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One-year economic consequences of accidents in a Swedish municipality
Accid. Anal. and Prev., Vol. 28, No. 2, pp. 209-219, 1996 Copyright 0 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved l-001-4575/96 $15.00 + 0.00
Pergamon oool-4575(95)ooo65-&3
ONE-YEAR ECONOMIC CONSEQUENCES OF ACCIDENTS IN A SWEDISH MUNICIPALITY KENT S. LINDQVIST Department
and HAKAN BRODIN
of Community Medicine, Faculty of Health Sciences, and the Center for Medical Technology Assessment, Linkijping University, S-581 85 LinkBping, Sweden (Accepted
12 September
1995)
Abstract-The objectives of this study were to develop a system to calculate the economic consequences of accidents and to account for the economic consequences of all accidents during 1 year in a district. A total population injury survey was done in an area with a population of over 41,000. All accidents (N=4926) occurring within a 12-month period and requiring medical care were noted. The costs (calculated at 1991 prices) to the health care service (outpatient care, including primary health care and hospital care) were SEK 23.7 million (US$3.59 million), to trade and industry SEK 79.7 million (US%12.08 million), and for health insurance SEK 9.1 million (US%1.38 million). The cost for society of uninsured people is not possible to estimate using loss of production. However, the time lost from “normal activities” was registered. If this time is valued at the same price as working hours, a welfare cost of SEK 43.1 million (US$6.53 million) should be added. In a forthcoming paper, an assessment of the cost-effectiveness of interventions against accidents will be published. Keywords-Epidemiology,
Accidents, Economic consequences, Community
intervention,
Base-line study
and the administrative costs of insurance companies, the judiciary and the police (Hort and Persson 1985) (lUS$ =6.6SEK, January 1991). The financial burden to the community for the medical care of persons involved in traffic accidents almost doubled between 1982 and 1985 (Cedervall and Persson 1988). Bjurulf (1991) estimates sickness benefit costs in 1987 for accidents at 12% of the total sickness benefit costs for illnesses and injuries in the Swedish County of ijstergiitland. Because our knowledge in this field is so limited, more detailed studies are required. Economic data from a defined geographical area can provide important information for comparison and, not least, for planning accident prevention work. The present study is therefore based on accident causes and their economic effects in a defined community with a view to forming a basis for an effective accident prevention programme. The study forms part of a community analysis of all accidents occurring in the course of year and leading to contact with inand outpatient care facilities (Lindqvist 1983). This, in turn, is part of a larger prevention programme, based on a five-stage model, where community analysis forms the first stage (Bracht and Kingsbury 1990). The objectives of the present study are:
INTRODUCTION There is a need for detailed knowledge about relation-
ships between the individual, the environment, casualtylimiting factors, and the economic consequences of accidents. Of all causes of death in Sweden, injuries are responsible for the greatest loss of years owing to premature death at ages l-64, the largest risk group being young men (SOU 1984). Injuries, together with infections and musculoskeletal diseases, are the commonest reasons for sick leave in Sweden. Injuries and musculoskeletal diseases predominate among the reasons for long periods of sick leave (Bjurulf et al. 1990). The World Health Organization points out in Healthfor AII Year 2000 the importance of preventing injuries. The goal in Europe is to reduce, by the year 2000, injury, disability and death arising from accidents by at least 25% (World Health Organization 1991). Little is known about what the cost of accidents is to the community. Up to the present in Sweden studies in the field have been concerned primarily with traffic accidents (Mattsson and Thompson 1975; Tolagen 1977; Persson 1983; Hort and Persson 1985; Persson 1987; Cedervall and Persson 1988). The community’s total financial outlay for road traffic accidents in 1982 in Sweden was 5.1 billion SEK, of which 2.5 billion was for medical care and loss of production, and 2.6 billion for damage to property
1. To develop a system to calculate the economic consequences of accidents; 209
210
K. S. LINDQVIST and H. BRODIN
2. To account for the economic consequences of all accidents in a district with over 41,000 inhabitants.
MATERIALS
AND
METHODS
Population and description of the district Motala lies in the western part of Gstergijtland County on Lake Vatter. On 31 December 1983, the total population was 41,432 (National Central Bureau of Statistics 1984), 82% residing in the built-up area, the rest in the surrounding countryside (Local Government in Motala 1985). All Motala residents were included in the study. Manufacturing, trade, and public administration were the chief occupations, with 77% of the gainfully employed working within these fields (National Central Bureau of Statistics 1981). The proportions of persons employed within the public and private sectors in Motala are very close to the national figures (in Motala 35% are public servants; 26% work for companies with more than 500 employees, 15% for companies with between 50 and 499 employees, 14% for companies with between 5 and 49 employees, and 11% for smaller businesses). The same is true of the proportion of gainfully employed, and of age and sex compositions (National Central Bureau of Statistics 1989). Motala has three health care centres and a county annex hospital with a casualty department. Methods An accident can be defined as “a sudden unexpected series of undesired occurrences in interplay between individual and environment which lead to personal injury” (Schelp and Svanstrom 1986). Traffic accidents are classified according to the E code of the International Classijication of Diseases (ICD). By definition, this category includes all accidents involving at least one vehicle of any kind. The definition used in the present study also embraces pedestrians injured in an accident not involving another person or vehicle, e.g. an injury caused by slipping or stumbling. This is in accordance with the Swedish Road and Traffic Research Institute’s definition of injuries resulting from traffic accidents (Nilsson 1986). A home accident is defined as an accident occurring in any type of home and/or residence-related premises such as a flat, a house, a driveway, a garage, an out-house, a garden, a yard, or a garden walk. A work-related accident is an accident at the workplace or another place where the injured employee happened to be at the time, either working or on a work-related assignment. Traffic accidents that occurred during the course of work are also included in this category. A sports accident is an
accident during games or physical training, whether for recreation or competition. “Other” accidents are those occurring in an environment or during an activity not defined above, e.g. another public place, school, daycare centre, etc. Sport-related accidents occurring at school are included in the sports accidents category (Lindqvist 1993). All accidental injuries treated at in- and outpatient facilities, excluding accidents registered only by works’ health services, school nurses, and district nurses, were recorded. The registration period covered the 54 weeks from 15 September 1983 to 30 September 1984, the first 2 weeks constituting a test period for registration and interview routines. A description of the registration and interview routines is published elsewhere (Lindqvist 1989, 1991). The Abbreviated Injury Scale (AIS) (American Association for Automotive Medicine 1980) was used as a measure of the gravity of the injury, and the classification according to diagnosis and external cause of injury (E code) follows the International Statistical Classijication of Diseases, Injuries, and Causes of Death (1965 revision, adapted by the National Social Welfare Board for indexing of hospital records and morbidity statistics). Age classification was set up with a view to agespecific accident risks, which mainly coincide with different school periods (preschool O-6 years; primary school 7-12 years; comprehensive school 13315 years; sixth-form college 16-19 years), and after that the age classification was divided in decades. This classification could also be used in planning preventive work. This study is performed in a socioeconomic perspective.. Costs are regarded as the values of the real resource use rather than just financial outlays. We have also aimed at a short term marginal cost perspective-the marginal cost per case-where the real costs exclude fixed costs like financing of buildings, equipment etc. Such costs will not change according to the treatment of single individuals or accidents. Furthermore, we have regarded the value of time as being equal for all people. This implies that we may add a social cost for elderly and children to the costs for lost production and absence from work. In cases where transfer costs are identified, we have specified those separately. Included in the costs of accidents are the marginal costs of medical care, of companies and of the health insurance system. The costs are calculated in 1991 year’s prices. Human costs in terms of pain and suffering, sorrow and distress are not included in the costs reported here. The duration of hospitalization and medically certified sick leave was noted during the year following the accident: 1 year after the accident 15 patients were still on sick leave, and seven
211
Economic consequences of accidents in Sweden
of the uninsured but none of the insured were still in the hospital. Thus, the sick leave days and days spent in hospital after the 1 year period are excluded for these patients. Eleven accidents were fatal, 1 within 24 hours. Liukkonen (1989, 1991) has developed a method for calculating company costs which is used in this study. Included, among other things, are the costs of employing replacements and loss of production. The cost is estimated at an average of SEK 258 per hour of absence. For those persons not on sick leave (shortterm absence) the average length of absence was estimated at 4 hours. Health insurance expenditure for a period of sick leave is based on the actual sickness benefit paid out. Payments between various societal groups do not entail any real cost to the community, but rather constitute so-called income transfers (Mattsson and Thompson 1975). In stating the costs we distinguish between social economic costs and transfers thus avoiding doublecounting. The former are made up of direct costs (i.e. partly variable costs and partly hotel costs for inpatient care) and indirect costs (i.e. the value of goods and services which could have been produced if the accident had not happened). In this study we have taken account only of production losses due to sick leave. Reduced productivity at work due to injury is not registered. The calculation of indirect costs has been the subject of much scientific interest. A recent survey of the problems can be found in Drummond (1992). Some readers advocate the inclusion of indirect costs as being an adequate way of measuring changes in resource use in society. Others argue that one should exclude indirect costs e.g. on the basis that the objective of health care could not be to give priority to treatments especially favourable to the gross national product, and that the inclusion of indirect costs will give the wrong incentives to the health care professionals. This study has adopted the principles from Drummond et al. (1989, p. 79) where indirect costs are estimated as the production loss from labour activities, but also activities defined as “restricted normal activities”. This concept includes all other activities, apart from the labour market, which can not be maintained. Similar approaches have been recommended by the COST 313 action of the European Commission (Alfaro et al. 1994), and in Sweden by the Stockholm County Council (Andersson et al. 1994). In a study of non-labour market activities, students, retired and children together represent over 90% of the population. Others include e.g. early retired, housewives, and unemployed people. The adopted principles suggest that there should be
specific motivations from the analyst if different values are to be assigned from lost labour market activities and other restricted activities to society. Since some restricted normal activities might be more valued than working hours and some less, depending on the well-being of the individual, it was decided to use the same value as for labour activities, SEK 2064 per diem (Liukkonen 1989) in the indirect cost estimations for the uninsured group. Health insurance expenditures in respect of sick leave are included as transfers. Medical care costs concern the direct costs of inand outpatient care. The costs of patient transportation and home nursing are not included. Details of the treatment of patients who were hospitalized and operated on policlinically (524 patients) were obtained by examining hospital records, and the cost was worked out for each patient individually. The cost for patients treated in outpatient units was estimated, on the basis of typical examples of the 10 commonest accident diagnoses, at SEK 734 per visit, taking into account the work done by personnel, the duration of the treatment and the measures taken. The number of visits per patient to outpatient units was estimated, on the basis of a sample study of 100 patients, at 1.5 visits per person injured in an accident. Details of the estimation of costs are published elsewhere (Breidmer and Gustafsson 1988; Gustafsson 1989). Nonparticipants
The number of nonparticipants in the study was 8%. An analysis of the reasons for nonparticipation (incomplete registration, overflow to the nearby university hospital, and refusals) are published elsewhere (Lindqvist 1989). RESULTS There were 28,856 emergency attendances by Motala residents recorded during the period 1 October 1983-30 September 1984. Of these, 4926 (17.1%) were accident cases. Of the accident victims, 91.8% were seen at the Motala hospital casualty department, and the remaining 8.2% at the three health care centres. During the study period 118.9 accidents occurred per 1000 Motala inhabitants. Home accidents accounted for the largest number, followed by “other” accidents and sports and exercise accidents, with work and traffic accidents last (Fig. 1). Costs for diflerent types of accident
Company costs for loss of production and replacing employees on sick leave predominated and accounted for 77% of the cost to the community.
