No abstract.
South African Medical Journal Vol. 95 (8) 2005: 591-59

Allard, D

Burch, VC

English

AJOL - African Journals Online

ORIGINAL ARTICLES591August 2005, Vol. 95, No. 8  SAMJThere are approximately 4.5 million registered firearms incirculation in South Africa (SA),1 a country of almost 45 millionpeople. Another 1 million weapons are estimated to be illegallyheld.1 It is therefore not surprising that a recent survey of morethan 25 000 non-natural deaths2 conducted by the NationalInjury Mortality Surveillance System (NIMSS) identifiedfirearms as the leading cause of non-natural death in SA.Approximately 45% of surveyed deaths were due to homicide,of which 50% were due to firearm injuries. If a nationalestimate of 70 000 non-natural deaths per year2 is used, it canbe assumed that at least 15 500 people die from firearm-relatedinjuries per annum in SA, a country not at war. This translatesinto the second highest firearm-related homicide rate (27/100 000) in 69 countries recently surveyed by the UnitedNations3 (Table I). While the national homicide rate providesgood evidence of the extent of fatal firearm violence, the ratesfor firearm-related homicide in large urban centres far exceedthe national average: Johannesburg (63/100 000), Durban (48/100 000) and Cape Town (40/100 000).The mortality burden of firearm injuries is clearly excessive,but the burden of non-fatal firearm-related injuries is estimatedto be far worse. A pilot study conducted by the National Non-fatal Injury Surveillance System (NANFISS)4 confirmed thehigh prevalence of interpersonal violence (53% of 1 122 patientssurveyed), and reported firearm-related trauma in at least 16%of cases injured as a result of violence. On the basis of thisinformation it seems likely that about 127 000 non-fatal firearminjuries are treated at SA state hospitals each year.The cost of rendering emergency treatment to this burden offirearm-related trauma has not been estimated to date. A studyconducted at Groote Schuur Hospital (GSH), one of the threelargest university-affiliated state hospitals in SA, found thatalmost 42% of 969 patients presenting with firearm-relatedinjuries required surgery.5 Abdominal firearm-related injuries (N = 161), accounting for almost 17% of presentations, were themost expensive to treat. It seems reasonable to estimate that atleast 20 000 emergency operations for abdominal firearm-related injuries are performed annually in SA state hospitals.Determining the minimum cost of treating serious abdominalgunshot injuries, i.e. those requiring admission to hospital andemergency surgery, would provide some perspective of theoverall fiscal burden borne by the SA health care budget,already stretched by an AIDS epidemic of extremeproportions.6Departments of Surgery and Internal Medicine, G F Jooste Hospital, Cape Town D Allard, Doc Med (Brussels), Med Spec Chir Gen (Belgium)V C Burch, MB BCh, MMed, FCP (SA)Corresponding author: D Allard (denisallard@mweb.co.za)The cost of treating serious abdominal firearm-relatedinjuries in South AfricaD Allard, V C BurchIntroduction. Firearms, the leading external cause of non-natural deaths in South Africa, claim approximately 15 000lives annually. Up to 127 000 firearm-injured victims seek statehealth care assistance per annum. The fiscal burden of treatingthese injuries is not known.Methods. All serious abdominal firearm-related injuries(requiring admission to hospital and emergency surgery)presenting to a state hospital over a 6-month period werereviewed. A cost analysis using five variables was performed:operating theatre time, duration of hospital and high-care unitstay, pharmaceutical and blood products used, laboratoryservices used and diagnostic imaging studies performed.Results. Twenty-three patients with serious abdominal gunshotinjuries were admitted, of whom 21 (91%) were treated at thehospital from admission until discharge. Each admission costapproximately US$1 467. Hospital stay (47%) and operatingtheatre (30%) costs accounted for most of the total cost.Pharmaceuticals and blood products (20%), laboratoryservices (2%) and imaging studies (1%) contributed less than25% to the total cost.Conclusion. Serious abdominal gunshot injuries cost at least 13-fold more than the annual per capita South Africangovernment expenditure on health. This fiscal burden ofapproximately US$2.9 million, almost 4% of the annual healthbudget, does not include the cost of treating other seriousgunshot injuries. These findings highlight the need forsuccessful violence prevention strategies in South African.S Afr Med J 2005; 95: 591-594.Table I. Firearm-related homicide rateFirearm-related homicide Country rate (/100 000 people)Columbia 54.0South Africa 26.6Brazil 25.8USA 6.2Canada 0.6Australia 0.4UK 0.1 591-594 pgs q5  7/27/05  3:52 PM  Page 591August 2005, Vol. 95, No. 8  SAMJORIGINAL ARTICLESThe aim of this study was to determine