The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 9

Scientific Articles | May 02, 2012

Economic Impact of Hand and Wrist Injuries: Health-Care Costs and Productivity Costs in a Population-Based Study

C.E. de Putter, MD¹; R.W. Selles, PhD¹; S. Polinder, PhD¹; M.J.M. Panneman, MSc²; S.E.R. Hovius, MD, PhD¹; E.F. van Beeck, MD, PhD¹

¹ Departments of Plastic, Reconstructive, and Hand Surgery (C.E.d.P. and S.E.R.H.), Rehabilitation Medicine (R.W.S.), and Public Health (S.P. and E.F.v.B.), Erasmus MC Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. E-mail address for C.E. de Putter: ddeputter@gmail.com. Email address for S. Polinder: s.polinder@erasmusmc.nl. E-mail address for E. F. Van Beeck: e.vanbeeck@erasmusmc.nl
² Consumer and Safety Institute, P.O. Box 75169, 1070 AD Amsterdam, The Netherlands. E-mail address for M.J.M. Panneman: m.panneman@veiligheid.nl

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Investigation performed at the Erasmus MC Rotterdam, Rotterdam, and the Consumer and Safety Institute, Amsterdam, The Netherlands

J Bone Joint Surg Am, 2012 May 02;94(9):e56 1-7. doi: 10.2106/JBJS.K.00561

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Abstract

Background:

Injuries to the hand and wrist account for approximately 20% of patient visits to emergency departments and may impose a large economic burden. The purpose of this study was to estimate the total health-care costs and productivity costs of injuries to the hand and wrist and to compare them with other important injury groups in a nationwide study.

Methods:

Data were retrieved from the Dutch Injury Surveillance System, from the National Hospital Discharge Registry, and from a patient follow-up survey conducted between 2007 and 2008. Injury incidence, health-care costs, and productivity costs (due to absenteeism) were calculated by age group, sex, and different subgroups of injuries. An incidence-based cost model was used to estimate the health-care costs of injuries. Follow-up data on return to work rates were incorporated into the absenteeism model for estimating the productivity costs.

Results:

Hand and wrist injuries annually account for $740 million (in U.S. dollars) and rank first in the order of most expensive injury types, before knee and lower limb fractures ($562 million), hip fractures ($532 million), and skull-brain injury ($355 million). Productivity costs contributed more to the total costs of hand and wrist injuries (56%) than did direct health-care costs. Within the overall group of hand and wrist injuries, hand and finger fractures are the most expensive group ($278 million), largely due to high productivity costs in the age group of twenty to sixty-four years ($192 million).

Conclusions:

Hand and wrist injuries not only constitute a substantial part of all treated injuries but also represent a considerable economic burden, with both high health-care and productivity costs. Hand and wrist injuries should be a priority area for research in trauma care, and further research could help to reduce the cost of these injuries, both to the health-care system and to society.

Figures in this Article

Introduction

Injuries to the hand and wrist account for approximately 20% of visits to emergency departments^1,2. Besides the impact of hand and wrist injuries on physical and mental health, they can lead to high health-care costs and prolonged time off from work^3-11. As a consequence, these injuries may impose a considerable economic burden to the community.

Because of rising health-care costs, economic analyses are considered increasingly important¹². To date, only a few single-center studies have estimated the costs of hand and wrist injuries, and population-based studies on this topic are scarce^13-25. From previous studies, we know that productivity costs due to work absenteeism generally are even larger than health-care costs²⁶. Population-based information about these economic production losses could therefore be important to policy makers in the area of injury control, but such an analysis has not been done for hand and wrist injuries.

The purposes of this nationwide study were to examine health-care costs and productivity costs due to hand and wrist injuries and to compare these costs with those of other main injury groups.

Materials and Methods

Model Description

Health care in The Netherlands is financed by a dual system. For all regular medical treatment, there is a system of obligatory health insurance, provided through private health insurance companies, that covers the entire population. These insurance companies are obliged to provide a standard package of insured treatments as defined by the Dutch government. Long-term medical care, especially that involving semipermanent hospitalization and disability costs, are covered by a state-controlled mandatory insurance for the whole population²⁷.