212
K. S. LINDQVIST and H. BRODIN
costs and 81% of health insurance expenditure. In remaining accident groups women’s share of community expenditure was slightly larger than that of men. In the case of home accidents the cost of medical care dominated among women (64%), while company costs dominated among men (77%). In the other accident groups company costs were highest for both sexes (Table 2).
Work 617 (13.7%)
Home 1723 (35.0%)
Age differences in costs Traffic 632 (12.8%) Fig. 1. Distribution
of different
types of accident.
Medical inpatient care costs amounted to a total of 18%, and these were particularly heavy in the case of home accidents (39%). For work accidents the cost of inpatient care was marginal. Home accidents accounted for the largest share of community costs (29%), the “other” accident group having the lowest share (14%). Health insurance expenditures on sickness benefit paid to persons on sick leave due to injury were divided fairly evenly between the various accident groups (Table 1). Gender differences in costs
Men accounted for the highest share of both the cost to the community (59%) and health insurance expenditures (70%) for accidents. The greatest differences between the sexes were found in work-related accidents where men accounted for 80% of the cost to the community and 86% of health insurance costs, despite the fact that in Motala the proportion of gainfully employed women (45%) was almost as high as the proportion of gainfully employed men (55%) (National Central Bureau of Statistics 1981). The sexes also differed substantially in respect of sports accidents, men accounting for 76% of the community Table 1. Accidents
classified
according
For both sexes it was in the 20-59 age group that the highest proportion of cost to the community occurred, with the exception of women home accident victims in the 70 and over age-group who had a large (50%) share of community costs. For traffic, “other” and sports accidents, women of 40 and over accounted for a higher proportion of the cost to the community than did younger women, while the share of community costs for men of 39 and younger was greater than that of older men. The age group 20 and above generally represented the highest cost, both male and female. However, women between 50 and 59 did produce cases of higher cost. Among male patients cost was spread more evenly across age groups, though the highest cost was to be found in the 30-59 age groupexcluding men with work-related injuries aged 60-69 (Table 3). Costs in relation to location and cause of injury
Injuries to the extremities accounted in all for 74% of the cost to the community. Among home, traffic and sports accidents, injuries to the lower extremities accounted for the largest proportion of the cost, while injuries to the upper extremities made up the largest share among work-related accidents and in the “other” accident group. Apart from occasional high cost injuries the average cost per case was highest in traffic and workrelated accidents, which incurred higher costs due to
to types of accident
and types of cost (million SEK) Types of accident
Types of cost Social economic cost Company costs Health care costs; outpatient inpatient Total Transfers Health insurance exnenditures on sickness
benefit
Work
Home
Traffic
Sports
Other
Total
17.8
16.5
16.7
16.8
11.9
79.1
0.7 0.3 18.8
1.7 11.6 29.8
0.6 3.2 20.5
1.0 1.7 19.5
1.0 1.9 14.8
5.0 18.7 103.4
2.1
1.9
1.7
2.1
1.3
9.1
Economic consequences of accidents in Sweden
213
Table 2. Costs of accidents classified according to types of accident and sex Types of accident/Sex Work Types of cost Social economic cost Company costs Health care costs; outpatient inpatient Total per cent Total million SEK
Home
Traffic
Sports
Other
Total
M
F
M
F
M
F
M
F
M
F
M
F
94
96
77
36
81
82
91
71
81
81
86
65
4 2 100 15.0
3 1 100 3.8
7 17 101 14.1
5 59 100 15.7
3 16 100 9.5
2 16 100 11.0
4 5 100 14.9
6 22 99 4.6
9 11 101 7.1
5 15 101 7.7
5 9 100 60.6
4 31 100 42.8
1.8
0.3
1.4
0.5
0.9
0.8
1.7
0.4
0.6
0.7
6.4
2.7
Transfers Health insurance expenditures on sickness benefit Million SEK
Table 3. Average social economic cost per case of accidents classified according to types of accident and age (n = actual number of accidents; thousand SEK) Types of accident
Age (yr) Women O-6 7-12 13-15 16-19 20-29 30-39 N-49 50-59 60-69 7@Total/n Total million SEK Men o-6 7-12 13-15 16-19 20-29 30-39 40-49 50-59 60-69 70Total/n Total million SEK
Work
Home
Traffic
Sports
Other
Total
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
1.3 (121) 1.3 (51) 1.4 (21) 11.4 (42) 9.5 (60) 16.8 (96) 16.8 (60) 34.1 (58) 19.7 (99) 39.7 (198) 19.5 (806) 15.7
1.3 (21) 6.9 (18) 1.3 (24) 4.3 (17) 23.3 (27) 66.7 (28) 73.3 (29) 122.3 (37) 15.1 (39) 22.0 (45) 38.5 (285) 11.0
1.1 (4) 2.1 (61) 1.6 (92) 7.6 (44) 29.2 (38) 28.0 (26) 44.0 (11) 285.0 (4) 1.4 (3) 470.2 (1) 16.0 (284) 4.6
2.0 (158) 1.3 (87) 1.6 (26) 11.1 (53) 16.3 (123) 25.1 (128) 34.5 (88) 26.0 (83) 16.4 (82) 14.7 (89) 15.4 (917) 14.1
1.3 (25) 2.9 (45) 1.4 (46) 20.2 (47) 42.7 (43) 70.5 (39) 49.6 (18) 63.5 (28) 12.5 (29) 24.2 (27) 27.2 (347) 9.5
-
(0)
Yl I:,’ 17:O (8) 23.6 (24) 33.8 (22) 53.2 (31) 21.0 (25) 14.8 (11) (0) 31.0 (122) 3.8
Yl 9.5 14.4 26.4 31.8 45.8 73.3 2.1 27.1 15.0
(0) ((,o; (50) (161) (136) (97) (77) (28) (4) (555)
injuries to the lower extremities, pelvis (Table 4).
spine, chest, and
Costs in relation to degree of severity
Serious injuries (AIS-3) accounted for 16% of the total cost to the community, but constituted only 3% of all accidents. Moderate injuries (AIS-2) accounted for 69% of the cost and made up 48% of the accidents, while minor injuries (AIS-1) accounted for 12% of the
1.1 (3) 2.5 (82) 1.4 (88) 14.3 (108) 30.9 (238) 50.8 (83) 46.1 (29) 11.8 (10) 1.3 (5) 1.1 (3) 23.0 (649) 14.9
1.5 (43) 1.2 (88) 2.4 (35) 11.0 (28) 31.5 (31) 20.8 (23) 39.0 (23) 105.0 (30) 44.8 (30) 9.8 (32) 21.3 (363) 7.7
1.4 (189) 1.9 (218) 1.7 (173) 9.6 (139) 21.4 (180) 27.8 (195) 40.0 (154) 73.5 (154) 22.2 (182) 34.9 (276) 23.0 (1,860) 42.8
1.8 (65) 2.2 (134) 1.2 (64) 7.1 (66) 15.5 (82) 47.4 (56) 9.8 (40) 42.1 (30) 5.6 (33) 12.9 (28) 11.8 (598) 7.1
1.9 (251) 2.2 (348) 1.4 (226) 12.4 (324) 22.9 (647) 37.1 (442) 32.1 (272) 38.8 (228) 22.3 (177) 15.5 (151) 19.8 (3,066) 60.6
cost and constituted 49% of all accidents. Among traffic accidents, 5% of all traffic injuries were of AIS3-5 degree of severity, and these accounted for no less than 25% of the community costs for traffic accidents. Apart from occasional high cost severe and critical injuries, many high cost injuries were sustained at the workplace or sports-related. In total, though, traffic accidents represent the highest cost per case ratio (Table 5).
