PERSPECTIVE ARTICLE

Costs of burn care: A systematic review

M. Jenda Hop, MD1,2; Suzanne Polinder, PhD3; Cornelis H. van der Vlies, MD, PhD4;
Esther Middelkoop, PhD2,5; Margriet E. van Baar, PhD1
1. Association of Dutch Burn Centers, Burn Center, Maasstad Hospital
4. Burn Center, Maasstad Hospital
3. Department of Public Health, Erasmus Medical Center, Rotterdam
2. Department of Plastic, Reconstructive and Hand Surgery, MOVE Research Institute, VU University Medical Center, Amsterdam, and
5. Association of Dutch Burn Centers, Red Cross Hospital, Beverwijk, The Netherlands

Reprint requests: ABSTRACT

Margriet E. van Baar, PhD, Burn Center,
Maasstad Hospital, PO Box 9100,
Rotterdam, AC 3007, The Netherlands.
Tel: 00 31 10 291 3428;
Fax: 0031 291 3135;
Email: baarm@maasstadziekenhuis.nl
Editorial comments by Lars-Peter Kamolz,
Gerald Sendlhofer, and David Lumenta
Manuscript received: July 16, 2013
Accepted in final form: April 01, 2014
DOI:10.1111/wrr.12189
Burn care is traditionally considered expensive care. However, detailed information
about the costs of burn care is scarce despite the increased need for this information
and the enhanced focus on healthcare cost control. In this study, economic literature
on burn care was systematically reviewed to examine the problem of burn-related
costs. Cost or economic evaluation studies on burn care that had been published in
international peer-reviewed journals from 1950 to 2012 were identified. The meth-
odology of these articles was critically appraised by two reviewers, and cost results
were extracted. A total of 156 studies met the inclusion criteria. Nearly all of the
studies were cost studies (n = 153) with a healthcare perspective (n = 139) from
high-income countries (n = 127). Hospital charges were often used as a proxy for
costs (n = 44). Three studies were cost-effectiveness analyses. The mean total health-
care cost per burn patient in high-income countries was $88,218 (range $704
$717,306; median $44,024). A wide variety of methodological approaches and cost
prices was found. We recommend that cost studies and economic evaluations employ
a standard approach to improve the quality and harmonization of economic evalua-
tion studies, optimize comparability, and improve insight into burn care costs and
efficiency.

Burn care is traditionally considered expensive care. This
assumption is supported by a recent study by Sanchez et al.,
who found that the mean annual cost of burn patient treatment
in Spain was $99,773 compared with $13,826 for the mean
annual cost of treatment for stroke survivors during their first
year poststroke and $13,823 for annual care for HIV/AIDS
patients.1 In todays economic climate, it is important to
attempt cost reductions in healthcare. Burn care costs are
thought to be high because patients with burns often need
specialized burn center treatment during a substantial length
of stay, including time- and material-intensive surgical and
nonsurgical wound care, intensive care, and long periods of
rehabilitation.2 Good insight into the extent of burn care costs
should be obtained prior to attempts to improve burn care
cost-effectiveness.
Health economics provide the necessary insights regarding
community resource allocation to maximize efficiency in
healthcare.3,4 Different types of economic studies can be per-
formed. Two types of studies are generally identified: cost
studies and economic evaluation studies. Cost studies can
provide valuable insight into the distribution of costs and
allow the development of specific cost-reducing measures.
Cost-of-illness studies, a specific type of cost study, aim to
measure and identify the societal costs associated with a par-
ticular disease.5 Economic evaluation studies primarily aim to
evaluate the outcomes and costs of different interventions that
are designed to improve health. Economic evaluation studies
provide information on the interventions that provide the most
favorable balance between costs and health effects.4 The
optimal use of resources is important because healthcare is
increasingly expensive and budgetary pressures are rising.
It is challenging to clearly report the results of health eco-
nomic evaluations. This spring, the Consolidated Health Eco-
nomic Evaluation Reporting Standards (CHEERS) statement
guidelines were published as a tool for optimizing health
economic evaluation reporting. This document attempted to
update the previous health economic evaluation guidelines
and consolidate them into one current, useful source of report-
ing guidance3 that could be applied to economic studies of
burn care. Central issues include the systematic reporting of
methodology (e.g., study perspective, time horizon, and cost
calculations) and results (incremental costs and outcomes and
the characterization of uncertainty and heterogeneity).
Several narrative literature reviews on the costs and quality of
burn care have been published in recent years.2,6,7 One review
focused on pediatric patients,7 whereas the other reviews
discussed the relationship between quality and cost-effective
burn care.2,6 The available reviews did not follow
the CHEERS recommendation that the methodology of the
included studies should be systematically assessed. The

436 Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Hop et al.
reviews did discuss several options for achieving burn care
cost reductions without compromising the quality of care,
including the use of ambulances instead of helicopters, the use
of less expensive dressing materials, and early excision and
grafting.2,6 Again, no systematic information discussed the
quality of the results of the included studies.
There is a lack of systematic information on the method-
ological quality of cost studies and economic evaluations in
the area of burn care. No overview of the extent or distribution
of burn care costs or of the global variation in these costs is
available. To define the problem of burn-related costs, a sys-
tematic literature review was performed in this study to evalu-
ate all of the existing economic literature on burn care. The
objectives of this review were (1) to assess the methodologi-
cal quality of economic studies on burn care; (2) to present the
range of medical costs and nonmedical costs of burn care; and
(3) to present economic evaluation studies of burn care. Costs
per treatment and per day compared with nonburn care costs
were included in the analyses.
METHODS
Search strategy
Searches of eligible studies were conducted in Medline
(PubMed) and EMBASE. The search terms used in Medline
included burns (MesH Terms), burn* (Title/Abstract), scald*
(Title/Abstract), thermal NEXT injury* (Title/Abstract), cost
and cost analysis (MesH Terms), and cost* (Title/Abstract).
The search terms used for EMBASE were burn*, scald*, and
cost* or cost allocation*. Reference lists of included articles
(published from 2002 to 2012) were screened for relevant
articles.
Selection criteria
The included studies met the following criteria:
Burn care cost studies or economic evaluation studies in
which costs per patient were reported in the methods or
results section
Empirical studies in all market economies that were pub-
lished in international peer-reviewed journals during the
period from January 1950 to May 2012 (reviews were
excluded)
Studies published in English, French, German, or Dutch
Data extraction
Relevant papers were selected by screening the titles (first
step), abstracts (second step), and entire articles (third step)
that were retrieved using the database and manual searches.
During each respective step, the title, abstract, or entire article
was screened to ensure that the article met the selection cri-
teria. The screening was conducted independently by two
researchers (MJH and MEB). Reviewer disagreements about
article eligibility were resolved through discussion with a
third researcher (SP). The full articles were extracted by two
researchers (MJH and MEB). The assessment of the quality of
the economic evaluations was based on the cost-utility analy-
sis reporting checklist recommended by the panel on cost-
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Costs of burn care
effectiveness in health and medicine5 and based on the
guidelines developed for economic submissions to the British
Medical Journal.
Furthermore, cost information in the following categories
was identified:
Total healthcare costs per burn patient
Unit price per hospital per inpatient day
Healthcare costs for burn patients vs. other patients
Economic evaluation studies: cost, effect, and incremen-
tal cost-effectiveness ratio (ICER)
In addition, detailed information on costs in high-income
countries (www.worldbank.org) was identified:
Costs related to injury characteristics: etiology and total
body surface area (TBSA) burned
The cost distribution (%) of different healthcare cost
components
The two independent reports were compared, and disagree-
ments were resolved through discussion with a third
researcher (SP). To enable the comparison of the costs pre-
sented in the included studies, all costs were converted to
2012 US dollars using currency and inflation correction. The
mean and median total healthcare costs per patient and the
hospital day prices were calculated using the data from all of
the studies that indicated total burn care costs or hospital day
prices, respectively. The costs prices per 1% TBSA burned
were calculated by dividing the total healthcare costs per
patient by the mean TBSA burned; figures were taken from
studies with both TBSA and total costs.
RESULTS
Literature search
The Medline search yielded 1,072 articles and 702 additional
articles were found in Embase. Finally, two articles were
retrieved by manual searching for a total of 1,776 unique
articles. Title screening resulted in the selection of 780
articles that appeared to meet all of the selection criteria. In
the second phase, abstract screening resulted in the exclusion
of 489 articles. Of the remaining 291 articles, 135 did not
meet the inclusion criteria after the papers had been fully
read; thus, the final sample includes 156 articles. Three full
texts could not be retrieved. The main reasons for exclusion
were failure to address burn care or burn patients and the
absence of a description of the studys cost calculations in the
methods or results.
Study characteristics: patients and methodology
The first study included in this review was published in 1967.
The studies were performed in various market economies, but
predominantly in high-income countries (n = 127). Most
studies were conducted in burn centers in North America. The
focus was primarily on general burn patients (n = 122).
However, some studies focused on pediatric burn patients
(n = 23) or compared burn patients with other patients
(n = 11). Some studies identified the TBSA, and the mean
TBSA burned (n = 91) ranged from 195%; most of these
studies focused on more severe burns (Table 1 and Supporting
Information Table S1).
437
Costs of burn care Hop et al.