the minimuminpatient cost of treating serious abdominal firearm-relatedinjuries in the SA state health care sector.MethodsThe study was conducted at G F Jooste Hospital (GFJH), a 188-bed state hospital within the municipal boundaries of CapeTown. The folders of all patients who underwent emergencysurgery for a firearm-related abdominal injury during the 6-month period 1 October 2002 - 30 April 2003, were reviewed.A cost analysis, based on five variables, was performed. Allcosts were calculated in South African rands (ZAR) and thenconverted to US dollars (US$) using an exchange rate of 1 US$= 7 ZAR (December 2003).Values were rounded off to thenearest US$. The five cost variables studied were: (i) operatingtheatre time (ZAR per minute); (ii) duration of hospital stay,including high-care unit admission, in days (ZAR per day); (iii) therapy, i.e. pharmaceuticals and blood products (ZAR perunit); (iv) laboratory services used (ZAR per unit); and (v) diagnostic imaging studies performed (ZAR per unit).Operating theatre costs (US$3.4 or ZAR24 per minute) andduration of hospital stay (general ward US$74 or ZAR518,high-care unit US$198 or ZAR1 384) costs were calculatedusing standard cost tables published annually by theDepartment of Health. These standard daily costs includelabour costs (professional, nursing, administrative andmanual).  The total cost of pharmaceuticals (perfusion fluids,medication, blood products) used per patient, from the time ofadmission until discharge, was calculated using standardpharmaceutical products cost tables. These tables (publishedannually by the Department of Health) reflect the latestgovernment tender prices of perfusion fluids and medicationavailable in the state health service. These prices do not includeprofessional labour costs. The cost of blood products used wasdetermined using the most recent price list issued by the SouthAfrican Blood Transfusion Service (SABTS). These annual pricelists reflect the cost of materials used, labour and transport. Thecost of laboratory services used was calculated using standardcost schedules published annually by the SA NationalLaboratory Services. These rates include the cost of materialsused, maintenance and labour. Diagnostic imaging study costswere calculated using standard rates quoted for state healthcare services. These rates include the cost of materials only.  Alldata were captured on checklists and entered onto Excelspreadsheets.  Descriptive parameters were calculated usingthe Statistica 6 software package (StatSoft Inc, Tulsa, USA).ResultsDuring the period studied, 128 patients required emergencythoracotomies or laparotomies for penetrating trauma (gunshotor sharp implement, e.g. knife) of the chest or abdomen.  Ofthese, 23 patients required emergency laparotomy for gunshotinjuries of the abdomen, i.e. an average of 1 gunshot-relatedlaparotomy per week.  Twenty-one of the 23 patients (91%)were managed at GFJH from admission until discharge. Twopatients were transferred postoperatively; 1 required transfer toGSH and 1 requested transfer to a private health care facility.All 21 patients discharged from GFJH were alive 1 month aftertheir operation.Table II highlights the variation in cost for each of thevariables studied.  The average cost per variable, expressed asa percentage of the total cost, was: 47% for hospital stay, 30%for operating theatre, 20% for pharmaceuticals and bloodproducts, 2% for laboratory services, and 1% for imagingstudies. The most expensive unit of cost per patient washospital stay: median cost US$592 for an average stay of 6.5days. The median cost of theatre facilities was US$444 perpatient (average operating time of approximately 130 minutesper laparotomy).  Overall, money spent on laboratory servicesand diagnostic imaging studies was limited by the veryselective use of investigations postoperatively. Less than 50% ofpatients (10 of 21) underwent laboratory tests postoperatively,only 19% (4 of 21) required tests in excess of US$50, andexpensive imaging studies, costing more than US$50 per unit,e.g. computed tomography (CT) of the abdomen, wereperformed on 1 patient only (Table II).As shown in Table II, the hospital spent a minimum of US$30 803 on the treatment of 21 abdominal gunshot victimsover a period of 6 months. On average, each victim cost thestate health service US$1 467 (approximately ZAR10 269).592Table II. Cost analysis per variable (N = 21)Basic minimum cost (US$)` Operating Hospital Therapy and Laboratory Imaging theatre stay blood products services studies TotalTotal 9 326 14 625 6 081 548 223 30 803Mean ± SD 444 ± 194 696 ± 441 290 ± 406 26 ± 47 11 ± 22 1 467 ± 984Median 411 592 86 4 6 1 106(range) 137 - 926 193 - 1 802 11 - 1 425 0 - 207 0 - 105 303 - 4 345591-594 pgs q5  7/27/05  3:52 PM  Page 592ORIGINAL ARTICLES593August 2005, Vol. 95, No. 8  SAMJDiscussionThis paper, using the best available information, provides areasonable estimate of the minimum in-hospital cost of treatingserious abdominal firearm-related injuries at a second-level SAstate hospital. For the purpose of this paper, serious firearm-related injuries were defined as gunshot injuries requiringadmission to hospital and emergency surgery.  