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The Costs of Child Maltreatment
69 The Costs of Child Maltreatment Kristine A. Campbell, MD, MSc
“Ignoring the direct and indirect expenditures associated with attempts to resolve this social problem will not make the task less costly nor will it result in the most efficient practice choices. While no one would argue that costs should be the sole determinant of policy, neither should costs be considered an inappropriate contributor to the decision-making process.” Deborah Daro, Confronting Child Abuse, 19881
INTRODUCTION How does one determine the costs of child maltreatment? For some, calculating a dollar value to describe the impact of maltreatment seems inappropriate. For others, the lifelong effect of maltreatment on children and society makes such calculations overwhelming. Yet in a society with competing economic priorities, understanding the costs of maltreatment, as well as the costs of programs designed to prevent or respond to maltreatment, is a critical step toward effective health and social policies. Intimate partner violence research supports this contention. Studies examining data from health maintenance organizations consistently find increased health care costs and use among women reporting a history of intimate partner violence.2-4 Total costs of intimate partner violence in 1995 were estimated at $5.8 billion, over $1300 per victim.2 Such data can support medical and social investments in prevention and intervention programs. Compared with intimate partner violence, however, determining the costs of child maltreatment poses unique challenges. The mandated social response to maltreatment adds costs of protective, investigative, and legal interventions often overlooked in the analysis of intimate partner violence. Associations of child maltreatment with learning disability, juvenile delinquency, and adult health problems make it difficult to draw boundaries around cost estimates for abuse. Economic analyses in pediatrics commonly reflect costs to caregivers related to diagnosis and care of an ill or injured child, an ethically challenging proposition if the caregiver is a possible perpetrator. It is beyond the scope of this chapter to suggest solutions to the philosophical and methodological challenges underlying the economic analysis of child maltreatment. The goals of this chapter are to provide a basic overview of approaches to economic analysis, to present best evidence related to the costs of child maltreatment, and to consider directions for future research in this area.5 634
OVERVIEW OF ECONOMIC ANALYSIS There are several approaches to economic analysis. Selecting the appropriate analytic approach depends on the question being asked and on the data available to the researcher (Figure 69-1). At the most basic level, an economic analysis provides an understanding of the costs associated with a given condition. A cost-of-illness (COI) analysis can provide critically important information about the medical and social costs associated with a health condition. COI does not differentiate costs based on medical decision-making, nor does it try to place a value on the outcomes gained by particular interventions. As such, COI alone cannot guide rational health care policy decisions. Cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) compare costs associated with competing interventions, and balance these costs against the health-related benefits of those interventions. This approach allows decision-makers to place a proposed intervention into four possible categories: (1) improves outcomes and saves money, (2) improves outcomes but costs money, (3) worsens outcomes but saves money, and (4) worsens outcomes and costs money. Clearly, interventions in the first category should be implemented, whereas those in the fourth should be set aside. Information gained in the full CEA analysis can guide policy decisions regarding interventions falling into the second and third categories based on funding realities and social priorities. A distinct approach to economic analysis is a cost-benefit analysis (CBA), in which the costs of medical interventions are balanced against the calculated monetary value of health outcomes. CBA provides a strictly economic perspective on medical and social interventions. Although CBA has applications in regulatory decision-making, it is unusual in the healthcare literature, where monetary valuation of health outcomes is generally viewed with skepticism or distaste.6-8 This chapter focuses on the application of COI, CEA, and CUA in improving our understanding of the costs of child maltreatment.
Cost-of-Illness Analysis How much does it cost to provide medical care for a child with abusive head trauma? What are the costs of mental health therapy for a child recovering from chronic sexual abuse? These are the questions answered by a COI analysis.
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
635
QUESTION
How much do we spend on child physical abuse every year?
What does it cost to prevent a case of physical abuse using Parent-Child Interaction Therapy in high-risk families?
What is the cost of improving health-related outcomes for children (and caregivers) using ParentChild Interaction Therapy in high-risk families?
Analytic approach
Cost of illness analysis (COI)
Cost effectiveness analysis (CEA)
Cost utility analysis (CUA)
Numerator: Direct medical costs (hospital, physician, medication) + Direct non-medical costs (caregiver costs, education, CPS) + Indirect costs (productivity losses)
Numerator: Intervention costs + Change in direct medical costs (hospital, physician, medication) + Change in direct non-medical costs (caregiver costs, education, CPS) + Change in indirect costs (productivity losses)
Numerator: Intervention costs + Change in direct medical costs (hospital, physician, medication) + Change in direct non-medical costs (caregiver costs, education, CPS)
Denominator: Measured units (per year, case, or person)
Denominator:
Denominator: Health adjusted survival unit (quality adjusted life years, QALY) *includes productivity losses
Natural units (years of life gained, cases averted, cures achieved) FIGURE 69-1 Visual comparison of cost-of-illness, cost-effectiveness, and cost-utility economic analyses.
As in all research, results of COI analyses are dependent on the assumptions built into the study design. Several important assumptions to consider are discussed in the following paragraphs. Sample selection: Costs may vary widely based on the sample selected for analysis. Imagine a COI analysis for children with abusive head trauma. Substantial data exist to support the assumption that most of these children are critically ill at presentation.9-11 It might be reasonable to assume that most of these children are admitted to intensive care units and to select a sample of PICU admissions with a diagnosis of subdural hemorrhage and child abuse for analysis. Yet this decision excludes potentially important subsets of children. As many as one tenth of children with abusive head trauma do not survive to admission (H.T. Keenan, University of Utah School of Medicine, personal communication, March 3, 2010). The proposed analysis excludes costs of children dying at home, in transport, or in the emergency room. Conversely, improvements in medical imaging and physician training may increase the numbers of mildly symptomatic children admitted to general medical or surgical services, bypassing the ICU altogether. Excluding those children never admitted to the ICU, whether because of early death or early diagnosis, could falsely inflate the medical costs associated with abusive head trauma. Time horizon: Researchers must explicitly define the time horizon of any economic analysis. Does an accounting of the medical costs of abusive head trauma include only the costs
of acute hospitalization, or extend to the lifelong costs of rehabilitation, durable medical equipment, and recurrent hospitalizations of a child with profound neurological disability?12,13 Should the medical costs of sexual abuse be limited to the acute medical examination and specific therapies, or should there be consideration of costs of mental illness and medical complications that are increasingly linked to abusive experiences in childhood?14-18 These decisions are driven by the objective of the analysis, but are shaped by the limitations of the data available. Perspective: The perspective of any economic analysis defines the data used in the analysis. From a medical payer perspective, the costs of abusive head trauma are the acute care and chronic medical needs of an injured child. From a societal perspective, however, the cost burden includes child protective services and legal investigations, foster care placement, prison costs for a perpetrator, and lost wages resulting from permanent neurological disability. Both perspectives are valid, although the results of each analysis will be dramatically different. Costs included: Estimating costs of child maltreatment raises unique questions regarding the scope of costs to be included. Direct medical costs are the most easily understood, encompassing the value of the health care “goods and services” needed for the proposed intervention. These can reflect the costs of a single hospitalization, or repeated encounters over time. Direct nonmedical costs reflect the value of resources outside of the medical system consumed by the
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intervention. Traditionally, these nonmedical costs account for time required of patients, family, and volunteers for the studied intervention. Nonmedical costs unique to child maltreatment can include child protection services, police investigation, legal intervention, foster care, special education, and costs of juvenile delinquency. Indirect costs, or productivity costs, can account for lost wages or productivity over time that can be attributed to a given health condition. Cost adjustment: Cost data often require adjustment for economic analysis. Perhaps the most commonly recognized cost adjustment is inflation adjustment, which allows for comparison of cost data across many years. These calculations typically rely on the general or medical component of the Consumer Price Index (CPI).19 A second adjustment frequently required for health care research is profit adjustment. In any medical system outside of a single-payer system, medical charges include a profit component that substantially overestimates the true medical costs of any intervention. There are several solutions to this dilemma. In prospectively collected data, researchers might have access to the true costs of the goods and services being used for the study. In many cases, however, researchers must rely on retrospective data that include only charge data. Under these circumstances, a cost-to-charge ratio can be applied to the economic data to better estimate true medical costs. These ratios are often available at national, regional, hospital, or departmental levels.
