137
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The Cost of Childhood
Unintentional Injuries and
the Value of Prevention
Ted R. Miller
Eduardo O. Romano
Rebecca S. Spicer
Abstract
Cost data are useful in comparing various health problems, assessing risks, setting
research priorities, and selecting interventions that most efficiently reduce health
burdens. Using analyses of national and state data sets, this article presents data on
the frequency, costs, and quality-of-life losses associated with unintentional childhood injuries in 1996. The frequency, severity, potential for death and disability,
and costs of unintentional injury make it a leading childhood health problem.
Unintentional childhood injuries in 1996 resulted in an estimated $14 billion in
lifetime medical spending, $1 billion in other resource costs, and $66 billion in
present and future work losses. These injuries imposed quality-of-life losses equivalent to 92,400 child deaths. Since Medicaid and other government sources paid
for 39% of the days children spent in hospitals due to unintentional injuries, the
government has a financial interest in, and arguably a responsibility for, assuring
the safety of disadvantaged children. Federal agencies, however, devote relatively
few public dollars to injury prevention research and programming.
Several proven child safety interventions cost less than the medical and other
resource costs they save. Thus, governments, managed care companies, and thirdparty payers could save money by encouraging the routine use of selected child
safety measures such as child safety seats, bicycle helmets, and smoke detectors.
Yet, these and other proven injury prevention interventions are not universally
implemented.
I
njury is a common and costly childhood affliction, accounting for
approximately 15% of medical spending from ages 1 to 19.1 Indeed, for
children and adolescents 5 to 19 years of age, injury rivals the common
cold in frequency.2 Injuries, however, are much more likely than colds to
have lasting effects. In 1996, unintentional injuries—primarily brain, spinal
cord, burn, and limb injuries—left an estimated 150,000 or more children
and adolescents permanently disabled and often in need of lifetime followup care.1 Another 13,000 children and adolescents were killed by unintentional injuries in the same year (see the article by Grossman in this journal
The Future of Children UNINTENTIONAL INJURIES IN CHILDHOOD Vol. 10 • No. 1 – Spring/Summer 2000
Ted R. Miller, Ph.D., is
principal research scientist at Pacific Institute
for Research and Evaluation in Landover,
MD, a nonprofit policy
research organization
specializing in preventive health.
Eduardo O. Romano,
Ph.D., is research associate at Pacific Institute
for Research and Evaluation in Landover,
MD, a nonprofit policy
research organization
specializing in preventive health.
Rebecca S. Spicer, M.P.H.,
is associate research scientist at Pacific Institute
for Research and Evaluation in Landover,
MD, a nonprofit policy
research organization
specializing in preventive health; and a
doctoral candidate at
the School of Public
Health, Department of
Health Policy and
Management, at Johns
Hopkins University.
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
issue). Coupled with this high death rate, the frequency, severity, and
disabling outcomes of unintentional injuries make them a costly childhood
health problem.
Quantifying the costs associated with childhood injuries is important.
Cost estimates reduce different outcomes or injuries—deaths, near
drownings, broken legs, or even damaged cars—to a common metric.
This makes cost data a useful element in gauging the relative size of various problems, assessing risks, setting research priorities, and selecting
interventions that most efficiently reduce the burden of injury. For example, injury costs by diagnosis can inform a decision about whether to use
a playground-improvement budget to fix swings (estimated to prevent
seven broken arms) or to fix slides (estimated to prevent two broken
legs). Measuring the benefit of interventions in dollars also helps planners and evaluators estimate the “net cost” of a safety investment (that is,
the total cost of the investment minus the benefits accrued). On a
broader scale, comparably measured costs of injury and illness can provide insight into the relative magnitude of these problems and can
inform resource allocation. Finally, cost data can be used for advocacy
purposes, by conveying risk reductions in a way that captures the attention of politicians, the media, and the public. For example, a car seat giveaway program targeting Medicaid recipients may reduce an infant’s risk
of death by 1% and save the government $50. While both risk reduction
and government savings are important, communicating the benefit in
monetary terms may be more informative for policymakers concerned
with state or federal budgets.
A widely quoted report, Cost of Injury in the United States: A Report to
Congress,3 estimated medical spending and other costs resulting from
childhood injuries, using data from the mid-1980s. This report provided
cost-of-injury estimates that helped draw recognition of injury as a major
public health threat. It did not differentiate injuries by intent, however,
combining unintentional injuries with intentional harm such as child
abuse and homicide. The report also grouped costs by only seven causes—
burns, drownings, falls, firearms, motor vehicles, poisonings, and other.
These groupings fail to distinguish among important subcategories of
motor vehicle injuries (that is, occupant, pedestrian, and bicycle) and they
do not capture other important injury categories, such as being struck by
or against an object, as often occurs in contact sports. With the arrival of
the new millennium, these cost estimates are outdated and may no longer
portray accurately the burden childhood injuries place on society.
This article defines the costs associated with childhood unintentional
injuries and briefly reviews the concepts used in estimating injury costs.
It then reports estimates of the lifetime costs of childhood unintentional
injuries using more recent, cause-specific, and child-specific data than
were previously available. This information allows for a cost comparison
between unintentional injuries and other child health problems and it
provides a basis for judging whether injury prevention research and
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
implementation efforts are adequately funded. To address that question
more fully, the article closes with a review of cost-effectiveness estimates
for selected childhood unintentional injury prevention interventions
compared with similar estimates for other child health measures.
Unintentional Injury Costs
and Quality-of-Life Losses
Defining Costs
Injuries among children and adolescents
impose a financial burden on many segments of society. Parents and health insurers, for example, assume responsibility for a
myriad of medically related expenses due to
injuries. Parents may be forced to stay home
from work to care for an injured child,
affecting both the family’s income and the
employers’ profit. Children who are disabled from an injury may be unable to work
in the future. Deciding which of these costs
to include in cost-of-injury estimates is critical, because the decision can influence the
estimated monetary burden of injuries by
orders of magnitude. As recommended by
the Panel on Cost-Effectiveness in Health
and Medicine,4 a nonfederal panel convened by the U.S. Public Health Service
(PHS), this article adopts a societal perspective
that attempts to estimate all costs associated
with childhood unintentional injuries—
costs to victims, families, government, insurers, and taxpayers. Other perspectives would
constrain the analysis to, for example, government expenditures or health care payer
expenditures, which include only a subset of
total injury costs.
Injury costs can be separated into
resource and productivity costs. Resource costs
are associated with caring for injury victims
and managing the aftermath of injury incidents, and they are dominated by the medical
costs of injuries. Productivity costs value wage
work and housework that children and adolescents will be unable to do because of their
injury, as well as the work that parents or
other adults forego to care for injured children. Box 1 describes more fully the cost-ofinjury concepts used in this article.
Because injuries sustained during childhood may impact the productivity of both children and their caregivers over time, accounting
for losses to both parties is critical. For example,
an employed adolescent temporarily disabled
from an injury may lose wages in the near term.
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Likewise, an injury that keeps a child home
from school for a few days may require that a
parent stay home to act as a caregiver. Since
such injuries are relatively frequent among children, total work losses for adult family members caring for injured children also are a
major cost. Of course, the most extreme impact
on productivity occurs when a child is killed or
permanently disabled by an injury. In such
instances, a lifetime of work is lost.
Defining Quality-of-Life Losses
This article focuses primarily on resource
and productivity costs associated with childhood unintentional injuries. However, these
costs do not fully capture the burden of
injuries to children. Injuries also affect children and families by reducing their quality
of life. Families who lose a child to injury
may suffer years of mental anguish. Children
who are permanently disabled by injury may
experience lifelong pain or suffer permanent loss of motor or cognitive functioning.
To capture these less quantifiable consequences of childhood injuries, quality-of-life
losses, valued in nonmonetary terms as
quality-adjusted life years (QALYs), also are
reported (see Box 2). Both monetary costs
and quality-of-life measures should be
considered when allocating resources, and
both should be incorporated into costeffectiveness analyses that weigh “net costs”
against quality-of-life improvements.
Estimating Costs
and Quality-of-Life Losses
The next section reports findings from an
analysis that estimated the present and
future costs of childhood unintentional
injuries that occurred during 1996. Injuries
were included that affected children ages 0
to 19 and resulted in a physician office visit,
an emergency department visit, a hospitalization, or a death. Cost-of-injury estimates
were computed by multiplying the number
of injury victims in 1996—stratified by age,
diagnosis, severity, and cause—by the corresponding costs per victim (in 1996 dollars).
Data for these estimates were abstracted
from the literature and 11 data sets
described in Table 1. Table 2 summarizes the
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
Box 1
Cost-of-Injury Concepts
Incidence-Based vs. Prevalence-Based Costs
■ Incidence-based costs are the present value of the lifetime costs that may result from
injuries that occur during a single year. For example, the incidence-based cost of
head injuries in 1996 estimates total lifetime costs associated with all head injuries
that occurred in 1996. Incidence-based costs measure the savings that prevention
can yield.
■ Prevalence-based costs measure all injury-related expenses during one year, regard-
less of when the injury occurred. For example, the prevalence-based cost of head
injuries in 1996 measures the total health care spending on head injuries during
1996, including spending on victims injured many years earlier. Prevalence-based
cost data are needed to project health care spending and evaluate cost controls.
Resource vs. Productivity Costs
Resource costs are broken down into medical costs and other resource costs. Productivity costs include immediate and future work losses due to a childhood injury.