While anaverage cost of US$1 467 (ZAR10 269) still underestimates thetotal in-hospital expense per patient (e.g. labour costs were notfactored into all the used government cost tables), the dataprovide a meaningful estimate of the minimum cost usingwell-defined cost units. The only other study attempting tocalculate the fiscal burden of gunshot injuries in SA estimatedthe hospital cost of serious abdominal firearm-related injuriesto be about ZAR8 564 per case in 1993.5 Unfortunately the costunits evaluated in this paper were not well described.Comparison of the data presented in these two papers shouldtherefore be done with caution.  However, if it can be assumedthat health care costs in SA have increased by at least 10% overthe past 10 years (1% per annum), then both papers suggestthat each serious abdominal gunshot injury currently costs theSA state health care system anaverage of more than ZAR10 000(approximately US$1 400).  By developed world standards thisper capita health expenditure does not seem excessive (TableIII).7 However, this figure represents an amount 13-fold greaterthan the annual per capita government expenditure on healthin SA in 2001 (Table III).  Even in SA, which has the highestannual per capita government health expenditure on theAfrican continent,7 the fiscal burden of serious abdominalfirearm-related injuries exceeds the per capita state health careexpenditure by a wide margin.By extrapolating the findings of this study, the national costof firearm-related injuries in SA starts to become apparent.Serious abdominal firearm-related injuries alone may becosting the SA government up to ZAR200 million (US$2.9million) per annum. This figure, roughly equivalent to 4% ofthe total national government expenditure on health per year,7is potentially being spent on less than 0.05% of the SApopulation – and does not include the cost of other seriousfirearm-related injuries, e.g. gunshot wounds of the head, neck,chest, spine or limbs, requiring hospital admission and surgery.Although this estimated expenditure represents only a fractionof the total cost per annum, the basic observation relevant tohealth care planning in SA is clear. The allocation of insufficientresources to manage the massive firearm-related burden oftrauma in SA may ultimately compromise the care of non-trauma patients competing for access to the same health careresources.Not only does the firearm-related trauma burden in SAexceed national fiscal resources, but it also threatens to exceedhuman resources in SA. Doctors in the public health system,currently employed at a rate of 22 per 100 000 population,8provide health care services for the almost 85% of SA residentswho do not have any form of private health insurance.9 Thismeans that at least 56 of every 66 (per 1 000 population)trauma cases seeking medical attention will be treated bydoctors working in the public health care system. From thislimited analysis, it is apparent that the trauma burdencurrently exceeds both financial and human public health careresources in SA.A criticism of this paper may be that it reflects the experienceof only one hospital treating serious abdominal firearm-relatedinjuries in the SA state health sector. While the limitations ofthe small study cohort are acknowledged, and a larger cohortof patients would be worth studying, it should be recognisedthat the high trauma caseload managed at GFJH recentlyrendered it suitable to be one of only two national pilot sitesfor the NANFISS study4 referred to previously. A major reasonfor this is that the hospital serves a densely populated area inwhich more than 1 million of Cape Town's estimated 2.7million residents10 live. Most of these people have a per capitamonthly income of less than ZAR300 (US$43) and reside insuburbs with the highest firearm-related homicide rates inCape Town.11 The firearm-related injury caseload of thishospital, representing the more severe end of the spectrum inSA, means that it serves well as a site of firearm-related traumaresearch.In addition to determining the cost of care, the possibilitythat unnecessary resources are being spent on the managementof firearm-related trauma victims should also be considered.Based on the findings of this study, however, it would seemthat patients are being treated in a cost-effective manner. Giventhe nature of the injuries sustained, neither the duration ofsurgery nor the length of hospital stay seems excessive. Theexpenditure on pharmaceuticals and blood products may seemhigh, but the cost of blood products has risen sharply sinceTable III. Annual per capita expenditure on healthPer capita expenditure on health per annum (US$)Total Governmentexpenditure expenditureTop five developed world countriesUSA 4 887 2 168Switzerland 3 774 2 146Canada 2 163 1 490UK 1 835 1 508Australia 1 741 1 246Top three African countriesSouth Africa 222 106Botswana 190 107Namibia 110 87591-594 pgs q5 SPOT  8/1/05  12:59 PM  Page 593August 2005, Vol. 95, No. 8  SAMJORIGINAL ARTICLEScomprehensive HIV screening of all blood products has beenimplemented. Blood, fresh-frozen plasma or platelet infusionscurrently cost US$54 - 64 (ZAR378 - 448) per unit (SABTS).Laboratory and imaging study expenses were minimal in thepatients studied.  