The Burden of the Current Curative Expenditure of Injury in Dalian, China-A study Based on "System of Health Accounts 2011"

doi:10.21203/rs.3.rs-42872/v1

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The Burden of the Current Curative Expenditure of Injury in Dalian, China-A study Based on "System of Health Accounts 2011"

https://doi.org/10.21203/rs.3.rs-42872/v1

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Background: Injury is one of the major public health problems, which causes more than 5 million deaths in the world every year. Cases of specific types of injury put a tremendous threat to human health and also add a heavy medical burden on individuals and societies. This study was to calculate and analyze the current curative expenditure (CCE) of injury in Dalian and consequently to provide control strategies for decision-makers.

Methodology: A total of 565 medical institutions were selected with multistage stratified cluster random sampling, containing 4,375,351 valid samples. Subsequently, the distribution of injury CCE in different dimensions (including age and site of injury) was analyzed under the framework of System of Health Accounts 2011(SHA 2011) using the established database.

Results: There were increases from 32.36/100,000 in 2006 to 37.34/100,000 in 2017 and from 46.12/100,000 in 2006 to 54.48/100,000 in 2017 in urban and rural residents respectively. The study found that the CCE of injury in Dalian had reached 1572.73 million RMB, accounting for 7.45% of the total curative care expenditure. In the 15-25 age group, the cost of injury accounts for a larger proportion of CCE than other age groups. Among the injuries in different regions of the body, injuries to the spine, lower limb, head and foreign body entering cost the most.

Conclusions: Dalian has a relatively serious burden of injury costs. The essential and primary goal is to reduce the cost and increase the benefit of attending to patients with injuries. Specific control strategies should be tilted toward the age group 15-25. Injuries to the spine, lower limb, head and foreign body entering also should be priorities of interventions.

Health Policy

Current curative expenditure

Injury

Control strategies

System of Health Accounts 2011

In recent years, the incidence and mortality of injury had an increasing trend on a global scale. Injuries–resulting from traffic collisions, drowning, poisoning, falls or burns - and violence - from assault, self-inflicted violence or acts of war–kill more than five million people worldwide annually and cause harm to millions more. They account for 9% of global mortality, and are a threat to health in every country of the world. Injuries have become a major public health problem facing all countries in the world [1]. Injuries are one of the leading causes of death in China, with about 300 million injuries occurring each year, accounting for 11% of deaths nationwide [2].

Injury was the leading killer of young people. About 1.25 million people died from road traffic injuries in 2013. Road traffic injuries are the leading cause of death among people aged 15 to 29. Globally, road traffic deaths increased by about 13 percent between 2000 and 2013 [3]. We estimated that road injuries will cost the world economy US$1.8 trillion (constant 2010 US$) in 2015-30, which is equivalent to an annual tax of 0.12% on global gross domestic product (GDP) [4]. Open lower limb fractures are expensive to treat at a cost of approximately £19,200 per patient in England [5]. This in turn, resulted in a great labor force and economic loss. Which then further stunted the process of social development. As a result of the high incidence and heavy financial burden of injury, governments around the world had become compelled to find the keys of decreasing and preventing such incidence frequencies because of the significant social impact and financial burden from them.

In China, the current curative expenditure (CCE) of injury was also a big challenge. Injuries imposed heavy costs on individuals and society. According to WHO estimation for China in 2016, the age-standardized Disability-Adjusted Life Years (DALYs) per 100,000 from injuries were 31343.7 [6]. In 2014, medical expenses for accidental injuries in Sichuan province were 491.15 million yuan [7]. In 2017, the CCE of injury in Gansu province was 3.831 billion yuan [8].

According to the report of China national statistical yearbook 2017, the mortality of injuries in 2016 for urban residents and rural residents were 37.34 and 54.48 per 100,000 respectively. Deaths from injuries contributed 6.08% of all deaths in urban residents and as much as 8.01% of all deaths in rural residents [9]. Approximately 50% of deaths in the age of 15–30 were due to injuries [10]. At the same time, more people were treated or hospitalized because of injuries. The burden of medical expenditure caused by injuries was predictably huge.

