The Dutch Burden of Injury Model Healthcare consumption absenteeism and

The Dutch Burden of Injury Model Healthcare consumption, absenteeism and loss of quality of life as a result of injury in the Netherlands Published by Consumer Safety Institute PO Box 75169 1070 AD Amsterdam The Netherlands October 2005 2 The Burden of Injury Model This text or parts of this text may be reproduced, provided the title of the publication and the address from which it can be obtained are clearly stated. Fact sheet / Internal report: 345 3 The Burden of Injury Model Introduction Accidental injury (sports injuries, accidents, self-mutilation, violence) constitutes a major problem for public health and causes considerable expense. It is necessary to collect data on the costs of injury as a result of accidents and information on the subsequent quality of the victims’ lives in order to ascertain the importance of injury prevention in relation to other health problems, and to set priorities regarding research and prevention within the problem area of (acute) physical injuries. The information can also be used to make economic evaluations of preventive measures. Information on the costs of injury and the quality of life for accident victims is also an important supplement to the basic information on the incidence of accidents and injury currently compiled by various registration systems. In the late 1990s, the Ministry of Public Health, Welfare and Sports commissioned the Dutch Consumer Safety Institute (Consument en Veiligheid) and the Department of Public Health (Instituut Maatschappelijke Gezondheidszorg) of the Erasmus Medical Centre to work together to develop a healthcare model for calculating the direct medical costs of injury patients. It was later decided to extend the healthcare model by adding models for calculating the rate of absenteeism and the indirect costs of injury patients: the absenteeism model. At the same time, a start was also made on developing a model for ascertaining the quality of life (‘burden of disease’) of injury patients after sustaining injury: the functional capacity model. All these models have now been incorporated into the so-called Dutch Burden of Injury Model. Method and data The Dutch Burden of Injury Model is used to estimate the level of healthcare consumption, the absenteeism, the direct medical costs, the indirect costs and the loss of quality of life for all patients treated in an Accident and Emergency department (A&E) in the Netherlands after having sustained injury, as registered by the Dutch Injury Surveillance System (Letsel Informatie Systeem (LIS)). The Injury Surveillance System of the Consumer Safety Institute registers information on victims treated in A&E departments as a result of accidents, violence or self-mutilation in a number of Dutch hospitals. These hospitals form a representative random sample of hospitals with 24-hour emergency care services in the Netherlands. Figures can therefore be calculated at a national level (Injury Surveillance System fact sheet, Consumer Safety Institute) 4 The Burden of Injury Model The model works according to the so-called incidence-based approach. The burden of injury is estimated for all injuries sustained during a specific period ( = incidence), starting from the moment the injury occurred up until the moment the patient recovers or dies. The incidence approach starts from the micro-level of individual patients (bottom-up) and works upwards towards estimating the level of healthcare consumption, absenteeism (including related costs) and the quality of life at the more aggregate level of injury groups and accident categories. Diagram 1 Structure of the Dutch Burden of Injury Model LIS Patient follow-up survey Standard healthcare registers Burden of injury model Healthcare model Absenteeism model Functional capacity model Mortality model Healthcare consumption Absenteeism from work Quality of life Direct medical costs Indirect costs Years Lived with Disability Years of Life Lost DALY’s Human costs To estimate the burden of injury for the purposes of the Burden of Injury Model, all injury patients are divided into patient groups. In principle, the groups are composed in such a way that they will be homogeneous with regard to the burden of injury. Patient groups are defined on the basis of characteristics (hospital admission status, age, gender, type and seriousness of the injury) with a predictive value in terms of healthcare consumption, absenteeism and quality of life. The Burden of Injury Model can be divided into three sub-models, namely the healthcare model, the absenteeism model and the functional capacity model. 