Cost Savings of Injury Prevention: A Model for Health Care Insurers

1. Cost Savings of Injury Prevention: A Model for Health Care Insurers Mike Gittelman, MD Associate Professor Division of Emergency Medicine Cincinnati Children’s Hospital Medical Center

2. Objectives • Why concentrate on injury prevention • History of injury prevention • Interventions to prevent injuries and their effectiveness • Cost effectiveness of injury prevention strategies

3. "I didn't know there was a problem" Past Top Stories "Why hasn't anyone ever told us" • Teen wounds six in High School shooting • 3 month old improperly restrained … loses life • House blaze fatally injures four children • Study finds playgrounds safer, but not enough "3 out of 4 improperly use the seats" "If we only knew that we shouldn't..."

4. Why Injury Prevention? • Injuries • Are the # 1 killer of children > 1 year of age • Cause more deaths than all other diseases combined • Almost all injuries are preventable • Prevention • Is everyone’s job • Saves health care dollars www.cdc.gov/pub/ncipc

5. U.S. Childhood Injuries - Deaths • Average Day in US • > 400 deaths due to injuries; > 50 in kids 0-19 y.o. • > 80,000 injuries resulting in hospitalizations and ED visits; >28,000 in kids 0-19 y.o. % total mortality Source: National Center for Injury Prevention and Control, 2008

6. International Age-Adjusted Injury Death Rates Source: Lois Fingerhut, NCHS, based on 2000-2004 data

7. Injury Death in U.S.: 1-4 Years of Age Source: National Center for Injury Prevention and Control, 2006

8. Injury Death in U.S.: 5-9 Years of Age Source: National Center for Injury Prevention and Control, 2006

9. Injury Death in U.S.: 10-14 Years of Age Source: National Center for Injury Prevention and Control, 2006

10. Injury Death in U.S.: 15-19 Years of Age Source: National Center for Injury Prevention and Control, 2006

11. Injury Deaths by Cause – US, 1-19 Years of Age, 2008 Source: National Center for Injury Prevention and Control, 2008

12. “If a disease were killing our children in the same proportions as injury, we would be outraged and demand this killer be stopped” C. Everett Koop, M.D. Former Surgeon General of the United States

13. History of Injury Prevention

14. History • Prior to the twentieth century • Early 1900s - carelessness causes injuries? • 1942 - Hugh DeHaven - biomechanics of injury prevention

15. Factors in the Prevention of Injury Victim Environment Agent

16. Matrix & Conceptual Framework for Injury Prevention Haddon, 1962

17. Public Health Approach to Prevention • Define the problem • Identify causes or risk factors • Develop or test interventions • Implement intervention and measure prevention effectiveness

18. Interventions to Prevent Injuries4 E Approach • Education • Media campaigns, school programs • Enforcement/Legislation • Child safety laws, speed limit enforcement • Engineering/Technology • Airbags, bike helmets, child safety seats • Environmental Modification • Bike lanes, safety gates, speed bumps

19. Effectiveness of Educational Interventions in Clinical Setting • 10,330 citations • 103 randomized clinical trials • 22 studies evaluated • Most assessed the effect on a safety behavior rather than on an injury rate • No eligible studies on pedestrian, drowning, motorcycle or firearm injuries. DiGuiseppi C, Roberts IG: Individual-level injury prevention strategies in the clinical setting. In: The Future of Children. Los Altos, California: The David and Lucille Packard Foundation, 2000

21. From BMJ, December 2003

23. Effectiveness of Legislative InterventionsPassive Techniques • Child resistant packaging • Mortality to youth < 5 years from unintentional ingestions decreased initially by 44%, 1973-1978 (460 fewer deaths, 200,000 less ingestions). • Regulating hot tap water temperature • Reduction of home hot water to 130oF • 1983 WA Law, tap water less than 130oF went from 20% to 77% in 5 yrs – 50% reduction in hospital admissions from scalds - Erdman, Pediatrics 1991 • Graduated licensing systems • CA and MD – 15-17 yr olds 5% reduction in crashes • OR – 16% reduction teen male driver crashes - Jones, J of Safety Research 1994

24. Effectiveness of Legislative InterventionsActive Techniques • Bike helmets • Increased usage from 0-71% in GA (Gilchrist, Pediatrics 2000) and 37-66% in OR (Ni, Arch Peds 1997) • Significantly decreased head injuries (MacPherson, Cochrane Database 2008) • Car safety and belt-positioning booster seats • Children ages 4-7 in states with laws are 39% more likely to be appropriately restrained in a booster seat or child safety seat than children in states without laws (CHOP study www.chop.edu/carseat) • After KY law > 80% restrained in car seat yet only 20% were restrained properly (CDC, MMWR 1998)

25. Injury Prevention Products Work! • Window guards decrease falls from windows by 50% • More than 70% of infant MVC deaths could be prevented by car seats • Reduced to 50-59% if not used appropriately • Odds of injury to preschooler in MVC is 59% lower if using a booster seat • Smoke alarms reduce risk of death in house fire by 50% • Bike helmets reduce risk of head injury by 85%

26. Combination of Interventions for Belt-Positioning Booster Seats • Ehiri, et al, Am J Prev Med 2006 • Education paired with incentive or distribution programs produced more consistent results than education-only interventions • Gittelman, et al, Academic EM 2006 * 42 (75%) used seat 100% of time

