care, anatomical and outcome criteria.

OBJECTIVE: To analyse international variation in clinical injury incidence, and explore the performance of different injury indicators in cross-country comparisons. METHODS: Hospital discharge data of seven European countries (Austria, Denmark, Ireland, Netherlands, Norway, England and Wales) were analysed. We tested existing and newly developed indicators based on (a) health care use, (b) anatomical criteria, or (c) expected health outcome: admissions excluding day-cases (a), hospital stay 4+ (a) and 7+ days (a), (serious) long-bone fractures (b), selected radiological verifiable fractures 'SRVFs' (b), and indicators based on international (Global Burden of Disease) and Dutch disability weights). Assessment criteria were reduction in incidence variation and length of stay in hospital, and the association between incidence and mortality rates. RESULTS: Indicators based on health care use led to increased variation in incidence rates. Long bone fractures and SRVFs, and both indicators based on injuries with moderate to high disability showed similar variation in clinical incidence compared to the crude rates, smaller variation in median length of stay in hospital and a good association with mortality rates. CONCLUSION: No perfect or near perfect indicators of clinical injury incidence exist. For international comparisons, indicators based on disability weights, SRVFs and long bone fractures may be sensible indicators to use, in the absence of a direct measure of anatomical severity.

Injuries associated with inline skating in the European region.

OBJECTIVES: To gain greater awareness and understanding of the circumstances leading to injuries associated with inline skating and to provide indices for determining preventive measures. METHODS: Data on injuries during inline skating were collected from seven member states of the European Union (EU) through the European Home and Leisure Accident Surveillance System (EHLASS). RESULTS: The mean incidence rate for injuries while inline skating is 17 per 100,000 inhabitants. In the EU in 1996, about 65,000 people were treated at an Emergency Department for an inline skate injury (excluding traffic injuries). About 60% of the victims are male, while the age group most at risk is 10-14 years old. Most injuries are due to a fall and wrist injuries are most common. CONCLUSIONS: The results of the analysis give indications for possible preventive measures. Although the features of the injuries often differ per country, the countries can learn from each other in preventing these types of injuries. Educational campaigns should be targeted at young teenagers, use of protective equipment (like wrist protectors) and skating techniques. EHLASS has potential for intercountry comparisons, but its value will improve if selecting hospitals and coding agreements will be standardised.

Epidemiological data and ranking home and leisure accidents for priority-setting.

OBJECTIVE: To determine how to use the multitude of available epidemiological data to rank accidents for prioritisation of prevention. METHODS: A stepwise method to rank accidents for priority-setting at any time is proposed. The first step is to determine the overall objectives of injury prevention. Based on these objectives, the relevant epidemiological criteria are determined. These criteria need to be weighed by experts in such a way that these weights can be used for every new cycle of priority-setting. Thus, every time the method is applied: first, the relevant types of accidents are identified; second, the epidemiological criteria are determined per type of accident; and third, the types of accidents are ranked by means of standardised weights per criterion. The proposed indirect method is illustrated by an empirical example. The results were compared with a direct method, i.e. ranking by an expert panel. RESULTS: In the pilot, we ranked four age groups of victims of a home and leisure accident: 0-4, 4-19 and 20-54 years of age, and victims aged 55 years or older. The resulting rankings differ largely per application; number one are victims older than 55 years or those of 20-54 years. CONCLUSIONS: The proposed method enables a structured, transparent way to set priorities for home and leisure accidents. It is a promising method, although further development is clearly necessary, based on the actual application of the model.

How adequate are emergency department home and leisure injury surveillance systems for cross-country comparisons in Europe?

The objective of this study was to assess whether the emergency department (ED) injury surveillance systems in Europe are suitable for cross-country comparisons. For this, the ED injury surveillance systems in Austria, Denmark, Greece, Ireland, the Netherlands, Norway and the UK (England, Wales) were considered. Standardised injury incidence and healthcare utilisation indices were calculated and the influence of measurement bias due to data collection and sampling differences, as well as trauma policy and health systems characteristics were assessed. The results showed that there was an over 3-fold variation of the grossly estimated incidence for home and leisure injuries (HLIs), with the highest values observed in England and Greece (111 and 104 per 1000 person years), and the lowest in Ireland and the Netherlands (27 and 48 per 1000 person years). The ranking of countries changed, however, when only injuries with an inherent need for ED treatment were considered (selected radiological verifiable fractures) with Austria topping the table followed by Greece and England. Thus, it is concluded that the naive use of ED injury surveillance systems for cross-country comparisons should be discouraged, as this is subject to measurement bias. Nevertheless, the observed variation in the healthcare utilisation and injury incidence, particularly among children and older people, indicates the potential to reduce the burden of HLI in Europe.

