Every state in the US now has a formal trauma system. Several studies are available that document the advantages of these systems in terms of outcomes and survival. Trauma professionals get this. But the governmental agencies and legislators who help create, fund, and maintain them tend to focus on cost as well.
Arkansas was the last state in the union to implement a trauma system. A study in press from the University of Arkansas details their experience. They examined the impact of the new system on mortality, patient care, and attempted to calculate a return on investment from the taxpayers in an effort to show the added value.
The study was commissioned by the Arkansas Department of Health and carried out by the state Trauma Advisory Council. It was led by out of state investigators in an effort to maintain impartiality. A comprehensive review of records was performed by a panel of 5 surgeons, 1 emergency physician, 2 trauma program managers, 1 ground and 1 flight paramedic. Preventable and potentially preventable deaths were identified and analyzed in depth. Value of life lost was calculated by using a conservative $100,000 per year lost. A total of 290 charts were reviewed pre-system, and 382 post-trauma system implementation using proportional sampling of about 2500 trauma deaths in one year.
Here are the factoids:
- A significantly higher percentage of patients were triaged to Level I trauma centers after the system was implemented
- Preventable mortality was decreased from 30% to 14% (!!)
- This means that 79 extra lives were saved due to implementation of the trauma system
- Non-preventable deaths with opportunity for improvement remained constant at about 55%
- Non-preventable deaths without opportunity for improvement increased from 16% to 38% (!)
- Using the most conservative VLL calculation, this equates to $2.4M in savings per life saved
- This adds up to $186M in savings to the taxpayers of Arkansas, a 9-fold return on their investment of $20M in the trauma system.
Bottom line: Wow! This nicely done studies gives us excellent insight into the hows and whys of the value of an organized state trauma system. It is likely that the triage system directed more patients to the most appropriate level of care, leading to fewer preventable deaths. And it enticed hospitals to up their game and make the move toward formal trauma center designation. This improved education and training at those centers, leading to better patient care.
There is a wealth of information in this study, and I recommend that everyone with an interest in or are already participating in their state trauma system read it in its entirety. Hospitals that are reluctant to join or are lagging in meeting criteria need to recognize that they are not serving their communities as well as they think. And legislators must realize that the financial impact of even a small investment has real and significant consequences to their constituents.
Reference: Does the Institution of a Statewide Trauma
System Reduce Preventable Mortality and Yield
a Positive Return on Investment for Taxpayers? JACS in press, 2017.
Many busy trauma hospitals have equally busy trauma ICUs. Frequently, trauma patients who need critical care are backed up in the emergency department (ED) while awaiting a bed in such cases. This slows ED throughput for other patients, and increases the possibility of an adverse event while waiting for the ICU bed.
The group at the University of Kentucky in Lexington will present an abstract examining the impact of keeping an open bed in the ICU, as well as having a charge nurse in that unit without a patient assignment to help manage bed availability and staffing.
Here are the factoids:
- The study examined highest level trauma activations in the ED requiring ICU admission before implementation of the open bed policy
- 303 patients pre-implementation were compared to 261 patients post-implementation
- The usual demographics were similar for both groups
- Time in the ED decreased from 4:17 to 2:34 after the open bed policy was instituted, which was highly significant
- ICU length of stay (LOS) for patients who were admitted after the policy was in place decreased despite an increase in ISS, but not significantly so
- There was no change in mortality
- There was a cost savings of about $1000 per patient due to increased nursing productivity and the decreased LOS
Bottom line: Making the effort to reserve a bed for an incoming trauma patient at all times seems to be well worth it. I have visited many hospitals with incredible logjams of these patients in the ED. Frequently, this has a disproportionate and negative impact on the throughput of other ED patients. Creating such a policy should serve to improve patient flow (and satisfaction: what family wants to spend hours sitting in the ED?) as well save money.
Reference: Maintaining an open ICU be for rapid access to the trauma intensive care unit is cost effective. Presented at EAST 2015, paper 28.
An anonymous user recently asked about decision-making with regard to anticoagulation reversal. Specifically, they were interested in using prothrombin complex concentrate (PCC) vs activated Factor VII (FVIIa). I’ve done a little homework on this question, and am going to include some information on the use of fresh frozen plasma (FFP), too.
Unfortunately, there’s not a lot of good data out there comparing the three. Enthusiasm for using FVIIa is waning because it is extremely expensive and the risk/benefit ratio is becoming clearer with time (more risk and less benefit than originally thought). PCC is attractive because it provides most of the same coagulation factors as FFP, but with far less volume. However, it is very expensive, too.
What to do? One of the best papers out there comes from the UK, where they looked at the cost effectiveness of PCC vs FFP in warfarin reversal. They reviewed a year’s worth of National Health Service patients from the standpoint of what it costs to gain a year of life after hemorrhage. They found that the cost was £1000-£2000 per life-year, and £3000 per quality adjusted life-year. This was more cost effective than using FFP. Unfortunately, I do not have access to the full text to review the details.
PCC has only been compared to FFP in the treatment of hemophilia, so it’s not possible to draw any conclusions. The course of therapy for perioperative management of hemophiliacs is lengthy (meaning hideously expensive), and there was a cost-savings seen ($400,000)! Since we use only short duration therapy in trauma patients, the savings will be far less.
Bottom line: PCC is probably as effective as FFP, with less risk of volume overload. It is probably more cost effective as well. As the population of people that are placed on warfarin ages and becomes more susceptible to volume overload from plasma infusions, I think that PCC is going to become the reversal agent of choice. Use of Factor VIIa will continue to wane. However, someone needs to do some really good studies so we don’t get suckered.
Reference: Modeling the cost-effectiveness of prothrombin complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom. Clinical Therapeutics 32(14):2478-2493, 2010.
The cost of care in a trauma center is high. When anything is expensive, it is natural to wonder about its cost-effectiveness. A group of biostatisticians recently looked at the treatment costs and cost-effectiveness of treating trauma patients in a trauma center vs an nontrauma hospital. They were very comprehensive in looking at costs, including costs for transportation, treatment at a transferring hospital, rehospitalization for acute care if needed, inpatient rehab, stays in longterm care or skilled nursing care facilities, outpatient care and informal care given by family members.
Treatment at a trauma center saved 3.4 lives per 100 patients treated. The overall added cost for treatment at a trauma center was about $36,000 per life year gained. However, in order to gauge cost-effectiveness we need to know what a year of life is worth. As you can imagine, this is tough to figure out. A number of researchers have looked at this, and it typically ranges from $50,000 to $200,000 per year. Thus, trauma center care is overall cost-effective.
The data was more closely analyzed, and it appears that the cost-effectiveness is greater for patients with more severe injuries. Unfortunately, cost-effectiveness is not as clear for patients who are 55 years or older.
The bottom line: Trauma is a leading cause of death in this country. The concept of treating more severely injured patients at trauma centers is both effective and cost-effective. Trauma systems need to be fine-tuned so that they get the right patient to the right hospital and so care for elderly patients continue to improve.
Reference: Nathens et al. The Value of Trauma Care. J Trauma 69(1):1-10, 2010.