K. S. LINDQVIST and H. BRODIN
214
Table 4. Average
social economic
cost per case of accidents classified according in-jury (n=actual number of accidents;
to types of accident, thousand SEK)
diagnosis,
and location
or cause of
Types of accident Work Location
Diagnosis*
or cause
I
Head
Home
Traffic
Sports
Other
Total
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
7.9 (121)
5.5 (340)
14.3 (105)
6.4 (77)
3.6 (170)
6.7 (813)
extremities
II
30.4 (242)
15.6 (541)
23.5 (147)
17.4 (201)
23.9 (256)
20.8 (1,387)
Spine, chest, and pelvis
III
60.3 (41)
13.7 (77)
31.8 (54)
11.7 (54)
16.4 (38)
24.6 (264)
Lower extremities
IV
52.7 (104)
38.1 (357)
80.6 (138)
34.3 (360)
18.7 (271)
38.7 (1,230)
Internal injuries (chest, abdomen, and pelvis); foreign bodies
V
94.1 (1)
Multiple lacerations and injuries; contusions or crush injuries
VI
14.6 (134)
Burns
VII
12.3 (23)
Nerves and spinal cord
VIII
~
Upper
Drugs, narcotics, toxic substances, radiation, heat, cold, atmospheric pressure, etc; complications of trauma etc.
IX
uninjured
Total/n Total million
I II III IV V VI VII VIII IX
3.1 (44)
economic
(0) (0)
1.4 (3)
1.5 (7) 1.6 (2)
(0) (0)
41.3 (3)
2.1 (5)
-
(0)
5.7 (76)
(0)
1.1 (1)
-
400.8 (2)
6.8 (55) 10.6 (9)
4.7 (1)
15.5 (9)
17.3 (1,723)
32.4 (632)
20.9 (933)
15.4 (961)
29.8
20.5
19.5
14.8
and Causes
of Death-1965
Classification
of Diseases,
Injuries,
11.4 (1,073)
1.6 (9) -
(0)
21.0 (4,926) 103.4
revision):
and above. With regard to the number of days of restricted activity, however, the proportions are reversed. The retired group reported 13,817 days, the
1403 children had experienced accidents, compared to 495 uninsured aged 16-64, and 643 aged 65 social
-
-
Estimated costs for uninsured persons
Table 5. Average
(0)
1.1 (1)
110.0 (8)
11.4 (204)
66.7 (1)
~
*Specification of diagnosis (International Statistical 800-804, 830,850-854, 870-874,879,910,930-933,935 810-819, 831-834,840-842, 880-887,912-915 805-809, 846-848, 875%878,911 820-829,835-839, 843-845, 890-897,916-917 860-869,934, 936-939 900-907,918,920&929 940-949 950-959 960-999
~
10.4 (236)
3.6 (3)
3.4 (34) 4.9 (5)
18.8
43.8 (1)
10.2 (180)
800.5 ( 1)
(0)
27.8 (677) SEK
728.3 (1)
11.4 (319)
22.2 (11)
Other Not known;
1.6 (2)
cost per case of accidents classified number of accidents;
according thousand
to types SEK)
of accident
and degree
of severity
(n=actual
Types of accident Work Degree of severity Minor (AIS-1) Moderate (AIS-2) Serious (AIS 3) Severe (life-threatening, survival probable) (AIS-4) Critical (survival uncertain) (AIS-5) Fatal within 24 hr (AIS-6) Not known; uninjured Total/n Total million
SEK
Home
Traffic
Sports
Other
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
11.7 (375) 42.2 (296) 328.9 (6)
3.4 (885) 26.9 (760) 86.8 (72)
4.1 (235) 37.5 (364) 117.5 (29)
3.4 (385) 26.6 (530) 237.6 (17)
4.4 (523) 27.2 (421) 65.0 (16)
-
(0) (0) (0) (0)
165.8 1.6
(4) (0) (0) (2)
762.3 901.3 1.1 729.3
(1) (1) (1) (1)
-
(0) (0) (0) 2.1 (1)
1.1
(0) (0) (0) (1)
27.8 (677)
17.3 (1,723)
32.4 (632)
20.9 (933)
15.4 (961)
18.8
29.8
20.5
19.5
14.8
Total SEK (n) 5.0 (2,403) 30.4 (2,371) 119.3 (140) 285.1 901.3 1.1 147.2
(5) (1) (1) (5)
21.0 (4,926) 103.4
Economic
consequences
uninsured aged 16-64 reported 5695 days, and children 1385 days. In the retired group, women dominated (61%) in number of accidents but the number of days they reported was more than four times that of men. If the welfare cost for the restricted days is estimated to be the same amount as the production cost for those in the labor force, these days would in total amount to SEK 43.1 million in 1991 prices. This sum can be compared to the total cost to the community for persons in the labor force, including treatment costs and production loss (SEK 103.4 million). Women reported a markedly larger share of the number of restricted days in all groups except in work-related accidents. The largest single group of restrictions appeared in retired women who had got moderate (AIS-2) or serious (AIS-3) lower extremity injuries in the home. This amounts to 3920 days19% of the total reported number of days. Estimated as previously, this would correspond to a welfare cost of SEK 8.1 million. Still, 71% of the number of accidents in the home had no reported activity restriction and only 25% had more than 2 restricted days. Ten per cent of the accidents reported a period of restricted activity of 3 weeks or longer. In total 90% of the women reported restricted activity of less than 3 weeks; 90% of the men, however, reported less than 1 week. Fifty-seven per cent of the accidents in the age group O-6 years occurred to boys. In the group consisting of early retired, as well as in the retired group, women dominated (55 and 61% respectively). Men dominated in the student and unemployed group (61 and 73% respectively). In this latter group 90% of the accidents reported a period of restricted activity of 4 days or less.
DISCUSSION The total cost to society of all injuries is unknown. There is very little comprehensive and ongoing reporting of injury costs (Baker et al. 1984; National Safety Council 1988; Rice et al. 1989; Baker et al. 1992). To a large extent, this is the consequence of problems in costing non-market issues. Many activities in health care and rehabilitation are e.g. subject to subsidized pricing. Also, many costs are impossible to reveal without considerable research. An example of this is the cost of lost production to companies, only reflected in lost profit, and which could not be revealed through studies of the company accounts. The study from Liukkonen (1989) is such an example. Finally, the development of economic methods for socioeconomic analysis lead to different
of accidents
in Sweden
215
opinions about what to include in the analysis and what the focus of the analysis should be. In particular the value of lost production to society has been discussed. However, until there is a convergence of details in the generally accepted methodology, the injury surveillance systems should still include the possibility of estimating the costs of injuries (Committee on Trauma Research et al. 1985). Some studies have been made of the financial outlays of different governing and insurance bodies. Such studies do not reveal the true resource use of the injury prevention and treatment which is the aim of the present study. A few studies of a similar approach have been made. A similar study was performed in Rauma Municipality, Norway (Aarseth and Vatne 1991). The costs were estimated using hospital accounts and insurance outlays. No attempt was made to estimate resource use, and insurance outlays were added to treatment costs. However, the treatment costs were comparable to those in the present study. Traffic injuries had the highest costs, 36%. In the present study, traffic accidents were 16% of the total treatment cost. Home accidents, which accounted for 56% in our study, were 29% in the Norwegian study. MacKenzie et al. (1988) performed a study of trauma patients discharged from hospital, aged 16-45, in Maryland, U.S.A. Results from different types of trauma could be compared with those of the present study. MacKenzie et al. report 30% of the total costs as due to head injuries and 32% of the costs to spine injuries. In the present study by far the largest share of the cost is accounted for by injuries to the extremities (72%). As we know from the results, most of these injuries are sustained by older people, who were not included in the MacKenzie et al. study. In the present study a separate analysis of the age group 16-45 was performed in order to compare it with the MacKenzie et al. study. The results were similar in that the cost of injuries to the extremities and head dominated in both studies, but differed inasmuch as 69% of the costs were taken up by extremity injuries in the present study, compared to 43% in the MacKenzie et al. study. In the latter study 26% of the accident costs consisted of head injuries compared to 18% in the present study. A study by Sjijgren and Bjijrnstig (1991) investigated the health care costs of injuries in a Swedish population. All accident injuries in the district, treated at a university hospital, were registered. People older than 60 were compared with those younger than 60. The elderly comprised slightly less than 20% of the population, but accounted for 42% of the costs. In the present study we found that the elderly comprised 37% of the population but 74% of the costs. The
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authors conclude that since the elderly account for a large part of the costs they should also be given commensurate priority in the research and intervention programmes. However, it is also important to take into account the benefits of health care in terms of quality of life. The differences in the results of the present study and the three other studies could be due to the studies having differently designed inclusion criteria and registration routines, as well as to differences in calculating unit prices, differences in the character of the catchment areas and in population structures, and to the fact that two of the studies are based on material concerning victims treated at hospital. The present community-based study was carried out in the municipality of Motala and comprises persons resident in the district who required consultation for treatment of an accidental injury. Basically, two perspectives could be used to study the costs to society due to accidents. The first, the cost-of-illness method, estimates the total cost of accidents to society. The second method, the cost-ofintervention approach, estimates the marginal (shortterm) costs to society of alternative small-scale projects. This method is more decision-oriented than the former since it can be used for analysis of different courses of action, which is the purpose of this study. The first, which is used in most studies in this area, can be used for overall macro-economic judgements. In principle, the estimation of direct treatment costs is a straightforward matter. The only major problem arises when service activities and administrative overhead costs are to be distributed among the treated patients. Indirect costs and/or welfare costs, however, present both conceptual and methodological problems. Hartunian et al. (1981) review the methodology for estimating the cost to society in matters of life and death. By and large they use the same technique as the present study. The authors also calculate the indirect costs, concluding that these costs amount to 70% of the total cost to society. In discussing the indirect cost approach, the authors argue that “This approach would be entirely appropriate if humans were considered simply as productive machines. The fact that societies value the very young and the elderly as well as the middle-aged signifies that attributes other than a person’s level of production (as measured by his present-value earnings) are important to human values” (Hartunian et al. 1981, p. 42). However, since the authors consider only “economic” costs they refrain from calculating other values. Hartunian’s study is a good representation of the present state of the art and the principles are also adopted by several policy forming bodies, such as Alfaro et al. (1994) and Andersson et al. (1994).
