This chapter presents an overview of the costs and consequences of unintentional injuries to health services and to children and their families, including the economic and HRQL aspects. It describes the methods used to recruit participants to the study and the analyses undertaken. It presents data to validate the PedsQL for a range of injuries in preschool children and to measure the costs of injury to the NHS and families and discusses the key findings of each study. Finally, it outlines its strengths and weaknesses and considers the implications of the results.
Introduction
To date, there has been little information on the cost of unintentional injuries to the NHS, to children and to families, without which the NHS cannot make informed choices about which interventions to fund to prevent home injuries in childhood.
Measuring HRQL is an integral part of measuring the cost of children’s injuries, yet tools for doing this have not been validated for a wide range of injury types and severities in preschool children.64,109–112We
therefore undertook a longitudinal study, nested within the case–control study described in work stream 1 (seeChapter 2). The primary objective of the study was to quantify children’s HRQL post injury and the costs to the NHS and families of such injuries and to assess the feasibility, acceptability and psychometric properties of the acute version of the PedsQL109in a paediatric population with injuries. HRQL and cost
data were analysed separately, with no attempt made to assign a monetary value to children’s HRQL for incorporation into the cost analysis. An alternative approach to assessing the costs of injuries would have been to estimate the burden of childhood injuries by measuring what society would be prepared to pay to avoid childhood injuries using willingness-to-pay methodology. Although the concept is appealing, practical difficulties have been well documented, relating mainly to the formulation of the questions asked and the interpretation of the responses given.113Information on costs and HRQL was used to inform
decision analyses (study K) estimating the cost-effectiveness of a range of strategies to prevent childhood falls, poisoning and scalds undertaken in work stream 5 (seeFigure 1for a diagram of the component parts of the programme grant).
Unintentional injuries from falls, poisonings and scalds do not just result in death and injury. They also place burdens on the NHS and other care agencies and on injured children and their families. At a personal level, these burdens can, for example:
l be financial (e.g. from loss of income if there is a need to take time off work, costs associated with travel to and from hospital or with making adaptations to the home)
l impact on a child’s education
l reduce a child’s ability to develop physically because of loss of mobility or reduction of fine motor skills
l affect employment prospects
l influence social interactions and life chances, for example as a result of severe scarring
The costs of injury
In the UK, there is very limited evidence on the costs of unintentional childhood injuries. However, such information is important for prioritising spending on prevention, treatment and rehabilitation services and for economic evaluations of interventions.114–116Several studies have attempted to quantify the economic
costs associated with unintentional injuries.30,117–122These have been undertaken from a variety of
perspectives including medical care costs,117,119,120medical and social care costs30or medical care, social
care and societal costs.118,121,122However, the estimates are not always specific to children30,118,121,122or,
when they do focus on children, studies do not always present data on the under-fives.11Some costs are
estimated based on other types of injuries, for example transposed from data on road traffic crashes.123
Although there are some data from other countries, estimates of the economic burden of injury cannot easily be compared between countries and across time because of differences in health-care systems, the absence of standardised methodologies, the different approaches used and a lack of epidemiological and cost data.124It should be noted that many previous cost and HRQL studies have used populations that
were likely to have sustained more serious injuries.
The costs of injury can be categorised as direct costs resulting from the injury (e.g. costs to the health-care system such as ambulance transport, ED visits, admissions, primary care attendances, rehabilitation and drug costs), indirect costs, which represent the value of lost output because of reduced productivity caused by injury and any resultant disability and losses because of premature death (e.g. costs to the child, family or society such as loss of income from carers taking time off work or lost productivity in later life by the injured or disabled child) and intangible costs (e.g. costs of pain, grief, suffering, etc.). Some studies and sources provide estimates of direct costs and some of direct and indirect costs combined, as described below, but intangible costs, which are difficult to measure in monetary terms, have not been quantified to date.
