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Reducing the Burden of Injury: Advancing Prevention and Treatment 2 Magnitude and Costs Injury is a major public health problem in America (see Figure 2.1). Consider the following: In 1995 in the United States, 59 million episodes of injuries were reported; 2.6 million hospital discharges and 37 million emergency department (ED) visits were for the treatment of injuries; 147,891 individuals died as a result of an injury; 77 percent of all deaths and 10 percent of the hospitalizations among 15 to 24-year-olds were caused by injuries; and 52 percent of all deaths and 17 percent of the hospitalizations among 5- to 14-year-olds were caused by injuries. Additionally, injury and its consequences accounted for 12 percent of all medical spending and the cost of injury was estimated at $260 billion1 (Miller et al., 1994, 1995; Fingerhut and Warner, 1997; E. MacKenzie, Johns Hopkins University, personal communication, 1998; see Figure 2.2). 1 The 1985 cost-of-injury estimates were updated to 1995 separately by type of cost. Direct costs were inflated using the appropriate component of the Consumer Price Index (hospital and related services, physicians' services, prescription drugs, professional medical services, and medical care services). Indirect costs were inflated using the index of hourly compensation in the business sector.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 2.1 Ten leading causes of death by age group, 1995. Source: NCIPC, 1998.
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Reducing the Burden of Injury: Advancing Prevention and Treatment
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 2.2 Burden of injury: United States, 1995. Source: Fingerhut and Warner, 1997. Measuring the overall magnitude of injury as a major public health problem is crucial in the development of a rational basis for resource allocation, for defining strategies for prevention interventions, and for determining their outcomes. As surveillance efforts have continued to improve, we have gained increasing knowledge about the magnitude of the injury problem and the costs to society; however, knowledge is sparse regarding nonfatal injuries, the settings in which they occur, and the total costs associated with injury morbidity. This chapter focuses on the impact of injury in terms of mortality, morbidity, and societal costs. Patterns of injury over time and within and across specific demographic subgroups are briefly described. The statistics and discussion presented in this chapter are based primarily on the work of Fingerhut and Warner (1997), unless otherwise noted. OVERALL BURDEN OF INJURY: MORTALITY RATES In 1995, 90,402 people died from unintentional injuries2 (61 percent of all injury fatalities, at a rate of 34.4 deaths per 100,000 persons); there were 22,552 2 Excludes 2,918 deaths due to adverse events.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 2.3 Leading causes of injury death by manner of death, United States, 1995. Source: Fingerhut and Warner, 1997. homicides (15 percent of all injury deaths, at a rate of 8.6 per 100,000) and 31,284 suicides (21 percent of injury fatalities, at a rate of 11.9 per 100,000). For at least the past 30 years, motor vehicle and firearm injuries have been the two leading causes of injury death (see Chapter 5). In 1995, motor vehicle traffic-related injuries accounted for 29 percent of all injury deaths, or 42,452 deaths. Firearm injuries accounted for 24 percent of all injury deaths and claimed a total of 35,957 lives. Motor vehicle deaths are generally classified as unintentional, whereas firearm injuries have been classified primarily as intentional. Of deaths due to firearms, 51 percent were suicides, 43 percent homicides, 3 percent unintentional, and approximately 3 percent other. Poisonings were the third leading cause of injury death (11 percent), followed by falls and suffocation (8 and 7 percent, respectively); drownings, fires and burns, and cutting and piercing injuries accounted for another 9 percent of all injury deaths (see Figure 2.3) (Fingerhut and Warner, 1997).
