Cost of Injury 

in the United States 

A Report to Congress 

1989 

Dorothy P. Rice 

Ellen J. MacKenzie 

and Associates 

PROPERTY OF NCIPC LIBRARY 

PLEASE RETURN TO NCIPC LIBRARY 

MS-K65 

Produced by 

Institute for Health & Aging 

University of California , San Francisco 

Injury Prevention Center, School of Hygiene and 

Public Health, The Johns Hopkins University 

for 

National Highway Traffic Safety Administration 

U.S. Department of Transportation 

Centers for Disease Control 

U.S. Department of Health and Human Services 
Single copies of this report may be requested from the Division of 

Injury Epidemiology and Control, Center for Environmental Health and 

Injury Control, Centers for Disease Control, 1600 Clifton Road, Koger 

Center, F-36, Atlanta, GA 30333. 

The authors are solely responsible for the content of this report, 

which does not necessarily reflect the views of the sponsoring 

institutions or the funding agencies. 

Citation: Dorothy P. Rice, Ellen J. MacKenzie, and Associates. Cost 

of Injury in the United States: A Report to Congress. San Francisco, CA: 

Institute for Health & Aging, University of California and Injury 

Prevention Center, The Johns Hopkins University, 1989. 

Please give full credit when citing or quoting any part of this 

publication. 
Authors 

Alison S. Jones 

Sharon R. Kaufman 

Gregory V. deLissovoy 

Ellen J. MacKenzie 

Wendy Max 

Elizabeth McLoughlin 

Ted R. Miller 

Dorothy P. Rice 

Leon S. Robertson 

David S. Salkever 

Gordon S. Smith 

Ida VSW Red, Editor -
Preface 

Injury is now recognized as a major public health problem in the 

United States. It is the fourth leading cause of all deaths, but among 

children and adults under age 45, it is the leading cause of death. Injury 

is costly to the nation in productive life years lost due to premature 

death and long term disability; in medical resources used for care, 

treatment, and rehabilitation of injured persons; and in pain and 

suffering of the injured persons, their families, and friends. 

Background 

The present report is the third in a series focusing attention on 

injury as a critical public health issue. Injury in America, the 1985 report 

from the National Academy of Sciences by the Committee on Trauma 

Research, the National Research Council, and the Institute of Medicine, 

launched the series. It found that serious, but remediable, inadequacies 

exist in the understanding of and approach to injury as a health problem, 

that current data systems are inadequate for planning and evaluating 

preventive programs, and that high priority should be given to research 

on the prevention and treatment of injuries and on the rehabilitation of 

injured persons. Emphasis was placed on the need for a center for injury 

control within the federal government and for more adequate resources 

for research on injury. 

Following the publication of Injury in America, Congress established 

a three-year pilot program for the study of injury control at the Centers 

for Disease Control (CDC). The new Division of Injury Epidemiology 

and Control began efforts in the following areas: research and data 

collection, professional training, promotion of health department 

programs, and coordination at federal, state, and local levels among 

public health workers and others involved in the field. 

In 1988, the National Academy of Sciences published Injury Control, 

the second in the series. This report reviewed the status and progress of 

the injury control programs at CDC. It commended the accomplishments of CDC activities, but concluded that the full intent of the 

recommendations made in Injury in America had not been met because of 

the lack of resources and the need for an organizational setting to make 

the program more widely recognizable as the federal focal point for the 

conduct and coordination of injury control research. 

The present Report to Congress, Cost of Injury in the United States, is 

the third in this series of injury reports. The 1987 Supplemental 

Appropriation Bill of the House of Representatives (100th Cong., 1st 

sess.) directed that research be conducted by the joint National Highway 

-_ 
vi Cost of Injury in United States 

Traffic Safety Administration (NHTSA) and CDC Trauma Research 

Program to evaluate the impact of injury and associated disability on 

American society. The report accompanying the legislation states: 

This research should identify the effect of injuries on state and 

local governments, local communities, families and 

individuals. Eighteen months following enactment of this Act, 

a report on the results of this research shall be submitted to the 

House and Senate Committees on Appropriations. In addition, 

long-term 

costs of treatment and rehabilitation of injuries, including 

motor vehicle injuries, and describe the extent to which 

existing government and non-government programs cover the 

economic and non-economic costs. The report shall further 

provide an estimate of the potential savings to all levels of 

government that could result from the prevention of injuries, 

including motor vehicle injuries, and their consequences (U.S. 

House of Representatives, p. 94). 

the report shall provide an estim ate of the nation's 

The present report addresses the purpose and objectives of the 

mandate. It was conducted under grants from NHTSA and CDC by two 

research organizations: the Institute for Health & Aging, University of 

California, San Francisco and the In jury Prevention Center, School of 

Hygiene and Public Health, The Johns Hopkins University (Grant Nos. 

DTNH22-88-Z-07145 and DTNH22-88-Z-07144). 

Organization of the Report 

The report contains five chapters on the incidence and cost of injury, 

a chapter featuring ten case studies of the long-term impact of injury, 

and recommendations resulting from the study. Following the Summary 

and an introduction, Chapters One and Two describe in detail the 

incidence and lifetime cost of injury. Chapter Three explores the sources 

of payment for costs incurred following injury and estimates transfer 

payments from public and private sources to injured persons or their 

survivors. Estimates of the willingness to pay for the reduction of injury 

are presented in Chapter Four. Chapter Five assesses potential savings 

from selected injury prevention programs. Chapter Six consists of ten 

case studies of injured persons in which personal narratives illustrate the 

long-term impact of injury on individuals, families, and society. Policy 

implications emerging from the case studies are presented. The 

recommendations that follow from the conduct of the study focus on the 

following issues: injury prevention and control, coding and 

measurement, data needs, and treatment and rehabilitation. 
vii 

Acknowledgments 

This report on the impact of injuries and their associated disabilities 

on American society represents a truly collaborative effort of the staff of 

two universities -- the Institute for Health & Aging, University of 

California, San Francisco (UCSF), and the Injury Prevention Center, 

School of Hygiene and Public Health, The Johns Hopkins University 

(JHU). It is the product of research supported by NHTSA and CDC. The 

study involved a multidisciplinary approach and many experts, all of 

whom contributed greatly to the production of this report. 

The authors wish to express their appreciation for the invaluable 

guidance, advice, assistance, support, encouragement and coordination 

provided throughout the project by Barbara Faigin, Project Officer, 

NHTSA. Several individuals in NHTSA also provided useful data and 

expert advice in various aspects of the research including Michael 

Finkelstein, Steven Luchter, Larry Blincoe, and Louis Lombardo. Mark 

Rosenberg and Stuart Brown, CDC, also provided invaluable guidance 

and support. 

The principal investigators at UCSF and at JHU gratefully 

acknowledge the professional expertise and assistance of several 

colleagues and support staff who had major responsibilities for the 

various components of the study. At UCSF, Sharon Kaufman, 

anthropologist, conducted the case studies of injured survivors and their 

families to measure the long-term impact of injury to themselves, their 

families, and society. Elizabeth McLoughlin, public health and injury 

control specialist, provided invaluable expertise in the development of 

injury incidence categories and the recommendations, writing several 

sections of the report, and carefully reviewing the entire manuscript. 

Wendy Max, economist, designed the lifetime cost model and was 

responsible for the estimation of the direct and indirect costs. The 

authors gratefully acknowledge the professional assistance of several 

colleagues at UCSF, including Mitchell P. LaPlante for his guidance in 

the use of several National Center for Health Statistics public use data 

tapes; Shubha Fanse for computer assistance; Kristin Jacobson and 

Norton Twite for word processing. Special recognition is given to the 

outstanding contribution of Scott Hood in development and layout of the 

tables and figures and for statistical assistance. We are especially 

grateful to Ida VSW Red for her special expertise and superior editing of 

the entire manuscript and for assuming full responsibility for overall 

design and production of the final report. 

At The Johns Hopkins University, Gordon Smith was instrumental 

in developing the incidence categories and rates. David Salkever, 

Gregory deLissovoy, and Alison Jones were responsible for estimating 
vii Cost of Injury in the United States 

the sources of payment. The authors would like especially to 

acknowledge the contributions of Maureen Fahey, Sharon Edelstein, and 

Susan Feely. Their expertise in working with large databases and their 

careful attention to detail was essential in developing the incidence 

figures and estimates of hospital costs. We are also grateful to Jewel 

Crum for her assistance in word processing, to Arlene Greenspan for 

conducting the survey of rehabilitation services administered through 

state governments, and to Byron Hamilton for providing information 

from the Uniform Data System for Medical Rehabilitation on source of 

payment for inpatient rehabilitation. 

Two consultants made special contributions to the report. Ted 

Miller, economist at The Urban Institute, wrote the chapter on 

willingness to pay and Leon Robertson, Injury Epidemiologist at Nanlee 

Research and Yale University, wrote the chapter on potential savings 

from injury prevention. 

The authors are indebted to the generosity of the ten participating 

survivors and their families whose tragedies and triumphs embody the 

essential subject matter of this report. We thank them for their 

willingness to share their personal stories. We also thank Joan Leon, 

Hale Zukos, and Byrd Dunaway from the World Institute on Disability 

for their assistance in providing background information about 

government regulations and legal issues in relation to injury and 

disability, and for preparing a useful annotated bibliography of 

publications in this area. We appreciate the time spent by health and 

social service professionals in locating study participants. 

We are indebted to several experts in the area of injury prevention 

and control who carefully reviewed the final manuscript and made 

important suggestions and comments incorporated in the final report. 

Special recognition is given to Professor Susan Baker of the Injury 

Prevention Research Center, The Johns Hopkins University, and Andrew 

McGuire of the Trauma Foundation, San Francisco General Hospital. 

Their leadership in injury epidemiology, prevention, and advocacy, 

established nationally through decades of work in the field, has guided 

the development of this report and its recommendations. 

We are privileged to have had the opportunity to conduct this 

important study and to have worked together to produce this report. 

Dorothy P. Rice

University of California, San Francisco

and

Ellen J. MacKenzie, Ph.D.

The Johns Hopkins University
ix 

Contents 

Preface v

Acknowledgments vii

Tables and Figures xi

Foreword xv

Summary xvii

Introduction 1

Chapter 1

Incidence of Injury 7

Overview 7

Patterns of Injury by Cause

Data Sources and Methods

Conclusion 34

Chapter 2

Economic Cost of Injury 37

Overview 38

Cause of Injury 43

Lifetime Cost of Injury 48

Class of Injury 48

Type of Cost 52

19 

27 

Economic and Measurement Concepts 70

Data Sources 72

Cost Estimation Methods

Data Limitations 81

Conclusion 83

Chapter 3

Source of Payment 87

Direct Expenditures 87

Transfer Payments 92

72 

Data Sources and Methods 94

Conclusion 100

Chapter 4

Willingness to Pay 202

To Reduce Fatal Injury Risk 101

To Reduce Nonfatal Injury Risk 104
x Cost of Injury in the United States 

To Avoid Specific and Minor Injuries

Conclusion 209

Chapter 5

Potential Savings from Injury Prevention

Background 111

Persuaded Behavior Change 114

Laws Addressing Individual Behavior

104 

111 

118 

Product Design and Environmental Changes 120

Data Needed for Estimation of Savings 125

Feasibility 135

Conclusion 136

Chapter 6

Long-Term Impact of Injury on Individuals, Families, and

Society: Personal Narratives and Policy Implications 139

Methods and Subjects 140

Ability and Desire to Work 142

Especially Vulnerable 149

Trauma to the Self 153

Attendant Services 156

Impact on the Family 161

Caring for Brain-Injured Adults 163

Caring for Severely Disabled Children 171

Conclusion 177

Recommendations 179

Injury Prevention and Control 179

Coding and Measurement Issues 181

Data Needs 185

Treatment and Rehabilitation

Appendix A Injury Diagnoses 193

Appendix B Methodology 197

Appendix C Detailed Tables 207

References 227

Glossary 247

Index 255

Biographical Sketches 281

191
Tables and Figures 

Table 

1 

2 

3 

4 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

Number and Rate of Injured Persons by Sex, Age, and Class of 

Injury, 1985 8 

Number and Rate of Injured Persons by Cause and Class of 

Injury, 1985 13 

Number and Rate of Injured Persons by Intent and Class of 

Injury, 1985 15 

Number and Rate of Hospitalized Injured Persons by Principal 

Diagnosis and Severity of Injury, 1985 18 

Lifetime Cost of Injury by Age, Sex, and Type of Cost, 1985 40 

Lifetime Cost of Injury by Cause and Type of Cost, 1985 44 

Lifetime Cost of Injury by Age, Sex, and Cause, 1985 47 

Lifetime Cost of Injury per Injured Person by Age, Sex, and 

Cause, 1985 49 

Lifetime Cost of Injury by Cause, Type of Cost, and First and 

Later Years, 1985 50 

Lifetime Cost of Injury by Age, Sex, and Class of Injury, 1985 

51 

Lifetime Cost of Injury by Cause and Class of Injury, 1985 53 

Lifetime Direct Cost of Injury by Type of Expenditure and 

Cause, 1985 55 

Injury Morbidity Losses by Age and Sex, 1985 56 

Injury Morbidity Losses by Sex and Cause, 1985 58 

Injury Mortality Losses by Age and Sex, 1985 59 

Injury Mortality Losses by Sex and Cause, 1985 63 

Mortality Losses Due to All Causes and Due to Injury by Age 

and Sex, 1985 65 

Mortality Losses Due to the Leading Causes of Death by Sex and 

Cause, 1985 66 

Cost-of-Injury Estimates by Type of Cost 84 
xii Cost of lnjury in the United States 

Table 

20

21

22

23

24

25

26

27

28

Direct Medical Care Cost of Injury by Source of Payment and

Age, 1985 89

Direct Medical Care Cost of Injury by Source of Payment and

Type of Expenditure, 1985 93

Transfer Payments for Disability and Death Due to Injury by

Source of Payment and Program, 1985 94

Transfer Payments for Death Due to Injury by Program, 1985 

99

Individual Willingness-to-Pay Estimates of Value of Life by Type

of Study, 1985 103

Individual and Societal Willingness-to-Pay Estimates for

Reduction of Nonfatal Injury by Severity, 1985 105

Societal Willingness-to-Pay Estimates to Avoid Selected Injuries

by Nature of Injury, 1987 108

Estimated Cost and Savings of Interventions to Reduce Injury

and Severity 113

Examples of Injury Control Countermeasures with Known

Effectiveness: Data Needed for Savings Analysis 127

Appendix C - Detailed Tables 

C-l

c-2

c-3 

C-4 

c-5 

C-6 

c-7 

United States Civilian Population Estimates, 1985 207 

Motor Vehicles: Number and Rate of Injured Persons by Sex,

Age, and Class of Injury, 1985 208

Falls: Number and Rate of Injured Persons by Sex, Age, and

Class of Injury, 1985 209

Firearms: Number and Rate of Injured Persons by Sex, Age, and

Class of Injury, 1985 210

Poisonings: Number and Rate of Injured Persons by Sex, Age,

and Class of Injury, 1985 211

Fires/Burns: Number and Rate of Injured Persons by Sex, Age,

and Class of Injury, 1985 212

Drownings/Near Drownings: Number and Rate of Injured

Persons by Sex, Age, and Class of Injury, 1985 213
xiii 

Table 

C-8 Other: Number and Rate of Injured Persons by Sex, Age, and

Class of Injury 214

C-9 Motor Vehicles: Lifetime Cost of Injury by Age, Sex, and Type of

cost, 1985 215

C-10 Falls: Lifetime Cost of Injury by Age, Sex, and Type of Cost,

1985 216

c-11 Firearms: Lifetime Cost of Injury by Age, Sex, and Type of Cost,

1985 217

C-12 Poisonings: Lifetime Cost of Injury by Age, Sex, and Type of

cost, 1985 218

c-13 Fires/Burns: Lifetime Cost of Injury by Age, Sex, and Type of

cost, 1985 219

c-14 Drownings/Near Drownings: Lifetime Cost of Injury by Age,

Sex, and Type of Cost, 1985 220

C-15 Other: Lifetime Cost of Injury by Age, Sex, and Type of Cost,

1985 221

C-16 Mortality, Including Deaths in Later Years, by Age, Sex, and

Cause of Injury, 1985 222

C-17 Life Expectancy in Years, by Age and Sex, 1985 223

C-18 Present Value of Lifetime Earnings by Age, Sex, and Discount

Rate, 1985 224

C-19 Selected Economic Variables Used in Estimating Mortality Cost

by Age and Sex, 1985 225

Figure

1 Distribution of Injured Persons by Sex and Class of Injury, 1985

10

2 Distribution of Injured Persons by Age and Class of Injury, 1985

10

3 All Causes: Injury Rate by Age and Sex, 1985 12

4 Distribution of Injured Persons by Cause and Class of Injury,

1985 14

5 Distribution of Injured Persons by Intent and Class of Injury,

1985 16
xiv Cost of Injury in the United States 

Figure

6 Motor Vehicles: Injury Rate by Age and Sex, 1985 20

7 Falls: Injury Rate by Age and Sex, 1985 22

8 Firearms: Injury Rate by Age and Sex, 1985 24

9 Poisonings: Injury Rate by Age and Sex, 1985 26

10 Fires/Burns: Injury Rate by Age and Sex, 1985 28

11 Lifetime Cost of Injury by Type of Cost, 1985 39

12 Distribution of Injured Persons and Lifetime Cost by Sex, 1985

41

13 Distribution of Injured Persons and Lifetime Cost by Age, 1985

42

14 Distribution of Lifetime Cost of Injury by Age and Type of Cost,

1985 43

15 Distribution of Injured Persons and Lifetime Cost by Cause, 1985

45

16 Distribution of Lifetime Cost of Injury by Cause and Type of

Cost, 1985 46

17 Injury Mortality Losses by Sex, 1985 60

18 Injury Mortality Losses by Age, 1985 61

19 Injury Mortality Losses by Cause, 1985 64

20 Mortality Losses Due to Leading Causes of Death, 1985 67

21 Federal Research Investment and Productivity Losses by Cause

of Death 69

22 Direct Medical Care Cost by Source of Payment and Age, 1985

90

23 Direct Medical Care Cost by Source of Payment, 1985 91

24 Transfer Payments by Source of Payment, 1985 95

Appendix C -- Figure 

C-l Present Value of Lifetime Earnings by Age, Sex, and Discount

Rate, 1985 226
xv 

Foreword 

Since the end of World War II, more than 6 million U. S. citizens 

have died from injuries. Such statements remain only numbers unless 

one can envision over 400 families grieving at a graveside every day of 

every year. If these injuries could have been prevented, persons who 

died prematurely would still be alive today. In addition to those who 

have died from injuries, millions more have been left with severe 

impairments that will endure for the rest of their lives. Yet this nation 

has failed to face the extraordinary losses sustained from the problem of 

injury. 

Injury is often viewed as the inevitable price of living in a modern 

society. This volume provides an estimate of that price as it examines 

the economic impact resulting from the failure to deal with injury as a 

major threat to public health. It is only through the systematic 

examination of the effect of injury on our society that we can fully 

understand how critical it is to develop a cure for this pervasive killer 

and crippler. 

The researchers reporting in this volume identify, for the first time, 

the magnitude of the economic effect of injury on the United States. The 

$158 billion economic cost of injury is compelling, but not nearly as 

compelling as the case studies. These personal narratives illustrate in 

human terms the impact of injury on our fellow citizens -- impacts that 

afflict hundreds of thousands of people each year. 

This groundbreaking study makes a number of vital contributions 

to our appreciation of the scope of the injury problem in this country. 

For the first time, reliable estimates are presented on the number of 

fatalities and injuries by cause, an essential step in developing 

intervention strategies. The information on who pays for injury costs 

reveals that all sectors of our society are bearing the enormous burden 

imposed by injury. 

The authors also identify strategies that have succeeded in reducing 

the impact of injury. These strategies have more than paid for 

themselves and can serve as meaningful examples of how, as a society, 

we can develop cures for this major public health problem. Failure to 

fully implement activities with a proven positive savings is a waste of 

human and financial resources. The savings will accrue to individuals, 

families, and friends, to all levels of government and the private sector, 

and to society at large. 

The science of injury control requires that competent researchers 

objectively assemble and analyze data in order to make progress in the 

prevention of injury and the treatment and rehabilitation of the injured. 

This major effort to describe the impact of injury in the United States 
xvi Cost of Injury in the United States 

helps to chart a path for a new and rapidly growing field. It is a 

contribution of major importance. The study provides the tools needed 

to better understand the impact of injury on our society and to take 

actions that will reduce the tremendous toll of death and disability in our 

nation. We need no longer accept injury as an inevitable risk of 20th 

century life. 

William H. Foege, M.D. 

Executive Director 

The Carter Center 

Emor y University 
Summary 

In 1987, Congress directed that research be conducted by the joint 

National Highway Traffic Safety Administration (NHTSA) and the 

Centers for Disease Control (CDC) trauma research program to evaluate 

the impact of injury and associated disability on the United States. The 

Institute for Health & Aging of the University of California and The 

Injury Prevention Center of the Johns Hopkins University conducted the 

research and prepared this report to Congress. 

This study evaluates the magnitude of the impact of injury on 

individuals, government programs, and society at large in terms of 

economic cost and of the effects of injury on people’s lives. 

Comprehensive data on incidence, cause, severity, lifetime cost, life year 

and productivity losses, and source of funds disaggregated by age and 

sex are presented. The following topics are addressed: 

0 Number of people in the United States who are injured

and number who die due to injury annually;

Aggregate lifetime and per person cost to society of injury;

Long-term cost of treatment and rehabilitation of injuries;

Years of life lost due to the disabling effects of injury and

premature death;

Age groups most affected by injury;

Number of persons injured from the major causes of

injury and associated cost;

Number of persons fatally injured, hospitalized, and

nonhospitalized and associated cost;

Burden of injury cost by source of payment;

Valuing pain and suffering;

Potential savings from preventive intervention strategies;

Federal government investment in research on prevention

and control of injury relative to research dollars spent for

the other leading causes of death;

Life-long consequences of injury to injured persons and

their families; and

Recommendations emerging from the study for the

prevention, control, and further research on the incidence

and cost of injury.

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 
xiv Cost of Injury in the United States 

Recommendations 

Injury Prevention and Control 

Recommendation: Direct greater resources to the prevention of 

injuries and the mitigation of their results through the application of 

existing knowledge and the development and evaluation of new 

strategies. Establish and fund a Center for Injury Control within CDC to 

provide a focal point for national injury prevention activities. Provide 

additional resources to existing agencies that currently pursue the 

prevention and control of injury resulting from motor vehicles, fires, 

consumer products, and occupational hazards. 

Recommendation: Conduct research and controlled experiments to 

evaluate the effectiveness and savings of a wide range of injury control 

interventions and implement programs shown to be cost effective. 

Recommendation: Conduct research to evaluate the societal 

barriers to the application of injury prevention strategies that have been 

proven to be effective. 

Coding and Measurement Issues 

Recommendation: Require the use of both cause and nature or 

type of injury codes for all hospital discharge data systems and for all 

data bases having the potential of providing national injury estimates. 

Require a separate field for the cause of injury code. 

Recommendation: Standardize coding of injuries by multiple 

coding of nature and cause of injury for all data bases intended to 

provide national estimates of injury. Agency needs for specific 

information can be met by the addition of customized codes. 

Recommendation: Ensure compatibility of International Classification of Diseases (ICD) and Abbreviated Injury Scale (AIS) for classifying anatomic description of injury to permit computerized conversion 

from ICD to AIS for assigning severity scores on national data bases. 

Recommendation: Conduct research on the development and 

evaluation of a valid and useful classification system for impairments 

that will meet the needs of researchers, program administrators, and 

rehabilitation specialists. 

Data Needs 

Recommendation: Develop a national coordinated program of 

injury surveillance for the quick identification and control of outbreaks 

of specific injuries and for epidemiologic research on injuries. For this 

effort, rely on the integration of uniformly collected data derived from 

multiple sources at both the national and local levels. To compensate for 
Summary xix 

the time lag inherent in national data bases, states in which the medical 

examiner and/or hospital discharge data have the necessary quality and 

currency could monitor their data as an early warning system. Provide 

resources to achieve these objectives. 

Recommendation: Expand core National Health Interview Survey 

(NHIS) questions relevant to injury to describe the circumstances of 

injury. In addition, conduct a comprehensive supplement to the NHIS 

on incidence, medical care, rehabilitation, and disability related to injury. 

Provide adequate funds for the expansion of the core NHIS questions 

and for the conduct of a comprehensive injury supplement. 

Recommendation: Conduct, with adequate funding, a follow-up 

survey of respondents to the proposed NHIS Injury Supplement to determine the long-term physical and economic consequences of injury in the 

general population. Oversample respondents with severe injury 

resulting in long-term disability. 

Recommendation: Develop a series of well-designed, closely coordinated studies of the long-term physical, psychological, and economic 

consequences of patients treated in several trauma centers throughout 

the nation. 

Recommendation: Conduct, with adequate funding, a national 

medical expenditure survey periodically, preferably every five years, to 

provide current expenditure data for the nation. 

Recommendation: Implement the recommendations of the 

National Academy of Sciences Panel on Occupational Safety and Health 

Statistics of the Committee on National Statistics as soon as possible to 

provide improved and accurate data on occupational injuries and 

fatalities. 

Recommendation: Require that firearm injuries, in addition to 

being reportable to the police, be reportable to health departments. Place 

greater emphasis on coding the type of firearm on the death certificate. 

Develop a national fatal firearm injury reporting system, comparable to 

the Fatal Accident Reporting System (FARS), with sufficient data for 

documenting the firearm problem and designing prevention strategies. 

Treatment and Rehabilitation 

Recommendation: Conduct collaborative interdisciplinary research 

to identify and evaluate factors in trauma care that produce optimal 

results. 

Recommendation: Greatly expand research for the development 

and evaluation of cost-effective model systems of rehabilitation and for 

the design and production of affordabl.e and reliable assistive de vices to 

serve the needs of people with disabilities. Involve people with 

disabilities in the decision-making process. 
xx Cost of Injury in the United States 

Highlights 

How many Americans are injured each year? About 57 million 

persons were injured in 1985 -- one in four U.S. residents. Injuries occur 

to persons of all ages and to both genders, but younger persons and 

males are most affected. 

57 Million Persons, 

One of Every Four 

U.S. Residents, 

Injured in 1985 

How severe are the injuries ? The injury death toll is very high --

143,000 persons died from injuries in 1985, making injury the fourth 

leading cause of death in the United States. Hospitalized injuries 

numbered 2.3 million, and 54 million persons were less severely injured, 

not requiring hospitalization. 

What are the leading injury causes ? Falls are the leading cause of 

injury, accounting for one out of five injuries. Motor vehicle injury, 

however, is the leading cause of injury death, accounting for one-third of 

fatal injuries. Falls are the leading cause of nonfatal injury, representing 

one-third of hospitalized injured persons and one-fifth of 

nonhospitalized injured persons. All other causes -- injuries due to 

cutting and piercing instruments or being struck by blunt objects, 

suffocation, railway and air transportation, etc. -- account for 20 percent 

of the deaths, 30 percent of hospitalizations, and 64 percent of 

nonhospitalized injuries. 

Leading Causes of Injury 

4

cc; Y 

Motor Vehicles Falls Firearms 

P Q 

0 

2x 

Poisonings Fire/Burns Drownings All 

Near Drownings Other 

Causes 
Summary xxi 

Motor Vehicles the Leading Cause of Injury Death 

Falls the Leading Cause of Nonfatal Injury 

r-n 

142,568 

Fatalities 

= 0.2 

9- 2.3 Million 

Hospitalized 

Injured Persons 

54 Million 

Non-hospitalized 

Injured Persons 

QI 0 

\ 

Y3% 

3% 

P 

B!iJ 

0.04% 

z 
xxii Cost of Injury in the United States 

What are the leading causes of hospitalization? Heart disease and 

injury are the two leading causes of hospitalization (excluding 

deliveries). During 1987, one of ten discharges and one of six days of 

care were injury-related. 

Who is injured ? The young and males are at greatest risk. Four of 

five injuries are sustained by persons under 45 years of age and the 

largest number of injuries occurs among those aged 25-44. Three in ten 

males and one in five females sustain injuries in a year. Males account 

for 72 percent of injury fatalities, and 56 percent of nonfatal injuries. 

How many injury deaths are intentional? More than one-third of 

all injury deaths result from intentional injuries and, of these, three of 

five are suicides and two of five, homicides. The remaining two-thirds 

are due to unintentional causes. 

Over One-Third of Injury Deaths Intentional 

Intent Unknown - 2% 

Homicide - 14% 

Unintentional 

Fatalities - 63% 

142,568 Fatalities 

What is the total lifetime cost of injury? Injury imposes a $158 

billion burden on the U.S. economy. This estimate represents the 

aggregate lifetime cost for the 57 million persons injured in 1985. The 

human capital approach is used to estimate the lifetime cost of injury. 

This method values productivity lost or reduced due to injury. By 1988, 

the total economic cost of injury sustained in 1985 is estimated at $180 

billion. 

$ Total Lifetime Cost of Injury 

1985 - $158 billion 

1988 - $180 billion 

What are the first and later year costs of injury? The lifetime cost 

of injury in the United States takes into account the cost incurred in the 

first year in which the injury occurs as well as the cost incurred in later 

years. Of the total lifetime cost of $158 billion, almost three-fourths, $116 
Summary 

billion, is for the first year cost and the remaining $41 billion is estimated 

to be incurred in later years. 

Is the economic toll greater for men or women? The risk of injury is 

highest among males; they sustain 57 percent of the injuries but account 

for 68 percent of the cost. Almost three in ten males (28%) living in the 

United States incur injuries in a year. The total lifetime cost of injury for 

males is more than double that for females -- $108 billion compared with 

$50 billion. The relatively higher cost for males reflects their higher labor 

force participation rate, earnings, and fatality rates. 

At what age is the economic toll largest? More injuries occur 

among adults aged 25-44 than in any other age group, and their lifetime 

cost is highest at $66 billion, 42 percent of the total cost. Injury to 

persons aged 15-24 ranks second, accounting for 25 percent of total cost. 

How much is spent for medical and nonmedical care of injured 

persons? Expenditures for medical care amount to $45 billion, 29 percent 

of the total lifetime cost. Included are amounts spent for hospital and 

nursing home care, physician services, drugs, appliances, and 

rehabilitation as well as for nonmedical care directly related to the injury. 

What is the value of losses in productivity for injured persons? The 

morbidity loss for persons disabled as a result of injury amount to 5.1 

million years of productive output lost, valued at $65 billion, two-fifths 

of the total economic cost. 

What is the death toll? Injury is the leading cause of death for 

Americans under 45 years of age. About 143,000 premature deaths from 

injury occurred in 1985 and an additional 13,000 deaths occurred in later 

years due to injury sustained in 1985. These premature injury deaths 

amount to a loss of 5.3 million life years lost, or 34 years per death. 

These losses to the economy amount to $47.9 billion at a 6 percent 

discount rate. 

Who pays? Public (federal, state, and local government) funds 

expended in 1985 amount to $11.6 billion covering 28 percent of the 

medical expenditure for injury; 72 percent is borne by private sources. 

Who bears the burden of disability and survivor benefit payments? 

These payments, some of which are used for medical care, amount to $53 

billion. Of this total, more than one-fourth comes from public programs 

(Social Security Disability Insurance, Supplemental Security Income, and 

Veterans Administration). 