We calculated direct health-care costs of injury and productivity costs due to work absenteeism. Annual incidence rates of emergency department visits were extracted from the Dutch Injury Surveillance System for outpatients and the National Hospital Discharge Registry for inpatients^28,29. In the Dutch Injury Surveillance System, all injuries treated at emergency departments are recorded, and similar methods in prior studies from other countries are applied^30,31. Thirteen hospitals, including three university hospitals and ten general hospitals, participated in this injury surveillance system during the study period. These geographically separated hospitals were selected to draw from both rural and urban areas and form a sample of 12% of the total number of injured patients presenting at the emergency departments in The Netherlands (population of 16.5 million in 2009). The people using these hospitals are representative of the Dutch population in terms of age and sex. In this way, extrapolations can be made to the national level^32,33. Injury diagnoses and injury mechanisms are registered by using the International Classification of Diseases of the World Health Organization, Tenth Revision (ICD-10). We considered all patients with injuries to the hand and wrist (codes S52.5, S52.6, S62.0, S62.1, S62.2-8, S63.0-7, S64.0-9, T11.3, S65-S69, T04.2, T05.0, T05.1, T11.4-9, S60.0-9, and S61.0-9 of the ICD-10) (see Appendix). Inclusion in the study was restricted to patients who were treated in an emergency department, so patients were excluded if they were fully treated by primary care practitioners without hospital referral. Injured patients were selected on the basis of the registered primary diagnosis, according to the EUROCOST classification of diagnostic groups as developed and recommended by European experts^32,34. In patients with multiple injuries, the primary injury was determined by application of an algorithm giving priority to spinal cord injury, skull and/or brain injury, and lower extremity injury over injuries in other body parts and to fractures over other types of injury^3,9,35.

Health-Care Costs

To estimate the direct health-care costs for 2007, we used a previously reported incidence-based cost model, which has been used in ten European countries (Fig. 1)^3,34-38. Per injury group, the number of patients, health-care consumption, and related costs were calculated on the basis of the registered data in the Dutch Injury Surveillance System, the Hospital Discharge Registry, and on a patient survey.

Fig. 1

Structure of the incidence-based cost model used in this study. LIS = Dutch Injury Surveillance System.

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Health-care consumption was divided into multiple categories in which all relevant types of medical care are used: before, during, and after emergency department visits (Table I). For each type of health-care service, we used the costs per volume unit that reflects the real resource. All resources in Table I were retrieved from separate data systems. In case of overlap between systems, the costs were attributed to only one data system. For example, if a patient attended the emergency department and subsequently was admitted, then the costs made at the emergency department were attributed to the emergency department data system, while the costs of admission were only attributed to the Hospital Discharge Registry data system. We calculated lifetime health-care costs of injury by multiplication of incidence, transfer probabilities (e.g., chance of hospital admission), health-care volumes (e.g., length of stay), and unit costs (e.g., costs per day of hospitalization). Incidence, transfer probabilities, and health-care volumes were subdivided by patient groups that are homogeneous in terms of health service use³⁹.

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TABLE I Unit Costs

Resource	Average Unit Costs*(US$)
General practitioner consultation	47
Emergency department visit† (range)	308 (240-836)
Outpatient department visit	225
Day case (inpatient procedure)	819
Hospitalization (cost per day)
University hospital	787
General hospital	581
Intensive care (cost per day)	2208
Medical procedures	Reimbursement fees
Nursing home (cost per day)	301
Home care (cost per hour)
Domestic care	32
Nursing care	59
Rehabilitation
Cost per day	492
Cost per hour of treatment	122
Physiotherapy (cost per visit)	33
Transportation by ambulance
Emergency	678
Scheduled	260

*Costs are given in 2007 U.S. dollars.
†Average costs, depending on injury diagnosis and severity. Costs are based on time deployment, medical staff, and materials.

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TABLE I Unit Costs

Resource	Average Unit Costs*(US$)
General practitioner consultation	47
Emergency department visit† (range)	308 (240-836)
Outpatient department visit	225
Day case (inpatient procedure)	819
Hospitalization (cost per day)
University hospital	787
General hospital	581
Intensive care (cost per day)	2208
Medical procedures	Reimbursement fees
Nursing home (cost per day)	301
Home care (cost per hour)
Domestic care	32
Nursing care	59
Rehabilitation
Cost per day	492
Cost per hour of treatment	122
Physiotherapy (cost per visit)	33
Transportation by ambulance
Emergency	678
Scheduled	260

*Costs are given in 2007 U.S. dollars.
†Average costs, depending on injury diagnosis and severity. Costs are based on time deployment, medical staff, and materials.

Health-care volumes were estimated with national registration data and a patient follow-up survey. A patient follow-up survey was performed among a sample of 9907 injured patients who had been treated at one of the emergency departments between February 1, 2007, and January 31, 2008. Data were collected on inhospital care, outpatient visits, general practitioner visits, outpatient physical therapy, home care, medication, and aids and appliances. In our cost model, hand surgeon visits are included in outpatient visits. However, in The Netherlands, not all patients with injuries to the hand and wrist are treated by hand surgeons. Some of these patients are also treated by physicians in other specialties, such as general surgeons or orthopaedic surgeons. The costs of an outpatient department visit are the same for the different specialties, and therefore the same unit price was used for all of these visits. Hospitalized patients and severe, less common injuries were overrepresented in the sample. Victims from self-inflicted injury and institutionalized persons were excluded. Questionnaires were sent by mail at two, five, and nine months after the injury event^40,41.