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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 2.1 Leading Causes of Injury Death, Trends, 1985–1995 Cause of Death Number of Deaths (all age groups), 1995 Trends, 1985–1995 Motor vehicle traffic 42,452 Decrease 15% from 1985 to 1993, increase 2% from 1993 to 1995 Firearm 35,957 Increase 22% from 1985 to 1993, decrease 11% from 1993 to 1995 Poisoning 16,307 Stable from 1985 to 1991 at about 5/100,000, in crease 18% from 1991 to 1995 Falls 11,275 Decrease 11% from 1985 to 1995 Suffocation 10,376 Stable from 1985 to 1995 at about 3/100,000 SOURCE: Fingerhut and Warner (1997). Trends in Injury Mortality Rates: 1985 to 1996 Although the leading causes of injury death have not changed over the past decade, some trends are important to note; these are described in detail by Fingerhut and Warner (1997) and illustrated in Figure 2.4 and Table 2.1. The age-adjusted unintentional injury death rate declined 12 percent between 1985 and 1995, whereas the suicide rate remained relatively constant, and the overall homicide rate increased 12 percent. The increase in the homicide rate has not been steady; there was a 32 percent increase between 1985 and 1991, followed by a decrease of 15 percent from 1991 to 1995. Age-adjusted motor vehicle traffic-related death rates declined 15 percent from 1985 to 1993, but increased 2 percent from 1993 to 1995. 3 In 1995, 18,428 persons 15 to 34 years of age died of a motor vehicle traffic injury, comprising 43 percent of all motor vehicle traffic injury deaths. The death rate in this age group declined about 18 percent from 1985 to 1993, to about 24 per 100,000 individuals (Fingerhut and Warner, 1997). From 1985 to 1995, the alcohol-related fatality rate for those 15–34 declined 32 percent, and the nonalcohol 3 In 1995, Congress repealed the national maximum Speed limit (effective December 8, 1995). Subsequently, 32 states also repealed their 55 mile per hour speed limits. Estimates suggest that these two actions have resulted in hundreds of additional deaths, but the full effect of the repeals has not yet been quantified (NHTSA, 1998).
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 2.4 Age-adjusted death rates for leading causes of injury: United States, 1995. Source: Fingerhut and Warner, 1997. fatality rate increased 13 percent. The National Highway Traffic Safety Administration (NHTSA) estimates that minimum-age drinking laws have reduced traffic fatalities of 18- to 20-year-olds by 13 percent since 1975 and have saved about 15,700 lives (Fingerhut and Warner, 1997). In 1995, 50 percent of all motor vehicle traffic fatalities among 15- to 34-year-olds were alcohol related. The age-adjusted firearm death rate increased by 22 percent from 12.8 per 100,000 in 1985 to 15.6 per 100,000 in 1993, followed by an 11 percent decline from 1993 to 1995 to 13.9 per 100,000. The increase in firearm death rates can be attributed almost exclusively to an increase in firearm homicides among adolescents and young adults ages 15 to 34. From 1985 to 1993, there was an increase of 83 percent in the firearm homicide rate of 15- to 34-year-olds, followed by a decline of 14 percent from 1993 to 1995 to 13.7 per 100,000 (Fingerhut and Warner, 1997). The firearm suicide rate for 15- to 34-year-olds increased by 10 percent from 1984 to 1994 and then declined by about 6 percent in 1995. The increase is attributed to an increase in firearm suicides among males by 13 percent from 1985 to 1994 (followed by a decline of 5 percent in 1995). During 1985–1995, the suicide rate of women declined 13 percent (Fingerhut and Warner, 1997).