How much does injury cost the federal government? The federal 

government pays $8.9 billion for the medical care cost of injured persons, 

mainly through Medicare and Medicaid. The federal government also 

pays $13 billion in disability and death benefits under Social Security 

Disability Insurance, Supplemental Security Income, and the Veterans 

Administration. Lost tax revenues are excluded. 
Cost of Injury in the United States 

How does the economic toll of injury compare with that of other 

leading causes of death? Injury is the fourth leading cause of death, but 

productivity losses from this cause are far greater than from the three 

other leading causes of death. Injury deaths represent 36 life years lost 

per death* and a productivity loss of $334,851 per death. Life years 

lost per death for the three other leading causes are 12 years for 

cardiovascular diseases (heart disease and stroke combined) and 16 

years for cancer. Cost per death is $51,000 for cardiovascular diseases 

and $88,000 for cancer. 

36 Life Years Lost per Injury Death* 

Life Years Lost Per Death 

“Excludes deaths in later years 

How do injury research expenditures compare with research 

spending on the other leading causes of death? Comparing federal 

research expenditures, injury research spending ($160 million) amounts 

to 11 percent of National Cancer Institute obligations ($1.4 billion) and 

17 percent of National Heart, Lung, and Blood Institute obligations 

($930 million). A very small amount of research funding is being 

allocated to injury, a most costly public health problem. 

Injury Research Underfunded 

m Injuries 

� Cancer 

a Cardiovascular 

Diseases 

Research Expenditures 

Per Life Year Lost 
Summary XXV 

Which causes of injury are the most costly ? The greatest economic 

losses are caused by motor vehicles, accounting for $49 billion, followed 

by falls ($37 billion), firearms ($14 billion), poisonings ($9 billion), fires 

and burns ($4 billion), and drownings and near drownings ($2 billion). 

All other causes of injury total $42 billion altogether. 

Motor Vehicle Injuries Most Costly 

ED �

_!!!L P 

Y 

Motor Vehicles Poisonings 

Falls Fire/Burns 

Drownings

Firearms Near Drownings 

$158 Billion Lifetime Cost All Other 

Can pain and suffering be quantified? The above economic cost, 

based on the human capital method, does not take into account the cost 

associated with pain, suffering, and reduced quality of life. An 

alternative method that incorporates the individual perspective on the 

value of these aspects of well-being is the willingness-to-pay approach. 

This method values human life according to the amount individuals 

spend on injury reduction with potential savings to society. This 

assessment yields values of $2 million to avoid death. The American 

public would be willing to pay an estimated $1.1 trillion per year to 

eliminate all fatal and nonfatal injuries. 

Can the economic losses due to injury be reduced? The number of 

severe injuries could be substantially reduced by greater application of 

current knowledge. The potential savings, net of the cost of injury 

control programs, are in the billions of dollars for interventions for which 

data are available. 

How can the impact of injury on individuals and their families be 

assessed? An anthropologist interviewed ten people or members of their 

families about how their lives were changed over a period of 2 to 18 

years following severe injury. These case studies describe the struggle to 

acquire the personal, therapeutic, legal, and financial aid that enables 

injured people to survive and create lives that are meaningful in terms of 

work, love, mutual support, recreation, and personal growth. 
�

xxvi Cost of Injury in the United States 

Findings 

Incidence and Cost 

Of the total 56.9 million persons injured in the United States in 1985, 

almost one-third (18.1 million) are in the 25-44 age group and account for 

more than two-fifths of the total lifetime cost ($65.8 billion). The second 

highest number of injuries, more than one-fifth (12.8 million), occurs 

among persons aged 15-24 and accounts for one-quarter of the total cost 

($39.1 billion). About 14 million children under age 15 also suffer from 

injuries and comprise one-quarter of total injuries and one-tenth of the 

cost ($13.8 billion). Persons under age 45 sustain almost four-fifths of all 

injuries and account for three-quarters of the total lifetime cost. 

Persons Aged 25-44 at Highest Risk and Most Costly 

57 Million Injured Persons 

25% 

$158 Billion Lifetime Cost 

0 

x 

Years 

0-4 

5-14 

a 

7F 

A 15-24 

&I 25-44 

t 45-64 

0 

#I 65+ 
Summary xxvii 

Cause of Injury 

Motor Vehicles 

7 

Incidence: Nearly 5.4 million injuries were caused by motor 

vehicles in 1985. Motor vehicles are the leading cause of injury death 

(45,923 fatalities) and the second leading cause for hospitalized (523,028) 

and nonhospitalized (4.8 million) injured persons. The 15-24 age group 

is at highest risk, and males in this age group are three times more likely 

to be injured or killed than are females. The elderly rank second in risk 

of dying of motor vehicle injuries. 

Lifetime Cost: Motor vehicle injuries account for 9 percent of total 

injuries and 31 percent or $48.7 billion in lifetime cost, ranking as the 

most costly of injury causes. Because of the high number of deaths 

among young adults, motor vehicle injuries account for over one-third of 

the mortality cost. Motor vehicle injuries rank second to falls in direct 

and morbidity costs. About 72 percent of the lifetime cost due to motor 

vehicles is incurred in the first year after injury. 

Per Person Cost: The average lifetime cost per person injured by a 

motor vehicle is $9,062. The average cost per fatal motor vehicle injury is 

$352,042, for a hospitalized person, $43,409, and for a person injured but 

not hospitalized, $1,570. 

Falls 

Incidence: Falls are the leading cause of nonfatal injury in the 

United States, accounting for an estimated 783,000 hospitalizations and 

11.5 million persons injured who did not require hospitalization. Falls 

account for 12,866 deaths. The death rate due to falls among the elderly 

aged 75 and older is nearly 12 times greater than the rate for all other 

ages combined, and the risk of hospitalization is nearly seven times as 

great. 

Lifetime Cost: Falls account for $37.3 billion in societal losses due 

to injury, second to motor vehicle injury. Because of the lengthy 

hospitalization of elders who fall, direct costs, $14.7 billion, account for 

39 percent of the total cost. The mortality cost is relatively low, $1.5 
xxviii Cost of Injury in the United States 

billion, because of the short life expectancy and low earnings of the 

population at greatest risk. The morbidity cost, $21 billion, is high 

because falls result in long-term disability, accounting for 57 percent of 

the total cost. 

Per Person Cost: The average lifetime cost per person for a fall 

injury is $3,033. The average cost per fatal fall is $99,669, the lowest of all 

causes of injury, reflecting the short life expectancy and low earning 

power of the elderly population at greatest risk. The average per person 

cost for hospitalization for a fall injury is $38,174 and for a person 

injured but not hospitalized, $499. 

Firearms 

Incidence: Injuries resulting from the use of firearms are the second 

leading cause of injury death in the United States. In 1985, 31,556 people 

were shot to death; 39 percent of the deaths were homicide, 56 percent 

were suicide, and 5 percent were unintentional. The risk of firearm 

death is highest for the 15-44 age group. Males over age 75, however, 

have the highest rate of any other age group, due primarily to suicide by 

firearm. There are an estimated 65,000 hospitalizations for treatment of 

firearm injuries, and 171,000 persons injured by firearm who did not 

require hospitalization. 

Lifetime Cost: Firearms rank third in the economic toll on society, 

amounting to $14.4 billion, or 9 percent of the total cost. Firearm injuries 

account for 5 percent of total injuries, but fatalities at young ages result 

in a high mortality cost and males are responsible for 86 percent of the 

cost. Firearm injuries account for $1.4 billion in morbidity cost and 12 

billion in mortality cost. 

Per Person Cost: The average per person cost of a firearm injury is 

very high, $53,831, because of the large number of fatal firearm injuries. 

The average per person cost for a fatality, $373,520, is the highest of any 

cause of injury. The average cost for hospitalization due to firearm 

injury is $33,159 and for a person injured but not hospitalized, $458. 

Poisonings 

Incidence: Poisonings account for 11,894 deaths, 218,500 injured 

persons hospitalized, and 1.5 million injured persons not requiring 
Summary xxix 

hospitalization. Almost all people who die of poisoning are over age 15, 

and nearly half of all poisoning deaths are ruled as suicide. Males are 1.9 

times as likely to die of poisoning as females. For nonfatal poisoning, the 

elderly, the very young, a.nd adolescents are at greatest risk. Very young 

children, aged 0-4 years, account for 21 percent of all nonhospi talized 

poisonings. 

Lifetime Cost: Poisoning accounts for 3 percent of total injuries and 

5 percent, or $8.5 billion, of the total lifetime cost of injury, ranking 

fourth in cost of injury. 

Per Person Cost: The average per person cost of fatal poisoning is 

$372,691, ranking second to the cost of firearm fatality per person 

because of the large number of poisoning deaths among adolescents and 

young adults. The average cost per person hospitalized for poisoning is 

$17,631 and $171 for those not hospitalized. 

Fires and Burns 

Incidence: Fire and bum injuries result in 5,671 deaths, 54,400 

hospitalizations, and 1.4 million burns not requiring hospitalization. The 

very young and the elderly are at highest risk for hospitalization due to 

burns. Males are slightly more at risk for fire and burn injuries than are 

females, but the gender differential is not as great as for other injuries. 

Lifetime Cost: Fire and burn injuries cost $3.8 billion, accounting 

for 3 percent of total injuries and 2 percent of the total lifetime cost of 

injury. 

Per Person Cost: The average lifetime per person cost for a fire or 

burn injury is $2,619. The average cost for a hospitalized bum patient is 

$35,303, twice that for poisonings. The average fire or burn fatality cost 

is $249,367 and $347 for a nonhospitalized injured person. 

Drownings and Near Drownings 

Incidence: In 1985, 6,171 people in the United States drowned. 

Males are four times as likely to drown as females. Very young children, 

aged 0-4, are at greatest risk for drownings and hospitalization for near 

drownings. Young people, aged 15-24, are also at high risk for 

drownings. 
xxx Cost of Injury in the United States 

Lifetime Cost: Drownings and near drownings account for $2.5 

billion in lifetime cost of injury, less than two percent of the total lifetime 

cost of injury. 

Per Person Cost: Because of the small sample of nonhospitalized 

injuries due to near drowning and the relatively high proportion of all 

injuries being fatalities, the average per person cost of near drowning is 

$64,993. The average fatality cost is $362,292 and for a hospitalized 

person, $31,408. 

Injuries from All Other Causes 0

Other 

Incidence: Injuries from all other causes account for 63 percent of 

the total number of injuries in the United States in 1985 -- 20 percent of 

deaths, 30 percent of hospitalizations, and 64 percent of nonhospitalized 

injuries. Included are injuries due to cutting and piercing instruments or 

being struck by blunt objects, suffocation, and railway and air 

transportation (see Appendix A for complete list). 

Lifetime Cost: Other injuries account for 27 percent, or $42.4 billion, 

of the total lifetime cost of injury. 

Per Person Cost: The low average per person cost ($1,187) reflects 

the large number of persons whose injuries do not require hospitalization, resulting in low medical treatment cost. 

Falls, Highest Incidence - Motor Vehicles, Highest Cost 

Injured Persons cost 

Number Rate per Total Per Injured 

Cause of Injury (000’s) 100,000 (millions) Person 

Total 56,859 23,985 $157,615 $2,772 

Motor Vehicles 5,372 2,266 48,683 9,062 

Falls 12,289 5,184 37,279 3,033 

Firearms 268 113 14,410 53,831 

Poisonings 1,702 718 8,537 5,015 

Fires/ Bums 1,463 617 3,832 2,619 

Drownings* 38 16 2,453 64,993 

Other 35,726 15,071 42,421 1,187 

* Includes Near Drownings 
Summary xxxi 

Class of Injury 

There are three classes of injury reflecting severity: 155,665 deaths 

(142,568 deaths occurring in 1985 plus 13,097 deaths occurring in later 

years due to injuries sustained in 1985), 2.3 million hospitalized injuries, 

and 54.4 million nonhospitalized injuries. The distribution of costs by 

class of injury reflects the severity of the injuries. Of the $158 billion 

lifetime cost, 31 percent is the cost of fatalities. More than half the cost 

(51%) is for injuries involving hospitalization and less than one-fifth 

(18%) for nonhospitalized injured persons. 

Fatalities Under 1% of All Injuries and 31% of Total Injury Cost 

Nonhospitalized 

Persons 

Hospitalized 

Persons 51% 

$158 Billion Lifetime Cost 

Cost per injured person by class of injury also reflects injury 

severity. Cost per person fatally injured amounts to $317,189. The cost 

per injured person hospitalized is $34,116, and per nonhospitalized 

injured person, the cost is $518. 

Fatalities 

The risk of death from injury is highest among males. Of the total 

155,665 injury fatalities occurring in 1985 and in later years, 72 percent 

are males and 28 percent are females. The lifetime cost for males, 
xxxii Cost of Injury in the United States 

however, is significantly higher, 81 percent of the total, reflecting higher 

labor force participation and higher earnings. 

Adults in the 25-44 age group account for 34 percent of the deaths 

due to injury. Since people who die prematurely in this age group are at 

the height of their productivity, the present value of future earnings lost 

is high. Productivity losses for this age group comprise half the total cost 

of fatalities. The cost per fatality for this age group amounts to $482,583. 

By contrast, 21 percent of fatalities are persons aged 65 and over, 

but less than 2 percent of the lifetime cost of fatality is in this age group. 

The cost per fatality aged 65 and over amounts to only $25,771 because 

of short life expectancy and low earnings. 

As might be expected, the elderly are at high risk of dying from all 

diseases, including injury. Thus, the risk of death as a result of injury is 

highest for adults aged 75 and over. Only 5 percent of the U.S. 

population is aged 75 and over, but this group accounts for 13 percent of 

all injuries resulting in death. Adolescents and young adults aged 15-24 

rank second in risk of injury severe enough to result in death. Rates are 

lowest for children aged 5-14. 

Hospitalized Injured Persons 

About 2.3 million persons sustained injuries severe enough to be 

hospitalized in 1985 at a total lifetime cost of $80 billion, $34,116 per 

hospitalized person. Of the 2.3 million hospitalized injured persons, 1.3 

million, or 56 percent, are males. The proportion of the total cost for 

hospitalized injury is higher for males -- 65 percent. Males are 

apparently involved in more serious injuries that incur higher costs. 

Injured persons aged 25-44 are the most costly for hospitalized 

injuries, comprising 37 percent of the total cost. The 15-24 age group is 

second costliest for hospitalized injuries. The cost per hospitalized 

person ranges from $20,661 for the elderly aged 65 and over to $43,169 

for adults aged 25-44. 
Nonhospitalized Injured Persons 

About 54.4 million injured persons, 96 percent of all persons injured 

in 1985, are not hospitalized. This injury class, although large, involves 

the least severe injuries. Costs amount to $28.2 billion, 18 percent of the 

total cost, and $518 per nonhospitalized injured person. Fifty-six percent 

of the 54.4 million nonhospitalized injured persons are males, and they 

incur about the same proportion (57%) of the $28.2 billion of 

nonhospitalized injury. 

Nonhospitalized injured adults aged 25-44 are the most costly, 

comprising 41 percent of the total cost. The 45-64 age group ranks 

second in cost, accounting for 20 percent of the total. The cost per 

nonhospitalized injured person, however, is highest for the elderly, 

amounting to $901 compared to $672 and $791 for those aged 25-44 and 

45-64, respectively. 

Per Injury Fatality Cost Highest 

Injured cost 

Persons Total Per injured 

Class of Injury (000’s) (millions) Person 

Total 56,859 $157,615 $2,772 

Fatalities 143 49,374 317,189 * 

Hospitalized 2,347 80,063 34,116 

Nonhospitalized 54,369 28,178 518 

* Based on 155,665 deaths, including 13,097 deaths 

in later years due to injuries sustained in 1985 
xxxiv Cost of Injury in the United States 

Type of Cost Defined 

The lifetime cost of injury includes the amounts spent for medical 

care and nonmedical services for persons injured in 1985, and the value 

of losses to society due to premature death or inability to work or to keep 

house. The lifetime cost takes into account the cost incurred the year in 

which the injury occurred and the cost incurred in each successive year. 

Direct cost includes the amount spent for personal 

health care for persons injured in 1985, including 

hospital and nursing home care, physician visits, 

prescription drugs, physical therapy, ambulance and 

helicopter services, attendant care, and other expenses 

such as wheel chairs and appliances for injured people. 

Nonmedical direct costs include expenditures for home modifications, 

vocational rehabilitation, and overhead and administrative costs for 

automobile and health insurance. Direct expenditures for medical and 

nor-medical care amount to $44.8 billion, or 29 percent of the total 

lifetime cost of injury. 

0$ 

Morbidity cost is the value of goods and services 

not produced because of injury-related illness and 

disability. To the degree that injury prevents or deters 

people from producing goods and services in the 

b marketplace, in the public sector, or in their homes, the 6% 

value of morbidity losses is a cost borne by the society. 

Estimates of morbidity cost involve applying average earnings to work 

years lost and imputing a dollar value to housekeeping services for those 

unable to perform them. Morbidity cost is valued at $64.9 billion, or 41 

percent of the total. 

Mortality cost is the value of the lifetime earnings 

lost by all who are fatally injured and die prematurely. 

This cost is the product of the number of injury deaths 

and the expected value of future earnings with gender 

6

R and age taken into account. This method takes into

consideration life expectancy at the age of death, changing patterns of earnings at successive ages, varying labor force 

participation rates, imputed value for housekeeping services, and a six 

percent discount rate to convert aggregate earnings over a lifetime to 

present worth. This is the human capital method. Mortality cost 

amounts to $47.9 billion, or 30 percent of the total. 
Summary xxxv 

Type of Cost Distributed 

Direct Cost 

Direct personal medical and nonmedical costs of care for injured 

persons amount to $44.8 billion. Of this total, $24.5 billion, or 55 percent, 

is spent for hospital care, including rehabilitation and the cost of 

professional services provided to hospitalized patients. Physician visits 

outside of hospitals rank second, estimated at $6.5 billion, or 15 percent 

of the direct cost. The third highest type of expenditure, $2.5 billion, or 5 

percent of the direct cost, is for nursing home care. 

Morbidity Cost 

Morbidity cost is the value of goods and services not produced 

because of injury-related illness and disability. Lifetime morbidity cost 

includes the value of output lost for injured persons who are disabled in 

later years as a result of injury sustained in 1985. Losses for persons 

injured and disabled in 1985 amount to 5.1 million life years or 9 life 

years lost per 100 injured persons. These losses translate to a total 

morbidity cost of $64.9 billion, or $1,145 per injured person. The greatest 

losses are for injured persons aged 25-44, followed by those aged 15-24. 

The morbidity cost for males is significantly higher than for females, 

$45 billion compared with $20 billion, respectively. On a per injured 

person basis, the morbidity cost amounts to $1,407 for males compared 

with $805 for females, reflecting the higher earnings and higher labor 

force participation of men. 

Disability (Morbidity) Accounts for Two-Fifths of Cost 

Mort 

idity 

$158 Billion Lifetime Cost 
xxxvi Cost of Injury in the United States 

Mortality Cost 

Applying expected lifetime earnings by age and sex to the 155,665 

deaths from injury sustained in 1985, including deaths in one or more 

years after the initial injury, results in a loss of 5.3 million life years, or 34 

years per death. These deaths represent a loss of $47.9 billion to the 

economy at a 6 percent discount rate, or $307,636 per death. For the 

111,867 males who died from injuries, an estimated 3.8 million life years 

are lost, 34 years per death, valued at $39.0 billion, or $349,030 per death. 

The 43,798 females who died from injuries represent a loss of 1.5 million 

life years, or 33 years per death. Because of the fewer deaths and lower 

earnings of females, losses for females are significantly lower than for 

males, amounting to a total of $8.8 billion, or $201,910 per death. Thus, 

males account for 72 percent of the injury deaths, 72 percent of the life 

years lost, and 82 percent of the productivity losses for 1985. 

Most people who die of injuries are relatively young -- one-third of 

the victims are aged 25-44. The total of life years lost for this age group, 

a function of both age and number of deaths, represents 39 percent of all 

life years lost to injury. In terms of lost earnings, this age group accounts 

for 51 percent of the total. By contrast, 38 percent of injury deaths are 

persons over age 45, accounting for 18 percent of life years lost and 13 

percent of productivity lost. 

Mortality Cost per Injured Person Highest for 25-44 Age Group 

Age Cost” (millions) Cost* per Injured Person 

and Indirect Indirect 

Sex Direct Morbidity Mortality Direct Morbidity Mortalitv** 

Total $44,807 $64,920 $47,888 $790 $1,145 $307,636 

04 1,810 1,384 933 445 340 210,403 

5-14 4,026 4,067 1,605 395 399 267,864 

15-24 8,934 15,725 14,483 702 1,236 427,278 

25-44 12,724 28,680 24,418 706 1,592 473,418 

45-64 6,757 11,311 5,903 920 1,540 211,936 

65+ 10,555 3,752 546 2,407 856 17,095 

* Discounted at 6 percent 

** Based on 155,665 deaths, including 13,097 deaths in later years 

due to injuries sustained in 1985 
Summary 

First and Later Year Costs 

Because many severe injuries result in long-term disability, the 

lifetime cost of injury takes into account the cost in the first year in which 

injury occurs as well as the cost incurred in later years. Productivity 

losses due to premature death are counted as first year costs. Of the total 

lifetime cost of $158 billion, three-fourths is the first year cost and the 

remainder is incurred in later years. 

Three-Fourths of Lifetime Cost Incurred in First Year 

~~ 

$116 Billion $41 Billion 

Research Investment and Productivity Losses 

Injury research expenditures are estimated at $160 million for fiscal 

year 1987 compared with expenditures for cancer research by the 

National Cancer Institute of $1.4 billion. The National Heart, Lung and 

Blood Institute spent $930 million for cardiovascular research in FY 1987. 

Comparing research investment per life year lost due to these three 

major causes of death shows that although injury is a large public health 

problem, it receives a disproportionately small share of research funding. 

Injury research spending per life year lost is 11 percent of that for cancer 

and 17 percent of the amount spent for cardiovascular research. Life 

years lost per injury death (36 years), however, are more than twice the 

number lost to cancer (16 years) and three times the number lost to 

cardiovascular diseases (12 years). Mortality cost per injury death 

($335,000) is almost four times the cost for cancer ($88,000) and more 

than six times the cardiovascular disease cost ($51,000). 

Source of Payment 

Of the total $44.8 billion direct cost, $41.7 billion is distributed by 

source of payment. The remainder, $3.1 billion, includes amounts spent 

for ambulance, helicopter, attendant care, and other expenses for which 

source of payment data are not available. 

About 72 percent of the direct cost is borne by private sources 

(private health insurance, workers’ compensation, uninsured care, and 

other private sources); public sources (federal, state, and local 

governments) account for 28 percent. Public sources, mainly Medicare, 
xxxviii. . . Cost of Injury in the United States 

pay 72 percent of the direct cost for injured persons aged 65 and over. 

For injured persons under age 65, however, 85 percent of the direct cost 

comes from private funds, mainly private health insurance. 

Of the hospital cost for injured persons, 32 percent comes from 

public sources, and the remaining 68 percent from private sources, 

mainly private health insurance. Private sources cover the bulk of 

expenditures for physician visits, prescription drugs, and physical 

therapy. For nursing home care, almost one-half of the expenditure 

comes from public sources, of which 57 percent are federal funds and 43 

percent, state and local government funds. 

Private Sources Bear the Greatest Injury Burden 

Amount 

(millions) Distribution 

Total $41,742 100.0 % 

Public 11,598 27.8 

Federal 8,860 21.2 

State and Local 2,738 6.6 

Private 30,144 72.2 

Workers’ Compensation 6,997 16.8 

Private Insurance 14,162 33.9 

Uninsured Care 6,932 16.6 

Private 2,053 4 9.

Transfer Payments 

Transfer payments represent a transfer of funds from one payer to 

another and do not represent new goods or services produced. 

Insurance settlements, for example, are funds transferred from the 

insurance company to the injured individual to pay for medical services 

that are counted in the direct medical cost. The magnitude of transfer 

payments due to injury is large, amounting to $52.6 billion for 1985 (lost 

taxes are excluded). Of this total, $23.3 billion (44 percent) consists of 

disability payments. Auto insurance pays $22.9 billion, or 44 percent, of 

all transfer payments. Workers’ Compensation programs pay $13.1 

billion in disability payments and an additional $1.7 billion in survivor 

benefits. Social Security pays $4.4 billion in disability payments and $2.9 

billion in survivor benefits. 
�

Summary 

Injury Transfer Payments - $52.6 Billion 

Program Total Public Private 

Total $52,578 $13,972 $38,606 

Veterans Administration 2,560 2,560

Social Security Disability Insurance 7,340 7,340

Supplemental Security Income 1,033 1,033

Workers’ Compensation 14,822 3,039 11,783

Private Insurance 3,898 3,898

Automobile Insurance 22,925 22,925

Of the total $52.6 billion, 27 percent is paid from public funds, 

including Social Security Disability Insurance, Veterans Administration, 

and Supplemental Security Income. Private funds, 73 percent of total 

transfer payments, include private disability and life insurance and 

Workers’ Compensation, a federally administered program primarily 

financed by employers. 

Willingness to Pay 

The total cost of injury in 1985 amounts to $158 billion, employing 

the human capital approach that measures the value of lost output due 

to reduced productivity of individuals killed, injured, or disabled. 

Willingness to pay, on the other hand, reflects the value placed on health 

and life by individuals and measures how much people are willing to 

pay for safer and healthier lives. It incorporates the value of pain, 

suffering, and loss in quality of life associated with injury. 

Based on a review of 29 studies, willingness to pay to save one life 

ranges from $1.0 million to $3.1 million, with a mean of $1.95 million. To 

avoid moderate to critical injuries, willingness-to-pay estimates range 

from $31,000 to $1.5 million. To avoid severe head injuries involving 

total impairment, quadriplegia, or very severe burns, willingness-to-pay 

estimates range from $2.6 million to $3.2 million. 

Potential Savings from Injury Prevention 

The large number of premature deaths and disabilities due to injury 

and the high economic cost, including large public sector expenditures, 

highlight the need to reduce the burden of injury in the United States. 

The application of current knowledge to implement a variety of injury 

control interventions can substantially reduce the incidence, severity, 

and accompanying cost of injury. Examples of successful interventions 
xl Cost of Injury in the United States 

to prevent injury range from the adoption of automatic braking, 

signaling and coupling systems for railroads in the nineteenth century to 

reductions in highway deaths resulting from Federal Motor Vehicle 

Safety Standards introduced since 1966. 

Interventions for which data are available to estimate savings to 

society are discussed. Many more interventions are identified, but 

adequate data are not currently available to estimate savings. For the 

interventions analyzed, the precision of estimates varies depending on 

research design and generalizability of research findings to the total U.S. 

population. Although there is some uncertainty in each estimate of 

injury reduction, there is no doubt that many serious injuries could be 

prevented or reduced in severity. 

Savings for the interventions are estimated on the basis of both the 

human capital and the willingness-to-pay methods. Employing the two 

methods shows the range of savings. The human capital method 

provides the lower level of savings; willingness-to-pay estimates are 

higher for each intervention. 

Air Bag Savings Highest 

Savings (millions) 

WillingHuman ness 

Intervention Capital to Pay 

Child pedestrian injury campaign

Bicycle helmet promotion

Driver education elimination

Minimum licensure at age 37

Motorcycle helmet use laws

Reduced ignition of cigarette paper

Air bags

Side crash protection

Automatic vehicle lights

$58 $180 

183 284 

863 2,230 

1,446 4,267 

97 1,200 

187 1,100 

4,650 19,491 

0 1,529 

0 534 
Summary xli 

Impact of Injury on Individuals and Families 

An anthropological investigation of ten injury survivors and family 

members defines devastating impacts outside the spectrum of economic 

cost measurement. Ten case studies describe the struggle to acquire the 

personal, therapeutic, legal, and financial aid that enables injured 

persons to survive, meet their basic needs, and create for themselves 

lives that are meaningful in terms of work, love, mutual support, 

recreation, and personal growth. Data were collected from five injury 

survivors, four parents of survivors, one spouse, and one sibling. The 

subjects present experiences, events, and concerns emerging as central to 

their lives two to eighteen years after a severe injury occurred. Though 

small, the California study group represents a range of economic, 

occupational, and educational backgrounds. 

The case studies illustrate the following injuries: automobile crash, 

motorcycle crash, near drowning, diving into shallow water, contact 

sport, brutal beating, fall following an illness, fall in the workplace, and 

crush following malfunctional workplace equipment. The studies 

represent the following residual disabilities: quadriplegia, ventilatordependent quadriplegia, brain damage, severe central nervous sys tern 

damage, facial disfigurement, amputated and deformed fingers, 

functionless hand and arm, and general weakness and inability to walk. 

Ten Personal Narratives 

R Males 

Females 

0-4 5-14 15-24 25-44 45-64 65+ 
xlii Cost of lnjury in the United States 

Case Study Findings 

Money is central to the well-being of the injured person and family. 

The cost of severe injury goes far beyond initial medical treatment and 

includes housing, disability-related equipment, long-term rehabilitation, 

education, and vocational training. For most individuals, the ability to 

financially survive a catastrophic injury depends on winning a large 

legal settlement in addition to having good private insurance coverage. 

It is realistic to be continually fearful of the cost of potential medical 

complications, follow-up surgical procedures, and future rehabilitation, 

housing, education, or job-training requirements. Needs do not stop 

with medical stabilization; they continue for years or for a lifetime. 

Consequences of severe injury have a far-reaching impact that goes 

beyond economic cost. Profound disability affects all aspects of injured 

persons’ existence for the rest of their lives. Disability disrupts, changes, 

and dominates family life forever. One family member, usually the 

mother or spouse, becomes the primary caregiver and devotes her life to 

the well-being of the injured person, calling on all the personal and 

community resources of which she is aware. 

Government benefits are determined on an either/or basis: disabled 

or employable, sick or healthy, indigent or ineligible for funds. Such 

inflexible criteria may not fit individual needs or unusual situations. 

Federal regulations are insensitive to the fact that many severely 

disabled people want to work and are capable of doing so. SSI and 

Medicaid have complex and variable eligibility criteria and are designed 

to provide benefits to the disabled at or below the poverty level. Services 

for the disabled are not consistently available across the country. 

A severe injury renders individual access to medical and social 

services, work, and housing questionable. Study subjects needed to 

negotiate for years with health care, legal, and insurance institutions in 

order to secure a place for themselves in society following injury. Access 

to long-term rehabilitation, psychological support, appropriate attendant 

services, housing, medication, equipment, and employment opportunities all had to be negotiated -- indeed, fought for -- within the regulations 

and policies of particular agencies and institutions. 

All individuals interviewed illustrate characteristic American 

values. In spite of their great need for the resources of society, injured 

persons exhibit a determination to be self-reliant and independent in the 

face of profound challenges. Family members maintain responsibilitv 

toward injured persons with disabilities regardless of the emotional and 

financial burden of the commitment. 
Introduction 

The impact of injury on society is enormous in terms of the 

economic cost, the public and private burden of the cost, and the 

devastating effect on the lives of injured persons and their families. The 

cost of years of life lost from premature death due to injury and from 

productive work losses due to disability is higher than from any other 

single cause of death, including heart disease and cancer. Expenditures 

for research on injury causation, prevention, and control nevertheless 

continue to be dwarfed by research expenditures for other health 

problems. This report evaluates the magnitude of the impact on 

individuals, government programs, and society at large in terms of 

economic cost and of the effects of injury on people’s lives. To evaluate 

these impacts, data are needed on the extent of the problem -- the 

number, causes, and severity of injuries in the United States -- as a basis 

for measuring the economic and human toll. Such measurements have 

been made by other researchers. Nevertheless, comprehensive data on 

incidence, cost, life years lost, source of funds, cause, and severity 

disaggregated by age and sex are not available in one document. 