■ Medical costs include emergency medical services, physician, hospital, rehabilita-
tion, prescription drug, and related treatment costs, as well as ancillary costs (that
is, for crutches, physical therapy, etc.), funeral/coroner expenses for fatalities, and
the administrative costs of processing medical payments to providers.
■ Other direct costs include police and fire department costs, plus the travel delay for
uninjured travelers resulting from transportation crashes and the injuries caused
by the crashes.
■ Work-loss costs include victims’ lost wages and the value of lost household work,
fringe benefits, and the administrative costs of processing compensation for lost
earnings through litigation, insurance, or public welfare programs such as food
stamps and Supplemental Security Income. Work losses by family and friends who
care for injured children also are included.
estimated frequency, by severity and age, of
the childhood unintentional injuries. This
article, however, focuses on injury costs and
quality-of-life losses. Total injury costs are
reported, as are costs stratified by cause, age,
severity, and cost category. Estimated QALY
losses were computed in a similar manner
and are reported following the cost-of-injury
findings. The methods used to estimate
injury frequency, costs, and quality-of-life
losses are described more fully in the Appendix at the end of this article.
Childhood Unintentional
Injury Costs
The estimated lifetime resource and productivity costs of unintentional injuries that
occurred during 1996 to U.S. children ages
0 to 19 equal $81 billion (see Table 3). This
estimate summarizes the costs for 22.2 million children—3 in every 10 children—who
suffered unintentional injuries serious
enough to require medical treatment or
cause at least half a day of restricted activity.
Of these children, more than 13,000 died
and 292,000 were hospitalized because of
their injuries. The overwhelming majority of
injured children, however, did not sustain
injuries severe enough to require a hospital
admission.
The bulk of the financial burden associated with childhood unintentional injuries
results from work losses experienced by
injured children and their caregivers. Present and future productivity losses
accounted for more than 80% ($66.5 billion) of the total lifetime childhood injury
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
Box 2
Quality-Adjusted Life Years
Estimating quality-adjusted life years (QALYs) is one way to value the good health lost to
an individual who suffers a health problem, is disabled, or dies prematurely. A QALY is
a measure based on individual preferences for states of health that assigns a value of “1”
to a year of perfect health and “0” to death.1 QALY losses are affected by the duration
and severity of a health problem. To estimate QALY losses, years of potential life lost to
a fatal injury are added to the number of years spent with an injury-related disability multiplied by a “weighting factor” that represents the severity of the disability.2 Such weighting factors can be estimated by using rating scales3 or by using trade-off methods that
elicit individual preferences between death and various health states.4,5
Endnotes:
1 Gold, M.R., Siegel, J.E., Russell, L.B., and Weinstein, M.C., eds. Cost-effectiveness in health and medicine. New York: Oxford
University Press, 1996.
2
Following the recommendations of the Panel on Cost-Effectiveness in Health and Medicine (note v), QALY losses in future
years are discounted to present value at a 3% discount rate as they are summed. See note no. 1, Gold, Siegel, Russell, and
Weinstein.
3
Hirsch, A., Eppinger, R., Shame, T., et al. Impairment scaling from the abbreviated injury scale. Washington, DC: National
Highway Traffic Safety Administration, 1983.
4
Miller, T.R., Pindus, N.M., Douglass, J.B., and Rossman, S.B. Databook on nonfatal injury: Incidence, costs, and consequences.
Washington, DC: The Urban Institute Press, 1995.
5
Drummond, M.F., O’Brien, B., Stoddart, G.L., and Torrance, G.W. Methods for the economic evaluation of health care programmes. 2d ed. New York: Oxford Medical Publications, 1997.
costs. Medical costs made up most of the
remainder, accounting for 17% ($13.8 billion) of lifetime costs. Thus, although unintentional injuries may be viewed
appropriately as a health problem, from a
cost perspective, injuries are even more an
economic problem. Each year injuries kill or
disable thousands of otherwise healthy children before they have had the opportunity
to use their talents to benefit society. The
current workforce is affected, too, as many
adult caregivers are forced to stay home to
tend to injured children.
Costs by Injury Severity
The most severe childhood injuries—those
that result in death—disproportionately
contribute to lifetime injury costs. Fatal
injuries accounted for less than 1% of all
childhood injuries in 1996, but they
accounted for more than 17% of injuryrelated costs. By contrast, the least severe
injuries—nonfatal injuries where the child
was not hospitalized—accounted for nearly
99% of all childhood injuries, yet they were
associated with 58% of the estimated lifetime costs (see Table 3). Thus, although the
very rare injury fatalities contributed disproportionately to the financial burden of
childhood injuries, the most common and
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least severe injuries still accounted for more
than half of the total injury costs.
The severity of childhood injuries also
affects the relative contribution of medical
costs, versus productivity losses, to total injury
costs. When a child suffers a nonfatal injury,
for example, caregiver work losses typically
cost much more than medical treatment.
Nonetheless, hospital care is expensive, and
medical costs account for a larger proportion
of total injury costs among hospitalized
(27%) than nonhospitalized (21%) injured
children. For children killed from an injury,
the overwhelming cost (96%) is the future
work that these children will never do. Medical costs account for less than 1% of the total
injury costs for these victims.
Costs by Age of Child
As children grow, their motor skills and cognitive skills develop and their environment
changes. Therefore, their injury risks shift.
Critical developmental milestones that affect
injury risk may include starting to crawl,
walk, attend school, ride a bicycle, drink
alcohol, and drive a car, as well as developing
an ability to recognize and make decisions
about dangerous situations. Thus, injury
rates, causes, and severity vary with age.
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
Table 1
Summary of Data Sources Used for Cost-of-Injury Analysis
Name and
Source
Population Covered
Years of
Data Used
Other Relevant
Information
Data Elements Used
BLS Annual Survey
of Occupational
Illnesses and
Injuries (Bureau
of Labor Statistics)
Annual sample of
lost-workday
occupational
incidents
1993
Days lost per injury
Restricted to
workers
CHAMPUS
Civilian Health
and Medical
Program of the
Uniformed
Services (U.S.
Department of
Defense)
Annual summary of
health care claims
for about 2 million
military dependents
and retirees
1992–94
• Ratio of professional
fees to hospital
payments
• Payments per
nonadmitted case
• Longitudinal for
one year
• Few males ages
18 to 45
• Few people over
age 65
Medstat, Inc.
claims data
(leased
proprietary data)
Proprietary health
care claims data on
employer-insured
families
1987–89
Ratio of medical costs
over time for child versus
adult injury victims with
comparable diagnoses
Longitudinal data
on children and
adults under age
65
NAMCS
National
Ambulatory
Medical Care
Survey (National
Center for Health
Statistics [NCHS])
Sample of doctor’s
office and clinic
visits
1995–96
Cause distribution (for
incidence estimates)
NCCI
Detailed claims
database
(National Council
on Compensation
Insurance)
Sample of workers’
compensation lostwork claims
1979–87
1992–96
• Percentage of
medical payments in
first year
• Disability probabilities
• Longitudinal
data
• Workdays lost to
qualify varies by
state
NHAMCS
National Hospital
Ambulatory
Medical Care
Survey (NCHS)
Sample of hospital
emergency department visits
1992–96
Cause distribution (for
incidence estimates)
Initial visits are hard
to distinguish
NHDS
National Hospital
Discharge Survey
(NCHS)
Annual sample of
hospital discharges
1996
• Hospital admissions by
age and cause
• Length of stay
• Percentage
discharged to nursing
home
• Payer distribution
Only 63% cause
coded
NHIS
National Health
Interview Survey
(NCHS)
Household interview
survey
1987–96
• Nonadmitted injury
cases
• Work-loss probabilities
• Self-reported
diagnoses
• Data covers the
two weeks prior
to interview
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
143
Table 1 (continued)
Summary of Data Sources Used for Cost-of-Injury Analysis
Name and
Source
Years of
Data Used
Population Covered
Other Relevant
Information
Data Elements Used
NMES
National Medical
Expenditure
Survey (NCHS)
Household interview
survey, with provider
follow-up
1987 (most
recent; updates
Rice and
MacKenzie’s
1980 data)
• Medical costs by
hospital admission
status and nature of
expense
• Visits per case
Cases identified
by self-reports from
14,000 households
U.S. Vital Statistics
(NCHS)
Annual census of
deaths
1996
Deaths by age, sex, and
cause (for incidence
estimates, productivity
computations)
Cases of unknown
intent were treated
as unintentional
Pooled six state
hospital discharge
surveys
(purchased from
those states)
Annual census of
hospital discharges
CA 1993
MD 1994–95
MO 1994
NY 1994
VT 1990
WA 1989–91
• Cause distribution (for
incidence estimates)
• Cost per day of stay
from MD and NY
• Readmission rates
from MO
Regressions
modeled effects
of age and sex on
cost per day
Adolescents, and to a lesser extent young
children ages zero to four, experience
higher rates of unintentional injuries that
are fatal or require hospitalization compared with children ages 5 to 14 (see Table
2). Similarly, injury costs are higher among
adolescents than other children. The total
lifetime resource and productivity costs of
unintentional injuries that occurred in 1996
are estimated to be $28 billion among
teenagers 15 to 19 years of age. Among
school-age and younger children, costs are
considerably less ($19 billion among 0- to 4year-olds, $20 billion among 5- to 9-year-olds,
and $14 billion among 10- to 14-year-olds).
Adolescents ages 15 to 19 also have higher
lifetime costs per child due to unintentional
injury ($1,500) compared with younger children or adults (see Figure 1).
