In order to compile a complete picture of the impact of musculoskeletal injuries, six major health care databases are used to estimate the number of visits to a health care provider in a specific year. Treatment episodes, for purposes of this study, have been defined as the accumulative total of cases for all diagnoses treated in physician offices, emergency departments, outpatient clinics, and hospital discharges. Diagnoses are based on variables within publicly available health care database that identify diagnoses or treatments based on ICD-9-CM codes submitted by health care providers. Databases used include from 3 to 25 diagnosis codes, or variables, per record. When analyzing the databases for a specific diagnosis or procedure, if any of the diagnosis variables in the database matches the code of interest, it is included in the total count. Hence, total numbers of injuries may exceed total records if more than one injury is sustained. In addition, health care visits, or episodes, are not the equivalent of patients, as there is some unknown probability that a person may have multiple visits over the year included in the database. While not an absolute, the numbers presented are a solid estimation of how a particular health care issue such as a musculoskeletal injury, compares to other health care issues.
Four of the databases included are produced by the National Center for Health Statistics (http://www.cdc.gov/nchs/index.htm [1]), a division of the Centers for Disease Control and Prevention, and include data on visits to physician offices (NAMCS), emergency departments (NHAMCS_ED), outpatient clinics (NHAMCS_OP), and hospital discharges (NHDS). These four databases include a representative sample that is weighted to reflect the U.S. population by demographic characteristics for the year from which the data is produced. The remaining two databases are produced by the Healthcare Cost and Utilization Project (HCUP: http://www.hcup-us.ahrq.gov/ [2] ) under the U.S. Department of Health and Human Services Agency for Research and Healthcare Quality. These two databases focus on hospital discharges (NIS) and visits to emergency departments (NEDS), and include millions of data points submitted by participating hospitals and emergency departments. HCUP data is also weighted for representativeness of the U.S. population. All databases are structured to provide only autonomous data. When the two databases were analyzed for hospital discharges and emergency department visits, they yielded similar results, supporting the validity of the findings reported.
Musculoskeletal injuries accounted for 4% of health care visits to physician offices, outpatient clinics, and hospital discharges. Visits to emergency departments for musculoskeletal injuries accounted for 15% of all emergency department visits. Overall, more than 65 million health care visits were made in 2010 for musculoskeletal injuries. By far, the largest share of these visits was to physician offices, accounting for nearly 80% of all visits and for 62% of visits for musculoskeletal injuries. Emergency departments and outpatient clinics see similar percentages of total patients (10% [NHAMCS_ED] and 8% [NHAMCS_OP]), but emergency departments are more likely to see patients with a musculoskeletal injury. Hospital discharges account for about 3% of patient visits for all health care reasons and for musculoskeletal injuries. (Reference Table 6A.2.2.1 PDF [3] CSV [4])
Three of four (77%) health care visits associated with an injury diagnosis are related to a musculoskeletal injury. The largest share is found in injury treatments in a physician's office, where four of five (81%) injuries treated are musculoskeletal. The smallest share, 68%, is for hospital discharges. (Reference Table 6A.2.2.4 PDF [5] CSV [6])
Females, in general, are more likely overall to have a health care visit than are males. With regard to musculoskeletal injury, however, this is true only for the category of health care visits related to hospital discharges, where females represent slightly more than their proportion in the general population. For other care sites, males represent a higher than expected proportion of visits for musculoskeletal injuries.
When it comes to age, persons 75 years and older are far more likely to have a hospital discharge for a musculoskeletal injury than those younger in age. Children, defined as those under the age of 17, utilize outpatient clinics for injury treatment more than persons of other age groups. Young adults between the ages of 18 and 44 years visit emergency departments more frequently for injury care, while their slightly older peers, those aged 45 to 64 years, visit physician offices most often. People aged 65 to 74 years comprise about the same proportion of the general population as those 75 years and older, but they make fewer health care visits for musculoskeletal injury treatment.
More than 18.3 million health care visits were for the treatment of fractures in 2010. A close second, sprains and strains accounted for 17 million health care visits. Contusions, open wounds, and dislocation visits numbered 9 million, 8 million, and 6.5 million, respectively. Other types of musculoskeletal injuries represented another 11 million visits. With the exception of contusions, musculoskeletal injuries are treated most frequently in a physician’s office. Nearly 5 million contusions were treated in emergency departments; this compares to 3.6 million treated in a physician's office. (Reference Table 6A.2.2.1 PDF [3] CSV [4], Table 6A.2.2.4 PDF [5] CSV [6], and Table 6A.2.2.5 PDF [7] CSV [8])
Males have a slightly higher rate of musculoskeletal injury than females, with 22.0 injury visits to all provider sites per 100 males in 2010. This compares to 20.5 injury visits per 100 females. The proportion of all musculoskeletal injury visits for males versus females is the reverse of that found in the general population: 51% male to 49% female injury visits versus the 49% to 51% male to female ratio found in the general population. Males are more likely to suffer open wounds (62%) and dislocations (56%). Females have correspondingly lower rates for these injuries, and an expected share of other types of musculoskeletal injuries.