27. The Cost of Childhood Unintentional Injuries and the Value of Prevention

28. Definitions: Costs and Savings Total Benefits per Unit: the amount the intervention saved by preventing injuries & other problems Aggregate Benefit/Unit = Total Benefits - Cost Benefit Cost Ratio (BCR): savings from preventing injuries divided by cost of the intervention Cost-effective: the BCR > 1.0 Return on investment in the intervention exceeds amount invested Laws typically have high BCR with less cost

29. Definitions: Costs and Savings Quality Adjusted Life Years (QALY) Measures disease burden – quality and quantity of life lived Years of potential life lost to fatal injury added to number of years spent with disability multiplied by factor depending on the severity of the disability Cost /Quality Adjusted Life Year = (Cost of intervention – medical & other resource savings)/QALY Hope for cost/QALY to be < $0

30. Frequency of Pediatric Injuries • More than 22 million children will sustain an injury serious enough to require medical attention • More than 150,000 will have a permanent disability and will need lifetime care

31. Costs of Pediatric Injuries • Injury accounts for 15% of medical spending • Estimated 14 billion in lifetime medical spending and 66 billion in present and future work losses • Medicaid and government agencies paid for 39% of days children spent in hospitals

32. PROBLEM SIZEAnnual Spending per U.S. Child, 0-19

33. What Injuries Are Driving The Costs?

35. Bicycle Helmets $10 bike helmet saves insurers $41 each • 1 year, head injuries to 4-15 year olds • 52,000 nonfatal head injuries, 93,000 nonfatal scalp injuries • 2200 permanent disabilities • Lifetime medical payments for these children approach $394 million • Every $10 bike helmet generates $570 in benefits to society • $50 in medical costs • $140 in future earnings and other tangible resources • $380 in quality of life costs • Universal bicycle helmet use by 4 to 15 year olds would prevent 1,200 - 1,700 permanently disabling injuries • If 85 percent wore helmets in 1 year, lifetime medical cost savings would total $197 to $256 million.

36. Child Passenger Seats – Ages 0-4 years A $50 Car Seat Saves $330 in Insurance and Tax Payments • *1 year, motor vehicle crashes • 58,000 injuries • 6500 disabling injuries • 500 fatalities • > 40% improperly restrained • > 70% of infant MVC deaths can be prevented by car seats • 50-59% if not used appropriately • Disbursement of seats to Medicaid families • Avert 51 minor injuries & 2 deaths/100,000 low income children • Cost Medicaid $26 per child over 4 years and save $1m/100,000 children • Goldstein, et al, Ambulatory Peds 2008 *From www.nhtsa.gov

37. A $50 child seat saves $2,181 (BCR 42) $1,515 $302 $208 $155 Medicalcost Otherresources Workloss Qualityof life

38. Have a seat and just reduce misuse saves $569/seatwith education costs of $7 (BCR 81) $294 $159 $57 $59 Medicalcost Otherresources Workloss Qualityof life

39. Belt Positioning Booster Seats – Ages 4-8 years • *1 year, motor vehicle crashes • 72,000 injuries • 7000 disabling injuries • 400 fatalities • 50% improperly restrained • Odds of injury is 59% lower using a booster seat • Unrestrained children 2.8 times, seat belt restrained 2.6 times more likely to die • A $30 booster seat produces cost savings > 9:1 of medical costs alone • http://www.cdc.gov/injury/pdfs/cost-MV-a.pdf *From www.nhtsa.gov

40. A booster seat with back costs $35 and saves $2,474 (BCR = 63) $1,347 $571 $356 $201 Medicalcost Otherresources Workloss Qualityof life

41. Smoke Alarms Equipping A Home with Smoke Alarms + Maintenance Costs $47 & Saves $780 (BCR 17) • Haddix, Injury Prev 2001 • Oklahoma Study • 10,000 battery operated smoke alarms distributed to homes • 2.6 times higher rate of fire in community compared to rest of OK city • Costs • $530,000 for giveaway • Calculated 20 fatal and 24 nonfatal injuries prevented • Translates into savings of 1.5 M medical costs and $14M productivity losses

42. Poison Control Centers (PCC) A Poison Control Center Call • > 1M pediatric ingestions annually • 39% kids < 3 years • 74% can be managed at home • 73% of families that visit an ED never called PCC • Medical spending for ingestions totals approximately $3 billion • Spending averaged $925 per case. • Miller, Ann of EM 1997

43. Comparison of Injury Savings vs. Infection Control

44. Proven Injury Prevention Interventions and Cost Effectiveness

45. Summary • Injuries are the number one cause of morbidity and mortality to children. • Some products have been proven to prevent injuries and if used can save health care dollars • Insurance companies currently pay for other preventative initiatives (eg. immunizations) that aren’t as cost effective • Laws and enforcement generally save the state money at little cost to them

46. Acknowledgements • Ted Miller, Pacific Institute for Research and Evaluation • Cost effectiveness calculations • NACHRI - Injury Prevention Webinar, Data Basics for Cost-outcome Analysis - 703-797-6042 • Rachael Weintraub for bringing our groups together

47. Questions?

48. Addendum Slides

50. Definitions of Costs • Incidence vs Prevalence Costs • Value of lifetime costs due to injury during a single year • Injury-related expenses during one year regardless of when the injury occurred • Resource vs Productivity Costs • Medical costs – ED, physician, rehab, prescription, etc • Other direct costs – police, EMS, traffic delay, etc • Work-loss costs – lost wages family, compensation processing (eg. litigation) • Quality-Adjusted Life Years (QALY) • Measures disease burden – quality and quantity of life lived • Years of potential life lost to fatal injury added to number of year spent with disability multiplied by factor depending on the severity of the disability