The direct medical cost of managing traumatic brain injuries at Port Moresby General Hospital, Papua New Guinea: a prospective cost of illness study

Introduction

Traumatic brain injury (TBI) poses a significant economic and public health challenge.¹ In 2019, an estimated 27.16 million new cases of TBI were diagnosed worldwide.² The resulting economic burden on health systems has become substantial, with in-hospital costs reported to reach as high as US$401,808 per patient.³

The incidence of TBI in Papua New Guinea (PNG) is reported at 168 cases per 100,000 population, ranking among the highest in the Western Pacific region.⁴ At Port Moresby General Hospital (PMGH), TBIs constitute 36% of all neurosurgical admissions, often necessitating resources to provide for surgery, intensive care monitoring, and rehabilitation.⁵

Understanding the financial impact of TBIs on both the hospital and patient is crucial, especially given that, in 2022, the average direct medical cost of traumatic injuries in PNG was K45,900.40 (US$13,311.12)⁶. Currently, there is no existing literature on the direct medical costs of TBIs in PNG to guide policymakers in making informed decisions about financing and resource allocation. Therefore, the objective of this study was to calculate the direct medical cost of managing TBI patients at PMGH.

Methods

Results

There were 77 patients admitted with TBI in this study. The male to female ratio was 5:1. The mean age of patients was 23.4 years; the minimum age was 5 years, and the maximum age was 70 years. Of the total patients, 36.4% (n = 28) were from Central Province as shown in Table 2. Alcohol-related injuries accounted for 76.6% (n = 59) of total admissions. Assaults accounted for 49% (n = 38) of admissions as shown in Fig. 1. There were no deaths during this study period, and the mean length of hospital stay was 10.5 days (s.d. ±3).

Fig. 1.

Aetiology of TBI in patients admitted to PMGH from 31 August 2023 to 1 January 2024.

Hospital costs

The total hospital cost amounted to K6,197,919.25 (US$1,549,479.81), accounting for 99.2% of the overall direct medical costs. As illustrated in Fig. 2, drugs and consumables made up 72.0% of the hospital costs, with salaries and wages accounting for the remaining 28%.

Fig. 2.

Percentage per hospital cost on patients admitted for TBI at PMGH from 31 August 2023 to 1 January 2024.

The total direct medical cost over the 6-month period was K6,246,779.25 (US$1,561,694.81) and, on average, the direct medical cost was K81,127.00 (US$20,281.75) per patient (s.d. ±341). The highest cost per TBI classification was that of severe head injury with costs incurring K95,328.03 (US$23,832.01) per patient (s.d. ±255) as shown in Fig. 3.

Fig. 3.

Mean cost per patient per head injury severity in patients admitted to PMGH from 31 August 2023 to 1 January 2024.

Table 4 shows the cost per aetiology. Motor vehicle accidents (MVAs) had the highest direct medical cost per patient per aetiology (in comparison to number of patients) with K60,029.00 per patient (US$15,007.25). Total ICU associated costs for drugs, consumables, and equipment was K638,221.50 (US$159,555.38) at an average per patient of K70,913.50 (US$17,728.38).

Table 4.Cost per aetiology for drugs and consumables for patients admitted with TBI to the surgical department from 31 August 2023 to 1 January 2024.

Aetiology	Number n = 77	Total direct medical cost in Kina	Mean cost per patient in Kina (US$)
Assault	38	2,209,337.87	58,140.47 (14,535.12)
Motor vehicle accident	18	1,080,535.14	60,029.00 (15,007.25)
Bush knife wound	11	629,563.79	57,233.07 (14,308.27)
Fall from height	8	439,498.65	54,937.33 (13,734.33)
Sports injury	1	70,870.83	70,870.83 (17,717.70)
Blunt trauma	1	54,124.04	54,124.04 (13,531.01)

The sensitivity analysis demonstrates that total direct medical costs are highly sensitive to changes in human resource costs, with a 20% increase leading to higher costs and a 20% decrease resulting in savings across all aetiologies (shown in Table 5).

Table 5.One-way sensitivity analysis as per varying cost of human resource by 20%.