An issue of special concern is how to treat costs of lost production not only to the companies, but to society. In many studies lost production has become the major cost item and is consequently decisive for the recommendations of the study. Mufioz (1984) also estimates direct and indirect costs, e.g. forgone earnings due to fatal and nonfatal injuries, of trauma in the United States. Mufioz found that the largest single group of costs was indirect costs for men, almost twice the direct cost for the same group. This result is not surprising, however, since the wages of men are in general higher than those of women. This is not discussed in Mufioz’ study, and his conclusion that this finding is valuable for legislation and policymaking, and also for improving medical efficiency or cost containment, does not note the consequence that, for instance, in preventive efforts wealthy white males will be preferred to poor black women. The obvious conflict between alleged economic incentives and the actual vast allocation of health care resources to the elderly, leads to a discussion of the relevance of economic arguments (Drummond 1981; Stoddart 1982; Drummond et al. 1989). Tolpin and Bentkover (1982) estimate the economic costs of sports injuries. The same conceptual definition is used as in other studies, but financial costs are also supplemented with two other kinds of costs, societal costs and social costs. Examples of the first kind are insurance administration costs and legal and court costs. The second kind is the negative value of disutility from psychosocial impairment that results from the injury. The authors recognize the problems of valuing productivity losses from people with different wages, and also of estimating the value of housewives’ services. The authors conclude that many other kinds of pain and suffering should be included in the estimations, although difficult to quantify, and that economic costs serve to highlight an important aspect of illness and injury, namely, the opportunity cost of sustaining such injuries in a society that must decide how to allocate its scarce resources. Normally, the indirect costs have to be treated with caution. In estimations where a considerable part of the study population is elderly, housewives, mentally retarded or young children, the indirect costs-measured as production loss-is without meaning. The idea that production losses are a cost to society means that an objective of each individual is to contribute to the gross national product. It is questionable whether this is a relevant standpoint. The ultimate goal of a civilized society is rather to support individuals in their “production of quality of life”. This quality could be produced by working in the labor market, doing domestic chores, reading fairy tales to the grandchildren or (with very small financial
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Economic consequences of accidents in Sweden
compensation) taking part in cultural activities. If this were not the case, care of the elderly, housework and cultural activities would not have the prevailing massive support from society. In this study, however, the dominating objective of society is to prevent accidents both in the working population and the others. Health insurance is a compulsory system and as a consequence the concept of transfer is debatable. Since the insured individual is not able to leave the system, it might be conceived as tax. The marginal cost to society might then be considered to be a real cost. As a consequence we have presented those transfer costs separately. Clearly, the value of avoiding restricted, nonworking hours is greater than zero. For some people the value might be much greater than the available market wages, for some it might be less. We have found no scientific evidence that a person’s income should reflect his value of time, since other immaterial values and “disvalues” should also be added to the monetary values. No other motive could be found to weigh the value of time differently for different individuals. The present study has then chosen to treat all time of equal value to all involved persons. To choose the value equal to production losses for representative Swedish industry could, for want of something better, be a reasonable compromise. The time records of the uninsured people may, however, also be underestimated. We have reason to believe that some individuals do not consider their time to be restricted in the way intended in the questionnaire. Consequently, some individuals might well have reported a shorter period of restricted activity after injury than others would have done in the same situation. The result will be that welfare costs for this group will be underestimated. The obvious overall result is that retired women, injured at home in their lower extremities, dominated the uninsured group. Almost 20% of the total uninsured number of days, in which normal activities were restricted belongs to this group. Compared to patients in the labour force, the welfare cost accruing to uninsured patients could be estimated at a further SEK 43.1 million, provided the disutility from restricted time, as defined earlier, could be compared to the disutility from time absent from work. In other words, if we take into account only production losses in work, we clearly make a serious underestimation, in this case about 30%, of the total sacrifices of members of society. There are three important conclusions to be drawn from this study. Firstly, it obviously appears important to assess not only the productive working time of the injured people, but also other time, in
which normal activities are restricted. How this time is to be assessed and what values are to be ascribed to it, is still under debate. Secondly, the previous finding reveals the conflict between the utilitarian and the duty-based ethical basis of health care activities. This conflict has to be discussed and brought not only into the scientific but also into the planners’ agenda, since the two principles will in some cases lead to contrasting results. Thirdly, the results show the need for well-controlled studies with alternatives to show the effects of different actions. In a forthcoming study, this will be accomplished through a comparison of the costs of injuries in two municipalities, when there has been intervention against accidents in one of the municipalities. The present study includes all accident types treated at in- and outpatient care units; accidents registered only by works’ health services, school nurses, and district nurses are excluded. In a pilot study (National Board for Consumer Policies 1982), it was recommended that the two last-named should be excluded because they were minor. The same might also apply to the works’ health services, but this possible source of error cannot be taken into consideration here. Nonparticipation was small in comparison to other similar studies. Analysis of the type of nonparticipation (incomplete registration, overflow to the nearby university hospital, and refusals) supports the assumption that the effect of nonparticipation is small. The results give a comprehensive view of the accident profile and its economic consequences in Motala. Ll Acknow[edgemenr-This study was supported Ostergotland County Council.
by grants from
REFERENCES Aarseth, S.; Vatne, J. Injuries in Rauma county, Norway 1983. Tidsskr. Nor. Laegeforen. 111: 41-44, 1991. (In Norwegian). Alfaro, J-L.; Chapuis, M.; Fabre, F. Socio-economic cost of road accidents. COST 313 final report. DirectorateGeneral XIII. Commission of the European Communities, Luxembourg: Office for Official Publications of the European Communities; 1994. American Association for Automotive Medicine, Joint Committee on Injury Scaling. The abbreviated injury scale-1980 revision. Arlington Heights, IL: AAAM; 1980. Andersson, S.; Fridh, A-C.; Gustafsson, R. A.; Johansson, P. ABC for economics of public health. SLL Blue Report No. 246. Stockholm, Sweden: Stockholm County Council; 1994. (In Swedish). Baker, S. P.; O’Neill, B.; Karpf, R. S. The Injury Fact Book. Lexington, MA: Lexington Books; 1984. Baker, S. P.; O’Neill, B.; Ginsburg, M. J.; Li, G. The Injury
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Fact Book, 2nd edition. New York: Oxford University Press; 1992. Bjurulf, P. Oral messages. Linkiiping, Sweden: Department of Community Medicine. University Hospital; 1991. Bjurulf, P.; Johansson, G.; Ljungdahl, L.; Persson, H.; Levin, J-E.; Astrand, G. Reporting sick in relation to diagnosis and occupation 1985-1987 in Gstergiitland County. Linkoping, Sweden: Department of Community Medicine. University Hospital; 1990. (In Swedish). Bracht, N.; Kingsbury, L. Community organization principles in health promotion. A five-stage model. In: Health promotion at the community level. Bracht, N. (Ed.). Newbury Park, California: Sage Publications; 1990: Chap. 3; 66-88. Breidmer, J.; Gustafsson, M. Accidents in Motala municipality in the course of a year-a report on costs. Linkiiping, Sweden: Department of Management and Economics. University of Linkiiping; 1988. (In Swedish). Cedervall, M.; Persson, U. The costs of personal injuries sustained in traffic accidents during 1985. A national estimate of the cost of these injuries totally and in the different age groups. Lund, Sweden: Department of Traffic Planning and Engineering, Institute of Technology, University of Lund; 1988. (In Swedish). Committee on Trauma Research; Commission on Life Sciences; National Research Council; Institute of Medicine. Injury in America. A Continuing Public Health Problem. Washington, DC: National Academy Press; 1985. Drummond, M. F. Welfare