The higher total injury costs among adolescents reflect the greater absolute number
of serious and fatal injuries that occur in this
age group and the types of injuries sustained. Approximately 6,900 youths ages 15
to 19 died from unintentional injuries that
occurred in 1996—more than the number
of deaths from unintentional injuries in all
other age groups combined (6,400 deaths).
The higher number of adolescent fatalities
translates into higher total injury costs in this
age group, since teenagers who are killed
lose a lifetime of future work. The causes of
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injuries sustained by adolescents also tend to
result in the most costly injuries per victim.
For example, as shown in Table 4, firearm
injuries are one of the most costly causes of
unintentional childhood injury per victim,
and such injuries, although rare, occur
much more frequently among adolescents
than children in any other age group
(data not shown). These troubling statistics
related to adolescent injury costs should not
be a surprise. Adolescence is a time of learning and a time of testing, so teenagers are
prone to engage in dangerous activities that
can prove costly.
Costs by Cause of Injury
Five primary causes of unintentional injury
account for almost 80% of total lifetime costs
among children ages 0 to 19.5 As shown in
Table 5, these causes include falls, motor
vehicle crashes on public roads (includes
occupant, pedestrian, or bicyclist injuries),
being struck by or against an object or
person, vehicle crashes not on public
roads, and cutting or piercing. These five
causes of unintentional injuries contribute
substantially to overall injury costs because
the combination of their frequency in the
population and the average cost per victim is
exceedingly high.
The relative importance of frequency
versus cost per case, however, varies by type
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
PHOTO OMITTED
of injury. For example, although individual
falls are not unreasonably costly ($4,200 per
victim as shown in Table 4), estimates from
this analysis found that falls are the leading
cause of injury hospitalization among children (data not shown). It is primarily because
of their frequency in the population that falls
cause the most costly childhood unintentional injuries overall. In contrast, although
motor vehicle crashes that injure children
occur much less frequently than falls, the
resulting injuries are often severe and costly.
It is primarily the severity of such injuries that
make motor vehicle traffic crashes the second
leading contributor to total unintentional
injury costs among children.
The relative importance of various injury
causes to total injury costs is different when cost
per victim is estimated rather than total cost (see
Table 4). Drowning or submersion, for example, causes the most expensive injuries, at
$21,000 per victim. Motor vehicle-pedestrian
($20,500), motor vehicle-pedalcycle ($17,600),
and unintentional firearm ($17,400) cause the
next most costly injuries per victim. Although
high-cost injuries occur less frequently than
many unintentional injury causes among children and adolescents, the severity of the
injuries and the long-term disability and deaths
that often result make them extremely expensive when they do occur.
Finally, the importance of the five most
costly unintentional injury causes is fairly
consistent across the child age categories,
although their relative importance differs
(see Table 5). For example, through age 14,
falls are the most costly cause of unintentional injury. Among 15- to 19-year-olds, however, motor vehicle crashes displace falls as
the most costly cause of injury. Also, some
causes only show up as leading contributors
for one age group. For example, burns are
among the five leading causes of injury costs
only for infants and young children ages 0 to
4, while drowning or submersion makes the
list only for children ages 10 to 14 (where it
edges out cutting and piercing injuries,
which are the fifth leading contributors for
other age groups).
Quality-of-Life Losses
Unintentional injuries among children
impose more than monetary costs on society.
Such injuries also reduce the quality of life for
injured children and their families. Children
injured in 1996 lost the equivalent of 2.7 million years of life, a loss comparable to 92,400
child deaths.6 Nearly half of QALYs lost were
associated with nonfatal injuries that did not
require hospitalization (see Table 3). The
losses for these injuries result from short-term
and long-term disabilities that arise when
complications develop or a nonfatal injury
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
145
Table 2
Number of Unintentional Injury Victims Ages 0 to 19 by the Severity of
Their Injury, United States, 1996
Age in Years
Severity
0 to 4
Fatality
5 to 9
10 to 14
15 to 19
Total
(0 to 19)
2,990
1,584
1,845
6,894
13,313
73,000
59,000
57,000
103,000
292,000
Nonhospitalized survivors
5,420,000
5,050,000
5,700,000
5,720,000
21,890,000
Total
5,500,000
5,110,000
5,760,000
5,830,000
22,195,000
Hospitalized survivors
Note: Includes 219 deaths later in childhood due to injuries in 1996. The article by Grossman in this journal issue excludes these
deaths.
Sources: 1996 U.S. Vital Statistics, 1996 National Hospital Discharge Survey, 1987–1996 National Health Interview Surveys, with intent modeled in data sets
where that information was missing.
like a facial laceration or arm fracture scars a
child or permanently restricts range of
motion. Injury fatalities, however, contributed
disproportionately to quality-of-life losses—
nearly 16% of QALYs lost resulted from
injury deaths, but only 1% of all childhood
injuries in 1996 resulted in death.
Similar to the patterns observed for injury
frequency and costs across age groups, total
estimated QALY losses were highest among
adolescents ages 15 to 19 (978,000 QALYs, a
loss comparable to 34,800 child deaths) and
lowest among children ages 10 to 14 (463,000
QALYs, a loss comparable to 16,500 child
deaths). The number of children in these age
groups is similar. The differences in QALY
losses result from the same injury frequency
and severity differences that cause higher
resource and productivity loss costs among
teenagers.
Five primary injury causes account for
81% of the QALY losses due to unintentional
injury among children ages 0 to 19. Four of
the five leading causes contributing to
resource and productivity costs and QALY
losses are identical (see Table 6). These
include falls, motor vehicle crashes on public
roads (includes occupant, pedestrian, and
bicycle injuries), being struck by or against
an object or person, and vehicle crashes not
on public roads. Some differences in the
leading causes of costs versus QALY losses
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also emerge within specific age groups. For
example, among five- to nine-year-olds,
injuries caused by being caught in or
between something—such as fingers caught
in doors—are among the top contributors
to QALY losses. Such injuries often result in
fingertip amputations, which can be disabling. They reduce quality of life but they
are not expensive to treat. Children who
suffer these injuries typically are not even
hospitalized.
Summary of Cost
and Quality-of-Life Losses
Unintentional injuries to U.S. children ages
0 to 19 that occurred in 1996 imposed $81
billion in lifetime resource and productivity
costs and swept away 2.6 million qualityadjusted years of life. The losses per child
averaged $1,060 and were highest among
adolescents. Five injury causes accounted for
nearly 80% of lifetime resource and productivity costs. These were falls, motor vehicle
crashes on public roads, other motor vehicle
or pedalcycle crashes, victims struck by or
against something, and cutting or piercing.
The first four of these causes, along with poisonings, also accounted for more than 80%
of QALYs lost to injury. When the total injury
costs for all children were compared with the
average cost per injury victim, however, a different pattern emerged. Some causes that
often lead to lethal or serious injury—such
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
Table 3
Estimated Lifetime Resource and Productivity Costs and QALY Losses Due to
Unintentional Injuries to Children Ages 0 to 19 in the United States, 1996
(Costs are in Millions of 1996 Dollars)
Other
Resource
Costs
Productivity
Costs
Total
Costs
Percentage
of Total
$110
$382
$13,400
$13,900
17.1%
412,000
15.5%
HospitalAdmitted
Injuries
$4,000
$10
$16,100
$20,100
24.7%
957,000
36.0%
Other Injuries
$9,700
$660
$37,000
$47,400
58.2%
1,287,000
48.5%
$13,800
$1,100
$66,500
$81,400
100.0%
2,656,000
100.0%
17.0%
1.4%
82.1%
100.0%
—
—
—
Medical
Costs
Fatal Injuries
Total
Percentage
of Total
QALYs
Lost
Percentage
of QALYs
Lost
Note: Computed at a 3% discount rate. Row and column totals differ due to rounding.
Source: Calculations by authors from data and methods presented in this article.
as unintentional firearm injury and drowning or submersion—had the highest costs
per victim. Because these causes are relatively infrequent, however, they did not contribute substantially to total injury costs.
The Implications of Injury
Costs for Investing in Safety
Behaviors and Practices
The first part of this article examined the
lifetime costs and quality-of-life losses associated with childhood unintentional injuries
that occurred during 1996. The following
sections explore the implications of these
costs for decisions about policy investments
in safety behaviors and practices. Specifically,
the sections examine how the medical costs
and lost productivity of childhood unintentional injuries compare with the costs of
other child health problems, with emphasis
on a payer’s perspective. This analysis points
to the government as a major player in childhood injury prevention and control. It also
raises the question of whether the level of
government funding for injury prevention
research makes sense relative to the overall
size of the problem and the costs incurred.
In part, funding priorities depend on
whether strategies for preventing childhood
injuries are cost effective relative to strategies
aimed at preventing other major child
health problems.
Comparing Costs and Sources
of Payment for Childhood Injury
and Illness
The estimated medical costs of childhood
injuries are comparable to the costs associated with low birth weight, an important
health problem afflicting children in the
United States. On a prevalence basis (as
defined in Box 1), roughly 13% of all medical spending on children ages 1 to 19
during 1996 was used to treat unintentional
injuries; these injuries accounted for 11%
of hospital admissions, 39% of nonadmitted emergency department visits, and 9%
of physician office visits for this age group.7
Analyses performed for this article suggest
that prevalence-based medical spending on
unintentional injury during 1996 totaled
$13 billion for children ages 0 to 19. By
comparison, the estimated prevalencebased medical spending on low birth
weight during 1996 was $9 billion to $10 billion for children from birth through age
14.8 Thus, unintentional injuries to children impose a health care burden relatively
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
147
Figure 1
Lifetime Costs per Child Resulting from Unintentional Injuries
in 1996 by Age Group
$1,400
Lifetime Costs (per Child)
$1,200
$1,000
$800
$600
$400
$200
$0
0 to 4
5 to 9
10 to 14
15 to 19
Average
0 to 19
Age Group
Source: Calculations by authors from data and methods presented in this article.
similar in magnitude to another major
child health problem—low birth weight.