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Reducing the Burden of Injury: Advancing Prevention and Treatment The age-adjusted injury death rate due to poisonings remained stable from 1985 to 1991 around 5 deaths per 100,000, followed by an 18 percent increase in the poisoning death rate from 1991 to 1995. Most of this increase can be attributed to the 44 percent increase in the rate among males 25–44 years. Poisoning rates in children declined during both periods. Rates for suffocation were stable from 1985 to 1995. During this same interval, drowning death rates declined 27 percent, and fire and burn death rates declined by 33 percent (Fingerhut and Warner, 1997). Mortality from falls declined by 11 percent during this period, although among the elderly, where rates are highest, the rate increased slightly. In 1995, falls accounted for 23 percent of the deaths due to injury among persons over age 65 and 34 percent of injury deaths for those 85 and older. Occupational injuries resulted in 77,675 fatalities for civilian workers from 1980 to 1992. This represents an annual average of 5.5 per 100,000 workers. In 1994 and 1995 the rates fell to 5 deaths per 100,000 workers. It has been estimated that, in 1995, occupational injuries cost $119 billion in lost wages and productivity, administrative expenses, health care, and other costs (NSC, 1997). Recent data indicate that, in 1996, 147,126 individuals died as a result of injury, which was a 2.5 percent decline in the injury death rate to 50.2 per 100,000 population. The motor vehicle traffic injury death rate remained unchanged at 15.8 per 100,000 and the firearm death rate declined 7 percent to 12.9 per 100,000 population. Most of the decline is attributed to the 11 percent decline in the firearm homicide rate (with a more modest decline of 3 percent in the firearm suicide rate). The death rate for poisoning, the third leading cause of injury death, increased slightly, just under 2 percent, in 1996. By manner of injury death, the age-adjusted death rates for all unintentional injury and for all suicide remained unchanged and the homicide rate declined about 11 percent (Peters et al., 1998). Preliminary data for 1997 indicate a 6 percent decline in overall injury mortality. Preliminary data, however, are subject to change once the final figures are all accounted for. Known biases in preliminary data are attributed, in part, to medical examiner and coroner cases for which amended certificates are filed later (Ventura et al., 1998). OVERALL BURDEN OF INJURY: MORBIDITY Whereas current surveillance and other data collection efforts provide information about the numbers and types of fatal injuries, much less is known about the incidence and patterns of nonfatal injuries (see Chapter 3). Almost one in four people in the United States sustains an injury during a single year. In 1995, injuries accounted for an estimated 8 percent of all short-stay hospital discharges and 37 percent of all emergency department visits. Injury as a first-listed diagnosis was identified in 2.6 million hospital discharges. In addition, there were 3.4 million more discharges with injury listed as a secondary diagnosis (Gillum et al., 1998). Falls are the leading cause of nonfatal injury visits to
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Reducing the Burden of Injury: Advancing Prevention and Treatment emergency departments, accounting for approximately 8 million visits to the emergency department yearly. Motor vehicles remain an important cause of injury accounting for approximately 3.8 million visits to the emergency department per year (Fingerhut and Warner, 1997). Although most nonfatal injuries are of minor severity and do not result in more than one or two days of restricted activity, a large number result in fractures, brain injuries, major burns, or other significant disability. In 1992–1994, the average hospital discharge rates for fractures—which account for nearly 2 out of 5 injury-related discharges—was 39.3 per 10,000 persons. During this same period, the other leading injury-related discharge diagnoses were poisonings, open wounds and lacerations, intracranial injuries, and sprains and strains. These accounted for 25 percent of first-listed injury hospital discharges. Fractures typically required six to seven days of hospitalization, whereas the other diagnoses, on average, required three to four days of hospitalization (Fingerhut and Warner, 1997). PATTERNS OF INJURY IN THE POPULATION Social and demographic characteristics may influence the risk of injury. Surveillance systems, through ongoing and systematic collection of data, can provide information that allows the identification of patterns of injury in specific localities or nationally. Data from surveillance systems may be used to implement prevention strategies in areas designated at high risk for specific types of injuries or hazards. Analyzing cause-specific injury data by age, gender, ethnicity, or occupation helps to focus prevention planning. Patterns of Injury by Age, Gender, Race, and Ethnicity Mortality The percentage of all deaths that were caused by an injury was greater for males (9 percent) than for females (4 percent). Among males ages 15–19 years and 20–24 years, 83 and 80 percent, respectively, of all deaths were caused by injuries compared with 69 and 56 percent among females. With increasing age, the percentages decrease for both males and females. For persons 65 years and over, about 2 percent of all deaths were caused by injuries. Although injury is a leading cause of childhood death, injury death rates are lowest for children under 15 years of age. The injury death rate for infants in 1995 (29 per 100,000 population) was about 2–3 times the rate for children 1–4 years, 5–9 years, and 10–14 years of age. For persons 15–74 years of age, injury death rates ranged from 49 per 100,000 at 55–64 years to 80 per 100,000 at 20–24 years. Although injury is not a leading cause of death in the elderly, rates
