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Morbidity due to major trauma is an important health problem worldwide.1 In New Zealand the burden of trauma is relatively high, with a high rate of major injuries per head of population. Data from the New Zealnd Health and Safety Commission’s Atlas of Healthcare suggest that around 8% of patients admitted to hospital with physical injuries have suffered major trauma,2 and the mortality in this group is 9%.3 Trauma affects patients of a younger age, and Māori are over-represented.

The economic burden of trauma is also significant worldwide, with the World Health Organization (WHO) estimating that US$518 billion is spent treating patients suffering from trauma. We have previously reported inpatient costs of major trauma in New Zealand, along with common drivers of higher costs. New Zealand trauma costs are in keeping with the international literature, but the cost is unlikely to be assessed properly using standard coding methods, with actual costs being more accurate.4

The readmission rate for patients with major trauma is seen as a quality marker in most contemporary trauma systems and has been recorded at 11% in New Zealand.3 The rate of representations to emergency departments is not reported. With the reductions in death from major trauma, the focus is shifting to preventing morbidity and assessing longer-term outcomes. It is also likely that there is significant costs associated with readmission and representation of major trauma patients, and that the majority of these episodes of care are preventable. Accurate data on the costs of these episodes is essential for guiding quality improvement initiatives and ensuring resources are appropriately allocated in the face of increasingly competitive demands. This is particularly important in episodes of care like this, which are potentially preventable with appropriate investment.

The rate, costs and resource implications associated with total representation comprising re-attendances to emergency departments and readmission in New Zealand have not previously been reported. There is also a paucity of data in the international literature.

The aim of this study was to define rate, costs and resource implications of total representations, re-attendance to the emergency department (ED) and readmission in patients who have suffered from major trauma in Northland.

Methods

All patients presenting to Northland District Health Board (DHB) with major trauma between 1 January 2016 and 31 December 2019 were included for analysis. Adult major trauma patients were defined as those aged 16 or over with an Injury Severity Score (ISS) >12. In line with the national trauma registry, injury secondary to hanging, poisoning and drowning were excluded. The primary cohort was identified from a prospectively maintained trauma database generated weekly by a trauma coordinator. Using the 2008 revision of the 2005 edition of the Abbreviated Injury Scale (AIS), AIS were calculated for all the patients by using coding and the patient clinical notes. The three most severely injured body regions have their scores squared and added together to retrospectively produce the ISS score.

Further information on the primary cohort was obtained from the hospital’s clinical results reporting system, CONCERTO, which included outcomes of pathological and radiological investigations as well as operative interventions. Patient demographics, including ethnicity, residence data and length of stay, were obtained from the hospital’s data warehouse. Re-admissions within 30 days and presentation to ED within 30 days were obtained from the hospitals data warehouse. Re-admission was defined as any assessment or treatment requiring acute admission to an inpatient facility or overnight assessment unit. Re-attendance to ED was defined as any unplanned presentation to ED resulting in assessment by a doctor. Re-presentation was defined as either re-admission or attendance to ED.

Case-by-case assessment of the representations was undertaken. If patients required simple interventions in ED that could be managed in the community by a general practitioner (GP) or a GP service, then they were deemed preventable.

Actual patient-level costs were calculated using the New Zealand Common Costing Standards (Version 17). The standards have been developed for use in the public health sector to provide common standards for the costing of DHB services. Actual costs were calculated using in-house, patient-level costing utilising CostPro software with adjustment for nursing cost-acuity based on data from TrendCare. Specialty-specific costs were used for physician contact times and overhead and allied health costs were included as an average of overall throughput. Diagnosis Related Groups (DRGs) case-weight costs, based on DRG codes used nationally, were also calculated using standard techniques.

Statistical analysis was performed with IBM SPSS, Armonk, New York, USA. Scale data was tested for normality with a Shapiro–Wilk test. Non-parametric data including age, length of stay and ISS was analysed with a Mann–Whitney U test. Nominal data, including ethnicity, gender, ICU admission and transfer, was tested using a Chi-squared.

This study was performed as part of a national quality improvement programme in major trauma and was approved locally as quality improvement work aimed at decreasing preventable readmissions. Costs were analysed to allow evidence based funding of QI initiatives. As such, ethical approval was not sought. Only anonymised data were used in the final analysis.