Cost-Effectiveness and Cost-Utility Analysis A CEA balances costs added by a medical intervention against lives saved, cases averted, or years of life added as a result of the intervention. A CUA is a specialized subset of CEA, in which outcomes are measured with a metric that accounts for quality of life, such as the quality adjusted life year (QALY). CUA has been identified as the preferred method for economic analysis by the Panel on Cost-Effectiveness in Health and Medicine.6 In contrast to COI analyses, which describe system costs without consideration of outcomes, CEA provides a measure of effectiveness of interventions in economic terms. An appropriately conducted CEA can improve our understanding of the incremental improvements in health expected with new expenditures and can guide health care decision-making at a policy level. Unfortunately, CEA techniques can be challenging to conduct and interpret. A poorly conducted CEA can dramatically misrepresent cost-effectiveness estimates because of inappropriate technique, inadequate data, or investigator bias. A misinterpreted CEA might reflect a simplistic utilitarian perspective, excluding the ethical principles of nonmalfeasance, beneficence, and justice that are critically important in decision-making around child maltreatment. The following overview is in no means a comprehensive review of CEA methodology, but provides a guide to important elements to be considered in the critical review of CEA literature. Costs: Consideration of costs for a CEA analysis includes the same element considered for COI analysis, with important additional considerations. A cost-effectiveness analysis is fundamentally a comparison of costs-to-benefit ratios between two or more interventions. Although the compari-
son intervention may be nothing more than “standard treatment” or “do nothing,” the analysis must account for change in direct and indirect costs under each intervention arm. In a randomized control trial, researchers may have full access to cost data for each arm. In a one-armed observational trial, however, costs for the study population may be compared with literature-derived costs of illness to examine cost-effectiveness of the intervention. Finally, a CEA can mimic a true randomized controlled trial by relying only on literaturederived data in circumstances in which adequate data for both intervention arms already exist. Researchers must examine the strength of the cost data available for comparison when relying on literature-derived values. Outcomes: In COI analysis, all costs are incorporated into the numerator. In CEA research, however, costs cannot simultaneously appear in the numerator, reflecting costs, and the denominator, reflecting outcomes. A CEA can include indirect costs accounting for lost work and wages in the numerator, but places years of life lost and gained in the denominator. In CUA, all indirect costs should be reflected in the health-related outcome metric used for the denominator. The choice of outcomes in CEA research is critical and controversial. The most basic metric is years of life gained, or lives saved, by a given intervention. There is increasing recognition, however, that such measures overlook quality of life concerns. In adult medicine, the prolongation of chronic and life-threatening illness can raise health expenditures for marginal survival gains with poor quality of life. In pediatrics, similar questions are considered in analysis of health care expenditures for technologically dependent infants and children. CUA relies on “utilities” to reflect concerns of quality of life over simple survival. The quality adjusted life years’ (QALY) measure remains the most commonly used metric to express the balance between length and quality of life (Table 69-1). Although conceptually appealing, practical issues around measuring quality of life and the interpretation of these measures are subject to intense ethical debate, particularly in pediatrics.20-22 It remains unclear how best to measure quality of life of young children. There are few—if any—validated measures of quality of life for children under 7 years of age, and researchers might rely on instruments that are
Table 69-1
Sample Calculation of Quality Adjusted Life Years (QALYs)
Condition
Years (0-1)
Utility (0-1)
Total QALYs (Time × Utility)
12 months of life in perfect health
1
1
1
10 months of life in perfect health
0.8
1
0.8
12 months of life with poor health
1
0.8
0.8
6 months of life with poor health
0.5
0.8
0.4
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
developmentally inappropriate for a pediatric population. In children who cannot participate in quality of life studies because of age or disability, proxy responses by parents and caregivers are typical substitutes.23,24 These issues are amplified by concerns of child maltreatment. How does one measure the impact of foster placement on the quality of life of a 15-month-old? How do we use parental proxies if we doubt the integrity of the parents? Although these considerations do not necessarily exclude quality of life metrics in the assessment of the cost-utility of an intervention, researchers must acknowledge the limitations of these measures and include analyses to account for these uncertainties. Discounting: Many primary care health interventions are made in anticipation of future, rather than immediate, health benefits. This is particularly true for pediatrics, where the benefits of a healthy childhood can be sustained over a lifetime. It is generally assumed, however, that immediate health is valued above future health. To address this concern, most economic analyses discount both costs and benefits at about 3% to 10% per year. This practice is not without question, however, since it can lead to undervaluing of preventive or pediatric health care.25 Sensitivity analysis: A unique characteristic of CEA is in the reflection of uncertainty. Medical literature traditionally relies on p-values and confidence intervals to describe uncertainty around a result. These statistics are not helpful in CEA because of modeling techniques that allow researchers to generate sample sizes to support unrealistically tight confidence intervals. For CEA, uncertainty is reflected in sensitivity analyses, in which the analysis is repeated over a rational interval of values of costs variables and outcome probabilities. For example, CEA of a home visitation program could include the expected number of home visits or the annual salaries of the home visitors, numbers that vary by program design, by geography, and by chance. Researchers should run the model using the lowest and the highest number of
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home visits as well as the lowest and the highest home visitor salaries. This type of sensitivity analysis provides the range of outcomes that can be reasonably expected under conditions of uncertainty. As almost all research in child maltreatment involves substantial uncertainty, any CEA of interventions for child abuse should reflect this uncertainty with careful sensitivity analyses.