Likewise, the long-term costs of treatment, rehabilitation, and lost 

productivity are rarely quantified. 

This report documents and evaluates each area presented in a set of 

statistical tables and figures. The incidence of injury runs into millions of 

persons, and the cost into billions of dollars. These data are especially 

valuable when they furnish clues to a more efficient attack on specific 

aspects of the injury problem. But estimates do not measure the full 

impact of the injury epidemic in the United States. Nor do they express 

the personal and economic hardships faced by individuals and their 

families in the wake of a severe disabling injury. The case studies 

presented herein provide a measure of that impact. 

While it is exceedingly difficult to quantify all aspects of the burden 

imposed on society by injury, it is important to translate this burden to 

economic terms in order to facilitate decision-making. The continued 

rise in health care expenditures and the growing pressures for cost 

containment may constrain the amount of limited resources available to 

provide the health care needed by Americans. 

The question then arises: just where should health care priorities be 

placed? The solution is to place priorities where there is likely to be the 

greatest improvement in welfare or well-being as measured by the 

magnitude of the economic and social burden of health problems. This 

means giving priority to the areas placing the greatest burden on society. 

For example, injury research expenditures by all federal agencies 

amounted to $160 million in 1987, about one-tenth of the National 
2 Cost of Injury in the United States 

Cancer Institute expenditures and one-sixth of the National Heart, Lung, 

and Blood Institute expenditures. Life years lost per injury death, 

however, are more than twice the number for cancer (36 years compared 

with 16 years) and three times those for cardiovascular diseases (12 

years). Moreover, the mortality cost per injury death ($335,000) is almost 

four times the cost for cancer ($88,000) and more than 6 and 1/2 times 

the cost for cardiovascular diseases ($51,000). There is, therefore, a clear 

case for allocating significantly increased funds to prevention, treatment, 

and research on injury in proportion to the burden placed on society. 

The economic burden of injury is also used to make program policy 

decisions, to prepare and deliver testimony, and to support agency 

budgets. The importance of relieving the severe consequences of injury 

can be weighed against the need to allocate funds to other social, public 

health, and medical care problems. 

Dimensions of the Injury Problem 

Injuries are costly -- in dollars, in pain, in grief, in lives. Substantial 

resources are used in the care, treatment, and rehabilitation of injured 

persons. The lives lost are among the young whose productivity is lost 

to society. The burden on public resources is large. The potential for 

reducing the number and severity of injuries and thus saving public and 

private funds is great. Finally, the long-term impact of injury on injured 

persons and their families is also significant. This study examines and 

documents all of these dimensions of the problem. 

Incidence of Injury (Chapter 1) 

One of four persons is injured annually in the United States. A total 

of 57 million persons incurred an injury in 1985. Over 142,000 residents 

of the United States were fatally injured, occasionally making headlines 

when several people died at once. More commonly, however, injury 

deaths, approximately 390 a day, occur in isolation or in pairs, caused by 

motor vehicle crashes, falls, firearms, poisonings, fires and burns, 

drownings, and other causes. Injury is the fourth leading cause of death, 

after heart disease, cancer, and stroke. For children and young adults 

under age 45, injury is the leading cause of death. 

Each year, 2.3 million residents of the United States are hospitalized 

as a result of injury, and 54 million seek some form of medical care for 

injuries. Injury is also a leading cause of disability; Americans spent 127 

million days in bed due to injuries in 1987. 

Nonfatal injuries cause pain and suffering, permanently damage 

bodies and brains, and affect job opportunities and families. As trauma 
Introduction 3 

care systems improve, more severely injured people survive, most 

frequently with inadequate financial resources to meet enormous needs. 

Economic Cost of Injury (Chapter 2) 

From the moment -- and it is often merely seconds -- required to 

sustain an injury, costs accrue. Emergency medical services; hospital, 

physician and rehabilitation charges; and loss of work and income are 

the most obvious costs of injuries. The life years lost due to illness, 

disability, and premature death are also costly to the nation. The life 

years lost annually add up to more than 10 million. 

The total lifetime cost of the 57 million persons injured in 1985 in the 

United States is enormous, estimated at $158 billion. This estimate is 

based on the human capital approach to cost-of-illness measurement. 

This method takes into account all the medical care and related resources 

used for care, treatment, and rehabilitation of injured persons. Also 

included is the value of medical care resources used and earnings 

forgone because of illness, disability, and premature death due to injury. 

Included is an imputed value for housekeeping services. However, 

several important injury effects are not measured, such as pain and 

suffering, reduced productivity of family members and caregivers, and 

the value of volunteer services. Legal and court costs and property 

damage are also not included because this report focuses on the cost of 

injury and excludes the costs associated with the damage caused by the 

event resulting in injury. 

Source of Payment (Chapter 3) 

The effort to define the range of effects of injury on individuals and 

society requires information on who bears the cost burden of injury. 

Much of that burden is due to the large expenditures for medical care 

paid by various types of payers -- federal, state, and local governments, 

private insurance, workers’ compensation, and individuals. Federal 

payments for medical care of injured persons amount to $8.9 billion for 

1985. In addition, the magnitude of transfer payments is assessed. 

Transfer payments represent a transfer of funds from public and private 

sources to injured persons or their survivors. Included are benefit payments made by government programs (e.g., Veterans Administration, 

Social Security, and Workers’ Compensation) and private insurance. In 

1985, the federal budget included payments of $12.8 billion for disability 

and death benefits. These program costs can be saved through 

reductions in the number and severity of injuries. 
4 Cost of Injury in the United States 

Willingness to Pay (Chapter 4) 

Another approach to injury loss measurement is the willingness-topay method, which bases the value of human life on the amount an 

individual would be willing to pay for a safer and healthier life by 

reducing the probability of illness or death. This approach incorporates 

all aspects of individual well-being including the value of pain and 

suffering. Although several measurement issues need to be studied 

further, values estimated by this approach have been used for costbenefit analysis in several government and private contexts. The value 

of life estimate using this technique is about $2 million compared to an 

average injury fatality cost of almost $350,000 using the human capital 

approach. 

Potential Savings from Injury Prevention (Chapter 5) 

During the past three decades, there have been reductions in 

fatalities and injuries, most notably from motor vehicle crashes. The 

potential exists, however, for even further reduction with appropriate 

allocation of research funding. This chapter addresses the issue with a 

view toward estimating potential savings based on specific injury 

prevention strategies. As with any assessment involving humans 

interacting with the physical forces of the environment, there are degrees 

of uncertainty in the reduction impact that would result from 

implementation of specific intervention actions. An assessment of 

several programs is presented for the reduction of injuries based on 

injury costs developed for this study by both human capital and 

willingness-to-pay methods. The results of this assessment suggest that 

action can be taken to further reduce injuries. However, more research is 

needed to better identify the most effective strategies for reducing 

injuries and their high costs. 

Long-Term Impact of Injury on Individuals, Families, and Society 

(Chapter 6) 

The lives of persons injured and their families are significantly 

affected by severe injuries that result in long-term disability. These 

impacts are outside the spectrum of economic cost measurement. 

Although previous case study research has been conducted on the 

changes that occur in peoples’ lives due to debilitating injury, more 

detailed information, collected in a systematic fashion, is needed before 

general conclusions can be drawn from the broad array of injury 

consequences. The approach taken is an anthropological investigation of 

10 injury cases to define the range of the debilitating and often 

devastating outcomes. The case studies describe many barriers that 
Introduction 5 

people with disabilities from injury must overcome in order to create 

meaningful and valuable lives. 

Recommendations 

The estimated number of persons injured and lifetime cost of injury 

in the United States are the best estimates based on existing data. The 

present study utilizes information from numerous sources, but in many 

cases estimates are necessarily made on the basis of limited data. The 

recommendations address four major issues. 

Injury Prevention and Control: Direct greater resources to the 

prevention of injury. Conduct research and controlled experiments to 

evaluate the effectiveness and savings of injury control interventions and 

to evaluate the societal barriers to application of injury prevention 

strategies. 

Coding and Measurement: Require all hospital discharge data 

systems to use both cause and nature of injury codes. Standardize the 

coding of injuries. Make International Classification of Diseases (ICD) 

and Abbreviated Injury Scale (AIS) systems for classifying injuries 

compatible. Conduct research to develop a classification system for 

impairments. 

Data Needs: Develop a coordinated national program of injury 

surveillance and provide sufficient resources to implement it. Expand 

core National Health Interview Survey (NHIS) injury questions and 

conduct a comprehensive injury supplement. Conduct longitudinal 

studies. Periodically conduct a national medical care expenditure survey 

to obtain injury cost data. Improve data on occupational injuries and 

fatalities and on firearm injuries. 

Treatment and Rehabilitation: Conduct interdisciplinary collaborative studies on trauma care and expand research on model 

rehabilitation systems. 
�

Chapter 1 

Incidence of Injury 

Essential to developing estimates of the economic cost of injury are 

data on incidence by major age, sex, and cause categories. Estimates of 

numbers and rates of injury are presented in this report for three 

mutually exclusive classes that reflect severity of injury: 1) injury 

resulting in death, including those occurring in and outside a hospital or 

other institution, 2) injury resulting in hospitalization with survival to 

discharge, and 3) injury requiring medical attention without hospitalization or injury resulting in one or more days of self-reported restricted 

activity without medical attention. Injury not severe enough to result in 

either medical attention or one or more days of restricted activity is 

excluded from the definition. Estimates of incidence and economic cost 

reported herein are for 1985, the most recent year for which reliable data 

for each class of injury are available. 

Within each class of injury (fatal, hospitalized, and nonhospitalized), 

incidence estimates were developed for each of seven age groups (O-4; 5-

14; 15-24; 25-44; 45-64; 65-74; 75 years and over), two sex groups, and 

seven categories of cause (motor vehicles, falls, firearms, poisonings, fires 

and burns, drownings and near drownings, and other). Injuries were 

classified by cause regardless of intent. For example, deaths classified as 

caused by firearms include those related to both the intentional and the 

unintentional use of firearms. For deaths and hospitalizations, estimates 

were also developed by the presumed intent of the injury, categorized as 

intentional, unintentional, or intent unknown. Sufficient data were not 

available, however, to produce comparable estimates of nonhospitalized 

injuries by intent. Specifics regarding the methods used in developing 

the incidence figures within each class of injury are detailed in the 

methods section at the end of the chapter. 

Overview 

In 1985, injuries resulted in 142,568 deaths (plus an additional 13,097 

deaths that occurred in later years resulting from injuries sustained in 

1985), 2.3 million persons hospitalized, and 54.4 million nonhospitalized 

injured persons in the United States (Table 1). This translates into a total 

of 56.9 million persons injured or 24 persons injured per year for every 

100 U.S. civilian residents (the number of persons in the U.S. is shown by 

age and sex in Appendix Table C-l). Almost one in four people in this 

country sustains an injury during a year. Many of these injuries are fatal 
8 Cost of Injury in the United States 

or serious enough to require hospitalization and are associated with 

long-term disability. 

Table 

Number and Rate of Injured Persons by Sex, Age, 

and Class of Injury, 1985 

Total Fatalities* Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (000's) Persons Number Persons Number Persons (000's) Persons 

Total 56,859 23,986 142,568 60.1 2,346,735 990.0 54,369 22,936 

0-4 4,071 22,621 4,363 24.2 112,434 624.8 3,954 21,972 

5-14 10,189 30,039 4,962 14.6 205,047 604.5 9,979 29,420 

15-24 12,750 32,892 29,412 75.9 464,078 1,197.2 12,257 31,619 

2544 18,063 24,769 47,824 65.6 678,318 930.1 17337 23,773 

4564 7,369 16,417 25,601 57.0 376,837 839.5 6,967 15,520 

65-74 2,385 14,006 11,877 69.8 179,958 1,056.9 2,193 12,879 

75+ 2,032 17,616 18,529 160.7 330,062 2,862.0 1,683 14,593 

Male 32,116 28,018 102,804 89.7 1321,573 1,152.9 30,692 26,776 

04 2,457 26,682 2,570 27.9 65,293 709.1 2,389 25,945 

5-14 5,984 34,457 3357 19.3 138,008 794.6 5,843 33,643 

15-24 8,027 41,686 23,095 120.0 318,412 1,653.7 7,685 39,912 

2544 10,945 30,551 37,612 105.0 454,053 1267.4 10,453 29,178 

45-64 3,463 16,166 18,693 87.2 201,620 941 .l 3243 15,138 

65-74 711 9,497 7,751 103.7 65,056 869.2 638 8,524 

75+ 530 13,038 9,726 239.4 79,131 1,947.l 441 10,851 

Female 24,742 20,209 39,764 32.5 1,025,162 837.3 23,677 19,339 

04 1,614 18,365 1,793 20.4 47,141 536.4 1,565 17,808 

5-14 4,205 25,403 1,605 9.7 67,039 405.0 4,136 24,988 

15-24 4,723 24,207 6,317 32.4 145,666 746.6 4,571 23,428 

2544 7,118 19,186 10,212 27.5 224,265 604.5 6,884 18,554 

45-64 3,907 16,650 6,908 29.4 175,217 746.7 3,725 15,874 

65-74 1,673 17,533 4,126 43.3 114,902 1,204.l 1,554 16,285 

75+ 1,502 20,106 8,803 117.9 250,931 3,359.6 1,242 16,629 

* Excludes 13,097 deaths occurring in later years due to injuries incurred in 1985 

Of the total 56.9 million persons injured in the United States in 1985 

almost one-third (18.1 million) occurs in the 25-44 age group. The second 

highest number of injuries, more than one-fifth (12.8 million), occurs 

among persons aged 15-24. About 14 million children under age 15 also 

suffer from injuries and comprise one-quarter of the total injured 
Incidence of Injury 9 

population. Thus, persons under age 45 sustain almost four-fifths of all 

the injuries in the United States. 

The risk of injury is highest among males; they sustain 56 percent of 

all injuries. Almost three of ten males (28%) incur injuries. Among 

females, the risk is lower -- one of five sustains injuries during a year. 

For both males and females, the largest number of injuries occurs among 

those aged 25-44. The risk is highest, however, among younger males 

than for any other sex or age group -- 42 percent of adolescent and young 

males aged 15-24 sustain injuries during a single year. Motor vehicle 

injuries are the leading cause of death for both males and females, 

whereas falls are the leading cause of nonfatal injury. These patterns by 

age, sex, and cause of injury are described below in more detail by class 

of injury. 

Age and Sex Patterns 

The largest number of injuries in each class is among males. Nearly 

three-quarters (72%) of injury deaths and over one-half (56%) of nonfatal 

injuries occur among males (Figure 1). Adults in the 25-44 age group 

account for 34 percent of deaths due to injury; 29 percent of injured 

persons hospitalized and 32 percent of the less severely injured 

nonhospitalized persons are in this age group. Adolescents and young 

adults aged 15-24 rank second in number of injuries for each class of 

injury. Ranking third in number of fatalities and hospitalizations are 

persons aged 45 to 64. Children aged 5-14 rank third in number of 

nonhospitalized injuries (Figure 2). Unlike other leading causes of death 

and hospitalization (such as cancer and heart disease), nearly 80 percent 

of the injuries resulting in death or hospitalization occur among persons 

less than 65 years of age; nearly two-thirds occur among persons less 

than 45 years of age. 

The risk or rate of injury presents a different picture (Figure 3). 

Although the number of deaths and hospitalizations due to injury for the 

elderly aged 75 and over are lower than the number in the three younger 

age groups (15-24, 25-44, and 45-64), the risk of both death and 

hospitalization as a result of injury is highest for adults aged 75 and 

older (161 and 2,862 per 100,000 U.S. civilian residents for deaths and 

hospitalizations, respectively). Their fatality and hospitalization injury 

rates are nearly three times as high as the rates for all ages combined. 

The elderly aged 75 and older comprise only 5 percent of the U.S. 

population but account for 14 percent of all injuries resulting in death or 

hospitalization. Adolescents and young adults aged 15-24 rank second 

in risk of injury severe enough to result in death or hospitalization (76 

and 1,197 per 100,000, respectively). Rates are lowest for children in the 

5-14 age group. 
10 Cost of Injury in the United States 

Figure 1

Distribution of Injured Persons by Sex and Class of Injury, 1985

0 Male 

Female 

Fatalities Hospitalized Persons Nonhospitalized Persons 

Figure 2

Distribution of Injured Persons by Age and Class of Injury, 1985

Fatalities Hospitalized Persons Nonhospitalized Persons 

•lll 75+

65-74

45-64

0 

I3 

� 25-44

15-24

I@ 5-14

w o-4 
Incidence of Injury 11 

Patterns of injury by age are considerably different for less severe 

injuries not resulting in hospitalization. The elderly aged 75 and older 

are at a comparatively low risk of minor injury (14,593 per 100,000). 

Children aged 5-14 and adolescents and young adults aged 15-24 are at 

the highest risk of minor injury (29,420 and 31,619 per 100,000, 

respectively). 

The risk of injury also varies by sex within each class of injury. In 

every age group except the very young, aged 0-4, the injury death rate 

for males is more than twice as high as the rate for females. In contrast, 

males are only 1.4 times as likely as females to sustain a nonfatal injury. 

Furthermore, among older adults, the risk to females of nonfatal injuries 

actually exceeds the risk to males. Among adults aged 65 and over, 

females are one and one-half to two times as likely as males to suffer a 

nonfatal injury. 

Cause of Injury 

The distributions by cause vary for deaths, hospitalizations, and 

nonhospitalizations as shown in Table 2 and Figure 4. The number of 

injuries and rates for each cause of injury are shown in Appendix Tables 

C-2--C-8. The two leading causes of injury death are related to motor 

vehicles and firearms. They account for 45,923 and 31,556 deaths, 

respectively (19.4 and 13.3 per 100,000, respectively). Together, these 

two leading causes of injury death comprise more than half of the injury 

deaths. In contrast, the leading cause of nonfatal injury is falls, 

accounting for 783,357 hospitalizations (331 per 100,000) and 11.5 million 

nonhospitalized injured persons (4,848 per 100,000). Motor vehicle 

injuries comprise the second leading cause of nonfatal injury, resulting in 

523,028 hospitalizations (221 per 100,000) and 4.8 million nonhospitalized 

injured persons (2,026 per 100,000). Firearms, on the other hand, account 

for less than 1 percent of nonfatal injuries. These differences in 

distribution by cause and class underscore the lethality of injuries 

involving firearms and motor vehicles. 

Injuries categorized as ‘other’ include a variety of causes. For 

deaths, other causes primarily include stabbings, suffocations from 

foreign bodies, and hangings and represent 20 percent of all injury 

deaths. Nonfatal injuries resulting from other causes are primarily those 

related to being stabbed, hit by an object or person, or injured by a 

cutting or piercing instrument. Thirty percent of hospitalized injuries are 

in this category. For less severe nonhospitalized injuries, additional 

common causes categorized as ‘other’ include animal and insect bites, 

one-time lifting or exertion, and twisting or stumbling, and they 

comprise 64 percent of nonhospitalized injuries. 
12 Cost of Injury in the United States 

Figure 3 

All Causes: Injury Rate by Age and Sex, 1985 

(rate per 100,000 population) 

300 

200 

100 

0 

0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Fatalities 

5-14 15-24 25-44 45-64 65-74 75+ 

Hospitalized Persons 

5-14 15-24 25-44 45-64 65-74 75+ 

� Males 

W Females 

Nonhospitalized Persons 
Incidence of Injury 13 

Table 2 

Number and Rate of Injured Persons by Cause 

and Class of Injury, 1985 

Total Fatalities* Hospitalized Nonhospitalized 

Rate per Rate per Rate per Rate per 

Number 100,000 100,000 100,000 Number 100,000 

Cause (000’s) Persons Number Persons Number Persons (000's) Persons 

Total 56,859 60.1 2,346,735 990.0 54,369 

Motor Vehicles 5,372 2,266 45,923 19.4 523,028 220.6 4,803 2,026 

Falls 12,289 5,184 12,866 5.4 783,357 330.5 11,493 4,848 

Firearms 268 ** 113 3l,556 13.3 65,129 27.5 171 ** 72 

Poisonings 1,702 7l8 11,894 5.0 218,554 92.2 1,472 621 

Fires/Burns 1,463 617 5,671 2.4 54,397 22.9 1,403 592 

Drownings 38 ** 16 6,171 2.6 5,564 2.3 26** 11 

Other 35,726 15,071 28,487 12.0 696,707 293.9 35,001 14,765 

Male 32,116 28,018 89.7 1,321,573 1,152.g 26,776 

Motor Vehicles 2,459 2,145 32,454 28.3 311,496 271.7 2 115 1,845 

Falls 5,633 4,914 7,002 6.1 317,980 277.4 5,308 4,631 

Firearms 216 ** 189 26,366 23.0 56,718 49.5 133** 116 

Poisonings 688 601 7,621 6.6 97,754 85.3 583 

Fires/Burns 797 696 3,438 3.0 38,946 34.0 755 659 

Drowningst 35 ** 30 4,951 4.3 3,928 3.4 26 ** 23 

Other 22,288 19,444 20,972 18.3 494,752 431.6 21,772 18,994 

Female 24,742 20,209 39,764 32.5 1,025,162 837.3 23,677 19,339 

Motor Vehicles 2,913 2379 13,469 11.0 211,532 172.8 2,688 2,196 

Falls 6,656 5,437 5,864 4.8 465,377 380.1 6,185 5,052 

Firearms 52 ** 42 5,190 4.2 8,411 6.9 38 ** 31 

Poisonings 1,014 828 4,273 3.5 120,800 98.7 889 726 

Fires/Burns 666 2,233 1.8 15,451 12.6 648 529 

Drowningst 3 ** 2 1,220 1.0 1,636** 1.3 

Other 13,438 10,976 7,515 6.1 201,955 165.0 13,229 10,805 

* Excludes 13,097 deaths occuring in later years due to injuries incurred in 1985 

** Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

t Includes Near Drownings 

Intent of Injury 

Slightly more than one-third of all injury deaths involve intentional 

injuries (Table 3 and Figure 5). Of 49,276 intentional injury deaths, 40 

percent are homicides (19,830) and 60 percent are suicides (29,446). The 

remaining two-thirds of the deaths are due to unintentional causes -- 51 

percent to motor vehicles, 13 percent to falls, and 36 percent to other 

causes. 
14 Cost of Injury in the United States 

Figure 4

Distribution of Injured Persons by Cause and Class of Injury, 1985

Motor Vehicles 

Falls 

Firearms 

Poisonings 

Fires/Burns 

Drownings 

0% 

I3 

� 

� 

0 Other Fatalities Hospitalized Persons Nonhospitalized Persons 

Information regarding intent of injuries resulting in hospitalization 

is less complete than for injury deaths. Intent is not uniformly recorded 

in the medical record, and if it is, this information often represents 

conjecture on the part of the physician or nurse completing the narrative 

description of the injury. To arrive at a rough estimate of the numbers of 

intentional and unintentional hospitalized injuries, it is assumed that all 

injuries resulting from motor vehicles, falls, fires, and near drownings 

are unintentional. The remaining injuries are categorized by intent as 

reflected in the International Classification of Disease (ICD-9) E-code 

(Commission on Professional and Hospital Activities, 1980). Using this 

approach, 84 percent of all hospitalized injuries are classified as the 

result of unintentional injury, a-nd 11 percent the result of intentional 

injury, including poisonings (31%), firearms (11%), and other assaultive 

injuries (58%). The remaining 5 percent can not be classified. 

Approximately one-half of the hospitalized injuries recorded as 

intentional are self-inflicted. Sufficient data are unavailable to categorize 

nonhospitalized injuries by intent. 
Incidence of Injury 15 

Table 3 

Number and Rate of Injured Persons by Intent 

and Class of Injury, 1985 

Fatalities* Hospitalized 

Rate per Rate per 

100,000 100,000 

Intent Number Persons Number Persons 

Total 142,568 60.1 2,346,735 990.0 

Unintentional 90,469 38.2 1,978,518 834.6 

Intentional 49,276 20.8 261,738 110.4 

Intent Unknown 2,823 1.2 106,480 44.9 

Male 102,804 89.7 1321,573 1,152.g 

Unintentional 62,628 54.6 1,096,692 956.8 

Intentional 38,156 33.3 169,264 147.7 

Intent Unknown 2,020 1.8. 55,618 48.5 

Female 39,764 32.5 1,025,162 837.3 

Unintentional 27,841 22.7 881,826 720.3 

Intentional 11,120 91. 92,474 75.5 

Intent Unknown 803 0 7. 50,862 41.5 

* Excludes 13,097 deaths occurring in later years due to injuries 

incurred in 1985 

Hospitalized Injuries by Nature and Severity 

Since hospitalized injuries include a broad spectrum of types and 

severities, these injuries are further distributed by nature and severity, 

using the International Classification of Disease/Abbreviated Injury 

Scale (ICD/AIS) (MacKenzie, Steinwachs, and Shankar, 1989) (Table 4). 

The AIS is a threat-to-life scale that categorizes injury severity by the 

nature of damage to different body regions. It ranges from 1 (minor 

injury) to 6 (maximum injury - virtually unsurvivable) (Committee on 

Injury Scaling, 1985). Injuries to the upper or lower extremities account 
16 Cost of Injury in the United States 

Figure 5

Distribution of Injured Persons by Intent and Class of Injury, 1985

lities 

El 

pitalized 

84% 

Unintentional 

Self-Inflicted 

Assault 

� Intent Unknown 

. 
Incidence of Injury 17 

for nearly one million hospitalized persons or 41 percent of the total. 

Slightly over one-third of these injuries are moderately severe or severe 

(ICD/AIS 3 or greater) . For many of these more severe injuries, recovery 

can be long and expensive, and even optimal treatment can result in 

permanent impairment involving chronic pain, loss of motion or 

contracture of joints, deformity, or loss of limb. The primary cause of 

hospitalized extremity injury is falls; they account for an estimated 30 

percent of upper extremity injuries and 50 to 60 percent of lower 

extremity injuries. Motor vehicle crashes also contribute significantly to 

the incidence of extremity injuries, accounting for an additional 15 to 20 

percent of all new cases. Another important cause of upper extremity 

injury relates to injuries involving machinery and tools, which account 

for approximately 20 percent of all hospitalized upper extremity injuries. 

About 300,000 individuals survive a head injury serious enough to 

result in hospitalization for one or more days. Head injury accounts for 

12 percent of all injury hospitalizations. Although the majority (73%) of 

these injuries are minor, conservative estimates of the number of persons 

who survive moderate (ICD/AIS 3), severe (ICD/AIS 4), and very severe 

(ICD/AIS 5) head injury are 45,974, 25,239 and 6,710, respectively. The 

long-term consequences associated with severe head injury are 

substantial. Several studies have documented the persistence of 

significant physical, neuropsychological, and psychosocial deficits 

following severe head injury. Less is known about the residual effects of 

minor head injuries, although there is increasing evidence to suggest that 

they are associated with a multitude of physical symptoms such as 

persistent headaches, as well as with significant psychosocial and 

behavioral problems and difficulty in performing one’s job. Motor 

vehicle crashes (including motorcycle, bicycle, and pedestrian) constitute 

the leading cause of head injury in the United States. They account for 

one-third to one-half of all head injuries. Falls are the second leading 

cause of head injury, accounting for an additional 20 to 30 percent of all 

injured persons. (Frankowski, Annegers, and Whitman, 1985). 

Other injuries accounting for more than 5 percent of total 

hospitalizations include those to the vertebrae (6%); soft tissue injuries to 

the abdomen, thorax, and neck (6%); and poisonings (9%). Although 

spinal cord injuries account for a very small proportion of the total (less 

than l%J, they result in significant physical and psychological changes. 

Individuals who survive a severe spinal cord injury require extensive 

long-term medical treatment and rehabilitation. While relatively few in 

number, these injuries have a substantial impact on the individual and 

society. Motor vehicles are the major cause of spinal cord injury, 

accounting for an estimated 30 to 60 percent of all injured persons. Falls 
18 Cost of Injury in the United States 

Table 4 

Number and Rate of Hospitalized Injured Persons by 

Principal Diagnosis and Severity of Injury, 1985 

Number 

Principal Severity of Live Rate per Percent 

Diagnosis (ICD/AIS) Discharges 100,000 Distribution 

Total na 2,346,735 990.0 100.0 % 

Head 1-2 * 212,496 89.6 91 

3 45,974 19.4 2.0 

4 25,239 10.6 1.1 

5 6,710 2.8 0.3 

Face l-2 * 83,649 35.3 3.6 

3,4,5 1,629 0.7 0.1 

Vertebrae 1-2 * 94,601 39.9 4.0 

3 44,659 18.8 1.9 

Spinal Cord 3 6,872 2.9 0. 3

4,5 6,267 2.6 0.3 

Abdomen/Thorax/Neck l-2 * 99,371 41.9 4.2 

3 34,786 14.7 1.5 

4,5 11,805 5.0 0.5 

Upper Extremities l-2 * 271,195 114.4 11.6 

3,4,5 18,332 7.7 0.8 

Lower Extremities l-2 * 364,327 153.7 15.5 

3,4,5 319,217 134.7 13.6 

Bums l-2 * 36,623 15.4 1.6 

3,4,5 2,708 1.1 0.1 

Unknown 26,168 11.0 1.1 

Foreign Bodies na 33,437 14.1 1.4 

Near Drownings na 5,564 2.3 02. 

Poisonings na 218,554 92.2 9.3 

Other Nature na 376,550 158.8 16.0 

* Includes cases of unknown ICD/AIS severity 

Note: na = not applicable 

constitute the second leading cause; they account for an additional 20 to 

30 percent of all spinal cord injuries. Approximately 5 to 10 percent of all 

spinal cord injuries are due to diving (Kraus, 1985a). 
Incidence of Injury 19 

Patterns of Injury by Cause 

The categorization of incidence and cost by cause of injury can be 

particularly useful in designing and targeting preventive strategies. For 

this reason, a more detailed discussion of the patterns of injury by age, 

sex, and severity class is presented below for each of the major cause 

categories. 

Motor Vehicles 

Motor vehicle crashes are the leading cause of injury death, 

resulting in 45,923 deaths in 1985. They also comprise the second leading 

cause of both injury hospitalizations (523,028) and less severe, 

nonhospitalized injuries (4.8 million). Adolescents and young adults 

aged 15-24 are at highest risk of both fatal and nonfatal injuries related to 

motor vehicles. Their rate for each class of injury is approximately twice 

the rate for all ages (Figure 6 and Appendix Table C-2). The elderly aged 

75 and older are also at a relatively high risk of dying from motor vehicle 

injury. The rate of motor vehicle deaths in this age group is second only 

to that in the 15-24 age group. 

Over age 15, males are more than twice as likely as females to die 

from a motor vehicle crash, with the largest male to female ratio (over 3-

fold) observed in the 15-24 and 25-44 age groups. Males under the age of 

45 are also more likely to be hospitalized as a result of a motor vehicle 

injury, although the sex differential is not as great as for fatalities (male 

to female risk ratio is 1.7). Males and females 45 years and older, on the 

other hand, are equally likely to be hospitalized. A somewhat different 

pattern is observed for minor, nonhospitalized injuries. Over age 15, 

females are at a slightly higher risk for nonhospitalized injury than are 

males (female to male risk ratio is 1.2), although among the elderly aged 

75 and older, males remain at higher risk. 

Major factors contributing to the likelihood of a crash include speed, 

vehicle instability and braking deficiencies, inadequate road design (e.g., 

excessive curvature or gradient, inadequate guardrail and shoulders) 

and alcohol intoxication, which is involved in about half of all fatal 

crashes. When a crash occurs, important determinants of the likelihood 

of injury include speed of impact, vehicle crashworthiness, and the use of 

airbags, safety belts, and motorcycle helmets (Waller, 1985). 