Results

Basic demographics

420 patients were identified as suffering from major trauma presenting to Northland District Health Board. This made up the primary cohort. Median age was 47 years (IQR 38). The male-to-female ratio was 2.2:1. 154 (37%) patients identified as Māori, and 266 (63%) patients identified as non-Māori.

Clinical characteristics and outcomes

131 (31%) patients were transferred to a tertiary center. Of the 289 (69%) patients kept at Whangarei Hospital, 72 (25%) were admitted to the intensive care unit (ICU) and 20 (5%) went directly to theatre from ED. Median ISS was 18 (IQR 10). Median length or stay was five days (IQR 10).

Representations

There were 90 unplanned representations in 63 patients (15%) within 30 days of discharge. The number of unplanned re-attendances to ED was 52 in 33 patients (8%). The number of unplanned readmission was 38 in 30 patients (7%). Mean length of stay in those readmitted was 1.9 days. None of the patients that were readmitted required admission to the ICU. Of those 63 patients who represented, 11 patients represented twice, 2 represented three times, 1 patient represented four times and 2 represented five times.

Cause of representation was categorised based on common complaints. 23 patients (36%) had wound complications, 17 (27%) had pain, 7 (11%) had a secondary injury, 6 (10%) had a concussion, 2 patients (3%) represented with either sepsis or medication-related issues and 6 patients (10%) couldn’t be categorised and were categorised as ‘other’.

Representation rates associated with index presentation factors are outlined in Table 1.

Table 1: Comparison of index presentation factors.

Costs

The total cost associated with representations in the primary cohort was $220,914, with a mean expenditure of $55,229 per year. The median cost of attendance to ED was $334 (IQR $181), and the total cost of attendance to ED was $20,304. Median cost of readmission was $3,643 (IQR $5151), and the total cost of readmission was $200,611. The costs of representation associated with demographics and outcomes are outlined in Table 2.

Table 2: Costs associated with gender, ISS, year and ethnicity.

Discussion

This study has outlined the rate, costs and resource implications of unplanned readmissions and re-attendance to ED in patients following admission due to major trauma in a provincial trauma centre. The representation rate was significant, with costs in patients requiring admission being ten times greater than those discharged from the emergency department. Up to a half of representations were preventable, with no characteristics significantly indicating risk of readmission.

The findings of this study are important and have implications for the resourcing of projects to prevent readmissions in major trauma. As a high proportion of representations are likely to be preventable, it would be reasonable to assume that the majority of costs associated with readmissions can be redirected to these programmes. Although it did not reach significance, there is a trend of increasing representation rates in Māori, which is potentially contributing to health inequity and increased morbidity. It is difficult to tell whether higher rates of representation means more or less inequity, and this question fell outside the scope of this study. This is an area that requires further study to ensure the significance of findings, as well as more detailed analysis of reasons for representation.

Despite the fact that representation rates represent an evidence-based marker of quality of care, and that the majority of these episodes are thought to be preventable across most hospital services, the data on representations in major trauma patients are lacking. As would be expected, the readmission rate in Northland is comparable with that seen in the New Zealand major trauma dataset,1 to which it contributes. Several other studies have evaluated admissions in trauma patients worldwide, some of which contain data on major trauma patients with readmission rates varying between 2–14%.6–13 In three papers, which specifically commented on major trauma and contained a large numbers of patients, the rate was 3-8%.7,8,13 Although inclusion criteria are broad across most studies, readmission rates in general are higher in the most severely injured. There is a large variation in reason for readmission across studies. It is likely based on this evidence that readmission rates in Northland, and indeed across New Zealand, can be decreased.

Data on costs of representation in major trauma patients is lacking in the medical literature. It is difficult to find relevant comparative evidence. However, we have published previous data on the total cost of treating patients suffering from major trauma in the Northern region, which was $1.5 million per annum during a similar time period. Representation therefore only adds 3% in spend, despite occurring in 15% of patients. This is small in comparison to the 38% increase in costs due to planned interventions following admission for major trauma patients in Queensland, Australia.14 Previous data have described a discrepancy between DRG costs and actual costs in major trauma patients,4 which is why actual costs were chosen in our study. As most representations and admissions are short and did not need significant intervention, it is unlikely that there is a wide variation from DRG costs when considering re-presentations.

