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Estimated lifetime medical and work-loss costs of emergency department-treated nonfatal injuries--United States, 2013.

A large number of nonfatal injuries are treated in U.S. emergency departments (EDs) every year. CDC's National Center for Health Statistics estimates that approximately 29% of all ED visits in 2010 were for injuries (1). To assess the economic impact of ED-treated injuries, CDC examined injury data from the National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) (2) for 2013, as well as injury-related lifetime medical and work-loss costs from the Web-Based Injury Statistics Query and Reporting System (WISQARS). NEISS-AIP collects data from a nationally representative sample of EDs, using specific guidelines for recording the primary diagnosis and mechanism of injury. Number of injuries, crude- and age-specific injury rates, and total lifetime work-loss costs and medical costs were calculated for ED-treated injuries, stratified by sex, age groups, and intent and mechanism of injury. ED-treated injuries were further classified as those that were subsequently hospitalized or treated and released. The rate of hospitalized injuries was 950.8 per 100,000, and the rate of treated and released injuries was 8,549.8 per 100,000. Combined medical and work-loss costs for all ED-treated injuries (both hospitalized and treated and released) were $456.9 billion, or approximately 68% of the total costs of $671 billion associated with all fatal and ED-treated injuries. The substantial economic burden associated with nonfatal injuries underscores the need for effective prevention strategies.

Numbers of ED-treated injuries, rates, and lifetime cost estimates by age and sex of the patient and by mechanism and intent of injury were analyzed using WISQARS (3). Rates were calculated using the U.S. Census Bureau's bridged race population estimates for 2013. Lifetime medical and work-loss costs were calculated from average costs of treating nonfatal injuries and earnings in 2010, adjusted to 2013 prices. Lifetime work-loss is the estimated wages lost because of time away from work while recovering from the injury, and the loss of income incurred for injuries that lead to permanent disability. For each ED-treated injury record, lifetime work-loss costs and medical costs were assigned using the age and sex of the injured person, along with the injury diagnosis and mechanism (4). Work-loss and medical costs for nonfatal injuries were developed from various sources, including days of work missed because of injury, from the Agency for Healthcare Research and Quality's (AHRQ) Medical Expenditure Panel Survey; hospital costs, from the Health Care Cost and Utilization Project; earnings data, from the U.S. Census Bureau's Current Population Survey; and life expectancy data, from CDC's National Center for Health Statistics. Number of injuries, rates, and total lifetime medical and work-loss costs were estimated for 2013, stratified by sex, age and intent of injury. Differences by race and ethnicity were not examined because those data are not available in the WISQARS nonfatal injury reports. The distribution of costs by mechanism of injury and ED discharge disposition of treatment (i.e., hospitalized or treated and released) was also assessed for seven selected mechanisms. Finally, the costs of ED-treated nonfatal injuries were compared with those of fatal injuries presented in another MMWR report (5).

For all ED-treated nonfatal injuries, the total costs were $456.9 billion; 63% of these costs were for hospitalized injuries, for which the total estimated lifetime medical and work-loss costs were $289.7 billion (Table 1). Approximately 65% of these costs were accounted for by males; these costs were also concentrated in the adult population, with more than three quarters of the cost being for persons aged [greater than or equal to]25 years. Unintentional injuries accounted for $253.5 billion in lifetime costs, or about 87% of costs for hospitalized injuries. Assault injuries and self-harm injuries (defined as an injury or poisoning resulting from a deliberate violent act inflicted on oneself) accounted for $26.4 billion and $11.3 billion of lifetime costs, respectively. Approximately 85% of costs for hospitalized assault injuries were borne by males ($22.5 billion), whereas costs for hospitalized self-harm injuries were more similar among males ($6.5 billion) and females ($4.7 billion). Costs for hospitalized violent injuries were concentrated among adults aged 15-44 years, with 72% of costs for assaults and 67% of self-harm costs accounted for by these age groups. In contrast, adults aged [greater than or equal to]45 years accounted for 59% of costs associated with hospitalized injuries that were unintentional.

Total estimated costs for injuries for which patients were treated and released were $167.1 billion (Table 2). Approximately 58% of these costs were accounted for by males ($96.2 billion), and 71% for persons aged <45 years. A very large share of these costs ($156.1 billion [93%]) was for unintentional injuries. Assault injuries and self-harm injuries accounted for $9.8 billion and $627 million in costs, respectively. Males accounted for about two thirds of assault costs ($6.4 billion), whereas females accounted for 60% of the self-harm costs ($377 million). Rates for nonfatal treated and released injuries from assaults and self-harm were highest among those aged 15-24 years, followed by those aged 25-44 years. Persons aged 15-44 years accounted for a large share of assault (83%) and self-harm costs (79%), whereas costs for unintentional treated and released injuries were more evenly distributed among age groups.

