degree of public costs, for both start-up and maintenance, varies depending on how sophisticated a system is desired. However, there is no formal study of nationwide public and private costs for trauma systems.

Hospital charges, at 55 percent of the total costs of injury, represented the largest single type of direct cost (Rice et al., 1989). Using data from the 1984, 1985, and 1986 National Hospital Discharge Surveys, MacKenzie and coworkers (1990) determined that hospital, including trauma center, expenditures for all types of trauma in 1985 totaled $11.4 billion (inclusive of professional fees). This study also estimated that 25 percent of the total charges (or $2.8 billion) would be incurred by trauma centers treating the severely injured if such centers were available throughout the United States. Even though only 12 percent of trauma patients are severely injured, they disproportionately incur 26 percent of the charges (MacKenzie et al., 1990). Goldfarb and colleagues (1996) used a large national hospital discharge database to find that the average charge per hospital stay for severely injured patients in 1987 ranged from $12,891 to $28,464. The highest charges were incurred at Level I trauma centers that were part of a formal system. The lowest average charges for the severely injured were incurred at hospitals that were neither publicly designated nor self-designated as trauma centers. The study controlled for patient severity and hospital and community characteristics. A separate study of 12,088 trauma center admissions over a five-year period (1989–1993) by O'Keefe and colleagues (1997) found per-patient costs at a single regional trauma center to average $15,032 for victims of all ages with blunt and penetrating injuries. Several categories of complications greatly enhanced costs, such as pneumonia, adult respiratory distress syndrome, and acute kidney failure. According to 1995 data from the Health Services Cost Review Commission in Maryland, the mean hospital charge for a trauma admission is about 40 percent higher than that for a non-trauma admission (H. Champion, University of Maryland, Baltimore, personal communication, 1998).

There appear to be few studies of prehospital or rehabilitation costs for patients with injuries. The IOM (1997a) noted some studies that combine acute care and rehabilitation charges for a subset of the most severely injured, those with spinal cord and traumatic brain injuries. It also noted studies of total medical expenditures for people with disabling conditions, yet only a fraction of these people were disabled as a result of injury. Consequently, there is a noticeable lack of studies strictly of rehabilitation charges for injured patients of varying levels of severity. Since there is increasing recognition that a significant portion of an injured patient's clinical and financial experience occurs in the rehabilitation setting, a major challenge yet to be addressed is to measure objectively patients' outcomes and costs, including unreimbursed costs, of prehospital through rehabilitative care.

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