Assessing the burden of injury in six European countries.

OBJECTIVE: To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS: Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS: We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION: The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.

Guidelines for the conduction of follow-up studies measuring injury-related disability.

BACKGROUND: Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies. METHODS: A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures. RESULTS: The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury. CONCLUSIONS: Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.

Functional outcome at 2.5, 5, 9, and 24 months after injury in the Netherlands.

BACKGROUND: The collection of empirical data on the frequency, severity, and duration of functioning is a prerequisite to identify patient groups with long term or permanent disability. METHODS: We fielded postal questionnaires in a stratified sample of 8,564 injury patients aged 15 years and older, who had visited an emergency department in the Netherlands. Measurements were at 2.5, 5, 9, and 24 months after the injury and included a generic health status classification (EQ-5D), socio-demographic, and medical information. We analyzed determinants of long-term functional outcome by multivariate regression analysis. RESULTS: Five months after the injury health status of nonhospitalized injury patients was comparable to the general population's health (EQ-5D summary measure 0.87). Health status of patients admitted for 3 days or less improved until 9 months (0.82). For those admitted more than 3 days health status improved until 24 months (0.48 toward 0.67), but remained below population norms. Hospitalization, age and sex (females), type of injury (spinal cord injury, hip fracture, and lower extremity injury), and comorbidity were significant predictors of poor functioning in the long term. CONCLUSIONS: Recovery patterns vary widely between nonhospitalized, shortly, and long hospitalized injury patients. Nonhospitalized injury patients recover within 5 months from an injury whereas a considerable group of hospitalized injury patients suffer from persistent health problems. Our study indicates the importance of health monitoring with an adapted longitudinal design for injury patients. The time intervals used should match the various stages of the recovery process, which depends on the severity of the injury studied.

Incidence and costs of injuries in The Netherlands.

BACKGROUND: Injuries are a major and persistent public health problem, but a comprehensive and detailed overview of the economic burden is missing. We therefore estimated the number of emergency department (ED) attendances and health care costs as a result of injury. METHODS: We estimated lifetime health care costs of injuries occurring in The Netherlands in the year 1999. Patient groups were defined that are homogeneous in terms of health service use. Health service use and costs per patient group was estimated with data from national databases and a prospective study among 5755 injury patients. RESULTS: Total health care costs due to injury in 1999 were euro 1.15 billion, or 3.7% of the total health care budget. Major cost peaks were observed among males between ages 15 and 44 due to a high incidence, and among females from age 65 onwards due to a high incidence and high costs per patient. For the age groups 0-14, 15-44, 45-64, and 65+ ED attendances per 1000 person years were 85, 85, 43, and 49, respectively, and costs per capita were euro 38, euro 59, euro 43, and euro 210, respectively. Costs per patient rise about linearly up to age 60 and about exponentially thereafter. From age 25 onwards, females have higher costs per patient than males. Hip fracture (20%), superficial injury (13%), open wounds (7%), and skull-brain injury (6%) had the highest total costs. Most costs were attributable to falls (44%) and traffic injuries (19%). CONCLUSION: Young adult males, elderly females, falls, hip fractures, and minor injuries without medical need for hospitalization account for a substantial share of health care costs.

Cost estimation of injury-related hospital admissions in 10 European countries.

