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  • Short Report
  • Open Access

Incidence and costs of injuries to children and adults in the United States

Injury Epidemiology20185:37

https://doi.org/10.1186/s40621-018-0167-6

  • Received: 12 June 2018
  • Accepted: 14 September 2018
  • Published:

Abstract

Background

Injuries are a leading cause of death and acquired disability, and result in significant medical spending. Prior estimates of injury-related cost have been limited by older data, for certain population, or specific mechanisms.

Findings

This study estimated the incidence of hospital-treated nonfatal injuries in the United States (US) in 2013 and the related comprehensive costs. Injury-related emergency department (ED) visits and hospitalizations were identified using 2013 Healthcare Cost and Utilization Project (HCUP) data. Models estimated the costs of medical spending and lost future work due to injuries in 2013 U.S. dollars. A total of 31,038,072 nonfatal injury-related hospitalizations and ED visits were identified, representing 9.8 per 100 people. Hospital-treated nonfatal injuries cost an estimated $1.853 trillion, including $168 billion in medical spending, $223 billion in work losses, and $1.461 trillion in quality of life losses.

Conclusions

Approximately one in 10 individuals in the US is treated in the hospital for injury each year, with high corresponding costs. These data support priority-setting to reduce the injury burden in the US.

Background

Injuries are a leading cause of death and acquired disability in children and adults, and result in significant medical spending nationwide. Prior estimates of injury-related cost have been from much older data (Danseco et al. 2000; Miller et al. 2000; Corso et al. 2006), for certain populations (e.g., children (Miller et al. 2000; Zaloshnja et al. 2012; Roy et al. 2008), Medicaid recipients (Roy et al. 2008)), for certain mechanisms (e.g., consumer products (Lawrence and Miller, 2014), agricultural (Zaloshnja et al. 2012)), or for cost totals that only include medical care (Dieleman et al. 2016). This study provides contemporary national estimates of the incidence of hospital-treated nonfatal injuries for children and adults in the United States in 2013 and the related comprehensive costs by age, household income, payer, metropolitan residence, disposition, injury severity score, injury mechanism and injury intent. While incidence describes the magnitude of the problem, costs provide a better measure of burden by accounting for multiple injury consequences – e.g., severity, disability – in a single unit of measurement.

Methods

Injury-related emergency department (ED) visits and hospitalizations were identified using 2013 Healthcare Cost and Utilization Project (HCUP) sample-based ED (Agency for Healthcare Research and Quality (AHRQ), n.d.) and inpatient (Agency for Healthcare Research and Quality (AHRQ)a, n.d.) datasets. This study used deidentified administrative data and was exempt from review by our institution. Injuries were defined as diagnoses 800–995 in the International Classification of Diseases, Ninth Revision, excluding late effects, 905–909. We used the standard external-cause matrix from the Centers for Disease Control and Prevention. (Centers for Disease Control and Prevention (CDC), n.d.-a; Centers for Disease Control and Prevention (CDC), n.d.-b).

We applied an established US injury cost model to the HCUP datasets to estimate the costs of injuries in 2013 U.S. dollars (Lawrence et al. 2015; Spicer et al. 2011). The Agency for Healthcare Research and Quality (AHRQ) weights HCUP Nationwide Emergency Department Sample (NEDS) and Nationwide Inpatient Sample (NIS) data to provide national estimates. 2014 NEDS estimates are based on sampling non-admitted cases from all EDs in 34 states. 2014 NIS estimates are based on a one-in-five random sample of inpatient discharges from every hospital in 44 states and the District of Columbia. (Agency for Healthcare Research and Quality (AHRQ), n.d. Agency for Healthcare Research and Quality (AHRQ)a, n.d.).

Costs include medical spending and lost future work. In addition, we take a societal perspective by including the estimated value of lost quality of life. Medicalspending includes hospital and professional services, emergency transport, rehabilitation, prescriptions, home health care, and medical equipment. Lost future work includes future value of work that patients would be unable to do if they were killed or permanently disabled. Future costs were stated in present value using a 3% discount rate. (Lawrence and Miller 2014). We valued quality of life lost with a widely published value of $152,733 per quality-adjusted life year, net of work loss (Miller and Hendrie, 2013). We used the same value per QALY of present-value life expectancy for all people. Because life-expectancy varies by age and sex, the total QALY loss to a death or permanently disabling injury also does.

