Prevalence and treatment of injuries in patients in German general practices

Every year around 5 million people die from injuries worldwide. This number accounts for 9% of all deaths [1]. It has been proven that men and young people die from injuries more often than women and the elderly, respectively [1–3]. In addition, injuries cause one million permanent disabilities in the European Union every year, and thus have a significant impact on public health in this region of the world [4]. The prevalence of injuries in Germany has only been examined by a few authors in recent years. In 2010, there were an estimated 8 million injuries and more than 20,000 injury deaths in this country [5,6]. In the same year, Rickels et al. found that the incidence of traumatic brain injuries in two separate regions of Germany was 332 per 100,000 people [7]. A cross-sectional telephone survey published in 2013 also estimated that more than 10% of the participants had been diagnosed with accidental injuries requiring medical treatment in the 12 months prior to the survey [8]. More recently, in 2016, Rommel and colleagues showed that at least 2.8% out of more than 14,000 adults were affected by an accident at work [9].

>> The risk of having been diagnosed with an accident at work was particularly associated with the factors gender, age and type of employment. Although these papers are of great interest, three of them are based on telephone survey data and one is based on hospital data. Furthermore, most of these previous studies focused on specific injuries. As a result, there is a lack of data on the overall frequency of injuries among people treated in general practitioner practices. Additionally, little is known regarding the various treatments prescribed to patients with injuries. In Germany, the majority of patients with serious injuries are observed and treated by orthopedists. However, primary care physicians are often responsible for treating patients with less serious injuries. The aim of the present study was therefore to analyze the prevalence and treatment of injuries in people observed in German general practitioner practices.
methodology
Database
The present retrospective study was conducted using data from the nationwide Disease Analyzer database (QuintilesIMS) [10]. This database includes demographic, clinical and pharmaceutical data obtained from a nationwide sample of primary care practices. QuintilesIMS regularly assesses the quality of the Disease Analyzer database and previous studies have shown that the database is representative of German general practices. Finally, it should be noted that in recent years this database has already been used in studies focusing on fractures and their risk factors [11–13].

Study population and outcome
This study included all patients (N=2,644,037) who visited at least one general practitioner's practice in Germany (N=1,063) in 2016. The first outcome was the prevalence of injuries treated in primary care practices (ICD-10 [International Classification of Diseases] codes: S00-T14). The study examined 12 different types of injuries: injuries to the head (S00-09), injuries to the neck (S10-19), injuries to the thorax (S20-29), injuries to the abdomen, lumbosacral region, lumbar spine and pelvis (S30-39 ), shoulder and upper arm injuries (S40-49), elbow and forearm injuries (S50-59), wrist and hand injuries (S60-69), hip and thigh injuries (S70-79), Injuries to the knee and lower leg (S80-89), injuries to the ankle region and foot (S90-99), injuries involving multiple body regions (T00-07), and injuries to unspecified parts of the trunk, extremities or other body regions (T08 -14). The second outcome was the proportion of injured patients referred to hospitals or specialists. The analysis included three treatment types: systemic anti-rheumatic drugs/analgesics (Anatomical-therapeutic-chemical classification system [ATC]: N02B, M01A), topical anti-joint and muscle pain agents (M02A), and heparins (B01AB).

