Cost Savings of Injury Prevention: A Model for Health
Care InsurersMike Gittelman, MDAssociate Professor
Division of Emergency MedicineCincinnati Children’s Hospital Medical Center
Objectives
• Why concentrate on injury prevention• History of injury prevention• Interventions to prevent injuries and their
effectiveness • Cost effectiveness of injury prevention
strategies
Past Top Stories
• Teen wounds six in High School shooting
• 3 month old improperly restrained … loses life
• House blaze fatally injures four children
• Study finds playgrounds safer, but not enough
Why Injury Prevention?• Injuries
– Are the # 1 killer of children > 1 year of age
– Cause more deaths than all other diseases combined
• Almost all injuries are preventable
• Prevention – Is everyone’s job– Saves health care
dollars
www.cdc.gov/pub/ncipc
U.S. Childhood Injuries - Deaths
• Average Day in US– > 400 deaths due to
injuries; > 50 in kids 0-19 y.o.
– > 80,000 injuries resulting in hospitalizations and ED visits; >28,000 in kids 0-19 y.o.
% total mortality
Source: National Center for Injury Prevention and Control, 2008
0
10
20
30
40
50
60
70
80
90
1-4 yr 5-9 yr 10-14 yr 15-19 yr
195519671988199820012006
International Age-Adjusted Injury Death Rates
Source: Lois Fingerhut, NCHS, based on 2000-2004 data
Injury Death in U.S.: 1-4 Years of Age
MVC27%
Fire/Burn11%Homicide
17%
Drowning21%
Suffocation7%
Pedestrian5%
Other12%
Source: National Center for Injury Prevention and Control, 2006
Injury Death in U.S.: 5-9 Years of Age
MVC44%
Fire/Burn11%
Homicide10%
Drowning14%
Suffocation3%
Other18%
Source: National Center for Injury Prevention and Control, 2006
Injury Death in U.S.: 10-14 Years of Age
MVC42%
Drowning9%
Fire/Burn4%
Suicide14%
Homicide13%
Suffocation3%
Other15%
Source: National Center for Injury Prevention and Control, 2006
Injury Death in U.S.: 15-19 Years of Age
MVC48%
Other8%
Downing4%
Poisoning2%
Homicide22%
Suicide16%
Source: National Center for Injury Prevention and Control, 2006
Injury Deaths by Cause – US, 1-19 Years of Age, 2008
Source: National Center for Injury Prevention and Control, 2008
Injury Cause # Deaths Rate/100,000
MVC 7,139 9.22
Firearm 2,845 3.67
Suffocation 1,307 1.69
Drowning 1,048 1.35
Poisoning 1,001 1.29
Pedestrian 876 1.13
Fire/Burn 607 0.78
“If a disease were killing our children in the same proportions as injury, we would be outraged and demand this killer be stopped”
C. Everett Koop, M.D.Former Surgeon General of the United States
History of Injury Prevention
History
• Prior to the twentieth century• Early 1900s - carelessness causes
injuries?• 1942 - Hugh DeHaven - biomechanics of
injury prevention
Factors in the Prevention of Injury
Victim
Environment Agent
Matrix & Conceptual Framework for Injury Prevention
Haddon, 1962Haddon, 1962
Host Agent PhysicalEnviron.
SE Environ.
Pre-event AgeRiding Skill
Brakes, tiresReflectors
WeatherSeparatefrom traffic
Funding forbike lanesTraffic
Event Helmetwearing
Affordabilityof helmetsHelmet lawsAttitudes
Post-event AgePhysicalcondition
EMS systemTraumacenters
Support fortrauma careTraining EMSpersonnel
Public Health Approach to Prevention
• Define the problem• Identify causes or risk
factors• Develop or test
interventions• Implement intervention
and measure prevention effectiveness
Interventions to Prevent Injuries
4 E Approach• Education
– Media campaigns, school programs
• Enforcement/Legislation– Child safety laws, speed limit
enforcement
• Engineering/Technology– Airbags, bike helmets, child safety seats
• Environmental Modification– Bike lanes, safety gates, speed bumps
Effectiveness of Educational Interventions in Clinical Setting 10,330 citations 103 randomized clinical trials 22 studies evaluated Most assessed the effect on a safety
behavior rather than on an injury rate No eligible studies on pedestrian, drowning,
motorcycle or firearm injuries.
DiGuiseppi C, Roberts IG: Individual-level injury prevention strategies in the clinical setting. In: The Future of Children. Los Altos, California: The David and Lucille Packard Foundation, 2000
From BMJ, December 2003
Effectiveness of Legislative Interventions
Passive Techniques• Child resistant packaging
– Mortality to youth < 5 years from unintentional ingestions decreased initially by 44%, 1973-1978 (460 fewer deaths, 200,000 less ingestions).
