To the best of our knowledge, this study was the first to study the CCE of injuries in dimensions of age and site of injury at this scale among the Chinese population. This research showed the evidence-based target population and categories of injuries that could be the priorities of interventions reducing the burden of injuries.
1. The rising mortality rate in injuries and its differences between urban and rural areas
Over the period 2006–2016, injury mortality has increased with fluctuations in China, reflecting a continued focus on injury treatment rather than prevention and increasing exposure to injury-related risk factors in the fast development of social economy . Overall, the mortality and composition ratio of injuries in Chinese rural areas were higher than in urban areas. The finding agreed with the research led by Chunhua He who indicated that injury mortality in under-5 children in rural areas was higher than in urban areas . The global context that the low and lower-middle-income areas typically had higher mortality rates containing injury mortality was also similar to the finding [21, 22]. It was probably because rural people were at higher risk of injuries since they usually live, work and go to school in unsafe environments. They also benefit less from basic public health services, and have less access to high-quality treatment and rehabilitation services due to the underdeveloped economy.
Injuries continue to be an important cause of morbidity and mortality globally. Injuries are the fifth leading cause of death in our country and impose a heavy financial burden on society and the state. When looking at the CCE according to the statistic provided by Dalian City, injuries are major public health issues and the enormous cost burden to sustain. So we study the cost of injury treatment in Dalian to evaluate its economic burden.
2. Differences in CCE consumption in different age groups, with emphasis on high consumption age groups
The study found that the CCE of injuries in Dalian had reached 1572.73 million RMB, accounting for 7.45% of the total curative care expenditure, 0.23% of GDP . Not only in China, but also the expenditure on injury treatment was high in some developed countries. The adjusted national medical cost of injuries was estimated at 56 billion dollars and out-of-pocket cost was approximately 4 billion dollars in the USA .
On one hand, the CCE of injuries in the 45–65 age group as the top one among the 8 age groups, accounting for 41.13% of the total CCE of injuries in Dalian. This may be due to the large population of this age group, resulting in the high cost of injuries. Based on the data of China Statistic Yearbook 2017, the proportion of the population aged 45–65 in the total population has reached 28.46%, which is the highest in the eight age groups. Another reason may be that middle-aged adults (aged 45–65 years) are more likely to be injured because they undertake more socially productive activities . On the other hand, the CCE of injuries contributed a higher proportion of total curative care expenditure in the 15–45 age group than that in other age groups. The latter situation could be explained by discharge records in 2016 that 36.7% of discharge patients of hospitals in this age group were diagnosed with injuries . This study showed that interventions should be implemented, targeting people at the age of 15–65.
3. There were special patterns of injury burden distribution among different age groups
For outpatient, the interpretation of the CCE of injuries in dimensions of age and type could be divided into three levels. As for under-15 children, the cost of injuries was mainly caused by “Injuries to the spine, skin or blood vessel and effects of foreign body entering” and “Injuries to the head”. The top two of young people aged 15 to 65 years and elderly people over the age of 65 were “head, lower limb” and “lower limb, head” respectively. The probable reason was that people in different age groups were vulnerable to different injuries. Mostly caused by falls, there were high rates of head injury admissions to hospitals occurred among 0–4-year-old (215.5 per 100,000) and people over 65 years of age (188.5 per 100,000) annually . These findings were consistent with the international mainstreams of opinions.The World Health Organization (WHO) reports that most deaths from falls happen in those aged 65 and older. For those 70 years or older, falls are the leading category in injury-related deaths. An injury surveillance system pilot study conducted in 4 low/middle-income countries found that falls accounted for the largest percentage (56%) of recorded injuries among children . A study conducted in India similarly found that the most common type of home injury in children aged 0–14 was falling . While children and the elderly were most likely exposed to foreign body and fall-related injuries, the heaviest injury cost burden of the youth was due to road traffic injuries . The inpatient data presented results similar to the outpatient.
4. Injuries to the spine, lower limb, head and the effects of foreign body entering were the points a farsighted society need attach importance to
The CCE was also different in various body regions of injuries. As results showed, the highest cost happened in “Injuries to the spine, skin or blood vessel and effects of foreign body entering”, followed by “Injuries to the lower limb” and “Injuries to the head”. That could be attributed to the high frequency and severity of these injury categories . According to the estimate of National Spinal Cord Injury Statistical Center, the annual incidence of spinal cord injury was approximately 54 cases per one million people in the USA, in which the leading causes were vehicle crashes and falls . A study carried out in New Zealand showed that head injuries remained a large proportion of injury-related deaths . Besides, our results of body regions of injuries basically consistent with those of Zhao Meitao. Research on the injury cost in Gansu Province, China shows that the cost of lower limb injury is as high as CNY 1.09 billion, which is the highest among all injury sites. Lower limb injury has a serious impact on the work and life of residents, and also causes heavy economic burden and social loss.The treatment cost of head injury is 847 million yuan. The special physiological structure of the head leads to serious injuries and consequences after the injury, and the treatment cost is high. It is urgent to strengthen the head safety education and control in traffic and occupational places . In terms of injuries to the extremities, extremity fractures had high costs due to high incidences and high productivity costs per patient . Meanwhile, the UK study also shows that open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient and associated with the severity and area of the limb injury .
5. Suggestions to decision-makers
Injuries had led to high economic costs, in fact, injury prevention was an enormous challenge in China. Chinese authorities need to allocate more resources of injury prevention to less developed areas, and especially western regions and rural areas. Up to date, National Health Accounts showed government health funding for preventive programs remained minimal . This article calls for increasing funding for injury-related prevention programs. We also highlight the importance of unintentional injury interventions, legislation, and enforcement at a national level . According to the characteristics of injuries in different age groups, the government can implement targeted interventions in different crowds and then test the effectiveness of them . For instance, to protect children from fall-related injuries, schools can install soft rubber and waterproof floor for schoolyards .
Our study has some limitations. Firstly, researchers considered the perfection of health information management system when choosing sample counties, which could have introduced biases. Secondly, The cost of injuries calculated in this study does not include the cost of subsequent treatment of other diseases resulting from the sequelae of injuries.