Table 1. Study characteristics: patients and methodology (n = 156)1,8162

Studies Studies
Study characteristics (n) Study characteristics (n)

Study continent Time horizon cost analysis

North America 91 <1 year 151
South America 1 15 years 1
Europe 25 610 years 2
Asia 24 Lifelong 2
Africa 9 Cost categories
Australia 6 Direct medical costs 143
Setting Direct medical and nonmedical costs 5
Burn center/unit 116 Direct medical and nonmedical costs and 2
Trauma center 2 indirect nonmedical costs
ICU 2 Direct medical and indirect nonmedical costs 6
General Hospital 27 Cost components*
Others 9 Initial transport to hospital 4
Type of patients Intramural care
General burn patient 122 Hospitalization 96
Pediatric patient 23 Surgical treatment 22
Burn patient vs. other patient 11 Dressings 34
Mean TBSA burned Medication 28
010% 27 Pressure garments 3
1120% 21 Allied health professionals 6
>20% 43 Diagnostics 14
Not described 65 Reconstructive surgery 2
Study design Emergency department 4
Randomized clinical trial 24 Outpatient hospital care 13
Controlled clinical trial 4 Productivity loss 2
Case control 12 Insurance claims 2
Cohort study 107 Patient costs, direct and productivity loss 4
Case study 9 Availability information calculation costs
Type of economic study Price data 44
Economic evaluation: cost-effectiveness analysis 3 Data sources 101
Cost study 153 Resources (healthcare consumption) 36
Economic perspective Data source and resources 31
Societal 4 Data source and resource and price data 17
Healthcare 139 Approach: bottom-up/ top-down
Insurance 8 Bottom-up 18
Individual 5 Top-down 4
Approach not described 134

*Diverse components per study are possible.

With various definitions: often including all hospital healthcare costs/charges, sometimes excluding physician fees, sometimes
excluding surgery/dressings, etc.
The main headings of cost components are presented in italic. A complete version of this table, including references per category,
can be found as Supporting Information Table S1 online.
ICU, intensive care unit; TBSA, total body surface area.

Cohort studies (n = 107) were the most common in this preferred economic approach is that of the societal study that
review, followed by randomized controlled trials (n = 24). takes into account costs to all members of a society,4 only two
The most frequently performed type of economic study was studies employed this perspective.1,8 Most studies employed
the cost study (n = 153). Although the most extensive and the healthcare perspective (n = 139). The time horizon of

438 Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Hop et al. Costs of burn care

most cost calculations was <1 year, and only acute burn care calculated acute burn hospitalization costs only. The mean
costs were generally examined; the costs during the rehabili- total healthcare cost per burn patient in high-income countries
tation phase were generally neglected. (73 studies) was $88,218 (range of $704$717,306; median
The relevant costs in these studies can be sorted into four of $44,024), whereas the corresponding figure was $5,196
categories: direct medical costs (e.g., the cost of hospital (range of $102$15,555; median of $3,559) for the 12 studies
stays), indirect medical costs (e.g., the cost of care during life of low- and middle-income countries. The costs of burn
years gained), direct nonmedical costs (e.g., traveling costs), patients per treatment and/or day were higher in most studies
and indirect nonmedical costs (e.g., productivity loss). The (7/11) than those of other patients (e.g., other injury or other
majority of studies (n = 143) only included direct medical ICU patients) (Table 3).
costs. The included cost components varied widely; some
articles calculated dressing costs only,924 whereas other Cost results: high-income countries
studies calculated total medical and nonmedical burn care
Detailed cost results for high-income countries are presented
costs.18 The most studied cost component was hospitalization
in Table 4. The mean cost of burn center days in high-income
(n = 96), followed by dressing (n = 34), medication (n = 28),
countries was $2,705 (range of $11111,607; median of
and surgery (n = 22).
$2,060). The mean cost of burn care per day in general hos-
Preferably, detailed information on cost calculations should
pitals in high-income countries was $1,959 (range of $585
be available. The cost price data of specific cost units, primarily
$4,314; median of $1,468). The mean total healthcare cost of
hospital day prices (n = 34), were presented in 44 studies. The
flame burns ($87,139) was generally higher than the cost of
data source, e.g., hospital charges (n = 44) or the hospital
scalds ($33,960).49,59,62,71. The mean cost of electric burns
finance department, was presented in 101 studies. Most studies
was $55,281.49,62,71 Several studies calculated the costs of
presented the total costs per patient without subdividing these
workplace-related burn injuries, indicating mean medical and
costs into more detailed healthcare sources. Information on
or claim costs of $16,232.80,93,115,117,148 A higher TBSA burned
resource use (the volume of healthcare consumption) was
was associated with increased costs,29,48,49,62,71,108 but no further
presented in 36 studies. The data source, resource use and cost
increase was reported above 80% TBSA.48,49,62 The costs per
price data were presented in only 17 studies. The cost price
1% TBSA burned were calculated to be $723 and $1,863 in
calculation methods of top-down and bottom-up indicate
two studies.8,57 We calculated cost prices per 1% TBSA burned
important choices regarding unit cost calculation. In top-down
in studies that presented both mean TBSA and mean total burn
cost calculations, the financial administration data of the
care costs. The mean total burn care cost per 1% TBSA in
healthcare provider is the primary source that is used to deter-
these 46 studies was $4,097 (range of $162$20,663; median
mine unit costs, e.g., the price of one hospital day is calculated
of $2,633). This mean was relatively consistent in different
by dividing the annual hospital costs by the number of hospital
subgroups of mean TBSA subgroups (010%, 1120%,
days. In bottom-up calculations, which are appropriate for
>20%), with mean figures of $3,883, $3,879, and $4,312 per
heterogeneous groups such as groups of burn patients, unit
1% TBSA, respectively. Mean total burn care cost per 1%
costs are determined by measuring the actual use of personnel,
TBSA in two studies on massive burns (>80% TBSA) was
materials, and equipment for a single patient.163 Eighteen
$2,729 (range of $2,374$3,086).
studies used a bottom-up approach to determine cost prices.
In high-income countries, hospitalization in the ICU and
Four studies used a top-down approach, and the approach was
general hospital days were an important cost component in
not described in most studies.
most studies that presented the distribution of acute burn care
hospital costs into different cost components (seven studies).
Cost results Hospitalization costs (including personnel costs) in studies
from a healthcare perspective amounted to 82% of the total
A total of 34 studies calculated the cost prices of a single
burn care costs per patient.45 Surgery was another important
hospital day (Table 2), and included costs were frequently not
cost category in most studies. Although they were often
defined. The mean cost of burn center days was $2,627 (range
studied, medication (e.g., medication for pain or itching or
of $111$11,607; median of $2,018). Only six studies sepa-
antimicrobial medication) and dressings appeared not to be
rately described burn center intensive care unit (ICU) days,
major cost categories in most studies (Figure 1).
and the mean cost was $3,164 (range of $1,590$4,657;
In addition to hospital costs, prehospital costs and health-
median of $2,969). US studies showed an increase in burn
care and nonhealthcare costs in the rehabilitation phase had to
center day costs over the years after inflation correction; the
be calculated in relation to burn injuries. Only four articles
cost was approximately $2,000 per day in the 1980s but rose
described prehospital costs, and three of these articles calcu-
to $5,000 per day in the past decade (Table 2a). Furthermore,
lated helicopter flight costs, with a mean of $14,013.39,109,123
the costs of burn care per day in general hospitals were
Furthermore, only two studies presented both healthcare and
described. The mean cost of burn care per day in general
nonhealthcare costs, such as caregiver costs and social and
hospitals was $1,159 (range of $25$4,314; median of $585)
labor costs. Medical costs represented only 1011% of the
(Table 2b). Only one unit price was provided for an ICU day
total costs per patient;1,8 the other 90% of the costs primarily
in a general hospital: $4,356. One study (Wheeler et al.,
related to productivity losses and informal care. No recent
USA25) presented both burn center day costs and general
studies describing rehabilitation costs, e.g., the costs of recon-
hospital day costs in patient with burns; the costs were $1,485
structive procedures, were found.
and $585, respectively.
The mean total healthcare cost per burn patient (85 studies)
Economic evaluations
was $76,497 (range of $102$717,306; median of
$36,696).1,8,25107 The range includes costs in different market This study identified three full economic evaluations in burn
economies and healthcare settings, and the majority of studies care, which were all cost-effectiveness analyses that

Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society 439
 Table 2a. Prices of unit cost: burn center hospital days and burn center ICU days (converted to US dollars, 2012)*

440
Unit cost burn Unit cost burn
Resource/data center hospital center ICU Total treatment
First author, Patients Mean source/bottom-up day day cost/n
Costs of burn care

year, country Patient type (n) %TBSA or top-down Definition of hospital day ($) ($) ($)

