What's new in critical illness and injury science? The costs of having a fall in Qatar!

In this issue of the International Journal of Critical Illness and Injury Science, we have provided insight into the incidence and financial impact of fall-related injuries in Qatar. The authors of the study assess the incidence and hospital costs of an occupational fall-related injury at approximately 114/100,000 workers and $15,000 USD per fall.[1]

Perspective can be gained by comparing this cost to the incidence and typical costs in the USA of 338/100,000 workers and $22,000 USD for a trauma admission and to the average yearly cost of hemodialysis in Saudi Arabia of $50,000 USD.[2-4] It must be emphasized that the present study design can only underestimate the incidence and true cost of these injuries and overestimate fatality rate - less severely injured patients may either have not been admitted to the trauma service or not been taken to other hospitals. Additionally, those who died before hospitalization and the costs incurred for ongoing medical care of foreign workers following repatriation were not included in the cost portion of the analysis.

Although Qatar has been ranked as the world's richest country by Forbes magazine in terms of GDP,[5] its health care expenditures in 2008 of $2.8 billion ranked 37th, at $1691 per capita for a country of 1.7 million people, compared to $7164 in the USA in 2008.[6] Consequently, this assessment of fall-related injury admitted to the only trauma center in Qatar accounts for 0.15% of Qatar's total health care expenditures, as compared to approximately 0.9% of all health care expenditures in the USA.[78] Consequently, while fall-related injuries represent a significant cost in Qatar, it appears to be proportionately less than North American estimates of health care expenditures based on the data presented.

One of the reasons for undertaking a cost-of-injury study is to provide an economic perspective on health care expenditures. Unfortunately, as pointed out by Currie et al, cost-of-injury studies suffer from significant limitations.[9] While they can raise public awareness and provide important starting points for discussions of prevention strategies, they may be less useful for establishing fiscally advantageous health policy. This information can only be obtained through an examination of the cost and effectiveness of the intervention strategy in conjunction with the cost of injury, as ineffective and/or expensive prevention strategies may result in increased overall costs. Consequently, additional data are required to assess whether the costs associated with fall-related injuries will be offset by a proposed prevention program.

The authors acknowledge that the data supporting the effectiveness of multifaceted injury prevention programs are limited. The most recent Cochrane Systematic Review on injury prevention identifies three types of interventions that have been studied: government regulation, drug-free workplace programs, and safety campaigns.[10] The review emphasizes that all studies are of low methodological quality, and have small effects at most. The data suggests that government regulation alone is not sufficient to reduce the incidence of fatal and non-fatal injuries in the construction industry. Conversely, implementation of drug-free workplace programs and safety campaigns do appear to have an initial effect on the rate of non-fatal injuries, but only safety campaigns result in sustained reduction in injury rates. The lack of sustained effect with drug-free workplace programs may be in part explained by an unintended shift in the pattern of drug use after implementation of drug-use screening programs. After an initial decrease in overall illicit drug intake, drug users begin to select compounds with shorter excretion half-lives (such as cocaine). By avoiding drugs whose metabolites remain detectable for weeks (such as marijuana), the drug users avoid the consequences of a positive drug screen. On the other hand, one could postulate that an important effect of implementation of a culture of safety in the workplace may be sustained behavioral change in its workers, resulting in persistent improvement in injury rates. Unfortunately, there is no data at present supporting or refuting the potential mechanisms of these effects.

The costs of these programs vary according to the scope and intensity of the interventions. Kaskutas et al describe the development of a comprehensive fall-prevention program based upon a needs assessment of apprentice carpenters coupled with an iterative curriculum development process.[11] This program includes a simulated work-site in which apprentice carpenters learn and practice safety skills. It should be noted that although participants felt that this comprehensive practical training was useful, no clear data exist with respect to the impact of even this intervention on hard endpoints such as rate of falls, injuries or death. Thus, questions remain regarding the utility of spending the substantial financial and human resources on implementing such a program, and ultimately what party or parties would be responsible for absorbing those costs. It should be noted that a financial analysis does not quantify the deep emotional costs of these falls. As mentioned, many of the patients suffer head and spinal trauma, which undoubtedly profoundly affects the quality of life of many of the survivors. The consequences for some individuals are likely devastating, making it difficult to argue against the ethical and moral need for ongoing surveillance of the problem and institution of legislation and injury prevention measures. Ultimately, specific decisions regarding how much money to spend on a variety of prevention options are necessary – a process that also includes defining and assigning economic value to human quality and quantity of life. Such decisions are major struggles for governments and policy makers. They require input from the populace, and demand careful consideration of societal and cultural values in the context of the competing needs of the population in question.