In previous studies, the data of injuries was mostly obtained from the death registration reporting system of China Center for Disease Control and Prevention or the National Injury Surveillance System (NISS) [11], being analyzed according to external causes. Most studies’analysis of the burden of injuries was based on incidence, mortality, death cause sequence and DALYs. However, those studies were lacking the details of treatment and payment. Measuring the cost of injuries and its characteristics is critical to identify priorities for policies, which are aimed at reducing injuries and their consequences. Therefore, the study of the CCE is still in need of further research [12–14].

System of Health Accounts 2011(SHA2011) is a new health care accounts system, it provides a framework to account the CCE by different types of diseases and different age groups, excluding the expenditure of prevention [15]. This study used SHA 2011 to analyze the distribution of injury cost burden in different age groups and in different classifications. Finally, the key objectives and methods were drawn to reduce the burden of injuries and provide references for decision-making departments.

Macro data

Macro data was obtained via 2017 Liaoning Health Statistical Yearbook, 2017 Liaoning Health Financial Yearbook, Dalian Current Health Expenditure Report 2016, etc. Injury mortality and its percentage of all causes of deaths in China (2006–2016) were collected base on China national statistical yearbook 2007–2017.

Sample data

A total of 565 health institutions were chosen with multistage stratified cluster random sampling in Dalian 2016. Firstly, this study selected seven districts and two counties and the municipal medical institutions and public health institutions in Dalian. Secondly, 21 institutions were chosen per district or county, including one general hospital, one maternal and child health hospital, one center of disease control and prevention, one traditional Chinese medicine hospital and 17 clinics. The next step in each district was to select five community health service centers (CHS) and three stations per CHS. The subsequent step in each county was to select 20 township hospitals and three subordinate village clinics, each in the respective township. Thirdly, researchers cleaned up and standardized the key information which was uploaded by these institutions, such as age, gender, disease, International Classification of Disease Tenth Revision (ICD-10) codes, expense, types of insurance, etc. Finally, the state database was created, containing 4,375,351 valid data after excluding the invalid or wrong messages.

Classification methods

This study divided the samples into eight age groups [16]. These age groups were grouped unevenly, It is mainly due to the difference of injury situation in different age groups, the degree and type of injury are different. Different children (infants under one year of age, and children under five years of age) have different injury sites and frequencies, and the causes of injury in the elderly are different from those in the young, so the costs are different, and they need to be distinguished by age [17, 18]. Including less than one, one and above, five and above, 15 and above, 25 and above, 35 and above, 45 and above, 65 and above. classify the injuries according to the regions of injury, using Chap. 19 of the ICD-10, and its coding range is S00-T97. In this study, the classification method was used to define different types of injuries, a total of 14 categories including head injury, neck injury and chest injury, etc.

Formula

When calculating the CCE, we must firstly exclude the data related to prevention and then ran the following formula, differentiating outpatient and inpatient.

In the above formula, S_CCE, S_INC and S_ALL were macro data, representing the CCE of all patients, curative income and basic expenditure allowance respectively in different medical institutions. S_kEXP and S_TEXP were sample data, representing the curative income in each patient and the total curative income respectively in different types of medical institutions. The ratio of S_kEXP to S_TEXP provided the sharing coefficient of S_INC. S_kSTA and S_TSTA were also derived from sample data, representing each patient’s stay days and the total stay days respectively, which ratio was the sharing coefficient of S_ALL. K could be the total of different age groups, the total of different types of diseases and so on. Using this formula could bring out the CCE in various dimensions [15]. All data analysis was performed using STATA12.0.