Although unintentional injuries account for a large majority of nonfatal injuries and their associated costs, intentional injuries are more costly on a per case basis (Figure 1). Overall, the mean medical and work-loss cost for an ED-treated nonfatal injury (including both hospitalized patients and patients treated and released) was $15,211; among unintentional injuries, the mean cost was $14,685, whereas the mean cost of an assault injury was $23,034. Self-harm injuries were the most costly on a per case basis ($25,121). Assaults and self-harm have considerably higher lifetime medical care costs, and assaults have higher work-loss costs than unintentional injuries.

Lifetime costs for ED-treated injuries were associated with a range of injury mechanisms (Figure 2), and in many cases, these mechanisms differed from those that accounted for fatal injury costs (5). For all ED-treated nonfatal injuries, 37% of costs were associated with injuries from falls, and 21% from transportation-related injuries. All poisonings accounted for only 2.6% of nonfatal injury costs; however, among fatal injuries (5), drug poisonings, a subset of all poisonings, accounted for the highest percentage of costs (27.4%) (5). Although firearm-related injuries accounted for approximately one fifth of costs associated with fatal injuries (5), they represent slightly more than 1% of costs from nonfatal injuries. Hospitalized injury costs were primarily associated with falls (41%) and transportation (25%). A large share of costs related to injuries that were treated and released were also associated with falls (30%), whereas other mechanisms, such as overexertion, accounted for a higher percentage of costs than for hospitalized injuries (14%).

Discussion

In addition to the recognized health, psychological, emotional, and social consequences of injury, ED-treated nonfatal injuries resulted in substantial costs for the U.S. health care system, as well as substantial work-loss costs in 2013; these costs provide a strong incentive to prevent injury. Although almost 90% of all ED-treated injury costs were associated with unintentional injuries, the costs per case were 57% higher for injuries resulting from assaults and 71% higher for injuries resulting from self-harm than for unintentional injuries.

Various mechanisms account for nonfatal injury costs; some, such as falls and transportation-related injuries (primarily motor vehicle crashes), account for large shares of nonfatal and fatal injury costs; whereas others are differentially distributed. Falls account for approximately one third of all (treated and released and hospitalized) nonfatal medical and work-loss costs. Falls were also the fifth leading mechanism for fatal injury costs, so effective prevention of fall injuries, such as strength and balancing exercises for older adults, could result in a substantial reduction in lifetime medical and work-loss costs (5). Transportation-related injury (primarily motor vehicle crashes), a leading contributor to fatal injury costs, also accounts for the second largest share of nonfatal injury costs (5). Some mechanisms that account for a large share of fatal injury costs, such as firearms and drug poisonings, account for a relatively small share of nonfatal injury costs (5), likely a consequence of their higher lethality.

The findings in this report are subject to at least three limitations. First, the costs measured account for medical costs for physical injury only and lost productivity associated with nonfatal injuries initially treated in hospital EDs. Costs of injuries treated in other health care settings, or injuries that were not medically treated, were not ascertained. Second, additional costs (e.g., for mental health or psychological treatment and costs for the criminal justice and emergency response systems) were not considered, nor were costs that might be incurred years after the initial injury, as in the case of child maltreatment (6). Therefore, these estimates likely represent an underestimate of the complete cost of injury. Finally, intent of injury and mechanism were assigned by trained coders based on brief narratives abstracted from patients' medical records for which the level of detail on circumstances varied. Inaccuracies in the abstraction and coding process might have affected the distribution of cost by intent and mechanism.

Although nonfatal injuries treated in EDs are common and costly, appropriate implementation of evidence-based strategies can reduce nonfatal injuries from the mechanisms that lead to the greatest cost burden. For example, primary seat belt laws, motorcycle helmet laws, sobriety checkpoints, and alcohol interlocks are effective in preventing motor vehicle-related injuries and can produce substantial economic benefits that greatly exceed the implementation costs (7). The relatively high rate of injuries from assaults and self-harm among adolescents and young adults underscores the need for early prevention strategies that take advantage of the best available evidence to enhance youths' skills, family relationships, and social environments to reduce risk for violence-related injuries. One example is Life Skills Training, a middle school classroom-based program to reduce substance use, which is a risk factor for violent behavior (8,9). Finally, the ED might also be a useful setting for implementing prevention. Studies of some screening and brief intervention programs for reducing excessive alcohol use, which is a risk factor for both unintentional and violent injuries, have shown that this intervention can reduce the likelihood of a subsequent visit to the ED for injury or violence-related causes (10). Expanded implementation of evidence-based programs and policies to prevent injuries and violence can reduce not only the pain and suffering of victims but also the considerable societal costs.

Summary

What is already known on this topic?