Jansen, 2012, Adult and 264 na +/+/na Diem rate; including overhead, nursing, allied health 1,846 na 55,030
Canada51 pediatric and support staff, dressing; excluding pharmacy,
physician fees, operative costs
Carayanni, 2011, Adult and 211 na //na Hospital day, ns 111 na 704
Greece103 pediatric
Sahin, 2011, Adult and 43 36 /+/na Hospital day charges: based on costs per occupied 435 na 15,555
Turkey79 pediatric bed day, dressings, medicine, injections, lab tests,
blood and blood products, surgery, meals,
beverages, special nutrition
Kastenmeier, Adult and 15,219 11 +/+/na Hospital day charges, ns 4,982 na 48,823
2010, USA55 pediatric
Patil, 2010, Adult 13 23 /+/bu ICU day: nursing and medical staff, medication, na 2,426 10,427
Australia87 fluids, laboratory, radiological investigation,
physiotherapy, wound dressings
Berger, 2010, Adult 46 27 +/+/na Hospital day, ns; ICU day, ns 651 2,575 na
Switzerland140
Strand, 2010, Pediatric 1,060 6 +/+/na Hospital day, ns 898 na 11,266
Sweden83
Pellatt, 2010, Pediatric 3 37 +/+/bu Ward day: including drugs, 50% medical staff 636 3,364 104,813
UK42 budget, nursing staff, catering/pediatric intensive
care unit (including overhead)
High dependency unit day (including overhead) 1,416 104,813
Duncan, 2009, Adult and na na /+/bu Standard ward bed, ns; occupied ICU bed, ns 1,281 4,371 na
UK141 pediatric
Hemington-Gorse, Adult and 3 38 +/+/td Low dependency ward, ns; ICU ward, ns 750 4,657 717,306
2009, UK26 pediatric
Pediatric ward, ns 1,812 na na
Papp, 2008, Pediatric 45 26 /+/na Hospital day: Kuopio Burn Unit (including regular and 2,377 na 47,537
Finland57 ICU days and operations)
Hospital day: Helsinki Burns Unit (including regular 2,621 na 47,195
and ICU days and operations)
Latenser, 2007, Adult and 26,176 na /+/na Hospital day charges, ns 5,637 na 68,484
USA49 pediatric
Fong, 2005, Adult 70 9 //na Hospital day, ns 2,018 na 26,541
Australia72
Wilson, 2004, Adult 217 37 +/+/na Hospital day, ns 5,343 na 136,967
USA38
Hop et al.

Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
 Table 2a. Continued.
Hop et al.

Unit cost burn Unit cost burn

Resource/data center hospital center ICU Total treatment
First author, Patients Mean source/bottom-up day day cost/n
year, country Patient type (n) %TBSA or top-down Definition of hospital day ($) ($) ($)

Suzman, 2001, Adult 76 13 +//na Hospital day (excluding physician fees) 4,794 na na
USA122
Sjberg, 2000, Adult and 226 na //na Hospital day, TBSA 2030% 3,729 na na
Sweden146 pediatric
Hospital day, ns, TBSA > 30% 4,438 na na
Yarbrough, 2000, Adult and 54 40 /+/na ICU day charges, estimation na 1,590 69,884
USA41 pediatric
Barret, 2000, Pediatric 20 92 //na Hospital day, ns 3,180 na 283,020
USA31
Saffle, 1997, Adult and 49 35 /+/na Hospital day charges, ns 11,607 na 449,970
USA29 pediatric
Wells, 1995, Adult and 26 1 //na Hospital day, ns 1,358 na 1,901
Canada99 pediatric

Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Saffle, 1995, Adult and 6,417 25 /+/na Hospital day charges, ns 4,410 na 64,834
USA50 pediatric
Wu, 1992, Adult and 10 48 +/+/na Hospital day, ns 1,032 na 44,413
Singapore60 pediatric
Pruitt, 1990, Adult and na 38 //na Hospital day (routine service costs: personnel 43%, 2,101 na na
USA135 pediatric medical supplies 17%, administration 19%, house
staff 4%, central services 3%, laundry 3%, others
15%)
Frank, 1987, Adult and 8,069 na +/+/na Hospital day (excluding physician fees) 3,337 na 79,482
USA47 pediatric
Dimick, 1986, Adult 1,553 33 +/+/na Hospital day charges (physical therapy, nutrition, 2,306 na 40,716
USA64 pharmacy, and other service in burn care)
Wheeler, 1983, Adult and 416 6 +/+/bu Hospital day (inpatient care including operating room 1,488 na 30,401
USA25 pediatric costs)
Vandenbussche, Adult and 285 na /+/na Hospital day (housing, medication, material, 626 na 18,385
1981, France75 pediatric personnel, overhead)
Sorensen, 1968, Adult and 208 na //na Hospital day (both unit days/outpatient clinic visit) 369 na 7,296
Denmark91 pediatric

*All studies were cost studies, except for one: Carayanni et al; cost-effectiveness analysis. In all studies, a healthcare perspective was adapted, included costs were only direct costs in
healthcare, and study period was <1 year. General hospital day prices of this study are presented in Table 2b. bu, bottom-up; ICU, intensive care unit; na, not available; ns, not specified; TBSA,
total body surface area; td, top-down.

441
Costs of burn care
 Costs of burn care Hop et al.

compared different dressings (Table 5). The clinical outcomes

Unit cost Unit cost Total treatment

used were the number of patients healed at day 21

costs/n

8,164

2,245
21,106
45,818
667

92,361

6,816
postburn10,12 and time to 50% wound healing.103 The calcu-
($)
lated costs included mean total hospital costs103 and mean
total dressing costs.10,12 To calculate cost-effectiveness, inter-
vention cost differences were divided by outcome differences
to generate an incremental ICER. All studies found a positive
hospital day ICU day

ICER in favor of intervention (Table 4). Two studies included

na

na
na
na
na

4,356

na
($)

a sensitivity analysis, which is necessary to study the effects

of measurement uncertainty. None of the studies performed
discounting, i.e., correction for costs in different years.
155

95
2,318
4,314
25

618

585
($)

DISCUSSION
This review systematically assessed the methodology, costs
and economic evaluations of 156 articles on the costs of burn
expenditure; excluding depreciation of
and interventions, salaries, and capital

equipment/ICU unit day: provided by

care. Nearly all studies were cost studies in high-income

bu, bottom-up; ICU, intensive care unit; na, not applicable; ns, not specified; TBSA, total body surface area; td, top-down.
Hospital day: including all treatments

countries and provided limited information on cost calcula-

tions and components. Charges were often used as a proxy to
Definition of hospital day

calculate costs. Broad ranges of costs were presented for burn

center days, ICU days, and total burn treatment. Burn care
was generally more expensive than other forms of healthcare.
charges, ns
estimation

There were few available economic evaluations comparing

head of department

the costs and effects of specific interventions; only three

studies from high-income countries satisfied the conditions of
Hospital day, ns

ns
ns

Hospital day, ns

an economic evaluation. Until now, reviews on the costs of

day,
day,
day,
day,

burn care have not focused on the methodology of the

Table 2b. Price of unit cost: general hospital days and ICU days (converted to US dollars, 2012)

included cost studies.2,6,7 This review provides the first over-

Hospital
Hospital
Hospital
Hospital

view of burn cost study methods and results.

Because of methodological variation and incomplete infor-
mation, it is difficult to determine the causes of the wide range
of costs found in this review. For example, the components
Patients Mean source/bottom-up
Resource/data

included in the prices of burn center days greatly varied; ICU

or top-down

and non-ICU costs were presented separately in some studies,

+/+/bu

+/+/bu
+/+/na

+/+/na
+/+/td
//na

//na

whereas others studies presented one price for burn center

days without identifying the included costs. The quality and
comparability of future economic studies of burn care may be
substantially enhanced by the development of an extensive
common core of basic methodological choices. We recom-
%TBSA

mend the use of a societal perspective, common cost catego-

>30
13

na
na
na
na

na

ries, and real cost calculations instead of the use of charges.

We also recommend that data sources for costs, price data for
cost units and data for healthcare consumption be disclosed. A
450

27
pediatric 32,500
pediatric 3,137
271

26

54

clear definition should also be used and disclosed for hospital

(n)

day costs. For example, the Dutch manual on the standard-

ization of costs defines a hospital day as including personnel
Adult and pediatric

pediatric

pediatric

Adult and pediatric

Adult and pediatric

(physicians/nurses), material, equipment, food and laundry,

medication, and overhead.163 Additionally, the recently pub-
Patient type

lished CHEERS statement can be used to ensure a more

transparent and complete approach to reporting methods and
and
and
and
and

findings.3
Adult
Adult
Adult
Adult

Despite the insufficient methodological information in most

articles, an attempt was made to answer some questions about
the costs of burn care. First, is burn care expensive? Burn care
Milenkovic, 2007, USA84
Ahachi, 2011, Nigeria97

was indeed more expensive in most studies that compared the

Wheeler, 1983, USA25
Forjuoh, 1998, USA59

healthcare costs of burn patients to those of other patients.

Allorto, 2011, South

Additionally, we made a detailed analysis of data from high-

Lofts, 1991, New
First author, year,

Courtright, 1993,

income countries to overcome the differences in price levels

Ethiopia104

between low-, middle-, and high-income countries. In high-

Zealand45

income countries, the costs of burn care per burn center day
Africa90
country

($2,705) were higher than those of burn care per day in a

general hospital ($1,959) and were higher than the standard
price ($608) of a general hospital day for all patient types in a

442 Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
 Hop et al.