Falls 

Falls are the leading cause of nonfatal injury in the United States, 

accounting for 783,357 hospitalizations and 11.5 million minor injuries 

that do not result in hospitalization. They also account for 12,866 deaths. 

The elderly are at highest risk of both dying and being hospitalized as 
20 Cost of Injury in the United States 

Figure 6 

Motor Vehicles: Injury Rate by Age and Sex, 1985 

(rate per 100,000 population) 

0 

0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Fatalities 

0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Hospitalized Persons 

Ei Males 

w Females 0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Nonhospitalized Persons 
Incidence of Injury 21 

the result of a fall (62 per 100,000 and 2,259 per 100,000, respectively) 

(Figure 7 and Appendix Table C-3). The death rate due to falls among 

the elderly aged 75 and older is nearly 12 times as great as the rate for all 

ages combined and the risk of hospitalization nearly 7 times as great. 

The risk of death or hospitalization-related to falls among children and 

young adults less than 45 years of age, on the other hand, is very small 

(less than 1 per 100,000 for deaths and less than 200 per 100,000 for 

hospitalizations). 

A different age pattern is observed for falls resulting in minor, 

nonhospitalized injuries. The elderly aged 75 and over remain the age 

group at highest risk; they account for 993,000 injuries or 8,610 per 

100,000. However, children less than 15 years of age are also at high risk; 

they comprise the second and third highest age groups at risk of minor 

injury due to falls. Falls represent over one-quarter of all minor injuries 

in this age group. 

Males at all ages are at higher risk of fall-related deaths than 

females, although the male to female ratio is considerably less (1.3) than 

for other causes. Elderly females, however, are at considerably higher 

risk of nonfatal fall-related injuries than males. Females aged 65 and 

over are more than twice as likely as males in the same age group to 

sustain a nonfatal injury resulting from a fall. 

Falls among the elderly tend to involve a trip or fall on a level plane. 

The high risk of death and serious injury resulting from falls among the 

elderly is due to several factors, including higher rates of osteoporosis 

and other medical conditions, as well as increased impairment of vision, 

gait, and balance. The use of medications is also correlated with falls 

among the elderly (Ray, Griffin, Schaffner, et al., 1987). Elders have a 

greater risk of complications, even with minor injuries. Falls resulting in 

hip fractures frequently signal the end of independent living for elderly 

persons. Falls are a significant risk among residents of nursing homes 

and chronic care facilities (Baker, O’Neill, and Karpf, 1984). Among 

younger people, most fatal falls are from a height (e.g., down stairs, out 

windows) (Gallagher, Guyer, Kotelchuck, et al., 1982). A classic program 

to install window bars in New York City reduced fall deaths among 

children (Speigel and Lindeman, 1977), although a more recent study 

questions whether the effect has been sustained (Bergner, 1982). 

Firearms 

Injuries resulting from either the unintentional or intentional use of 

firearms constitute the second leading cause of death due to injury in the 

United States. In 1985, 31,556 people died from firearm injuries (13 per 

100,000). For all ages, 39 percent of firearm deaths are homicides and 56 

percent are suicides. An additional 5 percent of firearm deaths are 
22 Cost of Injury in the United States 

Figure 7 

Falls: Injury Rate by Age and Sex, 1985 

(rate per 100,000 population) 

5-l4 15-24 25-44 45-64 65-74 75+ 

Fatalities 

0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Hospitalized Persons 

� Males 

� Females 5-14 15-24 25-44 45-64 65-74 75+ 

Nonhospitalized Persons 
Incidence of Injury 23 

unintentional. The risk of a firearm death is highest for adolescents and 

young adults aged 15-44 (18 per 100,000) although among males, the 

elderly aged 75 and over are at higher risk than any other subgroup of 

the population (42 per 100,000) (Figure 8 and Appendix Table C-4). Their 

rate is 1.8 times as high as the rate for all males and 1.4 times as high as 

for males aged 15-44. Firearm injuries resulting in death among elderly 

males are largely due to suicides; 93 percent of all firearm deaths among 

males 75 and older are suicides. This is in contrast to firearm deaths 

among younger males, almost half of which are homicides (48%). 

Patterns of incidence by age and sex are considerably different for 

nonfatal as opposed to fatal firearm injuries. For both hospitalized and 

nonhospitalized injuries, young adult males are at highest risk with 

relatively few injuries among females and the elderly. 

Handguns account for three-fourths of all gun-related homicides 

(U.S. DOJ, 1986), although recent increases in gang warfare and the 

adoption of assault weapons by drug traffickers may create different 

patterns of firearm deaths. Injury deaths caused by handguns are a 

uniquely American epidemic with a rate over 90 times greater than that 

of any other country. More than half of all suicides are committed with 

guns (American Medical Association, 1989). Alcohol has been found at 

autopsy in 45 percent of firearm-involved homicides (Goodman, Mercy, 

Loya, et al., 1986). Since the early 1970s, the year-to-year fluctuations in 

firearm availability has paralleled the numbers of homicides. While 

firearm retailers market handguns for self-protection, few firearm deaths 

in the home stem from acts of self-protection. Firearms are 

unintentionally or intentionally fired at family members, friends, or 

acquaintances (Kellerman and Reay, 1986). 

Poisonings 

In 1985, poisonings accounted for 11,894 deaths, 218,554 

hospitalizations and 1.5 million minor injuries (Figure 9 and Appendix 

Table C-5). Almost all poisoning deaths occur among persons over the 

age of 15. Young adults aged 25-44 are at highest risk of a poisoning 

death (8 per 100,000). Males are 1.9 times as likely as females to die of a 

poisoning. Nearly one-half (48 percent) of all poisoning deaths of adults 

are ruled suicidal. There is evidence to suggest that these statistics may 

nevertheless underestimate the number of suicidal poisoning deaths 

because deaths may be classified as unintentional when intent is not 

immediately obvious (Baker, Fisher, Masemore, et al., 1972). 

Patterns of nonfatal poisonings by age and sex are quite different 

from those resulting in death. Persons at highest risk of a hospitalization 

associated with poisoning include the elderly aged 75 and older (165 per 

100,000), very young children aged 0-4 (139 per 100,000), and adolescents 
24 Cost of Injury in the United States

Figure 8

Firearms: Injury Rate by Age and Sex, 1985

(rate per 100,000 population) 

200 

100 

0 

0-4 5-14 15-24 21-44 45-64 65-74 75+ 

Fatalities 

0-4 5-14 15-24 25-44 45-64 65-74 75+

Hospitalized Persons 

300

200

100

Males 

0

0-4 5-14 15-24 25-44 45-64 65-74 75+

H Females 

Nonhospitalized Persons 
Incidence of Injury 25 

and young adults aged 15-24 (130 per 100,000). Females aged 5 and older 

are at slightly higher risk of hospitalization than males, although the 

differences are small; for all ages, females are 1.2 times as likely as males 

to be hospitalized. Little is known about the intent of nonfatal 

poisonings resulting in hospitalization (42 percent are of unknown 

intent). Of the hospitalized injuries for which the intent is recorded, 

however, nearly two-thirds are ruled intentional (over 90 percent are 

recorded as self-inflicted). The risk of a less serious poisoning resulting 

in medical attention without hospitalization or in one or more days of 

restricted activity is highest among very young children aged 0-4 (1,745 

per 100,000). They account for 21 percent of all nonhospitalized injuries. 

Rates among the elderly, on the other hand, are low. 

Deaths among adults from poisonings most commonly involve 

motor vehicle exhaust, other gases or vapors, antidepressants and 

tranquilizers, barbiturates, alcohol, and opiates. Poisonings among 

children under age 5 comprise 60 percent of all calls to poison control 

centers but only 1 percent of fatalities. Poisoning deaths among young 

children have declined dramatically since 1960 largely because of 

changes in the formulation and packaging of dangerous drugs (Walton, 

1982). However, poisonings remain a major cause of hospitalization and 

emergency outpatient care. Poison control centers with hot lines provide 

consultation on appropriate emergency and therapeutic treatment for 

poisons, drugs, and other toxic substances involved in both unintentional 

and intentional poisonings (Chafee-Bahamon and Lovejoy, 1983. 

Fires and Burns 

In 1985, fires and burns resulted in 5,671 deaths, 54,397 persons 

hospitalized and 1.4 million persons with minor injuries. The elderly 

aged 75 and older are at highest risk of death due to fires and bums (8.6 

per 100,000), and young children aged 0-4 are at highest risk of nonfatal 

burns resulting in hospitalization (66 hospitalizations per 100,000) 

(Figure 10 and Appendix Table C-6). There is no consistent relationship 

with age for minor burns. Males are at slightly higher risk of both fatal 

and nonfatal injuries resulting from fires and burns, although the sex 

differential is not as great as for other injuries (1.7 for fatalities and 1.3 for 

nonfatalities). 

House fires cause three-fourths of all fire and burn deaths, with 

smoke inhalation and resulting carbon monoxide poisoning causing twothirds of these deaths (Birky, Halpin, Caplan, Fisher, McAllister, and 

Dixon, 1977). The same study reports alcohol involvement in 42 percent 

of fatal fires. The risk of dying in a housefire is halved in homes with 

operable smoke detectors. Smoke detectors are now present, but not 

always operable, in 82 percent of U.S. households (Hall, 1988). 
26 Cost of Injury in the United States 

Figure 9 

Poisonings: Injury Rate by Age and Sex, 1985 

(rate per 100,000 population) 

0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Fatalities 

0-4 

0-4 5-14 15-24 25-44 45-64 65-74 

Hospitalized Persons 

75+ 

1-3 Males 

, �  Females 5-14 15-24 25-44 45-64 65-74 75+ 

Nonhospitalized Persons 
Incidence of Injury 27 

Cigarettes, the primary ignition source of fatal fires, can be manufactured 

to be less likely to ignite furniture (Technical Study Group, 1987). A 

severe nonfatal burn is among the most devastating injuries a person can 

survive and may result in permanent scarring. Scalds are the most 

common burn injury and flame burns tend to be the most severe. 

Clothing ignition burns are now rare in children but are still a significant 

problem among the elderly (Tinsworth, 1985). 

Drownings and Near Drownings 

Drownings accounted for 6,171 deaths in 1985. There were an 

additional 31,564 near drownings, of which 5,564 resulted in 

hospitalization (Appendix Table C-7). Drowning rates are highest 

among very young children aged 0-4 (4 per 100,000) and among young 

adolescents and young adults aged 15-24 (4 per 100,000). Males are over 

four times as likely to drown as are females. 

Approximately 11 per 100,000 young children are hospitalized as 

the result of a near drowning; 145 per 100,000 experience a near 

drowning that results in outpatient medical treatment or one or more 

days of restricted activity. Estimates of near drownings are based on a 

small number of sampled cases. Thus, caution must be exercised in 

interpreting patterns of incidence by age and sex. The numbers suggest, 

however, that nearly 90 percent of all near drownings occur among very 

young children aged 0-4, and that males are over twice as likely as 

females to be treated as the result of a near drowning. 

Most drownings of young children occur in unprotected or 

unsupervised bodies of water such as swimming pools and can be 

prevented by adequate fences and self-latching gates around hazards 

close to home (Pearn and Nixon, 1977). Drownings among adolescents 

and young adults occur most often during swimming or boating 

activities, but effective strategies to prevent these drownings have yet to 

be developed. Alcohol has been detected in the majority of adults who 

drown while swimming or boating (Dietz and Baker, 1974), although the 

causal relationship needs further study (Howland and Hingson, 1988). 

Data Sources and Methods 

The major data sources used in estimating numbers of injuries are 

the National Mortality Detail File (for deaths), the National Hospital 

Discharge Survey (for live hospital discharges), and the National Health 

Interview Survey (for less severe, nonhospitalized injuries). Statewide 

hospital discharge abstract data from Maryland and California are used 

to supplement the information on cause for hospitalized injuries 

(Maryland HSCRC, 1988; California OSHPD, 1986). These data sources 

were chosen because they include population-based in formation on all 
28 Cost of Injury in the United States 

Figure 10 

Fires/Burns: Injury Rate by Age and Sex, 1985 

(rate per 100,000 population) 

10 

5 

0 0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Fatalities 

80 

60 

40 

20 

0 0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Hospitalized Persons 

I Females 0-4 5-14 15-24 25-44 45-64 65-74 75+ 

Nonhospitalized Persons 
Incidence of Injury 29 

injuries regardless of the cause of injury and the age of the injured. 

Numerous other national population-based data sets exist from which 

estimates of incidence can be derived for particular types of injury (e.g., 

motor vehicle injuries (U.S. NHTSA, 1988b; 1988c), injuries related to 

consumer products (U.S. CPSC, 1983), or occupational injuries (Panel on 

Occupational Safety and Health Statistics, 1987). Differences in study 

design and definitions across these studies, however, make it difficult to 

integrate their results in arriving at uniform figures across all types of 

injury and subgroups of the population. 

Age- and sex-specific intercensal estimates of the 1985 United States 

civilian population are used in calculating rates of injury per 100,000 

(U.S. Bureau of the Census, 1988). The civilian population consists of 

U.S. residents excluding members of the armed forces. The 1985 

population estimates are included in Appendix Table C-1. The 

definitions and assumptions used in developing estimates for each class 

of injury are discussed below. 

Deaths 

The data source for determining the number of injury deaths is the 

1985 National Mortality Detail File, a complete record of deaths 

occurring in the United States, excluding foreign resident deaths. An 

injury death is defined as any death with an underlying cause of injury 

as defined by the Ninth Revision of the International Classification of 

Diseases (ICD-9CM), E-Codes 800-999 excluding E870-E879 

(misadventures to patients during surgical and medical care) and E930-

E949 (drugs, medical and biological substances causing adverse effects in 

therapeutic use). This definition includes all traumatic injuries, burns, 

poisonings, and drownings. Deaths with an injury noted only as a 

contributing cause and not as the underlying cause are excluded from 

the definition. Restricting the definition to deaths with an underlying 

cause of injury underestimates the total number of injury-related deaths, 

especially among the elderly (Fife and Rappaport, 1987). However, since 

it is difficult to ascribe the death in these cases to the injury per se, the 

more conservative definition is used. 

The classification of ICD-9 E-codes by cause and intent of injury 

may be found in Appendix A. The classification by cause defined herein 

is somewhat different from that often used in national reports of injury 

mortality by cause because different categories of intent are combined 

under specific causes of injury. Caution should therefore be exercised in 

making direct comparisons. 
30 Cost of Injury in the United States 

Hospitalizations 

The 1984, 1985, and 1986 National Hospital Discharge Survey 

(NHDS) micro data tapes are used to develop estimates of the number of 

injuries resulting in hospitalization. The NHDS consists of hospital 

discharge abstracts uniformly collected for a probability sample of 

approximately 200,000 patients discharged each year from nearly 600 

short-stay, nonfederal hospitals located in the 50 states and the District of 

Columbia. Three years of NHDS data are used to provide more accurate 

estimates of incidence by age, sex, and nature of injury. National 

estimates of the number of hospitalizations are calculated by inflating the 

sample by the reciprocal of the probability of sample selection , adjusting 

for nonresponse. Annualized estimates for 1985 are ob tained by 

averaging the estimates over the three years. Estimates of less than 3,000 

have a relative standard error that may exceed 30 percent and are 

generally considered unreliable. These figures are noted in the tables 

with an asterisk. 

Included in the definition of an injury-related hospitalization is any 

live discharge with a principal diagnosis of an injury as defined by the 

ICD-9CM N-codes N800-N999, excluding N958 (traumatic 

complications), N905-N909 (late effects of injuries), N995 (adverse 

effects), and N996-N999 (complications of surgical and medical care). Ncodes are the International Classification of Disease (ICD) codes for the 

nature of injury and body part affected. For the three years (1984-86),a 

total of 41,601 live discharges included in the NHDS met these criteria. 

Selecting all hospital admissions with a principal diagnosis of 

trauma overestimates the incidence of injury resulting in hospitalization. 

This overcount occurs for two reasons. First, transfers from one acute 

care hospital to another may be counted twice. However, less than 2 

percent of injury hospitalizations are transfers (MacKenzie, Steinwachs, 

and Edelstein, 1988). A second and potentially more important source of 

overestimation is the inclusion of individuals who are rehospitalized for 

follow-up care of a previous injury. Hospitalizations classified by 

principal diagnosis as ‘complications’ or ‘late effects’ of injury, are 

excluded from the count by definition. Some of these rehospitalizations, 

however, have a principal diagnosis with a valid injury ICD N-code as 

defined above. These cases are not readily identifiable in the NHDS. 

However, several statewide hospital discharge abstract databases 

indicate whether admissions are elective or not. This classification is 

used as a surrogate for readmission. 

Estimates of the number of hospitalizations obtained from the 

NHDS are adjusted downward using the percent of live discharges from 

all Maryland acute care hospitals that were elective. Adjustments are 

made within 24 injury categories defined by the body region and severity 
�

Incidence of Injury 31 

of the principal or most severe injury sustained. Of all injury categories, 

12 percent of admissions were elective in Maryland (Maryland HSCRC, 

1988), a figure comparable to data from New Zealand in which first 

admissions and readmissions can be separately identified (New Zealand 

NHSC, 1989). 

Classification by Nature and Severity 

All injured persons discharged from the hospital are classified into 

one of 24 injury categories defined by the body region and severity of the 

principal or most severe injury sustained. Injury severity is determined 

using a computerized mapping of ICD-9CM coded discharge diagnoses 

into Abbreviated Injury Scale (AIS) scores, referred to as ICD/AIS scores 

(MacKenzie, Steinwachs, and Shanker, 1989). The AIS is the most widely 

recognized injury severity scoring system based on anatomic descriptors 

(Committee on Injury Scaling, 1985). The AIS is an ordinal scale ranging 

from 1 (minor injury) to 6 (maximum injury-virtually unsurvivable). 

A drawback to the widespread application of the AIS in large 

population-based research and evaluation in the past was the need to 

review the entire medical record for adequate scoring. Development of 

the ICD-9CM to AIS conversion table has enabled AIS severity scoring 

when only ICD-9CM coded discharge diagnoses are available. 

Assumptions used in assigning ICD/AIS scores are generally 

conservative. Validation studies further show that errors in chart 

abstracting and ICD coding lead to lower than average AIS values 

(MacKenzie et al., 1989). Therefore, ICD/AIS scores are slightly lower 

than AIS scores obtained by reviewing the entire medical record. Thus, 

the distribution by severity of persons discharged from the hospital is 

conservative. 

For the purpose of classification, all injured persons discharged 

from the hospital are grouped into 24 categories defined by the body 

region and AIS score of the principal diagnosis (Table 4). 

Classification by Cause 

A major limitation of the NHDS for estimating the incidence of 

hospitalized injuries is the lack of uniform coding of the cause of injury. 

The percent of cases in the NHDS for which the cause of injury can be 

identified either by an N-code (for drownings, poisonings, and burns) or 

by an E-code (for motor vehicles, falls, firearms, and other) is low --

approximately 25 percent. In most statewide discharge abstract 

databases, on the other hand, the percent of cases with information on 

cause is somewhat higher (50-60 percent). It has been shown, however, 

that even in these more complete databases, E-coding is not a random 

practice within or among hospitals, but is strongly correlated with the 
32 Cost of Injury in the United States 

age of the patient and the number and severity of injuries sustained 

(MacKenzie et al., 1988). Given a limited number of fields for recording 

diagnoses, hospitals are encouraged to record the conditions that 

influence the reimbursement rate. Thus, patients with multiple injuries 

and elderly patients who are likely to present with an underlying chronic 

disease or who develop complications during hospitalization are less 

likely to be assigned E-codes. 

Because of the limitations of both the NHDS and the statewide 

discharge abstract databases, the following procedures are used to 

distribute U.S. hospitalized injuries by cause. First, all injuries in the 

NHDS for which the cause is synonymous with the nature of injury are 

identified by an ICD-9CM N-code. These injuries include burns, (N940-

N949), near drownings (N994.1), poisonings (N960-N969; N970-N989), 

foreign bodies (N930-N939), and adverse effects (N990-994.0; N994.2-

N994.9). 

The remaining injuries are distributed by cause using hospital 

discharge abstract data from Maryland in which cause of injury is known 

for 59 percent of the cases. Maryland data are used for three reasons: 

first, a relatively high percent of hospitalized injuries are E-coded in the 

Maryland database. Second, the demographic distribution of the 

Maryland population is similar to that of the United States. Third, the 

distribution of injury deaths by cause occurring in Maryland is very 

similar to the distribution for the United States (Baker, O’Neill, and 

Karpf, 1984). As a further check on the suitability of using Maryland 

data, the distribution by cause for Maryland discharges was compared 

with distribution by cause for California discharges. Within age and 

nature of injury categories, the distributions are similar. 

Three years (1984-86) of live discharges from the 56 acute care 

hospitals in Maryland for which E-codes are recorded (N=68,211) are 

distributed by cause within the seven age groups, the male and female 

groups, and the 24 categories defining the body region and ICD/AIS 

severity of the principal injury. Based on the Maryland discharge data, 

the percent distributions of cause within each age, sex, and nature of 

injury category are multiplied by the NHDS estimates of the total 

number of hospitalizations within each group. 

Nonhospitalized Injuries 

Estimates of the number of minor injuries resulting in medical 

attention without hospitalization or in one or more days of restricted 

activity with no medical attention are derived using the National Health 

Interview Survey (NHIS) for 1984, 1985, and 1986. The NHIS is a 

continuous survey of a probability sample of households in the United 

States. Each year, approximately 50,000 households are sampled and 
Incidence of Injury 33 

information obtained on 122,000 individuals. In 1985, however, only 

three-quarters of the households were sampled and in 1986, only onehalf. Interviews are designed to obtain information about the health 

characteristics of each civilian noninstitutionalized member of the 

sampled households. Three years of data are used to provide more 

accurate estimates of incidence by age, sex, and cause of injury. National 

estimates are derived by weighting sample estimates by the reciprocal of 

the probability of selection, adjusted for nonresponse. Annualized 

estimates for 1985 are obtained by averaging the estimates over the three 

years. Estimates of less than 312,000 may have a relative standard error 

that exceeds 30 percent and are considered to have low statistical 

reliability. These data are marked in the tables. 

Included in the definition of nonhospitalized injuries are all acute 

injuries occurring within two weeks prior to interview, not resulting in 

hospitalization, but requiring medical attention (including consultation 

over the phone) or at least one full day of restricted activity. When a 

person is injured more than once in a two-week period, the injuries are 

counted separately. An acute injury is defined as any condition with an 

ICD-9CM N-code of N800-994, excluding N958 (traumatic 

complications), N905-N909 (late effects of injuries), N995 (adverse 

effects), and N996-N999 (complications of medical and surgical care). 

Nonhospitalized injuries are distributed by cause in the following 

manner. The NHIS distinguishes between motor vehicle versus nonmotor vehicle related injuries. Among the non-motor vehicle injuries, 

injuries related to fires and burns, poisonings, and near drownings can 

be further identified by the N-code used in the NHIS to classify the 

nature of the condition. The remaining injuries are distributed according 

to the distribution of cause for non-motor vehicle related injuries as 

reported in the NHIS conducted in 1972, the most recent year for which 

detailed information on the cause of injury was obtained (U.S. NCHS, 

1976). 

Data Limitations 

The incidence estimates presented in this report are derived from 

national databases that include a minimum of information on injuries 

within a certain class regardless of cause or age of the injured persons. 

At this time, there is no comprehensive source of information on all 

injuries from which more accurate estimates of incidence by cause, 

nature, and severity of injury can be derived. 

The databases used have limitations, however, and many 

assumptions and adjustments to the national data are necessary. In 

general, the estimates are believed to be conservative, both in overall 

magnitude and in distribution by severity. As noted above, the number 
34 Cost of Injury in the United States 

of injury deaths is underestimated, especially among the elderly for 

whom an injury may only be coded as a contributing rather than the 

underlying cause of death. The number of hospitalized injuries is also 

likely to represent an undercount since admissions to Veterans 

Administration and other state or federal hospitals are not included in 

the NHDS sample. Finally, injuries occurring in institutions such as 

mental institutions and prisons and not resulting in hospitalization are 

omitted from the totals since the NHIS collects information only on 

household members who are not institutionalized at the time of the 

interview. The NHIS is based on self-reporting, unlike the National 

Mortality Detail File and the NHDS, which are based on medical records. 

Therefore, there may be overcounting of injuries to survey respondents 

and undercounting of injuries to other household members. 

Due to limitations of the mapping from ICD-9CM codes to AIS 

severity scores, the distribution of traumatic injuries by severity is also 

likely to be conservative -- that is, the number of severe injuries 

(ICD/AIS 5) is underestimated. Comparison with more comprehensive 

sources on specific types of injury such as head injuries and spinal cord 

injuries, however, indicates that the bias is not great (Kraus, 1985a; 

Frankowski et al., 1985). 

In comparing these estimates to those derived from other studies or 

surveillance systems, the following potential sources of difference may 

be observed. First, classification by cause is without regard to intent. 

Also, definitions of specific cause categories may differ from one study to 

another. Second, estimates of hospitalized injuries exclude inpatient 

deaths. Thus, for example, the number of severe (ICD/AIS 5) head 

injuries in Table 4 includes only persons who survive to discharge 

although studies have shown that an equal number of people are 

admitted to a hospital with a severe head injury and subsequently die 

prior to discharge (MacKenzie et al., 1989; Kraus, Black, Hessol, et al., 

1984). These hospital deaths are included in the mortality figures. 

Finally, in comparisons of these estimates to those developed using more 

accurate information about the incidence of specific types or causes of 

injury, rates of injury may vary over time and across geographic regions. 

(Baker et al., 1987; U.S. CDC, 1988) 

Conclusion 

Incidence data are essential for estimating the cost of injury in the 

United States. About 56.9 million persons, one in four persons in the 

nation, are estimated to have been injured in 1985. Of this total number 

of injured persons, 142,568 died, 2.3 million were hospitalized, and 54.4 

million were less severely injured, not requiring, hospitalization. Injury 

occurs across the age range and to both genders, but younger persons 
Incidence of Injury 35 

and males are most affected. Four of five injuries occur annually among 

persons under age 45 and three in ten males sustain injuries in a year. 

Motor vehicles and firearms are the leading causes of injury death, 

accounting for more than half of all injury deaths. Falls, however, are the 

leading cause of nonfatal injury. 

The injury incidence data in this chapter represent a major 

contribution to understanding the full burden of injury in the United 

States. This is the first attempt to present a comprehensive picture of all 

injuries by sex, age, severity class, cause, and intent. The estimates are 

believed to be conservative, undoubtedly understating the overall 

magnitude of a serious public health problem facing the nation today. 
Chapter 2 

Economic Cost of Injury 

Injury, with its enormous death toll, high hospital costs, large 

number of nonhospitalized injured persons, and prevalence of long-term 

disabling conditions, imposes a multibillion dollar burden on the 

economy. The lifetime economic cost of injury to the nation is measured 

in this chapter in terms of the direct cost for medical treatment and 

rehabilitation of patients injured in 1985. Estimates also include life 

years lost and the indirect cost associated with loss of earnings due to 

short- and long-term disability and premature death from injury. 

The method for estimating lifetime economic cost is based on the 

incidence data presented in Chapter 1. The estimated charge per person 

by type of expenditure is applied to the number of injured persons for 

the direct cost. Morbidity and mortality costs are based on the human 

capital method, which estimates a value for productivity lost or reduced 

due to injury. The calculation of morbidity cost involves applying 

average earnings to work years lost for the employed injured population 

and attaching a dollar value to housekeeping services for those unable to 

perform them because of injuries sustained. 

Mortality cost is based on the number of injury fatalities reported in 

Chapter 1 and deaths occurring in later years due to injury sustained in 

1985. If these injured persons had not died prematurely, they would 

have continued to be productive for a number of years. The present 

value of future productivity loss constitutes an important component of 

the indirect cost of injury. The estimated cost or value to society of all 

injury fatalities is the product of the number of deaths and the expected 

value of an individual’s future earnings with sex and age taken into 

account. This method of derivation takes into consideration life 

expectancy for different age and sex groups, changing patterns of 

earnings at successive ages, varying labor force participation rates, 

imputed value for housekeeping services, and the discount rate by which 

to convert to present worth the potential aggregate earnings lost over the 

years. 

Life years lost due to morbidity and premature death from injury 

are estimated. For morbidity, productive life years lost are derived from 

the number of years lost from work for employed persons and from 

performance of housekeeping services by those who perform them as 

their major activity. Life years lost due to premature injury fatalities are 

estimated on the basis of the number of years of life expectancy 
38 Cost of Injury in the United States 

remaining at age of death for men and women. This method is different 

from the years of potential life lost (YPLL) used by the Centers for 

Disease Control (CDC). YPLL is based on the number of years lost 

before age 65 (U.S. CDC, 1986). The latter method significantly 

understates the total years of life lost due to injury because it does not 

count deaths of persons aged 65 years or older. In addition, it omits the 

years lost beyond age 65 for those who die before age 65. 

For each type of cost (i.e., direct, morbidity, and mortality), first and 

later year costs are based on a variety of studies and data bases 

providing estimates of the long-term disability associated with different 

types of injury. A 6 percent discount rate is used throughout to convert 

all costs to 1985 dollars. This discount rate is consistent with prior costof-injury studies. 

The model for estimating lifetime cost is shown in Appendix B and a 

more detailed description of the data sources and methods is presented 

at the end of this chapter. Throughout this chapter, per person costs are 

presented to the last dollar, but the estimates may be less precise and can 

be rounded to thousands of dollars. 

Overview 

For the 57 million persons injured in 1985, the cost amounts to 

$157.6 billion, or $2,772 per injured person (Table 5). Direct expenditures 

for hospital and nursing home care, physician services, drugs, and other 

medical and rehabilitation services amount to $44.8 billion or $790 per 

injured person (Figure 11). 

The direct cost is only the beginning. Disability from injury results 

in loss of output. Taking into account members of the labor force, 

housekeepers, and others unable to attend to their usual activities, more 

than 5 million life years are lost, 9 years per 100 injured persons, valued 

at $64.9 billion. The morbidity cost amounts to $1,145 per injured 

person. 

Other losses result from premature injury fatalities. Approximately 

143,000 premature deaths from injury occurred in 1985 and an additional 

13,000 deaths occurred in later years due to injury sustained in 1985. 

Premature death due to injury is extremely costly to the nation, 

amounting to an estimated annual loss of 5.3 million life years, or 34 

years per death. The loss to the economy amounts to $47.9 billion at a 6 

percent discount rate, or $307,636 per death. 

Sex Differences 

The total lifetime economic cost of injury for males is more than 

double that for females -- $108 billion compared with $50 billion. The 
Economic Cost of Injury 

Figure 11 

Lifetime Cost of Injury by Type of Cost, 1985 

39 

30

$157. 

% 

6 Billion 

Direct 

Morbidity 

Mortality 

cost per injured person is two-thirds higher for males than for females --

$3,363 compared with $2,005. Males comprise 57 percent of the total 

injured population but account for 68 percent of the cost (Figure 12). The 

distribution of lifetime cost by sex varies considerably by type of cost. 

Slightly more than half the direct cost (53%) is for males, but males 

account for 69 percent of the morbidity cost and 82 percent of the 

mortality cost. The relatively high cost for males reflects their higher 

labor force participation rate, earnings, and fatality rate. 

Age Differences 

The group aged 25-44 ranks highest in the number of injured 

persons. More than 18 million, or 32 percent, of the total injured persons 

are in this age group, and they account for 42 percent of the total cost 

(Figure 13). Persons aged 15-24 rank second in number of injuries and in 

cost, comprising 22 percent of injuries and 25 percent of the total cost. 