Productivity Costs

Productivity costs were defined as the costs associated with production loss and replacement due to illness, disability, and premature death⁴². In The Netherlands, the patient receives financial compensation from the employer, consisting of 70% of the patient’s monthly wage, during the time he or she is not able to work. We used the absenteeism model to estimate productivity costs for all patients between the ages of fifteen and sixty-four years. In this model, the friction cost method was used because health-care needs are most substantial in the first year after injury for the majority of injuries¹⁰. The essence of the friction cost method is that, in case of unemployment, absent workers will be replaced after an adaptation period (the friction period), and in this way further productivity costs may subsequently be prevented^42,43. (The friction period is estimated to be approximately three months. For example, when an individual has been on sick leave for seven months, a maximum of only ninety days of production losses will be included in cost estimates.)

Data were retrieved from the Dutch Injury Surveillance System follow-up survey with questions relating to work absence, absence duration, and return to work. These questions were only addressed to injured patients with paid jobs, to obtain information on absenteeism⁹. The observed duration of absenteeism in working days was converted into the costs of absenteeism according to age, sex, and type of injury, using the cost per employment hour. In national accounts, the net value added equals the total monetary value generated by all units engaged in production activities. We divided the net value added (obtained from Statistics Netherlands⁴⁴) by the total number of hours worked to calculate the productivity of one hour worked. This net value added per employment hour was adjusted for age and sex with use of the mean wage per category. We estimated the probability of employment within the injured population, using labor participation figures derived from the Injuries and Physical Activity in The Netherlands (IPAN) survey⁴⁵. This is a continuously executed telephone survey of a sample of 10,000 Dutch citizens with regard to accidents and sports injuries. These outcomes were adjusted for age with use of the national age distribution within the employed and unemployed population from Statistics Netherlands.

To calculate probabilities of work absenteeism, independent variables were tested as significant predictors of work status in forward step multivariate regression analyses⁹. We included an injury-by-hospitalization interaction term to test whether the distribution of work status by type of injury was significantly different between patients who were not hospitalized and those who were hospitalized. Adjustment for stratification could influence the identification of significant independent variables. To avoid this, we used bootstrap analysis (a resampling method) by which a specified number of population samples are drawn (iterations). The distribution of the drawn populations across the variables provides information about the significance of each variable. We performed 500 iterations to test the significance levels. The most significant variable was entered into the model, and the other variables were subsequently entered. This procedure was repeated until none of the variables was significant. The 95% confidence intervals of the variables in the univariate and final multivariate models were determined by using the 2.5% lowest and highest percentiles of 500 iterations. The probabilities of work absenteeism were multiplied with the average duration of absenteeism, classified by age, sex, type of injury, and admission status⁹. Finally, the estimated absenteeism in days was multiplied by the age and sex-specific productivity cost. All costs are reported in U.S. dollars, and we used the year 2007 average exchange rate for conversion from Euros to U.S. dollars (€1.00 = US$1.37).

Source of Funding

No external funding source was used in this study.

Results

Injury Incidence, Health-Care Costs, and Productivity Costs

The total number of injured patients treated at emergency departments in The Netherlands in 2007 was estimated at 920,000 (57% were male and 43% were female), resulting in an injury incidence of fifty-six per 1000 person-years. The total costs of injuries in The Netherlands were $4.4 billion, divided into $2.5 billion in direct health-care costs and $1.9 billion in productivity costs (Table II).

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TABLE II Health-Care and Productivity Costs of the Most Expensive Injury Types in 2007

	No. of Injuries* (thousands)	Cases (per 100,000)	Health-Care Costs† (millions)	Health-Care Costs per Case†	Productivity Costs† (millions)	Productivity Costs Per Case†	Total Costs† (millions)
Hand and wrist injuries	260	1575	329	1265	411	1580	740
Knee and lower leg fractures	66	400	233	3530	329	4985	562
Hip fractures	15	90	480	32,000	52	3465	532
Superficial injuries*	270	1600	301	1115	107	400	408
Skull brain injury	32	200	136	4250	219	6845	355
Other	277	1700	988	3570	801	2890	1789
All injuries	920	5600	2467	2680	1919	2086	4386

*Superficial injuries to hand or wrist were excluded.
†The values are given in U.S. dollars.