In terms of lost productivity, unintentional
injuries are more costly than child illnesses. In
1996, 43% of all deaths and related future
work-loss costs among children and adolescents ages 1 to 19 were the result of unintentional injury, while only 35% resulted from
illness (with the remaining 22% resulting
from intentional injury). Thus, fatal unintentional injuries caused greater work-related
productivity losses than all fatal childhood illnesses combined.
Given the tremendous financial burden
of childhood injuries, in terms of both medical and future productivity costs, investing
in effective injury prevention makes sense.
Who should invest in prevention, however,
largely depends on who pays the costs associated with childhood injuries. The remainder of this section examines separately the
payment sources for injury-related medical
costs versus lost productivity costs.
http://www.futureofchildren.org
Payment Sources for Medical Costs
The largest share of the medical costs of
injuries are paid by private insurers and
Medicaid (the government program for lowincome children and families). Private insurers paid for 43% of the days children spent in
hospitals due to unintentional injury, while
government sources, primarily Medicaid,
paid for another 39%, according to the
1996 National Hospital Discharge Survey
(NHDS).9 For other childhood illnesses, government sources paid for nearly half (49%)
of hospital days, while private insurers paid
for 40%. One reason for the lesser reliance
on government funding for injury hospitalizations is the presence of property-casualty
insurance (auto, home, and workers’ compensation), which NHDS states is the payer
for at least 5% of the injury costs but none of
the illness costs. Also, costly low birth weight
and related perinatal problems are concentrated in the Medicaid population,10 and
health care responsibility for children with
permanently disabling and costly chronic illnesses gravitates toward government.
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
Table 4
Burden of Childhood Unintentional Injury by Cause, per Victim, and
as a Percentage of Total
Per Victim
Cause
Percentage of Total
Resource
and
Productivity
Cost
QALY
Loss
Bites and Stings
$2,300
0.016
3%
1%
Burn/Anoxia
$4,500
0.112
3%
2%
Caught In/Between Objects
$1,900
0.105
1%
2%
Cut/Pierce
$2,200
0.039
5%
3%
$21,000
0.374
3%
2%
$4,200
0.130
27%
25%
$17,400
1.055
1%
2%
Motor Vehicle Traffic Occupant
$9,300
0.314
18%
19%
Motor Vehicle Traffic Pedalcycle
$17,600
0.626
1%
1%
Motor Vehicle Traffic Pedestrian
$20,500
0.721
3%
3%
Natural Environment
$3,000
0.226
1%
1%
Other Pedalcycle
$4,900
0.142
5%
4%
Other Pedestrian-Vehicle
$2,300
0.124
1%
1%
Other Vehicle
$12,800
0.511
3%
3%
Overexertion
$1,600
0.044
1%
1%
$300
0.046
1%
4%
$3,400
0.082
13%
9%
$11,000
0.412
1%
1%
Other Known Cause
$3,700
0.137
1%
1%
Unknown
$1,900
0.104
10%
16%
$3,600
0.119
100%
100%
Drowning/Submersion
Fall
Firearm
Poisoning
Struck By/Against
Suffocation and Choking
Total
Resource
and
Productivity
Cost
QALY
Loss
Note: Percentages may not total 100% due to rounding.
Source: Calculations by authors from data and methods presented in this article.
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
149
Table 5
Five Leading Causes of the Annual Resource and Productivity Costs
of Unintentional Injuries to Children in the United States, 1996
(Costs in Millions of 1996 Dollars)
Ages in Years
Priority
Ranking
Total
(0 to 19)
0 to 4
5 to 9
10 to 14
15 to 19
1
Fall
$7,230
Fall
$6,010
Fall
$3,930
Motor Vehicle
Traffica
$11,200
Fall
$20,620
2
Struck By/
Against
$2,580
Other Vehicleb
$2,550
Motor Vehicle
Traffica
$2,390
Fall
$3,450
Motor Vehicle
Traffica
$17,560
3
Motor Vehicle
Traffica
$1,450
Motor Vehicle
Traffica
$2,520
Struck By/
Against
$1,990
Struck By/
Against
$3,130
Struck By/
Against
$10,170
4
Burn/Anoxia
$1,120
Struck By/
Against
$2,470
Other Vehicleb
$1,600
Other Vehicleb
$1,200
Other Vehicleb
$6,130
5
Cut/Pierce
$770
Cut/Pierce
$1,990
Drowning/
submersion
$550
Cut/Pierce
$830
Cut/Pierce
$4,120
Percentagec
79%
81%
85%
84%
79%
a Motor vehicle traffic includes child occupant, pedestrian, and bicyclist injuries in crashes on public roads.
b Other vehicle includes motorized vehicle crashes not on public roadways (for example, in driveways, train-pedestrian
incidents) and pedalcycle crashes.
c Among injuries with known causes, the percentage of total costs that result from the five leading causes of injury.
Source: Calculations by authors from data and methods presented in this article.
Payment Sources for Lost Productivity
Work-loss costs fall heavily on victims and
their families, with modest contributions
from property-casualty insurance and
public welfare programs, including Supplemental Security Income (SSI) and food
stamps. Presumably, property-casualty
insurance (workers’ compensation or auto
insurance) partially covers work-loss costs
for the 5% of child injury victims whose
medical costs it pays. Almost all other workloss costs associated with child injury
deaths and disabilities are borne by children and their families. The financial
burden of short-term work losses by parents of injured children falls on parents
and their employers. The work-loss costs
for permanently and totally disabling
http://www.futureofchildren.org
childhood injuries (an estimated 12,000
victims per year) are split in unknown proportions between victims, insurers, and
public welfare programs.11
Low-income families may not be able to
afford safety measures (for example, child
safety seats, bicycle helmets, etc.) that protect
their children against injuries and related
financial and functional losses. Therefore,
without government and charitable intervention, children from low-income families may
be at greater risk for injuries because they
cannot afford safety measures.12 Safety funding decisions for this population, thus, need
to consider not just who bears the injury costs,
but also government’s role in providing lowincome children a fair start on life.
THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
150
Table 6
Five Leading Causes of the Annual QALY Losses from Unintentional
Injuries to Children in the United States, 1996
Ages in Years
Priority
Ranking
Total
(0 to 19)
0 to 4
5 to 9
10 to 14
15 to 19
1
Fall
216,800
Fall
216,800
Fall
109,200
Motor Vehicle
Traffica
364,600
Fall
648,000
2
Motor Vehicle
Traffica
52,800
Motor Vehicle
Traffica
89,700
Motor Vehicle
Traffica
89,200
Fall
105,200
Motor Vehicle
Traffica
596,300
3
Struck By/
Against
44,400
Struck By/
Against
53,600
Other Vehicleb
77,700
Struck By/
Against
97,800
Struck By/
Against
248,000
4
Burn/Anoxia
31,700
Other Vehicleb
53,100
Struck By/
Against
52,200
Other Vehicleb
56,900
Other Vehicleb
212,900
5
Other Vehicleb
25,200
Caught In/
Between
19,700
Poisoning
16,000
Poisoning
53,400
Poisoning
92,600
Percentagec
73%
90%
85%
83%
81%
a
Motor vehicle traffic includes child occupant, pedestrian, and pedalcyclist injuries in crashes on public roads.
b
Other vehicle includes motorized vehicle crashes not on public roadways (for example, in driveways, train-pedestrian
incidents) and pedalcycle crashes.
c
Among injuries with known causes, the percentage of total costs that result from the five leading causes of injury.
Source: Calculations by authors from data and methods presented in this article.
Are Current Federal Funding
Patterns for Health Care
Research Sensible?
As with illness, government plays a major role
in funding childhood injury prevention and
control efforts. Evidence reported in other
articles in this journal issue indicate that
effective prevention strategies exist for many
causes of childhood injury, including motor
vehicle crashes, bicycle injuries, and residential fires (see the articles by DiGuiseppi and
Roberts, by Klassen and colleagues, by
Schieber, Gilchrist, and Sleet, and by Mallonee in this journal issue). Furthermore, as
discussed in the next section of this article,
cost-effectiveness estimates indicate that
injury prevention strategies of proven effectiveness often are a good investment worthy
of wider implementation. Taken together,
these findings—that effective and cost-effective
injury prevention strategies exist—suggest
that government funding priorities should
be commensurate with the prevalence and
cost of childhood unintentional injuries relative to other child health problems.