The distribution by age of each cost component (direct, morbidity, 

and mortality) varies. For the direct cost, the 25-44 age group ranks 

highest (28%), followed by those 65 years and over (24%). The high 

direct cost for the injured elderly reflects the large number of falls among 

this age group requiring long stays in hospitals and nursing homes and 

incurring high costs. 
40 Cost of Injuryin the United States 

Table 5 

Lifetime Cost of Injury by Age, Sex, and Type of Cost, 1985 

Age Cost* (millions) Cost* per Injured Person 

and Indirect Indirect 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $157,615 $44,807 $64,920 $47,888 $2,772 $790 $1,145 $307,636 

0-4 4,127 1,810 1,384 933 

5-14 9,699 4,026 4,067 1,605 

15-24 39,142 8,934 15,725 14,483 

25-44 65,822 12,724 28,680 24,418 

45-64 23,971 6,757 11,311 5,903 

65+ 14,853 10,555 3,752 546 

Male 107,995 23,907 45,043 39,045 

0-4 2,531 1,074 865 592 

5-14 6,775 2,596 3,023 1,156 

15-24 29,137 5,793 11,436 11,908 

25-44 50,307 8,410 21,410 20,487 

45-64 15,428 3,408 7,397 4,623 

65+ 3,817 2,626 913 278 

Female 49,620 20,900 19,877 

o-4 1,596 736 519 341 

5-14 2,924 1,431 1,045 449 

15-24 10,005 3,141 4,289 2,575 

25-44 15,514 4,314 7,270 3,931 

45-64 8,544 3349 3,915 1,280 

65+ 11,036 7,929 2,839 268 

1,014 445 

952 395 

3,070 702 

3,644 706 

3,252 920 

3,364 2,407 

3,363 747 

1,030 438 

1,132 434 

3,630 724 

4,597 771 

4,455 989 

3,077 2,147 

2,005 846 

989 457 

695 340 

2,118 666 

2,179 607 

2,187 859 

3,476 2,508 

340 210,403 

399 267,864 

1,236 427,278 

1,592 473,418 

1,540 211,936 

856 17,095 

1,407 349,030 

352 226,149 

505 290,120 

1,429 449,328 

1,963 508,034 

2,147 228,351 

746 15,279 

805 201,910 

322 187,705 

249 223,639 

909 348,246 

1,023 349355 

1,004 168,262 

898 19,503 

* Discounted at 6 percent 

** Based on 155,665 deaths, including 13,097 deaths in later years due to injuries 

sustained in 1985 

Morbidity and mortality costs for injured persons aged 25-44 are 

highest. This age group accounts for 44 percent of the morbidity cost 

and 51 percent of the mortality cost. Losses for the 15-24 age group are 

also high, representing 24 percent of the morbidity cost and 30 percent of 

the mortality cost. Injured persons in the latter age group are in the 

prime of their lives. Many are severely injured and are disabled for 

several years or for life, thereby reducing their potential productivity. 
Economic Cost of Injury 41 

Others are fatally injured, causing substantial losses to the economy. 

Morbidity and mortality costs for the injured elderly are relatively low. 

The elderly group accounts for only 6 percent of morbidity losses and 

Figure 12 

Distribution of Injured Persons and Lifetime Cost by Sex, 1985 

43%

Million Injuries 

Billion Lifetime 

cost 

� Males 

 Females 

32 
42 Cost of Injury in the United States 

Figure 13

Distribution of Injured Persons and Lifetime Cost by Age, 1985

8% 

illion Injuries 

9% 3% 6%

15

42 

$157.6 Billion 

Lifetime Cost 

25% 

� 0-4

� 5-14

15-24

25-44

� 45-64

65 + 

1 percent of the mortality cost because of their short life expectancy, low 

labor force participation rate, and low earnings. 

The distribution by type of cost for each age group varies. For the 

elderly, direct cost far outweighs indirect cost -- direct, 71 percent; 
Economic Cost of Injury 43 

morbidity, 25 percent; and mortality, 4 percent (Figure 14). By contrast, 

for injured persons aged 15-24, direct cost comprises 23 percent of total 

lifetime cost; morbidity and mortality costs represent 40 and 37 percent, 

respectively. The high indirect cost for the younger age group again 

reflects their high injury fatality rate, the large number of years lost to 

productivity, high labor force participation rate, and high lifetime 

earnings. 

Figure 34 

Distribution of Lifetime Cost of Injury 

by Age and Type of Cost, 1985 

100% 

0% 

O-4 5-14 15-24 25-44 45-64 65+ 

Cause of Injury 

Direct

 Morbidity

� Mortality

The distribution of total lifetime cost by cause shows that the 

greatest losses are caused by motor vehicles and falls, accounting for $49 

billion and $37 billion, respectively (Table 6). Although the incidence 

rate for falls is higher than for motor vehicle crashes, the significantly 

larger number of motor vehicle fatalities among young persons results in 

higher lifetime costs. Motor vehicle injuries account for 9 percent of total 

injuries and 31 percent of the total economic cost (Figure 15). 

Firearms rank third in economic toll, amounting to $14.4 billion, or 9 

percent of the total cost. Injuries from firearms account for one-half of 

one percent of total injuries, but fatalities at young ages are high for this 

cause of injury, resulting in high costs. 
44 Cost of Injury in the United States 

Injuries due to other causes number 36 million, 63 percent of all 

injuries, and the total lifetime cost amounts to $42 billion or 27 percent of 

the total injury cost. Included in this category is a variety of injuries such 

as those due to cutting and piercing instruments; hangings; water, air, 

railway, and space transport accidents; and suffocation. For a complete 

list of the causes of injury included in the ‘other’ category, see Appendix 

A . 

Table 6

Lifetime Cost of Injury by Cause and Type of Cost, 1985

Cost* (millions) Cost* per Injured Person 

Indirect Indirect 

Cause of Injury Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $157,615 $44,807 

Motor Vehicles 48,683 12,270 

Falls 37,279 14,689 

Firearms 14,410 911 

Poisonings 8,537 1,703 

Fires/Burns 3,832 920 

Drownings t 2,453 78 

0ther 42,421 14,235 

Male 107,995 23,907 

Motor Vehicles 33,328 6,765 

Falls 21,041 5,445 

Firearms 12328 784 

Poisonings 5,589 726 

Fires/Burns 2,801 608 

Drownings t 2,117 56 

0 ther 30,790 9,524 

Female 

Motor Vehicles 15,355 5,506 

Falls 16,239 9,245 

Firearms 2,081 128 

Poisonings 2,948 977 

Fires/Burns 1,030 312 

Drownings t 335 22 

Other 11,631 4,711 

$64,920 $47,888 $2,772 $790 $1,145 $307,636 

19,085 17,328 9,062 2,304 3,583 330,843 

21,049 1,541 3,033 1,197 1,715 93,554 

1,418 12,080 53,831 3,860 6,006 370,706 

2,441 4394 5,015 1,007 1,444 369,402 

1,548 1,364 2,619 631 1,062 238,841 

107 2,268 64,993 2,466 3,389 360,707 

19,272 8,914 1,187 399 540 293,817 

45,043 3,363 747 1,407 349,030 

12,912 13,652 13,554 2,788 5,321 370,618 

14,335 1,261 3,735 968 2,548 138,042 

1,054 10,491 57,053 4,132 5,554 384,424 

1,599 3,265 8,119 1,066 2,349 428,358 

1,238 955 3,513 766 1,559 274,804 

76 1,986 60,704 1,873 2,526 391, 884 

13,831 7,435 1,381 428 621 331,363 

19,877 2,005 846 805 201,910 

6,173 3,676 5,271 1,899 2,129 236,553 

6,714 280 2,440 1,390 1,010 38,136 

365 1,589 40,338 2,749 7,855 300,035 

842 1,129 2,907 968 834 264,252 

310 408 1,548 470 468 182,844 

31 282 117,372 13,302 19,171 231,220 

5,441 1,479 866 351 405 187,187 

Discounted at 6 percent 

Based on 155,665 deaths, including 13,097 deaths in later years due to injuries sustained in 

1985 

Includes Near Drownings 
Economic Cost of Injury 45 

Figure 15

Distribution of Injured Persons and Lifetime Cost by Cause, 1985

56.9 Million Injured Persons 

63% 

* Injuries due to firearms and drownings each comprise less than .5% of 

total injuries 

$157.6 Billion Lifetime Cost 

% 

Motor Vehicles 

Falls 

Firearms 

Poisonings 

Fires/Burns 

Drownings 

Other 

Distribution by cause of injury varies among the three cost 

components (i.e., direct, morbidity, and mortality costs), reflecting 
46 Cost of Injury in the United States 

differing age, sex, medical care use, morbidity, and mortality patterns. 

Figure 16 shows the distribution of each cost component by cause of 

injury. As expected, for injuries with high fatality rates, the mortality 

cost represents a larger proportion of the total than do direct and 

morbidity costs. For example, 93 percent of the total economic cost of 

drownings and near drownings is lost lifetime earnings resulting from 

deaths. For falls, which result in high disability, the morbidity cost 

comprises the largest proportion of the total at 57 percent. The direct 

cost for falls is also relatively high at 39 percent. 

Figure 16 

Distribution of Lifetime Cost of Injury by Cause 

and Type of Cost, 1985 

100% 

0% 

H Direct 

 Morbidity 

 Mortality Motor Vehicles Falls Firearms Poisonings Fires/Burns Drownings

Lifetime cost per injured person varies for the different causes. 

Drownings and near drownings are highest, amounting to about $65,000 

per person. Next highest is firearms, at $54,000 per person (Table 6). 

Fatality due to both of these causes is high, especially for young age 

groups, accounting for the high cost per person. 

Table 7 presents the aggregate cost of injury by cause, age, and sex. 

For each cause of injury, the 25-44 age group has the highest total cost. 

The second costliest for each cause is the 15-24 age group, except for falls, 

for which the cost for persons aged 65 and over is second. The cost per 

injured person by cause, age, and sex shown in Table 8 presents a 

different picture. Because drownings are almost always fatal, their total 

cost per person is very high. The cost per person drowned for the 15-24 

age group is highest, at about $351,000, followed closely by the 25-44 age 
Economic Cost of Injury 47 

group at $340,000. The total cost per person injured by firearms ranks 

second and the highest cost is for persons aged 45-64, amounting to 

$149,000. Motor vehicle injuries rank third in total cost per injured 

person, estimated at about $9,000 with the highest cost for persons aged 

25-44. 

Table 7 

Lifetime Cost of Injury by Age, Sex, and Cause, 1985 

Age Cost* (millions) 

and 

Sex 

Motor Fire- Poison- Fires/ DrownTotal Vehicles Falls arms ings Burns ings** Other 

Total $157,615 $48,683 $37,279 $14,410 $8,537 $3,832 $2,453 $42,421 

0-4 4,127 1,004 1,161 33 168 326 183 1,252 

5-14 9,699 3,107 2,626 293 108 267 201 3,097 

15-24 39,142 16,107 6,456 4,204 1,484 785 767 9,340 

25-44 65,822 20,652 10,994 7,838 4,761 1,607 1,039 18,931 

45-64 23,971 5,939 6,243 1,848 1,429 642 236 7,634 

65+ 14853 1,874 9,799 193 588 205 27 2,167 

Male 107,995 33,328 21,041 12,328 5,589 2,801 2,117 30,790 

0-4 2,531 628 690 20 96 188 122 788 

5-14 6,775 2,145 1,820 241 52 176 163 2,178 

15-24 29,137 11, 379 4,792 3,669 942 630 700 7,025 

25-44 50,307 14,987 8,224 6,740 3,452 1,233 928 14,744 

45-64 15,428 3, 511 3,539 1,535 870 489 191 5,294 

65+ 3,817 679 1,976 125 177 86 13 761 

Female 49,620 15355 16,239 2,081 2,948 1,030 335 11,631 

0-4 1,596 377 471 13 72 138 61 464 

5-14 2,924 962 806 53 56 91 38 919 

15-24 10,005 4,728 1,663 535 542 155 67 2,315 

25-44 15514 5,665 2,770 1,098 1,309 374 111 4,187 

45-64 8,544 2,429 2,705 314 558 153 45 2,340 

65+ 11,036 1,195 7,823 68 411 120 14 1,406 

* Discounted at 6 percent 

** Includes Near Drownings 
48 Cost of Injury in the United States 

For each cause of injury, except drownings and near drownings, the 

cost per injured male is higher than for the average female. Relatively 

few women (3,000) compared with men (35,000) are injured in this 

manner. The cost per injured female is higher, however, because the few 

females included in the sample had high medical costs. 

Appendix Tables C-9--C-15 show the total lifetime cost and the 

amount per injured person by age, sex, and type of cost for each cause of 

injury. Appendix Table C-16 shows the number of deaths, including 

deaths in later years, by which the mortality cost per injured person is 

calculated. 

Lifetime Cost of Injury 

The lifetime cost of injury in the United States takes into account the 

cost incurred in the first year in which the injury occurs as well as the 

cost incurred in later years. Since many injuries result in long-term 

disability and premature death, the economic cost incurred in later years 

is high. Of the total lifetime cost of $157.6 billion, almost three-fourths, 

$116.4 billion, is for the first year cost and the remaining $41.2 billion is 

estimated to be incurred in later years (Table 9). The estimating 

procedure is described at the end of this chapter. 

The distribution of first and later year costs varies by cause of injury. 

For injuries resulting in a relatively large number of deaths, the first year 

cost comprises 94 to 98 percent of the total lifetime cost. This is because 

productivity losses due to premature death are considered to be a first 

year cost. For example, for drownings and near drownings, fatalities 

comprise 16 percent of the persons injured due to this cause, and the first 

year cost comprises 98 percent of the total. Likewise, 12 percent of 

firearm injuries are fatal and the first year cost accounts for 94 percent of 

the lifetime cost. By contrast, only one-tenth of one percent of falls result 

in death, and long-term disability often results from falls. For this cause 

of injury, 55 percent of lifetime cost is incurred in the first year and the 

remaining 45 percent in later years. 

The distribution by type of cost of first and later year costs varies: 87 

percent of the direct cost and 99.7 percent of the mortalitv cost occur in 

the first year. However, fully 54 percent of the morbidity cost occurs in 

later years. 

Class of Injury 

There are three classes of injury reflecting severity: 155,665 deaths 

(142,568 deaths occurring in 1985 plus 13,097 deaths occurring in later 

years due to injury sustained in 1985), 2.3 million hospitalized injured 
Economic Cost of Injury 49 

Table 8 

Lifetime Cost of Injury per Injured Person 

by Age, Sex, and Cause, 1985 

Age Cost* per Injured Person 

and Motor Fire- Poison- Fires/ DrownSex Total Vehicles Falls arms ings Burns ings** Other 

Total $2,772 $9,062 $3,033 $53,831 $5,015 $2,619 $64,993 $1,187 

0 - 4 1,014 8,963 882 108,386 495 2,253 6,376 588 

5-14 952 9,485 1,057 12,087 405 1,583 159,021 448 

15-24 3,070 9,135 3,538 69,720 10,839 2,118 351,406 1,087 

25-44 3,644 10,005 4,244 47,746 8,706 3,252 340,247 1,552 

45-64 3,252 7,485 3,558 148,516 5,582 4,977 155,285 1,726 

65+ 3,364 6,017 4,226 31,123 3,734 1,313 26,516 1,480 

Male 3,363 13,554 3,735 57,053 8,119 3,513 60,704 1,381 

0 - 4 1,030 8,993 996 148,146 608 3,173 4,434 543 

5-14 1,132 11,336 1,437 12,242 398 3,816 153,160 503 

15-24 3,630 14,912 4,476 70,078 22,973 3,509 379,937 1,187 

25-44 4,597 14,472 5,852 52,450 15,728 3,371 359,571 1,893 

45-64 4,455 13,801 4,943 150,637 9,523 4,541 159,460 2,319 

65+ 3,077 4,622 4,096 23,732 3,583 2,187 21,788 1,473 

Female 2,005 5,271 2,440 40,338 2,907 1,548 117,372 866 

0-4 989 8,913 755 77,694 398 1,615 54,257 683 

5-14 695 6,952 662 11,430 411 741 190,483 355 

15-24 2,118 4,727 2,205 67,363 5,652 811 196,748 866 

25-44 2,179 5,507 2,337 30,791 3,998 2,914 234,848 949 

45-64 2,187 4,505 2,603 138,946 3,394 7,182 139,839 1,093 

65+ 3,476 7,263 4,260 72,358 3,804 1,021 33,584 1,484 

* Discounted at 6 percent 

** Includes Near Drownings 
50 Cost ofInjuryin the United States 

Table 9 

Lifetime Cost of Injury by Cause, Type of Cost, 

and First and Later Years, 1985 

Cost* (millions) 

Total Direct Morbidity Mortality’ 

First Later First Later First Later First Later 

Cause Total Year Year Year Year Year Year Year Year 

Total $157,615 $116,403 $41,212 $38,859 $5,948 $29,805 $35,115 $47,739 $150 

Motor Vehicles 48,683 35,112 13,271 10,902 1,368 6,946 12139 17264 64 

Falls 37,279 20,451 16,829 12,061 2,628 6,892 14,157 1,497 44 

Firearms 14,410 13,515 894 812 100 638 780 12,065 14 

Poisonings 8,537 8,285 253 1,462 240 2,429 12 4,394 0 

Fires/Bums 3,832 3,065 766 852 68 850 697 1,363 1 

Other 

2,453 

42,421 

2,405 

33,570 

48 

8,851 

69 

12,702 

9 

1,533 

70 

11,980 

37 

7,292 

2,266 

8,888 

2 

26 

Percent Distribution by Cause 

Total 100.0 % 73.9 % 26.1 % 86.7 % 133 % 45.9 % 54.1 % 99.7 % 03 % 

Motor Vehicles 100.0 72.1 27.9 88.8 11.2 36.4 63.6 99.6 0.4 

Falls 100.0 54.9 45.1 82.1 17.9 32.7 673 972 2.8 

Firearms 100.0 93.8 6.2 89.1 10.9 45.0 55.0 99.9 0.1 

Poisonings loo.0 97.0 3.0 85.9 14.1 99.5 05 100.0 0.0 

Fires/Burns loo.0 80.0 20.0 92.6 7.4 54.9 45.1 100.0 0.0 

Dmwningst 100.0 98.0 2.0 88.1 11.9 653 34.7 99.9 0.1 

Other loo.0 79.1 20.9 89.2 10.8 62.2 37.8 99.7 03 

* Discounted at 6 percent 

*+ First year mortality costs are those associated with the 142,568 deaths occurring in 1985; later year mortality 

costs are those associated with the 13,097 deaths occurring in later years due to injuries sustained in 1985 

t Includes Near Drownings 

persons, and 54.4 million nonhospitalized injured persons. The latter 

class, although large, involves the least severe injuries. The distribution 

of costs by class of injury reflects the severity of the injuries. Of the 

$157.6 billion lifetime cost, 31 percent is the cost of fatalities. Included is 

a small amount of direct cost for deaths occurring within the first year of 

injury and requiring medical care. More than half (51%) of the lifetime 

cost is for injuries involving hospitalization and less than one-fifth (18%) 

for nonhospitalized injuries (Table 10). 

The cost per injured person by class of injury also reflects injury 

severity. The cost per fatal injury amounts to $317,189, the present value 

of forgone earnings for the average fatal injury. The cost per injured 

person hospitalized is $34,116, substantially greater than the $518 cost for 

nonhospitalized injured persons. 

Age and Sex 

The distribution of lifetime cost by class of injury varies by sex and 

age. Of the total 155,665 injury fatalities occurring in 1985 and in later 

years, 72 percent are males and 28 percent are females. The lifetime cost 
Economic Cost of Injury 51 

for males, however, is significantly higher, 81 percent of the total, 

reflecting higher labor force participation and higher earnings. 

Of the 2.3 million hospitalized injured persons, 1.3 million, or 56 

percent, are males. The proportion of total cost for hospitalized injuries 

is higher for males --65 percent. Males are involved in more serious 

injuries that incur higher costs. Males also incur more minor injuries 

Table 10 

Lifetime Cost of Injury by Age, Sex, and Class of Injury, 1985 

Cost* (millions) Cost* per Injured Person 

Age Hospi- Nonhospi- Hospi- Nonhospiand Sex Total Fatalities** talized talized Total Fatalitiestt talizedt talizedt 

Total $157,615 $49,374 $80,063 $28,178 $2,772 $317,189 $34,116 $518 

0-4 4,127 976 2,357 795 1,014 220,081 20,959 201 

5-14 9,699 1,670 6,061 1,967 952 278,754 29,561 197 

15-24 39,142 14,876 19,504 4,762 3,070 438,884 42,028 389 

25-44 65,822 24,891 29,282 11,648 3,644 482,583 43,169 672 

45-64 23,971 6,138 12,320 5,513 3,252 220,375 32,694 791 

65+ 14,853 822 10,538 3,493 3,364 25,771 20,661 901 

Male 107,995 40,086 51,737 16,172 3,363 358344 39,148 527 

04 2,531 617 1,432 482 1,030 235,664 21,934 202 

5-14 6,775 1,198 4,381 1,195 1,132 300,607 31,747 205 

15-24 29,137 12,205 14,267 2,664 3,630 460,550 44,807 347 

25-44 50,307 20,850 21,482 7,976 4,597 517,012 47,311 763 

45-64 15,428 4,786 7,491 3,150 4,455 236,423 37,153 971 

65+ 3,817 430 2,684 704 3,077 23,614 18,613 652 

Female 49,620 9,288 28,325 12,006 2,005 212,075 27,630 507 

04 1,596 359 924 313 989 197,617 19,608 200 

5-14 2,924 472 1,680 772 695 235,331 25,059 187 

15-24 10,005 2,671 5‘237 2,097 2,118 361,227 35,951 459 

25-44 15,514 4,042 7,801 3,672 2,179 359,190 34,783 533 

45-64 8,544 1,352 4,829 2,362 2,187 177,677 27,562 634 

65+ 11,036 393 7,854 2,789 3,476 28,630 21,469 997 

* Discounted at 6 percent 

** Includes a small amount of direct cost occurring within the first year of injury and 

requiring medical care 

t Nursing Home costs are distributed in hospitalized and nonhospitalized classes 

according to the source of admission to nursing home 

Based on 155,665 deaths, including 13,097 deaths in later years due to injuries sustained 

in 1985 
52 Cost of Injury in the United States 

than females. Fifty-six percent of the 54 million nonhospitalized injured 

persons are males, and they incur about the same proportion (57%) of the 

$28 billion cost of nonhospitalized injury. 

The 25-44 age group incurs the largest share of lifetime cost of 

fatalities. Of the 155,665 deaths resulting from injury in 1985,33 percent 

is in this age group. The productivity losses for this age group comprise 

half the total cost of fatalities. People who die prematurely in this age 

group are at the height of their productivity and the present value of 

future earnings lost is significant. By contrast, 20 percent of fatalities are 

persons aged 65 and over, but less than 2 percent of the lifetime cost of 

fatalities is in this age group. 

Injured persons aged 25-44 incur the most costly share of 

hospitalized and nonhospitalized injuries, comprising 37 percent and 41 

percent, respectively. The 15-24 age group is the second costliest for 

hospitalized injury, while the 45-64 age group ranks second for 

nonhospitalized injury. 

Cause of Injury 

Table 11 shows total cost and cost per injured person by cause and 

class of injury. The cost of motor vehicle fatalities ranks highest, totaling 

$18.4 billion, and the cost of fatalities due to firearms is second in rank at 

$12.2 billion. The lowest ranking cost is for fires and burns, at $1.4 

billion. On the basis of cost per fatality, firearms and poisonings rank 

highest at $373,520 and $372,691, respectively, reflecting the large 

number of deaths at younger ages for these causes of injury. 

The least costly fatalities are those from falls, estimated at $99,669 

per fatality. About 60 percent of the deaths resulting from falls are 

among persons aged 65 and over. Their labor force participation rate 

and earnings are low and life expectancy short, resulting in the lower 

cost per fatality ($99,669). 

The cost per hospitalized injured person ranges from $17,631 for 

poisonings to $43,409 for motor vehicle injuries. The second and third 

most costly hospitalized injuries are falls and fires and burns, at $38,174 

and $35,303, respectively. As expected, the cost per nonhospitalized 

injured person is by far the lowest, ranging from $4 to $1,570. Persons 

who sustain less severe injuries not requiring hospitalization use medical 

care services that are far less costly than services for hospitalized 

persons. 

Type of Cost 

As noted above, three types of lifetime cost are estimated: 1) direct 

cost, the expenditure for medical care services, amounting to $44.8 
Economic Cost of Injury 53 

billion, or 29 percent of the total lifetime cost of injury; 2) morbidity cost, 

valued at $64.9 billion, or 41 percent of the total; and 3) mortality cost, 

amounting to $47.9 billion at a 6 percent discount rate, or 30 percent of 

the total. A detailed description of each of type of cost follows. 

Table 11 

Lifetime Cost of Injury by Cause and Class of Injury, 1985 

Cost* (millions) Cost* per Injured Person 

Hospi- Nonhospi- Hospi- Non hospiCause Total Fatalities** talizedt talizedt Total Fatalitiestt talizedt 

Total 

Motor Vehicles

Falls

Firearms

Poisonings

Fires/ Burns

Other

Male

Motor Vehicles

Falls

Firearms

Poisonings

Fires/ Burns

Other

Female

Motor Vehicles

Falls

Firearms

Poisonings

Fires/ Burns

Drownings+.

Other

$157,615 $49,374 $80,063 

48,683 18,438 22,704 

37,279 1,642 29,904 

14,410 12,172 2,160 

8,537 4,433 3,853 

3,832 1,424 1,920 

2,453 2,278 175 

42,421 8,989 19347 

107,995 40,086 51,737 

33,328 14,437 15,258 

21,041 1317 17347 

12,328 10,567 1,694 

5,589 3,289 2,226 

2,801 992 1,463 

2,117 1,994 124 

30,790 7,490 13,626 

49,620 9,288 28,325 

15,355 4,001 7,446 

16,239 325 12,557 

2,081 1,604 465 

2,948 1,143 1,628 

1,030 432 458 

284 51 

11,631 1,499 5,721 

$28,178 $2,772 

7,541 9,062 

5,734 3,033 

78 53,831 

251 5,015 

487 2,619 

0 64,993 

14,086 1,187 

16,172 3,363 

3,633 13554 

2,377 3,735 

67 57,053 

74 8,119 

346 3,513 

0 60,704 

9,674 1,381 

12,006 2,005 

3,908 5,271 

3357 2,440 

12 40, 338 

177 2,907 

141 1548 

- 117,372 

4,411 866 

$317,189 $34,116 $518 

352,042 43,409 1, 570 

99,669 38,174 499 

373,520 33,159 458 

372,691 17,631 171 

249,367 35,303 347 

362,292 31,408 4 

296,266 27,769 402 

358344 39,148 527 

391,921 48,984 1,718 

144,143 54554 448 

387235 29,870 501 

431,608 22,766 127 

285300 37556 459 

393,464 31,462 4 

333,803 27,540 444 

212,075 27,630 507 

257506 35,198 1,454 

44,267 26,982 543 

302,860 55337 309 

267,610 13,476 199 

193,416 29,622 217 

232,825 31,278 

189,660 28,328 

* Discounted at 6 percent 

** Includes a small amount of direct cost occurring within the first year of injury and requiring 

medical care 

t Nursing home costs are distributed in hospitalized and non-hospitalized classes according to the 

source of admission to nursing home 

tt Based upon 155,665 deaths, including 13,097 deaths in later years due to injuries sustained in 1985 

$ Includes Near Drownings 

 Less than $500,000 

Direct Cost 

Direct cost includes all medical care costs and selected nonmedical 

costs. Medical care costs include amounts spent for personal health care 

of persons injured in 1985. Included are hospital and nursing home care, 
54 Cost of Injury in the United States 

physician visits, prescription drugs, physical therapy, ambulance and 

helicopter services, attendant care, and other expenses such as wheel 

chairs and appliances for injured persons. Included under hospital 

services are initial hospitalization, rehospitalization, emergency room 

visits, and inpatient rehabilitation. Nonmedical direct costs related to 

injuries include amounts spent for home modification, vocational 

rehabilitation, and overhead and administrative costs for automobile and 

health insurance. Other cost-of-injury studies, especially for motor 

vehicles, report substantially higher nonmedical costs because they 

include the value of property damage resulting from motor vehicle 

crashes (Faigin, 1976; U.S. NHTSA, 1983). Since the present report 

focuses on the cost of injury, nonmedical costs are limited to those 

related to the injured person and exclude the costs associated with the 

damage caused by the event resulting in injury. Settlements and benefit 

payments are transfer payments and are included in the medical care 

costs. Estimates of transfer payments are presented separately in 

Chapter 3. 

Direct personal medical and nonmedical costs of care for injured 

persons amount to $44.8 billion. Of this total, $24.5 billion, or 55 percent, 

is spent for hospital care, including the cost of professional services 

provided to hospitalized patients (Table 12). Physician visits outside of 

hospitals rank second, estimated at $6.5 billion, or 15 percent of the direct 

cost. The third highest type of expenditure, $2.5 billion, or 5 percent of 

the direct cost, is for nursing home care. 

Examination of the type of expenditure by cause of injury shows 

that hospital care is the most costly component for all causes of injury, 

ranging from $62 million for drownings and near drownings to $8.7 

billion for falls. Physician services outside the hospital rank second for 

all causes of injury except falls, for which nursing home care ranks 

second. 

Morbidity Cost 

Morbidity cost is the value of goods and services not produced 

because of injury-related illness and disability. To the degree that 

injuries prevent or deter individuals from producing goods and services 

in the marketplace, the public sector, or the household, the value of these 

losses is the cost borne by society. As indicated above, estimates of 

morbidity cost involve applying average earnings to work-years lost and 

imputing a dollar value to housekeeping services for those unable to 

perform them. Lifetime morbidity cost includes the value of output lost 

by persons disabled in later years as a result of injury sustained in 1985. 

Lifetime morbidity losses for persons injured in 1985 amount to 5.1 

million years of life, or 9 life years lost per 100 injured persons. These 
Economic Cost of Injury 55 

Table 12 

Lifetime Direct Cost of Injury by Type of Expenditure and Cause, 1985 

Cost? (millions) 

Motor Fire- Poison- Fires/ DrownType of Expenditure Total Vehicles Falls arms ings Burns ings** Other 

Total $44,807 $12,270 $14,689 $911 $1,703 $920 $78 $14,235 

Medical 38,752 7,900 13,891 863 1,613 876 74 13,535 

Hospital Services 24,515 5,937 8,734 753 1,281 671 62 7,077 

Initial 13,390 3374 4,941 455 742 471 32 3,375 

Rehospitalization 5,288 1,137 1,989 156 417 107 18 1,464 

Emergency Room Visits 2,619 336 490 18 33 67 3 1,672 

Inpatient Rehabilitation 3,218 1,090 1,314 124 89 26 9 566 

Physician Visits 6,504 1,105 1,573 54 148 110 5 3,509 

Prescriptions 1,158 120 258 6 22 33 0 719 

Physical Therapy 1,050 190 498 18 32 10 3 299 

Nursing Home 2,460 145 2,037 0 97 0 0 181 

Ambulance and Helicopter 668 97 240 9 33 51 1 237 

Attendant Care 156 51 61 12 0 1 3 28 

Other Expenses 2,241 255 490 11 0 0 0 1,485 

Nonmedical 6,054 4,370 798 48 90 44 4 700 

Home Modification 420 91 196 10 13 5 1 104 

Vocational Rehabilitation 157 31 49 4 13 4 0 56 

Auto Insurancett 3,934 3,934 0 0 0 0 0 0 

Health Insurancett 1,543 314 553 34 64 35 3 540 

* Discounted at 6 percent 

** Includes Near Drownings 

 Includes physician and other professional services for hospitalized persons 

tt Includes only administrative expenses 

losses translate to a total morbidity cost of $64.9 billion, or $1,145 per 

injured person. The greatest losses are for injured persons aged 25-44, 

followed by those aged 15-24. These two age groups have the largest 

number of hospitalized and nonhospitalized injuries resulting in 

employment and housekeeping losses. The morbidity cost for the 25-44 

age group amounts to $28.7 billion, or $1,592 per injured person. For 

persons aged 15-24, the morbidity cost totals $15.7 billion, or $1,236 per 

injured person (Table 13). 