5 The Burden of Injury Model Healthcare model The healthcare model is used to estimate the level of healthcare consumption and the related direct medical costs of all injury victims treated in an A&E department in the Netherlands, as registered in the Injury Surveillance System. In as far as this is possible, the healthcare model calculates the actual costs of healthcare consumption by injury victims. The healthcare units chosen give an accurate definition of the healthcare provided, and the costs per healthcare unit are a true reflection of the care facilities actually used. The information on healthcare consumption in the Burden of Injury Model originates from the Injury Surveillance System (LIS) and standard healthcare registers, such as the Dutch Information System on Hospital Care and Day Nursing (Landelijke Medische Registratie) of hospital admissions. However, as registration data is not available for all extramural healthcare provided to injury patients, a survey is held every four years amongst injury patients (from the Injury Surveillance System) who received treatment in an A&E department. The information obtained from this survey, which is known as the LIS-patient survey, provides insight into this type of healthcare. The healthcare consumption of every patient taking part in the survey is ascertained at three specified moments, namely 2½, 5 and 9 months after the accident took place. Various sources are used to estimate the cost prices. There are three methods of roughly calculating the costs per care unit in the healthcare model. In some healthcare sectors, it is possible to calculate cost prices on the basis of operating and production figures, sometimes supplemented by data from other research. This is the case for some of the care provided in hospitals, nursing homes and by the ambulance service, for example. For other sectors, the rates laid down by the Healthcare Charges Board (College Tarieven Gezondheidszorg) are assumed to be a good estimate of the actual costs. This is the case for operations, General Practitioners (GP) care and home care, for example. Finally, in the case of A&Ecare, an estimate of the actual consultation costs is made. The model can be used to calculate the costs for the various cost elements: referral and after-care by the GP, emergency ambulance transport, A&E care, other out-patient care services, day-care nursing, clinical nursing, inpatient therapeutical procedures, rehabilitation, nursing home care, out-patient physiotherapy, home care and pharmaceuticals. The direct medical costs are calculated as follows: for each cost element, patients in the Injury Surveillance System are categorised into patient groups according to specific characteristics (e.g. age or injury group). The average costs per patient group are calculated for each cost element. Per patient, the costs can be added up for all the cost elements. The costs for all the patients are then added up to arrive at a total estimate of the direct medical costs. 6 The Burden of Injury Model Table 1 gives an overview of the direct medical costs and the level of healthcare consumption for all injury patients, divided into care sectors. The direct medical costs of injuries from accidents in 2001 amounted to 1.3 billion Euros. This accounts for approximately 3% of the total Dutch healthcare budget for 2001. Table 1 Total direct medical costs (in million €) and volume of care for injury patients in 2001, divided into healthcare sectors Healthcare sector Hospital care A&E care Other out-patient care Hospital nursing (inc. day care and IC) Inpatient therapeutic procedures Home care Household assistance Home nursing Nursing home care Out-patient physiotherapy Ambulance services Emergency transport by ambulance Transport by ambulance on request Rehabilitation Inpatient rehabilitation Out-patient rehabilitation General practitioners Referral to A&E After-care Pharmaceuticals Painkillers Antibiotics Total Source: Burden of Injury Model 2001, Consumer Safety Institute Costs 830 190 140 450 52 120 53 63 110 75 71 57 14 47 35 12 19 3.7 15 2.6 1.9 0.8 1,300 % Volume of care 66 15 11 35 4 9 4 5 8 6 6 5 1 4 3 <1 1 <1 1 <1 <1 <1 100 4,900,000 410,000 170,000 810,000 110,000 160,000 130,000 85,000 3,000,000 1,800,000 620,000 3,500,000 1,000,000 1,300,000 1,300,000 140,000 Care unit Treatments Visits Nursing days Procedures Hours Hours Nursing days Treatments Journeys Journeys Nursing days Rehab. therapy hours Referrals Consultations Days used Days used 7 The Burden of Injury Model The portion of the total direct medical costs made up by traffic accidents, home and leisure accident and self-mutilation is larger than the portion of the A&Eincidence made up by these costs (table 2). Accidents in these categories result in relatively expensive injuries. However, the costs per victims of sports injuries, occupational accidents and injuries resulting from violence are lower than average. Table 2 A&E-incidence, average direct medical costs (€) per injury patient and total direct medical costs (in million €), by accident category in 2001 A&E-incidence % 53 14 17 10 1 4 100 Average costs 1,400 1,600 680 630 2,300 690 1,200 Total costs 770 220 110 60 34 25 1,300 % 61 18 9 5 3 2 100 Home and leisure Traffic Sports Occupational Self-mutilation Violence Total 520,000 140,000 160,000 94,000 14,000 37,000 990,000 Source: Burden of Injury Model 2001, Consumer Safety Institute Table 3 shows an example of a selection according to accident category, in this case the direct medical costs