1. Injury mortality and its percentage of all causes of death in China (2006–2016)

Table 1 illustrates the changes of injury-related mortality and composition ratio from 2006 to 2016 in China. In terms of mortality, there were increases from 32.36/100,000 in 2006 to 37.34/100,000 in 2017 and from 46.12/100,000 in 2006 to 54.48/100,000 in 2017 in urban and rural residents respectively. Injuries as the fifth leading cause of death contributed a lot to the burden on families and society. Moreover, the mortality and composition ratio of injuries in rural were greater than urban. (Table 1).

Table 1

Injury mortality and its percentage of all causes of death in China (2006–2016)
Year	Urban residents			Rural residents
Year	Mortality(per100,000)	Percentage(%)	Sequence	Mortality(per100000)	Percentage(%)	Sequence
2006	32.36	6.10	5	46.12	8.90	5
2007	37.63	6.09	5	52.07	8.96	5
2008	31.26	5.08	5	53.02	8.59	5
2009	34.66	5.59	5	54.11	8.25	5
2010	38.09	6.16	5	52.93	8.49	5
2011	33.93	5.47	5	56.50	8.85	5
2012	34.79	5.67	5	58.86	8.92	5
2013	39.01	6.30	5	57.14	8.72	5
2014	37.77	6.13	5	55.29	8.34	5
2015	37.63	6.05	5	53.49	8.07	5
2016	37.34	6.08	5	54.48	8.01	5

2. General situation of CCE

In 2016,The CCE for all diseases in Dalian was 21.109 billion RMB, including 7421.92 million RMB (35.16%) for outpatient service and 13686.90 million RMB(64.84%) for inpatient service. the CCE of injury in Dalian had reached 1572.73 million RMB, accounting for 7.45% of the total curative care expenditure, 0.23% of gross domestic product (GDP).

2.1 The CCE of injuries in different age groups

To identify the distribution of CCE of different age groups, the data was divided into 8 groups and we calculated the CCE both in outpatient and inpatient. The CCE of injuries in outpatient was 356.26 million RMB, accounting for 4.80% of total curative care expenditure in outpatient. The CCE of injury in inpatient was much higher than outpatient, which was 1216.47 million RMB, accounting for 8.89% of total curative care expenditure in inpatient.

Overall, injuries were responsible for 7.45% of Dalian’s total burden of disease expenditure. The CCE of injuries was gradually increasing from newborns to 65 years old, and the age group 45–65 had the highest CCE of injuries, while the age group less than 1 had the lowest figure. Compared to the other age groups, the CCE of injuries accounted for a larger proportion of total curative care expenditure in the 15–65 age group (Table 2).

Table 2

CCE and the CCE of injuries in different age groups (RMB)
Age group	Outpatient			Inpatient
Age group	CCE (Million)	The CCE of injuries (Million)	Percentage (%)	CCE (Million)	The CCE of injuries (Million)	Percentage (%)
༜1	61.48	0.73	1.19	161.70	2.83	1.75
≥ 1	365.79	11.26	3.08	299.33	4.26	1.42
≥ 5	419.65	16.72	3.98	211.15	15.12	7.16
≥ 15	366.70	25.78	7.03	242.76	62.83	25.88
≥ 25	1105.36	52.30	4.73	791.67	120.87	15.27
≥ 35	900.68	57.13	6.34	925.24	160.44	17.34
≥ 45	2399.59	142.18	5.93	5368.67	504.62	9.40
≥ 65	1802.66	50.16	2.78	5686.37	345.50	6.08
Total	7421.92	356.26	4.80	13686.90	1216.47	8.89

2.2 CCE for different injuries regions

To further understand the distribution of CCE of different types of injuries in the population, we divided 14 types of injuries according to the regions of injuries. In terms of injuries of outpatient, the highest expenditure happened in “Injuries to the head”, followed by “Injuries to the lower limb” and “Injuries to the spine, skin or blood vessel and effects of foreign body entering”. The top three accounted for 73.39% of the CCE of injuries (Fig. 1). However, classified by the ICD-10, the top three of CCE in injuries were “Injuries to the spine, skin or blood vessel and effects of foreign body entering”, “Injuries to the lower limb” and “Injuries to the head” in inpatient. A total of these three was about 733.60 million RMB, occupying 63.59% of the total in inpatient’s injuries (Fig. 2). The CCE of injuries was 1572.74 million RMB after the outpatient and inpatient were combined, the highest of which was “Injuries to the spine, skin or blood vessel and effects of foreign body entering”.