Each year, approximately 3 million persons are hospitalized and 27 million are treated and released in emergency departments (EDs) in the United States because of violence and unintentional injuries. Medical and work-loss costs associated with these injuries create a substantial economic burden for the health care system and the general public.

What is added by this report?

During 2013, the rate of nonfatal injuries treated in U.S. hospital EDs that resulted in hospitalization was 951 per 100,000, and the rate of nonfatal injuries that were treated and released was 8,549 per 100,000. Nonfatal injuries accounted for approximately $456 billion in medical and work-loss costs. The vast majority of ED-treated nonfatal injuries were unintentional. The majority of medical and work-loss costs associated with ED-treated nonfatal injuries were from falls (37% of costs) and transportation-related injuries (21% of costs).

What are the implications for public health practice?

Injury and violence prevention strategies can reduce a substantial source of morbidity and financial burden in the United States. Understanding how the cost burden is distributed across different mechanisms and segments of the population can allow prevention interventions to be targeted where they will have the greatest impact. The concentration of costs from falls (primarily among older adults) and transportation-related injuries suggests that a substantial proportion of costs can be avoided by implementation of prevention strategies that address these mechanisms and age groups.

References

(1.) CDC. National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. Available at http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf.

(2.) US Consumer Product Safety Commission National Electronic Injury Surveillance System. Available at http://www.cpsc.gov/en/Research-Statistics/NEISS-Injury-Data.

(3.) CDC. Nonfatal injury data. Available at http://www.cdc.gov/injury/wisqars/nonfatal.html.

(4.) Lawrence BA, Miller TA. Medical and work-loss cost estimation methods for the WISQARS Cost of Injury module. Available at http://www.pire.org/documents/WisqarsCostMethods.pdf.

(5.) Florence C, Simon T, Haegerich T, et al. Lifetime medical and work-loss costs of fatal injuries--United States, 2013. MMWR Morb Mortal Wkly Rep 2015;64:1074-7.

(6.) Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse Negl 2012;36:156-65.

(7.) Preusser DF, Williams AF, Nichols JL, Tison J, Chaudhary NK. Effectiveness of behavioral highway safety countermeasures. Available at http://onlinepubs.trb.org/onlinepubs/nchrp/nchrp_rpt_622.pdf.

(8.) Center for the Study and Prevention of Violence. Blueprints for healthy youth development. Available at http://www.blueprintsprograms.com.

(9.) Substance Abuse and Mental Health Services Administration. National Registry of Evidence-Based Programs and Practices. Available at http://www.nrepp.samhsa.gov.

(10.) Mello MJ, Nirenberg TD, Longabaugh R, et al. Emergency department brief motivational interventions for alcohol with motor vehicle crash patients. Ann Emerg Med 2005;45:620-5.

Curtis Florence, PhD [1]; Tamara Haegerich, PhD [2]; Thomas Simon, PhD [3]; Chao Zhou, PhD [1]; Feijun Luo, PhD [1]

[1] Division of Analysis, Research and Practice Integration, National Center for Injury Prevention and Control, CDC; [2] Division of Violence Prevention, National Center for Injury Prevention and Control, CDC; [3] Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC.

Corresponding author: Curtis Florence, cflorence@cdc.gov, 770-488-1398.

TABLE 1. Hospitalized * nonfatal injuries, rates per 100,000
population, and estimated lifetime medical and work-loss costs,
by sex, age group, and intent-United States, 2013

                                            Sex

Intent                  Total       Male       Female

All intents *
  ([dagger])
No. of injuries       3,005,772   1,639,305   1,366,326
Rate ([section])        950.81    1,053.19      851.41
Costs ([paragraph])    289,730     191,283     101,022
Unintentional
No. of injuries       2,486,337   1,351,321   1,134,950
Rate ([section])        786.49      868.17      707.23
Costs ([paragraph])    253,549     162,965      93,001
Assault
No. of injuries        169,076     134,952      34,115
Rate ([section])         53.48       86.70       21.26
Costs ([paragraph])     26,366      22,529       3,681
Self-harm
No. of injuries        344,914     147,871     196,977
Rate ([section])        109.11       95.00      122.74
Costs ([paragraph])     11,320       6,522       4,728

                                       Age group (yrs)

Intent                 0-14      15-24     25-44     45-64    [greater
                                                              than or
                                                               equal
                                                               to] 65

All intents *
  ([dagger])
No. of injuries       189,400   337,789   678,465   829,903   967,066
Rate ([section])      310.04    768.50    814.51    998.87    2,163.26
Costs ([paragraph])   22,352    38,106    75,308    87,932     69,783
Unintentional
No. of injuries       164,271   196,256   471,906   699,926   952,138
Rate ([section])      268.90    446.50    566.53    842.43    2,129.87
Costs ([paragraph])   20,125    27,636    61,344    80,462     69,199
Assault
No. of injuries        6,659    47,458    73,258    36,120      4,388
Rate ([section])       10.90    107.97     87.95     43.47       9.81
Costs ([paragraph])      906     7,113    11,962     5,728        462
Self-harm
No. of injuries       18,461    92,959    129,876   93,121     10,404
Rate ([section])       30.22    211.49    155.92    112.08      23.27
Costs ([paragraph])      595     3,212     4,373     2,800        317

* Includes nonfatal injuries initially treated in a hospital
emergency department that resulted in hospitalization or transfer
for specialized medical care.