To gain insight into the federal government’s allocation of resources for injury prevention versus prevention of major illnesses,
recent estimates of total federal civilian
injury prevention and treatment research
spending levels (fiscal year 1995–96) were
compared with National Institutes of Health
(NIH) research budgets for two other leading health problems—vascular disease
(heart attack and stroke) and cancer.13
Prevalence-based estimates of medical
spending for all ages in 1996 and published
estimates of years of potential life lost also
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
Figure 2
Years of Potential Life Lost, Medical Spending, and Research
Budgets for Injury, Vascular Disease (Heart Disease and Stroke),
and Cancer
30
25
Percentage
20
15
10
5
0
Injuries
Vascular Disease
Cancer
Medical Spending
Years of Potential Life Lost
Research Spending
Sources: Computations by authors from data in National Center for Injury Prevention and Control. Inventory of federally funded
research in injury prevention and control, 1995. Database. Atlanta, GA: Centers for Disease Control, 1997; National Institutes of
Health Web site; Bureau of the Census. Statistical Abstract of the United States 1997. Washington, DC: U.S. Government Printing
Office, 1997, Tables 144 and 153; and National health care data sets.
were compared for these three health problems.14 Unfortunately, research spending on
children could not be separated from government estimates, so estimates for all ages
combined are reported here. Prevention
versus treatment research spending also
could not be separated in this analysis.
Federal spending for research on injuries,
vascular disease, and cancer contrasted
sharply with the relative burdens of these
health problems, measured by medical
spending and years of potential life lost. As
shown in Figure 2, although injury, vascular
disease, and cancer accounted for similar proportions of medical spending (12%, 14%,
http://www.futureofchildren.org
and 9% respectively), research funding in
these areas varied substantially (2.4%, 5.9%,
and 10.5% respectively). Estimated research
spending on vascular disease ($900 million)
was approximately 2.4 times higher than estimated research spending on injuries ($370
million), and spending on cancer research
($1.6 billion) was more than four times
higher than injury research spending. Thus,
relative to problem size, research spending
on injuries is much lower than research
spending on vascular disease or cancer.
The estimated injury research spending
data used in this analysis was compiled by a
federal agency,13 but it should be interpreted
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
152
cautiously since injury research funding is
diffused across many federal agencies,
which makes it difficult to identify. Yet,
although it is difficult to assess current funding levels for injury prevention, increased
funding is warranted. Unfortunately, the
trend is not in this direction. Alarmingly,
based on the fiscal year 2000 federal budget,
it is likely that the Preventive Health Services Block Grant—which has supported
many state injury prevention programs as
well as chronic disease prevention—will be
reduced in future years.15 Moreover, some
policymakers are arguing that the remaining funds should be targeted for chronic
The study estimated that, based on actual
use, child safety seats were 54% effective
against child occupant fatalities and 52%
effective against nonfatal injuries.
disease only. The return on investment for
injury prevention strategies shown in the
cost-effectiveness analyses reported in this
article should be carefully weighed by these
decision makers.
How Cost Effective Are
Childhood Injury Prevention
Strategies?
Estimating the cost effectiveness of injury
prevention strategies relative to the cost
effectiveness of efforts aimed at mitigating
other child health problems is useful to
inform decisions about the allocation of
scarce resources. For example, the costs and
outcomes of one intervention (such as child
safety seat use) can be compared with the
costs and outcomes of another intervention
(such as immunizations) when the outcomes measured are the same. In healthrelated studies, the outcome considered
most frequently is good health measured in
QALYs. With cost-effectiveness estimates,
decision makers may decide to invest, for
example, only in interventions that save a
specified number of QALYs for a given cost.
Alternatively, they may decide to invest in
one intervention over another because it has
a more favorable cost-effectiveness ratio
(that is, cost per QALY is lower).
This section summarizes the cost effectiveness of seven childhood injury prevention
measures that published studies have
demonstrated to be effective (see Table 7).16
These seven measures were selected because
they primarily focus on unintentional childhood injuries, cover a range of risks and
approaches, have reasonably strong evidence
for effectiveness, and were analyzed using
uniform methods for estimating injury costs
and cost effectiveness. The cost effectiveness
of these injury prevention strategies is compared with published cost-effectiveness estimates for measures that have been widely
used to prevent other important neonatal
and childhood problems, including neonatal
intensive care, phenylketonuria screening,
and measles/mumps/rubella immunization.
The data presented here suggest that many
childhood injury prevention strategies have
similar cost-effectiveness ratios compared
with other well-accepted strategies to prevent
childhood illnesses. Yet, implementation of
childhood injury prevention strategies is
not widespread.
The Cost Effectiveness of Selected
Child Safety Measures
Table 7 lists the seven child safety measures
examined and the cost per QALY saved
from society’s perspective.17–22 Each safety
measure, the evidence for its effectiveness,
and cost-effectiveness estimates based on
previous analyses are summarized below.23
■ Child Safety Seats. A national study of outcomes in crashes where two infants or toddlers were restrained differently24 provided
effectiveness estimates for analyzing the cost
effectiveness of child safety seats.17 The
study estimated that, based on actual use,
child safety seats were 54% effective against
child occupant fatalities and 52% effective
against nonfatal injuries. These data were
combined with retail purchase price data
for a no-frills convertible seat that can be
used for infants and toddlers, with a 20%
allowance added to cover parent education
about need and installation. Applying these
estimates, child safety seats yielded net cost
savings.17 This finding holds even if one
adds the cost of passing child seat laws and
the time spent by parents buying and learning to use a seat. These estimates ignore
child discomfort costs and offsetting benefits from reduced driver distraction when a
toddler is not free to roam in the vehicle.
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
153
Table 7
Costs per QALY for Selected Injury Prevention Measures
(in 1997 Dollars)
Injury Prevention Measure*
Child Safety Seat17
<$0 **
Zero Tolerance of Alcohol, Drivers under Age 2119
<$0
Provisional Licensing, Midnight Curfew19
<$0
Bicycle Helmet, Ages 5 to 1518
<$0 **
Smoke Detector20
<$0
Childproof Cigarette Lighter21
$4,000
Poison Control Center22
a
Cost per QALYa
<$0
All estimates were computed at a 3% discount rate and are compared with the absence of the intervention. The cost per QALY saved was computed by dividing the QALYs saved per unit by the net cost of
the unit (which equals the unit cost minus the reduced medical care, property damage, insurance claims
administration, and other direct costs). When these direct cost savings exceeded the cost of the safety
measure, the cost per QALY saved is <$0.
* See related endnotes at the end of this article.
** Ignores discomfort and inconvenience costs.
Zero Alcohol Tolerance Laws. Every state has
passed zero alcohol tolerance laws making it
illegal for adolescents under age 21 to drive
with a blood alcohol level of 0.02% or
greater.25 Two multistate studies estimated that
these laws reduced alcohol-related crashes
among young drivers by 20%.25,26 The primary
cost of these laws is the freedom that youths
lose to drink illegally and then drive; police
enforcement and sanctioning impose much
smaller costs. Accounting for these costs, zero
tolerance laws yielded net cost savings.19
■
Graduated Licensing with Midnight Driving
Curfews. A broader approach to reducing the
costs of automobile crashes by young drivers
is graduated licensing, discussed by Schieber,
Gilchrist, and Sleet in this journal issue. The
cost effectiveness of graduated licensing programs that impose a midnight driving curfew
until the driver turns 19 years of age or drives
for at least six consecutive months without a
crash or moving violation has been estimated.19 Drawing on evidence from three
programs, researchers estimated that crashes
involving novice drivers decline by 5% with
these programs in place.27–29 The largest cost
of this intervention is lost mobility for young
http://www.futureofchildren.org
■
drivers (loss of the ability to legally drive independently between midnight and 5:00 A.M.,
plus loss of the ability to drive legally when a
license is revoked or suspended for curfew
violation). Enforcement and sanctioning
impose further costs. Nonetheless, taking
these costs into account, the graduated
licensing model yielded net cost savings.
Bicycle Helmet Use. The cost effectiveness of
a bicycle safety helmet purchased at a retail
cost of $25, as well as the cost effectiveness of
a bulk distribution program that delivered
helmets at half this price, have been analyzed.18 The estimated effectiveness of bicycle
helmets taken from case-control studies
showed that, even when misuse was considered, helmets prevented 68% to 85% of nonfatal head and scalp injuries and 65% of
upper and middle face injuries.30–32 Ignoring
children’s discomfort and inconvenience
costs and the time spent shopping for a
helmet, the study estimated that bicycle helmets offered net cost savings if at least half of
children with helmets wore them. Additional
analyses conducted for this article estimated
that if 85% of children who ride a bicycle
wear a helmet, helmet use offers a net cost
■
THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
154
PHOTO OMITTED
savings, even accounting for time spent shopping. This may be a realistic usage goal,
based on helmet use estimates following the
enactment of legislation in Georgia, where
90% of parents reported that their children
who owned a helmet wore it on their most
recent ride, with reported helmet use stable
across family income levels.33
Smoke Detectors. The cost effectiveness of
battery-operated smoke detectors has been
analyzed20 using National Bureau of Standards engineering estimates that smoke
detectors are 45% effective against deaths
and 30% effective against nonfatal injuries.34
The cost-effectiveness estimates reported
here further assume that smoke detectors
are 10% effective against property damage.
