The financial cost of treating polytrauma: Implications for tertiary referral centres in the United Kingdom

Summary

This observational study was designed to evaluate the financial cost and resources needed to treat a polytrauma patient at a tertiary care centre in the United Kingdom. Sixty-nine patients, from outside the normal hospital catchment area, were referred to a University Hospital and treated for polytrauma (injury severity score > 15). Fifty-one patients had head injuries in addition to other injuries. Fourteen patients died in hospital. Forty-seven patients spent 316 ITU days with a total of 832 hospital days. One hundred and ninety-six operating hours were used for their surgical treatment and only 13 patients required neurosurgical intervention. There were 580 radiological and 2967 blood investigations. The total cost of treating these patients was £974,874. The money received by the hospital from the respective primary care trusts was an average of £1500 per patient for the full treatment including follow up. Thus, the fiscal deficit was £871,375. This study indicates that the financial accounting for complex cases is antiquated and inaccurate within the NHS. Tertiary referral centres receive only 10% of the appropriate money for treatment of polytrauma patients. The number of patients is relatively small, but their impact on the local services is very high.

Introduction

Trauma is a leading cause of death before the age of 45 years. The expert and expeditious care of patients with multiple injuries directly bears upon the patient's mortality, morbidity and eventual functional recovery. Polytrauma also has serious social and economical implications, both for the patient and society. In 1994 alone, the cost of treating trauma in the United Kingdom (UK) was around £20 billion pounds. New technology and laws, such as air bags and compulsory use of rear seat belts, have improved survival rates from road accidents in the last decade. Patients may survive crashes that were previously fatal but are left with severe injuries that cause immense physical and psychological problems.

Polytrauma patients undergo complex medical management. Treatment of these patients will generally require resuscitation, emergency surgery, intensive care and complex reconstructive surgery. The recovery period, rehabilitation and hospital stay are often prolonged. There is good evidence that complex trauma patients are best managed at tertiary care centres,7, 8 which are fully equipped to deal with such emergencies and have sufficient specialist services, experience and expertise to undertake complex reconstructive surgery. The benefits of this type of systematic approach to managing rare and complex problems has been recognised in the UK by the development of cancer networks and designated centres for the management of patients with malignancy.² Severe trauma is the leading cause of death and disability in young patients, and costs more productive life-years than any other condition, but no formal system for the management of complex injuries has been introduced in the UK.

Despite this, many informal networks have developed within regions, often centred upon teaching hospitals or large general hospitals, where the presence of neurosurgical units have inevitably led to the referral of such patients. In addition, it has been recognised that some individuals possess skill in specific conditions, such as pelvic and acetabular fractures, where the outcome is known to be greatly improved with experience.3, 4 These injuries are caused by high violence and the patients often have complex injury patterns.

Although most clinicians recognise the value of these informal referral networks, the absence of a formal trauma network means that this work is often unrecognised by the Department of Health and purchasing authorities. The work is not underpinned by a sound physical and financial infrastructure. This places huge clinical pressures on units providing such services, where the constant and necessary use of operating theatres and intensive care beds for trauma patients has a knock-on effect on local patients, services and primary care trusts. In a recent example, a hospital management decided to stop tertiary referrals to a specialist pelvic and acetabular unit (www.bbc.co.uk/1/hi/health/2347615.stm) as the work was not properly financed and reduced their ability to provide routine elective surgery for the local population. This action is understandable but may have catastrophic effects on patients with complex injuries who are denied access to this surgical expertise. The focus on waiting list targets is deflecting resources away from specialist trauma services (including pelvic units) and has resulted in serious interruptions in treatment.¹

The National Health Service (NHS) is the single largest health care provider in the UK and provides almost all care for patients with complex, isolated injuries and polytrauma. Although trauma services are an integral part of emergency care provided by the NHS, no cost analysis of the management of polytrauma patients has been published. Studies on cost implications are scarce. In the United States, studies have compared use of resources by physicians at hospitals,⁶ use of resources by general practitioners in clinics and doctors in hospitals,⁵ and cost of non-urgent care in emergency departments.⁹ However, their findings are not directly applicable to the UK. Certainly, no studies have been published which analyse the cost of managing a polytrauma patient in a University Hospital.

Despite a constant rise in the cost of health care, hospitals continue to use antiquated cost control systems. Most health care organisations have a predetermined charge for each type of service, but these charges may not actually reflect the cost of providing the service.¹⁰ Knowing true costs will enable clinicians to select the most cost effective method of treating the patient, know the financial implications of adding tests or procedures, relate cost to established norms of care and negotiate more successfully with primary care trusts and strategic health authorities.

The present study was undertaken with the objective of evaluating the financial cost and resources needed to treat polytrauma patients at a tertiary care centre in the UK.