Aspects socio-économiques des traumatismes graves Hocine FOUDI Urgences-SAMU-SMUR CH Marc Jacquet D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Epidemiologie Mortalité en France en 2004 Cancer 227 Maladies cardiovasculaires 214 Traumatismes 37 VIH 1,5 Pour 100.000 hab 1 ère cause de mortalité des 15-35 ans 1 ère cause d années de vie perdues Surveillance épidémiologique des causes de décès en France, InVS 2007 L infection à VIH-sida en France, InVS 2008
Epidemiologie Aux Etats Unies 57 millions de blessés par an 2 millions d hospitalisations 150 000 décès 16 milliards $ en soins aigus 150 milliards $ en soins de suite, handicaps Elliott DC, Surg Clin North Am 1996;76:47-62
Caractéristique de la pathologie Evaluation de la gravité D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Injury Severity Score (ISS) ISS et AIS 2 6 régions corporelles Tête et cou 1 6 Face 3 Thorax Abdomen 4 Extrémités Revêtement cutané 5 5 niveaux de gravité (1 à 5) 3 lésions les plus graves ISS = somme des carrés Baker SP, J Trauma 1974;14:187-96
Revised Trauma Score (RTS) Revised Trauma Score Glasgow Coma Scale Pression Artérielle Systolique Fréquence Respiratoire Valeur 15-13 12-9 8-6 5-4 3 > 90 89-76 75-50 < 50 0 29-10 30 9-6 5-1 0 4 3 2 1 0 Champion HR, J Trauma 1989;29:623-9
Mechanism, GCS, Age, Arteriel Pressure (MGAP) Score MGAP Nombre de points Score de Glasgow (par point) Score de Glasgow Pression artérielle systolique > 120 mmhg + 5 60 120 mmhg + 3 < 60 mmhg 0 Trauma fermé (vs pénétrant) + 4 Age < 60 ans + 5 Total: 3 à 29 Sartorius et al, Crit Care Med 2010; 38: 831-7.
Mechanism, GCS, Age, Arteriel Pressure (MGAP) Sartorius et al, Crit Care Med 2010; 38: 831-7.
Algorithme de Vittel Groupe Vitttel, 2002
Algorithme de Vittel Groupe Vitttel, 2002
Algorithme de Vittel Groupe Vitttel, 2002
Algorithme de Vittel Groupe Vitttel, 2002
Concept de mort évitable Lié au réseau de soins D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Effect of a Voluntary Trauma System on Preventable Death and Inappropriate Care in a Rural State Esposito TJ, J Trauma 2003;54:663 670 Analyse comparative 1990-1998 de 347 décès traumatiques (90% fermés) 1990 (avant Trauma system) Décès évitable 13% (soins inapropriés) 1998 (après Trauma system) 8% (47% des décès liés à l airways)
Concept de mort évitable Lié à la qualité des soins D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Preventable or Potentially Preventable Mortality at a Mature Trauma Center Pedro GR, J Trauma 2007;63:1338-1347 Analyse rétrospective 1998-2005 de 2.081 décès traumatiques (75% fermés) 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% Delay in Treatment 51 décès évitables (2,5%) Clinical jugment error Missed diagnosis Technical eror Other % of the preventable/potentially preventable deaths
Concept de mort évitable Importance de la prévention D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Epidemiology of Severe Brain Injuries: A Prospective Population-Based Study Masson F, J Trauma 2001;51:481 489 497 TCG pris en charge en 1996 dans la région Aquitaine en France 17 TCG / 100.000 hab (1996) VS 24 TCG / 100.000 hab (1986)
Epidemiology of Severe Brain Injuries: A Prospective Population-Based Study Masson F, J Trauma 2001;51:481 489 497 TCG pris en charge en 1996 dans la région Aquitaine en France 17 TCG / 100.000 hab (1996) (48% AVP) VS VS 24 TCG / 100.000 hab (1986) (68% AVP)
Epidemiology of Severe Brain Injuries: A Prospective Population-Based Study Masson F, J Trauma 2001;51:481 489 497 TCG pris en charge en 1996 dans la région Aquitaine en France 17 TCG / 100.000 hab (1996) (48% AVP) VS VS 24 TCG / 100.000 hab (1986) (68% AVP) En IDF: 3 TCG / 100.000 hab (2007)
Organisation des soins quelle stratégie de transport? D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Pro/con debate: Is the scoop and run approach the best approach to trauma services organization? Haas B and Nathens AB, Crit Care. 2008;12(5):224. Advanced Life Support (ALS) «Play and Stay» VS Basic Life Support (BLS) «Scoop and Run»
Pro/con debate: Is the scoop and run approach the best approach to trauma services organization? Haas B and Nathens AB, Crit Care. 2008;12(5):224. Les règles d or du «Trauma System» anglo-saxon Pas de régulation médicale Protocoles de triages «paramedics» Délai d acheminement prioritaire Hôpital «Trauma Center» le plus proche Transfert si nécessaire Acceptation obligatoire
National Study on the Costs and Outcomes of Trauma regions. National Variability in Out-of-Hospital Treatment After Traumatic Injury Bulger EM, Ann Emerg Med 2007 Mar;49(3):293-301
Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study Yeguiayan et al, FIRST Study, Crit Care. 2011;15(1):R34. Etude prospective, multicentrique 2.703 patients (2.513 SMUR, 190 non SMUR) Critère d évaluation: mortalité à 30 jours Le SMUR réduit significativement le risque de décès à 30 Jours (OR: 0.55, 95% CI: 0.32 to 0.94,P = 0.03)
Organisation des soins quelle structure de prise en charge? D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Increased Survival Among Severe Trauma Patients: the impact of a national trauma system Peleg K, Arch Surg 2004 Nov;139(11):1231-6 25,00% 20,00% 15,00% 10,00% Mortalité totale Mortalité TCG 5,00% 0,00% 1997 1998 1999 2000 2001
