In the present study, with randomly included patients with major or severe hand injuries (HISS score >100; and range 50–100, respectively) and while median HISS scores did not differ by place of injury, work-related injuries had highest total costs. Interestingly, the health care costs of the work-related injuries were 40% higher than those occurring at home or during leisure time controlling for age, DASH at injury and quality of life measured by EQ-5D at 12 months. The total costs were 34% higher in the present patients injured at work. Irrespective of place of injury, costs of lost production constituted the major part of total costs in the patients that worked full time before injury. In contrast, health care costs were +66% in patients working part-time before the injury. We can only speculate as to why in our sample, but it is possible that jobs, where people work part-time, are more likely to be manual and with a possibility of subsequent difficulty to return to work as well as involve greater risks of injury. In addition, the regression analysis also showed that the health care costs were higher for patients with an age > 50 years (+52%). Thus, we had independent cost increases from age and labour market attachment. At one year after injury, 17 patients were still on sick leave and the return to work was related to severity of injury. Patients with severe injuries were near as four times as likely to return to work at a given point in time compared to patients with major injuries (Figure 3). However, several factors may be involved in an injured patient´s ability to return to work and the interconnection of the factors is complex. In a study of costs and utility in the treatment of back and neck pain, the best predictor for return to work when comparing several commonly used health measures was in fact the EQ-5D . Another important factor for return to work is the patients’ sense of coherence in the recovery after hand injuries [17, 18] and musculoskeletal pain . We continuously follow our patients with a tentative follow up of at least five years, since the importance of costs and other factors for hand injuries are high-lighted in literature [6, 20–23].
The injuries of the present patients could essentially be divided in three equal types; amputations (29%), complex injuries (i.e. combination of fractures, tendon, vessel and nerve injuries; 40%) and major nerve injuries, including full house, in the forearm (29%), while a burn injury was only present in a single patient. The health care costs were higher in the patients with amputations and complex injuries than in the patients with nerve injuries, in spite of those full house injuries were included in the latter category. There was a need for microsurgical reconstruction of blood vessels in almost half of all the cases, which may increase health care costs. Interestingly, all cases with amputations needed microsurgery, while only 3/18 cases (17%) of the complex injuries required microsurgery. In accordance with previous reports , the health care costs were only a minor part of the total costs for nerve injuries (i.e. > 80% were lost production). The corresponding percentages of lost production were even lower for the other two main categories (amputations 51%; complex injuries 69%). In the light of these results showing proportionately high costs of lost production, especially for nerve injuries, cost-efficient interventions leading to increasing return to work should have priority . The percentage of lost production (i.e. sick leave) is relevant when considering in on which patients resources for rehabilitation and return to work should be directed. The major part of total costs for nerve injuries were lost production indicating that the return to work should have priority in that category of patients. Nevertheless, the top priority of action is prevention of hand injuries, and this study supports interventions concentrated not only against work-related injuries, but particularly also towards injuries occurring during leisure, e.g. during “doing-your-self activities” .
All patients were considered to be fully mobilized at three months and allowed to use their hands without restrictions and thus we report DASH at 3, 6 and 12 months. Patients with longer sick leave had higher DASH scores, but DASH scores improved (i.e. decreased) significantly over time in all patients (Table 2). The improvement of DASH from 3 to 12 months was clinically relevant (median score improvement >10 ). In accordance with DASH scores, EQ-5D values also improved (i.e. increased) over time. The findings that patients who rated high EQ-5D values at 12 months had lower total costs are logical, since they had returned to work. There was a tendency of a positive association between increased improvement in DASH score between 3 and 12 months and total costs. One explanation may be that patients with high initial DASH score had a greater potential for improvement, but also were probably more costly in terms of health care resource need and sick leave.
A limitation of this study was that we randomly selected patients with a severe or major hand injury and not all patients during the study period. Our goal was to include as many patients as possible during the study period. These patients came randomly during day/night, weekdays and months and we (i.e. the authors) were also dependent on colleagues for including patients. Sometimes patients were not asked by the hand surgeon on call to participate in the study. However, we could not detect any differences in age, gender, weekday or month of injury between the included and not included patients (Table 1). However, there was a slight overrepresentation of major injuries among the included patients. The strength is the meticulous follow up of patients of costs of injury as well as the other aspects of outcome, such as the influence of sense of coherence [17, 25].
We used an episode-perspective to assess the size of costs and to discuss associations between costs, place of injury and patient reported outcomes. It is not a traditional cost-of-illness study, which calculates the burden of illness born by health care and other sectors, but typically it lacks more detailed patient information, including outcomes of treatment. Thus, our approach provides more information of direct clinical interest.