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The Journal of TRAUMA威 Injury, Infection, and Critical Care

Cost Estimation of Injury-Related Hospital Admissions in 10

European Countries
Suzanne Polinder, MD, Willem Jan Meerding, PhD, Margriet E. van Baar, PhD, Hidde Toet, MD,
Saakje Mulder, PhD, Ed F. van Beeck, PhD, and the EUROCOST reference group

Background: Injuries are a major admissions, with relatively high costs knee/lower leg, superficial injuries,
cause of total health care costs. Cost esti- per capita for Austria, followed by Den- skull-brain injuries, and spinal cord in-
mations may help identify injuries and mark and Norway. In Greece, Italy, Ire- juries. Home and leisure injuries (in-
high risk-groups to be considered for po- land, and Wales, intermediate costs per cluding sport injuries) and occupational
tential intervention. capita were found, but these costs were injuries combined make a major contri-
Methods: Hospital discharge registers relatively low for Spain, England, and bution (86%) to the hospital costs of in-
of 10 European countries were used to esti- the Netherlands. The patterns of costs jury.
mate injury incidence. Consensus was by age, sex, injury type, and external Conclusion: Elderly patients aged 65
reached between the participating countries cause are quite similar between the years and older, especially women, con-
about methodology, definition, classifica- countries. For all countries, costs per sume a disproportionate share of hospital
tion, cost measurements, and valuation to capita increase exponentially in older resources for trauma care, mainly caused
maximize crossnational comparability of age groups (age >65 years), due to the by hip fractures and fractures of the knee/
outcomes. The data of the countries were combined effect of high incidence and lower leg, which indicates the importance
also used to give an estimate of the costs per high costs per patient. The elderly fe- of prevention and investing in trauma
capita by age, sex, type of injury, and exter- males account for almost triple costs care for this specific patient group.
nal cause in Europe. compared with same age males. Young Key Words: Unintentional and inten-
Results: Large international differ- children and male adolescents are also tional injuries, Hospital costs, Interna-
ences were observed in injury incidence high-cost groups. Highest costs were tional comparison, Europe.
and associated costs related to hospital found for hip fractures, fractures of the
J Trauma. 2005;59:1283–1291.

njuries are a major cause of total health care costs in the with respect to severity and health care need.2– 4 This may
industrialized world. Because injuries represent a wide help policy makers to set priorities in injury prevention
variety of external causes and health consequences, and trauma care. Comprehensive cost estimates subdivided
comprehensive and detailed information on health care by injury diagnoses, external cause, and sociodemographic
costs may help to identify previously unnoticed health indicators show at a glance where costs might potentially
problems within this field.1 Similar to indicators of burden be saved or where interventions are most needed.
of disease, cost estimates provide a measure that enables The international application of injury cost models
rapid comparison among several types of injury that differ may enhance its value for policymaking purposes. An
international comparison of costs can both show common
Submitted for publication February 9, 2005. problems for several countries, as well as specific prob-
Accepted for publication June 27, 2005. lems for individual countries. This, however, is only pos-
Copyright © 2005 by Lippincott Williams & Wilkins, Inc. sible when data and methods used are harmonized between
From the Department of Public Health (S.P., W.J.M., M.E.B., E.F.B.),
Erasmus MC, University Medical Centre Rotterdam, Rotterdam, and the
countries. So far, within Europe, several cost-of-injury
Consumer Safety Institute (H.T., S.M.), Amsterdam, the Netherlands. studies were conducted.5–10 These studies, however, show
EUROCOST reference group: Robert Bauer, Austrian Institute for large differences with respect to their methodology, in-
Home and Leisure Safety, Sicher Leben, Austria; Claus Falck Larsen, cluding comprehensiveness, matters of definition and clas-
Copenhagen University Hospital, Denmark; Ronan Lyons, University of
sification, and the way they measure and value costs.2 So
Wales, United Kingdom; Tim McCarthy, Ministry of Health, Ireland;
Catherine Pérez, Municipal Institute of Public Health, Spain; Eleni Pet- far, they are limited to specific countries, injuries, health
ridou, Athens University Medical School, Greece; Alessio Pitidis, De- care sectors, and age groups. Because of incomparable
partment of Environment and Primary Prevention, National Institute of methods, the differences and commonalities of medical
Health, Italy; Anne Mette Tranberg Kejs, National Institute of Pubic costs of injury between European countries are not known.
Health, Denmark; Johannes Wiik, Norwegian Institute of Public Health,
Therefore, within the framework of an international
Address for reprints: Suzanne Polinder, MD, Department of Public project (EUROCOST), a uniform method with several har-
Health, Erasmus MC, PO BOX 2040, University Medical Centre Rotterdam, monization procedures was applied in 10 European
Rotterdam 3000 CA, the Netherlands; email: s.polinder@erasmusmc.nl. countries.11 In this article, the following question is ad-
DOI: 10.1097/01.ta.0000195998.11304.5b dressed: what are the costs of injury-related hospital ad-