In England, unintentional injuries occurring in or around the home are a leading cause of preventable death and disability for children aged<5 years.1Falls, poisonings (including suspected poisonings) and
thermal injuries are the most common causes of ED attendances3and hospital admissions.2Although the
majority of those injuries are not severe, the disproportionately large numbers of minor injuries are likely to account for the greater costs125compared with the costs of relatively rare serious injuries (which
individually would incur substantially higher lifetime costs).1
Each year in England,>280,000 children aged<5 years visit an ED as a result of falls, thermal injuries
or poisoning incidents.3These visits cost the NHS nearly £32M, based on the average cost of an ED
attendance of £114.31These figures do not include children treated by GPs or treated at home.126
In 2012/13 in England,>18,300 falls, 5100 poisonings and 1420 scalds among under-fives resulted in
emergency admissions.2About 90% of admissions were for<2 days but almost 16% of scalds, 4% of
falls and 2% of poisonings were more serious, requiring admission for>3 days [data available from
www.chimat.org.uk/earlyyears/injuries (accessed 4 October 2016)]. In total, the admissions cost the NHS £19.1M (at £586 per short-stay case and £2461 per long-stay case).30The most severe childhood injuries,
such as severe scalds and traumatic brain injuries (TBIs) from falls, disproportionally contribute to costs to the NHS and other care agencies because of the longer length of hospital stay, cost of treatments in intensive care units, repeated operations and long-term rehabilitation.
Falls constitute almost half of all injury-related admissions to children aged<5 years, with a rate of
between 500 and 600 admissions per 100,000 children annually between 2008/9 and 2012/13 in England.1A population-based study of TBIs in north Staffordshire in the 1990s reported that, among
under-fives, 62% of TBI cases (of all severities) resulted from falls, rising to>70% if children who were
dropped were included.127A study of children admitted with a TBI to intensive care units throughout
England and Wales reported that the admission rate among under-fives was 5.3 per 100,000 children annually, with falls constituting 38% of the 136 cases in the sample.128These injuries can impose short- or
long-term problems including post-traumatic stress,129disability and cognitive and social impairment,
impact negatively on learning ability and reduce chances of future employment and productivity. They also place significant financial130and psychological distress120,131on children and families, and are a major
economic burden to society.132
Estimates of short- and long-term costs of injuries, predominantly based on UK data, have been
highlighted in theChief Medical Officer’s Annual Report 201211(Table 31) and a recent report and data
analysis published by Public Health England.1The CMO’s report estimates the costs of severe injuries for
the under 15s,11as data are more readily available for injuries in this age group, whereas the Public Health
England report breaks down the data into age categories, separating the<5 years age group, and focuses
on the most common childhood injuries, including falls, poisonings and scalds.1Both reports highlight the
high financial costs, with the short-term health-care cost per case, that is, costs related to the hospital and other health service costs immediately after the injury, ranging from £2494 for the average cost of an injury to £14,000 for a serious road traffic injury.118The CMO
’s report notes that the lifetime cost of a childhood TBI can be up to £4.95M per case at 2012 prices.137,138
Calculating long-term costs can be complex, as this needs to take account of the long-term consequences of sustaining a severe injury such as educational costs (e.g. special needs for a disabled child), lost productivity costs and social care costs, which are not always well documented.1The potential total lifetime health-care,
social care and social security costs of TBI in childhood, based on the number of cases in 2003, was estimated to be between £640M and £2.24B.11
Using the methodology developed to cost road traffic accidents, the cost of a serious home accident (one requiring admission to hospital and including medical and support costs for the acute event, lost output over the period of recovery and the value of the avoidance of injury) to a child aged<5 years has been
estimated to be £33,200 in June 2009 prices using data for Great Britain.123(In this study,
‘serious’was defined in the same way as the term is used in the reporting of road casualties; namely, the injury required admission to hospital at least overnight and involved concussion, crushing, laceration of>5 cm, suspected
or actual fracture, multiple injuries or other internal injuries and the outcome of which was inpatient treatment or admission or transfer to a specialist, long-stay or other hospital.)