BACKGROUND: Injuries are a major cause of total health care costs. Cost estimations may help identify injuries and high risk-groups to be considered for potential intervention. METHODS: Hospital discharge registers of 10 European countries were used to estimate injury incidence. Consensus was reached between the participating countries about methodology, definition, classification, cost measurements, and valuation to maximize cross-national comparability of outcomes. The data of the countries were also used to give an estimate of the costs per capita by age, sex, type of injury, and external cause in Europe. RESULTS: Large international differences were observed in injury incidence and associated costs related to hospital admissions, with relatively high costs per capita for Austria, followed by Denmark and Norway. In Greece, Italy, Ireland, and Wales, intermediate costs per capita were found, but these costs were relatively low for Spain, England, and the Netherlands. The patterns of costs by age, sex, injury type, and external cause are quite similar between the countries. For all countries, costs per capita increase exponentially in older age groups (age > or =65 years), due to the combined effect of high incidence and high costs per patient. The elderly females account for almost triple costs compared with same age males. Young children and male adolescents are also high-cost groups. Highest costs were found for hip fractures, fractures of the knee/lower leg, superficial injuries, skull-brain injuries, and spinal cord injuries. Home and leisure injuries (including sport injuries) and occupational injuries combined make a major contribution (86%) to the hospital costs of injury. CONCLUSION: Elderly patients aged 65 years and older, especially women, consume a disproportionate share of hospital resources for trauma care, mainly caused by hip fractures and fractures of the knee/lower leg, which indicates the importance of prevention and investing in trauma care for this specific patient group.

Prevalence and prognostic factors of disability after childhood injury.

OBJECTIVE: To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term. METHOD: We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in The Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis. RESULTS: Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6-5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries. CONCLUSION: Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients.

The epidemiology of hand injuries in The Netherlands and Denmark.

Little is known about the magnitude of hand injuries at national levels. This paper quantifies and characterises the incidence of hand injuries that require acute medical attention at Emergency Departments in The Netherlands and Denmark. Except for the incidence rate and the referral after treatment, the overall picture of hand injuries is similar for both countries: hand injuries show a peak for teenagers, result mainly from home and leisure accidents, are mainly caused by objects and falls, the majority affect fingers and result mainly in superficial injuries, open wounds and fractures, a small proportion of the victims is admitted into hospital. We conclude that hand injuries are a real burden to society and are worthwhile to be prevented with special attention for home and leisure accidents and occupational accidents. Data recording on the backgrounds of accidents and their long term consequences should be improved.

Distribution and determinants of health and work status in a comprehensive population of injury patients.

BACKGROUND: Insight into the distribution and determinants of both short- and long-term disability can be used to prioritize the development of prevention policies and to improve trauma care. We report on a large follow-up study in a comprehensive population of injury patients. METHODS: We fielded a postal questionnaire in a stratified sample of 4,639 nonhospitalized and hospitalized injury patients aged 15 years and older, at 2, 5, and 9 months after injury. We gathered sociodemographic information, data on functional outcome with a generic instrument for health status measurement (EuroQol EQ-5D+) and data on work absence. RESULTS: The response rates were 39%, 75%, and 68% after 2, 5, and 9 months, respectively. The reported data were adjusted for response bias and stratification. The 2-month health status of nonhospitalized patients was comparable to the general population's health when measured by the EQ-5D summary score, although considerable prevalence of restrictions in usual activities (24.0%) and pain and discomfort (34.8%) were reported. Hospitalized patients reported higher prevalences of disability in all health domains. Their mean EQ-5D summary score increased from 0.62 at 2 months to 0.74 at 5 months but remained below the population norm at 9 months, particularly for patients with a long hospital stay. Patients with injuries of the spinal cord and vertebral column, hip fracture, and other lower extremity fractures reported the worst health status, also when adjusted for age, sex, and educational level. Age, sex, type of injury, length of stay, educational level, motor vehicle injury, medical operation, intensive care unit admission, and number of injuries were all significant predictors of functioning. Nonhospitalized and hospitalized injury patients lost on average 5.2 and 72.1 work days, respectively. Of nonhospitalized patients, 5% had not yet returned to work after 2 months, and 39%, 20%, and 10% of hospitalized patients had not yet returned to work after 2, 5, and 9 months, respectively. In a multivariate regression analysis, length of stay, type of injury, level of education, and intensive care unit admission appeared to be significant predictors of absence duration and return to work. CONCLUSION: Injury is a major source of disease burden and work absence. Both hospitalized and nonhospitalized patients contribute significantly to this burden.