The morbidity cost for males is significantly higher than for females, 

$45 billion compared with $20 billion. On the basis of cost per injured 

person, the morbidity cost amounts to $1,407 for males compared with 

$805 for females, reflecting lower earnings for women. Life years lost for 

injured males amount to 3.1 million years compared with 2.0 million for 
56 Cost of Injury in the United States 

Table 13

Injury Morbidity Losses by Age and Sex, 1985

Number of Life Years Lost Morbidity Cost* 

Injured Per 100 Per 

Age Persons** Total Injured Total Injured 

and Sex (thousands) (thousands) Persons (millions) Person 

Total 56,717 5,086 9 0

O-4 4,066 470 11.6 

5-14 10,184 822 8.1 

15-24 12,721 1,388 

. 

10.9 

25-44 18,015 1,314 7.3.

45-64 7,344 476 6.5 

65+ 4,386 616 14.0 

Male 32,014 3,059 9 6

0-4 2,454 262 10.7 

5-14 5,981 563 9.4 

15-24 8,003 950 11.9 

25-44 10,907 890 8.2 

45-64 3,445 255 7.4 

65+ 1,223 137 11.2 

Female 24,702 2,027 8 2. 

. 

0-4 1,612 208 12.9 

5-14 4,203 259 6 .2 

15-24 4,717 438 9 3. 

25-44 7,108 424 6 0.

45-64 3,900 221 5.7 

65+ 3,162 478 15.1 

$64,920 $1,145 

1,384 340 

4,067 399 

15,725 1,236 

28,680 1,592 

11,311 1,540 

3,752 855 

45,043 1,407 

865 352 

3,023 505 

11,436 1,429 

21,410 1,963 

7,397 2,147 

913 746 

19,877 805 

519 322 

1,045 249 

4,289 909 

7,270 1,023 

3,915 1,004 

2,839 898 

* Discounted at 6 percent 

** Excludes 142,568 deaths occurring in 1985 
Economic Cost of Injury 57 

females due to the higher number of injuries among males. The number 

of life years lost for males is 9.6 years per 100 injured persons compared 

with 8.2 years for females. 

Table 14 shows injury morbidity losses by cause of injury. 

Morbidity losses from falls rank highest, amounting to $21.0 billion, 

reflecting the large number of falls resulting in disability. Motor vehicle 

injuries rank second in total morbidity cost, amounting to $19.1 billion. 

The ranking by cause of injury for life years lost shows a different 

pattern: fires and burns, 1.3 million; motor vehicle injuries, 1.2 million; 

and falls, 363,000. The large number of life years lost for injuries from 

fires and burns and motor vehicles reflects the severity of these injuries 

that cause long-term disability. 

Mortality Cost 

A total of 155,665 deaths due to injury sustained in 1985 occurred in 

the United States. Alcohol is a major risk factor for many of these 

fatalities. About half the deaths due to motor vehicle traffic accidents, 

two-fifths of deaths from falls and from fires and burns, and three-tenths 

of drownings are estimated to involve alcohol (Parker, Shultz, Gertz, 

Berkelman, and Remington, 1987). 

Applying expected lifetime earnings by age and sex to the 155,665 

deaths from injury sustained in 1985, including deaths in later years, 

results in a loss of 5.3 million life years, or 34 years per death. These 

deaths represent a loss of $47.9 billion to the economy at a 6 percent 

discount rate, or $307,636 per death (Table 15). For the 111,867 males 

who died from injuries, an estimated 3.8 million life years are lost, 34 

years per death, valued at $39.0 billion, or $349,030 per death. The 43,798 

females who died from injuries represent a loss of 1.5 million life years, 

or 33 years per death. Because of the fewer deaths and lower earnings of 

females, losses for females are significantly lower than for males, 

amounting to a total of $8.8 billion, or $201,910 per death. Thus, males 

account for 72 percent of the injury deaths and life years lost, and 82 

percent of the productivity losses for 1985 (Figure 17). 

The number of injury deaths, life years lost, and discounted 

earnings vary by age. Most victims are relatively young -- one third are 

aged 25-44. The total of life years lost for this age group, a function of 

both age and number of deaths, represents 39 percent of all life years lost 

to injury. In terms of lost earnings, this age group accounts for 51 

percent of the total. By contrast, 38 percent of injury deaths are persons 

over age 45, accounting for 18 percent of life years lost and 14 percent of 

productivity lost (Figure 18). 
58 Cost of Injury in the United States 

Table 14

Injury Morbidity Losses by Sex and Cause, 1985

Number of Life Years Lost Morbidity Cost* 

Injured Per 100 Per 

Persons** Total Injured Total Injured 

Cause (thousands) (thousands) Persons (millions) Person 

Total

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Bums

Drownings t

Other

Male

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Bums

Drownings t

Other

Female

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Burns

Drownings t

Other

56,716 5,086 9.0 $64,920 $1,145 

5,326 1,173 22.0 19,085 3,583 

12,276 363 3.0 21,049 1,715 

236 188 79.8 1,418 6,006 

1,691 18 1.0 2,441 1,444 

1,457 1,259 86.4 1,548 1,062 

32 161 511.3 107 3,389 

35,698 1,924 5.4 19,272 540 

32,014 3,059 9.6 45,043 1,407 

2,426 737 30.4 12,912 5,321 

5,626 212 3.8 14,335 2,548 

190 126 66.4 1,054 5,554 

681 11 1.6 1,599 2,349 

794 636 80.2 1,238 1,559 

30 100 332.6 76 2,526 

22,267 1,238 5.6 13,831 621 

24,702 2,027 8.2 19,877 805 

2,900 436 15.0 6,173 2,129 

6,650 151 2.3 6,714 1,010 

46 62 134.6 365 7,855 

1,010 7 0.7 842 834 

663 622 93.8 310 468 

2 62 3,780.9 31 19,171 

13,431 686 5.1 5,441 405 

* Discounted at 6 percent 

** Excludes 142,568 deaths occurring in 1985 

t Includes Near Drownings 
Economic Cost of Injury 59 

Table 15

Injury Mortality Losses by Age and Sex, 1985

Life Years Lost Mortality Cost* 

Age Number of Total Per Total Per 

and Sex Deaths** (thousands) Death (millions) Death 

Total 155,665 5,285 34.0 $47,888 $307,636 

0-4 4,434 320 72.2 933 210,403 

5-14 5,992 337 56.2 1,605 267,864 

15-24 33,896 1,658 48.9 14,483 427,278 

25-44 51,579 2,045 39.6 24,418 473,418 

45-64 27,854 625 22.4 5,903 211,936 

65+ 31,910 300 94 546 17,095 

Males 111,867 3,827 34.2 39,045 349,030 

O-4 2,618 182 69.5 592 226,149 

5-14 3,986 219 54.9 1,156 290,120 

15-24 26,502 1,272 48.0 11,908 449,328 

2544 40,327 1,561 38.7 20,487 508,034 

45-64 20,245 431 21.3 4,623 228,351 

65+ 18,189 162 8.9 278 15,279 

Females 43,798 1,458 33.3 8,843 201,910 

O-4 1,816 138 76.0 341 187,705 

5-14 2,006 118 58.8 449 223,639 

15-24 7,394 386 52.2 2,575 348,246 

25-44 11,252 484 43.0 3,931 349,355 

45-64 7,609 194 25.5 1,280 168,262 

65+ 13,721 138 10.1 268 19,503 

. 

* Discounted at 6 percent 

** Includes 13,097 deaths in later years due to injuries sustained in 

1985 
60 Cost of Injury in the United states 

Figure 17 

Injury Mortality Losses by Sex, 1985 

Number of Deaths 

ty Cost 

Billion 

Males 

Females 
Economic Cost of Injury 61 

Figure 18 

Injury Mortality Losses by Age, 1985 

Number 7% of Deaths 

155,665 

22% 

18 

Life Years 

6% 13% Lost 

5.3 Million 
62 Cost of Injury in the United States 

Mortality losses by cause of injury are summarized in Table 16 and 

Figure 19. Motor vehicle and firearm injuries are the most devastating 

types of injury in number of deaths. Together they account for over half 

of all injury deaths (55%) and approximately 60 percent of life years lost 

and lost productivity. Motor vehicle injuries alone account for one-third 

of all injury deaths, 37 percent of lost years, and productivity losses of 

$330,843 per death. Firearm injuries are the most costly cause per death, 

representing a productivity loss of $370,706 per person, because the 

typical firearm victim is a young male. By contrast, the lowest 

productivity loss per death is $93,554, associated with falls; in this case, 

the typical victim is an elderly person with low earnings and short life 

expectancy. 

Mortality Losses Due to the Leading Causes of Death 

Deaths due to all causes and to injury in 1985 by age and sex are 

shown in Table 17. Excluded from this comparison are deaths in later 

years due to injuries sustained in 1985. Injury deaths comprise 7 percent 

of the 2.1 million deaths in the United States for 1985, 15 percent of the 

life years lost, and 26 percent of the productivity losses. 

The distribution by age of death for all causes differs from that for 

injury. Less than 2 percent of all deaths occur in the 15-24 age group, 

and less than 6 percent are in the 25-44 age group. By contrast, 21 

percent and 34 percent of injury deaths are in the 15-24 and 25-44 age 

groups, respectively. Deaths caused by injury comprise a 

disproportionately large share of deaths in young age groups compared 

with deaths from all causes. Injury deaths comprise 56 percent of all 

deaths in the 5-14 age group; 78 percent of all deaths in the 15-24 age 

group; and 41 percent of all deaths in the 25-44 age group. Life years lost 

and productivity losses due to injury deaths represent about the same 

proportions of the totals for these age groups. Premature deaths due to 

injury are extremely costly to the nation. 

Injury is the fourth leading cause of death, but productivity losses 

from this cause are far greater in terms of aggregate and per person 

losses than from the three leading causes of death (Table 18). For 

example, heart disease is the leading cause of death with 771,169 deaths, 

comprising 37 percent of the total number of deaths in the United States 

for 1985 (Figure 20). The mortality cost for diseases of the heart amounts 

to $41 billion, or $53,143 per death. Likewise, neoplasms and 

cerebrovascular diseases are the second and third leading causes of 

death, representing productivity losses of $88,369 and $40,751 per death, 

respectively. Life years lost per death for the three leading causes are 

11.8 years for diseases of the heart, 15.6 years for neoplasms, and 10.9 

years for cerebrovascular diseases. By -contrast, injury is the fourth 
Economic Cost of Injury 63 

Table 16

Injury Mortality Losses by Sex and Cause, 1985

Life Years Lost Mortality Cost* 

Number of Total Per Total Per 

Cause Deaths** (thousands) Death (millions) Death 

Total

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Burns

Drowningsi

Other

Male

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Burns

Drownings?

Other

Female

Motor Vehicles

Falls

Firearms

Poisonings

Fires/Bums

Other

155,665 5,285 34.0 $47,888 $307,636 

52,375 1,952 37.3 17,328 330,843 

16,470 436 26.5 1,541 93,554 

32,586 1,162 35.7 12,080 370,706 

11,894 275 23.1 4,394 369,402 

5,710 258 45.2 1,364 238,841 

6,287 206 32.8 2,268 360,707 

30340 995 32.8 8,914 293,817 

111,867 3,827 34.2 39,045 349,030 

36,836 1,362 37.0 13,652 370,618 

9,136 280 30.6 1,261 138,042 

27,289 945 34.6 10,491 384,424 

7,621 218 28.6 3,265 428,358 

3,477 170 48.9 955 274,804 

5,067 120 23.7 1,986 391,884 

22,439 733 32.7 7,435 331,363 

43,798 1,458 33.3 8,843 201,910 

15,539 590 38.0 3,676 236,553 

7,334 156 21.3 280 38,136 

5,297 217 41.0 1,589 300,035 

4,273 57 13.3 1,129 264,252 

2,233 88 39.4 408 182,844 

1,220 86 70.5 282 231,220 

7,901 262 33.2 1,479 187,187 

Discounted at 6 percent

Includes 13,097 deaths in later years due to injuries sustained in

1985

Includes Near Drownings
64 Cost of Injury in the United States 

Figure 19 

Injury Mortality Losses by Cause, 1985 

Number of Deaths 

155,665 

Life Years Lost 

5.3 Million 

37% 

� Motor Vehicles 

� Firearms 

25% � Fires/Burns 

� Drownings 

� Other 
Economic Cost of Injury 65 

Table 37 

Mortality Losses Due to All Causes and Due to Injury 

by Age and Sex, 1985 

All Deaths Injury Deaths* 

Life Years Lost Mortality Cost** Life Years Lost Mortality Cost** 

Age Number Total Total Number Total Total 

and of (thou- Per mill- Per of (thou- Per (mill- Per 

Sex Deaths sands) Death ions) Death Deaths sands) Death ions) Death 

Total 2,085,563 33,253 15.9 $183,643 $88,054 142,568 5,126 36.0 $47,739 $334,849 

0-4 47,369 3,501 73.9 9,366 197,724 4,363 318 72.9 931 213,428 

5-14 8,933 583 65.3 2,817 315,388 4,962 321 64.7 1,595 321,405 

15-24 37,935 2,065 54.4 18,438 486,047 29,412 1,593 54.2 14,422 490,344 

25-44 117,667 4,772 40.6 56,475 479,953 47,824 2,005 41.9 24,377 509,728 

45-64 403,114 8,843 21.9 73,115 181,376 25,601 601 23.5 5,878 229,607 

65+ 1,470,545 13,490 9.2 23,431 15,934 30,406 288 9.5 535 17,605 

Male 1,097,267 18,044 16.4 124,134 113,130 102,804 3,710 36.1 38,921 378590 

0-4 27,199 1,930 71.0 5,791 212,917 2,570 

5-14 5,485 343 62.5 1,859 338,988 3,357 

15-24 28,162 1,483 52.7 14,454 513,238 23,095 

80,848 3,150 39.0 42,921 530,880 37,612 

45-64 251,031 5,067 20.2 49,108 195,626 18,693 

65+ 704,542 6,071 8.6 10,001 14,194 17,477 

Female 988,296 15,209 1 5.4 59,509 60,214 39,764 1,417 35.6 8,818 221,762 

180 70.0 590 229,721 

209 62.3 1,148 341,930 

1,216 52.7 11,852 513,205 

1,533 40.8 20,453 543,787 

415 22.2 4,604 246,292 

156 8.9 273 15,619 

O-4 20,170 1,570 77.9 3575 177,236 1,793 

5-14 3,448 240 69.7 958 277,846 1,605 

15-24 9,773 582 595 3,984 407,692 6,317 

36,819 1,623 44.1 13, 554 368,125 10,212 

45-64 152,083 3,776 24.8 24,007 157,856 6,908 

65+ 766,003 7,418 9.7 13,431 17,534 12,929 

138 77.0 341 190,074 

112 69.6 447 278,474 

377 59.6 2,570 406,763 

472 46.2 3,924 384,286 

186 26.9 1,274 184,457 

132 10.2 262 20,289 

* Excludes 13,097 deaths in later years due to injuries sustained in 1985 

** Discounted at 6 percent 

leading cause of death, accounting for less than 7 percent of total deaths. 

But deaths from this cause represent 36 life years lost per death and a 

productivity loss of $334,851 per death. Injury fatalities involve younger 

people than those dying from other causes and result in higher 

productivity losses. 

Mortality Losses and Research Expenditures 

The economic burden of illness can be used to target programs and 

to set priorities when the costs of various illnesses are available for 

comparative purposes. However, there are almost no current lifetime 
66 Cost of Injury in the United States 

cost data available for other illnesses with which to compare the total 

costs developed in this report. Nevertheless, valid comparisons can be 

made on the basis of cost and life years lost for deaths occurring in 1985 

from various illnesses. 

Injury in America (Committee on Trauma Research, 1985) compares 

federal support for nonmilitary injury-related research with expenditures 

Table 18 

Mortality Losses Due to the Leading Causes of Death 

by Sex and Cause, 1985 

Life Years Lost Mortality Cost* 

Number of Total Per Total Per 

Cause Deaths (thousands) Death (millions) Death 

Total 2,085,563 

Diseases of the Heart 771,169 

Neoplasms 461,563 

Cerebrovascular Diseases 153,050 

Injuries** 142,568 

All Other 557,213 

Male 1,097,267 

Diseases of the Heart 398,208 

Neoplasms 246,914 

Cerebrovascular Diseases 60,780 

Injuries** 102,804 

All Other 288,561 

Female 988,296 

Diseases of the Heart 372,961 

Neoplasms 214,649 

Cerebrovascular Diseases 92,270 

Injuries** 39,764 

All Other 268,652 

33,253 15.9 $183,643 $88,054 

9,094 11.8 40,982 53,143 

7,210 15.6 40,786 88,365 

1,664 10.9 6,237 40,751 

5,126 36.0 47,739 334,851 

10,158 18.2 47,899 85,962 

18,044 16.4 124,134 113,130 

4,874 12.2 28,480 71,520 

3,467 14.0 22,565 91,388 

655 10.8 3,255 53,554 

3,710 36.1 38,921 378,594 

5,338 18.5 30,913 107,128 

15,209 15.4 59,509 60,214 

4,220 11.3 12,502 33,521 

3,743 17.4 18,221 84,887 

1,009 10.9 2,982 32,318 

1,417 35.6 8,818 221,758 

4,820 17.9 16,986 63,227 

* Discounted at 6 percent 

** Excludes 13,097 deaths in later years due to injuries incurred in 1985 
Economic Cost of Injury 67 

Figure 20 

Mortality Losses Due to Leading Causes of Death, 1985 

Number of Deaths 

.1 Million 

Years Lost 

33 Million 

7% 

ortality Cost 

$184 billion 

22% 

� Diseases of Heart 

 Neoplasms 

Cerebrovascular 

� Injuries 

A All Other 
68 Cost of Injury in the United States 

for research on neopla sms and cardiovascular diseases in 1983. The 

Committee undertook a careful and systematic review of research 

expenditures in federal agencies. The survey of federal agencies was 

based on reports of projects from the agencies and computerized indexes 

of research expenditures. The total federal expenditure for research on 

injury was approximately $112 million in fiscal year (FY) 1983. This total 

was then compared with the budgets of the National Cancer Institute 

and the National Heart, Lung and Blood Institute. In addition, data were 

presented for the years of life lost to age 65 for deaths in a year due to 

injury, cancer, and cardiovascular diseases (heart disease and stroke). 

The investigators conclude in Injury in America that support for 

research on injury prevention and control is relatively small, comprising 

about one-tenth of the expenditures for cancer research and less than 

one-fifth of cardiovascular disease research expenditures. I n terms of life 

years lost prior to age 65, however, injury accounts for 4.1 million years 

of life lost compared with 1.7 million years for cancer and 2.1 million 

years for cardiovascular diseases. The conclusion is that the smallest 

portion of research funding is being allocated to a most costly public 

health problem -- injury. 

The present study provides lifetime cost as another dimension for 

comparing the magnitude of leading health problems with the level of 

research investment for each. A rough approximation of expenditures 

for injury-related research in FY 1987 is $160 million. This estimate is 

based on the research expenditure data presented for each federal agency 

in Injury in America. These expenditures are inflated on the basis of the 

percent increase in the total research amounts for each agency reported 

from FY 1983 to FY 1987, as reported in the Budget of the United States 

Government: Appendix (U.S. Office of Management and Budget, 1986; 

1989) and in the NIH Basic Data Book (U.S. National Institutes of Health, 

1988). Budget obligations in FY 1987 amounted to $1.4 billion for the 

National Cancer Institute (NCI) and $930 million for the National Heart, 

Lung and Blood Institute (NHLB). 

Figure 21 compares the estimated FY 1987 research expenditures per 

life year lost with the mortality losses for 1985 expressed in total life 

years lost per death and lifetime cost per death. Injury research 

expenditures amount to 11 percent of the NC1 budget obligation and 17 

percent of the NHLB obligation. Life years lost per injury death (36 

years) are, however, more than twice the number lost to cancer (16 years) 

and three times the number lost to cardiovascular diseases (12 years). 

Mortality cost per injury death ($335,000) is almost four times the cost for 

cancer ($88,000) and more than six times the cardiovascular disease cost 

($51,000). It is apparent that injury, the largest public health problem, is 

receiving a disproportionately small share of research funding. 
Economic Cost of Injury 69 

Figure 21 

Federal Research Investment and Productivity Losses by Cause of 

Death 

300 

Research Expenditures 

Per Life Year Lost 

Life Years Lost Per Death 

EZI 

Injuries 

Cancer 

Cardiovascular 

Diseases 

Lifetime Cost Per Death 
�

70 Cost of Injury in the United States 

Economic and Measurement Concepts 

The research on the cost of injury in the United States on which this 

report is based develops a measure of the economic burden of injury. 

The estimates represent the monetary burden on society of injury-related 

illness and premature death. This study builds on and extends the 

analysis on the economic cost of illness begun by Dorothy Rice in 1965 

(Rice, 1965; 1966; 1967; Rice and Cooper, 1967; Cooper and Rice, 1976; 

Rice and Hodgson, 1981; Rice, Hodgson and Kopstein, 1985; Rice, 

Hodgson, Sinsheimer, Brower, and Kopstein, 1986; and Scitovsky and 

Rice, 1987). 

Cost-of-illness studies are typically divided into two components. 

The direct cost is the actual dollar expenditure related to the illness. The 

indirect cost represents the value of lost output due to reduced 

productivity caused by illness and disability and losses due to premature 

death. 

Human Capital and Willingness-to-Pay Approaches 

Two approaches are used for valuing the forgone productivity, or 

indirect cost, of illness. The human capital approach, developed by Rice, 

is the most commonly used method. In this approach, an individual is 

seen as producing over time a stream of output valued at market 

earnings or by the imputed worth of housekeeping services. The human 

capital concept assumes a social perspective and has the important 

advantage of employing data that are reliable and readily available. This 

approach is useful for answering questions regarding the economic 

burden of a disease for a specific time period (e.g., the cost of injury for 

1985) or for determining the savings of a specific procedure or 

intervention program that will reduce illness and/or improve survival 

rates. 

The human capital approach also has some drawbacks. Because its 

valuation of human life is based on market earnings, it yields very low 

values for children and retired elderly persons. Many injury victims fall 

into these categories. The human capital approach also undervalues life 

if labor market imperfections exist and wages do not reflect true abilities. 

For example, women and minorities are often paid wages that are lower 

than the value of what they produce. Certain dimensions of illness and 

death, such as pain, suffering, and reduced quality of life, are also 

ignored. 

The willingness-to-pay approach is often described as an alternative 

methodology for valuing human life. In reality, it is a conceptually 

different approach that captures other aspects of the value of life and is 

therefore useful for different purposes (Rice and Hodgson, 1982). The 

willingness-to-pay method values human life according to the amount 
Economic cost of Injury 71 

individuals are willing to pay for a change that reduces the probability of 

illness or death Shelling, 1968; Acton, 1975). This approach assumes an 

individual perspective and incorporates all aspects of well-being, 

including labor and non-labor income, and the value of leisure, pain, and 

suffering. The overriding objection to the willingness-to-pay method is 

that it requires substantial development prior to implementation, thereby 

limiting efforts to apply it. 

The present report presents a range of cost estimates using both 

approaches. The human capital approach is employed in this chapter 

and is the basis for estimating the total lifetime cost of injury. The 

willingness-to-pay approach is used in Chapter 4. Both approaches are 

employed in Chapter 5 to estimate the cost and savings of preventive 

interventions. 

Prevalence and Incidence Approaches 

Two approaches can be used to estimate the cost of illness and 

injury by the human capital method. Prevalence-based cost provides an

estimate of the direct and indirect economic burden incurred in a period 

of time (the base period) as a result of the prevalence of injury during 

this same base period, most often a year. Included is the cost of baseyear manifestations of illness or associated disability with onset in the 

base year or at any time prior to the base year. Prevalence cost measures 

the value of resources used or lost during a specified period of time, 

regardless of the time of onset of the illness or injury. 

Incidence cost represents the lifetime cost resulting from the illness. 

In the aggregate, incidence cost in a given base year refers to the total 

lifetime cost of all cases with onset of disease in the base year. The 

incidence cost is difficult to estimate because it requires knowledge of the 

likely course of an illness and its duration, including survival rates since 

onset; the amount and cost of medical care to be used during the 

duration of the illness; and the impact of the illness on lifetime 

employment, housekeeping, and earnings (Hodgson, 1983; Scitovsky, 

1982). 

Relatively few incidence-based studies exist, but the current state of 

the art is illustrated by Smart and Sanders (1976), who estimated the cost 

of spinal cord injuries caused by motor vehicle crashes in 1974; 

Hartunian, Smart, and Thompson (1981),who estimated the costs of 

cancer, coronary heart disease, stroke, and motor vehicle injuries; 

investigators at Policy Analysis, Inc. (1981), who examined the costs of 

breast cancer, diabetes mellitus, rheumatoid arthritis, stroke, and acute 

lymphocytic leukemia; and Oster, Colditz, and Kelly (1984), who 

estimated the cost of smoking and the benefits of quitting. The present 
72 Cost of Injury in the United States 

study develops estimates of the lifetime, or incidence-based, cost of 

injury. 

Data Sources 

Five national databases used extensively in the cost analysis are 

briefly described in the Glossary. The National Health Interview Survey 

(NHIS) provides estimates of service utilization and days of restricted 

activity for nonhospitalized injuries. The NHIS is not used to derive 

estimates for hospitalized injuries because the sample is too small. The 

National Hospital Discharge Survey (NHDS) is used to develop 

estimates of mean length of initial hospital stay. The data sources for 

incidence analysis are described in Chapter 1. 

The National Medical Care Utilization and Expenditure Survey 

(NMCUES) is used to estimate unit costs or charges for emergency room 

and physician visits, prescriptions, other medical expenses, outpatient 

physical therapy visits, and ambulance services. This survey was 

conducted in 1980, and includes data on health conditions, service 

utilization, and charges for 10,000 households. Costs are updated to 1985 

using the consumer price index (CPI). That is, the ‘prescription drug’ 

component of the CPI was used to update the prescription costs, the 

‘physicians’ services’ component to update physician visit costs, and the 

‘medical care services’ component to update other costs. 

The National Council on Compensation Insurance (NCCI) Detailed 

Claim Information database provides data on over 500,000 Workers’ 

Compensation injury cases followed for up to 7 years between 1979 and 

1986. This database is used to develop estimates of later year medical 

costs. 

The National Nursing Home Survey (NNHS) provides the basis for 

the estimates of nursing home costs and forgone productivity for this 

institutionalized population. The survey was conducted in 1985 and 

includes data on medical conditions, expenses, and length of stay for 

residents of over 1,000 nursing homes nationwide. 

A study by MacKenzie, Shapiro, and Siegel (1988) is used to obtain 

data on rehospitalization and service utilization for hospitalized injuries 

because there is no reliable national data source. This study followed 500 

Maryland trauma patients for one year and includes data on rates of 

service utilization and costs by nature of injury and severity. 

Cost Estimation Methods 

Costs are estimated for three classes of injury: fatalities, hospitalized 

injuries, and nonhospitalized injuries. The cost estimation methods for 

each class of injury are described by type of cost. Charges are used as a 

surrogate for resource costs. This approach is commonly employed in 
Economic Cost of Injury 73 

the cost-of-illness literature. However, due to market imperfections in 

the health care sector, charges may not accurately reflect costs. 

Fatalities 

The cost of fatal injury consists of direct cost and mortality cost. 

Costs are derived separately for fatalities at the scene of the injury, in the 

emergency room, and in the hospital. All injury fatalities are included in 

this category and not in the hospitalized and nonhospitalized categories. 

Direct Cost 

For purposes of calculating the direct cost associated with injury 

fatality, injuries are divided into three groups according to where the 

death occurred. Based on the distribution of trauma deaths in Maryland 

for 1986, 50 percent of deaths are assumed to occur at the scene of the 

injury, 29 percent in the emergency room, and 21 percent after admission 

to the hospital. This distribution is virtually identical to that reported by 

Trunkey (1983) of 50 percent, 30 percent, and 20 percent, respectively. 

The advantage of using the Maryland distribution is that separate 

distributions are available for motor vehicle injuries, fires, falls, firearm 

injuries, and other injuries. Drownings and poisonings are assumed to 

follow the overall distribution. 

Death at the Scene. An ambulance is assumed to be sent to the 

scene of each fatality. The one-way charge for ambulance services for 

nonhospitalized injuries from the National Medical Care Utilization and 

Expenditures Survey (NMCUES) is used. 

Death in the Emergency Room. All victims who die in the 

emergency room are assumed to arrive by ambulance. The NMCUES 

one-way ambulance charge for hospitalized injury is used. These 

persons also incur emergency room charges; an average charge per 

person is derived from Champion, Gainer, and Yackee (1986). 

Death in the Hospital. A distribution of the probability of 

transportation by ambulance is estimated separately for burns and nonburns. The burn data come from Honton, Richmond, and Stacey (1980) 

and the non-burn data from The Consumer Product Safety Commission 

(CPSC) Injury Cost Model (Technology + Economics, 1980). The oneway charge for hospitalized injuries from the NMCUES is used. 

Persons dying after admission to a hospital also incur emergency 

room, hospital, and physician charges. Emergency room charges are 

included in the hospital bill. Based on an analysis of the Maryland posttrauma recovery study, a factor of 1.25 is multiplied by the hospital 

charges to allow for physician and other professional fees (MacKenzie, 
74 Cost of Injury in the United States 

1988). The hospital charges are estimated by taking the mean cost per 

death from Maryland (distributed by age and cause), adjusting by a 

factor of .9572 to reflect the ratio of United States per diem charges to 

Maryland charges, and applying this cost per death to the number of 

deaths occurring nationally. 

rel 

Insurance Administration Cost. Several types of insurance are 

evant to the cost of injury. . Estimates are for auto insurance and health 

insurance. Insufficient data are available to estimate the costs of workers’ 

compensation or product liability insurance. The relevant costs for this 

study are the overhead and administrative costs. Settlements are 

excluded because they are transfer payments used to cover the medical 

and other costs already estimated. Transfer payments are discussed in 

Chapter 3. 

Blincoe (U.S. NHTSA, 1983; 1987) estimates the total cost of 

insurance administration for fatal motor vehicle injuries for 1985. This 

total is distributed by age and sex according to incidence. The 

methodology developed by the National Highway Traffic Safety 

Administration (U.S. NHTSA, 1983), is used to estimate health insurance 

administration costs as follows. In 1985,30.4 percent of personal health 

care expenditures were paid for by private insurance (U.S. HCFA, 1987). 

Insurance overhead was 13.1 percent of total premiums. Hence, the 

health insurance administration cost is estimated to be .304 times .131, or 

4.0 percent of the injury medical care cost. 