The authors accept the limitations of this study. It was retrospective in nature and absolute patient numbers are relatively low. Despite this we believe that the data are relevant and set a benchmark for guiding resource allocation to quality improvement programmes aimed at reducing representations in patients suffering from major trauma. It also demonstrates areas that will benefit most from resource allocation and should help guide equitable care for these patients. It is likely that specific resources are needed for preventing admissions due to pain and in Māori patients.

It is clear that further studies are needed in this important area of care, and studies evaluating the impact of initiatives designed to reduce representation rate will be particularly important.

This is the first study in New Zealand to define the rate, costs and resource implications of readmissions and re-attendance to ED in patients following admission due to major trauma. These data should help guide future quality improvement initiatives to reduce the rates and costs of representation in this group of patients.

Summary

Abstract

INTRODUCTION: The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand. AIM: The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland. METHOD: We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital’s clinical results reporting system and data warehouse. RESULTS: 420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days. CONCLUSION: This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.

Aim

Method

Results

Conclusion

Author Information

Henry Witcomb Cahill: Department of General Surgery, Northland District Health Board. Matthew McGuinness: Department of General Surgery, Northland District Health Board. Olivia Monos: Trauma coordinator, Northland District Health Board. Christopher Harmston: Department of General Surgery, Northland District Health Board.

Acknowledgements

Correspondence

Henry Witcomb Cahill, 1 Hopsital Road, Maunu, Whanagrei, 0210701516

Correspondence Email

Henry.witcomb@gmail.com

Competing Interests

Nil.

1. WHO, Injuries and Violence: The facts. 2010

2. Health Quality & Safety Commission New Zealand. Atlas of Healthcare Variation. Trauma. 2012 updated in 2016. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/trauma/

3. .Network, N.Z.M.T.R.N.T. Annual Report 2018-2019 2020; Available from: https://www.majortrauma.nz/assets/Publication-Resources/Annual-reports/National-Trauma-Network-Annual-Report-2018-19.pdf.

4. Lee, H., et al., Counting the costs of major trauma in a provincial trauma centre. N Z Med J, 2018. 131(1479): p. 57-63.

5. Ashton, C.M., et al., The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care, 1997. 35(10): p. 1044-59.

6. Copertino, L.M., et al., Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center. Am J Surg, 2015. 209(2): p. 268-73.

7. Moore, L., et al., Evolution of patient outcomes over 14 years in a mature, inclusive Canadian trauma system. World J Surg, 2015. 39(6): p. 1397-405.

8. Olufajo, O.A., et al., The truth about trauma readmissions. Am J Surg, 2016. 211(4): p. 649-55.

9. Osler, T., et al., Variation in readmission rates among hospitals following admission for traumatic injury. Injury, 2019. 50(1): p. 173-177.

10. Petrey, L.B., et al., Trauma patient readmissions: Why do they come back for more? J Trauma Acute Care Surg, 2015. 79(5): p. 717-24; discussion 724-5.

11. Rosenthal, M.G., et al., Early unplanned trauma readmissions in a safety net hospital are resource intensive but not due to resource limitations. J Trauma Acute Care Surg, 2017. 83(1): p. 135-138.

12. Spector, W.D., et al., Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care, 2012. 50(10): p. 863-9.

13. Vachon, C.M., M. Aaland, and T.H. Zhu, Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma Acute Care Surg, 2012. 72(2): p. 531-6.

14. Rowell, D., et al., What are the true costs of major trauma? J Trauma, 2011. 70(5): p. 1086-95.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Morbidity due to major trauma is an important health problem worldwide.1 In New Zealand the burden of trauma is relatively high, with a high rate of major injuries per head of population. Data from the New Zealnd Health and Safety Commission’s Atlas of Healthcare suggest that around 8% of patients admitted to hospital with physical injuries have suffered major trauma,2 and the mortality in this group is 9%.3 Trauma affects patients of a younger age, and Māori are over-represented.

