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The Cost Implication of Burn Care

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The Cost Implication of Burn Care THE COST IMPLICATION OF BURN CARE A PROSPECTIVE STUDY OF EARLY AND LATE COST A DISSERTATION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE FELLOWSHIP IN SURGERY (PLASTIC, BURNS AND RECONSTRUCTIVE) DR AHACHI, Chukwukadibia Nnabugwu 1 TABLE OF CONTENTS Title page………………………………………………. i Table of contents……………………………………. ii Declaration……………………………………….…… iii Attestation………………………………………….…. iv Ethical clearance…………………………………..… v Dedication…………………………………………..…. vi Acknowledgement………………………………….. vii Abstract…………………………………………….….. viii Introduction…………………………………………… 1 Literature review………………………………..….. 4 Patients and methods…………………………..… 46 Results………………………………………………..… 50 Discussion……………………………………………... 66 References ………………………..………………….. 79 Proforma for data collection…..………………… 99 2 DECLARATION I hereby declare that the work presented has been done by me under the supervision of Dr IO Fadeyibi (FMCS, FWACS), Dr MK Chira (FWACS) and Dr FO Abikoye (FWACS) at the National Orthopaedic Hospital, Igbobi-Lagos. It has not been submitted in part or in full for any other publication. DR CN AHACHI 3 4 5 DEDICATION To my parents, my wife, and my children: I am humbled by your unflinching support, love, and confidence in me. To my teachers for their patience and devotion. To the patients: your courage never ceases to amaze and inspire me. 6 ACKNOWLEDGEMENT I wish to thank all those who contributed to the realization and success of this work. I particularly acknowledge the immense assistance of my supervisors Dr IO Fadeyibi, Dr MK Chira, and Dr FO Abikoye. I also thank Dr SU Eyesan, Dr AO Ugwoegbulam and Dr AO Ajani for their encouragement and guidance. I express my sincere gratitude to all members of the Burns and Plastic Surgery Department, Medical and Health Records Department, and all other staff of the National Orthopaedic Hospital, Igbobi-Lagos for their assistance. I thank the Hospital authorities for their support. I also appreciate the efforts of the experienced researchers at the Nigerian Institute of Medical Research who gave very valuable advice, and all other friends that helped make this work a reality. Thank you all. 7 ABSTRACT Aims: Burn injuries present major challenges to the patients and the burn care providers. Cost is one of the most prominent aspects of these challenges. This is heightened by the high prevalence of poverty in our Society and inadequate funding of the Health Sector by all tiers of Government. The Cost Implication of Burn Care is a prospective study of the early and late costs incurred in the management of burns. Methods: Patients presenting with acute burn injuries or post-burn complications at the National Orthopaedic Hospital, Igbobi-Lagos between June 2007 and May 2008 were studied. Biodata and details of treatment related to cost were recorded. The data were updated at intervals as necessary for each case during the study. Results: Fifty-two patients were seen during the study period. The average cost per day was N8,855.00, while the average total cost of early treatment was N209,805.7 ±77,397.2, with a range of N14,470 to N2,206,950. Dressings accounted for 51.6% of the total early cost, in- patient charges were 18.5%, while surgery accounted for 4.3%. The average cost of late treatment was N208,761.6 ±169,959.3, with a range 8 of N13,050 to N738,940. Thirty-five percent of the total late cost was spent on surgery, 33.5% on in-patient charges, and 5.6% on dressings. The unquantifiable costs included job losses, lost man hours and social costs. Conclusions: The study showed that the monetary and non-monetary costs of burn care were significant. Suggestions on cost reduction were made. The role of burn prevention was also emphasized. CHAPTER I INTRODUCTION 1.1 BURNS: A REAL CHALLENGE Burn injuries represent one of the most devastating forms of trauma that can be sustained by any individual due to the pathophysiologic changes and prolonged metabolic effects .The injuries result in profound morbidity and high mortality.1-4 Morbidity has been shown to be as high as 50% in some studies,4while mortality ranged from 4.6% to 29%.5,6 Management of major burns involves prolonged hospital stay, use of costly medications, consumables, and possibly multiple surgical procedures.7 The outpatient management often 9 involves multi-specialist clinic visitations for varying lengths of time.8 Working hours are lost by both the victims and people looking after them. The cost implications of these may be quite heavy for the patients, the employers, and the country.9 Figures are however not readily available for most developing countries and statistical gaps exist even in developed countries.10 Burn injuries present major surgical, social and economic problems in both developing and developed countries. These problems are