“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 , 1988
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. Total costs of intimate partner violence in 1995 were estimated at $5.8 billion, over $1300 per victim. 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.
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. 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. 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. 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? , 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? 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 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). 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. 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 comparison 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 literature-derived 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. 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 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. , 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.
| 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 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