Mortality Cost 

The mortality cost, or the value of forgone productivity due to early 

death, is also estimated. In addition to the deaths that occurred in 1985, a 

number of individuals experienced shortened life expectancies, dying at 

an earlier age than they would have in the absence of injury. This is 

referred to as ‘late mortality.’ 

Mortality cost is the value of lost productivity resulting from injury, 

calculated as the product of injury-caused deaths and the present value 

of future earnings lost. The estimate of lifetime earnings takes into 

account varying labor force participation rates. The assumption is that 

people will be working and productive during their expected lifetime in 

accordance with the current pattern of work experience for their sex and 

age group. For this calculation, the percent of the population with 

earnings in 1985 published by the U.S. Bureau of the Census (1987a) is 

used. For injured persons with lower than average earnings, the 

mortality cost may be somewhat overestimated. 

Output losses are based on annual mean earnings by age and sex, 

adjusted for wage supplements such as employer contributions for social 

insurance, private pensions, and welfare funds. Cross-sectional profiles 
Economic Cost of Injury 75 

of mean earnings by age and sex are employed to estimate lifetime 

earnings. In applying these data, the future pattern of earnings of an 

average individual within a sex group is assumed to follow the pattern 

reported by the Bureau of the Census during a base year. This model 

recognizes that average individuals may expect their earnings to rise 

with age and experience in accordance with the cross-sectional data for 

the base year. Appendix B presents the formulas for estimating direct, 

morbidity, and mortality costs. 

Estimates based on marketplace earnings undervalue losses due to 

injuries sustained by individuals not in the paid labor force. The value of 

household work, therefore, must be added to earnings. Estimates of the 

value of household services are obtained by updating the regressionbased estimates of Feskin (1984). Her methodology involves calculating 

the mean time inputs for men and women who keep house and valuing 

the contributions by specific tasks performed with the prevailing wage 

rate for performance of similar tasks. The data for 1985 are analyzed in a 

regression framework so that controls for socioeconomic and 

demographic factors can be made. Data on family structure, education, 

income, and race are substituted into the regression equation developed 

by Peskin to estimate hours spent on household labor. The estimated 

hours are valued on the basis of 1985 wage rates by activity. 

Future changes in productivity of wage earners also need to be 

taken into account. Based on average changes in hourly earnings 

between 1980 and 1986, a one percent annual increase in productivity is 

assumed (U.S. Bureau of the Census, 1987b). Life expectancy, labor force 

participation rates, and average annual earnings are shown in Appendix 

Tables C-17 and C-18. The present value of lifetime earnings discounted 

at 4 and 6 percent are shown in Appendix Table C-19 and Appendix 

Figure C-l. 

For late mortality, shortened life expectancy is assumed to affect two 

types of injury: severe spinal cord injury (AIS 4 and 5) and severe head 

injury (AIS 5). Life expectancies are taken from DeVivo, Fine, Maetz, and 

Stover (1980). For spinal cord injury, an average of the life expectancy 

for paraplegia (incomplete and complete) and quadriplegia (incomplete 

and complete) is applied to all AIS 4 and 5 spinal cord injuries. 

Following Hartunian and associates (1981), the life expectancy for 

incomplete paraplegia is used for head injuries of AIS 5. The late 

mortality cost is calculated as the reduced value of discounted lifetime 

earnings due to life years lost in the future. 
�

76 Cost of Injury in the United States 

Hospitalized Injury 

The cost of hospitalized injury consists of direct cost and morbidity 

cost. Injured persons who die in the hospital are not counted in this 

category. 

Direct Cost 

The direct cost of hospitalized injury is estimated by applying 

service utilization rates obtained from various sources to the number of 

injured hospitalized persons from the National Hospital Discharge 

Survey (NHDS). Charges are derived from a number of sources. The 

resulting first year cost is the basis for estimating the lifetime cost with 

an adjustment factor obtained from the NCCI database. Finally, costs are 

distributed into cause categories based on the incidence of injuries. 

Initial Hospitalization. Charges for the initial acute care 

hospitalization are estimated using the following procedure. First, 

NHDS data are used to determine the mean length of stay within 

subgroups of the population defined by three age groups (O-14, 15-64, 

and 65+) and 24 groups defining the nature and severity of the injury 

(Table 4). These means are multiplied by the corresponding average per 

diem charges reported by all acute care hospitals in Maryland for 1984, 

1985, and 1986. These estimates are deflated by a factor of .9572, the ratio 

of the United States average per diem hospital charge to the Maryland 

average per diem hospital charge based on the 1985 Annual Survey of 

the American Hospital Association (AHA, 1986). The resulting estimates 

of hospital charges are inflated by 25 percent to account for professional 

fees (MacKenzie, 1988). Maryland per diem charges are used because 

they are computerized for all acute care discharges and because hospital 

charges are regulated by the state Health Services Cost Review 

Commission and have a known relationship to costs. All third-party 

payers pay full charges less a small discount for timely payment. 

Physician Visits. The number of physician visits out of the hospital 

during the first year for all types of injury (by body region and severity 

of principal injury) is from MacKenzie and associates (1988). For each 

type of injury, the number of injured persons is multiplied by the percent 

with physician visits times the mean number of visits to obtain the total 

number of visits. A per visit charge is applied from the NMCUES, based 

on a mean of charges for office, outpatient, and other visits. 

Prescription Drugs and ‘Other’ Items. Charges for prescription 

drugs and ‘other’ items are developed by applying the average charge 
Economic cost of Injury 77 

per person from the NMCUES to the number of injured hospitalized 

persons from the NHDS. 

Rehospitalization for Medical/Surgical, Mental/Emotional, or 

Rehabilitation Needs. The costs of rehospitalization for these three 

(mutually exclusive) purposes are based on rehospitalization rates from 

MacKenzie and associates (1988). For each category of cost, the number 

of injured hospitalized persons is multiplied by the percent 

rehospitalized times the average length of stay. This total is applied to 

all types of injury except burns. For burns, medical / surgical 

rehospitalization is based on an 8 percent readmission rate with a 6-day 

average length of stay in a typical burn unit. The daily charge used for 

medical/surgical rehospitalizations is the national average charge (AHA, 

1987) increased by 25 percent to allow for professional and physician fees 

(MacKenzie, 1988). The per diem charge applied to rehospitalization for 

rehabilitation is the mean daily rehabilitation charge reported by the 

National Association of Rehabilitation Facilities (Coopers & Lybrand, 

1985). This charge is not adjusted upward because professional and 

physician fees are typically included in the per diem charge for 

rehabilitation facilities. The daily charge used for mental/emotional 

rehospitalization is the rate reported for nonfederal psychiatric hospitals 

by the AHA (1987) inflated to account for professional and physician 

fees. 

Outpatient Physical Therapy. The number of visits for outpatient 

physical therapy is from MacKenzie and associates (1988). The number 

of injured hospitalized persons is multiplied by the percent with physical 

therapist visits times the mean number of visits per person. The charge 

per visit used is the charge for ‘other visits’ from the NMCUES. 

Ambulance. The distribution of the probability that a person would 

be transported by ambulance is discussed above under fatalities. For 

persons transported, the average charge from the NMCUES is used. 

Helicopter Transport. In 1985,61,500 patients were transported by 

helicopter, 43 percent of them for trauma (Hospital Aviation, 1988). The 

mean cost per trip nationally is reported by Collett (1988). All of the 

resulting costs are assumed to be for patients who were hospitalized, and 

it is assumed that 95 percent of them are for motor vehicle injury victims 

and 5 percent for bum victims. 

Later Year Medical Cost. An analysis of NCCI claims data reveals 

that the percent of lifetime cost incurred in the first year (assumed to be 

the 6-month and 18-month reporting periods) is distributed as follows: 

head injury, 80 percent; spinal cord injury, 78 percent; extremity injury, 

88 percent; abdominal/thoracic injury, 91 percent; and other injuries, 87 
78 Cost of Injury in the United States 

percent. These percentages are used to derive a total lifetime medical 

cost estimate for hospitalized injury. 

Attendant Care. The only available estimate for attendant care is 

for spinal cord injury victims (Miller, Luchter, and Brinkman, 1988). A 

weighted average of the discounted per person lifetime cost for AIS 4 

and 5 victims is developed and applied to the number of spinal cord 

injury AIS 4 and 5 cases from the NHDS. 

Vocational Rehabilitation .. Seventy-nine percent of the total 

vocational rehabilitation cost for 1985 in the NCCI database is due to 

hospitalized injuries. Fifty-seven percent of the total discounted 

rehabilitation cost for hospitalized injury occurs during the first year. 

Therefore, the first year estimate is multiplied by 1.76 (l/.57) to obtain 

the total lifetime vocational rehabilitation cost. Costs are distributed by 

age, sex, and cause according to incidence numbers. 

Insurance Administration Cost. The estimate of auto insurance 

administration cost is taken from Blincoe (U.S. NHTSA, 1983; 1987) and 

distributed by age and sex according to incidence. The methodology 

used to estimate the cost of health insurance overhead is discussed 

above. 

Morbidity Cost 

Morbidity cost consists of forgone productivity due to injury. First 

year morbidity losses are estimated separately from lifetime losses. 

Forgone earnings per person are estimated for an individual of a given 

age and sex with an injury of a specific type and severity and multiplied 

by the number of injured hospitalized persons to obtain the total cost 

estimate. 

First Year Cost. The approach used to estimate lost earnings (both 

market and imputed housekeeping services) during the first year after an 

injury is to estimate the earnings of the injured person and subtract it 

from the earnings of a healthy individual of the same age and sex. 

MacKenzie, Shapiro, Smith, Siegel, Moody, and Pitt (1987) report the 

percent of previously working individuals who are working full-time at 

12 months after the injury for all types of injury (by body region and 

severity). This percent is used to estimate post-injury earnings. 

An additional adjustment is made to allow for the individuals who 

work part-time after an injury, assuming part-time to be 20 hours per 

week, adjusted as follows. According to the 1978 Survey of Disability 

and Work, 34 percent of the total disabled population works full-time, 24 

percent works part-time, and 42 percent is unemployed (Lando, Cutler, 
Economic Cost of Injury 79 

and Gamber, 1982). Hence, it is assumed that of the injured individuals 

who are not working full-time, 57 percent is working part-time. 

According to data from the U.S. Bureau of the Census (1987b), 

disabled persons earn 91 percent as much as their healthy counterparts 

after controlling for percent of time worked. This percentage is used to 

estimate the first year cost. 

Lifetime Earnings Losses. In addition to persons who are unable to 

perform their usual duties during the first year after an injury, a number 

of individuals suffer permanent disability. It is assumed that such losses 

would apply to all individuals suffering head injuries and other types of 

severe injury. For each type of injury, the percent of persons working at 

four years after an injury is taken to be the percent working thereafter. 

Data on the percent of injured persons working at four years after 

an injury for all types of head injury (AIS 1 to 5) and severe extremity 

injury (AIS 3 and 4) are from MacKenzie and associates (1987). For 

spinal cord injury (AIS 4 and 5), reemployment rates are from DeVivo, 

Rutt, Stover, and Fine (1987). It is assumed that the employment 

experience of persons with severe abdominal/thoracic injury (AIS 4 and 

5) and severe ‘other’ injuries (AIS 3,4, and 5) would be similar to that of 

persons with incomplete paraplegia, obtained from El Ghatit and 

Hanson (1978). 

After reemployment rates are obtained, the procedure is similar to 

that used to calculate first year losses (i.e., lifetime earnings of the injured 

person are subtracted from those of a healthy individual of the same age 

and sex). An additional adjustment is made to allow for the reduced life 

expectancy of persons with severe spinal cord and head injuries. For 

these injuries, the reduction in expected life earnings calculated as ‘late 

mortality’ is subtracted from expected lifetime earnings. 

Nonhospitalized Injury 

The cost of nonhospitalized injury consists of direct cost and 

morbidity cost. Injured persons who die without being hospitalized are 

not counted in this category. 

Direct Cost 

The direct cost of nonhospitalized injury is estimated in three steps. 

First, first year cost estimates use NHIS utilization data and NMCUES 

cost data. Second, lifetime cost is estimated based on the percentage of 

cost incurred in later years from the NCCI data. Finally, costs are 

distributed by cause of injury using the age and sex distribution of 

injuries, relating nature of injury to cause of injury. In some cases, cost 

can be estimated directly by cause. 
80 Cost of Injury in the United States 

Emergency Room Visits and Physician Visits. The number of 

visits to physicians in emergency rooms and in all other settings is from 

the NHIS by nature of injury, age, and sex. The charge per visit comes 

from the NMCUES. For physician visits, the charge is the weighted 

average (weighted by the number of survey respondents) of visits in the 

outpatient department, physician’s office, and ‘other visits.’ 

Prescription Drugs and ‘Other Items.’ Charges for prescription 

drugs and ‘other’ items are estimated by applying the average charge per 

person for a given nature of injury from the NMCUES to the number of 

injured nonhospitalized persons from the NHIS. ‘Other’ expenses 

include crutches, hearing aids, orthopedic appliances, and eyeglasses. 

Ambulance. The probability of ambulance transport is assumed to 

be the same for hospital fatalities and live discharges. The development 

of this distribution is discussed above. For persons transported, a 

NMCUES average one-way charge for nonhospitalized injuries is used. 

Later Year Medical Cost. An analysis of the NCCI 1988 database is 

used to calculate medical cost in later years: Approximately 92 percent 

of the total discounted lifetime cost for nonhospitalized persons is 

incurred during the first year (assumed to be the 6-month and 18-month 

reporting periods). Therefore, first year cost is inflated by a factor of .09 

(l/.92) to arrive at the total lifetime cost for nonhospitalized injury. 

Vocational Rehabilitation. The total vocational rehabilitation 

expenditure for 1985 is estimated from an analysis of national data 

obtained from the Rehabilitation Services Administration. The total is 

distributed according to expenditures for nonhospitalized and 

hospitalized persons using the breakdown of expenditures reported in 

the NCCI data base, in which 21 percent of expenditures are for 

nonhospitalized and 79 percent for hospitalized persons. The 

rehabilitation cost for later years is obtained by multiplying first year 

costs by a factor of 1.43 (l/.70) to reflect the fact that 70 percent of the 

cost for nonhospitalized persons in the NCCI database is incurred during 

the first year. Costs are distributed by age, sex, and cause according to 

the distribution of injuries. 

Insurance Administration Cost. Auto insurance overhead cost is 

taken from Blincoe (U.S. NHTSA, 1983; 1987) and distributed by age and 

sex according to incidence. The methodology used to estimate the cost of 

health insurance overhead is discussed above. 

Morbidity Cost 

The morbidity cost of nonhospitalized injury consists of forgone 

productivity due to days lost from usual activity due to injury. Days of 

-. 
Economic Cost of Injury 82 

restricted activity are calculated from the NHIS for three groups of 

individuals: employed persons, persons keeping house, and persons 

attending school or involved in some other activity. For employed 

persons, work-loss days are multiplied by average daily earnings 

(consisting of both marketplace earnings and the imputed value of 

housekeeping services for persons in the labor force) for a healthy person 

of the same age and sex. For persons keeping house, days of restricted 

activity are multiplied by the average daily value of imputed 

housekeeping services for a healthy person of the same age and sex who 

is not in the labor force. For other people, an average of marketplace and 

housekeeping services is weighted by the labor force participation rate. 

This average daily value is multiplied by days of restricted activity. The 

assumption is that all indirect costs occur in the first year. 

Injury Resulting in Nursing Home Admission 

Injury resulting in nursing home admission is not considered a 

separate class of injury because such injuries are included in hospitalized 

or nonhospitalized injury estimates. Since 34.2 percent of residents are 

admitted from hospitals, this percentage of the cost of injury resulting in 

nursing home admissions is added to the cost of hospitalized injury. The 

remaining 65.8 percent of the cost is added to the cost of nonhospitalized 

injury. 

Direct Cost.. Nursing home cost is calculated as follows. The 

number of nursing home admissions for 1985 in which the admitting 

diagnosis was an injury was obtained from the 1985 National Nursing 

Home Survey. The distribution by average length of stay was also 

obtained. The number of admissions times length of stay is multiplied 

by the national average annual charge to obtain total charges. Later year 

charges are adjusted to reflect an 8 percent average increase in cost and a 

6 percent discount rate. Based on limitations of available data, these 

costs are distributed by cause by assuming that all fractures result from 

falls, and that the distribution of the remaining injuries would follow the 

distribution of injuries in the general population aged 65 and over. Costs 

are distributed by age and sex according to the published distribution of 

injury admissions (U.S. NCHS, 1989b). 

Morbidity Cost. Morbidity cost is obtained by multiplying length 

of stay in a nursing home times average annual earnings for a healthy 

individual of the same age and sex. 

Data Limitations 

The cost estimates presented in this report employ the best data 

available for developing national estimates. An effort is made to rely on 
82 Cost of Injury in the United States 

national data sources to the extent possible. Many estimates exist for 

specific types of injury or cost elements based on small samples or single 

locations. These are not used when the data are considered to be 

nonrepresentative, or when alternative information can be obtained at 

the national level. Nonetheless, several qualifications are in order. 

Several known costs are excluded because data are unavailable. No 

attempt is made to value the services of family members and friends who 

care for the injured. This ‘informal care’ cost is likely to be significant, as 

illustrated by the case studies, but there are no reliable data from which 

to make estimates. The insurance administration cost associated with 

workers’ compensation and product liability is a cost of injury. 

However, no national data exist from which to develop estimates. Some 

nonhospitalized injuries probably result in morbidity beyond the first 

year. But again, data are lacking. There are no national estimates of 

attendant care for the non-spinal cord injured. Severely injured persons 

may be institutionalized in residential or intermediate care facilities, but 

it is not possible to capture this cost. Legal costs and property damage 

costs are excluded because the focus of this report is the injury as 

opposed to the event causing the injury. In addition, legal and property 

damage costs are not available for all causes of injury. 

Some of the cost estimates are likely to be lower than they should 

be, again due to data limitations. For example, some studies find the 

lifetime cost of a severe head injury to be several million dollars. A few 

cost studies estimate the cost per person in excess of the estimates in this 

report. The reason for the difference is that anecdotal studies and results 

not documented at the national level are not used herein. Additionally, 

the care received by injured persons often may not be the state-of-the-art 

care that could ideally be received. The estimates are therefore 

conservative and do not reflect all that the nation should be spending on 

the care of injured persons. 

Certain cost elements are accurately estimated as a whole, but many 

assumptions are necessary for the age, sex, and cause distributions. The 

total national expenditure for vocational rehabilitation is known, for 

example, but the age-, sex-, and cause-specific breakdowns are not 

readily available. Similarly, the number of emergency helicopter 

transports is known, but detail on persons being transported is not 

available. 

The data sets employed differ significantly as to how the cost data 

can be broken down, necessitating many assumptions. For this reason, a 

breakdown of costs by AIS, nature, or intent of injury would be 

unjustified by the available data. For the reasons discussed above, the 

cost estimates presented in this report can be interpreted as a lower limit 

of the true cost of injury. As better data become available, the approach 
Economic Cost of Injury 83 

used herein can be refined and improved. However, these estimates are 

based on the best data available at the present time. 

Conclusion 

The economic cost of injury, as presented in this chapter, is 

enormous. It imposes a $158 billion burden on the U.S. economy, 

representing the aggregate lifetime cost for 57 million persons injured in 

1985. Direct expenditures for medical care (e.g., hospital care, physician 

services, drugs, appliances, and rehabilitation) and for nonmedical care 

(e.g.., home modification, vocational rehabilitation, and the 

administrative cost of automobile and health insurance) amount to $45 

billion, or 29 percent of the total cost. Morbidity for persons disabled as 

a result of injury amounts to 5 million life years lost, valued at $65 

billion, or 42 percent of the total cost. 

Premature death due to injury constitutes another large share of the 

total economic cost. Approximately 143,000 premature deaths from 

injuries occurred in 1985 and an additional 13,000 deaths occurred in 

later years due to injuries sustained in 1985. These premature injury 

deaths amount to a loss of 5.3 million life years lost, or 34 years per 

death. These losses to the economy amount to $48 billion at a 6 percent 

discount rate, or about $308,000 per death. The mortality cost accounts 

for 30 percent of the lifetime cost. 

More males than females suffer injuries and the total lifetime 

economic cost of injury for males is more that double that for females --

$108 billion compared with $50 billion. More injuries occur among 

adults aged 25-44 than in any other age group, and their lifetime costs 

are highest. More than 18 million, or 32 percent, of injured persons in 

1985 were in this age group and they accounted for 42 percent of the total 

cost. Injuries to persons aged 15-24 rank second in number and cost, 

accounting for 22 percent of the injuries and 25 percent of the total cost. 

The greatest economic losses are caused by motor vehicles and falls, 

accounting for $49 billion and $37 billion, respectively, although the total 

number of injuries due to falls is more than twice that for motor vehicles. 

However, deaths due to motor vehicles are three and one-half times the 

deaths due to falls, and a significantly large number of motor vehicle 

fatalities are among younger persons, resulting in high lifetime cost. 

Firearms rank third in economic toll and poisonings, fourth. 

The distribution of costs by class of injury reflects the severity of the 

injuries. Of the total $158 billion lifetime cost, 31 percent is for fatalities, 

51 percent for injuries involving hospitalization, and 18 percent for 

nonhospitalized injuries. 

Although cost-of-injury studies have been conducted in the past, the 

research on which the present report is based represents the first attempt 
84 Cost of Injury in the United States 

to quantify the magnitude of the national injury problem in economic 

terms by cause of injury, age, sex, and class of injury. Table 19 presents 

the cost of injury from past studies. Of the 15 prior studies, five relate to 

motor vehicle injury; two to spinal cord injury; one to unintentional 

injury; and one to trauma-related injury. Four studies encompass the 

cost of all illnesses in which injury is one of the major diagnostic 

Type 

of 

Injury 

Table 19 

Cost-of-Injury Estimates by Type of Cost 

Study Other DisPeriod Rel- count 

& Method Total Direct Indirect ated Rate Source 

All injuries* 1963 $11,811 $1,703 $10,108 - 4 Rice, 1966 

Prevalence 

All injuries* 1972 24,678 5,121 21,557 - 4 Cooper and 

PrevaIence Rice, 1976 

Motor vehicle 1974 828 249 579 - 6 Smart and 

spinal cord Incidence Sanders, 1976 

Motor vehicle 1975 32,900 1,000 16,000 15,900 7 Faigin, 1976 

Incidence 

All injuries* 1975 27,433 6,846 20,587 - 10 Berk, Paringer, 

Prevalence Mushkin, 1978 

Motor vehicle 1975 14,435 3,728 9,662 1,045 6 Hartunian 

Incidence et al., 1981 

Spinal cord 1977 2,910 516 2,394 - na Bureau of Econ. 

injuries Prevalence Research, 1985 

All injuries 1979 94,420 na na na 7 Edwards 

Prevalence et al., 1981 

Motor vehicle 1980 57,199 3,326 14,237 39,636 7 U.S. NHTSA, 

Incidence 1983 

All injuries* 1980 82,959 18,684 64,275 - 4 Rice, et al., 

Prevalence 1985 

Trauma rel- 1982 61,025 19,278 41,746 - 6 Munoz, 1984 

ated injuries Prevalence 

Unintentio- 1985 107,300 17,800 48,700 40,800 na Etter, 1987 

nal injuries Prevalence 

Accidental 1985 31,300 - 6 Miller, 

injuries Prevalence et al., 1987 

All injuries 1985 157,615 38,751 112,808 6,056 6 Rice and MacIncidence Kenzie, 1989 

Motor vehicle 1986 32,624 7,560 20,794 4,270 6 Miller and 

Incidence Luchter, 1988 

Motor vehicle 1986 74,200 5,270 16,380 52,550 7 U.S. NHTSA, 

Incidence 1983; 1987 

* These studies encompass the cost of all illnesses; the cost of injury is one of the major 

diagnostic categories reported 

Note: na = not available 
Economic Cost of Injury 85 

categories reported. One study is for all injuries, but the distribution by 

type of cost is not reported, and one reports only indirect cost. 

The table shows that estimated costs have risen over the years. 

More importantly, however, is the variation among the studies in the 

distribution of direct and indirect costs and the inclusion of other related 

costs, such as property damage. Four of the prior studies include 

estimates of other related costs that comprise from 7 to 71 percent of the 

total cost. 

In several studies of cost for the same year, the total cost varies 

substantially. Major differences among the studies result from the use of 

the incidence or prevalence approach and the use of different discount 

rates. Six of the 15 studies employ the incidence approach; the remaining 

studies use the prevalence method. Two studies do not indicate what 

discount rates are used; the other 11 studies employ discount rates 

ranging from 4 to 10 percent. Differences in cost are due to the use of 

different methodologies, estimating procedures, sources of data, and 

discount rates. 

The results of research on the lifetime cost of injury reported herein 

represent the most comprehensive and systematic effort to date to 

estimate the lifetime cost of injury disaggregated by the major causes of 

injury and by age, sex, and class of injury. Also included are the longterm costs of treatment, rehabilitation, and long-term productivity losses 

for persons injured, factors rarely quantified in earlier studies. 
Chapter 3 

Source of Payment 

The substantial economic burden placed on American society by 

injury is borne by various types of payers -- federal, state, and local 

governments; private insurance; workers’ compensation; and private 

individuals. Public sources include federal (e.g., Medicare, Medicaid, 

and the Veterans Administration), state, and local government. Private 

sources include private health, disability, and life insurance; Workers’ 

Compensation (federally administered, but almost exclusively financed 

by employers); and uninsured or uncovered care. 

Estimates of the direct medical care cost of injury borne by these 

various sources are presented as well as information on the distribution 

of related direct (nonmedical, vocational rehabilitation) costs among 

payers. In addition, estimates of the impact of injury on transfer 

payments are presented. Transfer payments are not costs per se in that 

they reflect only the transfer of funds from one payer to another rather 

than additional resource use. Insurance settlements, for example, are 

funds transferred from the insurance company to the hospital or 

individual to pay for medical services that have already been counted 

elsewhere. The impact of injury on transfer payment programs, 

however, and on the taxes and/or premiums used to finance them, can 

be substantial. Data sources and methods used in developing the 

estimates are discussed at the end of the chapter, followed by 

information on additional payment sources. 

Direct Expenditures 

Sources of payment for direct health care expenditures are analyzed 

across two dimensions, age of the injured person and treatment setting. 

Age is an important determinant of payment source. Adults are often 

covered by employment-related health insurance. The majority of 

medical care cost for persons aged 65 and over is paid by Medicare, a 

public source of payment. For children, payment source is related to 

parental financial and employment status. If a parent is in the 

workforce, employer-sponsored health insurance is usually available. 

Children of low-income or unemployed persons rely on public sources of 

payment. 

The second dimension in the analysis of source of payment is the 

type of expenditure or treatment setting. Persons who experience a 
88 Cost of Injury in the United States 

serious injury may pass through a continuum of care, including trauma 

care and inpatient hospitalization followed by outpatient visits, and 

perhaps rehabilitation. Less serious (and more common) injuries may 

involve treatment in only one setting, such as an emergency room or 

physician’s office. 

The National Medical Care Utilization and Expenditure Survey 

provides information on source of payment. This information is 

supplemented by other sources, including the National Hospital 

Discharge Survey (NHDS), the National Uniform Data System for 

Medical Rehabilitation, the National Institute of Mental Health Statistical 

Reporting System, and the National Nursing Home Survey. Direct 

lifetime costs are distributed by payer source. Data are not available on 

source of payment for ambulance and helicopter services, attendant care, 

and other expenses; these costs are therefore not distributed by payer 

source. Thus, $41.7 billion out of $44.8 billion in direct costs are 

distributed by source of payment. 

Age Patterns 

The distribution of national injury-related medical care 

expenditures by source of payment is shown in Table 20 and Figure 22; 

the distribution by age and source of payment is shown in Figure 23. 

Private sources account for 72 percent of the expense; 28 percent is borne 

by public sources. Within specific age categories, the distribution differs. 

Public sources pay for 72 percent of care for persons aged 65 and over 

through Medicare, Medicaid, and other government programs. For 

persons aged 15 to 44, on the other hand, private payments cover 86 

percent of injury-related medical care. Workers’ Compensation medical 

payments for injured persons account for one-fourth of total medical 

expenses for persons aged 15-64. 

Uninsured care comprises almost one-fourth of private payments 

for injured persons under age 45. The ‘uninsured care’ category includes 

direct out-of-pocket expenditures for copayment and uncovered services 

as well as an unknown amount of uncompensated care. In the case of 

services such as pharmacy, a large proportion of these charges represent 

out-of-pocket payments made by the household. In the case of hospital 

charges, however, a substantial portion of uninsured care eventually 

represents bad debt for the provider. Bad debt is ultimately shifted to 

the charges paid by both public and private payers. Therefore, the 

source of payment labeled as ‘uninsured care’ embodies a degree of 

uncertainty as to the true source of payment. 
Source of Payment 89 

Table 20 

Direct Medical Care Cost of Injury by Source of Payment 

and Age, 1985 

Source of

Payment Total O-14 15-44

Amount (millions) 

Total $41,742 $20,335 $7,462 

Public 

Federal 

Medicare 

Medicaid 

other 

State and Local 

Medicaid 

Other 

Private 

Workers’ Compensation* 

Private Insurance 

Private 

Uninsured Care** 

Total 

Public 

Federal 

Medicare 

Medicaid 

Other 

State and Local 

Medicaid 

Other 

Private 

Workers’ Compensation* 

Private Insurance 

Private

Uninsured Care**

11,598 1,104 2,828 1,014 6,652 

8,860 543 1,618 674 6,025 

6,270 12 498 388 5,372 

1,888 419 720 175 574 

702 312 400 111 79 

2,738 561 1,210 627 

1,370 348 603 147 472 

1,168 213 607 193 155 

30,144 3,580 17,507 6,448 2,609 

6,997 87 4,637 2,244 29 

14,162 2,356 7,617 3,129 1,060 

2,053 197 1,457 314 85 

6,932 940 3,796 761 1,435 

Distribution by Source of Payment 

100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 

27.8 23.6 13.9 13.6 71.8 

21.2 11.6 8.0 9.0 65.1 

15.0 0.3 2.4 5.2 58.0 

4.5 8.9 3.5 2.3 6.2 

1.7 2.4 20 1.5 0.9 

6.6 12.0 6.0 4.6 6.8 

3.8 7.4 3.0 2.0 5.1 

2.8 4.5 3.0 2.6 1.7 

72.2 76.4 86.1 86.4 28.2 

16.8 1.9 22.8 30.1 0.3 

33.9 50.3 375 41.9 11.4 

4.9 42 7.2 4.2 0.9 

16.6 20.1 18.7 10.2 15.5 

* Federally administered, but classified as private because almost exclusively 

financed by employers 

** Includes direct out-of-pocket expenditures by families, uncompensated care and 

free care 
90 Cost of Injury in the United States 

Figure 22 

Direct Medical Care Cost by Source of Payment and Age, 1985 

Ages 0-14 

2% 

7 

$4.7 Billion 

8% 

Ages 15-44 

$20.3 Billion 

$7.5 Billion 

Ages 65+ 

65% 

Federal 

 State and Local 

$9.3 Billion � Private 
Source of Payment 91 

Figure 23 

Direct Medical Care Cost by Source of Payment, 1985 

72% 

Federal 

State and Local 

$41.7 Billion � Private 

Patterns by Type of Expenditure 

Table 21 shows the distribution of medical expenditures by source 

of payment and type of expenditure. Included in hospital care 

expenditures are those for initial hospitalization, rehospitalization, 

medical/surgical care, mental health care, inpatient rehabilitation, and 

inpatient prescription drugs. Of expenditures for the hospital care of 

injured patients, 32 percent comes from public sources and the remaining 

68 percent from private sources, mainly private health insurance and 

Workers’ Compensation. 