Results

Incidence

A total of 31,038,072 nonfatal injury-related hospitalizations and ED visits were identified in 2013 (Table 1). This represents 9.8 per 100 people.
Table 1

Cost of Hospital-Treated Nonfatal Injuries in the United States, 2013 (2013 United States $)

 

Number

Medical

Work Loss

Quality of Life

Total Cost

Total Cost per Injury

All

31,038,072

$167,968,253,878

$223,116,101,911

$1,461,482,900,000

$1,852,567,255,789

$59,687

Age Group

  < 1

261,308

$1,432,470,125

$1,789,973,631

$22,287,154,385

$25,509,598,141

$97,623

 1–11

4,447,463

$12,032,484,055

$18,626,763,126

$181,322,230,105

$211,981,477,286

$47,663

 12–17

2,823,241

$8,816,169,603

$13,443,289,763

$145,256,948,411

$167,516,407,777

$59,335

 18–24

3,773,148

$13,600,427,953

$23,698,584,864

$186,399,030,940

$223,698,043,757

$59,287

 25–34

4,442,848

$17,457,020,563

$36,742,723,349

$205,840,515,715

$260,040,259,627

$58,530

 35–44

3,711,266

$15,005,365,402

$34,704,621,851

$150,463,641,515

$200,173,628,768

$53,937

 45–64

6,458,720

$40,319,428,609

$65,703,484,682

$314,280,411,223

$420,303,324,514

$65,075

 65+

4,800,513

$59,285,698,881

$28,387,430,398

$255,529,916,815

$343,203,046,094

$71,493

Household Income Quartile

 0-25th percentile

9,572,854

$47,498,738,599

$67,315,490,069

$419,419,736,702

$534,233,965,370

$55,807

 26th–50th percentile

8,347,113

$43,448,674,708

$57,933,681,503

$380,949,318,832

$482,331,675,043

$57,784

 31st-75th percentile

6,923,897

$39,294,070,461

$50,758,794,647

$339,582,090,153

$429,634,955,261

$62,051

 76th–100th percentile

5,533,774

$33,659,639,931

$40,997,146,789

$284,762,942,717

$359,419,729,437

$64,950

Payer

 Medicare

5,599,892

$62,116,899,402

$40,517,276,172

$297,763,145,616

$400,397,321,190

$71,501

 Medicaid

7,429,391

$29,171,568,219

$45,103,953,532

$314,054,136,094

$388,329,657,845

$52,269

 Other

15,231,785

$64,317,973,204

$113,654,085,383

$712,228,646,085

$890,200,704,672

$58,444

 Private/Commercial/PPO/HMO

2,776,540

$12,348,412,934

$23,823,408,746

$137,372,720,655

$173,544,542,335

$62,504

Rural/Urban

 Urban

24,549,308

$134,880,605,547

$179,608,748,796

$1,164,443,500,000

$1,478,932,854,343

$60,243

 Rural

6,292,866

$31,930,196,077

$41,617,835,131

$286,073,751,174

$359,621,782,382

$57,148

Disposition

 Treated and Released

28,387,504

$66,949,530,984

$86,132,322,982

$788,923,246,256

$942,005,100,222

$33,184

 Admitted

2,650,568

$101,018,722,894

$136,983,778,930

$672,559,644,444

$910,562,146,268

$343,535

Injury Severity Score (ISS)