ECONOMIC ANALYSIS IN CHILD MALTREATMENT26 Costs of Child Maltreatment (COI) Several studies have attempted to describe the total costs of child maltreatment in the United States (Table 69-2). All of these studies rely on important assumptions related to the incidence of hospitalization and medical care for physical injuries, as well as the causal link between abuse and observed outcomes among children after abuse. In 1988, Daro1 published the first estimates of the costs of child maltreatment, making informed assumptions regarding the need for inpatient treatment of abusive injury; ongoing medical, rehabilitative, and educational needs of abused children; and lifetime loss of earning potential attributed to childhood abuse. In 1996, the U.S. Department of Justice examined costs of child maltreatment.27 The authors acknowledged the limitations of the research, commenting that “… virtually no estimates of medical costs are available for child abuse,” and that “… this study’s estimates for child abuse should be viewed as very rough and worthy of further study.” In contrast to other studies, these authors calculated a monetary value for the quality of life costs of abuse, with estimates of $30,276 for emotional abuse, $82,506 for physical abuse, and $128,853 for sexual abuse. These intangible costs were by far the largest contributor to costs for all violent crimes in this
Summary of Studies Estimating Total Annual Costs of Child Maltreatment in the United States (All Costs Adjusted to 2007 Dollars)
Table 69-2 Study
Cases (n) 1
Costs Examined
Direct Medical Costs
Direct Nonmedical Costs
Indirect Productivity Costs
Daro, 1988* (Lifetime)
739,000 (23,648)
Costs/case Total costs
$56 ($1,761) $41 million
$3,177 $2.3 billion
$1,854-3,662 $1.4-2.7 billion
Miller, 1996†27 (Annual)
926,000 (all)
Costs/case Total costs Costs/case Total costs Costs/case Total costs Costs/case Total costs
$3,774 $3.5 billion $9,025 $1.7 billion $5,008 $1.8 billion $3,874 $1.3 billion
$2,639 $2.4 billion $1,659 $307 million $3,079 $1.1 billion $3,042 $1.0 billion
$3,157 $2.9 billion $3,013 $557 million $4,879 $1.7 billion $1,291 $435 million
Costs/case Total costs
$5,004 $7.8 billion
$40,520 $63.0 billion
$21,251 $33.0 billion
185,000 (sexual) 355,000 (physical) 337,000 Wang, 200728 (Annual)
1,553,800
*Daro estimated medical costs based only on the acute inpatient medical care of 23,648 children with severe physical abuse and is, therefore, a substantial underestimate of the true value. Direct medical costs are provided based on the total population of abused children and the subset of those with severe physical abuse. Daro also excluded many cost categories included in subsequent analyses. † Miller did not include child neglect in this economic analysis.
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analysis. Finally, the Prevent Child Abuse America Foundation provided a recent estimate of the total national costs of child maltreatment, again relying on informed estimates for their analysis.28 The wide range of estimates in these three studies reflects the differences in sample selected, perspective adopted, time horizon, and costs included by each of the authors. The limitations of these studies must be recognized. There is a tendency in these analyses to suggest causation where prior epidemiological studies have only identified an association. In other words, although maltreatment is associated with later need for special education, it is not clear that maltreatment causes this educational need. It is not clear that prevention of maltreatment would eliminate all of these excess educational costs.28 Although adult survivors of childhood maltreatment have a higher risk of illness, research identifies an additive effect of multiple childhood adversities rather than a direct correlation between child maltreatment and adult poor health.17 It might not be reasonable to assume that prevention of child abuse will eliminate these future medical costs. Efforts to describe acute medical costs associated with child abuse have used hospital charges for inpatient care of children diagnosed with abuse. These studies are limited by reliance on medical charges rather than medical costs, capturing medical resource utilization as well as profit margin associated with health care in the United States. By comparing medical charges in abuse-related hospitalizations to those in nonabuse-related hospitalizations, however, these studies do suggest relatively high medical resource utilization associated with child abuse (Table 69-3). These differences likely reflect the increased severity of injury, younger patient age, and increased length of stay in children with abuserelated hospitalizations. There is increasing evidence that childhood abuse results in increased health risks sustained into adolescence and adulthood. Two authors have linked self-reports of childhood maltreatment with healthcare utilization in adult women enrolled in a health maintenance organization.14,18 Both studies have observed moderate increases in health care costs among these women, suggesting that child abuse Table 69-3 Study
has a real and sustained effect on health and health care utilization among survivors.
Cost-Effectiveness of Child Maltreatment Programs Many authors have called for improved economic analysis of child abuse prevention and intervention programs, yet few such analyses exist.7,33-36 Population-based prevention programs tend to be resource intensive. One British study calculated that an 18-month home visiting program cost £3246 per child (2003-2004 British pounds), even accounting for costs saved in health care utilization and counseling in the intervention arm over the study period.37 In 2007 U.S. dollors, this is $6245.* Given the early cost demands of such programs, long-term CEA provides the opportunity to weigh the initial costs against sustained benefits. With this approach, parent training programs have been found to be cost saving in several published analyses. In an evaluation of the Nurse-Family Partnership in Elmira, New York, Olds et al38 concluded that the program of home visitation by nurses saved $4459 per family over 48 months because of lower utilization of welfare services among families enrolled in the treatment arm of the trial. The Rand Corporation estimated cost savings of the Elmira NurseFamily Partnership program of $24,594 per high-risk family over 15 years based on sustained reductions in welfare reliance for mother, reduced criminal justice costs for mothers and children, and increased tax revenues from maternal employment.39 An analysis of the Family Support Center, an integrated home/school/community program for highrisk families estimated cost savings of $9564 per high-risk family over approximately 6 years.40 Although this study relied on measured program costs over 1 year, it made broad assumptions regarding potential long-term cost savings based on literature review. In each of these studies, the finding of overall cost savings allowed the authors to avoid the difficult calculation of lives *2003–2004 UK pounds converted to 1998 U.S. dollars, then adjusted for inflation to 2007 dollars.
Medical Charges Associated with Hospitalizations Related to Child Abuse (All Charges Adjusted to 2007 Dollars) Study Sample
Mean Charges Abuse Sample (n)
Mean Charges Nonabuse Sample (n)
Ratio of Charges*
Ettaro et al, 200429
Children <3 yr of age with head trauma admission, 1995-1999
$49,884 (n = 89)
$19,503 (n = 288)
2.6
Irazuzta et al, 199730
PICU trauma admission, 1991-1994
$42,929 (n = 13)
$41,097 (n = 34)
1.0
Libby et al, 2003†31
Children <3 yr with head trauma admission, 1993-2000
$33,672 (n = 283)
$14,378 (n = 814)
2.3
Rovi et al, 200432
Post-neonatal pediatric hospitalization in HCUP database, 1999‡
$23,977 (n = 966)
$11,839 (n = 1,371,835)
2.0
*Ratio of medical charges for children hospitalized for abuse-related reasons compared with children with nonabuse-related hospitalizations. † Charges adjusted based using 1996 (study mid-point) CPI data. ‡ Healthcare Costs and Utilization Project (HCUP).