Table 3. Healthcare costs of burn patients vs. other patients (converted to US dollars, 2012)

Total costs burn Cost per day

Participants Resource/data patient/other burn patient vs. other
First author, (burn patient/other source/bottom-up patient patient
year, country Setting Type of patients patient) or top-down Results ($) ($)

Alinia, 2011, General hospital Burns/other firework related 723/1,094 //na Mean total hospital costs/n 239/120 na
Iran106 injury
Bucher, 2010, General hospital Ambulatory burns/other ?/7,806 //na Cost of an outpatient visit 776/1,628 na
USA110 wounds
Jiang, 2010, General hospital Scalds/total unintentional 1,279/6,213 /+/na Mean total hospital costs/n 248/208 na
China105 injury
Patil, 2010, ICU Burns ICU/other ICU 13/13 /+/bu Median total costs/n 9,863/9,714 1,003/988
Australia87 (matched for LOHS)
Kastenmeier, Burn center Burn/nonburn admissions 15,219/3,027 +/+/na Mean total hospital 48,823/128,312 4,982/7,638
2010, USA55 charges/n
Milenkovic, 2007, General hospital Burn admissions/all hospital 32,500/29,499,800 +/+/na Mean total hospital costs/n 21,106/10,980 2,371/2,153

Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
USA84 stays
Pressley, 2007, General hospital Pediatric burns/motor 12,558/385,385 /+/na Mean hospital charges/n 36,553/42,164 na
USA68* vehicle drivers 36,553/10,363
Pediatric burns/poisoning
Miller, 2006, Burn center Fire-flame/skin diseases 14,502/496 /+/na Mean hospital charges/n 104,869/148,572 na
USA62
Scald/skin diseases 9,053/496 43,260/148,572 na
Siritongtaworn, Trauma center Burns/other injury 33/189 /+/na Mean hospital costs/n 11,747/3,594 na
2006, (nervus/eye/skin)
Thailand82
Kagan, 2004, Burn center/university Burn patients undergoing 8/240 +/+/na Mean total hospital costs/n 242,879/106,289 4,762/3,684
USA32 hospital tracheostomy/nonburn
patients undergoing
tracheostomy (e.g.,
poisoning,
circulatory/respiratory
disorder)
Cornish, 2003, Burn center Burns (acute)/toxic 19/2 +/+/na Mean inpatient drug costs/n 1,485/1,045 na
Canada101 epidermal necrolysis

*Costs of several injuries were described in this study; the lowest and highest costs are presented in the table. ICU, intensive care unit; LOHS, length of hospital stay; na, not available; bu,
bottom-up.

443
Costs of burn care
Costs of burn care Hop et al.

Table 4. Healthcare costs of burn patients in high-income countries (converted to US dollars, 2012)

Mean ($) Range ($) Median ($) References

25,26,29,31,38,41,42,47,4951,55,57,60,64,72,75,83,87,99,103,122,135,140,141,146,148
Costs per burn 2,705 11111,607 2,060
center day
26,41,42,87,140,141
Costs per burn 3,164 1,5904,657 2,969
center ICU day
25,45,59,84
Costs per general 1,959 5854,314 1,468
hospital day
45
Costs per general 4,356 4,356 4,356
ICU day
1,8,2569,71,72,76,78,80,81,8385,8789,91,93,94,96,98,99,101103
Total healthcare 88,218 704717,306 44,024
costs/pt
49,59,62,71
Flame 87,140 50,508109,469 94,291
49,59,62,71
Scald 33,960 15,88232,526 33,981
49,62,71
Electric 55,281 26,07670,311 69,457
1,8,25,26,2830,32,3436,3843,45,50,52,5458,60,6367,70,7274,78,83,85,87,89,93,96,99,102
Costs per 1% 4,159 16220,663 2,633
TBSA

ICU, intensive care unit; pt, patient; TBSA, total body surface area.

high-income country (The Netherlands) (US$2012).163
However, burn centers deliver multidisciplinary care and have
achieved a significant reduction in mortality for patients with
major burns during the last 50 years.2 Furthermore, patients
who require this high level of care are primarily referred to
burn centers.164 The mean total healthcare cost per burn patient
in high-income countries ($88,218) was higher than the inpa-
tient costs of trauma and acute surgery patients in one study
($17,245 and $26,468, respectively165) and was also higher
than the inpatient cost of trauma patients in another study
(mean $10,603166). Healthcare costs for burn patients during
the rehabilitation phase and nonhealthcare costs such as pro-
ductivity losses are likely to be high. Unfortunately, these costs
were rarely studied; only Sanchez et al. presented costs from a
societal perspective, including indirect costs and direct non-
healthcare costs along with direct healthcare costs. This study
confirmed our assumption and showed that direct healthcare
costs represented only 10% of total costs. We can conclude that
Pellat, '10, UK (43)
Hemington-Gore, '09, UK (27)
Griths, '06, UK (97)
Khoo, '94, Singapore, >15% TBSA (94)
Khoo, '94, Singapore, <15% TBSA (94)
Eldad, '93, Israel (34)
Wu, '92, Singapore (61)
Los, '91, New Zealand (46)
0% 20% 40% 60% 80%
Figure 1. Distribution of total acute burn care hospital costs in
different cost components. Only studies calculating distribu-
tion of mean total burn care costs were included. ICU, inten-
sive care unit; TBSA, total body surface area.
burns have a high burden of illness and that burn care is indeed
expensive.
Comparison of cost levels between high- and low- and
middle-income countries showed substantial differences in
mean costs per patient ($88,218 vs. $5,196). Obviously, price
levels are different in low- and middle-income countries. In
addition, treatment protocols will deviate substantially
because of different therapeutic possibilities and limited
resources. Future studies in low- and middle-income coun-
tries using an optimal design are necessary to gain more
insight in the costs and cost-effectiveness of local burn care.
In these studies, attention to local treatment protocols, includ-
ing, for instance, the different windows for resuscitation and
active treatment vs. compassionate care, should be included to
understand differences in burn care costs between various
market economies.
What factors make burn care expensive? A subgroup analy-
sis of the studies conducted in high-income countries was
performed to answer this question. The number of included
studies from low- and middle-income countries was too small
for a subgroup analysis. Patient characteristics that predicted
% hospital days
high costs were high percentage of TBSA and flame burns.
The influence of other patient characteristics, including inha-
% ICU lation injury or comorbidity, was not described in included
studies. The percentage of TBSA burned seemed to be a stable
% surgery predictor of burn costs with a mean price of $4,097 per 1%
% dressing
TBSA burned. In massive burns (TBSA >80%), this predictor
cannot be used. Probably because of a high mortality, the
%others: medicaon, uids, price per 1% TBSA in these studies (n = 2) was lower ($2,729
diagnoscs, allied health
professionals, etc. vs. $4,097).
The most expensive burn care component in our review
100% was hospital stay. The included studies, however, often
focused on medication or dressings. We recommend that
future research on cost-effective burn care focus on reducing
hospital stay length without compromising the quality of care.
Our research group is currently conducting a trial of the
cost-effectiveness of laser Doppler imaging (LDI) in burn

444 Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Hop et al. Costs of burn care

care167 to analyze whether LDI will lead to earlier excision

Discounting
and grafting and less expensive hospital stays.73

No

No

No
Based on this systematic review, we conclude that numer-
ous economic studies in burn care in especially high-income
Sensitivity

countries have been previously performed. We propose a stan-

analysis

Yes

Yes
No
dard approach to cost studies and economic evaluations to
improve quality, enhance the harmonization of economic
studies, optimize comparability, and improve insight into burn
$1,806 in favor of silicone
hospitalization gained

care costs and efficiency. Furthermore, more studies on

ICER results

medical and nonmedical costs in the rehabilitation phase are

$1,243 in favor of
foam dressing
needed to gain better insight into burn burden from a societal
$90 per day of

hydrofiber
perspective. Cost studies in low-income and middle-income
countries are limited in number; additional studies are needed
to gain better insight into costs and cost-effectiveness in these
contexts. This research is urgently needed because of the high
management/rate of full
Mean hospital costs/days

incidence of burn and the limited resources in low-income

ICER numerator/

countries. Finally, because our resources are scarce and burn

Mean total dressing

epithelialization in
Mean total costs of
denominator

reepithelialization
of hospitalization

costs/rate of full

care in both low- middle- and high-income countries can

always be improved, future burn care randomized controlled
trials should include economic evaluation to reach an optimal
21 days
wound

balance between costs and health effects in global burn care.

p = 0.222

ACKNOWLEDGMENTS
C: 10.75
p = 0.00
Clinical
results

C: 66.2
Time of 50% wound I: 8.70

I: 78.3

p = na

C: 60
I: 74:

The authors would like to thank J. van Meel, Maasstad Hos-

pital Rotterdam librarian, for his efforts to collect several full
epithelialization at

epithelialization at
Clinical outcomes
Table 5. Economic evaluation: three cost-effectiveness analyses (converted to US dollars, 2012)

texts for this literature review. This research was financially

healing in days

supported by a grant from the Dutch Burns Foundation

% n with full

% n with full

(11.102).
21 days

21 days

Conflicts of Interest: None of the authors has a conflict of

interest.
results ($)

p < 0.001

and material) cost/n C: 1,440

p = 0.10

I: 1,269
Cost

REFERENCES
p = na
C:860

C:550
I: 331
I:805

C, Control; I, Intervention; ICER, cost-effectiveness ratio; na, not available; RCT, randomized controlled trial.