 0

4,007,518

$23,294,466,781

$9,224,703,223

$78,422,515,363

$110,941,685,367

$27,683

  < 5

23,472,855

$81,231,767,072

$125,971,348,386

$797,810,907,004

$1,005,014,022,462

$42,816

 5–14

1,533,316

$31,204,880,868

$36,049,311,657

$287,923,572,318

$355,177,764,843

$231,640

  > 15

2,024,383

$32,237,139,158

$51,870,738,645

$297,325,896,016

$381,433,773,819

$188,420

Region

 Northeast

486,635

$18,095,855,894

$24,090,562,684

$119,160,902,927

$161,347,321,505

$331,557

 Midwest

601,215

$21,715,142,226

$29,756,502,527

$144,768,266,911

$196,239,911,664

$326,406

 South

1,027,654

$36,344,852,910

$52,530,343,991

$258,276,688,480

$347,151,885,381

$337,810

 West

535,064

$24,862,871,864

$30,606,369,728

$150,353,786,126

$205,823,027,718

$384,670

Hospital Type

 Nonteaching

11,451,866

$26,985,059,893

$34,347,299,866

$311,700,719,574

$373,033,079,333

$32,574

 Teaching

11,244,316

$26,914,053,295

$35,054,247,432

$316,475,541,375

$378,443,842,102

$33,656

Costs

Hospital-treated nonfatal injuries in 2013 cost an estimated $1.853 trillion, including $168 billion in medical spending, $223 billion in work losses, and quality of life losses valued at $1.461 trillion (Table 1). The total estimated cost per injury was approximately $59,700, including approximately $5400 in medical spending, $7200 in lost future work and $47,100 in quality of life losses. The total costs per injury were highest for the oldest and youngest age groups; individuals < 1 year old ($97,623) and 65 years and older ($71,493). Total cost per injury was slightly higher for those with Medicare and Medicaid versus those with commercial insurance or other payer types. While 91.5% of patients with injuries were discharged, this represented only 8.8% of costs. In contrast, the 8.5% of patients admitted represented 91.2% of costs.

Falls and struck by/against injuries contributed to 35% of nonfatal injury costs (Table 2) and were the leading causes in all age groups (results not shown). The most severe and debilitating injuries will result in higher costs. Among hospital-treated nonfatal injuries, near-drownings, self-harm, and firearm-related violence are the most costly. The external cause of injury was not coded for cases accounting for 9% of total injury costs.
Table 2

Cost of Hospital-Treated Nonfatal Injuries in the United States by Mechanism, 2013 (2013 United States $)

 