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
saved, cases averted, or quality of life gained. When a program saves money, and meets or exceeds the outcomes observed under current practice, there is no need to further complicate the analysis. The decision to implement these programs, if the assumptions of the analysis are accepted, should be clear. These studies identified cost savings not in violence prevention but in improved parenting, improved socioeconomic status, and improved community integration. Studies relying only on violence prevention to demonstrate cost effectiveness of a program face a much stiffer challenge.41,42 Although the societal costs of child abuse are substantial, few studies examine the cost effectiveness of our interventions. One study examined the cost effectiveness of rehabilitation of child sexual abuse perpetrators, concluding that treatment programs may save $124,093 compared with traditional incarceration based on decreased recidivism in the 5 years following prison release. The authors acknowledge limitations in the estimates of recidivism within this population and make appropriate sensitivity analyses, pointing out that cost savings persist as long as recidivism rates among the untreated population remained higher than 3% (compared with 25% in the treated population).43 A more recent Australian study used a cost–benefit analysis to assess treatment programs for child sexual abuse perpetrators. Without providing specific program data, the authors conclude that the expected costs of such programs could range from a loss of $6850 to savings of $39,870 per treated prisoner (1998 Australian dollars). In 2007 U.S. dollars, this translates to savings of from $5525 to $32,160 per treated prisoner.* The estimates varied based on the interaction between the reduction in recidivism attributed to the treatment program and the range of tangible and intangible costs attributed to recidivism.44 Only one study has examined the cost effectiveness of a specific medical decision related to child maltreatment.45 The dilemma over when to obtain radiographic imagining (head CT) for a well-appearing infant presenting with nonspecific signs and symptoms that may reflect brain injury is common. Using literature-derived variables to model shortterm cost effectiveness of CT imaging in these children, the authors found that imaging could be cost saving from a medical perspective, but only when the probability of abusive head trauma rose above 16%. From a societal perspective, identification of abuse was almost always expensive when considered over a short 1-year time frame. The authors made no attempt to identify long-term outcomes for children with earlier recognition of abuse, citing limitations in available data to address these issues.
STRENGTH OF THE EVIDENCE It is widely accepted that violence, in its many forms, is expensive at individual and societal levels. Children can account for more than 35% of all crime victim costs.27 Despite this, clear evidence for costs of violence against children, and the cost effectiveness of programs responding to the problem, is generally lacking. Most estimates of the costs of child maltreatment rely heavily on assumptions that fail to account *1998 Australian dollars converted to U.S. dollars, then adjusted for inflation to 2007 U.S. dollars.
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for the multiple social confounders associated with child maltreatment and with its long-term outcomes. The consistent finding of cost effectiveness of prevention programs evaluated is encouraging, yet remains limited by our poor understanding of the true costs of child maltreatment.
DIRECTIONS FOR FUTURE RESEARCH Research in child maltreatment is rapidly accelerating. In 2007, the National Institutes of Health sought proposals for research that would move the field beyond an understanding of the epidemiology of maltreatment and toward “… largescale, community-based, effectiveness trials” of programs to prevent and respond to child maltreatment.46 As efforts to translate observational and behavioral science into policy and practice move forward, economic evaluation should be an integral component of emerging research. Researchers must recognize that the cost savings of many interventions might come more from secondary effects, such as reduced dependence on welfare programs or reduced need for special education, and not from primary prevention of maltreatment. Identifying the costs of abuse to victims and to society, as well as the costs of the programs proposed, will dramatically improve our understanding of the costs of child maltreatment and benefits of policies that protect children.
References 1. Daro D: The costs of prevention and intervention. In: Daro D (ed): Confronting Child Abuse: Research for Effective Program Design. The Free Press, New York, 1988. 2. National Center for Injury Prevention and Control: Costs of Intimate Partner Violence Against Women in the United States. Centers for Disease Control and Prevention, Atlanta, 2003. 3. Rivara FP, Anderson ML, Fishman P, et al: Healthcare utilization and costs for women with a history of intimate partner violence. Am J Prev Med 2007;32:89-96. 4. Wisner CL, Gilmer TP, Saltzman LE, et al: Intimate partner violence against women: do victims cost health plans more? J Fam Pract 1999;48:439-443. 5. Readers are referred to Cost-Effectiveness in Health and Medicine (Gold, 1996) and Valuing Health for Regulatory Cost-Effectiveness Analysis (Miller, 2006) for more detailed discussion on economic analysis and healthcare decision-making. 6. Gold MR, Siegel JE, Russell LB, et al (eds): Cost-Effectiveness in Health and Medicine. Oxford University Press, New York, 1996. 7. Corso PS, Lutzker JR: The need for economic analysis in research on child maltreatment. Child Abuse Negl 2006;30:727-738. 8. Miller W, Robinson LA, Lawrence RS (eds): Valuing Health for Regulatory Cost-Effectiveness Analysis. National Academy Press, Washington, 2006. 9. Hymel KP, Makoroff KL, Laskey AL, et al: Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. Pediatrics 2007;119:922-929. 10. Jayawant S, Rawlinson A, Gibbon F, et al: Subdural haemorrhages in infants: population based study. Br Med J 1998;317:1558-1561. 11. King WJ, MacKay M, Sirnick A, et al: Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. Can Med Assoc J 2003;168:155-159. 12. Ewing-Cobbs L, Kramer L, Prasad M, et al: Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics 1998;102:300-307. 13. Keenan HT, Runyan DK, Nocera M: Child outcomes and family characteristics 1 year after severe inflicted or noninflicted traumatic brain injury. Pediatrics 2006;117:317-324. 14. Bonomi AE, Anderson ML, Rivara FP, et al: Health care utilization and costs associated with childhood abuse. J Gen Intern Med 2008;23: 294-299.
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15. Chartier MJ, Walker JR, Naimark B: Childhood abuse, adult health, and health care utilization: results from a representative community sample. Am J Epidemiol 2007;165:1031-1038. 16. Edwards VJ, Holden GW, Felitti VJ, et al: Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: results from the adverse childhood experiences study. Am J Psychiatry 2003;160:1453-1460. 17. Felitti VJ, Anda RF, Nordenberg D, et al: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) study. Am J Prev Med 1998;14:245-258. 18. Walker EA, Unutzer J, Rutter C, et al: Costs of health care use by women HMO members with a history of childhood abuse and neglect. Arch Gen Psychiatry 1999;56:609-613. 19. Consumer Price Index. U.S. Department of Labor Statistics, Washington, DC, 2008. Available at ftp://ftp.bls.gov/pub/special.requests/ cpi/cpiai.txt. Accessed on October 1, 2008. 20. Keren R, Pati S, Feudtner C: The generation gap: differences between children and adults pertinent to economic evaluations of health interventions. Pharmacoeconomics 2004;22:71-81. 21. Griebsch I, Coast J, Brown J: Quality-adjusted life-years lack quality in pediatric care: a critical review of published cost-utility studies in child health. Pediatrics 2005;115:e600-614. 22. Prosser LA, Corso PS: Measuring health-related quality of life for child maltreatment: a systematic literature review. Health Qual Life Outcomes 2007;5:42. 23. Bennett JE, Sumner W, Downs SM, et al: Parents’ utilities for outcomes of occult bacteremia. Arch Pediatr Adolesc Med 2000;154:43-48. 24. Saigal S, Stoskopf BL, Burrows E, et al: Stability of maternal preferences for pediatric health states in the perinatal period and 1 year later. Arch Pediatr Adolesc Med 2003;157:261-269. 25. Brouwer WB, Niessen LW, Postma MJ, et al: Need for differential discounting of costs and health effects in cost effectiveness analyses. Br Med J 2005;331:446-448. 26. Except where noted, all costs have been adjusted to reflect 2007 U.S. dollars. 27. Miller TR, Cohen M, Wiersema B: Victim Costs and Consequences: A New Look. National Institute of Justice Research Report, US Department of Justice, Washington, DC, 1996. Available at http:// www.ncjrs.gov/pdffiles/victcost.pdf. Accessed on November 30, 2008. 28. Wang C, Holton J: Total Estimated Costs of Child Abuse and Neglect in the United States. Prevent Child Abuse America, Chicago, 2007. Available at http://member.preventchildabuse.org/site/ DocServer/cost_analysis.pdf?docID=144. Accessed on November 30, 2008. 29. Ettaro L, Berger RP, Songer T: Abusive head trauma in young children: characteristics and medical charges in a hospitalized population. Child Abuse Negl 2004;28:1099-1111.