of home and leisure accidents. The table shows that it makes a difference whether the various injury mechanisms are examined on the basis of the A&E-incidence or the total direct medical costs. Table 3 A&E-incidence, average direct medical costs (€) per injury patient and total direct medical costs (in million €) home and leisure accidents by injury mechanism in 2001 A&E-incidence % 51 27 6 3 2 5 2 <1 <1 <1 3 100 Average costs 2,100 490 480 870 850 410 1,100 790 2,100 1,300 2,300 1,400 Total costs 600 72 15 13 11 10 10 1.6 1.4 0.4 38 770 % 77 9 2 2 1 1 1 <1 <1 <1 6 100 Fall Contact with object Contact with person or animal Physical over-exertion Thermal reaction Foreign body Chemical reaction Electricity, radiation, explosion Respiratory obstruction Other specified Unknown Total 270,000 140,000 34,000 15,000 10,000 24,000 9,300 1,800 400 260 18,000 530,000 Source: Burden of Injury Model 2001, Consumer Safety Institute 8 The Burden of Injury Model Absenteeism model The absenteeism model is used to estimate absenteeism and the indirect costs resulting from absenteeism for all injury victims between the ages of 15 and 64 years treated in A&E departments in the Netherlands, as registered in the Injury Surveillance System. The information on absenteeism contained in the Burden of Injury Model originates from the LIS-patient survey. Patients in paid employment before the accident are asked a number of questions designed to provide insight into the likelihood of absenteeism, the duration of absenteeism measured in working days and the likelihood of resuming work. The duration of absenteeism in working days is converted into the costs of absenteeism (assuming paid employment) according to age and gender, using the Gross Value Added (Bruto Toegevoegde Waarde) per employment hour (a unit used for measuring labour productivity). The absenteeism model only estimates absenteeism for the first year. Data on absenteeism has not been calculated for patients treated in a hospital A&E department after self-mutilation. Table 4 Total and average absenteeism (in working days) for injury patients1 in paid employment, by accident category and age in 2001 15-24 years Total Average 7.6 14.3 9.9 5.9 7.2 9.0 Total 770,000 470,000 410,000 320,000 86,000 2,100,000 25-44 years Average 8.9 15.1 11.4 7.7 8.4 10.0 Total 630,000 290,000 100,000 180,000 25,000 1,200,000 45-64 years Average 13.1 19.3 14.0 11.1 10.2 13.8 Total 1,600,000 1,000,000 730,000 610,000 150,000 4,200,000 Total Average 9.9 15.8 11.2 7.9 8.3 10.6 Home and leisure Traffic Sports Occupational Violence Total 1 220,000 270,000 220,000 110,000 37,000 860,000 Absenteeism figures have not been calculated for self-mutilation patients treated in the A&E department of a hospital. Source: Burden of Injury Model 2001, Consumer Safety Institute The total number of working days lost by injury patients in paid employment through absenteeism was approximately 4.2 million in 2001 (table 4). This is an average of almost 11 working days per injury patient. Home and leisure accidents accounted for almost 40% of all absenteeism amongst injury patients in 2001 (1.6 million working days), and 24% was the result of traffic accidents (1.0 million working days). The highest average duration of absenteeism was seen amongst the victims of traffic accidents (16 working days). 9 The Burden of Injury Model The total costs of absenteeism due to injury amount to approximately 1 billion Euros (table 5), making it comparable with the direct medical costs. Home and leisure accidents account for the highest costs in terms of absenteeism, namely 430 million Euros. The highest average costs per patient can be found in the group of traffic victims, with an average of 3,900 Euros per patient. Table 5 Total indirect costs (in million €) for injury patients1 and average indirect costs per injury patient (€) in paid employment, by accident category and age in 2001 15-24 years Total Average 1,100 1,900 1,400 830 1,100 1,300 Total 200 130 110 89 23 560 25-44 years Average 2,400 4,000 3,000 2,100 2,300 2,700 Total 200 92 33 60 8.1 390 45-64 years Average 4,100 6,100 4,500 3,800 3,300 4,400 Total 430 260 170 160 37 1,100 Total Average 2,600 3,900 2,600 2,100 2,100 2,700 Home and leisure Traffic Sports Occupational Violence Total 1 32 36 30 15 5.5 120 Absenteeism figures have not been calculated for self-mutilation patients treated in the A&E department of a hospital. Source: Burden of Injury Model 2001, Consumer Safety Institute Table 6 gives an example of a selection according to accident categories, in this case the indirect costs (of absenteeism) of the top-5 (A&E-incidence) sports injuries. The costs of absenteeism resulting from accidents amongst footballers amount to 53 million Euros. However, the average indirect costs per patient are much higher for accidents related to horse-riding, namely 4,200 Euros. The indirect costs of the injuries usually rise in line with the age of the victims. Table 6 Total indirect costs (in million €) and average indirect costs (€) of the top-5 sports injuries (excluding gymnastics) for patients