([dagger]) All intents include legal intervention. Assault,
self-harm, and legal intervention include cases that are
confirmed or suspected. All other cases are considered
unintentional.

([section]) Injuries per 100,000 population.

([paragraph]) In millions of 2013 U.S. dollars. Cost estimates
were computed from average lifetime work-loss and medical costs
by mechanism and intent of injury. The base year for average
costs was 2010. Base year costs were indexed to 2013 prices and
applied to 2013 emergency department-treated injury counts.
Lifetime medical costs refer to the medical costs associated with
the injury event.

TABLE 2. Treated and released * nonfatal injuries, rates per
100,000 population, and estimated lifetime medical and work-loss
costs (in millions of dollars), by sex, age group, and
intent-United States, 2013

                                              Sex

Intent                  Total         Male        Female

All intents
  *([dagger])
No. of injuries       27,028,247   14,358,379   12,669,537
Rate ([section])       8,549.76     9,224.69     7,894.91
Costs ([paragraph])     167,135       96,233       70,701
Unintentional
No. of injuries       25,407,794   13,418,964   11,988,499
Rate ([section])       8,037.16     8,621.15     7,470.53
Costs ([paragraph])     156,087       89,042       66,883
Assault
No. of injuries       1,398,931      816,536      582,394
Rate ([section])         442.52       524.59       362.91
Costs ([paragraph])       9,753        6,358        3,371
Self-harm
No. of injuries         130,650       46,992       83,658
Rate ([section])          41.33        30.19        52.13
Costs ([paragraph])         627          245          377

                                  Age group (yrs)

Intent                  0-14        15-24       25-44

All intents
  *([dagger])
No. of injuries       5,819,455   5,014,247   7,580,392
Rate ([section])      9,526.17    11,407.84   9,100.41
Costs ([paragraph])     36,750      30,348      50,749
Unintentional
No. of injuries       5,681,198   4,504,264   6,909,368
Rate ([section])      9,299.85    10,247.58   8,294.83
Costs ([paragraph])     35,903      26,850      45,995
Assault
No. of injuries        120,616     434,671     584,023
Rate ([section])        197.44      988.91      701.13
Costs ([paragraph])        770       3,051       4,235
Self-harm
No. of injuries         15,766      48,818      41,825
Rate ([section])         25.81      111.07       50.21
Costs ([paragraph])         61         218         214

                          Age group (yrs)

Intent                  45-64     [greater
                                   than or
                                    equal
                                   to] 65

All intents
  *([dagger])
No. of injuries       5,665,770   2,947,418
Rate ([section])      6,819.33    6,593.18
Costs ([paragraph])     35,699      13,281
Unintentional
No. of injuries       5,386,913   2,925,179
Rate ([section])      6,483.70    6,543.43
Costs ([paragraph])     33,869      13,178
Assault
No. of injuries        239,462      20,091
Rate ([section])        288.22       44.94
Costs ([paragraph])      1,601          93
Self-harm
No. of injuries         22,819       1,422
Rate ([section])         27.47        3.18
Costs ([paragraph])        121           7

Sources: National Electronic Injury Surveillance System-All
Injury Program (NEISS-AIP) for injury rates, disposition, and
mechanism. Pacific Institute for Research and

Evaluation for unit cost estimates.U.S.Census Bureau for
population estimates.Numbers and rates computed using WISQARS
(http://www.cdc.gov/injury/wisqars).

* Includes nonfatal injuries for persons initially treated in a
hospital emergency department and then released.

([dagger]) All intents include legal intervention.Assault,
self-harm, and legal intervention include cases that are
confirmed or suspected.All other cases are considered
unintentional.

([section]) Injuries per 100,000 population.

([paragraph]) In millions of 2013 U.S.dollars. Cost estimates were
computed from average lifetime work-loss and medical costs by
mechanism and intent of injury.The base year for average costs
was 2010.Base year costs were indexed to 2013 prices and applied
to 2013 emergency department-treated injury counts.Lifetime
medical costs refer to the medical costs associated with the
injury event.
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Author:Florence, Curtis; Haegerich, Tamara; Simon, Thomas; Zhou, Chao; Luo, Feijun
Publication:Morbidity and Mortality Weekly Report
Date:Oct 2, 2015
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