30. Irazuzta JE, McJunkin JE, Danadian K, et al: Outcome and cost of child abuse. Child Abuse Negl 1997;21:751-757. 31. Libby AM, Sills MR, Thursston NK, et al: Costs of childhood physical abuse: comparing inflicted and unintentional traumatic brain injuries. Pediatrics 2003;112:58-65. 32. Rovi S, Chen PH, Johnson MS: The economic burden of hospitalizations associated with child abuse and neglect. Am J Public Health 2004;94:586-590. 33. Dubowitz H: Costs and effectiveness of interventions in child maltreatment. Child Abuse Negl 1990;14:177-186. 34. Plotnick RD, Deppman L: Using benefit-cost analysis to assess child abuse prevention and intervention programs. Child Welfare 1999;78: 381-407. 35. Courtney ME: National call to action: working toward the elimination of child maltreatment. The economics. Child Abuse Negl 1999;23: 975-986. 36. Weil TP: Children at risk: outcome and cost measures needed. J Health Hum Serv Adm 1999;21:92-108. 37. Barlow J, Davis H, McIntosh E, et al: Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation. Arch Dis Child 2007;92:229-233. 38. Olds DL, Henderson CR, Phelps C, et al: Effect of prenatal and infancy nurse home visitation on government spending. Med Care 1993;31: 155-174. 39. Karoly LA, Greenwood PN, Everingham SS, et al: Investing in our Children: What We Know and Don’t Know About the Costs and Benefits of Early Childhood Interventions. The RAND Corporation, Santa Monica, 1998, pp 73-103. 40. Armstrong KA: Economic analysis of a child abuse and neglect treatment program. Child Welfare 1983;62:3-13. 41. Dretzke J, Frew E, Davenport C, et al: The effectiveness and costeffectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children. Health Technol Assess 2005;9:iii,ix-x,1-233. 42. Foster EM, Jones D, Conduct Problems Prevention Research Group: Can a costly intervention be cost effective? An analysis of violence prevention. Arch Gen Psychiatry 2006;63:1284-1291. 43. Prentky R, Burgess AW: Rehabilitation of child molesters: a costbenefit analysis. Am J Orthopsychiatry 1990;60:108-117. 44. Shanahan M, Donato R: Counting the cost: estimating the economic benefit of pedophile treatment programs. Child Abuse Negl 2001;25: 541-555. 45. Campbell KA, Bogen DL, Berger RP: The other children: a survey of child abuse physicians on the medical evaluation of children living with a physically abused child. Arch Pediatr Adolesc Med 2006;160: 1241-1246. 46. Available at http://grants.nih.gov/grants/guide/pa-files/PA-07-437. html. Accessed on September 29, 2008.
“Ignoring the direct and indirect expenditures associated with attempts to resolve this social problem will not make the task less costly nor will it result in the most efficient practice choices. While no one would argue that costs should be the sole determinant of policy, neither should costs be considered an inappropriate contributor to the decision-making process.” Deborah Daro, Confronting Child Abuse, 19881
INTRODUCTION How does one determine the costs of child maltreatment? For some, calculating a dollar value to describe the impact of maltreatment seems inappropriate. For others, the lifelong effect of maltreatment on children and society makes such calculations overwhelming. Yet in a society with competing economic priorities, understanding the costs of maltreatment, as well as the costs of programs designed to prevent or respond to maltreatment, is a critical step toward effective health and social policies. Intimate partner violence research supports this contention. Studies examining data from health maintenance organizations consistently find increased health care costs and use among women reporting a history of intimate partner violence.2-4 Total costs of intimate partner violence in 1995 were estimated at $5.8 billion, over $1300 per victim.2 Such data can support medical and social investments in prevention and intervention programs. Compared with intimate partner violence, however, determining the costs of child maltreatment poses unique challenges. The mandated social response to maltreatment adds costs of protective, investigative, and legal interventions often overlooked in the analysis of intimate partner violence. Associations of child maltreatment with learning disability, juvenile delinquency, and adult health problems make it difficult to draw boundaries around cost estimates for abuse. Economic analyses in pediatrics commonly reflect costs to caregivers related to diagnosis and care of an ill or injured child, an ethically challenging proposition if the caregiver is a possible perpetrator. It is beyond the scope of this chapter to suggest solutions to the philosophical and methodological challenges underlying the economic analysis of child maltreatment. The goals of this chapter are to provide a basic overview of approaches to economic analysis, to present best evidence related to the costs of child maltreatment, and to consider directions for future research in this area.5 634
OVERVIEW OF ECONOMIC ANALYSIS There are several approaches to economic analysis. Selecting the appropriate analytic approach depends on the question being asked and on the data available to the researcher (Figure 69-1). At the most basic level, an economic analysis provides an understanding of the costs associated with a given condition. A cost-of-illness (COI) analysis can provide critically important information about the medical and social costs associated with a health condition. COI does not differentiate costs based on medical decision-making, nor does it try to place a value on the outcomes gained by particular interventions. As such, COI alone cannot guide rational health care policy decisions. Cost-effectiveness analyses (CEA) and cost-utility analyses (CUA) compare costs associated with competing interventions, and balance these costs against the health-related benefits of those interventions. This approach allows decision-makers to place a proposed intervention into four possible categories: (1) improves outcomes and saves money, (2) improves outcomes but costs money, (3) worsens outcomes but saves money, and (4) worsens outcomes and costs money. Clearly, interventions in the first category should be implemented, whereas those in the fourth should be set aside. Information gained in the full CEA analysis can guide policy decisions regarding interventions falling into the second and third categories based on funding realities and social priorities. A distinct approach to economic analysis is a cost-benefit analysis (CBA), in which the costs of medical interventions are balanced against the calculated monetary value of health outcomes. CBA provides a strictly economic perspective on medical and social interventions. Although CBA has applications in regulatory decision-making, it is unusual in the healthcare literature, where monetary valuation of health outcomes is generally viewed with skepticism or distaste.6-8 This chapter focuses on the application of COI, CEA, and CUA in improving our understanding of the costs of child maltreatment.