2.3 The CCE of different types of injuries for each age group

Table 3 provided a comparison of the CCE of different types of injuries by age groups in outpatient. Analyzing these data, we found that the most costly type of injury in the 0–15 age group was “Injuries to the spine, skin or blood vessel and effects of foreign body entering”. “Injuries to the head” was followed. The most costly type of injury in the 15–65 age group was “Injuries to the head”. “Injuries to the lower limb” was followed. In the 65 and above age group, the top two were “Injuries to the lower limb” and “Injuries to the head” (Table 3).

Table 3

CCE of different types of injury for each age group in outpatient (Ten thousand RMB)
Type of injury	Age group
Type of injury	༜1	≥ 1	≥ 5	≥ 15	≥ 25	≥ 35	≥ 45	≥ 65
Injuries to the head	23.24	258.62	466.24	784.36	1419.12	1608.11	3857.19	1198.99
Injuries to the neck	1.24	1.11	7.38	7.66	31.28	34.13	74.41	39.69
Injuries to the thorax	1.45	3.63	9.15	54.04	154.67	188.43	618.85	252.72
Injuries to the abdomen, lower back, lumbar spine and pelvis	1.03	4.89	29.00	86.61	263.60	336.97	1059.58	491.70
Injuries to the shoulder and upper arm	2.02	43.81	157.46	236.06	489.88	512.38	1409.77	424.44
Injuries to the lower limb	14.88	139.22	268.20	653.11	1380.95	1511.96	3497.85	1256.73
Injuries involving multiple body regions	0.80	12.23	41.29	21.41	77.55	94.03	245.88	71.33
Injuries to the spine, skin or blood vessel and effects of foreign body entering	26.46	617.74	616.58	599.13	1195.21	1162.19	2673.99	916.91
Burns, corrosions and frostbite	0.00	15.45	10.34	14.95	24.91	43.40	125.23	47.13
Poisoning, drug reactions and allergic reactions	0.19	15.63	38.57	94.12	132.65	134.23	268.58	134.21
Other and unspecified effects of external causes	1.83	12.57	7.16	14.05	16.85	30.59	50.35	38.51
Complications of trauma, of surgical and medical care	0.14	1.08	18.25	6.23	26.02	22.49	64.86	34.03
Old fractures and injuries	0.00	0.17	1.60	4.23	15.52	31.80	271.89	109.63
Sequelae of poisoning	0.00	0.00	1.07	1.76	1.54	2.00	0.00	0.00

As can be seen the inpatient data in Table 4, the most costly type of injury in the age group 0–15, 15 and above were “Injuries to the head” and “Injuries to the spine, skin or blood vessel and effects of foreign body entering” respectively. In addition, the CCE of injuries to the shoulder, upper arm and lower limb deserves emphases of the government (Table 4).