economics and cost benefit analysis in health care. Scottish J. Political Econ. 28:125-145; 1981. Drummond, M. F. Cost-of-illness studies. A major headache. PharmacoEconomics 2:1-4; 1992. Drummond, M. F.; Stoddart, G. L.; Torrance, G. W. Methods for the economic evaluation of health care programmes. Oxford: Oxford Medical Publications; 1989. Gustafsson, M. Work-related accidents in Motala municipality and their cost to the community. Linkiiping, Sweden: Department of Management and Economics. University of Linkoping; 1989. (In Swedish). Hartunian, N. S.; Smart, C. N.; Thompson, M. S. The incidence and economic costs of major health impairments. Lexington, MA: Lexington Books; 1981. Hort, K.; Persson, U. What did road traffic accidents cost in 1982? IHE-report 19853. Lund, Sweden: The Swedish Institute for Health Economics; 1985. (In Swedish). Lindqvist, K. An accident-free municipality. Mapping of and intervention in accidents in Motala municipalityProject design. Motala, Sweden: Western Health and Medical Service District; 1983. (In Swedish). Lindqvist, K. Epidemiology of accidents in a Swedish municipality. Accid. Anal. Prev. 21:33-43; 1989. Lindqvist, K. Epidemiology of traffic accidents in a Swedish municipality. Accid. Anal. Prev. 23:509-519; 1991. Lindqvist, K. Towards community-based injury prevention. The Motala Model. Medical Dissertation No. 404. Linkaping, Sweden: Department of Community Medicine. Linkiiping University; 1993. Liukkonen, P. What does absence from work cost? Employers’ Stockholm, Sweden: The Swedish Confederation; 1989. (In Swedish). Liukkonen, P. Get to grips with the costs-rake in the
profits! Stockholm, Sweden: Personnel and Organization Administration, City of Stockholm; 1991. (In Swedish). Local Government in Motala. Motala municipality’s statistics for 1985. Motala, Sweden: Local Government in Motala; 1985. (In Swedish). MacKenzie, E. J.; Shapiro, S.; Siegel, J. H. The economic impact of traumatic injuries. One-year treatment-related expenditures. JAMA 260:3290-3296; 1988. Mattsson, B.; Thompson, S. Road traffic accidents and health care costs. SOU 1975:13. Stockholm, Sweden: Liber; 1975. (In Swedish). Mufioz, E. Economic costs of trauma, United States, 1982. J. Trauma. 24:237-244; 1984. National Board for Consumer Policies. Increase safety IPilot project-Registration of accidents in Ostergiitland County, March 1982. Vallingby, Sweden: National Board for Consumer Policies; 1982. (In Swedish). The National Central Bureau of Statistics. Population and housing census 1980. Grebro, Sweden: The National Central Bureau of Statistics; 1981. (In Swedish). The National Central Bureau of Statistics. Demopak 1983. Grebro, Sweden: The National Central Bureau of Statistics; 1984. (In Swedish). The National Central Bureau of Statistics. Annual regional employment statistics (ARSYS), 1987. Grebro, Sweden: The National Central Bureau of Statistics; 1989. (In Swedish). National Safety Council. Accident Facts 1988. Chicago: National Safety Council; 1988. The National Social Welfare Board. Classification of diseases 1968. Systematic list (International statistical classification of diseases, injuries, and causes of death, 1965 revision, adapted for indexing of hospital records and morbidity statistics). Stockholm, Sweden: The National Social Welfare Board; 1982. (In Swedish). Nilsson, G. Slipping-accidents. Report No. 291. Linkbping, Sweden: Swedish Road and Traffic Research Institute (VTI); 1986. (In Swedish). Persson, U. Cycle accidents and their costs. Lakartidningen. 80~4771-4773; 1983. (In Swedish). Persson, U. Motorcycle accidents and the costs of personal injury in 1982 and 1986. IHE-report 1987:4. Lund, Sweden: The Swedish Institute for Health Economics; 1987. (In Swedish). Rice, D. P.; MacKenzie, E. J.; Associates. Cost of Injury in the United States. A Report to Congress. San Francisco: Institute for Health and Aging. University of California, and Injury Prevention Center. The Johns Hopkins University; 1989. Schelp, L.; Svanstrom, L. One-year incidence of home accidents in a rural Swedish municipality. Stand. J. Sot. Med. 14:75-82; 1986. Sjogren, H.; Bjiirnstig, U. Trauma in the elderly: The impact on the health care system. Stand. J. Prim. Health Care 9:203-207; 1991. SOU 198439, health and medical care for the 1990’s. HS 90 main report. Stockholm, Sweden: SOU; 1984. (In Swedish). Stoddart, G. L. Economic evaluation methods and health and the Health Professions policy. Evaluation 5:393-414; 1982. Tolagen, A. Persons injured in traffic accidents in Gstergiitland. An examination of persons injured in traffic in the County of Gstergiitland during an 18-month
Economic consequences of accidents in Sweden
period. Linkiiping, Sweden: Department of Surgery, Faculty of Health Sciences, University of Linkoping; 1977. (In Swedish). Tolpin, H. G.; Bentkover, J. D. The economic costs of sports injuries. In: Sports injuries: the unthwarted epidemic. Vinger, P.F.; Hoerner, E.F. (Eds). Boston, MA: John Wright; 1982: Chap. 5: 37-47.
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World Health Organization. International statistical classification of diseases, injuries, and causes of death. 8th revision. Geneva, Switzerland: WHO, 1965. World Health Organization. Updating of the European regional health for all targets. EUR/RC41/8. Regional Committee for Europe. Forty-first session, Lisbon, lo-14 September, 1991.
Pergamon oool-4575(95)ooo65-&3
ONE-YEAR ECONOMIC CONSEQUENCES OF ACCIDENTS IN A SWEDISH MUNICIPALITY KENT S. LINDQVIST Department
and HAKAN BRODIN
of Community Medicine, Faculty of Health Sciences, and the Center for Medical Technology Assessment, Linkijping University, S-581 85 LinkBping, Sweden (Accepted
12 September
1995)
Abstract-The objectives of this study were to develop a system to calculate the economic consequences of accidents and to account for the economic consequences of all accidents during 1 year in a district. A total population injury survey was done in an area with a population of over 41,000. All accidents (N=4926) occurring within a 12-month period and requiring medical care were noted. The costs (calculated at 1991 prices) to the health care service (outpatient care, including primary health care and hospital care) were SEK 23.7 million (US$3.59 million), to trade and industry SEK 79.7 million (US%12.08 million), and for health insurance SEK 9.1 million (US%1.38 million). The cost for society of uninsured people is not possible to estimate using loss of production. However, the time lost from “normal activities” was registered. If this time is valued at the same price as working hours, a welfare cost of SEK 43.1 million (US$6.53 million) should be added. In a forthcoming paper, an assessment of the cost-effectiveness of interventions against accidents will be published. Keywords-Epidemiology,
Accidents, Economic consequences, Community
intervention,
Base-line study
and the administrative costs of insurance companies, the judiciary and the police (Hort and Persson 1985) (lUS$ =6.6SEK, January 1991). The financial burden to the community for the medical care of persons involved in traffic accidents almost doubled between 1982 and 1985 (Cedervall and Persson 1988). Bjurulf (1991) estimates sickness benefit costs in 1987 for accidents at 12% of the total sickness benefit costs for illnesses and injuries in the Swedish County of ijstergiitland. Because our knowledge in this field is so limited, more detailed studies are required. Economic data from a defined geographical area can provide important information for comparison and, not least, for planning accident prevention work. The present study is therefore based on accident causes and their economic effects in a defined community with a view to forming a basis for an effective accident prevention programme. The study forms part of a community analysis of all accidents occurring in the course of year and leading to contact with inand outpatient care facilities (Lindqvist 1983). This, in turn, is part of a larger prevention programme, based on a five-stage model, where community analysis forms the first stage (Bracht and Kingsbury 1990). The objectives of the present study are:
INTRODUCTION There is a need for detailed knowledge about relation-
ships between the individual, the environment, casualtylimiting factors, and the economic consequences of accidents. Of all causes of death in Sweden, injuries are responsible for the greatest loss of years owing to premature death at ages l-64, the largest risk group being young men (SOU 1984). Injuries, together with infections and musculoskeletal diseases, are the commonest reasons for sick leave in Sweden. Injuries and musculoskeletal diseases predominate among the reasons for long periods of sick leave (Bjurulf et al. 1990). The World Health Organization points out in Healthfor AII Year 2000 the importance of preventing injuries. The goal in Europe is to reduce, by the year 2000, injury, disability and death arising from accidents by at least 25% (World Health Organization 1991). Little is known about what the cost of accidents is to the community. Up to the present in Sweden studies in the field have been concerned primarily with traffic accidents (Mattsson and Thompson 1975; Tolagen 1977; Persson 1983; Hort and Persson 1985; Persson 1987; Cedervall and Persson 1988). The community’s total financial outlay for road traffic accidents in 1982 in Sweden was 5.1 billion SEK, of which 2.5 billion was for medical care and loss of production, and 2.6 billion for damage to property
1. To develop a system to calculate the economic consequences of accidents; 209
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K. S. LINDQVIST and H. BRODIN