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The Journal of TRAUMA威 Injury, Infection, and Critical Care

Table 1 Description of the Data System Used per Country

Country Data System Coverage Registered Cases

Austria Hospital Discharge Register 100% 187,225

Denmark National Discharge Register 100% 99,618
Greece ED Injury Surveillance System 100%* 144,000
Ireland Hospital Inpatient Enquiry 95% 58,196
Italy Hospital Discharge Register 90–95% 928,317
Netherlands Dutch Information System 100% 102,768
Norway National Injury Register 100% 66,962
Spain Hospital Discharge Register 90% public/30%private 194,856
England Hospital Discharge Register 100% 632,179
Wales Hospital Discharge Register 100% 48,266
*National estimates derived from ED visits.

missions in Europe, subdivided by country, age, sex, injury and Greece, the admitted injury population is relatively
type, and external cause? young. For the other countries, the percentage of patients
older than 65 years varies from 65 to 75%.
Data Sources Injury Incidence
The following countries participated in the EUROCOST All participating countries delivered HDR data using the
project: Austria, Denmark, England, Greece, Ireland, Italy, same inclusion criteria, definitions, and classifications. Based
Netherlands, Norway, Spain, and Wales. For the EURO- upon this international agreement, similar selections of acci-
COST project, two primary data sources were used to esti- dents (i.e., external causes), injuries (i.e., medical diagnoses),
mate the incidence and health care consumption for each and cost elements (i.e., health care sectors) were studied in all
country: hospital discharge registers (HDR) with (almost) full countries. In our analysis, only injury principal diagnoses
national coverage and the emergency department (ED) sam- were included, and cases with an injury diagnosis as a sec-
ple-based surveillance systems (both from the year 1999). ondary or subsequent diagnosis were not included in the
This article focuses only on the admitted injury patients. analysis. Selecting an injury on the basis of any diagnostic
HDR data were used as the primary data source to estimate field is problematic because some countries had only infor-
injury incidence of admitted patients for all injuries combined mation available about the principal diagnosis. Furthermore,
(intentional and unintentional). For Greece, we used the ED in many cases where the injury diagnosis appears in the
data system to estimate the number of hospitalizations be- second or subsequent diagnosis fields, it would be difficult to
cause no HDR data were made available. The data systems determine whether the person would have been “admitted” to
that were used are presented in Table 1. This shows coverage the hospital if they had only the injury.13 However, only
rates of 90 to 100% of the HDR systems of all countries including injury principal diagnosis will result in a slight
except Spain, where 90% of the public hospitals but only underestimation of the injury incidence of admitted patients.
30% of the private hospitals are covered. For Greece, the We used the international classification of disease codes
respective figures are based on the number of the ED visits E800 to E999 (ICD-9)14 to select and classify injuries, except
from which the total number of hospital admissions can be “misadventures to patients during surgical and medical care”
approximated.12 Figure 1 gives a description of the age dis- (ICD-9 E870 – 876), “surgical and medical procedures as the
tribution for admitted injury patients per country. In Ireland cause of abnormal reaction of patients or later complication,
without mention of misadventure at the time of procedure”
(ICD-9 E878 – 879), “drugs, medicaments and biological sub-
stances causing adverse effects in therapeutic use” (ICD-9
E930-E949), and “late effects of injury” (ICD-9 E905-E909).
Unintentional injuries (E47-E53) including transport injuries
(E470-E474, E479) and intentional injuries (E54-E56) were
analyzed. Furthermore, injuries were classified by location
and type into 39 groups (and an aggregation level of 29
groups)15 after consultations with experts in traumatology,
orthopedics, and rehabilitation, to represent groups of patients
that have homogeneous health care consumption.
Day cases and inpatients with length of stay of zero were
both classified as a day patients and were excluded from the
Fig. 1. Age distribution for admitted injury patients by country. analyses presented. Due to the lack of reliable information on