Table 4

CCE of different types of injury for each age group in inpatient (Ten thousand RMB)
Type of injury	Age group
Type of injury	༜1	≥ 1	≥ 5	≥ 15	≥ 25	≥ 35	≥ 45	≥ 65
Injuries to the head	183.13	217.65	393.17	1077.56	2135.74	2532.87	7989.89	4034.74
Injuries to the neck	8.44	0.00	5.78	49.10	264.79	313.86	2562.80	2492.32
Injuries to the thorax	7.70	9.94	42.85	97.83	245.24	592.08	2419.16	1750.91
Injuries to the abdomen, lower back, lumbar spine and pelvis	0.64	5.91	25.62	456.05	630.90	1309.01	4103.74	2606.48
Injuries to the shoulder and upper arm	0.68	60.75	343.79	1036.39	2287.04	3036.08	6935.01	2551.33
Injuries to the lower limb	25.03	30.71	243.11	1258.90	2266.28	3170.91	11142.59	8426.26
Injuries involving multiple body regions	0.00	0.00	7.14	3.97	13.49	28.00	59.52	19.59
Injuries to the spine, skin or blood vessel and effects of foreign body entering	53.37	32.33	288.04	1906.17	3416.66	4081.13	12054.58	10399.11
Burns, corrosions and frostbite	2.99	19.89	19.35	77.26	64.41	169.52	575.29	169.62
Poisoning, drug reactions and allergic reactions	1.00	44.90	103.08	228.80	541.51	538.87	1587.84	1425.62
Other and unspecified effects of external causes	0.00	3.89	0.20	2.20	37.89	31.69	95.20	120.07
Complications of trauma, of surgical and medical care	0.00	0.00	7.66	80.41	126.42	213.87	756.26	366.72
Old fractures and injuries	0.00	0.00	32.01	8.52	56.83	20.96	128.20	73.45
Sequelae of poisoning	0.00	0.00	0.51	0.00	0.00	5.00	51.63	114.00
Figure title and legend

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 [19]. 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 [20]. 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 [23]. 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 [24].

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 [25]. 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 [10]. 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 [26]. 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 [27]. A study conducted in India similarly found that the most common type of home injury in children aged 0–14 was falling [28]. 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 [29]. 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 [30]. 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 [31]. A study carried out in New Zealand showed that head injuries remained a large proportion of injury-related deaths [26]. 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 [8]. In terms of injuries to the extremities, extremity fractures had high costs due to high incidences and high productivity costs per patient [32]. 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].

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 [33]. 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 [21]. 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 [34]. For instance, to protect children from fall-related injuries, schools can install soft rubber and waterproof floor for schoolyards [35].

6. Limitation

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.

Injuries were among the most prominent public health problems in the world. The CCE of injuries in Dalian had reached 1572.73 million RMB in 2016, accounting for 7.45% of the total curative care expenditure. People in age group 15–65 and “Injuries to the spine, lower limb, head and foreign body entering” should be priorities of interventions. This study proposed that control strategies can be tilted toward underdeveloped areas and prevention services, and can be targeted at different age groups.

WHO

World Health Organization; GDP:Gross domestic product; CCE:Curative care expenditure; DALYs:Disability adjusted life years; NISS:National Injury Surveillance System; SHA 2011:System of Health Accounts 2011; CHS:Community health service center; ICD-10:International Classification of Disease Tenth Revision

Acknowledgments

The authors express thanks to China National Health Development Research Center for their help with SHA 2011 analysis.

Authors’contributions

XW and YBY designed the study, helped in implementing the project and reviewed the manuscript. SS and LNY did the pre-research was the main drafters of the manuscript. LNY established database and contributed statistical analysis. XZH, YLZ and BXL searched papers and did some of manuscript editing. All contributing authors are aware of and agree to the submission of this manuscript.

Funding

This work was supported by National Natural Science Foundation of China (grant number: 71673299); Social Science Fund Project Planning of Liaoning Province (grant number: JG16DB518); and Science and Technology Found of Shenyang (grant number: 18-015-7-20).

Availability of data and material

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study was supported by Health Commission of Dalian city and Ethics Committee of China Medical University. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards. This manuscript adheres to the appropriate reporting guidelines and community standards for data availability.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no conflict of interest.

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The Burden of the Current Curative Expenditure of Injury in Dalian, China-A study Based on "System of Health Accounts 2011"

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Abstract

Figures

Background

Methodology

Macro data

Sample data

Classification methods

Formula

Results

1. Injury mortality and its percentage of all causes of death in China (2006–2016)

2. General situation of CCE

2.1 The CCE of injuries in different age groups

2.2 CCE for different injuries regions

2.3 The CCE of different types of injuries for each age group

Discussions

Conclusion

Abbreviations

Declarations

References

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