1. Sanchez JL, Bastida JL, Martnez MM, Moreno JM, Chamorro

Mean cost of hospital

I: hydrofiber (Aquacel AG) Mean dressing (labor

JJ. Socio-economic cost and health-related quality of life of

Cost outcomes

Mean total wound

burn victims in Spain. Burns 2008; 34: 97581.

management

2. Stavrou D, Weissman O, Winkler E, Millet E, Nardini G,

Tessone A, et al. Managing the relationship between quality
costs/n
stay/n

and cost-effective burn care. Burns 2011; 37: 36776.

3. Husereau D, Drummond M, Petrou S, Carswell C, Moher D,
Greenberg D, et al. CHEERS Task Force. Consolidated Health
silicone foam dressing
iodine + bepanthenol
Intervention: control

Economic Evaluation Reporting Standards (CHEERS) state-

I: silver containing soft
I: moist exposed burn

C: silver sulfadiazine

C: silver sulfadiazine
ointment (MEBO)

ment. BMJ 2013; 346: f1049.

4. Drummond MF, Sculpher MJ, Torrance GW, OBrien BJ,
C: povidone

Stoddart GL. Methods for the economic evaluation of health

care programmes. New York: Oxford University Press, 2005.
5. Gold MR, Siegel JE, Russel LB, Weinstein MC. Cost-
effectiveness in health and medicine. New York: Oxford Uni-
source/bottom-up

versity Press, 1996.

Resource/data

or top-down

6. Mandal A. Quality and cost-effectivenesseffects in burn care.

+/+/na
+//na
//na

Burns 2007; 33: 41417.

7. Bass MJ, Phillips LG. Economics of pediatric burns. J
Craniofac Surg 2008; 19: 88890.
8. Snchez JL, Pereprez SB, Bastida JL, Martnez MM. Cost-
design
Study

RCT

RCT

RCT

utility analysis applied to the treatment of burn patients in a

specialized center. Arch Surg 2007; 142: 507.
211

Silverstein, 2011, 100

82
n

9. Lang EM, Eiberg CA, Brandis M, Stark GB. Biobrane in the

treatment of burn and scald injuries in children. Ann Plast Surg
Carayanni, 2011,
First author, yr,

Caruso, 2006,

2005; 55: 4859.