2. To account for the economic consequences of all accidents in a district with over 41,000 inhabitants.
MATERIALS
AND
METHODS
Population and description of the district Motala lies in the western part of Gstergijtland County on Lake Vatter. On 31 December 1983, the total population was 41,432 (National Central Bureau of Statistics 1984), 82% residing in the built-up area, the rest in the surrounding countryside (Local Government in Motala 1985). All Motala residents were included in the study. Manufacturing, trade, and public administration were the chief occupations, with 77% of the gainfully employed working within these fields (National Central Bureau of Statistics 1981). The proportions of persons employed within the public and private sectors in Motala are very close to the national figures (in Motala 35% are public servants; 26% work for companies with more than 500 employees, 15% for companies with between 50 and 499 employees, 14% for companies with between 5 and 49 employees, and 11% for smaller businesses). The same is true of the proportion of gainfully employed, and of age and sex compositions (National Central Bureau of Statistics 1989). Motala has three health care centres and a county annex hospital with a casualty department. Methods An accident can be defined as “a sudden unexpected series of undesired occurrences in interplay between individual and environment which lead to personal injury” (Schelp and Svanstrom 1986). Traffic accidents are classified according to the E code of the International Classijication of Diseases (ICD). By definition, this category includes all accidents involving at least one vehicle of any kind. The definition used in the present study also embraces pedestrians injured in an accident not involving another person or vehicle, e.g. an injury caused by slipping or stumbling. This is in accordance with the Swedish Road and Traffic Research Institute’s definition of injuries resulting from traffic accidents (Nilsson 1986). A home accident is defined as an accident occurring in any type of home and/or residence-related premises such as a flat, a house, a driveway, a garage, an out-house, a garden, a yard, or a garden walk. A work-related accident is an accident at the workplace or another place where the injured employee happened to be at the time, either working or on a work-related assignment. Traffic accidents that occurred during the course of work are also included in this category. A sports accident is an
accident during games or physical training, whether for recreation or competition. “Other” accidents are those occurring in an environment or during an activity not defined above, e.g. another public place, school, daycare centre, etc. Sport-related accidents occurring at school are included in the sports accidents category (Lindqvist 1993). All accidental injuries treated at in- and outpatient facilities, excluding accidents registered only by works’ health services, school nurses, and district nurses, were recorded. The registration period covered the 54 weeks from 15 September 1983 to 30 September 1984, the first 2 weeks constituting a test period for registration and interview routines. A description of the registration and interview routines is published elsewhere (Lindqvist 1989, 1991). The Abbreviated Injury Scale (AIS) (American Association for Automotive Medicine 1980) was used as a measure of the gravity of the injury, and the classification according to diagnosis and external cause of injury (E code) follows the International Statistical Classijication of Diseases, Injuries, and Causes of Death (1965 revision, adapted by the National Social Welfare Board for indexing of hospital records and morbidity statistics). Age classification was set up with a view to agespecific accident risks, which mainly coincide with different school periods (preschool O-6 years; primary school 7-12 years; comprehensive school 13315 years; sixth-form college 16-19 years), and after that the age classification was divided in decades. This classification could also be used in planning preventive work. This study is performed in a socioeconomic perspective.. Costs are regarded as the values of the real resource use rather than just financial outlays. We have also aimed at a short term marginal cost perspective-the marginal cost per case-where the real costs exclude fixed costs like financing of buildings, equipment etc. Such costs will not change according to the treatment of single individuals or accidents. Furthermore, we have regarded the value of time as being equal for all people. This implies that we may add a social cost for elderly and children to the costs for lost production and absence from work. In cases where transfer costs are identified, we have specified those separately. Included in the costs of accidents are the marginal costs of medical care, of companies and of the health insurance system. The costs are calculated in 1991 year’s prices. Human costs in terms of pain and suffering, sorrow and distress are not included in the costs reported here. The duration of hospitalization and medically certified sick leave was noted during the year following the accident: 1 year after the accident 15 patients were still on sick leave, and seven
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Economic consequences of accidents in Sweden
of the uninsured but none of the insured were still in the hospital. Thus, the sick leave days and days spent in hospital after the 1 year period are excluded for these patients. Eleven accidents were fatal, 1 within 24 hours. Liukkonen (1989, 1991) has developed a method for calculating company costs which is used in this study. Included, among other things, are the costs of employing replacements and loss of production. The cost is estimated at an average of SEK 258 per hour of absence. For those persons not on sick leave (shortterm absence) the average length of absence was estimated at 4 hours. Health insurance expenditure for a period of sick leave is based on the actual sickness benefit paid out. Payments between various societal groups do not entail any real cost to the community, but rather constitute so-called income transfers (Mattsson and Thompson 1975). In stating the costs we distinguish between social economic costs and transfers thus avoiding doublecounting. The former are made up of direct costs (i.e. partly variable costs and partly hotel costs for inpatient care) and indirect costs (i.e. the value of goods and services which could have been produced if the accident had not happened). In this study we have taken account only of production losses due to sick leave. Reduced productivity at work due to injury is not registered. The calculation of indirect costs has been the subject of much scientific interest. A recent survey of the problems can be found in Drummond (1992). Some readers advocate the inclusion of indirect costs as being an adequate way of measuring changes in resource use in society. Others argue that one should exclude indirect costs e.g. on the basis that the objective of health care could not be to give priority to treatments especially favourable to the gross national product, and that the inclusion of indirect costs will give the wrong incentives to the health care professionals. This study has adopted the principles from Drummond et al. (1989, p. 79) where indirect costs are estimated as the production loss from labour activities, but also activities defined as “restricted normal activities”. This concept includes all other activities, apart from the labour market, which can not be maintained. Similar approaches have been recommended by the COST 313 action of the European Commission (Alfaro et al. 1994), and in Sweden by the Stockholm County Council (Andersson et al. 1994). In a study of non-labour market activities, students, retired and children together represent over 90% of the population. Others include e.g. early retired, housewives, and unemployed people. The adopted principles suggest that there should be
specific motivations from the analyst if different values are to be assigned from lost labour market activities and other restricted activities to society. Since some restricted normal activities might be more valued than working hours and some less, depending on the well-being of the individual, it was decided to use the same value as for labour activities, SEK 2064 per diem (Liukkonen 1989) in the indirect cost estimations for the uninsured group. Health insurance expenditures in respect of sick leave are included as transfers. Medical care costs concern the direct costs of inand outpatient care. The costs of patient transportation and home nursing are not included. Details of the treatment of patients who were hospitalized and operated on policlinically (524 patients) were obtained by examining hospital records, and the cost was worked out for each patient individually. The cost for patients treated in outpatient units was estimated, on the basis of typical examples of the 10 commonest accident diagnoses, at SEK 734 per visit, taking into account the work done by personnel, the duration of the treatment and the measures taken. The number of visits per patient to outpatient units was estimated, on the basis of a sample study of 100 patients, at 1.5 visits per person injured in an accident. Details of the estimation of costs are published elsewhere (Breidmer and Gustafsson 1988; Gustafsson 1989). Nonparticipants
The number of nonparticipants in the study was 8%. An analysis of the reasons for nonparticipation (incomplete registration, overflow to the nearby university hospital, and refusals) are published elsewhere (Lindqvist 1989). RESULTS There were 28,856 emergency attendances by Motala residents recorded during the period 1 October 1983-30 September 1984. Of these, 4926 (17.1%) were accident cases. Of the accident victims, 91.8% were seen at the Motala hospital casualty department, and the remaining 8.2% at the three health care centres. During the study period 118.9 accidents occurred per 1000 Motala inhabitants. Home accidents accounted for the largest number, followed by “other” accidents and sports and exercise accidents, with work and traffic accidents last (Fig. 1). Costs for diflerent types of accident
Company costs for loss of production and replacing employees on sick leave predominated and accounted for 77% of the cost to the community.
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K. S. LINDQVIST and H. BRODIN
costs and 81% of health insurance expenditure. In remaining accident groups women’s share of community expenditure was slightly larger than that of men. In the case of home accidents the cost of medical care dominated among women (64%), while company costs dominated among men (77%). In the other accident groups company costs were highest for both sexes (Table 2).
Work 617 (13.7%)
Home 1723 (35.0%)
Age differences in costs Traffic 632 (12.8%) Fig. 1. Distribution
of different
types of accident.
Medical inpatient care costs amounted to a total of 18%, and these were particularly heavy in the case of home accidents (39%). For work accidents the cost of inpatient care was marginal. Home accidents accounted for the largest share of community costs (29%), the “other” accident group having the lowest share (14%). Health insurance expenditures on sickness benefit paid to persons on sick leave due to injury were divided fairly evenly between the various accident groups (Table 1). Gender differences in costs
Men accounted for the highest share of both the cost to the community (59%) and health insurance expenditures (70%) for accidents. The greatest differences between the sexes were found in work-related accidents where men accounted for 80% of the cost to the community and 86% of health insurance costs, despite the fact that in Motala the proportion of gainfully employed women (45%) was almost as high as the proportion of gainfully employed men (55%) (National Central Bureau of Statistics 1981). The sexes also differed substantially in respect of sports accidents, men accounting for 76% of the community Table 1. Accidents
classified
according
For both sexes it was in the 20-59 age group that the highest proportion of cost to the community occurred, with the exception of women home accident victims in the 70 and over age-group who had a large (50%) share of community costs. For traffic, “other” and sports accidents, women of 40 and over accounted for a higher proportion of the cost to the community than did younger women, while the share of community costs for men of 39 and younger was greater than that of older men. The age group 20 and above generally represented the highest cost, both male and female. However, women between 50 and 59 did produce cases of higher cost. Among male patients cost was spread more evenly across age groups, though the highest cost was to be found in the 30-59 age groupexcluding men with work-related injuries aged 60-69 (Table 3). Costs in relation to location and cause of injury
Injuries to the extremities accounted in all for 74% of the cost to the community. Among home, traffic and sports accidents, injuries to the lower extremities accounted for the largest proportion of the cost, while injuries to the upper extremities made up the largest share among work-related accidents and in the “other” accident group. Apart from occasional high cost injuries the average cost per case was highest in traffic and workrelated accidents, which incurred higher costs due to
to types of accident
and types of cost (million SEK) Types of accident
Types of cost Social economic cost Company costs Health care costs; outpatient inpatient Total Transfers Health insurance exnenditures on sickness
benefit
Work
Home
Traffic
Sports
Other
Total
17.8
16.5
16.7
16.8
11.9
79.1
0.7 0.3 18.8
1.7 11.6 29.8
0.6 3.2 20.5
1.0 1.7 19.5
1.0 1.9 14.8
5.0 18.7 103.4
2.1
1.9
1.7
2.1
1.3
9.1
Economic consequences of accidents in Sweden
213
Table 2. Costs of accidents classified according to types of accident and sex Types of accident/Sex Work Types of cost Social economic cost Company costs Health care costs; outpatient inpatient Total per cent Total million SEK
Home
Traffic
Sports
Other
Total
M
F
M
F
M
F
M
F
M
F
M
F
94
96
77
36
81
82
91
71
81
81
86
65
4 2 100 15.0
3 1 100 3.8
7 17 101 14.1
5 59 100 15.7
3 16 100 9.5
2 16 100 11.0
4 5 100 14.9
6 22 99 4.6
9 11 101 7.1
5 15 101 7.7
5 9 100 60.6
4 31 100 42.8
1.8
0.3
1.4
0.5
0.9
0.8
1.7
0.4
0.6
0.7
6.4
2.7
Transfers Health insurance expenditures on sickness benefit Million SEK
Table 3. Average social economic cost per case of accidents classified according to types of accident and age (n = actual number of accidents; thousand SEK) Types of accident
Age (yr) Women O-6 7-12 13-15 16-19 20-29 30-39 N-49 50-59 60-69 7@Total/n Total million SEK Men o-6 7-12 13-15 16-19 20-29 30-39 40-49 50-59 60-69 70Total/n Total million SEK
Work
Home
Traffic
Sports
Other
Total
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
1.3 (121) 1.3 (51) 1.4 (21) 11.4 (42) 9.5 (60) 16.8 (96) 16.8 (60) 34.1 (58) 19.7 (99) 39.7 (198) 19.5 (806) 15.7
1.3 (21) 6.9 (18) 1.3 (24) 4.3 (17) 23.3 (27) 66.7 (28) 73.3 (29) 122.3 (37) 15.1 (39) 22.0 (45) 38.5 (285) 11.0
1.1 (4) 2.1 (61) 1.6 (92) 7.6 (44) 29.2 (38) 28.0 (26) 44.0 (11) 285.0 (4) 1.4 (3) 470.2 (1) 16.0 (284) 4.6
2.0 (158) 1.3 (87) 1.6 (26) 11.1 (53) 16.3 (123) 25.1 (128) 34.5 (88) 26.0 (83) 16.4 (82) 14.7 (89) 15.4 (917) 14.1
1.3 (25) 2.9 (45) 1.4 (46) 20.2 (47) 42.7 (43) 70.5 (39) 49.6 (18) 63.5 (28) 12.5 (29) 24.2 (27) 27.2 (347) 9.5
-
(0)
Yl I:,’ 17:O (8) 23.6 (24) 33.8 (22) 53.2 (31) 21.0 (25) 14.8 (11) (0) 31.0 (122) 3.8
Yl 9.5 14.4 26.4 31.8 45.8 73.3 2.1 27.1 15.0
(0) ((,o; (50) (161) (136) (97) (77) (28) (4) (555)
injuries to the lower extremities, pelvis (Table 4).
