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 $