more pronounced in the developing world where paucity of resources constitutes the greatest handicap in burn care.11 In the United States, the cost of burn care is estimated at $2000 per day!12 A study of scald injuries in children done in the United Kingdom put the average cost of management at £1850 per case.13 Burn disasters have recently taken epidemic proportions in Nigeria.14 Factors that have been implicated include the worsening socio-economic status, irregular electric power supply, scarcity and adulteration of petroleum products – often leading to hoarding and inappropriate storage, as well as repeated vandalizing of petroleum pipelines.3,9,15 Other factors include ignorance, poor domestic and industrial safety practices, and high incidence of road traffic accidents.1 10 Caring for the victims of these fire accidents has been demanding financially, emotionally, physically and in many other ways. Many studies from all over the world have highlighted the financial and other inestimable costs of burn care, making it obvious that burns present a major financial challenge.5,16,17 1.2 AIMS AND OBJECTIVES OF THE STUDY. The goals of this study are to: 1. To identify the monetary and non-monetary cost of early and late burn care. 2. To study the factors that influence the cost of management of burns patients. 1.3 JUSTIFICATION FOR THE STUDY Cost is a major factor in burns management. However, there is a paucity of studies on the socioeconomic aspects of burn care. This makes it more difficult to appreciate enormity of the economic and social burden placed on the burn patient and his loved ones. Studies 11 that highlight these issues may help to attract more funding for burn care. A study of burn care costs also serves as a kind of audit which helps the clinician to focus his energies on practices that are beneficial to the patient and discard those that are neither beneficial nor cost-efficient. CHAPTER II LITERATURE REVIEW 2.1 BURNS A burn injury is coagulative necrosis of the skin with or without the involvements of underlying tissue – possibly extending as deep down as bone.18 Causes of burns include both physical and chemical agents. In thermal burns, the degree of injury depends on the temperature of the heat source and the duration of exposure of the tissue to it.18 In chemical burns, the nature and concentration of the causative agents are important in determining the extent of the injuries. 2.2 EPIDEMIOLOGY 12 There are no community-based studies of burn injuries in Nigeria but there has been an upward trend in the number of cases of burns recorded in Nigerian hospitals recently.19,20 A number of hospital- based studies have been carried out including those at Lagos,1 Zaria,2,6 Port Harcourt,3 Ibadan,19 and Enugu.21 A community-based study of 955 randomly-selected children carried out in Ghana put the percentage of scalds at 45, contact at 33, flame at 19, and others at 3.22 National incidence figures were not found for Nigeria and for the rest of the West African region. However, reports of hospital admissions from various Nigerian tertiary institutions paint an unpleasant picture. An average of 100 hospital admissions per year was reported by Fasika in Ibadan.19 A study of 89 burn patients admitted to the Lagos University Teaching Hospital between 1968 and 1975 showed an age incidence of 1 day to 54 years with 56.2% occurring in children below the age of 15 years.1 Domestic accidents accounted for 70.8%. The mortality rate was 13.5% and there was severe morbidity in the surviving cases. The average admission period in 73 cases was 37 days, and the average total healing time in 57 cases was 54 days. Similarly, 245 adult burn patients admitted to the Ahmadu Bello University Teaching Hospital, Zaria between 1971 and 1981 were 13 studied by Mabogunje and Lawrie.2 Major burn injuries accounted for about 80%, moderate injuries, 11%, and minor injuries 8%. Contributing factors were socioeconomic including the use of firewood for cooking and warmth during the Harmattan, loose indigenous garments, thatched roofs of houses, inappropriate storage of petroleum products, and epileptic seizures. Flame burns predominated with a spike during the Harmattan season. Puerperal hot sitz baths was a major cause of the scalds which occurred mainly among women. The overall mortality was 22%. A two-year study of 141 new cases of burns treated at the University of Calabar Teaching Hospital between January 1984 and December 1985 showed a predominance of minor injuries: 64.5%.5 Moderate injuries accounted for 28.4%, while 7.1% sustained major injuries. Mortality was 4.6% and co-related with the predominance of minor injuries. Most of the injuries were from domestic accidents.5 Ninety-two patients were studied in Port Harcourt, 46.7% of whom were children in the 0-5 years age group.3 The overall mortality was 26.1% and co-related with severity of injury.
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