spine, chest, and
Costs in relation to degree of severity
Serious injuries (AIS-3) accounted for 16% of the total cost to the community, but constituted only 3% of all accidents. Moderate injuries (AIS-2) accounted for 69% of the cost and made up 48% of the accidents, while minor injuries (AIS-1) accounted for 12% of the
1.1 (3) 2.5 (82) 1.4 (88) 14.3 (108) 30.9 (238) 50.8 (83) 46.1 (29) 11.8 (10) 1.3 (5) 1.1 (3) 23.0 (649) 14.9
1.5 (43) 1.2 (88) 2.4 (35) 11.0 (28) 31.5 (31) 20.8 (23) 39.0 (23) 105.0 (30) 44.8 (30) 9.8 (32) 21.3 (363) 7.7
1.4 (189) 1.9 (218) 1.7 (173) 9.6 (139) 21.4 (180) 27.8 (195) 40.0 (154) 73.5 (154) 22.2 (182) 34.9 (276) 23.0 (1,860) 42.8
1.8 (65) 2.2 (134) 1.2 (64) 7.1 (66) 15.5 (82) 47.4 (56) 9.8 (40) 42.1 (30) 5.6 (33) 12.9 (28) 11.8 (598) 7.1
1.9 (251) 2.2 (348) 1.4 (226) 12.4 (324) 22.9 (647) 37.1 (442) 32.1 (272) 38.8 (228) 22.3 (177) 15.5 (151) 19.8 (3,066) 60.6
cost and constituted 49% of all accidents. Among traffic accidents, 5% of all traffic injuries were of AIS3-5 degree of severity, and these accounted for no less than 25% of the community costs for traffic accidents. Apart from occasional high cost severe and critical injuries, many high cost injuries were sustained at the workplace or sports-related. In total, though, traffic accidents represent the highest cost per case ratio (Table 5).
K. S. LINDQVIST and H. BRODIN
214
Table 4. Average
social economic
cost per case of accidents classified according in-jury (n=actual number of accidents;
to types of accident, thousand SEK)
diagnosis,
and location
or cause of
Types of accident Work Location
Diagnosis*
or cause
I
Head
Home
Traffic
Sports
Other
Total
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
7.9 (121)
5.5 (340)
14.3 (105)
6.4 (77)
3.6 (170)
6.7 (813)
extremities
II
30.4 (242)
15.6 (541)
23.5 (147)
17.4 (201)
23.9 (256)
20.8 (1,387)
Spine, chest, and pelvis
III
60.3 (41)
13.7 (77)
31.8 (54)
11.7 (54)
16.4 (38)
24.6 (264)
Lower extremities
IV
52.7 (104)
38.1 (357)
80.6 (138)
34.3 (360)
18.7 (271)
38.7 (1,230)
Internal injuries (chest, abdomen, and pelvis); foreign bodies
V
94.1 (1)
Multiple lacerations and injuries; contusions or crush injuries
VI
14.6 (134)
Burns
VII
12.3 (23)
Nerves and spinal cord
VIII
~
Upper
Drugs, narcotics, toxic substances, radiation, heat, cold, atmospheric pressure, etc; complications of trauma etc.
IX
uninjured
Total/n Total million
I II III IV V VI VII VIII IX
3.1 (44)
economic
(0) (0)
1.4 (3)
1.5 (7) 1.6 (2)
(0) (0)
41.3 (3)
2.1 (5)
-
(0)
5.7 (76)
(0)
1.1 (1)
-
400.8 (2)
6.8 (55) 10.6 (9)
4.7 (1)
15.5 (9)
17.3 (1,723)
32.4 (632)
20.9 (933)
15.4 (961)
29.8
20.5
19.5
14.8
and Causes
of Death-1965
Classification
of Diseases,
Injuries,
11.4 (1,073)
1.6 (9) -
(0)
21.0 (4,926) 103.4
revision):
and above. With regard to the number of days of restricted activity, however, the proportions are reversed. The retired group reported 13,817 days, the
1403 children had experienced accidents, compared to 495 uninsured aged 16-64, and 643 aged 65 social
-
-
Estimated costs for uninsured persons
Table 5. Average
(0)
1.1 (1)
110.0 (8)
11.4 (204)
66.7 (1)
~
*Specification of diagnosis (International Statistical 800-804, 830,850-854, 870-874,879,910,930-933,935 810-819, 831-834,840-842, 880-887,912-915 805-809, 846-848, 875%878,911 820-829,835-839, 843-845, 890-897,916-917 860-869,934, 936-939 900-907,918,920&929 940-949 950-959 960-999
~
10.4 (236)
3.6 (3)
3.4 (34) 4.9 (5)
18.8
43.8 (1)
10.2 (180)
800.5 ( 1)
(0)
27.8 (677) SEK
728.3 (1)
11.4 (319)
22.2 (11)
Other Not known;
1.6 (2)
cost per case of accidents classified number of accidents;
according thousand
to types SEK)
of accident
and degree
of severity
(n=actual
Types of accident Work Degree of severity Minor (AIS-1) Moderate (AIS-2) Serious (AIS 3) Severe (life-threatening, survival probable) (AIS-4) Critical (survival uncertain) (AIS-5) Fatal within 24 hr (AIS-6) Not known; uninjured Total/n Total million
SEK
Home
Traffic
Sports
Other
SEK (n)
SEK (n)
SEK (n)
SEK (n)
SEK (n)
11.7 (375) 42.2 (296) 328.9 (6)
3.4 (885) 26.9 (760) 86.8 (72)
4.1 (235) 37.5 (364) 117.5 (29)
3.4 (385) 26.6 (530) 237.6 (17)
4.4 (523) 27.2 (421) 65.0 (16)
-
(0) (0) (0) (0)
165.8 1.6
(4) (0) (0) (2)
762.3 901.3 1.1 729.3
(1) (1) (1) (1)
-
(0) (0) (0) 2.1 (1)
1.1
(0) (0) (0) (1)
27.8 (677)
17.3 (1,723)
32.4 (632)
20.9 (933)
15.4 (961)
18.8
29.8
20.5
19.5
14.8
Total SEK (n) 5.0 (2,403) 30.4 (2,371) 119.3 (140) 285.1 901.3 1.1 147.2
(5) (1) (1) (5)
21.0 (4,926) 103.4
Economic
consequences
uninsured aged 16-64 reported 5695 days, and children 1385 days. In the retired group, women dominated (61%) in number of accidents but the number of days they reported was more than four times that of men. If the welfare cost for the restricted days is estimated to be the same amount as the production cost for those in the labor force, these days would in total amount to SEK 43.1 million in 1991 prices. This sum can be compared to the total cost to the community for persons in the labor force, including treatment costs and production loss (SEK 103.4 million). Women reported a markedly larger share of the number of restricted days in all groups except in work-related accidents. The largest single group of restrictions appeared in retired women who had got moderate (AIS-2) or serious (AIS-3) lower extremity injuries in the home. This amounts to 3920 days19% of the total reported number of days. Estimated as previously, this would correspond to a welfare cost of SEK 8.1 million. Still, 71% of the number of accidents in the home had no reported activity restriction and only 25% had more than 2 restricted days. Ten per cent of the accidents reported a period of restricted activity of 3 weeks or longer. In total 90% of the women reported restricted activity of less than 3 weeks; 90% of the men, however, reported less than 1 week. Fifty-seven per cent of the accidents in the age group O-6 years occurred to boys. In the group consisting of early retired, as well as in the retired group, women dominated (55 and 61% respectively). Men dominated in the student and unemployed group (61 and 73% respectively). In this latter group 90% of the accidents reported a period of restricted activity of 4 days or less.