The economic burden of trauma is also significant worldwide, with the World Health Organization (WHO) estimating that US$518 billion is spent treating patients suffering from trauma. We have previously reported inpatient costs of major trauma in New Zealand, along with common drivers of higher costs. New Zealand trauma costs are in keeping with the international literature, but the cost is unlikely to be assessed properly using standard coding methods, with actual costs being more accurate.4

The readmission rate for patients with major trauma is seen as a quality marker in most contemporary trauma systems and has been recorded at 11% in New Zealand.3 The rate of representations to emergency departments is not reported. With the reductions in death from major trauma, the focus is shifting to preventing morbidity and assessing longer-term outcomes. It is also likely that there is significant costs associated with readmission and representation of major trauma patients, and that the majority of these episodes of care are preventable. Accurate data on the costs of these episodes is essential for guiding quality improvement initiatives and ensuring resources are appropriately allocated in the face of increasingly competitive demands. This is particularly important in episodes of care like this, which are potentially preventable with appropriate investment.

The rate, costs and resource implications associated with total representation comprising re-attendances to emergency departments and readmission in New Zealand have not previously been reported. There is also a paucity of data in the international literature.

The aim of this study was to define rate, costs and resource implications of total representations, re-attendance to the emergency department (ED) and readmission in patients who have suffered from major trauma in Northland.

Methods

All patients presenting to Northland District Health Board (DHB) with major trauma between 1 January 2016 and 31 December 2019 were included for analysis. Adult major trauma patients were defined as those aged 16 or over with an Injury Severity Score (ISS) >12. In line with the national trauma registry, injury secondary to hanging, poisoning and drowning were excluded. The primary cohort was identified from a prospectively maintained trauma database generated weekly by a trauma coordinator. Using the 2008 revision of the 2005 edition of the Abbreviated Injury Scale (AIS), AIS were calculated for all the patients by using coding and the patient clinical notes. The three most severely injured body regions have their scores squared and added together to retrospectively produce the ISS score.

Further information on the primary cohort was obtained from the hospital’s clinical results reporting system, CONCERTO, which included outcomes of pathological and radiological investigations as well as operative interventions. Patient demographics, including ethnicity, residence data and length of stay, were obtained from the hospital’s data warehouse. Re-admissions within 30 days and presentation to ED within 30 days were obtained from the hospitals data warehouse. Re-admission was defined as any assessment or treatment requiring acute admission to an inpatient facility or overnight assessment unit. Re-attendance to ED was defined as any unplanned presentation to ED resulting in assessment by a doctor. Re-presentation was defined as either re-admission or attendance to ED.

Case-by-case assessment of the representations was undertaken. If patients required simple interventions in ED that could be managed in the community by a general practitioner (GP) or a GP service, then they were deemed preventable.

Actual patient-level costs were calculated using the New Zealand Common Costing Standards (Version 17). The standards have been developed for use in the public health sector to provide common standards for the costing of DHB services. Actual costs were calculated using in-house, patient-level costing utilising CostPro software with adjustment for nursing cost-acuity based on data from TrendCare. Specialty-specific costs were used for physician contact times and overhead and allied health costs were included as an average of overall throughput. Diagnosis Related Groups (DRGs) case-weight costs, based on DRG codes used nationally, were also calculated using standard techniques.

Statistical analysis was performed with IBM SPSS, Armonk, New York, USA. Scale data was tested for normality with a Shapiro–Wilk test. Non-parametric data including age, length of stay and ISS was analysed with a Mann–Whitney U test. Nominal data, including ethnicity, gender, ICU admission and transfer, was tested using a Chi-squared.

This study was performed as part of a national quality improvement programme in major trauma and was approved locally as quality improvement work aimed at decreasing preventable readmissions. Costs were analysed to allow evidence based funding of QI initiatives. As such, ethical approval was not sought. Only anonymised data were used in the final analysis.

Results

Basic demographics

420 patients were identified as suffering from major trauma presenting to Northland District Health Board. This made up the primary cohort. Median age was 47 years (IQR 38). The male-to-female ratio was 2.2:1. 154 (37%) patients identified as Māori, and 266 (63%) patients identified as non-Māori.

Clinical characteristics and outcomes

131 (31%) patients were transferred to a tertiary center. Of the 289 (69%) patients kept at Whangarei Hospital, 72 (25%) were admitted to the intensive care unit (ICU) and 20 (5%) went directly to theatre from ED. Median ISS was 18 (IQR 10). Median length or stay was five days (IQR 10).

Representations

There were 90 unplanned representations in 63 patients (15%) within 30 days of discharge. The number of unplanned re-attendances to ED was 52 in 33 patients (8%). The number of unplanned readmission was 38 in 30 patients (7%). Mean length of stay in those readmitted was 1.9 days. None of the patients that were readmitted required admission to the ICU. Of those 63 patients who represented, 11 patients represented twice, 2 represented three times, 1 patient represented four times and 2 represented five times.