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Reducing the Burden of Injury: Advancing Prevention and Treatment were higher for persons 75–84 years and 85 years of age and over, at 116 and 281 per 100,000 persons. Injury death rates were higher for males than for females in each age group except for infancy when the rates were similar. In 1995 for children 1–9 years of age, injury death rates for males were about 1.5 times the rates for females, and the difference increases with age. The mortality sex ratio (the ratio of death rate for males to that for females) jumped from 2.1:1 at ages 10–14 years to 4.6:1 at 20–24 years. The mortality sex ratio for persons 65 years and over was about 2:1. Injury death rates vary with race and ethnicity. The average annual injury death rate for 1993–1995 among teenagers and young adults 15–34 years of age was higher for the black population and for American Indian/Alaskan Natives (referred to as American Indians) (119 per 100,000) than for Hispanics (78 per 100,000), non-Hispanic white population (58.0 per 100,000), and Asian or Pacific Islanders (referred to as Asians) (36 per 100,000). Unintentional injury death rates and suicide rates were higher for American Indians than for other racial and ethnic groups. Homicide rates were higher for the black population than for other groups. Motor vehicle traffic injuries were the leading cause of unintentional injury in each race and ethnic group. Hospitalization In 1993–1994, 9 percent of all discharges had a first-listed injury diagnosis. For persons 25 years and over, 7–9 percent of discharges were for an injury. Differences by sex were greater for persons ages 15–24 years (31 percent among males compared with 4 percent among females) and for persons 25–44 years of age (17 percent for males compared with 5 percent for females) than for other ages (Figure 2.5). For both white and black males 15–44 years, 20 percent of all hospital discharges were for an injury compared with about 5 percent among females. The age and gender patterns for injury-related hospitalization are different than those for mortality. In general, discharge rates for persons with a first-listed diagnosis of injury increase with age. In 1993–1994 the average annual rates for children under 5 years of age and 5–14 years of age were 57 percent and 42 percent of the rate for young persons ages 15–24 years (90 discharges per 10,000 persons), and that rate is about one-half the rate for persons 65–74 years of age, and about a fifth of the rate for persons 75 years of age and over (412 per 10,000 persons). Although injury discharge rates for males and females were similar (108 and 99 per 10,000 persons) for all ages combined, gender discharge rates vary considerably by age. At ages 15–24 years the discharge rates for males were twice those for females (119 compared with 60 per 10,000), whereas for the elderly 75 years of age and over, the rate for males was about 70 percent of the rate for females (322 compared with 463 per 10,000 persons).
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Reducing the Burden of Injury: Advancing Prevention and Treatment Figure 2.5 Hospital discharge rates for injury by age and sex: United States, 1993–1994. Source: Fingerhut and Warner, 1997. Hospitalization rates for black males under 15 years, 15–44 years, and 45–64 years of age were about twice the rates for white males. At ages 65 years and over, the rates for white and black males were similar. Among females, discharge rates for black children were about twice the rates for white children and differences narrowed with increasing age. For persons 65 years of age and over, injury discharge rates for white females were 1.4 times the rates for black females. Emergency Department Visits About 4 of 10 ED visits were for injuries. In 1993–1994, injury visit rates were similarly high for children under 5 years of age and for persons 15–24 years of age and were similarly lower for people aged 45–64 years and 65–74 years compared with other age groups. At ages 5–14 years, 15–24 years, and 25–44 years, injury visit rates for males were 1.4 times the rates for females, and among those 75 years of age and over, the visit rate for females was 1.3 times the rate for males. ED injury visit rates for black males and females were higher than for white males and females, 23 and 17 per 100 persons compared with 16 and 12 per 100 persons. Rates for black males and females were higher than for white persons