Smoke detectors are not strictly child safety
devices; they also benefit children by saving
their parents and grandparents. The costeffectiveness analysis accounted for time and
money spent buying, installing, and maintaining an average of 1.6 smoke detectors
per home. Using these estimates, smoke
detectors offer net cost savings.20
■
Child-Safe Cigarette Lighters. In 1993, the
U.S. Consumer Product Safety Commission
(CPSC) required that all cigarette lighters
have a dual-action catch that children ages
zero to five cannot readily operate.21 The
CPSC used engineering and experimental
research to estimate the effectiveness as
■
approximately a 70% reduction in fires
started by children ages zero to five playing
with lighters. This change in product design
cost $.15 per cigarette lighter. The regulation
costs $3,000 to $4,000 per QALY saved.21
Poison Control Centers. Poison control centers, professionally staffed sources of free
telephone advice about how to respond to
and prevent potentially toxic exposures,
have been shown to reduce the unnecessary
use of health care services.22 Studies from
two jurisdictions where services became
unavailable estimated that the centers
appropriately reduced medical visits for poisoning by more than 37%.35,36 The cost per
poison control center telephone call came
from a national summary of center financial
reports.37 Using these estimates, poison control center calls yield net cost savings.22 An
analysis of the robustness of this finding in
regards to changes in the estimated effectiveness found that poison control centers
offer net cost savings as long as the estimated
reduction in medical visits is at least 7%.22
■
Comparison with the Cost Effectiveness
of Other Child Health Risks
To further interpret the cost-effectiveness
analyses of childhood injury prevention
efforts, similar estimates of cost per QALY
saved for seven other neonatal and child
health risks were examined (see Table 8).
These examples were selected because the
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
155
Table 8
Costs per QALY for Selected Other Child Health Measures
(in 1997 Dollars)
Cost per QALYa
Child Health Measure*
Hepatitis B Vaccination of Newborns38
$26,000–$55,000
Restriction of Cigarette Sales to Minors38
$1,000
Cereal Fortification with Folic Acid to Improve
Pregnancy Outcomes39
a
<$0
Neonatal Intensive Care, Weight 500 to 999 Grams40
$23,000
Neonatal Intensive Care, Weight 1,000 to 1,499 Grams40
$13,000
Phenylketonuria Screening of Newborns41
<$0
Measles/Mumps/Rubella Immunization41
<$0
All estimates were computed at a 3% discount rate and are compared to the absence of the intervention.
* See related endnotes at the end of this article.
cost-effectiveness studies were of good quality, used or could be converted to a 3% discount rate, and represented diverse
approaches to child risk reduction.38–41
Many of these estimates—including cereal
fortification with folic acid, selected newborn vaccinations, and newborn screening
for phenylketonuria—offered net cost savings. Efforts to reduce cigarette sales to
minors cost $1,000 per QALY saved. Hepatitis B vaccination of newborns and neonatal
intensive care were less cost effective. The
cost estimates in these studies all focused on
the costs of delivering health care, food supplements, or health education. They
ignored time spent by parents and child discomfort and inconvenience. Thus, the costs
are accounted for less completely than in
many of the safety studies, so comparisons of
cost-effectiveness estimates should be made
with caution.
Summary of Cost-Effectiveness
Estimates
This section summarized the cost effectiveness of seven childhood unintentional injury
prevention interventions, and it compared
these estimates with the cost effectiveness of
other widely accepted interventions aimed at
improving the health of infants and children.
Six of the injury prevention interventions
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offered net cost savings; one measure cost
$4,000 per QALY saved. Two recent reviews
of cost-effectiveness analyses in health and
safety conclude that net cost savings are
“fairly rare,” so childhood injury prevention
efforts score well.38,41
The cost effectiveness of childhood
unintentional injury prevention strategies
reviewed here also compares favorably with
the cost effectiveness of several widely
implemented childhood illness prevention
measures. These findings should be interpreted cautiously, however, since the studies
are not completely comparable, especially
in their methods for estimating QALY
savings. They should, however, be reasonably robust since the injury studies generally
account for costs more comprehensively
than do the illness studies.
Despite some uncertainty about the costeffectiveness estimates reported here, these
findings suggest that society may profit from
implementing many child safety measures,
and more widespread use of them may be
warranted. Third-party payers—such as
managed care organizations, other health
insurers, and auto insurers—may save
money by advocating for, subsidizing, or
paying to promote routine use of some
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THE FUTURE OF CHILDREN – SPRING/SUMMER 2000
PHOTO OMITTED
safety measures, such as child safety seats
and smoke detectors. The potential cost
savings may be particularly great for lowincome families on Medicaid, since these
parents often cannot afford the safety
devices purchased by wealthier parents.
Finally, many other injury prevention
measures merit careful evaluation and, if
effective, cost-effectiveness analyses.
These include readily grasped, smalldiameter handrails without sharp edges;
window guards; pool fencing ordinances;
learn-to-swim programs (which potentially could increase risk); restrictions on
child gun access; childproof cabinet
latches; plastic plug covers for electric outlets; rounded corners on furniture; and
home safety inspections. Particularly for
safety measures that are expensive, widespread adoption should await these costeffectiveness analyses.
Conclusions
In 1996, unintentional injuries were the most
prevalent and expensive health risk faced by
children and adolescents ages 1 to 19. Childhood unintentional injuries that occurred in
1996 resulted in $14 billion in lifetime medical spending, $1 billion in other resource
costs, and $66 billion in present and future
work losses. These injuries imposed quality-oflife losses equivalent to 92,400 child deaths.
The most costly risks were falls, motor vehicle
crashes, and incidents in which children were
unintentionally struck by or against an object.
Despite their relatively small numbers, deaths
and hospitalized injuries accounted for half
of the injury costs.
Most unintentional injuries are, in theory,
preventable, and proven strategies exist to
reduce the injury toll. Moreover, the costs of
preventing injuries are often less than the
costs of treatment. This suggests that managed
care companies, state Medicaid agencies, and
other third-party payers could save money by
subsidizing or promoting routine use of
selected child safety measures such as child
safety seats. Tax dollars could be saved by providing child safety seats and bicycle helmets to
infants and children enrolled in Medicaid.
Insurance bills could be reduced by equipping homes with working smoke detectors.
Yet, these and other proven injury prevention
interventions often are not widely implemented. When personal freedom clashes with
child safety, Americans strongly value their
freedom. Furthermore, unintentional injury
is under-appreciated as a major child health
problem. Federal agencies fund disproportionately little research on injury prevention
measures and devote relatively few public dollars to injury prevention programming.
Children pay the price for the nation’s
underinvestment in injury prevention; many
die unnecessarily, and others suffer from
long-term disabilities. This article suggests
that, with funding and will, the nation can
prevent these devastating injuries. Until this
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
happens, unintentional childhood injuries
will remain a costly national tragedy.
The research reported in this article was supported by a grant from the National Highway Traffic Safety Administration (grant number
DTHN22-97-8-55072); a Children’s Safety Network contract from the Health Resources and Services Administration, U.S. Department of Health
and Human Services (contract number MCJ-24098-0006); and a grant from The David and
Lucile Packard Foundation. Participating in the
International Collaborative Effort on Injury Statistics—sponsored by the National Center for
Health Statistics with funding from the National
Institute of Child Health and Human Development, National Institutes of Health—also contributed critically to this research.
Appendix
Methods of Estimating Childhood Unintentional Injury
Costs and Quality-of-Life Losses
Throughout most of this article, cost estimates refer to incidence-based costs—the lifetime costs associated with childhood unintentional injuries that occurred during
1996 (see Box 1). Prevalence-based costs—the costs associated with childhood unintentional injuries accrued in 1996, regardless of when the injury occurred—are discussed only in reference to spending on injury versus illness. This appendix focuses
on the estimation of incidence-based costs.
The Theory behind Estimating Future Costs
The incidence-based costs reported estimate the present value of all expected costs
over the child’s expected life span. For costs that will occur in future years, the “present value” is estimated, defined as the amount one would have to invest today in
order to pay these costs when they come due. The present value of future costs
depends on how many years in the future the costs are borne and on the “discount
rate.” The discount rate applied to future costs to estimate their present value is
independent of inflation. This article uses the 3% discount rate recommended by
the Panel on Cost-Effectiveness in Health and Medicine.1
Methods for Estimating Injury Occurrence, Costs, and Quality-of-Life Losses
Estimating the costs and quality-of-life losses associated with childhood unintentional injuries required separately estimating the frequency of injuries (stratified by
severity, diagnosis, cause, and age), the present and future costs (resource and productivity) of the injuries, and the quality-adjusted life years (QALYs) lost due to
injury. Table 2 presents the injury frequency data used in this analysis.
The subsections below summarize the data sources and limitations of the methods used to estimate each component of injury frequency, cost, and quality-of-life
losses in this analysis. Detailed technical notes on the methods and results tables by
cause and age group are available from the authors.
Estimating Injury Occurrence
Injury Frequency, Severity, and Diagnoses
The frequency, severity, and diagnoses for childhood injury were estimated primarily from three federal sources: the 1996 U.S. Vital Statistics census for injury deaths;
the 1996 National Hospital Discharge Survey (NHDS) for hospitalized injury survivors; and 1987–1996 National Health Interview Surveys (NHIS) for other
injury survivors. Poisonings handled over the telephone by poison control centers
were estimated from Toxic Exposure Surveillance System data collected in 1992.2
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Appendix (continued)
These data sets provide nationally representative estimates, but they have
methodological limitations that may lead to undercounting or overcounting
injuries. For example, the NHDS does not clearly distinguish initial hospitalizations
from transfers and follow-up hospitalizations, so some injuries may have been
counted more than once, even though an attempt was made to remove transfers
and follow-ups from the analyses. Because of small survey responses, many years of
NHIS data were pooled to obtain the distribution of diagnoses for nonhospitalized
survivors by age group, and this distribution was assumed to be stable over time. This
assumption may not be accurate, however, because managed care probably has
reduced the likelihood of hospital admission differentially across diagnoses. The
NHIS survey also is limited because it relies on victim rather than medical descriptions of injury, and it does not include homeless or institutionalized populations.