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Cost of Injury-Related Hospital Admissions in Europe

Table 2 Calculated Comprehensive Unit Costs (€, 1999) for One Inpatient Day in Hospital and for an Emergency
Department Visit
Country Inpatient Days in Hospital Emergency Department Visit

Austria 461 97
Denmark 465* 113
Greece 277 51
Ireland 389* 94
Italy 363 81
Netherlands 365 99
Norway 555 122
Spain 298 82
England 227† 103
Wales 227† 103
*No unit costs were available. The comprehensive unit costs were calculated by adjusting the mean costs of an inpatient day in hospital
(€381) to national price level.
†Econometric estimation of United Kingdom hospital costs from literature.21

readmissions (they could only be distinguished for three Information about unit costs was gathered by a question-
countries), these are included in all analyses as first admis- naire, filled out by country representatives. The questionnaire
sions. was formulated in such a way that for all countries similar
To adjust for differences in the demographic composi- cost categories were included. With this information, we
tion of the countries, age-standardized (18 groups) and sex- calculated comprehensive unit costs for each country: unit
standardized incidence rates (per 1,000) and costs per capita costs for one inpatient day in hospital and ED visit, on
(mean costs per inhabitant) were calculated for the year 1999 average for all patients (not only injury patients) for general
using the direct method of standardization. The total popula- and university hospitals, and public and private hospitals. The
tion of the participating countries was used as the reference comprehensive unit costs include costs for staff, diagnostics,
population. therapy and medication, and overhead costs (e.g., hotel and
management costs). If data on specific cost categories were
Cost Calculations absent for a country, these were estimated based on the mean
An incidence-based approach was used, calculating the costs of these categories in other countries, adjusted for
medical costs of injuries occurring in a specific year (1999). differences in price level among countries. For England and
A full description of the cost model can be found in the final Wales, unit cost per inpatient day had to be derived from the
report of EUROCOST.11 The calculation of the direct med- literature. An overview of the comprehensive unit costs for
ical costs (costs within the healthcare sector) of injury is each country is given in Table 2. Costs were calculated in
restricted to hospital costs of inpatients, consisting of costs Euros (year 1999).
per inpatient day in hospital and ED costs preceding the The data of the 10 participating countries were also
hospitalization. The hospital cost of inpatients is the sum of pooled to give an estimate of the costs per capita (i.e., abso-
the number of ED visits multiplied by the costs per ED visit lute costs divided by the number of inhabitants) by injury,
and the number of hospital admissions multiplied by length of external cause, age, and sex for the EUROCOST countries in
stay and unit costs per inpatient day. total.

Table 3 Costs per Capita, Incidence, and Mean Costs per Patient for Admitted Injury Patients (All Causes) per
Country Cost per Capita (€) Incidence (per 1,000) Cost per Patient (€) Mean Length of Stay (days)

Austria 75 22.9 3,242 6.9

Denmark 51 18.1 2,745 6.1
Greece 30 13.4 2,166 7.6
Ireland 26 15.2 1,690 4.2
Italy 25 16.6 1,506 4.2
Netherlands 19 6.5 2,954 8.4
Norway 42 14.7 2,819 5.0
Spain 14 4.8 2,771 9.3
England 18 11.8 1,418 5.9
Wales 23 15.6 1,399 6.5
EUROCOST 24 12.2 1,965 6.4

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The Journal of TRAUMA威 Injury, Infection, and Critical Care

medical costs of injury in Europe. Traffic injuries are respon-

sible for the other 12% of hospital costs in Europe. The mean
hospital costs per admitted patient are the highest for traffic
injuries (€2,330), followed by nontraffic injuries (€2,140),
which are home and leisure, sport, and occupational acci-
dents. They are relatively low for violence (€730) and suicide
(€670). The observed variation is due to large differences in
health care use per category.

