Financial burden of orthopaedic gunshot-related injury management at a major trauma centre

Abstract

Background. Violence and injuries are a significant global public health concern, and have a substantial emotional, physical and economic impact on society. In South Africa (SA), the Western Cape Injury Mortality Profile shows that homicides increased from 38 deaths per 100 000 in 2010 to 52 deaths per 100 000 in 2016. This increase is directly related to an increase in firearm-related homicides, which doubled from 2010 to 2016. Previous research estimated the average cost per gunshot wound (GSW)-related orthopaedic patient at USD2 940. GSWrelated patient numbers as well as treatment costs have escalated exponentially over the past few years. Objectives. To calculate the financial costs involved in managing gunshot-related orthopaedic injuries both surgically and non-surgically at a tertiary centre in SA. Methods. After ethics approval, a retrospective review of all GSW patients seen in the emergency unit at Tygerberg Hospital in 2017 was undertaken. Patient records yielded data on the following parameters: injury site and characteristics, imaging modalities, orthopaedic management, hospital admission and duration of hospitalisation, theatre episodes, orthopaedic implants and blood products administered. Cost analysis was performed using this information. Results. A total of 389 patients (360 male and 29 female), average age (range, standard deviation) 28 (3 -69, 9.50) years, were treated during the study period. Patient records identified a total of 449 orthopaedic injuries. A total of 187 patients were admitted, with 175 requiring surgical fixation. The conservatively calculated cost of managing this patient group was ZAR10 227 503. The average management cost per patient was ZAR26 292, with an average of ZAR46 670 per case requiring surgical management and ZAR8 810 for non-surgical cases (the average USD-ZAR exchange rate in 2017 was USD1-ZAR13.30). Conclusions. The total cost of managing 389 patients with gunshot-related orthopaedic injuries at a tertiary hospital was ZAR10 227 503. Improved understanding of these costs will help the healthcare system better prioritise orthopaedic trauma funding and training and highlights the urgent need for cost-saving measures, specifically primary prevention initiatives.

The case of the disappearing bullet: An extraluminal compression of the biliary tree

“…Rampant escalation of interpersonal violence and increasing incidence of firearm-related injuries has necessitated efficient management of gunshot wounds as an essential part of daily practice in South African ERs and trauma units. 3 Due to the variable and unpredictable trajectory of gunshot wounds, it is essential practice to carefully examine for and document entry and exit wounds, and in the case of no visible exit, utilise further imaging to assess for retained bullets as well as possible bullet trajectories. Bullet migration is a well-documented phenomenon, and can take years to occur, thus theoretically, patients with retained bullets should be followed up and monitored for development of symptoms as the migration of bullets from their initial sites may be unpredictable.…”

Civilian gunshot injuries in orthopaedics: a narrative review of ballistics, current concepts, and the South African experience

“…Gunshot injuries are also expensive to treat with a high percentage of victims requiring operative intervention when compared to blunt trauma [11,12,13]. Complications will likely further add to the healthcare burden.…”

“…Complications will likely further add to the healthcare burden. Most of civilian gun-related injuries occur in young male patients in lower-income countries where healthcare is already under-resourced [1,5,6,10,13,14]. Except for the direct cost of the healthcare event there is also indirect costs like loss of income and need for ongoing care which further compounds the significant public health concern.…”

The burden and outcomes of firearm injuries at two district-level emergency centres in Cape Town, South Africa: A descriptive analysis

“…[14] Beyond mortality data and without adequate injury surveillance, the available SA firearm injury literature is further limited in scope and depth. The focus is on pre-hospital, [15] hospital-specific, [16][17][18][19][20][21] or tertiary and orthopaedic services, [22][23][24][25][26] with little co-ordinated research documenting the complete burden of this injury profile on health services and society. There is no local research documenting rates of recidivism or strategies that reduce this, or the escalation of violent injury patterns that is suggested by the international literature.…”