Greece103

10. Caruso DM, Foster KN, Blome-Eberwein SA, Twomey JA,

USA12

USA10
country

Herndon DN, Luterman A, et al. Randomized clinical study of

hydrofiber dressing with silver or silver sulfadiazine in the

Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society 445
Costs of burn care
management of partial-thickness burns. J Burn Care Res 2006;
27: 298309.
11. Borsuk DE, Gallant M, Richard D, Williams HB. Silver-coated
nylon dressings for pediatric burn victims. Can J Plast Surg
2007; 15: 2931.
12. Silverstein P, Heimbach D, Meites H, Latenser B, Mozingo D,
Mullins F, et al. An open, parallel, randomized, comparative,
multicenter study to evaluate the cost-effectiveness, perfor-
mance, tolerance, and safety of a silver-containing soft silicone
foam dressing (intervention) vs silver sulfadiazine cream. J
Burn Care Res 2011; 32: 61726.
13. Cuttle L, Naidu S, Mill J, Hoskins W, Das K, Kimble RM. A
retrospective cohort study of Acticoat versus Silvazine in a
paediatric population. Burns 2007; 33: 7017.
14. Silver GM, Robertson SW, Halerz MM, Conrad P, Supple KG,
Gamelli RL. A silver-coated antimicrobial barrier dressing used
postoperatively on meshed autografts: a dressing comparison
study. J Burn Care Res 2007; 28: 71519.
15. Demling RH, DeSanti L. Closure of partial-thickness facial
burns with a bioactive skin substitute in the major burn popu-
lation decreases the cost of care and improves outcome.
Wounds 2002; 14(6).
16. Torrati FG, Rossi LA, Ferreira E, Dalri MC, de Carvalho EC,
dos Santos Barbeira CB. Analysis of cost of dressings in the
care of burn patients. Burns 2000; 26: 28993.
17. Busche MN, Herold C, Schedler A, Knobloch K, Vogt PM,
Rennekampff HO. [The Biobrane glove in burn wounds of the
hand. Evaluation of the functional and aesthetic outcome and
comparison of costs with those of conventional wound man-
agement]. Handchir Mikrochir Plast Chir 2009; 41: 34854.
18. Gerding RL, Imbembo AL, Fratianne RB. Biosynthetic skin
substitute vs. 1% silver sulfadiazine for treatment of inpatient
partial-thickness thermal burns. J Trauma 1988; 28: 12659.
19. Mabrouk A, Boughdadi NS, Helal HA, Zaki BM, Maher A.
Moist occlusive dressing (Aquacel() Ag) versus moist open
dressing (MEBO()) in the management of partial-thickness
facial burns: a comparative study in Ain Shams University.
Burns 2012; 38: 396403.
20. Muangman P, Nitimonton S, Aramwit P. Comparative clinical
study of Bactigras and Telfa AMD for skin graft donor-site
dressing. Int J Mol Sci 2011; 12: 50318.
21. Cockington RA. Ambulatory management of burns in children.
Burns 1989; 15: 2713.
22. Summer GJ, Hansen FL, Costa BA, Engrav LH, Sharar SR.
The Unna cap as a scalp donor site dressing. J Burn Care
Rehabil 1999; 20: 1838, discussion 182.
23. Muangman P, Muangman S, Opasanon S, Keorochana K,
Chuntrasakul C. Benefit of hydrocolloid SSD dressing in the
outpatient management of partial thickness burns. J Med Assoc
Thai 2009; 92: 13005.
24. Cox SG, Cullingworth L, Rode H. Treatment of paediatric
burns with a nanocrystalline silver dressing compared with
standard wound care in a burns unit: a cost analysis. S Afr Med
J 2011; 101: 72831.
25. Wheeler JR, Harrison RV, Wolfe RA, Payne BC. The effects of
burn severity and institutional differences on the costs of care.
Med Care 1983; 21: 1192203.
26. Hemington-Gorse SJ, Potokar TS, Drew PJ, Dickson WA. Burn
care costing: the Welsh experience. Burns 2009; 35: 37882.
27. Carr JA, Phillips BD, Bowling WM. The utility of bronchos-
copy after inhalation injury complicated by pneumonia in burn
patients: results from the National Burn Repository. J Burn
Care Res 2009; 30: 96774.
446
Hop et al.
28. Kucan J, Bryant E, Dimick A, Sundance P, Cope N, Richards
R, et al. Systematic care management: a comprehensive
approach to catastrophic injury management applied to a cata-
strophic burn injury populationclinical, utilization, economic,
and outcome data in support of the model. J Burn Care Res
2010; 31: 692700.
29. Saffle JR, Wiebke G, Jennings K, Morris SE, Barton RG. Ran-
domized trial of immune-enhancing enteral nutrition in burn
patients. J Trauma 1997; 42: 793800, discussion 8002.
30. Munster AM, Weiner SH, Spence RJ. Cultured epidermis for
the coverage of massive burn wounds. A single center experi-
ence. Ann Surg 1990; 211: 6769, discussion 67980.
31. Barret JP, Wolf SE, Desai MH, Herndon DN. Cost-efficacy of
cultured epidermal autografts in massive pediatric burns. Ann
Surg 2000; 231: 86976.
32. Kagan RJ, Gamelli R, Kemalyan N, Saffle JR. Tracheostomy in
thermally injured patients: does diagnosis-related group 483
adequately estimate resource use and hospital costs? J Trauma
2004; 57: 8616.
33. Eldad A, Stern Z, Sover H, Neuman R, Ben Meir P,
Wexter MR, et al. The cost of an extensive burn survival. Burns
1993; 19: 2358.
34. Cianci P, Williams C, Lueders H, Lee H, Shapiro R, Sexton J,
et al. Adjunctive hyperbaric oxygen in the treatment of thermal
burns. An economic analysis. J Burn Care Rehabil 1990; 11:
1403.
35. Clayton MC, Solem LD, Ahrenholz DH. Pulmonary failure in
geriatric patients with burns: the need for a diagnosis-related
group modifier. J Burn Care Rehabil 1995; 16: 4514.
36. Alden NE, Bessey PQ, Rabbitts A, Hyden PJ, Yurt RW. Tap
water scalds among seniors and the elderly: socio-economics
and implications for prevention. Burns 2007; 33: 6669.
37. Takayanagi K, Kawai S, Aoki R. The cost of burn care and
implications for efficient care. Clin Perform Qual Health Care
1999; 7: 703.
38. Wilson SJ, Knipe CJ, Zieger MJ, Gabehart KM, Goodman JE,
Volk HM, et al. Direct costs of multidrug-resistant
Acinetobacter baumannii in the burn unit of a public teaching
hospital. Am J Infect Control 2004; 32: 3424.
39. Saffle JR, Edelman L, Morris SE. Regional air transport of burn
patients: a case for telemedicine? J Trauma 2004; 57: 5764,
discussion 64.
40. Ganzoni N. Intensive care of patients with burnsinvestment,
costs and clinical aspects. Helv Chir Acta 1972; 39: 60712.
41. Yarbrough DR 3rd, Philbeck TE Jr, Simmons FM, Finnell K,
Smith P, Warren JB, et al. Therapeutic and financial outcomes
using a pulsating low-air-losssurface for patients surviving
severe posterior burns. Ostomy Wound Manage 2000; 46: 649.
42. Pellatt RA, Williams A, Wright H, Young AE. The cost of a
major paediatric burn. Burns 2010; 36: 120814.
43. Danks RR, Wibbenmeyer LA, Faucher LD, Sihler KC, Kealey
GP, Chang P, et al. Methamphetamine-associated burn injuries:
a retrospective analysis. J Burn Care Rehabil 2004; 25: 4259.
44. Davidson SB, Blostein PA, Walsh J, Maltz SB, Elian A,
Vandenberg SL. Resurgence of methamphetamine related
burns and injuries: a follow-up study. Burns 2013; 39: 11825.
45. Lofts JA. Cost analysis of a major burn. N Z Med J 1991; 104:
48890.
46. Liebau J, Pallua N, Machens HG, Berger A. [Budget analysis in
a burn center for severely burned patients]. Unfallchirurg 1996;
99: 8759.
47. Frank HA, Berry C, Wachtel TL, Johnson RW. The impact of
thermal injury. J Burn Care Rehabil 1987; 8: 2602.
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Hop et al.
48. Jeng JC. Growth rings of a tree: progression of burn care
charges abstracted from a decade of the National Burn Reposi-
tory. J Burn Care Res 2007 SepOct; 28: 65960.
49. Latenser BA, Miller SF, Bessey PQ, Browning SM, Caruso
DM, Gomez M, et al. National Burn Repository 2006: a ten-
year review. J Burn Care Res 2007; 28: 63558.
50. Saffle JR, Davis B, Williams P. Recent outcomes in the treat-
ment of burn injury in the United States: a report from the
American Burn Association Patient Registry. J Burn Care
Rehabil 1995; 16 (3 Pt 1): 21932, discussion 2889.
51. Jansen LA, Hynes SL, Macadam SA, Papp A. Reduced length
of stay in hospital for burn patients following a change in
practice guidelines: financial implications. J Burn Care Res
2012; 33: e2759.
52. Shalom A, Friedman T, Wong L. Burns and diabetes. Ann
Burns Fire Disasters 2005; 18: 313.
53. Mathews JJ, Supple K, Calistro A, Gamelli RL. A burn center
cost-reduction program. J Burn Care Rehabil 1997; 18: 358
63, discussion 357.
54. Nicolau DP, White RL, Friedrich LV, Kays MB. The costs of
burn care: an analysis with an emphasis on the use of parenteral
antimicrobials. J Burn Care Rehabil 1994; 15: 24450.
55. Kastenmeier A, Faraklas I, Cochran A, Pham TN, Young SR,
Gibran NS, et al. The evolution of resource utilization in
regional burn centers. J Burn Care Res 2010; 31: 1306.
56. Weinsier RL, Heimburger DC, Samples CM, Dimick AR, Birch
R. Cost containment: a contribution of aggressive nutritional
support in burn patients. J Burn Care Rehabil 1985; 6: 436
41.
57. Papp A, Rytknen T, Koljonen V, Vuola J. Paediatric ICU
burns in Finland 19942004. Burns 2008; 34: 33944.
58. Hunt JL, Purdue GF. Cost containment/cost reduction: the eco-
nomic impact of burn DRGs. J Burn Care Rehabil 1986; 7:
41721.
59. Forjuoh SN. The mechanisms, intensity of treatment, and out-
comes of hospitalized burns: issues for prevention. J Burn Care
Rehabil 1998; 19: 45660.
60. Wu WT, Ngim RC. Anatomy of a burns disaster: the Miri Bank
explosion. Ann Acad Med Singapore 1992; 21: 6408.
61. Anderson NJ, Bonauto DK, Adams D. Psychiatric diagnoses
after hospitalization with work-related burn injuries in Wash-
ington State. J Burn Care Res 2011; 32: 36978.
62. Miller SF, Bessey PQ, Schurr MJ, Browning SM, Jeng JC,
Caruso DM, et al. National Burn Repository 2005: a ten-year
review. J Burn Care Res 2006; 27: 41136.
63. Burke BA, Lewis RW 2nd, Latenser BA, Chung JY,
Willoughby C, Kealey GP, et al. Methamphetamine-related