Fig. 2. Hospital cost per capita (€) for admitted injury patients by Costs by Injury Type
age and sex for the EUROCOST countries. Table 4 shows the share of specific injuries in costs per
capita, injury incidence, and mean costs per patient for ad-
mitted patients for the EUROCOST countries. Injury patients
RESULTS admitted with a hip fracture have by far the highest share in
Costs by Country total costs, caused by the highest incidence rate and also the
Table 3 shows the costs of admitted injury patients for highest mean costs per patient. Among the five injuries with
each participating EUROCOST country. Large international highest cost per capita, we further observe two injuries with
differences exist in costs per capita of injury-related hospital both high incidence and high costs per patient (fracture of the
admissions. Compared with the mean costs per capita for the knee/lower leg and skull brain injury, including concussion),
EUROCOST countries in total (€24), Austria generated three one injury with high incidence but low costs per patient
times higher costs per capita, followed by Denmark and (superficial injury), and one injury with low incidence and
Norway with (almost) twice as high costs. In Greece, Ireland, high costs per patient (vertebral column/spinal cord injury).
Italy, and Wales, intermediate costs per capita were found Apart from hip fracture, spinal cord injury, lower extremity
and costs per capita were substantial below the mean for injuries (fractures and complex soft-tissue injuries), and
Spain, England, and the Netherlands. The variation in costs burns cause high costs per admitted patient.
per capita between the countries is mainly caused by the high The patterns of the injuries with highest costs per capita
variation in injury incidence between the countries and is in per country are quite similar between the countries (Table 5).
lesser order due to differences in the mean costs per patient. The costs per capita are for all countries (except Spain) by far
The mean costs per patient are low in England and Wales and the highest for hip fractures (Fig. 3). Furthermore, fracture of
relatively high in Austria, the Netherlands, and Norway. the knee/lower leg (all countries) and skull-brain injuries and
Despite different cost levels, age and sex patterns between the superficial injuries (seven countries) were in the top five
countries were broadly similar. injuries with the highest cost per capita. Skull-brain injuries
generate relatively low costs per capita in Ireland, England,
Costs by Age and Sex and Wales, which might be due to traffic safety. Poisoning
Figure 2 gives an overview of the costs per capita for all (the Netherlands, Norway, and Wales) and burns (Norway
admitted injury patients by age and sex for the EUROCOST and Ireland) result in high costs per capita, probably caused
countries combined. Peaks in costs per capita are observed by a registration effect. Injury patients with wrist and upper-
among children 0 – 4 years old and among 15- to 24-year-old arm fractures generate relatively high costs per capita in
males, due to high incidence rates among these age groups. England, which might indicate that England has a stringent
Costs per capita increase exponentially in older age admission policy for this group of patients.
groups (age ⱖ65 years) and older females in particular, due Austria generates the highest cost per capita for all injury
to the combined effect of high incidence and high costs per groups shown in Figure 2. The countries with highest mean
patient. In total, 46% of total costs of injury-related hospital cost per capita (Austria, Norway, and Denmark) show re-
admissions are due to persons older than 65 years. Though markably higher costs per capita for hip fractures, fracture
women sustained only 45% of the total number of injuries, knee/lower leg, skull-brain injury, and spinal-cord injury
they accounted for 59% of the costs. This is mainly because compared with countries with relatively low cost per capita
many of the injuries suffered by older women require a high (Netherlands, Spain, Ireland, England, and Wales).
level of care and females outnumber males at higher ages. In Figure 4 the costs of the elderly (patients older than 65
years) are shown as a proportion of the total costs. For most
Costs per Accident Category countries, 20 to 30% of total costs of admitted injury patients
Home and leisure, sport, and occupational accidents were due to this specific patient group; this group accounted
combined make a major contribution (86%) of the total hos- for 40% of total costs in Greece. Only in Spain is the share of
pital costs of injury in Europe. The costs of violence and this patient group below 10%. For all countries, females
suicide, on the contrary, are both less than 1% of the total account for 75 to 85% of these costs.