• Regulating hot tap water temperature– Reduction of home hot water to 130oF– 1983 WA Law, tap water less than 130oF went from 20%
to 77% in 5 yrs – 50% reduction in hospital admissions from scalds - Erdman, Pediatrics 1991
• Graduated licensing systems– CA and MD – 15-17 yr olds 5% reduction in crashes– OR – 16% reduction teen male driver crashes
- Jones, J of Safety Research 1994
Effectiveness of Legislative Interventions
Active Techniques• Bike helmets
– Increased usage from 0-71% in GA (Gilchrist, Pediatrics 2000) and 37-66% in OR (Ni, Arch Peds 1997)
– Significantly decreased head injuries (MacPherson, Cochrane Database 2008)
• Car safety and belt-positioning booster seats– Children ages 4-7 in states with laws are 39% more
likely to be appropriately restrained in a booster seat or child safety seat than children in states without laws (CHOP study www.chop.edu/carseat)
– After KY law > 80% restrained in car seat yet only 20% were restrained properly (CDC, MMWR 1998)
Injury Prevention Products Work!• Window guards decrease falls from
windows by 50%• More than 70% of infant MVC deaths could
be prevented by car seats– Reduced to 50-59% if not used appropriately
• Odds of injury to preschooler in MVC is 59% lower if using a booster seat
• Smoke alarms reduce risk of death in house fire by 50%
• Bike helmets reduce risk of head injury by 85%
Combination of Interventions for Belt-Positioning Booster Seats
• Ehiri, et al, Am J Prev Med 2006– Education paired with incentive or distribution
programs produced more consistent results than education-only interventions
• Gittelman, et al, Academic EM 2006
Control(45)
Education (46)
Education +
Booster(56)
P-value
Use a booster
1 (2%) 0 (0%) *55 (98%)
P<0.001
* 42 (75%) used seat 100% of time
The Cost of Childhood Unintentional Injuries and the Value of Prevention
Definitions: Costs and Savings• Total Benefits per Unit: the amount the
intervention saved by preventing injuries & other problems
• Aggregate Benefit/Unit = Total Benefits - Cost
• Benefit Cost Ratio (BCR): savings from preventing injuries divided by cost of the intervention
• Cost-effective: the BCR > 1.0Return on investment in the intervention
exceeds amount investedLaws typically have high BCR with less cost
Definitions: Costs and Savings
Quality Adjusted Life Years (QALY)• Measures disease burden – quality and
quantity of life lived• Years of potential life lost to fatal injury
added to number of years spent with disability multiplied by factor depending on the severity of the disability
Cost /Quality Adjusted Life Year = (Cost of intervention – medical & other resource savings)/QALY
Hope for cost/QALY to be < $0
Frequency of Pediatric Injuries
• More than 22 million children will sustain an injury serious enough to require medical attention
• More than 150,000 will have a permanent disability and will need lifetime care
Costs of Pediatric Injuries
• Injury accounts for 15% of medical spending
• Estimated 14 billion in lifetime medical spending and 66 billion in present and future work losses
• Medicaid and government agencies paid for 39% of days children spent in hospitals
PROBLEM SIZEAnnual Spending per U.S. Child, 0-19
$590
$300
$1,320
$1,590
InjuryMedical
Cost
Clothing TotalInjuryCost
Food
What Injuries Are Driving The Costs?
Vehicular Injury Costs/1000 Kids by Age
0 1-3 4-6 7-9 10-12 13-15
O ccupan t O the r N onO ccupan t P eda lcycle -M V N onM V C yc le
Bicycle Helmets• 1 year, head injuries to 4-15
year olds– 52,000 nonfatal head injuries,
93,000 nonfatal scalp injuries– 2200 permanent disabilities
• Lifetime medical payments for these children approach $394 million
• Every $10 bike helmet generates $570 in benefits to society– $50 in medical costs– $140 in future earnings and other
tangible resources– $380 in quality of life costs
• Universal bicycle helmet use by 4 to 15 year olds would prevent 1,200 - 1,700 permanently disabling injuries– If 85 percent wore helmets in 1
year, lifetime medical cost savings would total $197 to $256 million.