Males have a higher rate of injuries seen in a physician's office, while females are more likely to be discharged from a hospital or seen in an emergency department because of a musculoskeletal injury. Because injuries for which a patient is hospitalized are potentially more severe than those seen in a physician office, it might be surmised that females may incur more severe musculoskeletal injuries.
(Reference Table 6A.2.2.1 PDF [3] CSV [4] and Table 6A.2.2.5 PDF [7] CSV [8])
Age is also a factor in the rate of musculoskeletal injury health care visits, with the rate per 100 persons increasing from 19.5 for children (ages 0 to 17 years) to 33.9 for people age 75 years and older. This rate increase is found across all provider sites. However, because elderly people comprise a smaller share of the general population, the actual number of injuries for which treatment is delivered is much larger in the younger age brackets. Those aged 45 to 64 years, with 22.3 million visits, had the largest number of musculoskeletal injuries treated in 2010. Older people aged 65 to 74 years had just over 5 million injury visits, while those age 75 years and older accounted for 6.3 million episodes.
Elderly people are particularly prone to fractures, accounting for 23% of fractures treated in 2010, while representing only 6% of the general population. Overall, the elderly accounted for 12% of all musculoskeletal injuries. Those between the ages of 18 and 44 years are disproportionately prone to dislocations and sprains and strains requiring medical attention. (Reference Table 6A.2.2.2 PDF [9] CSV [10] and Table 6A.2.2.5 PDF [7] CSV [8])
In 2010, a substantial majority of the 5.8 million dislocations (76%) were treated in physician offices. Dislocation of the knee or leg joint represented 86% of these injuries, with the shoulder (8%) the only other anatomic site to account for more than a very small fraction of dislocations. This finding is likely an artifact of an ICD-9 coding anomaly. Isolated acute ligamentous injuries of the knee, (ie, anterior cruciate ligament [ACL], medial collateral ligament [MCL], posterior cruciate ligament [PCL], and lateral collateral ligament [LCL] disruptions) are coded as dislocations using ICD-9-CM methodology, whereas equivalent injuries in other joints are coded as sprains or strains rather than dislocations. True complete dislocations of the knee joint are actually very rare, and associated with marked morbidity.
More than one-third (36%) of the 11.8 million sprain and strain injuries treated in physician offices in 2010 were to the back and sacroiliac joint. Shoulder (31%) and ankle and foot injuries (23%) represented the other two most common anatomic sites for sprains and strains treated in physician offices.
The total number of fractures of the upper and lower extremities treated in physician offices, emergency departments, and hospitals, while fluctuating from year to year, has varied between 12 million and 15 million from 1998 to 2010. Upper limb fractures, including those of the arm, forearm, wrist, hand, and fingers, have accounted for slightly more than one-half of all fractures, with a range of 52% to 59%. Fractures of the upper arm, or humerus, are the least common. In recent years, upper arm fractures have accounted for about 20% of total upper limb fractures. Fractures of the wrist, hand, and fingers occur slightly more often than fractures of the forearm.
Lower limb fractures, which include those of the hip and upper leg (femur), lower leg, ankle, foot, and toes, are reported in similar numbers to upper limb fractures, ranging from 11 million to 15 million. Between two-third and three-fourth of lower limb fractures occur in the ankle, foot, and toes. Breaks of the lower leg (tibia and fibula) are the least common overall.
The majority of fracture care episodes, 65% to 73%, occurred in a physician’s office. Fewer than one in ten fractures (8% or less) were treated with inpatient hospitalization in any given year. However, it is possible that initial care for a fracture was either at the ED or in a hospital admission, with follow-up visits associated with a physician’s office visit. It is, therefore, likely each individual fractures may have been associated with multiple episodes of care. (Reference Table 6A.2.3.1 PDF [11] CSV [12] and Table 6A.2.3.2 PDF [13] CSV [14])
Links:
[1] http://www.cdc.gov/nchs/index.htm
[2] http://www.hcup-us.ahrq.gov/
[3] https://www.boneandjointburden.org/docs/T6A.2.2.1.pdf
[4] https://www.boneandjointburden.org/docs/T6A.2.2.1.csv
[5] https://www.boneandjointburden.org/docs/T6A.2.2.4.pdf
[6] https://www.boneandjointburden.org/docs/T6A.2.2.4.csv
[7] https://www.boneandjointburden.org/docs/T6A.2.2.5.pdf
[8] https://www.boneandjointburden.org/docs/T6A.2.2.5.csv
[9] https://www.boneandjointburden.org/docs/T6A.2.2.2.pdf
[10] https://www.boneandjointburden.org/docs/T6A.2.2.2.csv
[11] https://www.boneandjointburden.org/docs/T6A.2.3.1.pdf
[12] https://www.boneandjointburden.org/docs/T6A.2.3.1.csv
[13] https://www.boneandjointburden.org/docs/T6A.2.3.2.pdf
[14] https://www.boneandjointburden.org/docs/T6A.2.3.2.csv