1286 December 2005

Cost of Injury-Related Hospital Admissions in Europe

Table 4 Injury Incidence and Costs per Capita of Admitted Injury Patient by Injury Group (Level 1) Ranked by
Share in Costs per Capita
Cost per Capita Incidence Mean Costs
Injury Group
€ Rank Per 1,000 Rank € Rank

Fracture: hip/pelvis/femur shaft 10.92 1 2.3 1 5,530 1

Fracture: knee/lower leg 2.46 2 0.9 5 3,504 4
Skull-brain injury (including concussion) 1.66 3 1.2 3 2,822 7
Superficial injury 1.16 4 0.9 6 1,312 23
Vertebral column/spinal cord 1.11 5 0.5 13 3,305 5
Fracture: ankle 1.03 6 0.5 10 2,636 9
Other and unspecified injury 0.91 7 1.1 4 2,327 11
Fracture: upper arm 0.74 8 0.3 17 2,818 8
Open wounds 0.67 9 0.8 7 1,949 14
Poisoning 0.61 10 1.7 2 1,370 22
Fracture: wrist 0.59 11 0.8 8 1,374 21
Fracture: elbow/forearm 0.59 12 0.6 9 1,726 16
Dislocation/sprain/strain: knee 0.56 13 0.4 15 1,727 15
Burns 0.54 14 0.2 18 4,065 2
Internal organ injury 0.39 15 0.2 19 2,865 6
Fracture: rib/sternum 0.34 16 0.2 20 2,126 13
Complex soft-tissue injury: upper extremity 0.30 17 0.4 14 1,440 17
Fracture: foot/toes 0.30 18 0.2 24 2,514 10
Open wounds 0.29 19 0.5 12 1,165 25
Complex soft-tissue injury: lower extremity 0.29 20 0.2 22 3,535 3
Facial fractures 0.27 21 0.5 11 1,379 20
Fracture: hand/finger 0.21 22 0.4 16 1,131 26
Sprain/strain: ankle/foot 0.20 23 0.1 25 1,430 18
Sprain/strain: shoulder/elbow 0.19 24 0.2 23 1,225 24
Fracture: clavicle/scapula 0.14 25 0.1 26 2,152 12
Eye injury 0.09 26 0.1 27 1,391 19
Foreign body 0.09 27 0.2 21 1,083 27
Sprain/strain: wrist/hand/fingers 0.05 28 0.1 28 0,775 28

DISCUSSION country-specific data possible. Previous cost-of-injury studies

The cost model provides insight into hospital costs of were limited to specific injuries, health care sectors, and age
admitted injury patients in Europe for all external causes, groups, which made cross-country comparisons difficult.
injury types, and age/sex categories. Large international dif- However, our study also has several limitations, based on
ferences in hospital costs are observed, but the pattern of using administrative data from different countries.
costs per capita by age, sex, injury type, and external cause is Application of our cost model has so far been limited to
broadly similar in all countries. Accidents among older peo- 10 European countries. Countries without nationwide data
ple (ⱖ65 years) are a major source of hospital costs in all systems on hospital admissions due to injury (e.g., Germany)
participating countries. Young children and male adolescents did not participate in the EUROCOST project. Expansion of
are also high-cost groups. Injuries with the highest hospital the cost model to other European countries could further
costs per capita are hip fractures, fractures of the knee/lower enhance its value. Our cost model uses an incidence-based
leg, superficial injuries, skull-brain injuries, and vertebral approach. For that reason, the observed incidence rates per
column/spinal cord injuries. country are a primary source of international variation in
A major strength of our study is that it presents estimates costs. The incidence of injuries recorded in hospital-based
of hospital costs of injuries based on one uniform method, surveillance systems may vary due to real underlying differ-
which makes comparisons between countries and pooling of ences in exposure, injury risk, and demographics, and/or due

Table 5 Top Five Injuries with Highest Hospital Costs by Country

Rank Austria Denmark Greece Ireland Italy

1 Hip fracture Hip fracture Hip fracture Hip fracture Hip fracture
2 Skull-brain injury Skull-brain injury Fracture: knee/lower leg Fracture: ankle Skull-brain injury
3 Fracture: knee/lower leg Fracture: knee/lower leg Superficial injury Burns Vertebral column/spine
4 Superficial injury Superficial injury Fracture: ankle Fracture: knee/lower leg Fracture: knee/lower leg
5 Dislocation/sprain/strain: knee Vertebral column/spine Skull-brain injury Open wounds Superficial injury

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The Journal of TRAUMA威 Injury, Infection, and Critical Care

Fig. 3. Hospital costs by injury type (top five highest costs for EUROCOST) by country.