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TABLE II Health-Care and Productivity Costs of the Most Expensive Injury Types in 2007

	No. of Injuries* (thousands)	Cases (per 100,000)	Health-Care Costs† (millions)	Health-Care Costs per Case†	Productivity Costs† (millions)	Productivity Costs Per Case†	Total Costs† (millions)
Hand and wrist injuries	260	1575	329	1265	411	1580	740
Knee and lower leg fractures	66	400	233	3530	329	4985	562
Hip fractures	15	90	480	32,000	52	3465	532
Superficial injuries*	270	1600	301	1115	107	400	408
Skull brain injury	32	200	136	4250	219	6845	355
Other	277	1700	988	3570	801	2890	1789
All injuries	920	5600	2467	2680	1919	2086	4386

*Superficial injuries to hand or wrist were excluded.
†The values are given in U.S. dollars.

Hand and wrist injuries accounted for $740 million in 2007 and ranked first in the order of most expensive injury types, before knee and lower limb fractures ($562 million), hip fractures ($532 million), and skull-brain injury ($355 million). An amount of $411 million (56% of the costs due to hand and wrist injuries) was related to productivity costs. The high productivity costs are also reflected in the age distribution, showing that people of working age (twenty to sixty-four years) were responsible for approximately 75% of all costs due to hand and wrist injuries (Figs. 2 and 3). This was due to the large contribution of productivity costs in this age group ($192 million) in men.

Fig. 2

Total health-care and productivity costs (U.S. dollars in millions) due to hand and wrist injuries in The Netherlands in 2007, according to sex and age group.

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Fig. 3

Mean health-care and productivity costs per case (U.S. dollars in thousands) due to hand and wrist injuries in The Netherlands in 2007, according to sex and age group.

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Within the overall group of hand and wrist injuries (see Appendix), hand and finger fractures were the most expensive group ($278 million), again largely due to the age group of twenty to sixty-four years ($236 million). Fractures of the hand and finger are responsible for almost half of the total productivity losses, due to a combination of the high number of fractures in the working age group of twenty to sixty-four years and the high costs per patient because of the longer time off from work with such injuries compared with even more frequently occurring injuries, such as open wounds or superficial injuries.

Wrist fractures cause high health-care costs per patient, especially in patients over sixty-five years old, and therefore represent high total health-care costs. More than half of the patients with hand and wrist injuries have open wounds or superficial injuries, but they account for <10% of the observed economic burden. This group has relatively low health-care costs per case and low productivity loss. The number of patients with complex soft-tissue injuries (e.g., a crush injury or traumatic amputation) was low, but at the individual patient level, these injuries cause both high health-care costs and productivity loss.

Discussion

A major strength of the present study is that it is based on population-based nationwide inpatient and outpatient data on the incidence and costs of hand and wrist injuries. Registries with national coverage were used to analyze the health-care resources that are most important for injuries, such as hospital inpatient care, medical procedures, rehabilitation treatment, and nursing home care and long-term care at home. International validation studies, including data systems of ten European countries, have shown that the Dutch Injury Surveillance System has a high level of completeness and validity^32,33. Furthermore, this study presents a comprehensive incidence-based cost model in which both health-care and productivity costs were included for all injuries^10,34. Because a uniform coding method has been used to estimate the costs, it was possible to compare the health-care use and related health-care costs of all types of injuries with a uniform methodology. The incidence-based cost model was developed in The Netherlands, but has been used in ten European countries. This has shown similar distributions by age, sex, and injury type in other countries as in The Netherlands. Furthermore, previous cost-of-illness studies from the Dutch National Institute of Public Health and the Environment produced results for injury costs that were similar to those in our model^33,37,38.

In calculating productivity costs, the absenteeism model estimates the costs for the first year after injury. In this study, we used the friction cost method because in the majority of injuries, health-care needs are most substantial in the first year after the injury¹⁰. In health economics, several methods have been proposed to estimate the costs due to economic production losses. Many previous cost-of-illness studies and economic analyses have used the human capital method. In the human capital method, productivity loss is considered from the patient’s perspective and is calculated as the product of the total hours of lost productivity until the age of retirement in a population and the hourly wage. While many previous studies used the human capital method, this approach has often been criticized because of overestimations of the magnitude of productivity costs. The friction cost method more accurately measures productivity costs because it takes into account that, in case of unemployment, absent workers will be replaced after an adaptation period^42,43.