Cause of representation was categorised based on common complaints. 23 patients (36%) had wound complications, 17 (27%) had pain, 7 (11%) had a secondary injury, 6 (10%) had a concussion, 2 patients (3%) represented with either sepsis or medication-related issues and 6 patients (10%) couldn’t be categorised and were categorised as ‘other’.

Representation rates associated with index presentation factors are outlined in Table 1.

Table 1: Comparison of index presentation factors.

Costs

The total cost associated with representations in the primary cohort was $220,914, with a mean expenditure of $55,229 per year. The median cost of attendance to ED was $334 (IQR $181), and the total cost of attendance to ED was $20,304. Median cost of readmission was $3,643 (IQR $5151), and the total cost of readmission was $200,611. The costs of representation associated with demographics and outcomes are outlined in Table 2.

Table 2: Costs associated with gender, ISS, year and ethnicity.

Discussion

This study has outlined the rate, costs and resource implications of unplanned readmissions and re-attendance to ED in patients following admission due to major trauma in a provincial trauma centre. The representation rate was significant, with costs in patients requiring admission being ten times greater than those discharged from the emergency department. Up to a half of representations were preventable, with no characteristics significantly indicating risk of readmission.

The findings of this study are important and have implications for the resourcing of projects to prevent readmissions in major trauma. As a high proportion of representations are likely to be preventable, it would be reasonable to assume that the majority of costs associated with readmissions can be redirected to these programmes. Although it did not reach significance, there is a trend of increasing representation rates in Māori, which is potentially contributing to health inequity and increased morbidity. It is difficult to tell whether higher rates of representation means more or less inequity, and this question fell outside the scope of this study. This is an area that requires further study to ensure the significance of findings, as well as more detailed analysis of reasons for representation.

Despite the fact that representation rates represent an evidence-based marker of quality of care, and that the majority of these episodes are thought to be preventable across most hospital services, the data on representations in major trauma patients are lacking. As would be expected, the readmission rate in Northland is comparable with that seen in the New Zealand major trauma dataset,1 to which it contributes. Several other studies have evaluated admissions in trauma patients worldwide, some of which contain data on major trauma patients with readmission rates varying between 2–14%.6–13 In three papers, which specifically commented on major trauma and contained a large numbers of patients, the rate was 3-8%.7,8,13 Although inclusion criteria are broad across most studies, readmission rates in general are higher in the most severely injured. There is a large variation in reason for readmission across studies. It is likely based on this evidence that readmission rates in Northland, and indeed across New Zealand, can be decreased.

Data on costs of representation in major trauma patients is lacking in the medical literature. It is difficult to find relevant comparative evidence. However, we have published previous data on the total cost of treating patients suffering from major trauma in the Northern region, which was $1.5 million per annum during a similar time period. Representation therefore only adds 3% in spend, despite occurring in 15% of patients. This is small in comparison to the 38% increase in costs due to planned interventions following admission for major trauma patients in Queensland, Australia.14 Previous data have described a discrepancy between DRG costs and actual costs in major trauma patients,4 which is why actual costs were chosen in our study. As most representations and admissions are short and did not need significant intervention, it is unlikely that there is a wide variation from DRG costs when considering re-presentations.

The authors accept the limitations of this study. It was retrospective in nature and absolute patient numbers are relatively low. Despite this we believe that the data are relevant and set a benchmark for guiding resource allocation to quality improvement programmes aimed at reducing representations in patients suffering from major trauma. It also demonstrates areas that will benefit most from resource allocation and should help guide equitable care for these patients. It is likely that specific resources are needed for preventing admissions due to pain and in Māori patients.

It is clear that further studies are needed in this important area of care, and studies evaluating the impact of initiatives designed to reduce representation rate will be particularly important.

This is the first study in New Zealand to define the rate, costs and resource implications of readmissions and re-attendance to ED in patients following admission due to major trauma. These data should help guide future quality improvement initiatives to reduce the rates and costs of representation in this group of patients.

Summary

Abstract

INTRODUCTION: The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand. AIM: The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland. METHOD: We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital’s clinical results reporting system and data warehouse. RESULTS: 420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days. CONCLUSION: This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.