Statistical analyses
Descriptive analyzes were conducted as part of this retrospective cross-sectional study. Injury prevalence, defined as the proportion of individuals with at least one injury diagnosis, was assessed in the overall population and in several subgroups divided by gender and age (men, women, <18, 18-25, 26-30, 31-40, 41 -50, 51-60, 61-70, 71-80 and >80 years). In addition, the prevalence of injury patients receiving drug treatments and referrals to hospital or specialist care was estimated in the overall population and in the 12 different injury subgroups. All analyzes were performed using SAS 9.3 (SAS Institute, Cary, NC, USA).
Results
In 2016, there were 297,528 patients with injury diagnoses in German general practices. This corresponds to 11.3% of the total study population (Table 1). Apart from unspecified injury diagnoses, the most common diagnosis was an ankle and foot injury (N=34,650). The prevalence of injuries was highest in people >80 years (18.0%)
and lowest in those aged 31-40 years (9.5%;
Fig. 1). There were an average of 280 injury diagnoses per general practice (137 men and 143 women). Of the individuals who received an injury diagnosis, 49% were men and 51% were women (Table 2). The proportions of treatments in the overall study population and in the different injury groups are listed in Table 3. In total, 55% of the injured patients received systemic antirheumatic drugs or analgesics, 13% received topical agents for joint and muscle pain, and 7% received heparins. In addition, 8% of the injured were referred to hospitals, 14% to surgeons, and 11% to orthopedists (Fig. 2).
discussion
More than 10% of patients seen in German general practices in 2016 were diagnosed with an injury. The most common injuries were the ankle region and the foot. Additionally, people aged 80 had the highest injury rate and those aged 31 to 40 had the lowest injury rate. Finally, it was estimated that the majority of injury patients had received either topical or systemic treatments and that a minority had subsequently been referred to hospitals or specialists.
The key finding of this retrospective cross-sectional analysis is that approximately 11% of the study population were diagnosed with an injury. To our knowledge, this is the first study specifically on the prevalence of injuries in German general practices. A recently published report by the Robert Koch Institute found that more than 8 million injuries and more than 20,000 deaths from injuries were recorded in Germany in 2010 [6]. The authors further estimated that approximately 8% of the population aged 18 years and older were involved in accidents requiring medical treatment in the same year. Consistent with previous studies [1–3], they found that men and younger individuals are more likely to sustain such injuries than women and older individuals. Interestingly, most accidents occurred at home or during leisure activities.
They further found that ankle and foot injuries were the most common and that almost one in five patients with ankle and foot injuries were between 18 and 25 years old. This result is probably due to the fact that ankle and foot injuries are often diagnosed in athletes or in patients with physically demanding jobs. In 2007, Fong et al. conducted a systematic review of 227 studies aimed at analyzing sports-related injuries [14]. They estimated that 16% of patients had ankle injuries and that the ankle was the most commonly injured body part in 24 of 70 sports considered. In 2011, Wallace and colleagues found similar rates of ankle and foot injuries among active-duty soldiers in the U.S. Army. Here too, these injuries affected 16% of the study population [15]. In addition, the authors estimated that a history of ankle and foot injuries was one of the largest risk factors for developing such injuries. By considering the overall study population of the present retrospective study, we showed that the prevalence of injuries was highest in individuals over 80 years of age (18%). It is worth mentioning that this specific age group represented 36% of patients with hip and thigh injuries. When these results are combined, it becomes clear that falls may be a major cause of injury in older adults. In 2014, Rapp and colleagues estimated that fall rates in Germany increased with age among men [16]. Another study conducted in Ecuador found that 11% of individuals in an older study population reported fall-related injuries, with regular alcohol consumption, number of comorbid conditions, and urinary incontinence identified as risk factors [17].
Another important finding of our study is that the treatment and management of injury patients in German general practices appears to be satisfactory. Of particular interest, 55% of the study population received systemic anti-rheumatic drugs or analgesics. Although high rates of pain have been reported in injured patients admitted to the emergency department [18], it is conceivable that the prevalence of pain may be lower in individuals diagnosed with an injury in primary care practices. This hypothesis suggests that most of the injured patients with pain received analgesics. Over-the-counter medications may also have been used to treat people with mild pain. In addition, 13% and 7% of the individuals diagnosed with injuries also received topical joint and muscle pain medications and heparins, respectively. Since systemic analgesics are associated with significant side effects [19–21], it is possible that general practitioners prefer to prescribe topical agents for minor injuries. Heparin prescription rates were particularly high in patients diagnosed with lower extremity injuries. This high proportion could be explained by the fact that these individuals are at particularly high risk of developing deep vein thrombosis or pulmonary embolism [22,23]. Finally, it was estimated that only a minority of patients were referred to hospitals or specialist practices. Because individuals with serious injuries are often treated directly in the emergency room or in orthopedic practices [24,25], the majority of injury patients seen by primary care physicians do not require intensive care. Although this was not addressed in our study, it is conceivable that injury patients were also treated by members of other medical professions (e.g., physiotherapists and osteopaths).
Although the current results are of particular interest, this study has some limitations that should be noted here. First, it was not possible to analyze the impact of injury severity on injury treatment and management because information on injury severity was not available. Second, there was no data on the causes and circumstances that led to the injuries. Third, we were unable to examine the use of nonprescription medications, although these medications may have been commonly used in patients with minor injuries. Finally, no information was available regarding factors that may have been associated with injury (e.g., lack of sleep, alcohol consumption, or drug use). The main strengths of this study are the number of primary care practices and the number of patients available for analysis.
In 2016, more than one in ten patients in German general practices were diagnosed with an injury. The management and treatment of injured individuals in this setting appeared satisfactory. <<