$29
$12
Auto Health
$10 bike helmet saves insurers $41 each
Child Passenger Seats – Ages 0-4 years
• *1 year, motor vehicle crashes– 58,000 injuries– 6500 disabling injuries– 500 fatalities– > 40% improperly restrained
• > 70% of infant MVC deaths can be prevented by car seats– 50-59% if not used appropriately
• Disbursement of seats to Medicaid families– Avert 51 minor injuries & 2
deaths/100,000 low income children
– Cost Medicaid $26 per child over 4 years and save $1m/100,000 children
– Goldstein, et al, Ambulatory Peds 2008
A $50 Car Seat Saves $330 in Insurance and Tax Payments
*From www.nhtsa.gov
A $50 child seat saves $2,181 (BCR 42)
$155 $208 $302
$1,515
Medicalcost
Otherresources
Workloss
Qualityof life
Have a seat and just reduce misuse saves $569/seat
with education costs of $7 (BCR 81)
$57 $59
$159$294
Medicalcost
Otherresources
Work
loss Qualityof life
Belt Positioning Booster Seats – Ages 4-8 years
• *1 year, motor vehicle crashes– 72,000 injuries– 7000 disabling injuries– 400 fatalities– 50% improperly restrained
• Odds of injury is 59% lower using a booster seat– Unrestrained children 2.8 times, seat belt
restrained 2.6 times more likely to die
• A $30 booster seat produces cost savings > 9:1 of medical costs alone
– http://www.cdc.gov/injury/pdfs/cost-MV-a.pdf
*From www.nhtsa.gov
A booster seat with back costs $35 and saves $2,474 (BCR = 63)
$356$201
$571
$1,347
Medicalcost
Otherresources
Work
loss Qualityof life
Smoke Alarms
• Haddix, Injury Prev 2001– Oklahoma Study– 10,000 battery operated
smoke alarms distributed to homes
– 2.6 times higher rate of fire in community compared to rest of OK city
– Costs• $530,000 for giveaway• Calculated 20 fatal and
24 nonfatal injuries prevented
• Translates into savings of 1.5 M medical costs and $14M productivity losses
$9 $1
$110
$660
Med
ical
Pro
p
Dam
age
Oth
er
Tan
gib
le
Qu
alit
y of
Lif
e
Equipping A Home with Smoke Alarms + Maintenance Costs $47 & Saves $780 (BCR 17)
Poison Control Centers (PCC)• > 1M pediatric
ingestions annually– 39% kids < 3 years– 74% can be managed at
home
• 73% of families that visit an ED never called PCC
• Medical spending for ingestions totals approximately $3 billion– Spending averaged $925
per case. • Miller, Ann of EM 1997
A Poison Control Center Call
Comparison of Injury Savings vs. Infection Control
Proven Injury Prevention Interventions and Cost Effectiveness
Summary• Injuries are the number one cause of
morbidity and mortality to children.• Some products have been proven to
prevent injuries and if used can save health care dollars
• Insurance companies currently pay for other preventative initiatives (eg. immunizations) that aren’t as cost effective
• Laws and enforcement generally save the state money at little cost to them
Acknowledgements
• Ted Miller, Pacific Institute for Research and Evaluation– Cost effectiveness calculations– NACHRI - Injury Prevention Webinar, Data
Basics for Cost-outcome Analysis - 703-797-6042
• Rachael Weintraub for bringing our groups together
Questions?
Addendum Slides
Definitions of Costs• Incidence vs Prevalence Costs
– Value of lifetime costs due to injury during a single year– Injury-related expenses during one year regardless of
when the injury occurred
• Resource vs Productivity Costs– Medical costs – ED, physician, rehab, prescription, etc– Other direct costs – police, EMS, traffic delay, etc– Work-loss costs – lost wages family, compensation
processing (eg. litigation)
• Quality-Adjusted Life Years (QALY)– Measures disease burden – quality and quantity of life
lived– Years of potential life lost to fatal injury added to
number of year spent with disability multiplied by factor depending on the severity of the disability
Cost of Injuries in 2005 Ages 0-19
050,000
100,000150,000200,000250,000300,000350,000400,000450,000500,000
Dol
lars
(in
Mil
lion
s)
Medical Care FutureEarnings
Quality of Life Total
Miller, T., Children’s Safety Network Economics and Insurance Resource Center, 2006
American Academy of Pediatrics TIPP Sheet
Counseling for Ages 0-4 Costs $11/Visit & Saves $97/Visit (BCR 9)
References: Injury Costs & Prevention Savings
• The Cost of Child and Adolescent Injuries and The Savings from Prevention, T Miller, E Finkelstein, E Zaloshnja, D Hendrie. In K Liller (ed.), Injury Prevention for Children and Adolescents: Research, Practice, and Advocacy, Washington DC: American Public Health Association, 15-64, 2005.
• Incidence and Economic Burden of Injuries in the United States, 2000, with E Finkelstein, P Corso, T Miller, I Fiebelkorn, E Zaloshnja, B Lawrence. New York City: Oxford University Press, 2006.
• Cost-Outcome Analysis in Injury Prevention and Control: 84 Estimates for the United States, T Miller, D Levy, Medical Care, 38:6, 562-582, 2000.
SUMMARY
• Injury is the leading child health risk
• Prevention yields large savings for taxpayers
• Unrealistic to expect State gov’t savings
• Targeting to Medicaid population can help
• Laws & enforcement often save the State $
• People do not understand big numbers
• Select costs to suit the audience
• You cannot spend some savings
• Put a face with the $