Cost-of-Illness Analysis How much does it cost to provide medical care for a child with abusive head trauma? What are the costs of mental health therapy for a child recovering from chronic sexual abuse? These are the questions answered by a COI analysis.
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
635
QUESTION
How much do we spend on child physical abuse every year?
What does it cost to prevent a case of physical abuse using Parent-Child Interaction Therapy in high-risk families?
What is the cost of improving health-related outcomes for children (and caregivers) using ParentChild Interaction Therapy in high-risk families?
Analytic approach
Cost of illness analysis (COI)
Cost effectiveness analysis (CEA)
Cost utility analysis (CUA)
Numerator: Direct medical costs (hospital, physician, medication) + Direct non-medical costs (caregiver costs, education, CPS) + Indirect costs (productivity losses)
Numerator: Intervention costs + Change in direct medical costs (hospital, physician, medication) + Change in direct non-medical costs (caregiver costs, education, CPS) + Change in indirect costs (productivity losses)
Numerator: Intervention costs + Change in direct medical costs (hospital, physician, medication) + Change in direct non-medical costs (caregiver costs, education, CPS)
Denominator: Measured units (per year, case, or person)
Denominator:
Denominator: Health adjusted survival unit (quality adjusted life years, QALY) *includes productivity losses
Natural units (years of life gained, cases averted, cures achieved) FIGURE 69-1 Visual comparison of cost-of-illness, cost-effectiveness, and cost-utility economic analyses.
As in all research, results of COI analyses are dependent on the assumptions built into the study design. Several important assumptions to consider are discussed in the following paragraphs. Sample selection: Costs may vary widely based on the sample selected for analysis. Imagine a COI analysis for children with abusive head trauma. Substantial data exist to support the assumption that most of these children are critically ill at presentation.9-11 It might be reasonable to assume that most of these children are admitted to intensive care units and to select a sample of PICU admissions with a diagnosis of subdural hemorrhage and child abuse for analysis. Yet this decision excludes potentially important subsets of children. As many as one tenth of children with abusive head trauma do not survive to admission (H.T. Keenan, University of Utah School of Medicine, personal communication, March 3, 2010). The proposed analysis excludes costs of children dying at home, in transport, or in the emergency room. Conversely, improvements in medical imaging and physician training may increase the numbers of mildly symptomatic children admitted to general medical or surgical services, bypassing the ICU altogether. Excluding those children never admitted to the ICU, whether because of early death or early diagnosis, could falsely inflate the medical costs associated with abusive head trauma. Time horizon: Researchers must explicitly define the time horizon of any economic analysis. Does an accounting of the medical costs of abusive head trauma include only the costs
of acute hospitalization, or extend to the lifelong costs of rehabilitation, durable medical equipment, and recurrent hospitalizations of a child with profound neurological disability?12,13 Should the medical costs of sexual abuse be limited to the acute medical examination and specific therapies, or should there be consideration of costs of mental illness and medical complications that are increasingly linked to abusive experiences in childhood?14-18 These decisions are driven by the objective of the analysis, but are shaped by the limitations of the data available. Perspective: The perspective of any economic analysis defines the data used in the analysis. From a medical payer perspective, the costs of abusive head trauma are the acute care and chronic medical needs of an injured child. From a societal perspective, however, the cost burden includes child protective services and legal investigations, foster care placement, prison costs for a perpetrator, and lost wages resulting from permanent neurological disability. Both perspectives are valid, although the results of each analysis will be dramatically different. Costs included: Estimating costs of child maltreatment raises unique questions regarding the scope of costs to be included. Direct medical costs are the most easily understood, encompassing the value of the health care “goods and services” needed for the proposed intervention. These can reflect the costs of a single hospitalization, or repeated encounters over time. Direct nonmedical costs reflect the value of resources outside of the medical system consumed by the
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SECTION VIII SPECIAL TOPICS
intervention. Traditionally, these nonmedical costs account for time required of patients, family, and volunteers for the studied intervention. Nonmedical costs unique to child maltreatment can include child protection services, police investigation, legal intervention, foster care, special education, and costs of juvenile delinquency. Indirect costs, or productivity costs, can account for lost wages or productivity over time that can be attributed to a given health condition. Cost adjustment: Cost data often require adjustment for economic analysis. Perhaps the most commonly recognized cost adjustment is inflation adjustment, which allows for comparison of cost data across many years. These calculations typically rely on the general or medical component of the Consumer Price Index (CPI).19 A second adjustment frequently required for health care research is profit adjustment. In any medical system outside of a single-payer system, medical charges include a profit component that substantially overestimates the true medical costs of any intervention. There are several solutions to this dilemma. In prospectively collected data, researchers might have access to the true costs of the goods and services being used for the study. In many cases, however, researchers must rely on retrospective data that include only charge data. Under these circumstances, a cost-to-charge ratio can be applied to the economic data to better estimate true medical costs. These ratios are often available at national, regional, hospital, or departmental levels.
