The economics of burn care
By: Paul Trueman
Hospital Episode Statistics for England and Wales demonstrate the scale of burn injuries and associated costs, with the paediatric and elderly population being the most at risk. In the year 2009/2010 there were:
- Over 11,000 admissions
- Accounting for over 47,000 bed days
- Involving over 3400 critical care admissions
Health and economic impacts of burn care can be divided into direct (healthcare) costs, indirect (non-healthcare) costs and intangible costs (Table 1; Figure 1).
Table 1. Costs associated with burn care.
Reconstruction: specialist care, surgery (ICU, burns unit)
Rehabilitation: Multi-disciplinary inpatient or outpatient care
Reintegration: outpatient and community care
Patient and carer costs
Pain, suffering, quality of life
Figure 1. Distribution of costs in burn care (From Sanchez et al, 2008).
Approaches to burn care
Clinical and economic evidence is required to identify the most efficient approaches to burn care and in this respect economic stakeholders need to recognise the challenges that are inherent in conducting research in this indication. Burn care is not immune from the economic realities facing health services and when addressing the costs associated with treatment options the difficulties inherent in conducting randomised controlled trials (RCTs) in burns patients needs to be appreciated.
Regrettably there is limited evidence on the cost effectiveness of individual dressings/treatments, although early evidence suggests that dressing costs make up a very small fraction of the total cost of care. In assessing overall costs rationale for dressing selection should consider impacts on other total costs, such as reducing pain on dressing change, which may facilitate out-patient management and/or return to work which reduce the financial burden to the hospital system and the patient/economy respectively. With respect to the latter, societal costs of burns typically exceed the healthcare costs in the form of:
- Productivity losses
- Caregiver time
- Home care costs
- Permanent disability in severe cases
Quality of life (QOL) considerations are also important with burn care making an impact on the commonly reported domains of quality of life, either in the acute phase or during rehabilitation (Figure 2). However, there is a lack of robust quantifiable evidence on the impact of burns on QOL, with the available evidence tending to use disease-specific scales such as the Burn Specific Health Scale.
Figure 2. Burns and QOL.
Cost-effective burn care
In defining cost effective burn care it should be emphasised that cost-effective care does not necessarily equate to the least costly care. The true aim is to achieve the best possible outcomes for any given expenditure which can be influenced by:
- Burn severity
- Diagnosis – accuracy and speed
- Intervention, and Treatment pathways.
Regarding burn severity our interests lie primarily in the costs and outcomes of treating non-complex burns.
Looking at both complex and non-complex burns, cost is positively associated with the severity of the burn in question. Griffiths et al (2006) report the mean cost of treating an uncomplicated paediatric minor scald in a UK burns centre to be £1850, whereas costs soar for complex burns as shown by Pellat et al (2010) who reported the mean cost of treating a paediatric burn covering 30-40% of total body surface area (TBSA) to be £63,157. In this respect Klein et al (2008) reported that for each additional TBSA % that was grafted with autologous skin grafts, hospital costs increased by US$2,639.
Cost is also associated with patient age; children account for 40-50% of all severe burn injuries whereas the elderly account for between 10% and 16% of all severe burn injuries. With respect to mean levels of hospital stay, which also drives the cost of treatment and increases with burn severity, Brusselaers et al (2010) report this to be 15-16 days in the paediatric population and 18-26 days in the elderly population. Hospital episode statistics from England and Wales demonstrate the impact that burn severity has on costs in relation to average length of stay (ALOS), with length of stay and associated costs increasing with severity (Table 2)
[Insert table 2]
Table 2. Burn severity and ALOS
In a prospective, cross-sectional study in a Spanish burn centre, Sanchez et al (2008) collected information on healthcare and non-healthcare costs for 898 patient admissions categorised according to DRG code. Mean annual healthcare costs ranged from US$5,000 – US$41,000 (Figure 3).
[Insert Fig 3]
Figure 3. Healthcare and non-healthcare costs relating to burn care (From Sanchez et al, 2008).
Burns have far reaching health and economic impact. However, the commoner non-complex burns are relatively inexpensive. High cost severe burns are relatively rare, but when looking at individuals with severe burns the high associated expense leads to a general perception that burn care is expensive to treat across the board. Non-healthcare costs are associated with a high proportion of the cost relating to burn patients
Brusselaers et al. Critical Care 2010, 14:R188. http://ccforum.com/content/14/5/R188
Griffiths et al. Burns journal of the International Society for Burn Injuries (2006) Volume: 32, Issue: 3, Pages: 372-374
Klein et al. (2008)
Pellat et al. Burns journal of the International Society for Burn Injuries (2010) Volume: 36, Issue: 8, Pages: 1208-1214
Sanchez et al. Burns Volume 34, Issue 7, November 2008, Pages 975-981