Injury Intent and Causes
The unintentional injury cause distributions used in this analysis are nationally
representative, classified by external cause of injury codes, and cover all medically treated injuries (see Table 2). Intent and cause were modeled with
intent/cause-coded data from 1996 U.S. Vital Statistics, 1996 NHDS, pooled
1992–1996 National Hospital Ambulatory Medical Care Surveys (NHAMCS),
pooled 1995–1996 National Ambulatory Medical Care Surveys (NAMCS), and
pooled hospital discharge data from six states. For injuries with differing severity
or place of treatment, these data sets either provided national intent/cause distributions or enabled those distributions to be estimated from national data sets
describing injury incidence by age group and diagnosis. The vital statistics mortality census included external cause of injury codes, as did 63% of 1996 NHDS
injury cases. The causes for NHDS cases without external cause of injury codes
were inferred from external cause coded cases for the same diagnosis group and
age group, which introduces some unknown level of inaccuracy.
Similarly, for nonhospitalized injury survivors, available national data on the distribution of intent/cause by diagnosis and age group were applied to pooled,
nationally representative 1987–1996 NHIS data on nonhospitalized injury frequency to estimate intent and causes. The cause distributions by diagnosis group
and by age group, however, were taken from available external cause coded federal
provider surveys—the 1995–1996 NAMCS and the 1992–1996 NHAMCS. The
NAMCS and NHAMCS are limited in that they do not cover all ambulatory care;
they count visits rather than injury victims; they fail to distinguish some follow-up
visits from initial visits; and sample sizes are small. As a result, causes for 10.4% of
childhood injury cases, almost entirely cases treated only in physician offices, were
unable to be estimated.
Estimating Injury Costs
Injury costs were divided into resource costs (medical and other) and productivity costs
(costs of work losses).
Resource Costs
Medical costs were estimated using the methods employed in building the U.S. Consumer Product Safety Commission’s (CPSC) injury cost model, except the methods
were tailored to children. These methods have been documented elsewhere.3
Briefly, costs of initial treatment were extracted from nationally representative or
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
Appendix (continued)
statewide data sets. By diagnosis, medical follow-up, rehabilitation, and long-term
costs computed from national data on the percentage of medical costs associated
with initial treatment were added. Due to data unavailability, these percentages were
less current than the costs for initial treatment, although they were tailored to children. The primary data sources used to compute medical costs included: NHDS,
hospital discharge data from Maryland and New York, payment summaries from the
Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), longitudinal MEDSTAT health care claims data, and longitudinal Detailed Claims
Information data from the National Council on Compensation Insurance. Data for
other resource costs—including police, fire department, and travel delay costs—
were available from previous research.4,5 Conceptually, these costs should not vary
by victim age.
Productivity Costs
Productivity cost estimates also paralleled the CPSC injury cost model3 where those
estimates were tailored to children. For nonfatal injuries, the work loss cost is the
sum of the lifetime loss due to permanent disability (averaged across permanently
disabling and nondisabling cases), plus the loss due to temporary disability. For fatal
injuries, the work-loss cost is the present value of expected lifetime earnings, fringe
benefits, and household work. The primary data sets used to estimate the extent of
productivity losses included the 1987–1996 NHIS, the 1993 Survey of Occupational
Injury and Illness of the U.S. Bureau of Labor Statistics, and the Detailed Claims
Information database from the National Council on Compensation Insurance.
Data Limitations
While primarily large, nationally representative data sets were used to estimate
injury costs, data had limitations that may have biased the cost estimates. For example, although hospitalization cost estimates used in this analysis are age-specific,
other data are not. Specifically, the permanent disability cost estimates associated
with productivity losses account for the longer life span of children but are not childspecific in other respects. The work-loss cost estimates in this analysis have other
drawbacks as well. Because women and minorities are paid less than white males for
comparable work, productivity costs undervalues their lives.6 For example, using a
3% discount rate, at age seven the present value of lifetime wage and household
work loss resulting from the death of a girl is $788,000, compared with $1,003,000
for the death of a boy. Because children’s earnings are in the future, their present
value also is less than the present value of earnings losses of young adults, even
though more years of future work are lost.6 Some of the minor cost contributors in
this analysis, notably coroner costs, also have limitations, because data used to estimate them are 10 to 20 years old. Inflating these old estimates to current dollars may
introduce some inaccuracy, but they contribute too little to total costs to justify the
expense of collecting new estimates. Finally, the cause-estimating process for nonfatal injuries required several assumptions and failed to associate causes with almost
10% of the costs (virtually all for nonfatal injuries treated only in doctor offices).
Thus, many of the cost estimates presented in this analysis may be underestimates.
Estimating Lost Quality-of-Life
Quality-of-life losses were estimated as the sum of years of potential life lost to fatal
injury plus the QALY losses resulting from nonfatal injury. For each death or
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Appendix (continued)
paralyzing injury that shortens the life span, the years of life lost were estimated from
a life expectancy table.7,8 For QALY losses associated with temporary or permanent
disability, estimates by injury diagnosis and victim age were taken from a previous
study.9 These estimates combined physician ratings of the impact of injuries over time
on a person’s ability to think, see, walk, and so forth, and on pain,8,9 with diagnosisspecific National Council on Compensation Insurance data on the probability that
an injury would permanently reduce earning capacity or prevent the victim from
working and on the percentage earnings reduction.10 The rating scales used were not
tailored to children, although the physicians were asked to rate probable impairment
levels and durations separately for children. The estimated impairment impacts were
translated into QALY losses using survey data that weighed the relative importance
that respondents placed on different dimensions of impact.11–15 Most of these weights
were specific to a child and adolescent population.
1
Gold, M.R., Siegel, J.E., Russell, L.B., and Weinstein, M.C., eds. Cost-effectiveness in health and medicine. New York:
Oxford University Press, 1996.
2
Litovitz, T., Holm, K.C., Clancy, C., et al. 1992 annual report of the American Association of Poison Control Centers
Toxic Exposure Surveillance System. American Journal of Emergency Medicine (1993) 11:494–555.
3
Miller, T.R., Lawrence, B.A., Jensen, A.F., et al. Estimating the cost to society of consumer product injuries: The
revised injury cost model. Bethesda, MD: U.S. Consumer Product Safety Commission, 1998.
4
Miller, T.R., and Levy, D.T. Cost-outcome analysis in injury prevention and control: A primer on methods. Injury Prevention (1997) 3:288–93.
5
Miller, T.R. Costs and functional consequences of U.S. roadway crashes. Accident Analysis and Prevention (1993)
25:593–607.
6
Rice, D.P., and E.J. MacKenzie and Associates. Cost of injury in the United States: A report to Congress. San Francisco, CA: Institute for Health and Aging, University of California, and Injury Prevention Center, The Johns Hopkins University, 1989.
7
Bureau of the Census. Statistical abstract of the United States 1997. Washington, DC: U.S. Government Printing
Office, 1997, Table 217.
8
Hirsch, A., Eppinger, R., Shame, T., et al. Impairment scaling from the abbreviated injury scale. Washington, DC:
National Highway Traffic Safety Administration, 1983.
9
Miller, T.R., Pindus, N.M., Douglass, J.B., and Rossman, S.B. Nonfatal injury costs and consequences: A data book.
Washington, DC: The Urban Institute Press, 1995.
10
National Council on Compensation Insurance. Detailed claims information special tabulation. Boca Raton, FL:
NCCI, 1998.
11
Carsten, O. Relationship of accident type to occupant injuries. Report no. UMTR-86-15. Ann Arbor, MI: University of
Michigan Transportation Research Institute, 1986.
12
Green, C.H., and Brown, R. Life safety: What is it and how much is it worth? Garston, Watford, UK: Building Research
Establishment, Department of the Environment, 1978.
13
Kaplan, R.M. Human preference measurement for health decisions and the evaluation of long-term care. In Values
and long-term care. R.L. Kane and R.M. Kane, eds. Lexington, MA: Lexington Books, 1982, pp. 157–88.
14
Kind, P., Rachel, R., and Williams, A. Valuation of quality of life: Some psychometric evidence. In The value of life
and safety. M.W. Jones-Lee, ed. New York: North-Holland Publishing, 1982, pp. 159–70.
15
Torrance, G.W. Multiattribute utility theory as a method of measuring social preferences for health states in long-term
care. In Values and long-term care. R.L. Kane and R.M. Kane, eds. Lexington, MA: Lexington Books, 1982, pp. 127–56.
1. This estimate comes from the analyses reported in this article.
2. Bureau of the Census. Statistical abstract of the United States 1997. Washington, DC: U.S. Government Printing Office, 1997, table 217.
3. Rice, D.P., and E.J. MacKenzie and Associates. Cost of injury in the United States: A report to Congress. San Francisco, CA: Institute for Health & Aging, University of California, and Injury Prevention Center, The Johns Hopkins University, 1989.
4. Gold, M.R., Siegel, J.E., Russell, L.B., and Weinstein, M.C., eds. Cost-effectiveness in health and
medicine. New York: Oxford University Press, 1996.
5. An estimated 10% of the lifetime costs were associated with nonhospitalized, nonfatal injuries
of unknown causes. The available data lacked sample cases that could provide insight into
intent and causes of these cases.