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Reducing the Burden of Injury: Advancing Prevention and Treatment among children under 5 years of age and among persons 15–24 years, 25–44 years, and 45–64 years of age. Racial differences were larger for males ages 25–44 years and 45–64 years than for younger or older persons and were larger for females 25–44 years of age than for other groups. (Visit rates by ethnicity were not considered reliable.) Patterns of Injury by Cause Among children 1–14 years of age, motor vehicle traffic injuries were the leading cause of death in 1995. Among infants, suffocation was the leading cause of injury death. The five leading causes of injury death among infants and children under 15 years of age—motor vehicle traffic injuries, fires and burns, drowning, suffocation, and firearms—accounted for 80 percent of injury deaths. Among teenagers 15–19 years of age and young adults 20–24 years of age, motor vehicle traffic-related injuries and firearm-related injuries were the two leading causes of death in 1995. For older adults 65–74 years, motor vehicles and firearms were the two leading causes of injury deaths, accounting for one-half of injury mortality. At ages 75–84 years, motor vehicles and falls were the cause of close to one-half of all injury deaths. For those 85 years and over, falls caused one-third of injury deaths. Hospital discharge rates for open wounds and for internal injuries for all males were 3 times the rates for all females. At ages 15–24 years the discharge rate for open wounds for males was 4.5 times the rate for females. On the other hand, discharge rates for poisoning for females 15–24 years and 45–64 years were 1.6 times the rates for males. In 1992–1994, three out of five injury hospitalizations among elderly persons 75 years of age and over were for fractures, and more than one-half of the fractures were to the hip. Hip fracture rates for elderly females were twice the rates for males. Among young children and the elderly, falls were the most common cause of injury visits to the ED. For young persons 15–24 years, injuries resulting from being struck, from motor vehicle crashes, and from falls were most likely. The most common injury diagnoses among young children were open wounds and lacerations; for those 15–24 years, superficial injuries and sprains and strains resulted in ED visits, and among the elderly (and especially among females), fractures were the leading diagnosis. Patterns of Occupational Injury More than 125 million civilian workers are employed in the United States, with some risk of injury present in all jobs (NIOSH, 1996). In 1995, 6,210 fatal work injuries (5 per 100,000 workers) were reported in the Census of Fatal Occupational Injuries (BLS, 1996). Overall, transportation-related incidents are the
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Reducing the Burden of Injury: Advancing Prevention and Treatment leading cause (23 percent) of occupational injury deaths. Since 1980, homicide has been the second leading cause of occupational injury deaths, surpassing machine-related deaths (13 percent) (CDC, 1998). One in six occupational deaths in 1995 was a homicide, which was the leading cause of death for females in occupational settings, and accounted for 46 percent of fatal work injuries (Fingerhut and Warner, 1997). Occupations with the highest risk of fatal injury include truck drivers, fishermen, timber cutters, and airplane pilots. Although information about nonfatal occupational injuries is not as comprehensive as that for deaths, they are estimated to number more than 13 million each year (Leigh et al., 1997). Nearly one-half (46 percent) of these injuries are disabling. Approximately one-third of nonfatal injuries are sustained by workers in eight industries (restaurants and bars, hospitals, nursing and personal care facilities, trucking and non-air courier services, grocery stores, department stores, motor vehicles and equipment, and hotels and motels), with the highest incidence rate (17.8 per 100 full-time workers) reported in persons employed in nursing and personal care facilities (BLS, 1997). THE COST OF INJURY The scope of the injury problem is measured primarily in terms of numbers and rates of death and in years of potential life lost (YPLL) due to premature death. It has become increasingly apparent over the past decade, however, that although death rates and YPLL are powerful indicators of the relative magnitude of the injury problem, they do not adequately measure the full burden of injuries on society. In 1996, unintentional injury was third in YPLL before age 75, following diseases of the heart and malignant neoplasms. In fact, all injury (including homicide and suicide) is the leading cause of YPLL before age 75 (Table 2.2) (NCHS, 1998). With few exceptions, the rank ordering of YPLL for injury follows the ordering for leading causes of injury death. Notably out of order, however, is the YPLL for fall-related deaths. Despite the fact that, overall, more injury deaths are attributed to falls than to suffocations, more YPLLs are associated with suffocations because they tend to occur at younger ages than deaths due to falls. Totaling deaths and years of life lost, however, does not take into account the additional costs to federal, state, and local governments of public programs (e.g., Medicare, Medicaid, veterans' benefits); the costs to private insurance programs; and the costs accruing to injured individuals, their families, employers, and society in general. These are measured as both economic and quality-of-life factors of the cost of injury.