Aim

Method

Results

Conclusion

Author Information

Henry Witcomb Cahill: Department of General Surgery, Northland District Health Board. Matthew McGuinness: Department of General Surgery, Northland District Health Board. Olivia Monos: Trauma coordinator, Northland District Health Board. Christopher Harmston: Department of General Surgery, Northland District Health Board.

Acknowledgements

Correspondence

Henry Witcomb Cahill, 1 Hopsital Road, Maunu, Whanagrei, 0210701516

Correspondence Email

Henry.witcomb@gmail.com

Competing Interests

Nil.

1. WHO, Injuries and Violence: The facts. 2010

2. Health Quality & Safety Commission New Zealand. Atlas of Healthcare Variation. Trauma. 2012 updated in 2016. Available from: https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/trauma/

3. .Network, N.Z.M.T.R.N.T. Annual Report 2018-2019 2020; Available from: https://www.majortrauma.nz/assets/Publication-Resources/Annual-reports/National-Trauma-Network-Annual-Report-2018-19.pdf.

4. Lee, H., et al., Counting the costs of major trauma in a provincial trauma centre. N Z Med J, 2018. 131(1479): p. 57-63.

5. Ashton, C.M., et al., The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence. Med Care, 1997. 35(10): p. 1044-59.

6. Copertino, L.M., et al., Early unplanned hospital readmission after acute traumatic injury: the experience at a state-designated level-I trauma center. Am J Surg, 2015. 209(2): p. 268-73.

7. Moore, L., et al., Evolution of patient outcomes over 14 years in a mature, inclusive Canadian trauma system. World J Surg, 2015. 39(6): p. 1397-405.

8. Olufajo, O.A., et al., The truth about trauma readmissions. Am J Surg, 2016. 211(4): p. 649-55.

9. Osler, T., et al., Variation in readmission rates among hospitals following admission for traumatic injury. Injury, 2019. 50(1): p. 173-177.

10. Petrey, L.B., et al., Trauma patient readmissions: Why do they come back for more? J Trauma Acute Care Surg, 2015. 79(5): p. 717-24; discussion 724-5.

11. Rosenthal, M.G., et al., Early unplanned trauma readmissions in a safety net hospital are resource intensive but not due to resource limitations. J Trauma Acute Care Surg, 2017. 83(1): p. 135-138.

12. Spector, W.D., et al., Thirty-day, all-cause readmissions for elderly patients who have an injury-related inpatient stay. Med Care, 2012. 50(10): p. 863-9.

13. Vachon, C.M., M. Aaland, and T.H. Zhu, Readmission of trauma patients in a nonacademic Level II trauma center. J Trauma Acute Care Surg, 2012. 72(2): p. 531-6.

14. Rowell, D., et al., What are the true costs of major trauma? J Trauma, 2011. 70(5): p. 1086-95.

Contact diana@nzma.org.nz
for the PDF of this article

View Article PDF

Morbidity due to major trauma is an important health problem worldwide.1 In New Zealand the burden of trauma is relatively high, with a high rate of major injuries per head of population. Data from the New Zealnd Health and Safety Commission’s Atlas of Healthcare suggest that around 8% of patients admitted to hospital with physical injuries have suffered major trauma,2 and the mortality in this group is 9%.3 Trauma affects patients of a younger age, and Māori are over-represented.

The economic burden of trauma is also significant worldwide, with the World Health Organization (WHO) estimating that US$518 billion is spent treating patients suffering from trauma. We have previously reported inpatient costs of major trauma in New Zealand, along with common drivers of higher costs. New Zealand trauma costs are in keeping with the international literature, but the cost is unlikely to be assessed properly using standard coding methods, with actual costs being more accurate.4

The readmission rate for patients with major trauma is seen as a quality marker in most contemporary trauma systems and has been recorded at 11% in New Zealand.3 The rate of representations to emergency departments is not reported. With the reductions in death from major trauma, the focus is shifting to preventing morbidity and assessing longer-term outcomes. It is also likely that there is significant costs associated with readmission and representation of major trauma patients, and that the majority of these episodes of care are preventable. Accurate data on the costs of these episodes is essential for guiding quality improvement initiatives and ensuring resources are appropriately allocated in the face of increasingly competitive demands. This is particularly important in episodes of care like this, which are potentially preventable with appropriate investment.