An inherent limitation of a population-based survey of this scale is the lack of available clinical details of the injury—for example, the anatomic location of a fracture, the fracture type, or whether the fracture was open or closed. This was due to the use of nonspecific fracture codes, such as wrist fracture, including distal radial fractures and fractures of the carpal bones. Therefore, the precise distribution of distal radial fractures and carpal fractures is not known. We used a broad classification system, which aggregated several severe injuries (traumatic amputations, crush injuries, and injuries to blood vessels and muscles and tendons) in one single category: complex soft-tissue injuries (see Appendix). Despite the heterogeneity of this injury category, this limitation will not have influenced the cost estimates importantly because of the low frequencies on the population level. Another limitation of this study is that we only included patients who were treated in the emergency department. In The Netherlands, there are specialized hand surgery centers that treat patients outside a hospital setting. However, these centers generally perform elective surgery, and almost all patients with acute injuries to the hand or wrist are treated at the emergency department or by a general practitioner. In 2007, approximately 920,000 injured patients visited an emergency department, and the same number of patients was treated by a general practitioner or other primary health-care providers. Most patients treated outside the hospital setting have minor injuries, such as cuts, abrasions, dislocations, sprains, and strains. For this reason, and assuming that the cost per patient is not different from the cost per patient with minor injuries treated at the emergency department, we estimated that they will add only 2% to 5% to our cost estimate.

A previous study from The Netherlands showed that the costs due to injuries are comparable with those of cancer and stroke^3,12. However, to our knowledge, this is the first population-based study that shows that the total costs of hand and wrist injuries are a real economic burden to society and compares both health-care costs and productivity costs with expenditures for other injuries. This comprehensive approach hampers a straightforward comparison with other studies done with use of other analytic methods and populations. A previous population-based study from The Netherlands estimated health-care costs due to all injuries to be US$1.58 billion in 1999, resulting in US$90 per capita for males and US$108 for females³. Fractures were expected to have the highest costs of all injuries because of possible admissions, longer rehabilitation, casting, radiographs, and surgery. That study found hip fractures to be the most expensive injury group in the proportion of health-care costs, representing 20.4%. However, the study did not estimate productivity costs. In the same study, the proportion of health-care costs due to fractures of the wrist, hand, and fingers together represented 6.3% of the total costs. Total health-care costs were lower than those in our study, which may largely be explained by the fact that data used in that study were derived from 1999.

Rosberg et al. reported costs due to lost production after hand injuries to be 67% of the total costs, while Trybus et al. estimated the proportion of productivity costs to be up to 96%^14,15. Other studies from Sweden have analyzed treatment and rehabilitation costs of a nerve injury for an employed person and found productivity costs to be 87% of the total costs and 55% to 65% for tendon injuries^16,17. The proportion of productivity costs for hand and wrist injuries in our study (56%) is comparable with or even lower than that found in most previous clinical studies. Differences are probably due to variation in methods used to obtain data or case mix, different cost elements, different time periods, and different health-care and social security systems. For example, Day et al. reported that patients with hand and wrist disorders who receive Workers’ Compensation contribute to increased health-care costs and spend longer periods of time out of work than do patients who are not receiving this compensation⁴⁶.

Clinical research on surgical and rehabilitation interventions for hand and wrist injuries that aim to lower the time off from work—for example, minimally invasive surgery techniques or early active mobilization therapy—may have a large economic potential. A patient-oriented rehabilitation program after hand surgery reduces the time off from work⁴⁷, and early dynamic motion after tendon transfers can shorten rehabilitation time⁴⁸. In the field of public health, epidemiological research may elucidate the main causes of hand and finger fractures, for example, to develop prevention strategies targeted at the most costly injuries.

In conclusion, hand and wrist injuries not only constitute a substantial part of all injuries seen in the emergency department but also represent a considerable economic burden to society. In this population-based study, these injuries have both high health-care and productivity costs, with the latter making the largest contribution. Hand and wrist injuries should be a priority in trauma research and trauma care to guide interventions so as to reduce the costs of these injuries, both to the health-care system and to society.

Appendix

Tables showing the diagnostic groups used in the study, with the corresponding ICD-10 codes, and the health-care and productivity costs of hand and wrist injuries in The Netherlands in 2007 are available with the online version of this article as a data supplement at jbjs.org.

Acknowledgements

Note: The authors thank C. Draisma from the Consumer and Safety Institute for data collection.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

netherlands ; wrist injuries ; economics ; hand ; health care

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C.E. de Putter, R.W. Selles, S. Polinder, M.J.M. Panneman, S.E.R. Hovius, E.F. van Beeck; Economic Impact of Hand and Wrist Injuries: Health-Care Costs and Productivity Costs in a Population-Based Study. The Journal of Bone & Joint Surgery. 2012 May;94(9):e56 1-7.

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