The huge financial cost of providing basic in-hospital care forserious abdominal gunshot injuries raises the question ofintervention, i.e. violence prevention programmes. Suchprogrammes require accurate ongoing surveillance data. Boththe fatal (NIMSS) and non-fatal injury surveillance systems(NANFISS) recently launched in SA by the Violence and InjurySurveillance Consortium have started providing insight intothe extent of the problem. Similar injury surveillancemechanisms have been, and need to be, launched in otherAfrican countries where violence is perceived to be a majorcause of morbidity and mortality.  The systems developed inSA may serve as useful models upon which to base the designof robust data gathering tools required to properly informintervention strategies that will stem the rising tide of violence,in particular gun violence, in SA and the rest of sub-SaharanAfrica.ConclusionEach surgical treatment for gunshot wounds of the abdomencosts the state health service a minimum of over ZAR10 200, afigure 13-fold greater than the annual per capita governmentexpenditure on health.References1. Gun Control Alliance. Statistics on Gun Violence in South Africa. CapeTown: Gun ControlAlliance, 2002. http://www.gca.org.za/facts/statistics.htm (last accessed 18 July 2005).2. Matzopoulos R, Seedat M, Cassim M. A Profile of Fatal Injuries in South Africa: Fourth AnnualReport of the National Injury Mortality Surveillance System (NIMSS). Cape Town: South AfricanMedical Research Council/University of South Africa Crime, Violence and Injury LeadProgramme, 2002. http://www.sahealthinfo.org/violence/nimmssannual2002.pdf (lastaccessed at the time of writing in 2004).3. United Nations Economic and Social Council: Commission on Crime Prevention andCriminal Justice. Criminal Justice Reform and Strengthening of Legal Institutions Measures toRegulate Firearms (Report E /CN.15 /1997/4). Vienna: United Nations Commission on CrimePrevention and Criminal Justice, 1997. http://www.uncjin.org/Documents/6comm/4e.pdf(last accessed 18 July 2005).4. Peden M, Matzoupolos R, Maziko M, et al. Final Report: Pilot South African National Non-FatalInjury Surveillance System (NANFISS). Cape Town: South African Medical Research Council/Council for Scientific and Industrial Research /University of South Africa Crime, Violenceand Injury Lead Programme, 2000. http://www.sahealthinfo.org/violence/finalreport.pdf(last accessed at the time of writing in 2004).5. Peden M, Van der Spuy J. The cost of treating firearm victims. Trauma Review 1998; 6: 4-5.6. Bradshaw D, Groenewald P, Laubscher R, et al. Initial Estimates from the South African NationalBurden of Disease Study, 2000. Cape Town: South African Medical Research Council, 2003.http://www.mrc.ac.za/bod/bod.htm (last accessed 18 July 2005).7. World Health Organization. The World Health Report 2003: Shaping the Future. Geneva: WorldHealth Organization, 2003. http://who.int/whr/2003/annex_6_en.xls (last accessed 18 July2005).8. The South African Health Review 2000: Indicators. Durban: Health Systems Trust, 2000.http://www.hst.org.za/sahr/2000.indicators.htm (last accessed 18 July 2005).9. Goudge J, Cornell J, McIntyre D, Mabatsha S. Private sector financing.  In: Ntuli A, SulemanF, Barron P, McCoy D, eds. South African Health Review 2001. Durban: Health Systems Trust,2001. http://www.hst.org.za/sahr/2001 (last accessed 18 July 2005).10. Dorrington RE.  Projection of the Population of the Cape Metropolitan Area 1996 - 2031. CapeTown: School of Public Health, University of the Western Cape, 2000.http://www.capetown.gov.za/home/demographics.asp (last accessed 18 July 2005).11. Prinsloo M. The Extent of Gun Violence in Cape Town, South Africa. CapeTown: South AfricanMedical Research Council /University of South Africa Crime, Violence and Injury LeadProgramme, 2001. http://www.sahealthinfo.org:80/violence/gunviolence.pdf (last accessedat the time of writing in 2004).594591-594 pgs q5 SPOT  8/1/05  12:59 PM  Page 594

The cost of treating serious abdominal firearm-related injuries in South Africa

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The cost of treating serious abdominal firearm-related injuries in South Africa

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