to artificial differences in registration and health care prac- caused by minor injuries (ICD/Abbreviated Injury Scale
tice. [AIS]⫽1, 2).16 An important limitation of our data are the
At the upper end of the spectrum of international differ- unavailability of AIS scores. Therefore, polytrauma patients
ences, Austria has a very high clinical incidence and cost per (seriously injured patients, usually with multiple injuries)
capita for all injury groups, in particular compared with Spain could not be distinguished. The mean costs per polytrauma
and the Netherlands at the lower end. Austria has also a patient have recently been estimated at €32,166,17 which far
relatively high clinical incidence of low severity injuries outnumbers the mean costs per patient by injury type found in
(superficial and remaining injuries, mainly dislocation/sprain/ our study. Other information relating severity of injury was
strain in the knee, fractures of the arm/ankle, and open also not available in the data systems. For instance, only one
wounds), which indicates a low admission threshold for this country had information about the proportion of intensive
country. At the opposite, it seems that Spain and the Neth- care unit admissions available (Austria, 3.4%). Another lim-
erlands have a high admission threshold, indicated by their itation arises because readmissions could not be distinguished
high mean length of stay (9.3 and 8.4 days, respectively, from first admissions in most countries. For the countries
compared with a mean of 6.4 days). The low injury incidence with available information (Austria, 0.7%; the Netherlands,
in Spain might partly be due to a misclassification of external 2.6%; Norway, 8.6%) readmissions are mainly caused by hip
cause codes in the data system and can partly be explained by fractures, skull-brain injuries, and poisoning, resulting in an
an underestimation of admissions of injury patients in private overestimate of injury incidence for these injury types for
hospitals. In earlier research,10 the incidence for hospitalized most countries. Furthermore, day cases were excluded from
traffic patients was double. analyses because they result in a bias in the estimates of
It should be considered that registration effects influence injury incidence when included.13
the observed patterns by type of injury in our study as well. In this study we focused on hospital costs because no
The high hospital costs for superficial injuries for almost all reliable data on health care consumption for other health care
countries might indicate a conservative coding practice, un- sectors was available. Further development of the model
derestimating other types of injury (such as internal organ should include long-term consumption of outpatient care,
injuries) because they are incompletely recognized and re- rehabilitation, and/or nursing home treatment. This is partic-
corded. However, earlier research in the United States also ularly relevant for injuries with long-term health care need,
found that one-half of total hospital costs of acute trauma was such as spinal cord and skull-brain injury (Meerding WJ,

Table 5 Continued
Rank Netherlands Norway Spain UK, England UK, Wales

1 Hip fracture Hip fracture Fracture: knee/lower leg Hip fracture Hip fracture
2 Skull-brain injury Skull-brain injury Hip fracture Fracture: knee/lower leg Poisoning
3 Fracture: knee/lower leg Fracture: knee/lower leg Superficial injury Fracture: wrist Fracture: knee/lower leg
4 Vertebral column/spine Burns Vertebral column/spine Superficial injury Superficial injury
5 Poisoning Poisoning Skull-brain injury Fracture: upper arm Open wounds

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Cost of Injury-Related Hospital Admissions in Europe

Fig. 4. Hospital costs of elderly (ⱖ65 years) with a hip fracture as proportion of total costs by country.

