Elsevier

Injury

Volume 43, Issue 11, November 2012, Pages 1908-1916
Injury

Health resource utilisation costs in acute patients with persistent midline cervical tenderness following road trauma

https://doi.org/10.1016/j.injury.2012.07.181Get rights and content

Abstract

Introduction

The costs associated with patients discharged with isolated clinician-elicited persistent midline tenderness and negative computed tomography (CT) findings have not been reported. Our aim was to determine the association of acute and post-acute patient and injury characteristics with health resource costs in such patients following road trauma.

Methods

In a prospective cohort study, road trauma patients presenting with isolated persistent midline cervical tenderness and negative CT, who underwent additional acute imaging with MRI, were recruited. Patients were reviewed in the outpatient spine clinic following discharge, and were followed up at 6 and 12 months post-trauma. Multivariate linear regression was used to assess the association of injury mechanism, clinical assessment, socioeconomic factors and outcome findings with health resource costs generated in the acute hospital and post-acute periods.

Results

There were 64 patients recruited, of whom 24 (38%) had cervical spine injury detected on MRI. Of these, 2 patients were managed operatively, 6 were treated in cervical collars and 16 had the cervical spine cleared and were discharged. At 12 months, there were 25 patients (44%) with residual neck pain, and 22 (39%) with neck-related disability. The mean total cost was AUD $10,153 (SD = 10,791) and the median was $4015 (IQR: 3044–6709). Transient neurologic deficit, which fully resolved early in the emergency department, was independently associated with higher marginal mean acute costs (represented in the analysis by the β coefficient) by $3521 (95% CI: 50–6880). Low education standard (β coefficient: $5988, 95% CI: 822–13,317), neck pain at 6 months (β coefficient: $4017, 95% CI: 426–9254) and history of transient neurologic deficit (β coefficient: $8471, 95% CI: 1766–18,334) were associated with increased post-acute costs.

Conclusion

In a homogeneous group of road trauma patients with non fracture-related persistent midline cervical tenderness, health resource costs varied considerably. As long term morbidity is common in this population, a history of resolved neurologic deficit may require greater intervention to mitigate costs. Additionally, adequate communication between acute and community care providers is essential in order to expedite the recovery process through early return to normal daily activities.

Introduction

The assessment of the cervical spine and the exclusion of cervical spine injury are among the most common issues in trauma management following road crashes. The prevalence of cervical spine injury in all cases of trauma is 3.7%, including 2.8% in alert patients and 7.7% in obtunded patients.1 Whilst exclusion of acute injury removes the threat of cervical instability, neck pain and associated disability may persist regardless of radiographic findings. In fact, the severity of initial neck pain intensity appears to be a predictor of long term pain severity.2, 3, 4, 5 This may be a reflection of the variability of success in the wide variety of health resource measures and combinations of therapy used to manage post-traumatic neck pain, including physiotherapy, exercises, early mobilisation, analgesics, psychology and rest.

Much of the evidence related to acute cervical spine trauma focuses on the detection and management of injury and the measurement of clinical outcomes, whereas evidence related to long term demographic and cost outcomes is limited. Health resource costs can vary considerably over seemingly homogeneous patient groups. In a group of alert road trauma patients who had acute midline cervical tenderness on palpation and negative computed tomography (CT) findings, we aimed to quantify and categorise the costs associated with injury and symptom management over the 12-month post-trauma period. We also aimed to determine whether factors associated with these expenses may explain the variability in costs. As acute emergency department and hospital costs were likely to be a reflection of length of stay and services aimed at injury detection and management, we hypothesised that the presence and severity of cervical spine injury would determine inpatient costs. Conversely, we suspected that costs attributed to the post-acute period would be associated with psychological and socioeconomic factors, rather than injury morphology or mechanism. We have previously reported the acute clinical and post-acute outcome findings from a larger study from which this subset of patients was derived.6, 7

Section snippets

Methods

There are approximately 15,000 trauma presentations to the emergency department of our Level 1 trauma centre per year, and major trauma constitutes 10% of these presentations. In a prospective cohort study, alert trauma patients presenting over a 2 year period to January, 2009, with midline cervical tenderness and negative acute computed tomography (CT) findings were screened for inclusion. Those in whom midline tenderness was persistent, who were investigated further with cervical magnetic

Results

There were 741 acute trauma patients with persistent midline cervical tenderness and negative CT findings, who were investigated with MRI during the recruitment period. Of these, there were 554 excluded for the presence of skull base, cervical spine or upper thoracic spine fractures (n = 338), painful distracting injury (n = 113), persistent neurologic deficit (n = 17), history of cervical spine surgery or injury (n = 20) or MRI >96 h post-admission.6 Nine patients refused consent. Of the 178 remaining

Discussion

Cervical spine injuries are most commonly associated with hyperflexion, hyperextension, lateral flexion, rotational forces and axial loading, and most often result from motor vehicle accidents.22, 23 Fracture or malalignment evident on CT or MR imaging allows for decisive management decisions to be made, but soft tissue cervical injuries of less certain clinical significance can remain untreated and may result in enduring symptoms. Additionally, although the presence of acute and persistent

Conclusion

The relationship between costs and acute clinical, radiographic, injury mechanism and post-acute outcome characteristics in patients with persistent midline cervical tenderness and negative CT imaging has not been reported previously. In our study, mechanism of injury, radiographic findings and psychological outcomes were not found to influence the costs of health resource utilisation. A history of resolved neurologic deficit in these patients may signal the presence of subclinical injury and

Conflicts of interest

There are no conflicts of interest to declare.

Acknowledgements

The authors are indebted to the Transport Accident Commission for project funding support, and we gratefully acknowledge the assistance of David Attwood and Simone Boer of the Claims Research Department of the Transport Accident Commission for assistance with patient cost data retrieval. The Transport Accident Commission had no other involvement in the study.

References (44)

  • J.M. Schellingerhout et al.

    Prognosis of patients with nonspecific neck pain: development and external validation of a prediction rule for persistence of complaints

    Spine

    (2010)
  • Ackland HM, Cameron PA, Wolfe R, Malham GM, Varma DK, Fitt GJ, et al. Outcomes at 12 months following early MRI in...
  • G.W. Hendey et al.

    Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma

    Journal of Trauma

    (2002)
  • J.R. Hoffman et al.

    Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group

    New England Journal of Medicine

    (2000)
  • F. Denis

    The three column spine and its significance in the classification of acute thoracolumbar spinal injuries

    Spine

    (1983)
  • F. Denis

    Spinal instability as defined by the three-column spine concept in acute spinal trauma

    Clinical Orthopaedics and Related Research

    (1984)
  • R.P. Snaith

    The hospital anxiety and depression scale

    Health and Quality of Life Outcomes

    (2003)
  • A.S. Zigmond et al.

    The hospital anxiety and depression scale

    Acta Psychiatrica Scandinavica

    (1983)
  • H. Vernon et al.

    The Neck Disability Index: a study of reliability and validity

    Journal of Manipulative and Physiological Therapeutics

    (1991)
  • Transport Accident Commission. Summary of Benefits and Provisions; July...
  • Transport Accident Commission. Annual report 2011; 2011. Available from:...
  • J.A. Barber et al.

    Analysis of cost data in randomized trials: an application of the non-parametric bootstrap

    Statistics in Medicine

    (2000)
  • Cited by (0)

    Funded by the Transport Accident Commission, Victoria, Australia (Grant no. NV16).

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