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Reducing the Burden of Injury: Advancing Prevention and Treatment TABLE 2.2 Leading Causes of Years of Potential Life Lost (YPLL), Costs to Society, and Deaths Disease or Condition Age-Adjusted YPLL Before Age 75, 1996 (per 100,000 (population)a Cost Estimate ($ billions, constant 1996 dollars)b Number of Deaths (1996)a Injuryc 1,919.0 260d 147,126e Cancer 1,554.2 115.4 539,533 Heart diseases 1,222.6 144.9 733,361 HIV infection and AIDS 401.9 NA 31,130 Stroke; cerebrovascular diseases 210.2 32.6 159,942 Chronic obstructive pulmonary diseases 161.1 31.8 106,027 Diabetes 153.5 102.7 61,767 Chronic liver disease and cirrhosis 145.7 4.8 25,047 Pneumonia and influenza 114.5 25.4 83,727 a SOURCE: NCHS (1998). b These cost estimates were prepared by different authors, using different years as points of reference: heart disease (1991); cancer (1990); stroke (1993); pulmonary disease (1991); pneumonia (1991); diabetes (1992); liver disease (1985); and kidney disease (1985). All estimates (except injury) have been calculated to 1996 dollars and encompass both direct costs and indirect costs attributable to patient mortality (premature death), patient morbidity (reduced productivity), and other non-health care costs. NA = Not available. SOURCE: IOM (1998). c Injury includes unintentional injuries, suicide, and homicide. d The 1985 cost of injury in the United States estimates (Rice et al., 1989) were updated to 1995 separately by type of cost. Direct costs were inflated using the appropriate component of the Consumer Price Index (hospital and related services, physicians' services, prescription drugs, professional medical services, and medical care services). Indirect costs were inflated using the index of hourly compensation in the business sector. e SOURCE: Peters et al. (1998). Estimates of the economic cost of injury combine information on the incidence and impact of both fatal and nonfatal injuries into a single measure that is readily understandable by policy makers, employers, and the insurance industry. Using a cost-of-illness or human capital approach to valuing health, estimates of the cost of injury have been derived for several major categories (e.g., motor vehicles, firearms, falls, fires and burns, poisonings) of injury (Rice et al., 1989; Max and Rice, 1993; Miller et al., 1995; NSC, 1997; Blincoe, 1997; Leigh et al.,
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Reducing the Burden of Injury: Advancing Prevention and Treatment 1997).4 These costs include (1) direct costs of medical care (both acute and long term) and other nonmedical goods and services related to the injury (e.g., costs for home modifications, vocational rehabilitation, administrative costs for delivering health and indemnity insurance); (2) indirect morbidity costs (i.e., the value of foregone productivity due to injury-related illness and disability); and (3) indirect mortality costs (i.e., the value of foregone productivity due to death at an early age). Also included in some analyses are costs associated with property damage, police and fire services, and legal fees related to compensation (Miller et al., 1995; Blincoe, 1997). These costs can add significantly to the overall cost of injuries from certain mechanisms such as motor vehicle crashes and fires or burns. Costs accrued to family members who lose time from work in order to take care of the injured can also contribute to the total lifetime costs, but these are difficult to determine (Chirikos, 1989). One of the more comprehensive cost-of-illness studies on injury costs was published by Rice and colleagues (1989). In this study, estimates of the cost of injury were derived by age, gender, and six major injury mechanisms (motor vehicle, firearms, falls, fire or burns, poisonings, and drownings or near drownings). Total lifetime costs associated with both fatal and nonfatal injuries were estimated at $158 billion in 1985 and $182 billion in 1988 (Rice et al., 1989). When inflated to 1995 dollars, the total cost approaches $260 billion. The cost of fatalities represents a disproportionate share of total lifetime costs; while accounting for less than 1 percent of all injuries, fatal injuries contributed to 31 percent of the total calculated cost. An additional 51 percent of the costs accrue among persons with injuries resulting in hospitalization. Less than one-fifth of the total costs are associated with the overwhelming number of injuries that result in one or more days of restricted activity but do not require hospitalization (Rice et al., 1989). Direct medical-care and nonmedical-care expenditures account for an estimated 28 percent of the total costs of injury; approximately 55 percent of these direct costs are spent on hospital care (including both acute care and rehabilitation). Miller and colleagues (1994) found that treatment of injuries and their long-term effects (excluding nursing home care and medical care for the institutionalized population) accounted for 12 percent of the total medical care spending in the United States, totaling an estimated $69 billion (in 1993 dollars). Injuries were identified as second only to cardiovascular disease ($80 billion) as a leading contributor to total health care costs. The authors further estimated that injuries account for 10 percent of all hospital inpatient expenditures, 46 percent of ED expenditures, and 16 percent of total outpatient and ambulatory care expenditures. 