Cost-Effectiveness and Cost-Utility Analysis A CEA balances costs added by a medical intervention against lives saved, cases averted, or years of life added as a result of the intervention. A CUA is a specialized subset of CEA, in which outcomes are measured with a metric that accounts for quality of life, such as the quality adjusted life year (QALY). CUA has been identified as the preferred method for economic analysis by the Panel on Cost-Effectiveness in Health and Medicine.6 In contrast to COI analyses, which describe system costs without consideration of outcomes, CEA provides a measure of effectiveness of interventions in economic terms. An appropriately conducted CEA can improve our understanding of the incremental improvements in health expected with new expenditures and can guide health care decision-making at a policy level. Unfortunately, CEA techniques can be challenging to conduct and interpret. A poorly conducted CEA can dramatically misrepresent cost-effectiveness estimates because of inappropriate technique, inadequate data, or investigator bias. A misinterpreted CEA might reflect a simplistic utilitarian perspective, excluding the ethical principles of nonmalfeasance, beneficence, and justice that are critically important in decision-making around child maltreatment. The following overview is in no means a comprehensive review of CEA methodology, but provides a guide to important elements to be considered in the critical review of CEA literature. Costs: Consideration of costs for a CEA analysis includes the same element considered for COI analysis, with important additional considerations. A cost-effectiveness analysis is fundamentally a comparison of costs-to-benefit ratios between two or more interventions. Although the compari-
son intervention may be nothing more than “standard treatment” or “do nothing,” the analysis must account for change in direct and indirect costs under each intervention arm. In a randomized control trial, researchers may have full access to cost data for each arm. In a one-armed observational trial, however, costs for the study population may be compared with literature-derived costs of illness to examine cost-effectiveness of the intervention. Finally, a CEA can mimic a true randomized controlled trial by relying only on literaturederived data in circumstances in which adequate data for both intervention arms already exist. Researchers must examine the strength of the cost data available for comparison when relying on literature-derived values. Outcomes: In COI analysis, all costs are incorporated into the numerator. In CEA research, however, costs cannot simultaneously appear in the numerator, reflecting costs, and the denominator, reflecting outcomes. A CEA can include indirect costs accounting for lost work and wages in the numerator, but places years of life lost and gained in the denominator. In CUA, all indirect costs should be reflected in the health-related outcome metric used for the denominator. The choice of outcomes in CEA research is critical and controversial. The most basic metric is years of life gained, or lives saved, by a given intervention. There is increasing recognition, however, that such measures overlook quality of life concerns. In adult medicine, the prolongation of chronic and life-threatening illness can raise health expenditures for marginal survival gains with poor quality of life. In pediatrics, similar questions are considered in analysis of health care expenditures for technologically dependent infants and children. CUA relies on “utilities” to reflect concerns of quality of life over simple survival. The quality adjusted life years’ (QALY) measure remains the most commonly used metric to express the balance between length and quality of life (Table 69-1). Although conceptually appealing, practical issues around measuring quality of life and the interpretation of these measures are subject to intense ethical debate, particularly in pediatrics.20-22 It remains unclear how best to measure quality of life of young children. There are few—if any—validated measures of quality of life for children under 7 years of age, and researchers might rely on instruments that are
Table 69-1
Sample Calculation of Quality Adjusted Life Years (QALYs)
Condition
Years (0-1)
Utility (0-1)
Total QALYs (Time × Utility)
12 months of life in perfect health
1
1
1
10 months of life in perfect health
0.8
1
0.8
12 months of life with poor health
1
0.8
0.8
6 months of life with poor health
0.5
0.8
0.4
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
developmentally inappropriate for a pediatric population. In children who cannot participate in quality of life studies because of age or disability, proxy responses by parents and caregivers are typical substitutes.23,24 These issues are amplified by concerns of child maltreatment. How does one measure the impact of foster placement on the quality of life of a 15-month-old? How do we use parental proxies if we doubt the integrity of the parents? Although these considerations do not necessarily exclude quality of life metrics in the assessment of the cost-utility of an intervention, researchers must acknowledge the limitations of these measures and include analyses to account for these uncertainties. Discounting: Many primary care health interventions are made in anticipation of future, rather than immediate, health benefits. This is particularly true for pediatrics, where the benefits of a healthy childhood can be sustained over a lifetime. It is generally assumed, however, that immediate health is valued above future health. To address this concern, most economic analyses discount both costs and benefits at about 3% to 10% per year. This practice is not without question, however, since it can lead to undervaluing of preventive or pediatric health care.25 Sensitivity analysis: A unique characteristic of CEA is in the reflection of uncertainty. Medical literature traditionally relies on p-values and confidence intervals to describe uncertainty around a result. These statistics are not helpful in CEA because of modeling techniques that allow researchers to generate sample sizes to support unrealistically tight confidence intervals. For CEA, uncertainty is reflected in sensitivity analyses, in which the analysis is repeated over a rational interval of values of costs variables and outcome probabilities. For example, CEA of a home visitation program could include the expected number of home visits or the annual salaries of the home visitors, numbers that vary by program design, by geography, and by chance. Researchers should run the model using the lowest and the highest number of
637
home visits as well as the lowest and the highest home visitor salaries. This type of sensitivity analysis provides the range of outcomes that can be reasonably expected under conditions of uncertainty. As almost all research in child maltreatment involves substantial uncertainty, any CEA of interventions for child abuse should reflect this uncertainty with careful sensitivity analyses.
ECONOMIC ANALYSIS IN CHILD MALTREATMENT26 Costs of Child Maltreatment (COI) Several studies have attempted to describe the total costs of child maltreatment in the United States (Table 69-2). All of these studies rely on important assumptions related to the incidence of hospitalization and medical care for physical injuries, as well as the causal link between abuse and observed outcomes among children after abuse. In 1988, Daro1 published the first estimates of the costs of child maltreatment, making informed assumptions regarding the need for inpatient treatment of abusive injury; ongoing medical, rehabilitative, and educational needs of abused children; and lifetime loss of earning potential attributed to childhood abuse. In 1996, the U.S. Department of Justice examined costs of child maltreatment.27 The authors acknowledged the limitations of the research, commenting that “… virtually no estimates of medical costs are available for child abuse,” and that “… this study’s estimates for child abuse should be viewed as very rough and worthy of further study.” In contrast to other studies, these authors calculated a monetary value for the quality of life costs of abuse, with estimates of $30,276 for emotional abuse, $82,506 for physical abuse, and $128,853 for sexual abuse. These intangible costs were by far the largest contributor to costs for all violent crimes in this
Summary of Studies Estimating Total Annual Costs of Child Maltreatment in the United States (All Costs Adjusted to 2007 Dollars)
Table 69-2 Study
Cases (n) 1
Costs Examined
Direct Medical Costs
Direct Nonmedical Costs
Indirect Productivity Costs
Daro, 1988* (Lifetime)
739,000 (23,648)
Costs/case Total costs
$56 ($1,761) $41 million
$3,177 $2.3 billion
$1,854-3,662 $1.4-2.7 billion
Miller, 1996†27 (Annual)
926,000 (all)
Costs/case Total costs Costs/case Total costs Costs/case Total costs Costs/case Total costs
$3,774 $3.5 billion $9,025 $1.7 billion $5,008 $1.8 billion $3,874 $1.3 billion
$2,639 $2.4 billion $1,659 $307 million $3,079 $1.1 billion $3,042 $1.0 billion
$3,157 $2.9 billion $3,013 $557 million $4,879 $1.7 billion $1,291 $435 million
Costs/case Total costs
$5,004 $7.8 billion
$40,520 $63.0 billion
$21,251 $33.0 billion
185,000 (sexual) 355,000 (physical) 337,000 Wang, 200728 (Annual)
1,553,800
*Daro estimated medical costs based only on the acute inpatient medical care of 23,648 children with severe physical abuse and is, therefore, a substantial underestimate of the true value. Direct medical costs are provided based on the total population of abused children and the subset of those with severe physical abuse. Daro also excluded many cost categories included in subsequent analyses. † Miller did not include child neglect in this economic analysis.
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SECTION VIII SPECIAL TOPICS
analysis. Finally, the Prevent Child Abuse America Foundation provided a recent estimate of the total national costs of child maltreatment, again relying on informed estimates for their analysis.28 The wide range of estimates in these three studies reflects the differences in sample selected, perspective adopted, time horizon, and costs included by each of the authors. The limitations of these studies must be recognized. There is a tendency in these analyses to suggest causation where prior epidemiological studies have only identified an association. In other words, although maltreatment is associated with later need for special education, it is not clear that maltreatment causes this educational need. It is not clear that prevention of maltreatment would eliminate all of these excess educational costs.28 Although adult survivors of childhood maltreatment have a higher risk of illness, research identifies an additive effect of multiple childhood adversities rather than a direct correlation between child maltreatment and adult poor health.17 It might not be reasonable to assume that prevention of child abuse will eliminate these future medical costs. Efforts to describe acute medical costs associated with child abuse have used hospital charges for inpatient care of children diagnosed with abuse. These studies are limited by reliance on medical charges rather than medical costs, capturing medical resource utilization as well as profit margin associated with health care in the United States. By comparing medical charges in abuse-related hospitalizations to those in nonabuse-related hospitalizations, however, these studies do suggest relatively high medical resource utilization associated with child abuse (Table 69-3). These differences likely reflect the increased severity of injury, younger patient age, and increased length of stay in children with abuserelated hospitalizations. There is increasing evidence that childhood abuse results in increased health risks sustained into adolescence and adulthood. Two authors have linked self-reports of childhood maltreatment with healthcare utilization in adult women enrolled in a health maintenance organization.14,18 Both studies have observed moderate increases in health care costs among these women, suggesting that child abuse Table 69-3 Study
has a real and sustained effect on health and health care utilization among survivors.