DISCUSSION The total cost to society of all injuries is unknown. There is very little comprehensive and ongoing reporting of injury costs (Baker et al. 1984; National Safety Council 1988; Rice et al. 1989; Baker et al. 1992). To a large extent, this is the consequence of problems in costing non-market issues. Many activities in health care and rehabilitation are e.g. subject to subsidized pricing. Also, many costs are impossible to reveal without considerable research. An example of this is the cost of lost production to companies, only reflected in lost profit, and which could not be revealed through studies of the company accounts. The study from Liukkonen (1989) is such an example. Finally, the development of economic methods for socioeconomic analysis lead to different
of accidents
in Sweden
215
opinions about what to include in the analysis and what the focus of the analysis should be. In particular the value of lost production to society has been discussed. However, until there is a convergence of details in the generally accepted methodology, the injury surveillance systems should still include the possibility of estimating the costs of injuries (Committee on Trauma Research et al. 1985). Some studies have been made of the financial outlays of different governing and insurance bodies. Such studies do not reveal the true resource use of the injury prevention and treatment which is the aim of the present study. A few studies of a similar approach have been made. A similar study was performed in Rauma Municipality, Norway (Aarseth and Vatne 1991). The costs were estimated using hospital accounts and insurance outlays. No attempt was made to estimate resource use, and insurance outlays were added to treatment costs. However, the treatment costs were comparable to those in the present study. Traffic injuries had the highest costs, 36%. In the present study, traffic accidents were 16% of the total treatment cost. Home accidents, which accounted for 56% in our study, were 29% in the Norwegian study. MacKenzie et al. (1988) performed a study of trauma patients discharged from hospital, aged 16-45, in Maryland, U.S.A. Results from different types of trauma could be compared with those of the present study. MacKenzie et al. report 30% of the total costs as due to head injuries and 32% of the costs to spine injuries. In the present study by far the largest share of the cost is accounted for by injuries to the extremities (72%). As we know from the results, most of these injuries are sustained by older people, who were not included in the MacKenzie et al. study. In the present study a separate analysis of the age group 16-45 was performed in order to compare it with the MacKenzie et al. study. The results were similar in that the cost of injuries to the extremities and head dominated in both studies, but differed inasmuch as 69% of the costs were taken up by extremity injuries in the present study, compared to 43% in the MacKenzie et al. study. In the latter study 26% of the accident costs consisted of head injuries compared to 18% in the present study. A study by Sjijgren and Bjijrnstig (1991) investigated the health care costs of injuries in a Swedish population. All accident injuries in the district, treated at a university hospital, were registered. People older than 60 were compared with those younger than 60. The elderly comprised slightly less than 20% of the population, but accounted for 42% of the costs. In the present study we found that the elderly comprised 37% of the population but 74% of the costs. The
216
K. S. LINDQVIST and H. BRODIN
authors conclude that since the elderly account for a large part of the costs they should also be given commensurate priority in the research and intervention programmes. However, it is also important to take into account the benefits of health care in terms of quality of life. The differences in the results of the present study and the three other studies could be due to the studies having differently designed inclusion criteria and registration routines, as well as to differences in calculating unit prices, differences in the character of the catchment areas and in population structures, and to the fact that two of the studies are based on material concerning victims treated at hospital. The present community-based study was carried out in the municipality of Motala and comprises persons resident in the district who required consultation for treatment of an accidental injury. Basically, two perspectives could be used to study the costs to society due to accidents. The first, the cost-of-illness method, estimates the total cost of accidents to society. The second method, the cost-ofintervention approach, estimates the marginal (shortterm) costs to society of alternative small-scale projects. This method is more decision-oriented than the former since it can be used for analysis of different courses of action, which is the purpose of this study. The first, which is used in most studies in this area, can be used for overall macro-economic judgements. In principle, the estimation of direct treatment costs is a straightforward matter. The only major problem arises when service activities and administrative overhead costs are to be distributed among the treated patients. Indirect costs and/or welfare costs, however, present both conceptual and methodological problems. Hartunian et al. (1981) review the methodology for estimating the cost to society in matters of life and death. By and large they use the same technique as the present study. The authors also calculate the indirect costs, concluding that these costs amount to 70% of the total cost to society. In discussing the indirect cost approach, the authors argue that “This approach would be entirely appropriate if humans were considered simply as productive machines. The fact that societies value the very young and the elderly as well as the middle-aged signifies that attributes other than a person’s level of production (as measured by his present-value earnings) are important to human values” (Hartunian et al. 1981, p. 42). However, since the authors consider only “economic” costs they refrain from calculating other values. Hartunian’s study is a good representation of the present state of the art and the principles are also adopted by several policy forming bodies, such as Alfaro et al. (1994) and Andersson et al. (1994).
An issue of special concern is how to treat costs of lost production not only to the companies, but to society. In many studies lost production has become the major cost item and is consequently decisive for the recommendations of the study. Mufioz (1984) also estimates direct and indirect costs, e.g. forgone earnings due to fatal and nonfatal injuries, of trauma in the United States. Mufioz found that the largest single group of costs was indirect costs for men, almost twice the direct cost for the same group. This result is not surprising, however, since the wages of men are in general higher than those of women. This is not discussed in Mufioz’ study, and his conclusion that this finding is valuable for legislation and policymaking, and also for improving medical efficiency or cost containment, does not note the consequence that, for instance, in preventive efforts wealthy white males will be preferred to poor black women. The obvious conflict between alleged economic incentives and the actual vast allocation of health care resources to the elderly, leads to a discussion of the relevance of economic arguments (Drummond 1981; Stoddart 1982; Drummond et al. 1989). Tolpin and Bentkover (1982) estimate the economic costs of sports injuries. The same conceptual definition is used as in other studies, but financial costs are also supplemented with two other kinds of costs, societal costs and social costs. Examples of the first kind are insurance administration costs and legal and court costs. The second kind is the negative value of disutility from psychosocial impairment that results from the injury. The authors recognize the problems of valuing productivity losses from people with different wages, and also of estimating the value of housewives’ services. The authors conclude that many other kinds of pain and suffering should be included in the estimations, although difficult to quantify, and that economic costs serve to highlight an important aspect of illness and injury, namely, the opportunity cost of sustaining such injuries in a society that must decide how to allocate its scarce resources. Normally, the indirect costs have to be treated with caution. In estimations where a considerable part of the study population is elderly, housewives, mentally retarded or young children, the indirect costs-measured as production loss-is without meaning. The idea that production losses are a cost to society means that an objective of each individual is to contribute to the gross national product. It is questionable whether this is a relevant standpoint. The ultimate goal of a civilized society is rather to support individuals in their “production of quality of life”. This quality could be produced by working in the labor market, doing domestic chores, reading fairy tales to the grandchildren or (with very small financial
217
Economic consequences of accidents in Sweden
compensation) taking part in cultural activities. If this were not the case, care of the elderly, housework and cultural activities would not have the prevailing massive support from society. In this study, however, the dominating objective of society is to prevent accidents both in the working population and the others. Health insurance is a compulsory system and as a consequence the concept of transfer is debatable. Since the insured individual is not able to leave the system, it might be conceived as tax. The marginal cost to society might then be considered to be a real cost. As a consequence we have presented those transfer costs separately. Clearly, the value of avoiding restricted, nonworking hours is greater than zero. For some people the value might be much greater than the available market wages, for some it might be less. We have found no scientific evidence that a person’s income should reflect his value of time, since other immaterial values and “disvalues” should also be added to the monetary values. No other motive could be found to weigh the value of time differently for different individuals. The present study has then chosen to treat all time of equal value to all involved persons. To choose the value equal to production losses for representative Swedish industry could, for want of something better, be a reasonable compromise. The time records of the uninsured people may, however, also be underestimated. We have reason to believe that some individuals do not consider their time to be restricted in the way intended in the questionnaire. Consequently, some individuals might well have reported a shorter period of restricted activity after injury than others would have done in the same situation. The result will be that welfare costs for this group will be underestimated. The obvious overall result is that retired women, injured at home in their lower extremities, dominated the uninsured group. Almost 20% of the total uninsured number of days, in which normal activities were restricted belongs to this group. Compared to patients in the labour force, the welfare cost accruing to uninsured patients could be estimated at a further SEK 43.1 million, provided the disutility from restricted time, as defined earlier, could be compared to the disutility from time absent from work. In other words, if we take into account only production losses in work, we clearly make a serious underestimation, in this case about 30%, of the total sacrifices of members of society. There are three important conclusions to be drawn from this study. Firstly, it obviously appears important to assess not only the productive working time of the injured people, but also other time, in
which normal activities are restricted. How this time is to be assessed and what values are to be ascribed to it, is still under debate. Secondly, the previous finding reveals the conflict between the utilitarian and the duty-based ethical basis of health care activities. This conflict has to be discussed and brought not only into the scientific but also into the planners’ agenda, since the two principles will in some cases lead to contrasting results. Thirdly, the results show the need for well-controlled studies with alternatives to show the effects of different actions. In a forthcoming study, this will be accomplished through a comparison of the costs of injuries in two municipalities, when there has been intervention against accidents in one of the municipalities. The present study includes all accident types treated at in- and outpatient care units; accidents registered only by works’ health services, school nurses, and district nurses are excluded. In a pilot study (National Board for Consumer Policies 1982), it was recommended that the two last-named should be excluded because they were minor. The same might also apply to the works’ health services, but this possible source of error cannot be taken into consideration here. Nonparticipation was small in comparison to other similar studies. Analysis of the type of nonparticipation (incomplete registration, overflow to the nearby university hospital, and refusals) supports the assumption that the effect of nonparticipation is small. The results give a comprehensive view of the accident profile and its economic consequences in Motala. Ll Acknow[edgemenr-This study was supported Ostergotland County Council.
by grants from
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