The rate, costs and resource implications associated with total representation comprising re-attendances to emergency departments and readmission in New Zealand have not previously been reported. There is also a paucity of data in the international literature.

The aim of this study was to define rate, costs and resource implications of total representations, re-attendance to the emergency department (ED) and readmission in patients who have suffered from major trauma in Northland.

Methods

All patients presenting to Northland District Health Board (DHB) with major trauma between 1 January 2016 and 31 December 2019 were included for analysis. Adult major trauma patients were defined as those aged 16 or over with an Injury Severity Score (ISS) >12. In line with the national trauma registry, injury secondary to hanging, poisoning and drowning were excluded. The primary cohort was identified from a prospectively maintained trauma database generated weekly by a trauma coordinator. Using the 2008 revision of the 2005 edition of the Abbreviated Injury Scale (AIS), AIS were calculated for all the patients by using coding and the patient clinical notes. The three most severely injured body regions have their scores squared and added together to retrospectively produce the ISS score.

Further information on the primary cohort was obtained from the hospital’s clinical results reporting system, CONCERTO, which included outcomes of pathological and radiological investigations as well as operative interventions. Patient demographics, including ethnicity, residence data and length of stay, were obtained from the hospital’s data warehouse. Re-admissions within 30 days and presentation to ED within 30 days were obtained from the hospitals data warehouse. Re-admission was defined as any assessment or treatment requiring acute admission to an inpatient facility or overnight assessment unit. Re-attendance to ED was defined as any unplanned presentation to ED resulting in assessment by a doctor. Re-presentation was defined as either re-admission or attendance to ED.

Case-by-case assessment of the representations was undertaken. If patients required simple interventions in ED that could be managed in the community by a general practitioner (GP) or a GP service, then they were deemed preventable.

Actual patient-level costs were calculated using the New Zealand Common Costing Standards (Version 17). The standards have been developed for use in the public health sector to provide common standards for the costing of DHB services. Actual costs were calculated using in-house, patient-level costing utilising CostPro software with adjustment for nursing cost-acuity based on data from TrendCare. Specialty-specific costs were used for physician contact times and overhead and allied health costs were included as an average of overall throughput. Diagnosis Related Groups (DRGs) case-weight costs, based on DRG codes used nationally, were also calculated using standard techniques.

Statistical analysis was performed with IBM SPSS, Armonk, New York, USA. Scale data was tested for normality with a Shapiro–Wilk test. Non-parametric data including age, length of stay and ISS was analysed with a Mann–Whitney U test. Nominal data, including ethnicity, gender, ICU admission and transfer, was tested using a Chi-squared.

This study was performed as part of a national quality improvement programme in major trauma and was approved locally as quality improvement work aimed at decreasing preventable readmissions. Costs were analysed to allow evidence based funding of QI initiatives. As such, ethical approval was not sought. Only anonymised data were used in the final analysis.

Results

Basic demographics

420 patients were identified as suffering from major trauma presenting to Northland District Health Board. This made up the primary cohort. Median age was 47 years (IQR 38). The male-to-female ratio was 2.2:1. 154 (37%) patients identified as Māori, and 266 (63%) patients identified as non-Māori.

Clinical characteristics and outcomes

131 (31%) patients were transferred to a tertiary center. Of the 289 (69%) patients kept at Whangarei Hospital, 72 (25%) were admitted to the intensive care unit (ICU) and 20 (5%) went directly to theatre from ED. Median ISS was 18 (IQR 10). Median length or stay was five days (IQR 10).

Representations

There were 90 unplanned representations in 63 patients (15%) within 30 days of discharge. The number of unplanned re-attendances to ED was 52 in 33 patients (8%). The number of unplanned readmission was 38 in 30 patients (7%). Mean length of stay in those readmitted was 1.9 days. None of the patients that were readmitted required admission to the ICU. Of those 63 patients who represented, 11 patients represented twice, 2 represented three times, 1 patient represented four times and 2 represented five times.

Cause of representation was categorised based on common complaints. 23 patients (36%) had wound complications, 17 (27%) had pain, 7 (11%) had a secondary injury, 6 (10%) had a concussion, 2 patients (3%) represented with either sepsis or medication-related issues and 6 patients (10%) couldn’t be categorised and were categorised as ‘other’.

Representation rates associated with index presentation factors are outlined in Table 1.