burns in the cornbelt. J Burn Care Res 2008; 29: 5749.
64. Dimick AR, Potts LH, Charles ED Jr, Wayne J, Reed IM. The
cost of burn care and implications for the future on quality of
care. J Trauma 1986; 26: 2606.
65. Munster AM, Smith-Meek M, Sharkey P. The effect of early
surgical intervention on mortality and cost-effectiveness in
burn care, 197891. Burns 1994; 20: 614.
66. Gray DT, Pine RW, Harnar TJ, Marvin JA, Engrav LH,
Heimbach DM. Early surgical excision versus conventional
therapy in patients with 20 to 40 percent burns. A comparative
study. Am J Surg 1982; 144: 7680.
67. Warden G, Kravitz M, Schnebly A. The outpatient management
of moderate and major thermal injuries. J Burn Care Rehabil
1981; 2: 15962.
68. Pressley JC, Trieu L, Kendig T, Barlow B. National injury-
related hospitalizations in children: public versus private
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Costs of burn care
expenditures across preventable injury mechanisms. J Trauma
2007; 63 (3 Suppl. ): S1019.
69. Saffle JR, Larson CM, Sullivan J, Shelby J. The continuing
challenge of burn care in the elderly. Surgery 1990; 108: 534
43.
70. Hussmann J, Kucan JO, Russell RC, Bradley T, Zamboni WA.
Electrical injuriesmorbidity, outcome and treatment rationale.
Burns 1995; 21: 5305.
71. Shields BJ, Comstock RD, Fernandez SA, Xiang H, Smith GA.
Healthcare resource utilization and epidemiology of pediatric
burn-associated hospitalizations, United States, 2000. J Burn
Care Res 2007; 28: 81126.
72. Fong J, Wood F, Fowler B. A silver coated dressing reduces the
incidence of early burn wound cellulitis and associated costs of
inpatient treatment: comparative patient care audits. Burns
2005 Aug; 31: 5627.
73. Engrav LH, Heimbach DM, Reus JL, Harnar TJ, Marvin JA.
Early excision and grafting vs. nonoperative treatment of burns
of indeterminant depth: a randomized prospective study. J
Trauma 1983; 23: 10014.
74. Gore DC. Outcome and cost analysis for outpatient skin graft-
ing. J Trauma 1997; 43: 597600.
75. Vandenbussche F, Krizek M, Robbe M, Besse MD, Truffaut A,
Clavel HP. [Actual estimate of the cost of severe burns. Results
for the year 1979Lille]. Lille Med 1981; 26: 11822,
(French).
76. Onarheim H, Jensen SA, Rosenberg BE, Guttormsen AB. The
epidemiology of patients with burn injuries admitted to Nor-
wegian hospitals in 2007. Burns 2009; 35: 11426.
77. Foglia RP, Moushey R, Meadows L, Seigel J, Smith M. Evolv-
ing treatment in a decade of pediatric burn care. J Pediatr Surg
2004; 39: 95760, discussion 95760.
78. Hayes-Lundy C, Ward RS, Saffle JR, Reddy R, Warden GD,
Schnebly WA. Grease burns at fast-food restaurants. Adoles-
cents at risk. J Burn Care Rehabil 1991; 12: 2038.
79. Sahin I, Ozturk S, Alhan D, Aikel C, Isik S. Cost analysis of
acute burn patients treated in a burn centre: the Gulhane expe-
rience. Ann Burns Fire Disasters 2011; 24: 913.
80. Fordyce TA, Kelsh M, Lu ET, Sahl JD, Yager JW. Thermal
burn and electrical injuries among electric utility workers,
19952004. Burns 2007; 33: 20920.
81. Wibbenmeyer LA, Amelon MA, Loret de Mola RM, Lewis R
2nd, Kealey GP. Trash and brush burning: an underappreciated
mechanism of thermal injury in a rural community. J Burn Care
Rehabil 2003; 24: 859.
82. Siritongtaworn P, Peunchompoo N. Economic problem of
referred trauma cases in Siriraj Hospital. J Med Assoc Thai
2006; 89: 16219.
83. Strand O, San Miguel L, Rowan S, Sahlqvist A. Retrospective
comparison of two years in a paediatric burns unit, with and
without acticoat as a standard dressing. Ann Burns Fire Disas-
ters 2010; 23: 1825.
84. Milenkovic M, Russo CA, Elixhauser A Hospital Stays
for Burns, 2004. HCUP Statistical Brief #25. Rockville,
MD: Agency for Health Care Research and quality; 2007
Jan.
85. Klein MB, Hollingworth W, Rivara FP, Kramer CB, Askay
SW, Heimbach DM, et al. Hospital costs associated with pedi-
atric burn injury. J Burn Care Res 2008; 29: 6327.
86. Zhou HC, Wu YC, Jiang Y, Zhang SH. [Management of exten-
sive deep partial thickness burn wounds by dermabrasion
during early postburn shock stage]. Zhonghua Shao Shang Za
Zhi 2003; 19: 21922.
447
Costs of burn care
87. Patil V, Dulhunty JM, Udy A, Thomas P, Kucharski G, Lipman
J. Do burn patients cost more? The intensive care unit costs of
burn patients compared with controls matched for length of
stay and acuity. J Burn Care Res 2010; 31: 598602.
88. Bassett GR. Childhood burns, causes and economic conse-
quences. Northwest Med 1968; 67: 1468.
89. Linn BS, Stephenson SE Jr, Bergstresser P, Smith J. Do dollars
spent relate to outcomes in burn care? Med Care 1979; 17:
83543.
90. Allorto NL, Clarke DL, Thomson SR. A cost model case com-
parison of current versus modern management of burns at a
regional hospital in South Africa. Burns 2011; 37: 10337.
91. Sorensen B, Thomsen M. Cost of burns in Denmark. Scand J
Plast Reconstr Surg 1968; 2: 325.
92. Nursal TZ, Yildirim S, Tarim A, Caliskan K, Ezer A, Noyan T.
Burns in southern Turkey: electrical burns remain a major
problem. J Burn Care Rehabil 2003; 24: 30914.
93. Khoo AK, Wee JT, Ngim RC, Wong MK. Occupational burns
in the Burns Centre at the Singapore General Hospital. Ann
Acad Med Singapore 1994; 23: 6803.
94. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Adams D,
et al. A silver-impregnated antimicrobial dressing reduces hos-
pital costs for pediatric burn patients. J Pediatr Surg 2007; 42:
21113.
95. Steenkamp WC, van der Merwe AE, de Lange R. Burn injuries
by paraffin stoves. S Afr Med J 2002; 92: 445.
96. Griffiths HR, Thornton KL, Clements CM, Burge TS, Kay AR,
Young AE. The cost of a hot drink scald. Burns 2006; 32:
3724.
97. Ahachi CN, Fadeyibi IO, Abikoye FO, Chira MK, Ugburo AO,
Ademiluyi SA. The direct hospitalization cost of care for acute
burns in Lagos, Nigeria: a one-year prospective study. Ann
Burns Fire Disasters 2011; 24: 94101.
98. Bishai D, McCauley J, Trifiletti LB, McDonald EM, Reeb B,
Ashman R, et al. The burden of injury in preschool children in
an urban Medicaid Managed Care organization. Ambul Pediatr
2002; 2: 27983.
99. Wells NJ, Boyle JC, Snelling CF, Carr NJ, Courtemanche DJ.
Lower extremity burns and Unna paste: can we decrease health
care costs without compromising patient care? Can J Surg
1995; 38: 5336.
100. Kai-Yang L, Shi-Hui Z, Hong-Tai T, Yi-Tao J, Zhao-Fan X,
Dao-Feng B, et al. The direct hospitalisation costs of paediatric
scalds: 2-year results of a prospective case series. Burns 2009;
35: 73845.
101. Cornish P, Mittmann N, Gomez M, Cartotto RC, Fish JS. Cost
of medications in patients admitted to a burn center. Am J Clin
Dermatol 2003; 4: 8617.
102. Kagan RJ, Warden GD. Care of minor burn injuries: an analysis
of burn clinic and emergency room charges. J Burn Care Res
2001; 22: 33740.
103. Carayanni VJ, Tsati EG, Spyropoulou GC, Antonopoulou FN,
Ioannovich JD. Comparing oil based ointment versus standard
practice for the treatment of moderate burns in Greece: a trial
based cost effectiveness evaluation. BMC Complement Altern
Med 2011; 11: 122.
104. Courtright P, Haile D, Kohls E. The epidemiology of burns in
rural Ethiopia. J Epidemiol Community Health 1993; 47:
1922.
105. Jiang X, Zhang Y, Wang Y, Wang B, Xu Y, Shang L. An
analysis of 6215 hospitalized unintentional injuries among chil-
dren aged 014 in northwest China. Accid Anal Prev 2010; 42:
3206.
448
Hop et al.
106. Alinia S, Rezaei S, Daroudi R, Hadadi M, Akbari Sari A.
Extent, nature and hospital costs of fireworks-related injuries
during the Wednesday Eve Festival in Iran. J Inj Violence Res
2013; 5: 1116.
107. Oncul O, Yksel F, Altunay H, Aikel C, Celikz B, Cavuslu S.
The evaluation of nosocomial infection during 1-year-period in
the burn unit of a training hospital in Istanbul, Turkey. Burns
2002; 28: 73844.
108. Warden GD, Saffle JR, Kravitz M. Potential DRG reimburse-
ment vs actual cost for burn care. II. Referral distance. J Burn
Care Rehabil 1986; 7: 4851.
109. Vercruysse GA, Ingram WL, Feliciano DV. Overutilization of
regional burn centers for pediatric patientsa healthcare system
problem that should be corrected. Am J Surg 2011; 202: 8028,
discussion 8089.
110. Bucher BT, Seigel J, Rosenblum E, Nesslein C, Keswani S,
Foglia RP, et al. A pediatric acute wound service: a novel
approach in wound management. J Pediatr Surg 2010; 45:
16770, discussion 170.
111. Armour AD, Shankowsky HA, Swanson T, Lee J, Tredget EE.
The impact of nosocomially-acquired resistant Pseudomonas
aeruginosa infection in a burn unit. J Trauma 2007; 63: 164
71.
112. Neely AN, Mayes T, Gardner J, Kagan RJ, Gottschlich MM. A
microbiologic study of enteral feeding hang time in a burn
hospital: can feeding costs be reduced without compromising
patient safety? Nutr Clin Pract 2006; 21: 61016.
113. Palmieri TL, Lee T, OMara MS, Greenhalgh DG. Effects of a
restrictive blood transfusion policy on outcomes in children
with burn injury. J Burn Care Res 2007; 28: 6570.
114. Patel NP, Brandt CP, Yowler CJ. A prospective study of the
impact of a critical care pharmacist assigned as a member of the
multidisciplinary burn care team. J Burn Care Res 2006; 27:
31013.
115. Horwitz IB, McCall BP. An analysis of occupational burn
injuries in Rhode Island: workers compensation claims, 1998
to 2002. J Burn Care Rehabil 2005; 26: 50514.
116. Corpron CA, Martin AE, Roberts G, Besner GE. The
pediatric burn unit: a profit center. J Pediatr Surg 2004; 39:
9613.
117. Horwitz IB, McCall BP. Quantification and risk analysis of
occupational burns: Oregon workers compensation claims,
