|Year : 2017 | Volume
| Issue : 1 | Page : 21-25
Costs of management of injuries in emergency room patients in Ilorin
Gbadebo H Ibraheem, Chima K Ofoegbu, Babatunde A Solagberu, Lukman O Abdur-Rahman, Adedeji A Adekanye, Abdur-Rasheed A Nasir
Centre for Injury Research and Safety Promotion, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||7-Jun-2017|
Gbadebo H Ibraheem
Centre for Injury Research and Safety Promotion, University of Ilorin Teaching Hospital, Ilorin, Nigeria
Source of Support: None, Conflict of Interest: None
Background: Injuries pose a significant economic problem to communities in every society. Studies aimed at estimating the costs of management of injuries are very limited in this environment.
Materials and Methods: The patients who presented to the emergency unit of the University Teaching Hospital, Ilorin, Nigeria, with traumatic injuries were recruited. The expenses were classified into various groups.
Results: Of the 165 patients recruited, majority were young adult men. The mean direct cost per injury was N4061 ($27.1) with the cost of drugs accounting for the largest share of the costs. The costs incurred were higher with the increasing severity of injury.
Conclusion: The direct costs of management of injuries from this study represent a significant economic drain to the low-income population of this environment. Extrapolating these cost estimates of medical treatment to the fatal as well as the even larger non-fatal injury burden in Nigeria exposes the immense financial drain to the individual and community.
Keywords: Economic burden, health insurance, injury costing, poverty
|How to cite this article:|
Ibraheem GH, Ofoegbu CK, Solagberu BA, Abdur-Rahman LO, Adekanye AA, Nasir ARA. Costs of management of injuries in emergency room patients in Ilorin. J Med Trop 2017;19:21-5
|How to cite this URL:|
Ibraheem GH, Ofoegbu CK, Solagberu BA, Abdur-Rahman LO, Adekanye AA, Nasir ARA. Costs of management of injuries in emergency room patients in Ilorin. J Med Trop [serial online] 2017 [cited 2017 Aug 20];19:21-5. Available from: http://www.jmedtropics.org/text.asp?2017/19/1/21/207588
| Introduction|| |
Injuries pose an economic problem of immense proportion to communities in every society. It is the leading cause of death of persons aged between 1 and 44 years, accounting for up to 72% of deaths in some age groups (e.g. 15–24 years). The cost of injury also imposes an enormous burden on communities. A 1986 estimate for Australia gives a figure of $11 billion per year. Nigeria has high incidence rates of fatal and non-fatal injuries due to interpersonal violence, road traffic crashes, burns, falls and other unintentional causes. Although the actual costs associated with these injuries remain relatively unknown, the estimated direct cost of the medical treatment, rehabilitation and administration of these victims as well as the indirect costs from time off work for the victims as well as their relatives may run into billions of naira. Various studies have estimated the social and economic consequences of specific types of injury. According to a report of the World Health Organization, road traffic injuries account for almost 1.2 million deaths a year around the world and for 20–50 million injuries or disabilities. The economic consequences of road traffic crashes are also very important, in terms of both lost productivity and healthcare resources needed. In economic terms, the cost of road crash injuries is estimated at roughly 1% of the gross national product in low-income countries, 1.5% in middle-income countries and 2% in high-income countries.
Information about costs is the first step towards the assessment of the cost effectiveness of strategies to reduce the effect of various forms of unintentional injury. The economic burden from injuries can be quantified through cost-of-injury studies, using techniques adopted from cost-of-illness research.
Studies aimed at estimating financial losses that are incurred as a result of traumatic injuries by the patient and caregivers are very limited. Studies such as these are important for planning emergency response as well as evaluating the cost effectiveness of health intervention.
This study aimed to assess the direct medical costs accrued from various types of injuries by the patients and serve as a guide to assessing the economic burden that these injuries place on the community.
| Materials and methods|| |
The patients were consecutively recruited from the accident and emergency over a 6-month period. The patients who died at presentation or discharged against medical advice shortly after admission were excluded from the study. The patients whose data were incomplete were also excluded from the study.
For the patients recruited, the details of their diagnosis, clinical findings at presentation as well as initial investigation results were obtained from the patients’ folders. The patients were also followed up during the period of admission, noting the expenses incurred. Expenses were divided into five major groups: Investigations (including laboratory and radiological); Drugs including all oral and parenteral medications as well as intravenous fluids and blood transfusion; Consumables including the costs of dressings as well as other consumables; Procedures including the costs of suturing of lacerations as well as surgical procedures and Admission costs. Investigation costs were calculated based on the price lists obtained from the laboratories and the radiology department. The quantity of each drug used was based on that prescribed by the attending clinician. The costs of the various drugs were calculated based on a price list obtained at the hospital pharmacy at the onset of data collection.