A National Evaluation of the Effect of Trauma-Center Care on Mortality MacKenzie EJ, NEJM 2006 Jan 26;354(4):366-78 45,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 5,00% 0,00% < 55 ans > 55 ans max AIS 3 max AIS 4 max AIS 5-6 TC 5,90% 12,30% 2,30% 8,30% 30,20% Non TC 9% 13,10% 1,60% 11,80% 43,20%
Organisation des soins quelle stratégie d orientation? D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Direct Transport Within An Organized State Trauma System Reduces Mortality in Patients With Severe Traumatic Brain Injury Härt R, J trauma 2006 Jun;60(6):1250-6 80,00% 70,00% 60,00% Dead Alive 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 20,70% Direct 25,60% Indirect
Délai (en heure) Medical pre-hospital management reduces mortality in severe blunt trauma: a prospective epidemiological study Yeguiayan et al, FIRST Study, Crit Care. 2011;15(1):R34. Délai d admission en centre spécialisé 7 6 5 P < 0,001 6,4 h (5,0 8,4) 4 3 2 1,9 h (1,3 2,5) 1 0 Transport Direct Transport indirect
Aspect financier D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Evaluation of a Mature Trauma System Durham R, Ann Surg 2006 Jun;243(6):775-83 Mean cost per admission Designated trauma hospitals $11,825 Non-trauma hospitals $6,028 Additional cost associated with treatment in trauma hospital $5,797 Improvement in odds of survival 0.178 Marginal cost per life saved $32,514 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal cost per life-year saved $746 Mean charge per admission Designated trauma hospitals $57,657 Non-trauma hospitals $35,772 Additional charge associated with treatment in trauma hospital $21,885 Improvement in odds of survival 0.178 Marginal charge per life saved $122,750 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal charge per life-year saved $2,815
Evaluation of a Mature Trauma System Durham R, Ann Surg 2006 Jun;243(6):775-83 Mean cost per admission Designated trauma hospitals $11,825 Non-trauma hospitals $6,028 Additional cost associated with treatment in trauma hospital $5,797 Improvement in odds of survival 0.178 Marginal cost per life saved $32,514 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal cost per life-year saved $746 Mean charge per admission Designated trauma hospitals $57,657 Non-trauma hospitals $35,772 Additional charge associated with treatment in trauma hospital $21,885 Improvement in odds of survival 0.178 Marginal charge per life saved $122,750 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal charge per life-year saved $2,815
Evaluation of a Mature Trauma System Durham R, Ann Surg 2006 Jun;243(6):775-83 Mean cost per admission Designated trauma hospitals $11,825 Non-trauma hospitals $6,028 Additional cost associated with treatment in trauma hospital $5,797 Improvement in odds of survival 0.178 Marginal cost per life saved $32,514 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal cost per life-year saved $746 Mean charge per admission Designated trauma hospitals $57,657 Non-trauma hospitals $35,772 Additional charge associated with treatment in trauma hospital $21,885 Improvement in odds of survival 0.178 Marginal charge per life saved $122,750 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal charge per life-year saved $2,815
Evaluation of a Mature Trauma System Durham R, Ann Surg 2006 Jun;243(6):775-83 Mean cost per admission Designated trauma hospitals $11,825 Non-trauma hospitals $6,028 Additional cost associated with treatment in trauma hospital $5,797 Improvement in odds of survival 0.178 Marginal cost per life saved $32,514 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal cost per life-year saved $746 Mean charge per admission Designated trauma hospitals $57,657 Non-trauma hospitals $35,772 Additional charge associated with treatment in trauma hospital $21,885 Improvement in odds of survival 0.178 Marginal charge per life saved $122,750 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal charge per life-year saved $2,815
Evaluation of a Mature Trauma System Durham R, Ann Surg 2006 Jun;243(6):775-83 Mean cost per admission Designated trauma hospitals $11,825 Non-trauma hospitals $6,028 Additional cost associated with treatment in trauma hospital $5,797 Improvement in odds of survival 0.178 Marginal cost per life saved $32,514 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal cost per life-year saved $746 Mean charge per admission Designated trauma hospitals $57,657 Non-trauma hospitals $35,772 Additional charge associated with treatment in trauma hospital $21,885 Improvement in odds of survival 0.178 Marginal charge per life saved $122,750 Life expectancy for a 33-year-old (all races and sex)* 43.6 Marginal charge per life-year saved $2,815
The Impact of a New Trauma Center on an Existing Nearby Trauma Center Simon R, J Trauma 2009 Sep;67(3):645-50 X Centre A X Nouveau Centre X Centre B
The Impact of a New Trauma Center on an Existing Nearby Trauma Center Simon R, J Trauma 2009 Sep;67(3):645-50
Mortalité The Impact of a New Trauma Center on an Existing Nearby Trauma Center Simon R, J Trauma 2009 Sep;67(3):645-50
Overtriage vs Undertriage Overtirage: estimation 25-50% Mackenzie et al, N Eng J 2006 Undertriage:?