Toet H, Mulder S, van Beeck EF, unpublished data, 2004). of extramural care, direct nonmedical costs) and countries to
Earlier studies show that hospital care comprises on average make prioritizing possible based on total expenses. For pur-
69% of total health care costs in the Netherlands (Meerding poses of setting priorities in injury prevention and trauma
WJ, Toet H, Mulder S, van Beeck EF, unpublished data, care, detailed information about external causes, severity
2004), 73% in the United States,18 and 71% in Australia.19 (AIS/Injury Severity Score), and polytrauma should be avail-
Our results confirm outcomes of other studies1 in which able, along with information about economic costs as as-
hip fractures, mainly due to home and leisure injuries among sessed in this study. Moreover, it would be worthwhile to
elderly people, and skull-brain injuries were found as major analyze the differences in costs for specific injury groups
sources of injury costs (also Meerding WJ, Toet H, Mulder S, (e.g., fractures, brain injury) in more detail and disentangle
van Beeck EF, unpublished data, 2004). In the United States, the effect of differences in treatment and operation strategies
it was also found that spinal cord injuries accounted for a and differences in the way trauma care is delivered (including
large share in total hospital expenditures.16 The high costs of the specialties involved, such as trauma surgeons, orthopedic
fractures of the knee and/or lower leg (9%), and of lower- surgeons, and neurosurgeons). Therefore, research in this
extremity injuries in general (54% of total costs) are consis- area should be encouraged, including international studies on
tent with findings in Sweden (46% of health care costs of costs of polytrauma with the help of trauma center databases.
unintentional injuries),5 and the United States (45% of hos- Based on our current study, we conclude that the elderly
pital costs of injuries).16 In a classical study from the United older than age 65 years consume a disproportionate share of
States,20 medical costs for admitted injury patients were es- hospital resources for trauma care, mainly caused by hip
timated at about $8,800 per capita (adjusted for inflation up to fractures and fractures of the knee/lower leg. They consti-
1999), which is more than three times the estimate in our tuted only 16% of the European population in 1999, but
present study ($2,600). This difference can partly be ex- accounted for 40% of total hospital costs,21 and the propor-
plained by the use of charges instead of unit costs in the US tion of the population that is elderly is growing rapidly.
cost calculations. However, in another cost study in the Additional work should focus on societal cost– benefit anal-
United States,16 twofold greater mean costs for admitted yses of interventions targeting elderly, quality of life follow-
injury patients were also found ($5,400). Because many ing trauma, and injury prevention needs (e.g., prevention of
methodological and country-specific issues may cause differ- falls) of the elderly. Other priority areas are skull-brain inju-
ences between Europe and the United States, a full compar- ries, spinal cord injuries, burns, and complex soft-tissue in-
ison will need a specific study, with harmonized methods for juries of the lower extremities, deserving special attention as
the United States and Europe. being the most important “low frequency, high impact” types
The total hospital costs generated by injuries indicate the of injury. Our cost model can contribute to policy setting by
relative importance of injuries in the healthcare sector as a identifying types of injuries and high cost groups for potential
whole and may be useful in convincing politicians of the intervention.
importance of preventing injuries and investing in trauma
care. Our cost model can be used for prioritizing policies by REFERENCES
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8. van Beeck E. Medical costs and economic production losses due to intensive care unit (ICU) stays and use of the ICU in
injuries in the Netherlands. J Trauma. 1997;42:1116 –1123. Germany.2 Unfortunately, comparing two different databases
9. Kidholm K, Soegaard J. A study of the cost of injury in road does not necessarily explain differences between two differ-
accidents [in Norwegian]. Odense: Odense University Press, 1997. ent populations based on different medical systems.
10. Bastida JL, Aguilar PS, Gonzalez BD. The economic costs of traffic
The Polinder article found large European country dif-
accidents in Spain. J Trauma. 2004;56:883– 889.
11. Polinder S, Meerding WJ, Toet H, et al. A surveillance based ferences in costs per inpatient day, with Norway being most
assessment of medical costs of injury in Europe: phase 2. expensive and the United Kingdom being less than half the
Amsterdam: Consumer and Safety Institute, 2004. cost, as well as emergency department costs with Norway
12. Dessypris N, Petridou E, Skalkidis Y, et al. Countrywide estimation again being most expensive and Greece being almost 60%
of the burden of injuries in Greece: a limited resources approach.
less. Although the US population over 65 years of age is
J Cancer Epidemiol Prev. 2002;7:123–129.
13. Langley J, Stephenson S, Cryer C, Borman B. Traps for the unwary projected to double between years 2000 and 2030 with an
in estimating person based injury incidence using hospital discharge anticipated increase in the number of elderly patients injured,
data. Inj Prev. 2002;8:332–337. the Eurocost data shows quite clearly that the elderly female
14. World Health Organization. International Classification of Diseases, accounts for a disproportionate share of hospital resources
9th edition. Geneva: World Health Organization, 1997.
due primarily to hip fractures, which is the top injury with
15. Meerding WJ, Toet H, Mulder S, et al. A surveillance based
assessment of medical costs of injury in Europe: phase 1. highest hospital cost in 9 out of the 10 countries examined,
Amsterdam: Consumer and Safety Institute, 2002. with fracture of the knee or lower leg and skull or brain injury
16. Mackenzie EJ, Morris JA, Smith GS, Fahey M. Acute hospital costs following in prevalence and cost.1,3 In fact, 46% of the total
of trauma in the United States: implications for regionalized systems costs of injury-related hospital admissions are due to persons
of care. J Trauma. 1990;30:1096 –1101.
17. Schwermann T, Grotz M, Blanke, S. Ruchholtz, et al. Evaluation der
over 65 years, with women accounting for 45% of overall
Kosten von polytraumatisierten Patienten insbesondere aus der injuries, but accounting for 59% of the costs.
Perspektive des Krankenhauses. Unfallchirurg. 2004;107:563–574. Interestingly, Spain has the highest mean length of stay
18. Miller TR, Lestina DC. Patterns in US medical expenditures and but has the lowest cost per capita, suggesting that there is an
utilization for injury, 1987. Am J Public Health. 1996;86:89 –93. overtriage with many patients with minimal or no injury
19. Mathers CD, Penm R, Stevenson C, Carter R. Health system costs of
diseases and injury in Australia, 1993– 4. Health and Welfare
being admitted for “observation,” a practice that is being
Expenditure Series No. 2. Canberra: AIHW, 1998. performed less and less in the United States due to the fact
20. Rice DP, MacKenzie EJ. Cost of injury in the United States: a report that the number of trauma and critical care beds compared
to congress. San Francisco: Institute for Health and Ageing, with 10 years ago have decreased, despite an increasing
University of California, 1989. number in the US census. In fact, a survey of 12 geographic
21. European Network for Safety among Elderly. The right for a better
and socially diverse European countries suggests that stan-
quality of life. Available at: http://www.cc.uoa.gr/health/socmed/
hygien/eunese/. Accessed November 11, 2005. dardization of management of training would have merit,
especially in a region of the world that is becoming more
cohesive through the European Union. However, it also must
EDITORIAL COMMENT be recognized that not all countries have philosophies or even
The observational review article by Polinder et al. on health care that would allow complete uniformity.4
“Cost of Injury-Related Hospital Admissions in Europe” uses The current database does not allow an analysis of the
hospital discharge information from 10 European countries to differences in costs for specific injury groups in detail. It also
examine the use of hospital resources for injured patients and does not allow further analysis of ICU patients regarding days
to determine the population that is not only most vulnerable on the ventilators, number of ventilated patients, or compli-
to injury but also the most costly. As we all know, popula- cations that may occur prolonging hospitalization.
tion-based registries provide the best demographic and over- Ideally, it would be optimal to take the best of each
all information of care provided by a region. However, there country and make that the model trauma system for the