Aetiology	Original total cost (Kina)	Total cost with 20% increase (Kina)	Total cost with 20% decrease (Kina)
Assault	2,209,337.87	2,651,205.43	1,767,470.29
Motor vehicle accident	1,080,522.00	1,296,626.40	864,417.60
Bush knife wound	629,563.77	755,476.52	503,651.02
Fall from height	439,498.65	527,398.37	351,598.91
Sports injury	70,870.83	85,044.99	56,696.66
Blunt trauma	54,124.04	64,948.85	43,299.23

Discussion

This study examines the direct medical costs of managing TBI patients at a tertiary hospital in PNG. The age distribution of TBI cases observed aligns with previous studies, which reported a higher incidence among individuals aged 18–40 years in PNG.^12–14 Additionally, our findings show a predominance of male cases, consistent with the 2019 global age-standardised incidence rate of 346 per 100,000 population.²

Assaults and MVAs were identified as the leading causes of TBI in this study. Similarly, a previous study by Liko et al. found that assaults and MVAs accounted for 32 and 49% of all TBI cases, respectively, at PMGH.¹³ On a global scale, Huang et al. reported that falls contribute to over 30% of TBI cases worldwide, whereas MVAs were more prevalent as a cause of TBIs in African countries.²

MVAs incurred the highest direct medical cost per patient among all TBI aetiologies in this study. In 2018, 8.9% of all admissions to PMGH were MVA-related, with 46% of the patients being pedestrians.¹⁵ Our study revealed that the average cost of drugs, consumables, and equipment for managing TBI cases resulting from MVAs was K60,029.00 (US$15,007.25) per patient. This aligns with findings of Rubin, who reported in-hospital TBI costs ranging from US$12,100.00 to US$21,000.00.¹⁶

In PNG, severe head injuries account for 30–59% of all TBI admissions.^8–11 Globally, they represent 52.8% of all TBI cases.² In this study, we found that managing a single patient with a severe head injury cost K95,328.03 (US$23,832.01). These high costs are primarily due to the significant morbidity associated with severe head injuries, which drives up direct healthcare expenses.¹⁶ This was particularly evident among patients admitted to the ICU, where K638,221.50 (US$159,555.38) was spent on drugs and consumables over the 5-month duration of the study.

Weil et al. identified alcohol intoxication as one of the strongest predictors of sustaining a TBI.¹⁷ In this study, 76.6% (n = 59) of patients were under the influence of alcohol at the time of injury. Alcohol abuse remains a significant public health concern in PNG, with the World Health Organization highlighting that the country has surpassed critical levels of alcohol-related issues. This is compounded by outdated laws governing the regulation, manufacturing, sale, and consumption of alcohol.^18,19

In PNG, the public health system is primarily funded by the government through the National Department of Health and the Department of Personal Management. This study found that the hospital bore 99.2% of all direct medical costs. In many low- to middle-income countries, out-of-pocket payments account for over 50% of total health expenditure.²⁰ Although the PNG government covers the majority of healthcare costs, 29% of individuals in rural areas seeking surgical care are pushed into poverty due to expenses related to transport, food, and accommodation.²¹

Our sensitivity analysis showed that total direct medical costs are highly sensitive to changes in human resource costs (Table 5). The most significant impact is observed in conditions with higher patient volumes, such as assault and motor vehicle accidents, where total costs increase or decrease notably. In contrast, conditions with fewer patients, like sports injury and blunt trauma, show less dramatic changes.

The outcomes of TBI patients largely depend on the severity of the injury. A study by Kaptigau reported a case fatality rate of just under 30% among patients with moderate to severe head injuries managed at PMGH.²² However, in the present study, no deaths were recorded. This may have been as a result of our exclusion criteria in which head injury patients were excluded if they had polytrauma or had died while being managed at the emergency department. To mitigate costs, preventive measures have focused on addressing MVAs and alcohol consumption. Additionally, preventing secondary brain injury is crucial and can be achieved by maintaining cerebral oxygenation and blood pressure through proper airway management, ventilation support, fluid administration, and the use of inotropes.²³ This is particularly important, as a study by Umo et al. found that TBI patients with hypoxia in PNG faced the highest risk of mortality.¹²

This study has several limitations. The direct medical costs reported do not account for expenses related to power, water, building infrastructure, or outpatient follow-up care. Additionally, the medical and dental catalogue used for cost estimation was last updated in 2012, and confirmation of blood alcohol levels was not possible, with data relying solely on patient history. Consequently, the costs presented are likely underestimated, as a comprehensive societal cost analysis could not be conducted. Despite these limitations, the study successfully achieved its objectives and provides valuable preliminary data on the direct medical costs of managing TBI at PMGH.

Conclusion

TBIs are a common cause of admission to PMGH and are associated with significant direct medical costs. Furthermore, variations in human resource costs can notably influence the total cost, especially for high-volume conditions. Public health interventions and government policies should focus on regulating alcohol production and consumption, as well as improving road traffic safety, to reduce the economic burden of TBIs.

Supplementary material

Supplementary material is available online.