The duration of admission was determined after discharge. Admission fees were calculated based on the number of days spent in the accident and emergency as well as the various surgical wards. Trauma scores were calculated for the patients based on their clinical presentation and diagnosis. Abbreviated Injury Scores (AIS) and Injury Severity Scores (ISS) were calculated for each of the patients.
Data were captured and analyzed using the Statistical Package for the Social Sciences version 17 software (SPSS Inc., Chicago, IL, United States) and presented as frequencies and proportions for categorical data and mean ± standard deviation for continuous data. P values <0.05 were considered significant.
| Results|| |
A total of 165 patients were recruited during the study period. Of these, 119 (72%) were males and 46 (28%) were females with a male-to-female ratio of 2.6:1. The age of the patients varied from 2 to 85 years, with a mean age of 29.3 years (±14.51). A total of 128 patients (77.6%) were eventually discharged home, whereas 31 patients (18.8%) discharged against medical advice and six patients (3.6%) died.
A total of 152 patients (92%) had single region injuries, whereas 13 patients (7.9%) had multiple region injuries. AIS for the patients ranged from 1 to 6 with an overall mean of 2.1 ± 1.2. The AIS correlated well with the eventual outcome with a mean AIS of 1.8 among patients who were eventually discharged home; 2.9 among patients who discharged against medical advice and 4.1 among patients who eventually died (P = 0.028), which is shown in [Figure 1].
The ISS for the patients ranged from 1 to 25 with a mean ISS of 5.1 ± 4.8. The proportion of the patients with major trauma (ISS ≥ 16) was 6.7% (11 patients), and all the deaths had ISS ≥ 16. The patients who were eventually discharged home had a mean ISS of 3.7; those who discharged against medical advice had a mean ISS of 8.1 and those who eventually died had a mean ISS of 17.5 (P = 0.158).
The costs incurred by the patients in naira ranged from N355–112,885 ($2.8–885.4), with a mean cost of N4061 ± 10,107, which was equivalent to $31.9 at an exchange rate of N127.3 to a dollar at the time. The largest share of the costs was taken up by drugs, with an average cost of N1511 ± 1597 (37.2%) per patient (range N220–14,595) followed by procedures with an average cost of N910 ± 3526 (22.4%) per patient (range N0–32,640); admissions with an average cost of N772 ± 2342 (19%) per patient (range N0–24,500); investigations with an average cost of N530 ± 3349 (range N0–42,630) and finally consumables with an average cost of N339 ± 288 (range N0–1665), as shown in [Figure 2].
There was no statistical difference in age or gender among those who died, discharged against medical advice or were discharged home. Multiple injuries were not associated with the outcome, and there was no statistical age difference between those who had multiple injuries and those with single region injuries although those with multiple injuries tended to be younger (24.3 years vs. 29.8 years).
The injury severity was significantly higher in the patients with multiple injuries compared with those with single region injuries. The mean AIS for those with single region injuries was 1.932 compared to those with multiple injuries 4.077 (P < 0.0001); and the mean ISS for single region injuries was 4.6 compared with 10.5 for those with multiple injuries [Figure 3].
The costs incurred by the patients with multiple injuries were higher than those with single region injuries across all groups of expenses (P = 0.004; 0.19; 0.23; 0.014 and 0.001, respectively), as shown in [Figure 4].
The costs incurred by the patients with severe injuries (ISS ≥ 16) were also significantly higher than those with less severe injuries (ISS < 16) across all groups of expenses [Table 1].
| Discussion|| |
In spite of the fact that the Nigerian population is almost equally balanced between male and female, 72% of the patients studied were male. This is expected because male participants have been shown to have higher injury incidence rates than female participants., The costs incurred from injuries to men also have higher impact on economic impact in the community. In South Korea, men represent 50% of the population, yet they account for 81.7% ($32,566 million) of the total cost of injuries and 85.9% of the total years of potential life lost to injury. This cost disparity between men and women primarily results from the higher rate of fatal injuries in men and the subsequent higher productivity losses. The mean age of the patients was 29.3 years with majority of the patients being young adults. This is also similar to results from studies in other parts of the world. The high rate of injury in this particular group illustrates the need for effective targeting of this age group for any intervention strategies to significantly reduce the burden of injury in the community. Involvement of this working class group results in greater lifetime costs, which are not only from direct costs of treatment, but also from indirect costs, especially from lost income and productivity losses as well as from the cost of premature deaths amongst those that died.