Table 1: Comparison of index presentation factors.

Costs

The total cost associated with representations in the primary cohort was $220,914, with a mean expenditure of $55,229 per year. The median cost of attendance to ED was $334 (IQR $181), and the total cost of attendance to ED was $20,304. Median cost of readmission was $3,643 (IQR $5151), and the total cost of readmission was $200,611. The costs of representation associated with demographics and outcomes are outlined in Table 2.

Table 2: Costs associated with gender, ISS, year and ethnicity.

Discussion

This study has outlined the rate, costs and resource implications of unplanned readmissions and re-attendance to ED in patients following admission due to major trauma in a provincial trauma centre. The representation rate was significant, with costs in patients requiring admission being ten times greater than those discharged from the emergency department. Up to a half of representations were preventable, with no characteristics significantly indicating risk of readmission.

The findings of this study are important and have implications for the resourcing of projects to prevent readmissions in major trauma. As a high proportion of representations are likely to be preventable, it would be reasonable to assume that the majority of costs associated with readmissions can be redirected to these programmes. Although it did not reach significance, there is a trend of increasing representation rates in Māori, which is potentially contributing to health inequity and increased morbidity. It is difficult to tell whether higher rates of representation means more or less inequity, and this question fell outside the scope of this study. This is an area that requires further study to ensure the significance of findings, as well as more detailed analysis of reasons for representation.

Despite the fact that representation rates represent an evidence-based marker of quality of care, and that the majority of these episodes are thought to be preventable across most hospital services, the data on representations in major trauma patients are lacking. As would be expected, the readmission rate in Northland is comparable with that seen in the New Zealand major trauma dataset,1 to which it contributes. Several other studies have evaluated admissions in trauma patients worldwide, some of which contain data on major trauma patients with readmission rates varying between 2–14%.6–13 In three papers, which specifically commented on major trauma and contained a large numbers of patients, the rate was 3-8%.7,8,13 Although inclusion criteria are broad across most studies, readmission rates in general are higher in the most severely injured. There is a large variation in reason for readmission across studies. It is likely based on this evidence that readmission rates in Northland, and indeed across New Zealand, can be decreased.

Data on costs of representation in major trauma patients is lacking in the medical literature. It is difficult to find relevant comparative evidence. However, we have published previous data on the total cost of treating patients suffering from major trauma in the Northern region, which was $1.5 million per annum during a similar time period. Representation therefore only adds 3% in spend, despite occurring in 15% of patients. This is small in comparison to the 38% increase in costs due to planned interventions following admission for major trauma patients in Queensland, Australia.14 Previous data have described a discrepancy between DRG costs and actual costs in major trauma patients,4 which is why actual costs were chosen in our study. As most representations and admissions are short and did not need significant intervention, it is unlikely that there is a wide variation from DRG costs when considering re-presentations.

The authors accept the limitations of this study. It was retrospective in nature and absolute patient numbers are relatively low. Despite this we believe that the data are relevant and set a benchmark for guiding resource allocation to quality improvement programmes aimed at reducing representations in patients suffering from major trauma. It also demonstrates areas that will benefit most from resource allocation and should help guide equitable care for these patients. It is likely that specific resources are needed for preventing admissions due to pain and in Māori patients.

It is clear that further studies are needed in this important area of care, and studies evaluating the impact of initiatives designed to reduce representation rate will be particularly important.

This is the first study in New Zealand to define the rate, costs and resource implications of readmissions and re-attendance to ED in patients following admission due to major trauma. These data should help guide future quality improvement initiatives to reduce the rates and costs of representation in this group of patients.

Summary

Abstract

INTRODUCTION: The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand. AIM: The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland. METHOD: We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital’s clinical results reporting system and data warehouse. RESULTS: 420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days. CONCLUSION: This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.

Aim

Method

Results

Conclusion

Author Information

Henry Witcomb Cahill: Department of General Surgery, Northland District Health Board. Matthew McGuinness: Department of General Surgery, Northland District Health Board. Olivia Monos: Trauma coordinator, Northland District Health Board. Christopher Harmston: Department of General Surgery, Northland District Health Board.

Acknowledgements

Correspondence

Henry Witcomb Cahill, 1 Hopsital Road, Maunu, Whanagrei, 0210701516

Correspondence Email

Henry.witcomb@gmail.com

Competing Interests

Nil.

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