1990 to 1997. J Burn Care Rehabil 2004; 25: 32836.
118. Nguyen LT, Massman NJ, Franzen BJ, Ahrenholz DH,
Sorensen NW, Mohr WJ 3rd, et al. Telemedicine follow-up of
burns: lessons learned from the first thousand visits. J Burn
Care Rehabil 2004; 25: 48590.
119. Redlick F, Roston B, Gomez M, Fish JS. An initial experience
with telemedicine in follow-up burn care. J Burn Care Rehabil
2002; 23: 11015.
120. Baggs J, Curwick C, Silverstein B. Work-related burns in
Washington State, 1994 to 1998. J Occup Environ Med 2002;
44: 6929.
121. Wahl WL, Franklin GA, Brandt MM, Sturm L, Ahrns KS,
Hemmila MR, et al. Does bronchoalveolar lavage enhance our
ability to treat ventilator-associated pneumonia in a trauma-
burn intensive care unit? J Trauma 2003; 54: 6338.
122. Suzman MS, Sobocinski K, Himel H, Yurt RW. Major burn
injuries among restaurant workers in New York City: an under-
appreciated public health hazard. J Burn Care Rehabil 2001;
22: 42934.
123. De Wing MD, Curry T, Stephenson E, Palmieri T, Greenhalgh
DG. Cost-effective use of helicopters for the transportation of
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Hop et al.
patients with burn injuries. J Burn Care Rehabil 2000; 21:
53540.
124. Miller PL, Matthey FC. A cost-benefit analysis of initial burn
cultures in the management of acute burns. J Burn Care
Rehabil 2000; 21: 3003.
125. Mathews JJ, Aleem RF, Gamelli RL. Cost reduction strategies
in burn nutrition services: adjustments in dietary treatment of
patients with hyponatremia and hypophosphatemia. J Burn
Care Rehabil 1999; 20 (1 Pt1): 804.
126. Evasovich M, Klein R, Muakkassa F, Weekley R. The eco-
nomic effect of child abuse in the burn unit. Burns 1998; 24:
6425.
127. Best T, Lobay G, Moysa G, Tredget E. A prospective random-
ized trial of absorbable staple fixation of skin grafts for burn
wound coverage. J Trauma 1995; 38: 91519.
128. Lujan HJ, Dries DJ, Gamelli RL. Comparative analysis of
bedside and operating room tracheostomies in critically ill
patients with burns. J Burn Care Rehabil 1995; 16 (3 Pt 1):
25861.
129. Barone CM, Mastropieri CJ, Peebles R, Mitra A. Evaluation of
the Unna Boot for lower-extremity autograft burn wounds
excoriated by pruritus in pediatric patients. J Burn Care
Rehabil 1993; 14: 3489.
130. Rue LW 3rd, Cioffi WG, McManus WF, Pruitt BA Jr. Wound
closure and outcome in extensively burned patients treated
with cultured autologous keratinocytes. J Trauma 1993; 34:
6627.
131. Maxwell G, Silverstein P. Burn center reimbursement analysis.
J Burn Care Rehabil 1992; 13: 5979.
132. Bauman LW, Hawkins ML, Howdieshell TR, Till AH, Treat
RC. Bilaminate synthetic dressing for partial thickness burns.
Lack of cost reduction for inpatient care. Am Surg 1991; 57:
1313.
133. Gerding RL, Emerman CL, Effron D, Lukens T, Imbembo AL,
Fratianne RB. Outpatient management of partial-thickness
burns: biobrane versus 1% silver sulfadiazine. Ann Emerg Med
1990; 19: 1214.
134. Kealey GP, Jensen KL, Laubenthal KN, Lewis RW. Prospec-
tive randomized comparison of two types of pressure therapy
garments. J Burn Care Rehabil 1990; 11: 3346.
135. Pruitt BA, Mason AD, Goodwin CW. Epidemiology of burn
injury and demography of burn care facilities. Probl Gen Surg
1990; 7: 23551.
136. Warden GD, Saffle JR, Kravitz M. Potential DRG reimburse-
ment vs actual cost of burn care. I. Patients with burns of less
than 25% TBSA. J Burn Care Rehabil 1986; 7: 458.
137. McMillan SS, Parker CJ, Winkler JB, Hilton JG, Herndon DN.
Prediction of operating room costs. J Burn Care Rehabil 1985;
6: 4446.
138. Sadove AM, Creekmur TA, Brueggemann SG, McGregor K,
Bennett JE. Early excision: a financial assessment. J Burn Care
Rehabil 1985; 6: 4423.
139. Lotter O, Jaminet P, Amr A, Chiarello P, Schaller HE,
Rahmanian-Schwarz A. Reimbursement of burns by DRG in
four European countries: an analysis. Burns 2011; 37: 110916.
140. Berger MM, Davadant M, Marin C, Wasserfallen JB, Pinget C,
Maravic P, et al. Impact of a pain protocol including hypnosis
in major burns. Burns 2010; 36: 63946.
141. Duncan RT, Dunn KW. Cost of burn care in the British Isles
and service remuneration options. Burns 2009; 35 (S): S10.
142. Taghizadeh R, Gilbert PM. Comparison of commonly used
mesher types in burns surgery revisited. Burns 2008; 34: 109
10.
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society
Costs of burn care
143. Windle EM. Nutrition support in major burn injury: case analy-
sis of dietetic activity, resource use and cost implications. J
Hum Nutr Diet 2008; 21: 16573.
144. Gravvanis AI, Tsoutsos DA, Iconomou TG, Papadopoulos SG.
Percutaneous versus conventional tracheostomy in burned
patients with inhalation injury. World J Surg 2005; 29: 15715.
145. Favaro P. Aspects pharmaco-economiques du traitement des
brulures. Ann Pharm Fr 2002; 60: 2607.
146. Sjberg F, Danielsson P, Andersson L, Steinwall I, Zdolsek J,
Ostrup L, et al. Utility of an intervention scoring system in
documenting effects of changes in burn treatment. Burns 2000;
26: 5539.
147. Carsin H, Ainaud P, Le Bever H, Rives JM, Le Coadou A,
Stephanazzi J. [Objectives, results and future prospects of burn
treatment in 1997]. Bull Acad Natl Med 1997; 181: 130719.
148. de Roche R, Lscher NJ, Debrunner HU, Fischer R. Epidemio-
logical data and costs of burn injuries in workers in Switzer-
land: an argument for immediate treatment in burn centres.
Burns 1994; 20: 5860.
149. Mashreky SR, Rahman A, Khan TF, Rahman F. Consequences
of non-fatalelectrical injury: findings of community-based
national survey in Bangladesh. Injury 2012; 43: 10912.
150. Petkar KS, Dhanraj P, Kingsly PM, Sreekar H, Lakshmanarao
A, Lamba S, et al. A prospective randomized controlled trial
comparing negative pressure dressing and conventional dress-
ing methods on split-thickness skin grafts in burned patients.
Burns 2011; 37: 9259.
151. Muangman P, Pundee C, Opasanon S, Muangman S. A pro-
spective, randomized trial of silver containing hydrofiber dress-
ing versus 1% silver sulfadiazine for the treatment of partial
thickness burns. Int Wound J 2010; 7: 2716.
152. Mashreky SR, Rahman A, Chowdhury SM, Giashuddin S,
Svanstrm L, Khan TF, et al. Burn injury: economic and social
impact on a family. Public Health 2008; 122: 141824.
153. Mashreky SR, Rahman A, Chowdhury SM, Giashuddin S,
Svanstrm L, Linnan M, et al. Consequences of childhood
burn: findings from the largest community-based injury survey
in Bangladesh. Burns 2008; 34: 91218.
154. Venakatachalapathy TS, Mohan Kumar S, Saliba MJ. A com-
parative study of burns treated with topical heparin and without
heparin. Ann Burns Fire Disasters 2007; 20: 18998.
155. Al-Kaisy AA, Salih Sahib A, Al-Biati HA. Effect of zinc
supplement in the prognosis of burn patients in Iraq. Ann Burns
Fire Disasters 2006; 19: 11522.
156. Al-Kaisy AA, Salih Sahib A. Role of the antioxidant effect of
vitamin e with vitamin C and topical povidone-iodine ointment
in the treatment of burns. Ann Burns Fire Disasters 2005; 18:
1930.
157. Ang ES, Lee ST, Gan CS, See PG, Chan YH, Ng LH, et al.
Evaluating the role of alternative therapy in burn wound man-
agement: randomized trial comparing moist exposed burn oint-
ment with conventional methods in the management of patients
with second-degree burns. Medgenmed 2001; 3: 3.
158. Danchivijitr S, Chokloikaew S, Chantrasakul C,
Trakoolsomboon S. An outbreak of methicillin-resistant
Staphylococcus aureus (M.R.S.A.) in a burn unit. J Med Assoc
Thai 1995; 78 (Suppl. 1): S1114.
159. Ogundipe KO, Adigun IA, Solagberu BA. Economic burden of
drug use in patients with acute burns: experience in a develop-
ing country. J Trop Med 2009; 2009: 734712.
160. Allam AM, Mostafa W, Zayed E, El-Gamaly J. Management of
the Acute Partial-thickness Burned Hand; Moist Exposed Burn
Ointment or Silver Sulphadiazine Cream both Combined with a
449
Costs of burn care
Polyethylene Bag. Ann Burns Fire Disasters 2007; 20:
1448.
161. Atiyeh BS, Dham R, Kadry M, Abdallah AF, Al-Oteify M,
Fathi O, et al. Benefit-cost analysis of moist exposed burn oint-
ment. Burns 2002; 28: 65963.
162. Williams F, Knapp D, Wallen M. Comparison of the character-
istics and features of pressure garments used in the manage-
ment of burn scars. Burns 1998; 24: 32935.
163. Hakkaart-van Roijen L, Tan SS, Bouwmans CAM.
[Standardisation of costs: the Dutch manual for costing
in economic evaluations]. Diemen: College voor
zorgverzekeringen, 2010.
164. Vloemans AF, Dokter J, van Baar ME, Nijhuis I, Beerthuizen
GI, Nieuwenhuis MK, et al. Epidemiology of children admitted
to the Dutch burn centres. Changes in referral influence admit-
tance rates in burn centres. Burns 2011; 37: 11617.
165. Fakhry SM, Martin B, Al Harakeh H, Norcross ED, Ferguson
PL. Proportional costs in trauma and acute care surgery
patients: dominant role of intensive care unit costs. J Am Coll
Surg 2013; 216: 60714.
450
Hop et al.
166. Curtis K, Lam M, Mitchell R, Black D, Taylor C, Dickson C,
et al. Acute costs and predictors of higher treatment costs of
trauma in New South Wales, Australia. Injury 2014; 45: 279
84.
167. Hop MJ, Hiddingh J, Stekelenburg CM, Kuipers HC,
Middelkoop E, Nieuwenhuis MK, et al. LDI study group. Cost-
effectiveness of laser Doppler imaging in burn care in the
Netherlands. BMC Surg 2013; 13: 2.
Supporting Information
Additional Supporting Information may be found in the
online version of this article at the publishers web-site:
Supporting information Table S1. Study characteristics:
patients and methodology (n=156)
Wound Rep Reg (2014) 22 436450 2014 by the Wound Healing Society