in paid employment, by type of sport and age in 2001 15-24 years Total Average 1,400 1,900 1,700 950 1,200 1,400 Total 35 11 7.2 4.6 2.5 110 25-44 years Average 3,100 4,500 5,000 2,000 2,500 3,000 Total 5.0 4.7 2.1 0.6 1.0 33 45-64 years Average 4,800 8,000 5,200 2,500 4,000 4,500 Total 53 18 10 6.7 4.2 170 Total Average 2,500 4,200 4,200 1,600 2,300 2,600 Football Horse-riding Roller blading/in-line skating Hockey Swimming Total 13 2.4 1.1 1.5 0.7 30 Source: Burden of Injury Model 2001, Consumer Safety Institute 10 The Burden of Injury Model Functional Capacity Model The functional capacity model is used to calculate the loss of quality of life (‘burden of disease’) for all injury victims of 14 years and above treated in A&E departments in the Netherlands, as registered in the Injury Surveillance System. Information on the burden of disease in the Burden of Injury Model also originates from the LIS-patient survey. The surveys comprise a tool for measuring the functional outcome of injury patients, namely the EuroQol. This tool generates an overall picture of health by means of measurements in five dimensions (EQ-5D): mobility, self-care, usual activities, pain/discomfort and anxiety/depression. A question about cognitive ability (EQ-5D+) has also been included to measure the consequences of head injuries. The health status portrayed by the five dimensions can be summarised and converted into one single measurement: the EQ-5D sum score. This measurement, which starts at full health (1) and goes right through to dead (0), can be interpreted as a judgement on the relative desirability of a health status compared with perfect health. Using this sum score, it is possible to compare the health status of groups of patients in relation to the various types of illnesses and/or injuries, and to monitor the effects of time on the various illnesses and/or injuries. The functional capacity model makes it possible to calculate the health status (also known as the functional capacity level), in the form of an EQ-5D sum score. The functional capacity model also calculates the disability within the individual health dimensions. It only estimates the negative effects of injury during the first year. The long-term effects of injury on the level of functional capacity are not (yet) included. Table 7 shows the average health status of injury patients divided into accident category and admission status after treatment in an A&E department. Two-and-ahalf months after the accident, there was little variation in the average health status of patients not admitted to hospital. However, two-and-a-half months after the accident, there is more variation between the categories regarding the average health status of injury patients who were admitted to hospital. Between five and nine months after the accident, very little improvement can be seen in the health status. In the case of home and leisure accidents, the average health status changes from 0.57 after two-and-a-half months to 0.70 after five months. 11 The Burden of Injury Model Table 7 Average health status (EQ-5D sum score) of injury patients, by accident category, admission status and measuring moment in 2000 Not admitted - 2½ months Admitted - 2½ months Admitted - 5 months 0.70 0.78 0.83 0.80 0.80 0.74 Admitted - 9 months 0.67 0.78 0.85 0.84 0.86 0.73 Home and leisure Traffic Violence Sports Occupational Total 0.87 0.86 0.90 0.88 0.92 0.88 0.57 0.67 0.76 0.70 0.69 0.62 Source: Burden of Injury Model 2000, Consumer Safety Institute The functional capacity model can also be used to calculate the so-called ‘Years Lived with Disability’ (YLD). The necessary data on the loss of quality of life and the duration of the health status originate from the LIS-patient survey. The loss of quality of life is the same as the difference between the EQ-5D sum score and the standard scores for the general population or the best conceivable health status. The average YLD can be calculated by multiplying the resulting differences by the duration of the health status. The total number of YLD can then be calculated by multiplying the YLD predicted by the underlying determinants by the number of injury patients in the Injury Surveillance System. YLD estimates cannot be made for injury victims under 14 years-old and self-mutilation patients, as no data has been collected for these groups. Estimates of the functional consequences for patients not admitted to hospital relate to the period up until two-and-a-half months after the accident. The YLD can be interpreted as the number of years lost due to lost quality of life. The value given to the loss of quality of life is equivalent to the value given to lost years of life. In Table 8, the total and average YLD according to accident category and admission status is expressed as the difference with the best conceivable health status. A patient injured as a result of a home and leisure accident loses an average of 0.17 YLD. A patient injured as a result of a home and leisure accident and admitted to hospital loses more than twice as many YLD, namely 0.35 YLD. 12 The