Several UK studies have estimated the costs of childhood scalds. An average cost of acute inpatient treatment for a minor, uncomplicated paediatric scald [one involving<10% of the total body surface area
(TBSA)] has been estimated to be £1850 in 2002/3 prices,139whereas the average cost of acute inpatient
treatment of a‘major scald’(30–40% TBSA) in 2007–9 in a paediatric burns unit was as high as
£55,000.119For a bathwater scald, NHS treatment costs were £25,226 and the wider societal costs were
£71,902 at 2010 prices.140
Health-related quality of life following childhood injury
The resource and productivity costs do not fully capture the burden of childhood injuries125as they do not
take account of the quality of life of, or psychological impact on, the child and family. The most commonly used generic measure of HRQL is the European Quality of Life-5 Dimensions (EQ-5D).141The EQ-5D
measures health using five domains to produce 243 health states to which societal preference weights are assigned to generate a single‘utility index’value, captured on a scale ranging from 0 [for death (or negative values for states worse than death)] to 1 (perfect health) and which depend on the severity of the health problem.125,142The utility index is multiplied by the time lived within a health state to calculate
quality-adjusted life-years (QALYs). Thus, 1 year lived in perfect health equates to 1 QALY and a year of life lived in less than perfect health equates to<1 QALY. The EQ-5D has previously been used to measure
HRQL following injury,125,133but at the time of initiating our study it had not been used in injured children
aged<5 years.143The Child Health Utility 9D is a child-specific measure of HRQL but at the time of our
study it had been validated only for use in children age 7–11 years (Katherine Stevens, University of Sheffield, April 2010, personal communication).
TABLE 31 Costs of injury Cost Value updated to 2012 prices Base
values Incidence (if applicable) Population base Unit Source
Average cost of ED treatment leading to admission £146 per patient £146 per patient NA Number of cases: 135,131
(HES 20122) Average cost for the UK(all types, all ages) Curtis 30
Average cost for minor injury services leading to admission £66 per patient £66 per patient NA Number of cases: 135,131 (HES 20122)
Average cost for the UK (all types, all ages)
Curtis30 Short-term costs, healthcare, RTI £14,000 £13,500 0–4 years: 82.5 per 100,000; 5–14 years: 55.75 per 100,000133
Population estimates: 0–4 years: 3,393,400; 5–14 years: 6,091,500134
Total seriously injured (at least 3-day hospital stay): 6196
Average cost of a serious RTI (all ages)
Department for Transport135
Short-term costs, health care, RTI
£14,000 £13,500 NA 2272 seriously injured or killed on the road136
minus about 40 killed (HES 2010)=2232
Average cost of a serious RTI (all ages)
Department for Transport135
Short-term costs, health care £2494 €2769 0–4 years: 82.5 per 100,000; 5–14 years: 55.75 per 100,000133 Population estimates: 0–4 years: 3,393,400; 5–14 years: 6,091,500134
Total seriously injured (at least 3-day hospital stay): 6196
Average cost of an injury (all types, all ages)
Polinderet al.118
Cost of a serious burn, short-term, health care
£65,788 £63,157 NA NA Average cost of inpatient
treatment for a major burn, including high-dependency unit care
Pellattet al.119
Lifetime cost of a paediatric TBI (medical costs)
£271,805 £268,000 5.6128
448128
Indication of the lifelong medical cost for a child who suffers a severe TBI at age 3 years
Adapted from Wright (2011)137
by the Child Accident Prevention Trust138
continued PROGRAMME GRANTS FOR APPLIED RESEARCH 2017 VOL. 5 NO. 14 Printer and Controller of HMSO 2017. This work was produced by Kendrick et al. under the terms of a commissioning contract issued by the Secretary of State for issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in p rofessional journals suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial rep roduction should be NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, Uni versity of Southampton Science SO16 7NS, UK.
TABLE 31 Costs of injury (continued) Cost Value updated to 2012 prices Base
values Incidence (if applicable) Population base Unit Source
Lifetime cost of a paediatric TBI (all costs)
£4.95M £4.89M 5.6128 448128 Indication of the lifelong
medical cost, educational cost, productivity loss, benefits and tax loss for a child who suffers a severe TBI at age 3 years
Adapted from Wrightet al.137 by the Child Accident Prevention Trust138
Short- and long-term costs of TBI health care and non-health care
£1.43M AUS$
2.1M
5.6128
448 (n=47 for cyclists)128 Lifetime average cost of a
TBI (all ages) including all health-care costs plus social care costs, productivity losses, carer costs, etc.