Number

Medical

Work Loss

Quality of Life

Total

Total Cost per Injury

UNINTENTIONAL INJURIES

 Cut/pierce

1,912,149

$3,631,594,141

$4,922,277,919

$28,292,232,329

$36,846,104,389

$19,269

 Drowning/submersion

9762

$167,756,380

$585,909,962

$2,699,855,258

$3,453,521,600

$353,773

 Fall

8,810,752

$64,201,479,065

$72,918,304,289

$505,230,956,245

$642,350,739,599

$72,905

 Fire/flame

80,131

$754,650,203

$728,172,630

$5,538,602,465

$7,021,425,298

$87,625

 Hot object/substance

292,856

$988,725,136

$1,708,949,240

$12,359,395,079

$15,057,069,455

$51,415

 Firearm

35,858

$358,159,858

$703,471,847

$2,983,640,338

$4,045,272,043

$112,815

 Machinery

113,545

$544,119,276

$1,846,062,780

$10,644,611,515

$13,034,793,571

$114,798

 MVT Occupant

2,498,200

$13,763,057,426

$22,257,235,570

$97,781,307,804

$133,801,600,800

$53,559

 MVT Motorcyclist

157,995

$2,736,135,308

$5,580,436,675

$21,245,276,186

$29,561,848,169

$187,106

 MVT Pedal cyclist

53,983

$527,900,384

$1,123,476,662

$5,165,720,968

$6,817,098,014

$126,281

 MVT Pedestrian

137,296

$2,181,788,505

$3,548,142,901

$16,715,035,234

$22,444,966,640

$163,478

 MVT Unspecified

219,970

$1,053,152,143

$1,820,906,676

$9,972,036,013

$12,846,094,832

$58,399

 MVT Other

17,891

$111,877,667

$248,974,328

$1,464,181,060

$1,825,033,055

$102,010

 Pedal cyclist, other

324,071

$1,476,820,932

$3,263,738,075

$20,108,440,875

$24,848,999,882

$76,678

 Pedestrian, other

19,026

$169,750,289

$289,186,145

$1,884,173,134

$2,343,109,568

$123,153

 Transport, other

294,317

$2,358,186,236

$5,066,645,020

$29,023,314,277

$36,448,145,533

$123,840

 Bites and stings

1,234,452

$2,547,309,358

$2,869,717,927

$27,803,209,134

$33,220,236,419

$26,911

 Other natural/environmental

178,925

$1,168,724,588

$1,414,612,181

$6,270,658,638

$8,853,995,407

$49,484

 Overexertion

2,335,656

$6,555,552,120

$10,283,916,364

$65,455,667,267

$82,295,135,751

$35,234

 Poisoning

469,441

$2,957,904,882

$836,596,717

$19,797,098,590

$23,591,600,189

$50,255

 Struck by/against

3,274,620

$8,646,126,741

$14,196,566,363

$142,802,749,122

$165,645,442,226

$50,585

 Suffocation

37,714

$2,035,124,771

$572,859,762

$2,216,460,767

$4,824,445,300

$127,921

 Other spec & classification

1,108,881

$4,457,686,594

$4,606,013,305

$54,204,054,262

$63,267,754,161

$57,055

 Other specified, NEC

679,383

$2,473,750,166

$3,703,018,649

$23,312,983,807

$29,489,752,622

$43,407

 Unspecified

2,116,751

$9,391,792,223

$12,521,017,713

$60,497,266,532

$82,410,076,468

$38,932

SELF-HARM INJURIES

 Cut/pierce

104,661

$555,649,912

$1,526,402,750

$5,323,753,810

$7,405,806,472

$70,760

 Drowning/submersion

265

$3,418,777

$21,334,930

$76,901,789

$101,655,496

$383,493

 Fall

2377

$133,419,753

$216,937,041

$674,562,123

$1,024,918,917

$431,271

 Fire/flame

1561

$47,016,669

$35,395,270

$354,039,886

$436,451,826

$279,685

 Hot object/substance

178

$1,007,084

$2,947,776

$35,191,197

$39,146,057

$220,435

 Firearm

2686

$192,070,049

$336,463,687

$1,240,360,400

$1,768,894,136

$658,446

 MVT Other

823

$19,532,106

$42,591,826

$153,183,991

$215,307,923

$261,588

 Other natural/environmental

123

$2,690,121

$4,270,614

$13,651,834

$20,612,569

$167,359

 Poisoning

279,444

$2,061,419,009

$799,796,068

$9,522,661,850

$12,383,876,927

$44,316

 Suffocation

9076

$123,411,128

$873,402,854

$2,603,923,204

$3,600,737,186

$396,752

 Other specified & classifiable

1875

$73,774,938

$172,400,608

$544,485,818

$790,661,364

$421,619

 Other specified, NEC

27,623

$175,461,682

$411,227,781

$1,413,948,899

$2,000,638,362

$72,426

 Unspecified

7271

$34,820,468

$79,108,294

$270,489,268

$384,418,030

$52,869

ASSAULT

 Cut/pierce

73,932

$491,701,003

$1,138,106,551

$5,476,377,890

$7,106,185,444

$96,118

 Drowning/submersion

69

$642,802

$1,964,335

$7,164,047

$9,771,184

$141,881

 Fall

1646

$12,022,160

$37,569,063

$169,630,025

$219,221,249

$133,196

 Fire/flame

595

$3,858,466

$9,261,217

$69,978,211

$83,097,894

$139,678

 Hot object/substance

1962

$15,993,005

$17,535,750

$153,556,467

$187,085,222

$95,368

 Firearm

30,131

$927,098,739

$1,530,254,784

$6,968,840,319

$9,426,193,842

$312,844

 MVT Occupant

1660

$6,798,022

$12,494,180

$130,515,813

$149,808,015

$90,225

 Poisoning

1761

$7,901,485

$2,498,250

$92,294,308

$102,694,043

$58,317

 Struck by/against

611,218

$2,512,923,350

$6,795,903,883

$56,416,139,291

$65,724,966,524

$107,531

 Suffocation

3006

$10,208,810

$27,416,530

$127,393,050

$165,018,390

$54,888

 Other specified & classifiable

119,372

$604,801,671

$1,005,672,954

$7,496,925,042

$9,107,399,667

$76,294

 Other specified, NEC

165,835

$571,842,316

$1,014,664,619

$11,060,805,689

$12,647,312,624

$76,265

 Unspecified

169,769

$879,584,274

$2,260,749,692

$17,139,072,436

$20,279,406,402

$119,453