4 Rice and colleagues (1989) estimate lifetime (incidence-based) costs and Miller and colleagues (1995) estimate annual prevalence costs. These are two different approaches, have different purposes, and may not produce similar results.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Although costs derived using the cost-of-illness or human capital approach provide some assessment of the economic impact of fatal and nonfatal injury, it is readily acknowledged that each is inadequate as a measure of the overall burden of injury, largely because they value life and health only in terms of foregone productivity and do not factor in pain, suffering, and reduced quality of life. Further, these estimates yield low values for the retired, the elderly, housewives, and children, since future earnings are typically discounted to present value and no monetary value is allowed for activities outside the marketplace. However, some critics of the human capital method claim that it overestimates true indirect costs because it does not take into account the possibility of substitution among workers when there is relatively high unemployment. These critics contend that indirect costs should be restricted to temporary production losses and to resources expended to recruit and train new employees. A variant on the human capital method—the friction cost method—attempts to account for the substitution of employees, although in practice it is difficult to apply because of a lack of good estimates of the friction period (i.e., time between the occurrence of the injury and the point at which previous production levels are restored; Koopmanshap and Rutten, 1994; van Beeck et al., 1997). An alternative approach to valuing life and health involves a willingness-to-pay methodology. This method values human life according to the amount individuals are willing to pay (or in some instances actually do pay) for small changes such as reductions or increases in the probability of illness or death. It is a fundamentally different approach to estimating the burden of injury in terms of indirect costs, since it builds on the perspective of society as a population of consumers rather than producers. To derive willingness-to-pay estimates, individual preference values are obtained using one of two approaches. Using the revealed-preference method, a variety of data is used to reveal the trade-offs between dollars and risk of injury that people have actually made. These data have included wage premiums that compensate workers for risky jobs (an estimate of the price of increased risk), court awards for pain and suffering, and data on the actual consumption of goods that reduce the risk of injury (an estimate of the price of reduced risk), such as the costs of smoke detectors and extra safety features on cars (Drummond et al., 1997). The strength of the revealed-preference approach is that it is based on actual behavior; however, requisite data are often difficult to obtain. An alternative approach to obtaining preferences is referred to as the stated-preference approach. Using this approach, preferences are obtained by asking people directly about their willingness to pay for changes that reduce the probability of death and/or disability (Drummond et al., 1997). The stated-preference approach, although theoretically appealing, is difficult to apply in practice because it assumes that people do indeed have well-formulated preferences about the value of nonmarket goods and, further, that they can articulate these preferences in a rational and consistent manner.
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Reducing the Burden of Injury: Advancing Prevention and Treatment Regardless of the approach used, willingness-to-pay estimates of human costs are considerably higher than estimates of lost productivity obtained using a human capital approach. For example, based on a review of 47 technically sound studies, the willingness to pay to save one life ranges from $1 million to $3.8 million (average $2.3 million), whereas the human capital estimate of foregone productivity per injury death averaged across the age at death is only $334,849 (Rice et al., 1989; Miller, 1990). The choice of a particular approach for computing the economic costs of injury will, in part, be dictated by the intended use of the derived estimates. The application of all methods discussed above is limited by our lack of understanding of these outcomes. For example, more research is needed to refine methodologies and evaluate the relative utility of alternative approaches, and all require better data on the long-term consequences of injury in terms of treatment needs, reduced productivity, and overall quality of life. New and exciting approaches are being developed to quantify the burden of disease and injury in noneconomic terms. These methods typically