The Delivery of Critical Care Services in US Trauma Centers: Is the Standard Being Met? Nathens AB, J Trauma 2006;60:773 784
The Delivery of Critical Care Services in US Trauma Centers: Is the Standard Being Met? Nathens AB, J Trauma 2006;60:773 784
Impact of minimal injuries on a level I trauma center Hoff WS, J Trauma 1992 Sep;33(3):408-12 344 ISS 4 / 2927 Emergency Department Trauma Team Nombre de patients Ambulance Hélicoptère Trauma Score 135 (39%) 135 0 7 12 209 (61%) 118 91 5-12 GCS Procédures invasives Dms Réanimation Dms Hôpital Coût du séjour ($) 11-15 2.5 (0-10) 1.2 (0-2) 2.6 (1-18) 1,566 11-15 4.0 (0-15) 1.4 (0-12) 2.8 (1-36) 3,836
Maîtrise des dépenses et Qualité des soins D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Lives saved Using a Cost-Benefit Analysis to Estimate Outcomes of a Clinical Treatment Guideline: Testing the Brain Trauma Foundation Guidelines for the Treatment of Severe Traumatic Brain Injury Faul M, J Trauma 2007;63:1271 1278 BTF Compliance and Estimates Lives saved 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 50% Compliance 1306 Lives saved Current state Hight Compliance 3607 Lives saved 30 40 50 60 70 80 Percent Compliance 4326 2904 Estimated number of lives saved based on brain trauma Foundation guidelines compliance
Using a Cost-Benefit Analysis to Estimate Outcomes of a Clinical Treatment Guideline: Testing the Brain Trauma Foundation Guidelines for the Treatment of Severe Traumatic Brain Injury Faul M, J Trauma 2007;63:1271 1278
Impact socio-économique Influence de l âge D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Acute hospital costs of trauma in the United States: Implications for regionalized systems of care Mackenzie EJ, J Trauma 1990 sep;30(9):1096-101 2.107.955 patients hospitalisés pour trauma Dépenses estimées: 11,4 milliards $ Prédominance adultes jeunes Surcoût lié à la prise en charge des patients plus âgés 48% 15-44 ans (46% des dépenses) 23% > 65 ans (33% des dépenses)
Cost Estimation of Injury-Related Hospital Admissions in 10 European Countries Plinder S, J Trauma 2005 Dec;59(6):1283-90
Coût par habitant ( ) Cost Estimation of Injury-Related Hospital Admissions in 10 European Countries Plinder S, J Trauma 2005 Dec;59(6):1283-90 Age
Impact socio-économique Influence du niveau socio-culturel D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Functional recovery and medical costs of trauma: an analysis by type and severity of injury Mackensie EJ, J Trauma 1988;28:281-97 Le niveau socio-culturel influence la réinsertion sociale du patient quel que soit son degré de récupération fonctionnel
Impact socio-économique Influence de l origine ethnique D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Ethnic Disparities Exist in Trauma Care Shafi S, J Trauma 2007 Nov;63(5):1138-42 58.792 patients avec TCG Analyse rétrospective, Rééducation au décours?
Impact socio-économique Influence du niveau de couverture sociale D.U. Médecine d urgence, Traumatismes graves, prise en charge des premières heures
Payer Status: The Unspoken Triage Criterion Nathens AB, J Trauma 2001 May;50(5):776-83
Conclusion