Access Economics Pty Limited122
HES, Hospital Episode Statistics; NA, not applicable; ONS, Office for National Statistics; RTI, road traffic injury. Extracted from the supporting information for table 3.2 of the report of the CMO.11
Contains public sector information licensed under the Open Government Licence v3.0. © Crown Copyright. WHAT ARE THE NHS, CHILD AND FAMILY COSTS OF FALLS, POISONINGS AND SCALDS? (WORK STREAM 2) NIHR Journals Library www.journalslibrary.nihr.ac.uk
There is a dearth of research data in the UK on the estimation of QALYs for childhood injuries. The Long Term Health and Healthcare Outcomes of Accidental Injury (HALO) study followed a cohort of serious accident casualties aged≥16 years (assembled from six previous cohort studies conducted by the same research group). Health state utilities were estimated using the EQ-5D. This study reported that the average QALY loss was between 0.1 and 0.2 QALYs per year, resulting in an average loss of 1.7 QALYs (primarily because of loss of quality rather than length of life) over the following 10 years for those who survived to 6 months after injury compared with a general population, after adjusting for mortality in that general population. The study did not measure QALY loss by injury type or in children aged<5 years. In
the constituent cohorts there were 65 cases of injury victims aged<16 years at the time of the accident
but only those aged≥16 years were included in the HALO follow-up cohort (HALO study final report
2009, J Nicholl, University of Sheffield, April 2010, personal communication).
In the absence of UK data measuring utility decrements associated with injury, data from other countries may be useful in estimating QALY losses. Phillipset al.140estimate that a bathwater scald in a young child
results in a loss of 9.1 QALYs, based on a utility decrement of 0.13 ascertained from a Spanish study of burn injuries in children and adults,144in which utilities were ascertained using the EQ-5D, multiplied by
70 additional expected life-years.
Two studies in the USA quantified QALY losses for other types of injuries (poisonings and falls).125,145
The first of these studies did not use a validated measure of health state utilities.125Rather, diagnosis- and
age-specific estimates of QALY losses combined physician ratings of the longitudinal impact of injuries on pain and functioning146,147with diagnosis-specific data on the likelihood that the injury would permanently
impact on the ability to work or earnings potential.148The physician rating scales were not specific to children,
but raters were asked to rate the likelihood of impairment and duration thereof separately for children and adults. Survey data, weighting the relative importance placed by respondents on different dimensions of impact, were used to translate the estimated impairment impacts into QALYs; most of these weights were specific to children and adolescents. The utility decrements for a fall ranged from 0.1 to 0.13 and for poisoning ranged from 0.03 to 0.046.125The second study145was of children aged 5
–17 years following a TBI resulting from a fall and reported an average utility index, based on the Quality of Well-being Index,149,150
of 0.687 at 3 months and 0.675 at 6 months. HRQL varied widely in this study, with the utility index ranging from 0.093 to 1.0 at the 3- and 6-month interview points.145QALY losses have also been described by injury
severity (in those aged<20 years) in a US study for all types of childhood injuries (including poisoning and
medically treated child neglect) and the values per injured case were 28.2 for fatal injury, 1.6 for an admitted case and 0.04 for a non-admitted case.151In this study, QALYs were computed on the basis of lives lost to
fatal injuries and years of life spent in a disabled state, weighted by physician ratings of the functional loss arising from the severity of the disability; QALY losses in future years were discounted to present values at a 3% annual rate. Physician ratings were based on those routinely used by the US National Highway Traffic Safety Administration;146the author acknowledges that these are not fully validated ratings and that they
were>20 years old at the time of writing (2006).
Methodological issues in the measurement of HRQL in children aged<5 years are attributed to a shortage
of appropriately validated instruments that are sensitive to rapid developmental stages,152lack of health
state utility classification instruments for under 5s and use of proxies in the assessment of a child’s health state.153,154However, proxy reporting is justified by the lack of cognitive and language comprehension skills