In this study, the average direct treatment cost incurred per patient was N4061 ($27.1). This estimate, however, underestimates the financial burden from each injury case for several reasons. First, the calculated costs do not include the costs of nursing care, medical consultation and specialist care which are borne by the government in this hospital. They also do not include the cost of drugs used after discharge as well as the cost of follow-up. In addition, it has been shown in various studies in other parts of the world that indirect costs often comprise a larger percentage of the total costs than direct costs. An analysis of various studies in industrialized nations in 2007 estimated the total cost per injury case as $3536, with 71% of this being indirect costs. Studies on economic costs of various injuries have consistently shown that indirect costs far outweigh direct costs. Productivity losses have been shown to be 1.1 times higher than direct healthcare costs in Canada, 2.2 times higher than in Australia and 2.4–4.0 times higher than in the USA. In South Korea, indirect costs were shown to be 7.5 times higher than direct costs. In addition, cross-national comparisons show that premature death accounted for the largest proportion of total injury costs in most countries (20.6–31.3%). Estimates of costs attributable to indirect expenses and premature death in this environment are, however, not available.
Despite this underestimation, the calculated costs for each injury are still very significant in a nation where the gross national income per capita is $1140 and 64% of the population live below the international poverty line of US$1.25 per day. This is even more significant when put into context that it represents only a fraction of the total costs incurred by each injury episode, to the injured, his care-giver(s) as well as to the community in general.The cost of drugs accounted for 37.2% of the total costs with procedures and admission costs accounting for another 41.4%. The studies of firearm injuries in South Africa have also shown the costs of hospital stay, theatre use and drugs, making up a major share of the average costs incurred per patient.
Higher ISS were noted among the patients who discharged against medical advice compared to those who were completely managed and subsequently discharged home. Although the collated data do not specify the particular nature of the injuries in this category of the patients, a previous study from this centre has shown that majority of the patients who discharged against medical advice are those who have long bone fractures who chose to opt for traditional bone setter management. They undoubtedly will have greater injury severity and consequently greater costs than those who suffer bruises and lacerations and are managed and discharged home promptly.
Despite its limitations, this study represents another step towards stimulating multi-sectoral interest in the development of a costing system for installation in the public health sector in Nigeria and may also highlight lessons and challenges for public health sectors in other low-income environments where similar strategies are being considered. Certainly, a pressing challenge to the development of a public health sector injury costing system is the development of a culture of costing. Once such a culture has been established, the system-specific challenges of installing a national injury costing system may be more fully addressed.
| Conclusion|| |
The calculated direct costs from this study represent a significant economic drain, especially to the low-income population of this environment. Extrapolating even these limited cost estimates of direct medical treatment to the fatal as well as the even larger non-fatal injury burden in Nigeria exposes the immense financial drain on the public health system. This is valuable not only for health planning and management, but also for health practitioners and policy makers wishing to promote the redirection of fiscal resources towards prevention efforts. Further studies will be needed to obtain a more comprehensive estimate of the total costs of injuries in this environment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nilsen P, Hudson D, Lindqvist K. Economic analysis of injury prevention-applying results and methodologies from cost-of-injury studies. Int J Inj Control Saf Promot 2006;13:7-13.
Small TJ, Sheedy JM, Grabs AJ. Cost, demographics and injury profile of adult pedestrian trauma in inner Sydney. ANZ J Surg 2006;76:43-7.
Patel MS, Jones MA, Jiggins M, Williams SC. Does the use of a “track and trigger” warning system reduce mortality in trauma patients? Injury 2011;42:1455-9.
Lim SJ, Chung WJ, Cho WH. Economic burden of injuries in South Korea. Inj Prev 2011;17:291-6.
Reddy GN, Singh D, Singh AJ. Extent and determinants of cost of road traffic injuries in an Indian city. Indian J Med Sci 2009;63:549-56.
] [Full text]
Angus DE, Cloutier E, Albert T, Chénard D, Shariatmadar A. The Economic Burden of Unintentional Injury in Canada. Ontario, Canada: The SMARTRISK Foundation; 1998.
Rice DP, MacKenzie EJ, Jones AS, Kaufman SR, DeLissovoy GV, Max W et al.
Cost of injury-United States: A report to congress, 1989. JAMA 1989;262:2803-4.
Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence and lifetime costs of injuries in the United States. Inj Prev 2006;12:212-8.
Allard D, Burch VC. The cost of treating serious abdominal firearm-related injuries in South Africa. S Afr Med J 2005;95:591-4.
Nasir AA, Babalola OM. Clinical spectrum of discharges against medical advice in a developing country. Indian J Surg 2008;70:68-72.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]