Burden of Injury Model Table 8 Total and average Years Lived with Disability expressed as the difference with the best conceivable health status, by accident category and admission status in 2000 Not admitted Total Average 0.150 0.134 0.102 0.108 0.096 0.132 Admitted Total 14,000 4,800 560 1,200 1,100 22,000 Average 0.350 0.256 0.185 0.219 0.217 0.301 Total Total 72,000 19,000 4,200 14,000 11,000 120,000 Average 0.168 0.153 0.108 0.112 0.102 0.147 Home and leisure Traffic Violence Sports Occupational Total 58,000 14,000 3,600 13,000 9,700 100,000 Source: Burden of Injury Model 2000, Consumer Safety Institute Table 9 gives an example of a selection according to accident category, in this case the YLD as the difference with the best conceivable health status of traffic accident victims. It is noticeable that when the accident does not involve a motor vehicle, the YLD is slightly higher than when this is the case. Table 9 Total and average Years Lived with Disability represented as the difference with the best conceivable health status of traffic accident victims, by motor vehicle involvement and admission status in 2000 Not admitted Total Average 0.146 0.110 0.131 0.126 0.134 Admitted Total 1,700 450 2,500 150 4,800 Average 0.305 0.225 0.236 0.242 0.256 Total Total 7,200 1,800 9,500 520 19,000 Average 0.167 0.126 0.149 0.146 0.152 No motor vehicle Moped Car Unknown Total 5,500 1,300 7,000 370 14,000 Source: Burden of Injury Model 2000, Consumer Safety Institute 13 The Burden of Injury Model Conclusion The Dutch Burden of Injury Model makes it possible to compare and integrate information from various sources in a structured manner, in order to obtain comprehensive information on the burden of injury. The table below reiterates the most important results from the Burden of Injury Model. Table 10 The total direct medical and indirect costs (in million €) and total number of Years Lived with Disability (YLD) expressed as the difference with the best conceivable health status for injury patients, by accident category in 2001 Direct medical costs Indirect costs 430 260 170 160 37 1,100 YLD 1 72,000 19,000 14,000 11,000 4,200 120,000 Home and leisure Traffic Sports Occupational Self-mutilation Violence Total 1 770 220 110 60 34 25 1,300 data from 2000. Source: Burden of Injury Model 2000/2001, Consumer Safety Institute In combination with the Dutch Injury Surveillance System, the Burden of Injury Model provides a comprehensive picture of the incidence, level of healthcare consumption, rate of absenteeism, health status and direct medical and indirect costs of acute physical injuries in the Netherlands. This makes the model a new source of information for setting priorities in the area of injury-prevention policy and for evaluating policy measures. A list of available reports and articles has been included for those wishing to read more about the Dutch Burden of Injury Model. The Dutch Consumer Safety Institute “Consument en Veiligheid” can also provide more information: Consumer Safety Institute Prevention research Mr. H. Toet Tel. Fax. +31 20 5114555 +31 20 6692831 E-mail h.toet@consafe.nl 14 The Burden of Injury Model Available publications Reports Meerding WJ, Toet H, Polinder S, Hertog PC den, Mulder S, van Beeck EF. Verantwoordingsverslag Kostenmodel 1997-2000. Amsterdam: Consument en Veiligheid, 2004. (Internal report). (In Dutch) Meerding WJ, Looman CWN, Essink-Bot ML, Toet H, Mulder S, van Beeck EF. Functioneren na een ongevalsletsel: Frequentie en determinanten van beperkingen na 2½-, 5- en 9-maanden. Amsterdam: Consument en Veiligheid, 2003. (Internal report). (In Dutch) Meerding WJ, Birnie E, Mulder S, Hertog PC den, Toet H, van Beeck EF. Kosten van letsels door ongevallen in Nederland: wetenschappelijke verantwoording. Amsterdam: Consument en Veiligheid, 2000. (In Dutch) Meerding WJ, Birnie E, Mulder S, Hertog PC den, Toet H, van Beeck EF. Costs of injuries in the Netherlands. Amsterdam: Consumer Safety Institute, 2000. Articles Meerding WJ, Looman CWN, Essink-Bot ML, Toet H, Mulder S, van Beeck EF. Distribution and determinants of health and work status in a comprehensive population of injury patients. Journal of Trauma -Injury Infection & Critical Care 2004;56(1):150-161. Meerding WJM, Toet H, Mulder S, van Beeck EF. Health care costs of injury in the Netherlands. In thesis: Describing health and medical costs, and the economic evaluation of health care: application in injuries and cervical cancer, 2004. Meerding WJM, Mulder S, van Beeck EF. Cost of injury studies: do they bring us more than confusion. In thesis: Describing health and medical costs, and the economic evaluation of health care: application in injuries and cervical cancer, 2004. Mulder S, Meerding WJ, van Beeck EF. Setting priorities in injury prevention: the application of an incidence-based cost model. Injury Prevention 2002;8:74-78. Mulder S, Beeck EF van, Meerding WJ. New directions in injury surveillance: Development of a model for continuous monitoring of direct medical costs. International Journal of Consumer & Product Safety 1999; 6(1):11-23.