Cost-Effectiveness of Child Maltreatment Programs Many authors have called for improved economic analysis of child abuse prevention and intervention programs, yet few such analyses exist.7,33-36 Population-based prevention programs tend to be resource intensive. One British study calculated that an 18-month home visiting program cost £3246 per child (2003-2004 British pounds), even accounting for costs saved in health care utilization and counseling in the intervention arm over the study period.37 In 2007 U.S. dollors, this is $6245.* Given the early cost demands of such programs, long-term CEA provides the opportunity to weigh the initial costs against sustained benefits. With this approach, parent training programs have been found to be cost saving in several published analyses. In an evaluation of the Nurse-Family Partnership in Elmira, New York, Olds et al38 concluded that the program of home visitation by nurses saved $4459 per family over 48 months because of lower utilization of welfare services among families enrolled in the treatment arm of the trial. The Rand Corporation estimated cost savings of the Elmira NurseFamily Partnership program of $24,594 per high-risk family over 15 years based on sustained reductions in welfare reliance for mother, reduced criminal justice costs for mothers and children, and increased tax revenues from maternal employment.39 An analysis of the Family Support Center, an integrated home/school/community program for highrisk families estimated cost savings of $9564 per high-risk family over approximately 6 years.40 Although this study relied on measured program costs over 1 year, it made broad assumptions regarding potential long-term cost savings based on literature review. In each of these studies, the finding of overall cost savings allowed the authors to avoid the difficult calculation of lives *2003–2004 UK pounds converted to 1998 U.S. dollars, then adjusted for inflation to 2007 dollars.
Medical Charges Associated with Hospitalizations Related to Child Abuse (All Charges Adjusted to 2007 Dollars) Study Sample
Mean Charges Abuse Sample (n)
Mean Charges Nonabuse Sample (n)
Ratio of Charges*
Ettaro et al, 200429
Children <3 yr of age with head trauma admission, 1995-1999
$49,884 (n = 89)
$19,503 (n = 288)
2.6
Irazuzta et al, 199730
PICU trauma admission, 1991-1994
$42,929 (n = 13)
$41,097 (n = 34)
1.0
Libby et al, 2003†31
Children <3 yr with head trauma admission, 1993-2000
$33,672 (n = 283)
$14,378 (n = 814)
2.3
Rovi et al, 200432
Post-neonatal pediatric hospitalization in HCUP database, 1999‡
$23,977 (n = 966)
$11,839 (n = 1,371,835)
2.0
*Ratio of medical charges for children hospitalized for abuse-related reasons compared with children with nonabuse-related hospitalizations. † Charges adjusted based using 1996 (study mid-point) CPI data. ‡ Healthcare Costs and Utilization Project (HCUP).
CHAPTER 69 THE COSTS OF CHILD MALTREATMENT
saved, cases averted, or quality of life gained. When a program saves money, and meets or exceeds the outcomes observed under current practice, there is no need to further complicate the analysis. The decision to implement these programs, if the assumptions of the analysis are accepted, should be clear. These studies identified cost savings not in violence prevention but in improved parenting, improved socioeconomic status, and improved community integration. Studies relying only on violence prevention to demonstrate cost effectiveness of a program face a much stiffer challenge.41,42 Although the societal costs of child abuse are substantial, few studies examine the cost effectiveness of our interventions. One study examined the cost effectiveness of rehabilitation of child sexual abuse perpetrators, concluding that treatment programs may save $124,093 compared with traditional incarceration based on decreased recidivism in the 5 years following prison release. The authors acknowledge limitations in the estimates of recidivism within this population and make appropriate sensitivity analyses, pointing out that cost savings persist as long as recidivism rates among the untreated population remained higher than 3% (compared with 25% in the treated population).43 A more recent Australian study used a cost–benefit analysis to assess treatment programs for child sexual abuse perpetrators. Without providing specific program data, the authors conclude that the expected costs of such programs could range from a loss of $6850 to savings of $39,870 per treated prisoner (1998 Australian dollars). In 2007 U.S. dollars, this translates to savings of from $5525 to $32,160 per treated prisoner.* The estimates varied based on the interaction between the reduction in recidivism attributed to the treatment program and the range of tangible and intangible costs attributed to recidivism.44 Only one study has examined the cost effectiveness of a specific medical decision related to child maltreatment.45 The dilemma over when to obtain radiographic imagining (head CT) for a well-appearing infant presenting with nonspecific signs and symptoms that may reflect brain injury is common. Using literature-derived variables to model shortterm cost effectiveness of CT imaging in these children, the authors found that imaging could be cost saving from a medical perspective, but only when the probability of abusive head trauma rose above 16%. From a societal perspective, identification of abuse was almost always expensive when considered over a short 1-year time frame. The authors made no attempt to identify long-term outcomes for children with earlier recognition of abuse, citing limitations in available data to address these issues.
STRENGTH OF THE EVIDENCE It is widely accepted that violence, in its many forms, is expensive at individual and societal levels. Children can account for more than 35% of all crime victim costs.27 Despite this, clear evidence for costs of violence against children, and the cost effectiveness of programs responding to the problem, is generally lacking. Most estimates of the costs of child maltreatment rely heavily on assumptions that fail to account *1998 Australian dollars converted to U.S. dollars, then adjusted for inflation to 2007 U.S. dollars.
639
for the multiple social confounders associated with child maltreatment and with its long-term outcomes. The consistent finding of cost effectiveness of prevention programs evaluated is encouraging, yet remains limited by our poor understanding of the true costs of child maltreatment.
DIRECTIONS FOR FUTURE RESEARCH Research in child maltreatment is rapidly accelerating. In 2007, the National Institutes of Health sought proposals for research that would move the field beyond an understanding of the epidemiology of maltreatment and toward “… largescale, community-based, effectiveness trials” of programs to prevent and respond to child maltreatment.46 As efforts to translate observational and behavioral science into policy and practice move forward, economic evaluation should be an integral component of emerging research. Researchers must recognize that the cost savings of many interventions might come more from secondary effects, such as reduced dependence on welfare programs or reduced need for special education, and not from primary prevention of maltreatment. Identifying the costs of abuse to victims and to society, as well as the costs of the programs proposed, will dramatically improve our understanding of the costs of child maltreatment and benefits of policies that protect children.
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