Keynote lecture: Costs of burns and plastic surgery: The UK experience
Abstract: The growing cost of healthcare is of concern to every society globally. Its importance has been brought into stark relief by the economic crisis seen in many parts of the world and Europe in particular. A great many pieces of work have looked at healthcare costs and claimed to represent the cost of therapeutic interventions but a review of the global literature on this subject has revealed systematic errors of methodology in the majority. A common feature in the literature is confusion between charges made by a hospital and the true cost of the care provided if calculated by other methodologies.
A long-term programme of work in England has been focused particularly on burns and plastic surgery in an attempt to establish the true cost of care provided on a patient by patient basis. The findings of this work have indicated that some of the conclusions commonly held are indeed correct: Staff time and input to a particular patient is the single largest cost driver to the cost of the care that patient receives by that a surprisingly small contribution to the overall cost is made by disposables, be they implants, injectables, dressing materials etc.
By understanding the details behind departmental income and by breaking down burns and plastic surgery workloads into different clinical silos it is possible to identify those areas of work which are profitable to a department and a hospital while identifying some surprisingly important areas of work make a loss but may be acting as effective loss leaders. It can be concluded that clinician perceptions of cost are frequently inaccurate.
It is hoped this work will form the basis of a more rational and accurate understanding of the costs of surgical care in burn and plastic surgery and might hopefully lead in certain health economies to a more rational and accurate approach to surgical care remuneration and even service organisation and capacity.
This conference aimed to help make it clear about ‘what matters’ in preventing serious burns and scalds among young children. The epidemiological data came from iBID which included the main causes of such injuries, their impact and who are most at risk. Other presentations focused on up-to-date methodology of ‘what works’ – the most effective ways to reduce deaths and serious injuries caused by burns and scalds. The intention was for workers in prevention to pick up ideas and strategies.
Introduction: In the UK, burn injuries are estimated to cause around 13K admissions every year and they have a mortality of approximately 1.2%. But these are just estimates since no study has been made that can demonstrate the true incidence and prevalence of burn injuries. The aim of this study is to describe the clinical epidemiology of burn injuries for the years 2003-2011
Methods: Data form international Burn Injury Database, which is the database for specialised services, were analysed for all admissions (2003-11) in England and Wales. Data was broken down according to age, sex and Primary Care Trusts. Admission rates were adjusted for world population according to World Health Organization population tables.
Results: Admissions for males accounted for 63% and the remaining 37% to females. The mean burn surface area was 3.98 (95% 3.92-4.04). The most frequent reason for burn injury admission was scald (38%). The median age group was 10-<20 for all years with the exception of 2011 which was 1-<10yrs. Mortality was overall 1.25. Admissions based on sex and age were highest for the age groups 1-<10yrs for both genders.
Conclusion: Mortality from burn injuries is decreasing, a finding that follows the western world trends. There is an increase in admissions in burn services but that could be an artefact of the database being used from all services over the passage of time. These results will be vital for service development and planning as well as prevention strategies and commissioning.
The 2nd BBA Prevention Study Day was held in Liverpool in association with the Annual BBA scientific meeting.
Data from iBID was presented to illustrate the wider range of preventable injuries being seen by the burn services in England and Wales.
A paper on the dynamic assessment of mortality prediction models using Statistical Process Control (SPC) methods was presented at the 16th Congress of the International Society of Burn Injuries (ISBI) in Edinburgh.
[This work won the best poster prize of the American Burn Association meeting, Palm Springs, April 2013]
Introduction: Many mortality prediction models have been developed for use to predict outcome in thermally injured patients. Of these the Abbreviated Burn Severity Index (ABSI), Belgian Outcome of Burn Injury (BOBI) score  and Baux Score (BS)  have shown promise in validation studies on independent data. However the performance quality of these prediction models has not been assessed in the midst of changing temporal conditions. Statistical Process Control (SPC), which is widely used in industry to control quality in critical processes, has recently been used to monitor outcomes in surgery and intensive care. This technique has not been used to measure the performance quality of prediction models in burns over time.