involve the calculation of quality-adjusted life years (QALYs). The QALYs associated with a particular injury are calculated as the average number of years of life remaining after the occurrence of the injury, multiplied by a weight reflecting the quality of life during each of these years (Torrance and Feeny, 1989). The weights used to calculate QALYs should be based on the preferences people have for various health states and are expressed on an interval scale, with optimal health having a value of 1 and death having a value of 0. They have been derived using a variety of different health state classification systems, including the EuroQol (EuroQol Group, 1990), the Health Utilities Index (Feeny et al., 1995), and the Quality of Well-Being Scale (Kaplan and Anderson, 1988). These systems differ in the domains used to define various health states, the specific technique used to estimate preferences, and the fundamental assumptions made about the value of life when deriving estimates. Since substantial discrepancies may arise depending on the method used, it is important that standard approaches be developed (Gold et al., 1996). Extensive research is needed, however, before such a standard can be promulgated. Given the potential utility of QALYs as a composite measure of the burden of injury in noneconomic terms, the committee recommends that priority be given to the development and application of preference-based measures of quality of life that are valid across the broad spectrum by injury types and severities. To date, there have been few applications of the QALY methodology for measuring the impact of injury (Holbrook et al., 1994; MacKenzie et al., 1996). Of some note, however, is the work recently completed by the World Health Organization in collaboration with the World Bank and Harvard University (Murray and Lopez, 1996), which has developed an internationally standard form of the QALY, referred to as the disability-adjusted life year (DALY). Although questions remain regarding the precise methods used in deriving DALY
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Reducing the Burden of Injury: Advancing Prevention and Treatment estimates, the effort represents a milestone in the development of new approaches for measuring the burden of disease in terms other than just the direct costs of mortality. This method results in the estimate that injuries account for 11 percent of the global burden of disease as measured by the number of DALYs experienced by the world's population. In projecting the future global burden of disease, it was found that road traffic injuries alone will rise from ninth place overall as a leading cause of disease burden to third place by the year 2020. Violence, which is currently in nineteenth place as a cause of disease burden is expected to rise to twelfth place and suicide from seventeenth place to fourteenth place (Murray and Lopez, 1996). These projections underscore the importance of injury as a major source of both death and disability now and in the future. REFERENCES Blincoe LJ. 1997. Economic Costs of Motor Vehicle Crashes: 1994. Washington, DC: National Highway Traffic Safety Administration. BLS (Bureau of Labor Statistics). 1996. BLS. [World Wide Web document]. URL http://www.bls.gov.oshcftab.htm (accessed July 1998). BLS (Bureau of Labor Statistics). 1997. News Release: Workplace Injuries and Illnesses in 1995. Washington, DC: U.S. Department of Labor. USDL 97-76. CDC (Centers for Disease Control and Prevention). 1998. Fatal occupational injuries, United States, 1980–1994. Morbidity and Mortality Weekly Report 47(15):297–302. Chirikos TN. 1989. Aggregate economic losses from disability in the United States: A preliminary assay. Milbank Quarterly 67:59–91. Drummond MF, O'Brien B, Stoddart GL, Torrance GW. 1997. Methods for the Economic Evaluation of Health Care Programs, 2d edition. New York: Oxford University Press. EuroQol Group. 1990. EuroQol: A new facility for the measurement of health-related quality of life. Health Policy 16:199. Feeny D, Furlong W, Boyle M, Torrance GW. 1995. Multi-attribute health status classification systems: The Health Utilities Index. PharmacoEconomics 1:490–502. Fingerhut LA, Warner M. 1997. Injury Chartbook. Health, United States, 1996–97. Hyattsville, MD: National Center for Health Statistics. Gillum BS, Graves EJ, Wood E. 1998. NHDS Annual Summary, 1995. NCHS Vital Health Statistical Series. Hyattsville, MD: National Center for Health Statistics. Gold MR, Siegel JE, Russell LB, Weinstein MC. 1996. Identifying and valuing outcomes. In: Gold MR, ed. Cost-Effectiveness in Health and Medicine. New York: Oxford University Press. Holbrook TL, Hoyt DB, Anderson JP, Hollingsworth-Fridlund P, Shackford SR. 1994. Functional limitation after major trauma: A more sensitive assessment using the Quality of Well-Being scale. The trauma recovery pilot project. Journal of Trauma 36(1):74–78. IOM (Institute of Medicine). 1998. Scientific Opportunities and Public Needs: Improving Priority Setting and Public Input at the National Institutes of Health. Washington, DC: National Academy Press.
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