UNDETERMINED INTENT

 Cut/pierce

3731

$13,136,329

$31,468,294

$124,000,521

$168,605,144

$45,196

 Drowning/submersion

233

$912,250

$8,301,876

$31,576,211

$40,790,337

$175,358

 Fall

3950

$39,802,960

$99,196,652

$333,040,805

$472,040,417

$119,510

 Fire/flame

2913

$15,518,883

$31,234,477

$242,655,585

$289,408,944

$99,345

 Hot object/substance

595

$3,699,041

$7,221,322

$73,345,138

$84,265,501

$141,740

 Firearm

4014

$74,095,787

$129,846,857

$546,583,710

$750,526,354

$186,991

 MVT Other

459

$3,147,206

$6,780,905

$29,228,290

$39,156,401

$85,342

 Other natural/environmental

2703

$58,901,837

$45,949,242

$145,873,538

$250,724,617

$92,761

 Poisoning

126,707

$892,799,765

$326,704,590

$5,843,044,484

$7,062,548,839

$55,739

 Suffocation

267

$1,684,991

$9,729,591

$19,947,053

$31,361,635

$117,601

 Other specified & classifiable

463

$4,000,582

$9,817,663

$43,121,482

$56,939,727

$122,885

 Other specified, NEC

14,025

$64,785,622

$98,439,086

$539,613,549

$702,838,257

$50,114

 Unspecified

76,146

$313,398,577

$320,997,827

$2,566,738,535

$3,201,134,939

$42,039

LEGAL INTERVENTIONa

 Cut/pierce

1449

$3,102,948

$6,635,734

$22,866,321

$32,605,003

$22,502

 Firearm

1383

$41,617,599

$57,218,311

$234,236,902

$333,072,812

$240,832

 Poisoning

349

$645,957

$336,617

$13,470,021

$14,452,595

$41,469

 Struck by/against

41,824

$127,374,328

$266,063,345

$1,325,708,220

$1,719,145,893

$41,104

 Other specified & classifiable

1174

$9,406,164

$8,221,940

$41,502,028

$59,130,132

$50,375

 Other specified, NEC

121

$1,064,568

$2,915,549

$9,994,667

$13,974,784

$115,142

 Unspecified

6937

$20,238,437

$42,810,948

$214,315,994

$277,365,380

$39,984

UNSPECIFIED INTENT

 Drowning/submersion

443

$27,326,952

$54,731,485

$204,710,316

$286,768,754

$646,970

 Other natural/environmental

49,694

$686,083,672

$522,349,852

$2,757,831,073

$3,966,264,597

$79,814

 Poisoning

81,013

$677,091,885

$163,997,422

$4,002,093,054

$4,843,182,361

$59,783

 Suffocation

28,327

$1,760,326,274

$379,312,268

$1,302,485,774

$3,442,124,316

$121,514

 Other specified & classifiable

57,020

$351,856,081

$246,844,436

$698,824,829

$1,297,525,346

$22,756

Unspecified

2,499,592

$18,048,042,991

$24,246,394,615

$139,111,309,043

$181,405,746,649

$72,574

MVT Motor vehicle traffic

NEC Not elsewhere classifiable

*Deaths due to injuries inflicted by police or other law enforcement agents

Discussion

Approximately one in 10 individuals in the United States is injured each year are treated in a hospital, with high corresponding costs. Our calculated rate of 9.8 injuries per 100 people in 2013 is nearly half that of the 18.135 injuries per 100 population estimate by Corso et al. based on data from 2000. (Corso et al. 2006) While a prior study of US spending on personal health care found that injuries accounted for $168 billion (8%) of the $2.1 trillion in medical spending in 2013, our comprehensive injury medical spending estimate exceeds that, even while excluding the 12 million injuries treated in physician’s offices and clinics. (Dieleman et al. 2016) Limitations of the study include the absence of outpatient and ambulatory data, as well as the possibility of misclassification based on ICD codes.

These cost data from 2013 support priority-setting and selection of interventions to reduce the burden of injury in the United States.

Abbreviations

ED: 

Emergency department

HCUP: 

Healthcare Cost and Utilization Project

MVT: 

Motor vehicle traffic

NEC: 

Not otherwise classifiable

Declarations

Funding

Dr. Zonfrillo was supported by the National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, grant 5K08HD073241.

Availability of data and materials

Please contact author for data requests.

Authors’ contributions

This study was designed by MRZ, RSS, and TRM. Data analysis and collection was done, or supervised, by MRZ, RSS, BAL, TRM. Data interpretation and manuscript preparation were done by MRZ, RSS, BAL, TRM. All authors made significant contributions to drafting and critical revision of the manuscript and approved the final version.

Ethics approval and consent to participate

The study was not human subjects research and was exempt from review. Consent to participate not applicable.

Competing interests

The authors declare that they have no competing interests.

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Hasbro Children’s Hospital and Alpert Medical School of Brown University, Providence, RI, USA
(2)
Pacific Institute for Research and Evaluation, Calverton, MD, USA
(3)
Curtin University School of Public Health, Perth, Australia
(4)
Department of Emergency Medicine, Alpert Medical School at Brown University, 55 Claverick St., 2nd floor, Providence, RI 02903, USA

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Copyright

© The Author(s). 2018

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