6. Discounted to present value at a 3% discount rate.
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The Cost of Childhood Unintentional Injuries and the Value of Prevention
7. Costs were estimated from National Health Interview Survey and National Hospital Discharge
Survey (NHDS) data, Maryland and New York hospital data on cost per day, and Civilian
Health and Medical Program of the Uniformed Services cost data. This prevalence-based estimate is consistent with the most current published estimate, which analyzed 1987 National
Medical Expenditure Survey data. See Miller, T.R., Lestina, D.C., and Galbraith, M.S. Patterns
of childhood medical spending. Archives of Pediatrics and Adolescent Medicine (1995) 149:
369–73. Visit counts are from the NHDS with intent modeled where missing, the National
Hospital Ambulatory Medical Care Survey, and the National Ambulatory Medical Care Survey.
8. Lewitt, E.M., Baker, L.S., Corman, H., and Shiono, P.H. The direct cost of low birth weight.
The Future of Children (Spring 1995) 5,1:35–56. Their estimate was inflated to 1996 dollars with
the same price adjuster used in the injury estimates.
9. National Center for Health Statistics. 1996 national hospital discharge survey. Public use data
tape. Hyattsville, MD: NCHS, 1998.
10. Hughes, D., and Simpson, L. The role of social change in preventing low birth weight. The
Future of Children (Spring 1995) 5:87–102.
11. See note no. 3, Rice and MacKenzie, chapter 3.
12. For example, low-income parents are less likely to own a child safety seat than other parents,
but those who do own child safety seats use them at the same rate as other parents. See Mayer,
M., and LeClere, F.B. Injury prevention measures in households with children in the United States,
1990. From Vital and Health Statistics of the Centers for Disease Control and Prevention/
National Center for Health Statistics. Advance data no. 250. Hyattsville, MD: NCHS, 1994.
13. The injury estimates are from a database maintained by the National Center for Injury Prevention and Control (Inventory of federally funded research in injury prevention and control, 1995. Atlanta, GA: Centers for Disease Control, 1997), which includes both intentional
and unintentional injuries. The estimates for other causes come from the National Institutes
of Health (NIH) budget and exclude spending by the Agency for Health Care Policy and
Research. Both estimates exclude spending by the Departments of Defense and Veterans
Affairs. These estimates may not have captured all research on occupational injuries, possibly
underestimating injury research funding. Activities comparable to some of the activities
included under NIH research spending on cancer would not have been labeled as research
in the injury estimate, possibly overstating cancer research funding.
14. See note no. 2, Bureau of the Census, table 144.
15. Institute of Medicine. Reducing the burden of injury. Washington, DC: National Academy Press,
1999.
16. Cost effectiveness is measured as the net cost per quality-adjusted life year (QALY) of good
health produced or saved. To compute cost effectiveness, the costs of implementing a prevention measure and the direct costs and QALYs it is expected to save are estimated. Subtracting
the direct cost savings from the costs of implementing the intervention yields the net cost. If the
net cost is less than zero, the measure produces “net cost savings.” If this is not the case, dividing
the net cost by the QALYs saved produces a cost per QALY saved. The cost-effectiveness analyses
provide results relative to the preintervention situation.
17. Miller, T.R., Demes, J.C., and Bovbjerg, R.R. Child seats: How large are the benefits and
who should pay? In Child occupant protection. SP-986. Warrendale, PA: Society for Automotive Engineers, 1993, pp. 81–90. This article, “The cost of childhood unintentional injuries
and the value of prevention,” reports an updated estimate that raised the cost per child
safety seat to $50.
18. Miller, T.R., and Levy, D.T. Reducing highway crash costs: The cost-outcome analyses. In
Transportation, traffic safety, and health. H. von Holst, A. Nygren, and A.E. Andersson, eds.
Stockholm, Sweden: Karolinska Institute, 1998, pp. 171–98.
19. Miller, T.R., Lestina, D.C., and Spicer, R.S. Highway crash costs in the United States by driver
age, blood alcohol level, victim age, and restraint use. Accident Analysis and Prevention (1998)
30:137–50.
20. Miller, T.R., and Levy, D.T. Cost-outcome analysis in injury prevention and control: A primer
on methods. Injury Prevention (1997) 3:288–93.
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21. U.S. Consumer Product Safety Commission (CPSC), Safety standard for cigarette lighters, 58
Fed. Reg. 131 (July 12, 1993) 16 C.F.R. pt. 1210. In this study, the burn injury costs were
replaced with more recent CPSC burn injury costs, which match the injury costs used in the
other six studies.
22. Miller, T.R., and Lestina, D.C. The costs of poisoning in the U.S. and the savings from poison
control centers: A benefit-cost analysis. Annals of Emergency Medicine (1997) 29:239–45.
23. Six of the seven estimates come from previously published benefit-cost analyses that used a
2.5% discount rate and similar injury costs to one another. The seventh is from a regulatory
analysis of dual-catch cigarette lighters. For this article, all seven estimates were recomputed
using a 3% discount rate. Supplementing the published information with unpublished
details, the cost per QALY saved for each study was computed.
24. Partyka, S. Lives saved by child safety seats from 1982 through 1987. Report no. 89-1A-O-002. 12th
International Technical Conference on “Experimental Safety Vehicles.” Gothenburg, Sweden,
May 29–June 1, 1989.
25. Hingson, R., Heeren, T., and Winter, M. Effects of lower legal blood alcohol limits for young
and adult drivers. Alcohol, Drugs, and Driving (1995) 10:243–52.
26. Hingson, R., Heeren, T., Howland, J., and Winter, M. Reduced BAC limits for young people:
Impact on night fatal crashes. Alcohol, Drugs, and Driving (1991) 7:117–27.
27. Hagge, R.A., and Marsh, W.C. An evaluation of the traffic safety impact of provisional licensing. Report no. CAL-DMV-RSS-88-116. Sacramento, CA: Department of Motor Vehicles, 1988.
28. McKnight, A.J., Tippetts, A.S., and Marques, P.R. Provisional driver license system for followup evaluation of Maryland youth license control demonstration project. Report no. DOT-HS807-669. Washington, DC: National Highway Traffic Safety Administration, 1990.
29. Langley, J.D., Wagenaar, A.C., and Begg, D.J. An evaluation of the New Zealand graduated
driver licensing system. Accident Analysis and Prevention (1996) 28:139–46.
30. Thompson, D.C., Nunn, M.E., Thompson, R.S., and Rivara, F.P. Effectiveness of bicycle safety
helmets in preventing serious facial injury. Journal of the American Medical Association (1996)
276:1974–75.
31. Thompson, D.C., Thompson, R.S., and Rivara, F.P. Effectiveness of bicycle safety helmets in
preventing head injuries. Journal of the American Medical Association (1996) 276:1968–73.
32. Thompson, R.S., Rivara, F.P., and Thompson, D.C. A case-control study of the effectiveness of
bicycle safety helmets. New England Journal of Medicine (1989) 320:1361–67.
33. Schieber, R.A., Kresnow, M.J., Sacks, J.J., et al. Effect of a state law on reported bicycle helmet
ownership and use. Archives of Pediatrics and Adolescent Medicine (1996) 150:707–12.
34. Dardis, R. The value of life: New evidence from the marketplace. American Economic Review
(1980) 70:1077–82.
35. Zech, C. Letter to J.R. Maurer and J.H. Trestrail from Blue Cross/Blue Shield of Michigan,
August 12, 1993. In Poison control centers: Is there an antidote for budget cuts? Hearing before
the Subcommittee on Human Resources and Intergovernmental Relations, Committee on
Government Operations, U.S. House of Representatives, 103rd Cong., 2nd Sess. (March 15,
1994). Washington, DC: U.S. Government Printing Office, 1994.
36. King, W.D., and Palmisano, P.A. Poison control centers: Can their value be measured? Southern Medical Journal (1991) 84:722–26.
37. Litovitz, T., Kearney, T.E., Holm, K., et al. Poison control centers: Is there an antidote for
budget cuts? American Journal of Emergency Medicine (1994) 12:585–99.
38. Graham, J.D., Corso, P.S., Morris, J.M., et al. Evaluating the cost-effectiveness of clinical and
public health measures. Annual Review of Public Health (1998) 19:125–52. Used estimates for
hepatitis vaccination and cigarette sales to minors from comparably computed costs per
QALY saved at a 3% discount rate.
39. Kelly, A.E., Haddix, A.C., Scanlon, K.S., et al. Appendix B: Cost-effectiveness of strategies to
prevent neural tube defects. In Cost-effectiveness in health and medicine. M.R. Gold, J.E. Siegel,
L.B. Russell, and M.C. Weinstein, eds. New York: Oxford University Press, 1996. Estimated
cost per QALY saved from cereal fortification at a 3% discount rate.
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40. Boyle, M.H., Torrance, G.W., Sinclair, J.C., and Horwood, S.P. Economic evaluation of neonatal intensive care of very low birth weight infants. New England Journal of Medicine (1983)
308:1330–37. Estimated cost per QALY saved of neonatal intensive care was at a 5% discount
rate. The estimate in Table 8 was recomputed at a 3% discount rate and omitted expected
earnings gains (an indirect cost) from the calculation of net costs to avoid double counting.
This estimate unavoidably reflects 1978 treatment capabilities, so it may not measure current
cost effectiveness very accurately.
41. Tengs, T.O., Adams, M.E., Pliskin, J.S., et al. Five hundred life-saving interventions and their
cost effectiveness. Risk Analysis (1995) 15:369–90. Used measles immunization and phenylketonuria screening estimates of costs per life year saved computed at a 5% discount rate. Estimates were recomputed using a 3% discount rate.
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