Methods: A database of 48,410 acute thermally injured patients admitted to UK burn centres between 2003 and 2011 (inclusive) was constructed from the international Burn Injury Database (iBID). These were chronologically arranged by date of admission into 24 sequential groups to establish a time-sequenced dataset. Each of the groups comprised 2000 patients apart from the last group, which included 2410 patients. The prediction performance of ABSI, BOBI and BS was evaluated over time by applying these models to the 24 time periods. The C-index (AUC on ROC analysis) was used to track the quality of the prediction models.
Results: Twenty-four chronological c-indices for the 3 scoring systems (ABSI, BOBI, BS) were derived. The mean c-indices for the scoring systems were BS 0.952 (95%CI 0.918-0.986), ABSI 0.931 (95%CI 0.892-0.971) and BOBI 0.826 (95%CI 0.812-0.843) with BS providing the best measure of outcome. However X-bar charting with 3-sigma upper and lower limits for the c-indexes showed deterioration of BS with transient loss of control over time, which was not seen with ABSI or BOBI.
Conclusions: This study supports the novel use of SPC to detect significant changes in prediction model performance over time. SPC has the potential to detect changes in model performance that could remain unnoticed using current quality control measures.
The Informatics Group of the NNBC has considered reports concerning various telemedicine projects in burn care from across England and Wales. There are three such projects, two of which are network based and one national.
1) A detailed presentation from the South East network was received concerning the development of a tele-referral system using a secure website on which participating emergency departments would register and be able to send text and images for consideration by the burn care team. This has been piloted in East Grinstead (TRIPS) and it is hoped a roll the project out across the network in a phased fashion through 2012.
2) Discussions are underway in the Northern network concerning the potential using telemedicine in a variety of roles but with no specific projects having been identified. A meeting to consider the options was held in Wakefield in early September and future discussions will be held.
3) As part of the iBID software redevelopment a follow-on project was described at its initiation in 2007 to build into the software the ability to accommodate a tele-referral system. With finalisation the iBID software and distribution in 2012 it is anticipated the tele-referral component would then go into full-time development.
The Informatics Group has undertaken to keep all such projects under review and report their progress to the NNBC.
Further to an invitation from the organising committee of the Australian Royal College of Surgeons, a presentation was given by Ken Dunn to the meeting in Adelaide in which he provided an overview of the discussions underway in the UK about the funding of trauma care, with particular reference to burn services.
Additional discussions were had concerning the nature of the burn injury registries in both the UK and Australasia and the potential for collaborative data sharing and research between the two organisations. It was agreed that such data sharing would be considered in detail once be new version of the iBID software was in use in 2012.
The 1st BBA Prevention Study Day was held in the Birmingham Council offices at the kind invitation mayor of Birmingham. The keynote speaker was the MP for Wakefield Mary Creigh who presented the successful outcome of her Bill to modify the UK Building regulations to introduce TMVs into new and renovated buildings.
The Informatics Group of the NNBC has considered the first draft of information about burn services that could be made publicly available. This work was initiated at the request of the NNBC and is in line with Department of Health policy and that of Commissioners of Specialised Services. The difficulties of providing information about specialised services that is comprehensive but understandable and meaningful to a non-medical readership poses significant challenges.
It is intended to provide a first draft for NNBC consideration in the autumn, after which a period of consultation with stakeholders will follow. The potential for providing information in a visual manner, in the form of maps was considered, using some of the existing examples:
Further to an invitation from the Central and Eastern Europe Burns Forum, iBID presented information about the ongoing debate in the UK, and elsewhere, concerning the funding of trauma services with particular reference to burn services. The various methods used in various health economies for burn service remuneration and the different costing methodologies in use in Europe were discussed. The difficulties of providing a high cost and low volume service in a financially challenging environment were universally acknowledged.
Some of the profound organisational challenges being experienced by some services were also detailed during what was a most enjoyable and informative meeting. The ability of iBID to provide information in line with its professed aims was applauded by the meeting but the difficulty of collecting standardised information across so many language, cultural and organisational boundaries was appreciated.