1290 December 2005

Cost of Injury-Related Hospital Admissions in Europe

region. However, due to differences in the health care sys- resources. Unfortunately, the global shortage of healthcare
tems, the role of the various caregivers and the difficulty of providers may make it difficult to improve on the intensity of
ensuring that there is a uniform method of data collection, the care that the population requires, which is a frightening
results of this study must be interpreted with caution. Also, as thought as we all go through the aging process.
costs of health care delivery in general appear to be more Marc J. Shapiro, MD, MS
expensive in the United States, it would also be worthwhile to SUNY Stony Brook
be able to attempt to look at both of these systems on either Stony Brook, NY
side of the Atlantic to see where in the United States costs
might be diminished without a change in patient outcome or REFERENCES
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creases health care expenditures in the United States, with Admissions in 10 European Countries. J. Trauma. 2005;59:1283–
some fields experiencing upwards of 30% increase in annual 2. Hildebrand F. Management of polytraumatized patients with
malpractice premiums. associated blunt chest trauma: a comparison of two European
All in all, the issues in managing trauma patients are countries. Injury Int J Care Injured. 2005;36:293–302.
similar around the world. As healthcare improves, our pop- 3. Clark DE, Chu MK. Increasing importance of the elderly in a trauma
system. Am J Emerg Med. 2002;20:108 –111.
ulations are increasing in age and with additional comorbidi- 4. Uranus S, Lennquist S. Trauma Management and Education in
ties and decreased physiologic reserve, the elderly are requir- Europe: A survey of twelve geographically and socioeconomically
ing increased intensity and utilization of our health care diverse European countries. Eur J Surg. 2002;168:730 –735.

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