More Trauma Care Spending Doesn't Raise Survival Rates

Spending more on trauma care does not necessarily improve survival rates, a national study suggests.

Research published in The Journal of Trauma and Acute Care Surgery finds that the cost of treating trauma patients in the western United States is 33% higher than the cost for treating similarly injured patients in the Northeast.

Researchers, however, don't know why.

"Spending more doesn't always mean saving more lives," said study leader Adil H. Haider, MD, a trauma surgeon, associate professor of surgery at the Johns Hopkins University School of Medicine and director of Hopkins' Center for Surgical Trials and Outcomes Research. "If doctors in the Northeast do things more economically and with good results, why can't doctors out West do the same thing? This study provides a potential road map for cutting unnecessary costs without hurting outcomes."

The Hopkins study analyzed three years of data from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. They identified 62,678 adults with a primary injury in one of five areas: blunt injury to the spleen, collapsed lung and bleeding in the chest, shinbone fracture, mild traumatic brain injury and liver injury.

The Hopkins researchers note that trauma-related disorders are among the five most expensive medical conditions. After controlling for variables such as chronic diseases that could bias the findings, the researchers estimated that the average per-person cost in the Northeast for trauma care for all five injury types combined was $14,022.

The cost was 18% higher in the South, 22% higher in the Midwest and 33% higher in the West.

The most expensive care was for liver injury and the average cost of care in the Northeast was $16,213. The cost was 18% more in the South, 22% more in the Midwest and 35% more in the West. The Northeast had the lowest costs for all five injury types while the West had the highest, even after factoring differences in the consumer price index.

Michael F. Rotondo, MD, FACS, a trauma and acute care surgeon, chair of the department of surgery at the University of North Carolina in Greenville, told HealthLeaders Media he "was not surprised" by the study's findings "by virtue of the fact that the healthcare practice in the country is incredibly variable."

"All politics are local but all healthcare is local as well," says Rotondo, who is also and chair for the Committee on Trauma at the American College of Surgeons. "As someone who worked in an urban environment at the University of Pennsylvania for 10 years and now for 13 years have been in a rural environment, that is clearly the case in terms of style of practice, and that is true, but also in the economics of practice. It is very different from one region of the country to another."

While he called the study "thoughtful and provocative" Rotondo says its value is limited because it relies upon "high level administrative databases" that don't delve into the specifics of each case.

"By virtue of the methodology available to the investigators they were not able to say what is driving the expenses," he says. "The message I get out of this and exactly why the College of Surgeons supports this sort of research is that we have to focus on hard-edged comparative effectiveness where we are looking at the quality of the outcomes and the cost."

Rotondo says there could be any number of reasons for the price variance. "There is tremendous advantage to having hospitals near each other and lots of physicians in a region because it allows the providers to do collective bargaining in essence with suppliers. This could be strictly a difference in pricing related to implants or it could be pharmacy costs. It may not have anything to do with physician fees or practice patterns," he says.

"When we look at our supply costs in rural environments, they are much higher because of the way contracts are drawn. We have a lot more work to do to sort out and get down to answer these sorts of seminal questions and this is the kind of research that spurs on us."

Ricardo Martinez, MD, the former director of the National Highway Transportation Safety Administration, told HealthLeaders Media that trauma care has made great strides in improving survival rates, "and now we have to look at what is the most cost-effective care." He says the Hopkins study provides an excellent reason to promote evidence-based medicine.

"With all the growing data we have to look at the information coming out to see what is truly of value and what doesn't make a difference," says Martinez, an emergency physician who is now CMO with Atlanta-based North Highland consultants.

"For example, the growth of ultrasound has eliminated a lot of CT scans, but that takes years to disseminate and become adopted. Trauma care is one of the programs that has the best data so can we use that data to be more cost effective. We know it saves lives and we can use it to save money too."

Martinez says the growth in the use of telemedicine, more sophisticated databases, and the Internet is creating and spreading knowledge at a dizzying rate. "The problem is being overloaded with information so we have to maintain our focus," he says. "What is best for the patient and what is the best cost-effective way to do that?"

Haide said researchers looking to cut costs must not look only at survival rates alone to make sure the more expensive care isn't better in some way. He said higher-cost regions may have patients with less pain and fewer disabilities after recovery.

"If surgeons are fixing tibia fractures in the West in a way that's more expensive but makes patients more comfortable, that would not be a trivial finding," Haider said. "We really need to drill down and figure out what parts of care improve outcomes and what parts drive up costs without improving any outcomes or aspects of care important to patients."

The study was funded by the National Institutes of Health's National Institute of General Medical Science, the American College of Surgeons and the Hopkins Center for Health Disparities Solutions.