For outpatient care rendered in emergency departments, clinics, and 

private physician offices, private sources (mainly private health 

insurance) cover the bulk of expenditure -- 85 percent of the total. 

Private sources also pay for nearly three-quarters (74%) of the outpatient 

visits to physical therapists. Three-fifths of expenditures for prescription 

drugs are paid by patients or family members (i.e., self-pay); only 10 

percent is from public sources, mainly Medicaid. 

Some injured persons require extended convalescent or chronic care 

as the aftermath of an injury. For the elderly, many nursing home 

admissions are triggered by a decline in functional status resulting from 

a fall (often leading to hip fracture). Almost one-half (47%) of 
�

92 Cost of Injury in the United States 

expenditure for nursing home care comes from public sources with 43 

percent in state and local government payments. 

Nonmedical Care Expenditures 

Of the four types of nonmedical direct expenditure, three (home 

modifications and health and auto insurance administrative expenses) 

are assumed to be funded entirely by the private sector. The fourth 

category, vocational rehabilitation, is funded by a federal-state matching 

program. It is estimated that 80 percent of these funds are financed by 

the federal government and 20 percent by state government. The federal 

share of vocational rehabilitation costs of $157 million shown in Table 12 

is $126 million, and the state share is $31 million. 

Transfer Payments 

Transfer payments include amounts paid from public and private 

sources to injured persons or their survivors. Transfer payments are 

defined here to mean monetary compensation alone. Benefit payments 

for medical care and other goods and services are captured in the 

analyses of levels and payment sources for direct costs described above. 

The transfer payment analysis is confined to the major programs 

operated through the public sector - Veterans Administration, Old Age, 

Survivors, and Disability Insurance (OASDI), Supplemental Security 

Income (SSI), and Workers’ Compensation. Also included are private 

sector automobile, life, and disability insurance benefits. Other sources 

of transfer payments (compensation awarded in legal proceedings, 

payments from public-sector and private-sector retirement systems to 

persons retiring because of disability due to injury) may be large, but are 

not included here since information is not available on either the total 

amount of such payments or on the amount going to persons disabled 

because of injury. Since administrative cost is not included for the 

programs analyzed, estimates refer to benefit payments alone. 

Transfer payments for disability and death due to injury paid by 

each program and the estimated distribution of payments by funding 

source are shown in Table 22 and summarized in Figure 24; for the 

programs included in the present study, transfer payments for disability 

and death due to injury amount to $52.6 billion; 44 percent of the total 

($23.3 billion) consists of disability payments. Automobile insurance 

paid $22.9 billion, 44 percent of all transfer payments (Miller, 1989). 

Workers’ Compensation programs paid over $13 billion in disability 

payments and an additional $1.8 billion in benefits to surviving 

beneficiaries. The third largest payer of benefits was Social Security, 

which paid $4.4 billion in disability payments and $2.9 billion in 
Source of Payment 93 

Table 21 

Direct Medical Care Cost of Injury by Source of Payment 

and Type of Expenditure, 1985 

Nursing 

Source of Hospital Physician Prescription Physical Home 

Payment Total Care Visits Therapy Care 

Amount (millions) 

Total $41,742 $28,479 $1,372 $1,480 

Public 11,598 1,327 148 351 695 

Federal 8,360 7,403 737 70 259 396 

Medicare 6,270 5,696 395 5 148 25 

Medicaid 1,888 1,195 249 51 55 341 

Other 702 512 93 14 56 30 

State and Local 2,738 1,681 590 78 92 299 

Medicaid 1,570 1,017 196 36 44 278 

Other 1,168 664 394 42 48 21 

Private 30,144 19,395 7,534 1,402 1,021 785 

Workers’ Compensation’ 6,997 5,419 1,252 163 163 NA 

Private Insurance 14,162 9,835 3,585 309 414 12 

Private 2,053 1,072 726 92 151 12 

Uninsured Care** 6,932 3,069 1,971 838 293 761 

Distribution by Source of Payment 

Total 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 

Public 27.8 31.9 15.0 9.5 25.6 47.0 

Federal 21.2 26.0 8.3 4.5 18.9 26.8 

Medicare 15.0 20.0 4.5 0.3 10.8 1.7 

Medicaid 4.5 4.2 2.8 3.3 4.0 23.0 

Other 1.7 1.8 1.0 0.9 4.1 2.0 

State and Local 6.6 5.9 6.7 5.0 6.7 20.2 

Medicaid 3.8 3.6 2.2 2.3 3.2 18.8 

Other 2.8 2.3 4.4 2.7 3.5 1.4 

Private 72.2 68.1 85.0 90.5 74.4 53.0 

Workers’ Compensation” 16.8 19.0 14.1 10.5 11.9 NA 

Private Insurance 33.9 34.5 40.5 19.9 30.2 0.8 

Private 4.9 3.8 8.2 5.9 11.0 0.8 

Uninsured Care” 16.6 10.8 22.2 54.1 21.4 51.4 

* Federally administered, but classified as private because almost exclusively 

financed by employers 

* Includes direct out-of-pocket expenditures by families, uncompensated care and free 

care 
94 Cost of Injury in the United States 

survivor benefits. Of the total cost, more than one-fourth ($14 billion) 

was paid by the federal government; the private sector paid $38.6 billion. 

Table 22 

Transfer Payments for Disability and Death Due to Injury by Source 

of Payment and Program, 1985 

11,783 

Supple- Pri- AutoSource Veterans Social mental Workers’ vate mobile 

of Admin- Security Security Compen- Insur- InsurPavment Total istration (OASDI) Income sation ance ance 

Amount (millions> 

Total $52,578 $1,033 $14,822 $22,925 

Public 13,972 2,560 7,340 

Federal 12,751 

State and Local 1,221 

Private 22,925 

Distribution by Source of Payment 

100.0 % 100.0 % 100.0 % 100.0 % 

Public 100.0 0.0 

Federal 24.3 82.3 13.5 0.0 

State and Local 2.3 17.7 7.0 0.0 

73.4 79.5 

Data Sources and Methods 

Direct Medical Care Expenditure 

For the distribution of direct medical care expenditure, a variety of 

data sources is used. The resulting figures represent a best estimate and 

not an exact accounting. 

The major data source is the National Medical Care Utilization 

Survey (NMCUES), which tracked medical care use and expenditures in 

approximately 10,000 households encompassing some 17,000 

individuals, over an entire year. Baseline information collected for each 

respondent household includes demographic information on household 

members and a determination of pre-existing medical conditions. Each 

respondent was interviewed quarterly to document episodes of illness, 

encounters with health care providers, and health care expenditures. 
�

Source of Payment 95 

The NMCUES data set makes it possible to identify each medical 

condition experienced by an individual during the study year, the 

treatment services obtained for the condition, and the charges for these 

services. Each condition is classified in terms of primary and secondary 

diagnoses (ICD codes). Medical services obtained for each condition are 

listed, together with the cost for each hospitalization, medical visit, 

prescription, or other item. Expenditures are further classified with 

respect to a list of thirty possible payment sources. 

Figure 24 

Transfer Payments by Source of Payment, 1985 

Federal 

$53 Billion �

State and Local 

Private 

The NMCUES public use data tapes identify persons who reported 

any medical condition during the study year with an injury-related 

diagnosis (ICD code). For each such individual, a record contains 

demographic characteristics, nature of the injury, medical care services 

used, charges for these services, and source of payment. The aggregated 

records form one of the principal data sets used in the present study. 

Important limitations of the NMCUES data bear on the results of this 

study. Although the full NMCUES data set is statistically representative 

of the 1980 United States population as a whole, the number of injuryrelated events that occurred among study participants was relatively 

small, limiting the extent of the analysis. 

Two reporting issues affect the computation of source of payment 

data. The NMCUES does not assign a value to ‘free care’ (i.e., medical 
96 Cost of Injury in the United States 

services for which the provider 

present study is to estimate 

necessary to impute a value 

waives the fee). Since the purpose of the 

the full economic cost of injury, it is 

when care is identified as ‘free from 

provider.’ The value is based on the average charge reported in the 

NMCUES for a person with a similar medical condition. A second issue 

concerns medical services for which the source of payment is classified 

as ‘self pay.’ A more accurate description is ‘uninsured care’ - charges 

not covered by a third-party payment plan (either public or private). The 

uninsured payment category includes both direct out-of-pocket 

expenditure by injured individuals or their families, and uncompensated 

care. 

The primary use of the injury data extracted from the full NMCUES 

data set was to determine the distribution of injured persons by age and 

source of payment. For example, tables were generated showing, for 

each of ten injury classifications, the proportion of persons in each of 

four age categories. The NMCUES data were also used to determine the 

source of payment for medical care when the cost of an injury was 

covered by several sources of payment and to construct tables allocating 

total payment for a specific type of medical service to various payers, 

conditioned on the identity of the primary payer. These distributions 

were used to allocate estimates of 1985 expenditure for injury-related 

medical care to age and payment categories. 

A second major source of data is the National Hospital Discharge 

Survey (NHDS), a large data set based on discharge abstracts for persons 

treated in a representative sample of U.S. short-stay hospitals. For each 

patient whose records are abstracted, the NHDS files contain 

demographic information, diagnostic codes classifying the injury, and 

the principal source of payment. Three years of data (1984-1986) are 

aggregated to reduce the effect of random year-to-year variation. The 

NHDS file is used to develop counts of injured persons, categorized by 

age, nature of injury, and primary payment source. To produce 

estimates of source of payment for hospital care, the distribution of 

payment conditioned on primary payer from NMCUES is combined 

with counts of injured persons classified by primary payer from NHDS. 

One reporting problem in NHDS concerns the identity of the 

primary source of payment, which ultimately may not be the primary 

payer. For example, a person injured in an automobile crash may have 

health insurance coverage under a Blue Cross Plan. The discharge 

abstract would identify Blue Cross as the primary payment source. 

However, cost of care may ultimately be paid by the insurance company 

of the person held liable for the crash. 

This reporting issue can also lead to understating payments for onthe-job injuries attributed to Workers’ Compensation Insurance. The 

discharge abstract of a person treated for an industrial injury is likely to 

-_ 
Source of Payment 97 

show the employee’s group health insurance plan as primary payer. 

Therefore, other sources of data were used to more accurately assess the 

contribution of Workers’ Compensation. Under this program, total 

hospital and medical benefits amount to $7.1 billion for 1985, as reported 

by the Social Security Administration (Bixby, 1989). Analysis of Workers’ 

Compensation claims shows that 98.8 percent of the total payment is 

injury-related. Thus, $7 billion was distributed by age and sex and type 

of expenditure according to the distribution reported in the NMCUES. 

A variety of other sources are also used to estimate the distribution 

of medical expenditure by age and source of payment. Data on payment 

for injury-related rehabilitation is from the Uniform Data System for 

Medical Rehabilitation, which tracks the cost of cases treated in 

rehabilitation hospitals. Estimates of the cost of treating injury-related 

emotional distress are from the National Institute of Mental Health 

Statistical Reporting System. The cost of nursing home care is from the 

National Nursing Home Survey. The cost of injury-related outpatient 

care (emergency rooms, clinics, physicians’ offices) and prescription 

drugs are derived by adjusting 1980 estimates calculated from NMCUES 

to 1985 price levels. 

Transfer Payments 

The principal data source for estimates of injury-caused disability 

payments is the Survey of Income and Program Participation (SIPP) 

conducted by the U.S. Bureau of the Census. SIPP is a longitudinal 

survey designed to elicit detailed information on the economic status of 

households and persons in the United States. The universe for this 

survey consists of the resident noninstitutionalized U.S. population. 

Persons living in military barracks are excluded. The sample consists of 

approximately 21,000 housing units, one-fourth of which are interviewed 

each month with reinterviews at four-month intervals. Because the recall 

period for each interview is four months, annual estimates are obtained 

by calculating four-month figures and multiplying by three (McMillen, 

1989). 

Wave III of the SIPP, conducted from May to August 1984, included 

questions referring to the four months prior to the interview month. This 

file consists of detailed income information on 56,197 individuals. Wave 

III is used because it includes, in the accompanying Topical Module, 

items indicating whether an individual between the ages of 16 and 72 has 

a work limitation caused by an injury (U.S. Bureau of the Census, 1986). 

Questions were asked of each person at their initial interview during 

Wave I of the SIPP (October 1983 through January 1984) about the 

sources from which income is received and the reason(s) that the income 

is received. 
2)

98 Cost of Injury in the United States 

For specific age categories, five sources of income could be received 

as a result of a disability: 1) Veterans Administration (VA) 

compensation/pension for ages 16-64; 2) private disability insurance 

(PDI) benefits, ages 16-72; 3) Social Security Disability Insurance (SSDI), 

ages 18-64; 4) Supplemental Security Income (SSI), ages 16-72; and 5) 

Workers’ Compensation (WC), ages 16-72. Within each of these five 

income source and age categories, the percent of the total amount 

received over the four-month recall period by persons who report a work 

limitation as the result of an accident or injury is calculated. Information 

from the NCCI data tapes on the share of Workers’ Compensation cost 

attributable to injury is also employed. 

Among the programs included in the estimates, the private sector is 

the sole funding source for private insurance. Using the data presented 

by Nelson (1988), Workers’ Compensation payment can be apportioned 

across three funding sources: federal, state and local, and private. 

Benefit payments for 1984 are allocated into four categories: private 

insurance carriers, state fund disbursements, federal fund 

disbursements, and self-insured employers. Actual payments from state 

and local government employers will differ from the state fund 

disbursements because state funds may provide coverage to some 

private employers and because some state and local government 

employees (unlike federal employees) are covered under self-insurance 

or (to a lesser degree) private carriers. 

Benefit payments to state and local government employees are 

assumed to comprise one-half of the state fund disbursement amount. 

Based on this assumption and the data cited above, it is estimated that 

13.5 percent of payment is financed by the federal government, 7.0 

percent by state and local government, and 79.5 percent by the private 

sector. About 60 percent of the federal government share is financed 

from the coal excise tax used to support the Black Lung Trust Fund. 

Among public sector programs, only SSI is not funded entirely by 

the federal government. Federal SSI payments to the blind and disabled 

in 1984 comprised 82.4 percent of total SSI benefit payments. State 

supplements comprise the remaining 17.6 percent. 

Transfer payments resulting directly from deaths caused by injury 

come from a variety of public and private sources, including private life 

insurance, benefits paid to survivors of veterans, survivor benefits paid 

by Workers’ Compensation, and survivor benefits paid by the Social 

Security Disability Insurance program. Not included are payments 

resulting from legal liability claims and payments to surviving 

beneficiaries from pension funds. The total dollar amounts paid by the 

four sources and the estimated injury-related payments are shown in 

Table 23. 
Source of Payment 99 

Table 23 

Transfer Payments for Death Due to Injury by Program, 1985 

InjuryTotal Related 

Payments Payments 

Program (millions) (millions) 

Total $58,136 $6,392 

VA Survivor Benefits 3,435 287 

Workers’ Compensation 1,712 1,681 

Social Security OASDI 34,805 2,906 

Private Life Insurance 18,184 1,518 

Several sources of data are taken into account in estimating the 

proportion from each of four payers allocated to injury-caused deaths. In 

the case of Workers’ Compensation, it is assumed that a large fraction of 

payments is for injury-caused deaths. Examination of the NCCI data 

suggests that 98.2 percent of the Workers’ Compensation payment for 

death and disability is due to injuries. Applying this same percentage to 

the payments to survivors yields an estimated 1985 payment of $1.7 

billion. 

For VA survivor benefits, the percent due to injury-caused mortality 

is assumed to be the same as the percent of all deaths caused by injury in 

the male population aged 20 and over. In 1985, according to the U.S. 

National Center for Health Statistics, this figure was 8.35 percent. 

Applying this percentage to the total payment figure yields an estimated 

pay-out due to injury-caused deaths of $287 million. This percentage 

(8.35) is used to apportion Social Security and life insurance payments, 

yielding respective payment estimates of $2.9 billion and $1.5 billion. 

Summing over the four estimates yields a figure of $6.4 billion as the 

total amount of transfer payments resulting from injury deaths. 

Additional Payment Sources 

As noted above, additional private-sector sources of funding for 

transfer payments have not been included in the present estimates. A 

variety of state programs also fund such payments for which dollar 

amounts are not available at the national level. To explore the 

prevalence and potential importance of these state-specific programs, the 

authors relied on telephone contacts with state officials in seven states: 
100 Cost of Injury in the United States 

Maryland, Illinois, Texas, New York, Florida, California, and 

Massachusetts. All of these states report having a crime victim’s 

compensation program, though the coverage and financing sources for 

these programs vary. Several states use federal matching funds; others 

report exclusive use of state funds. Six of the seven states report special 

programs for head and/or spinal cord injury victims. These programs 

primarily serve to fund medical and other related direct expenditures 

(e.g., rehabilitation services and appliances) with less emphasis on 

transfer payments per se. To the extent that these programs have 

developed or expanded since 1980 (the date of the NMCUES data 

collection effort), their presence may result in understatement of the 

share of medical and other related direct expenses paid by state 

governments. 

Conclusion 

Approximately 72 percent of the direct expenditures for medical 

care and rehabilitation are borne by private sources (private health 

insurance, Workers’ Compensation, uninsured care, and other private 

sources). Public sources (Medicare, Medicaid and other federal, state, 

and local sources) account for 28 percent of direct costs. 

this total, 27 percent was paid from public sources, including Social 

Security Disability Insurance, Veterans Administration, Supplemental 

Security Income, and Workers’ Compensation. Private funding, 73 

percent of transfer payments, came from sources including employer- employerfinanced Workers’ Compensation and private disability, life, and 

automobile insurance. The data for 1985 make clear the fact that the 

burden of injury payments is borne by all sectors of the society. 
Chapter 4 

Willingness to Pay 

The willingness-to-pay method of estimating the cost of injury is 

conceptually different from the human capital approach presented in 

Chapter 3. Human capital refers to individual worth measured by the 

production over time of a stream of output estimated at market value. 

Willingness to pay, on the other hand, reflects the value placed on health 

and life by individuals. Willingness-to-pay research is an effort to derive 

social preferences regarding public policy and assess the burden of pain, 

suffering, and loss in quality of life associated with injury. Thus, the 

willingness-to-pay method attempts to value life comprehensively. 

Societal cost, according to the willingness-to-pay approach, has two 

components: 1) individual willingness to pay defined as the value a 

typical person places on health and safety, and 2) the cost the rest of 

society saves by preventing or controlling an injury. This chapter focuses 

primarily on the first term, how much people are willing to pay, and 

actually do pay, for safer and healthier lives. The second term, the 

savings society gains through injury prevention and control, includes 

increased tax revenues; reduced transfer payments in Medicare, food 

stamps, unemployment compensation, etc.; reduced private insurance 

payments; and reduced costs for administering transfer payment and 

insurance programs (Miller, Brinkman, and Luchter, 1988; U.S. NHTSA, 

1983). 

To Reduce Fatal Injury Risk 

The literature on individual willingness to pay as a measure of the 

value of human life has grown in recent years. Some works are 

theoretical (Cropper and Sussman, 1988; Mishan, 1988; Rosen, 1988; 

Smith, 1987); some are philosophical (Administrative Conference of the 

United States, 1988; Gillette and Hopkins, 1988; Menzel, 1986; Merkhofer, 

1987; Miller, 1988; Robinson, 1986; Viscusi, 1986; Wenz, 1986); and others 

are empirical (Blomquist, 1988; Fisher, Chestnut, and Violette, 1989; 

Garen, 1988; Gerking, de Haan, and Schultze, 1988; Hammitt, 1988; 

Moore and Viscusi, 1988). Miller (1989) evaluates 49 studies on this issue 

and concludes that 29 are of reasonably good quality. The most common 

problems with the remaining studies are: 1) faulty surveys, such as 

asking about probabilities too small for people to understand, restricting 

respondents to a few students or professors, or ignoring responses of 
102 Cost of Injury in the United States 

zero; and 2) use of inaccurate risk variables, such as a variable on risk by 

industry that ascribes the same risk to the janitor, the secretary, and the 

machinery operator, or a variable on risk by occupation that was based 

on only one year of data and involved more occupations than deaths, 

thus causing most occupations to have equal risks of zero rather than 

varying, small levels of risk. 

The 29 studies of good quality have estimated the values of a 

reduction in individual risk of fatal injury or illness based on four 

possible elements: 

Extra wages received for risky jobs;

Price and demand for products that increase health and

safety;

Personal tradeoffs made between time, money, comfort,

and safety; and

Surveys about individual willingness to invest money to

increase health and safety.

Miller converted the estimates from the 29 studies to 1985 after-tax 

dollars and recomputed those that involved a discount rate or value of 

time using consistent values for these parameters. Following the 

Blomquist method (1982),Miller also adjusted the values obtained to 

assure that behavior be interpreted in terms of perceived, rather than 

actual, risk levels. Table 24 shows the value of life by type of study. 

Across the 29 studies, the individual willingness to pay to save one 

life ranges from $1.0 million to $3.1 million, with a mean of $1.95 million 

and a standard deviation of $0.5 million. This level of uncertainty is 

typical of the effectiveness estimates in most cost-benefit analyses. 

Furthermore, the emergence of values in a similar range from studies 

using many different approaches and data sets suggests that the 

methodological concerns raised by individual studies are not of central 

importance. For example, existing data appear to underestimate the risk 

of fatal workplace injury. A comparison across studies implicitly 

assumes that the willingness to pay to avoid death is the same for slow, 

painful death as for sudden death, and that the willingness to pay to 

reduce risk does not vary significantly between unavoidable risks like 

nuclear disaster and risks like auto crashes, over which the individual 

has some control. In addition, the choice for some workers may be 

between a risky job and unemployment rather than a less risky, but 

lower-paying, job. 

To give a simple example of the estimation of the value of human 

life, a study might estimate that the average person spends $200 on 

optional auto safety features that reduce the chance of dying 

prematurely by 1 in 10,000. Dividing $200 by the 1 in 10,000 probability 
Willingness to Pay 103 

Table 24 

Individual Willingness-to-Pay Estimates of Value of Life 

by Type of Study, 1985 

Amount 

Type of Study and Sources (millions*) 

Average of 29 Studies $ 1.95 

Extra Wages for Risky Jobs (15 studies) 1 .00-3.00 

Demand and Price 

Safer cars (Winston & Mannering, 1984) 1.90

Smoke detectors (Dardis, 1980) 1.00- 1.80

Houses in polluted areas (Smith & Gilbert, 1984) 2.30

Life insurance (Landefeld & Seskin, 1982) 1.10

Behavior 

Pedestrian tunnel use (Melinek, 1974) 1.80 

Safety belt use (Blomquist, 1979; 1988) 1.30-3.10 

Speed choice (Jondrow, Bowes, & Levy, 1983) 1.30-1.60 

Driver’s travel time (Miller, 1989) 1.00- 1.20 

Surveys 

Cancer (Landefeld, 1979) 2.40 

Safer bus (Jones-Lee, Hammerton, & Phillips, 1985) 2.60 

Safer job (Gegax, 1984) 2.00 

Auto safety (Viscusi, Magat, & Huber, 1989) 2.20 

Source: All estimates from Miller, 1989a; references in parentheses 

show primary sources prior to adjustment or value extraction from 

behavioral models 

* After-tax dollars 

suggests that the average person is willing to spend $2 million to assure a 

safe and healthy life. This value estimation does not imply that most 

people would actually be able to pay $2 million to avoid dying 

-_ 
104 Cost of Injury in the United States 

prematurely. The estimate is based on the small amounts people 

regularly pay - in dollars, time, discomfort, and inconvenience -- to 

reduce health risks. The aggregate expenditure of $2 million on health 

and safety, by ten thousand people, prevents one anonymous, statistical 

individual from dying. That is the price average Americans pay for 

safety. 

To Reduce Nonfatal Injury Risk 

The $1.95 million value per life is based on the behavior of people 

who have an average of roughly 40 years to live. If the net present value 

of 40 future life years is $1.95 million, the implied value per life year is 

roughly $120,000, based on a 6 percent discount rate. Willingness to pay 

to prevent a nonfatal injury can be estimated by multiplying this value 

times the years of functioning lost to injury, discounted to present value. 

The percentage of functioning lost to different types of moderate 

and severe injuries has been estimated by a small number of physician 

experts (His et al., 1983). The ratings cover three time periods: the year 

after the injury, the second through fifth years, and thereafter. They 

examine six aspects of functioning: physical dependency, mobility, pain, 

and cognitive, cosmetic, and sensory functioning. Subsequently, the 

ratings were extended to a more comprehensive range of injuries 

(Carsten, 1986). Aided by the Guides to the Evaluation of Permanent 

Impairment (AMA, 1984), developed by physician panels of the American 

Medical Association, Carsten also developed a method for combining the 

ratings by functional aspect into a summary impairment rating. Luchter 

(1987) used the physician ratings to compute average impairment by 

injury severity, based on the relative incidence by severity of different 

injuries in auto crashes. 

Table 25 shows estimates by injury severity of individual and 

societal willingness to pay to prevent nonfatal injuries. The societal 

amounts range from $30,000 for prevention of an injury of moderate 

severity to $1.5 million to prevent a critical injury. To prevent a fatal 

injury, the societal amount is estimated at $2 million. Thus, the 

willingness-to-pay estimates for reduction in critical nonfatal injuries and 

fatal injuries are roughly 4.5 to 6 times the cost per death caused by 

injury -- $317,187, estimated by the human capital approach. 

To Avoid Specific and Minor Injuries 

Arthur (1981) presents a theoretical model of willingness to pay that 

is readily extended to nonfatal events. The model indicates that 

willingness to pay to reduce the incidence of an injury equals willingness 

to pay for life times the relative loss associated with the injury and 
Willingness to Pay 105 

Table 25 

Individual and Societal Willingness-to-Pay Estimates for 

Reduction of Nonfatal Injury by Severity, 1985 

Injury Individual Societal 

Severity (thousands*) (thousands*) 

Nonfatal Injury 

Moderate 

Serious 

Severe 

Critical 

Fatal Injury 

$25 $30 

100 115 

260 375 

1,225 1,525 

1,950 2,000 

Source: Miller, Brinkman, and 

Luchter, 1988 

* After-tax dollars 

with death. The extended model was used to determine willingness to 

pay to prev ent selected injuries and to assess the reasonableness of the 

values obtained from the physician ratings. 

The medical decision-making literature is rich in scales that score 

the relative loss associated with different levels of health status. Some 

articles focus on chronic conditi ons -- for example, the loss due to a heart 

attack, hearing impairment, or kidney failure. Others create functional 

ability indexes or scales and score the relative loss at each point on the 

scale. The scores indicate total loss, including family loss in quality of 

life and pain and suffering, as well as financial loss. 

Selected injuries were scored on several scales of reasonable quality, 

and the median loss across scales was used to estimate willingness to 

pay. On all the scales, the loss score for death was one, while the score 

for perfect health was zero. Scores were estimated for three groups of 

injuries: fates worse than death, serious injuries preferable to death, and 

minor injuries. 

Fates Worse Than Death 

Severe head injury, severe burns, and quadriplegia are examples of 

fates many people consider worse than death. Indications that people 

feel some fates are worse than death are easy to find. American slang is 
106 Cost of Injury in the United States 

filled with such phrases as “He’d be better off dead,” or “I’d rather die.” 

Mercy killing is a hotly debated issue. The suicide rate soars for people 

with central nervous system disorders or AIDS (Marzuk et al., 1988). The 

largest jury awards have been primarily for severe injury, rather than 

death. The question of whether death or paralysis from the neck down is 

worse generally yields split, but emphatic, opinions. 

Guilt, regret, stress, loneliness, bereavement, and pain can be much 

worse than death. The stressful uncertainty faced by the loved ones of a 

permanently unconscious person can exact a terrible cost. Three studies 

outlined below provide adequate information to assess the loss 

associated with fates generally considered worse than death. 

Through sample surveys in Canada, Torrance (1982) developed 

scores according to status on four dimensions of functioning (mobility 

and physical activity, self-care and role function, emotional well-being 

and social activity, and health problems). He obtained further insight 

into fates worse than death by asking parents whether it would be better 

to bear a disabled baby or experience a still birth. One weakness of the 

health problems scale used by Torrance is that it has only one moderate 

level each for pain and disfigurement. Green and Brown (1978) surveyed 

British students about the relative severity of death and a variety of 

injuries. 

Kind, Rosser, and Williams (1982) estimated scores on a twodimensional health status scale. One dimension measures disability, 

with 1 representing full mobility and 8, unconsciousness. The second 

dimension measures distress, with 1 being none and 4, severe. Median 

scores were computed from the noneconomic component of British jury 

awards, which follow an informal schedule. 

The loss scores for quaciriplegia and head injury resulting in longterm unconsciousness or total permanent disability were taken directly 

from the studies. Quadriplegia scores averaged about a 10 percent 

greater loss than death, while totally disabling head injury scores 

averaged about a 15 percent greater loss. 

An important caution about these loss scores is that values vary 

widely among individuals. For example, Torrance (personal 

communication, 1988) found that partial and complete quadriplegics 

who adjust to their injury perceive their loss as 65 percent, while 

quadriplegics who sue for the right to starve to death clearly perceive a 

loss exceeding 100 percent. The 110 percent loss estimate for complete 

quadriplegia is an average loss score based on a survey of people with 

differing expectations about their ability to adjust. 

The losses associated with severe burns were computed from the 

functional scales based on the impairment ratings reported by His and 

associates (1983). The physician ratings suggest that severely burned 
Willingness to Pay 107 

people over 45 generally would need an attendant for the rest of their 

lives, be confined to bed, and experience some mental impairment, as 

well as substantial disfigurement and pain. Severe burns are essentially 

the worst fate possible, with a loss almost 40 percent greater than the loss 

associated with death. It is little wonder that the debate over death with 

dignity is becoming more heated as the survivability of persons with 

these injuries and other severe health conditions increases. 

Severe Injuries Preferable to Death 

Functional scales were applied to paraplegia and partially disabling 

head injury, as was a scale developed by Kaplan (1982). Based on 

sample surveys in the U.S., this scale assumes no fate is worse than 

death. The scale has three dimensions (mobility, physical activity, and 

social activity) and adjustments for a diversity of symptom-problem 

complexes. It includes adjustments for pain by body part (at a single 

severity level) and for information related to disfigurement. 

On average, complete paraplegia is associated with about a 60 

percent loss, incomplete paraplegia about a 50 percent loss, and 

incomplete quadriplegia about a 90 percent loss. Torrance (personal 

communication, March 1988) reports that paraplegics who have adjusted 

well to the condition rate their loss at about 45 percent. Partially 

disabling head injuries are associated with losses ranging from 15 to 62 

percent, depending on the severity of long-term consequences. 

Miller and associates (1988) used the loss scores for serious burns, 

head injuries, and spinal cord injuries to validate selected willingness-topay estimates. They estimated individual willingness to pay to avoid 

critical injury at 1.1 million, which is on the same order of magnitude as 

the 1.2 million computed in Table 25 from the Carsten (1986) estimates of 

impairment and life years lost. The estimated willingness to pay to 

avoid a severe injury is $310,000, compared to the $260,000 computed 

from the impairment estimates. 

Table 26 shows the estimated societal willingness to pay to avoid 

selected injuries. The highest amounts result from severe nonfatal 

injuries, rather than fatalities. Included is an estimated $3.6 million to 

avoid a severe burn, $2.9 to $3.2 million to avoid a totally disabling head 

injury, and $2.2 to $2.6 million to avoid injury resulting in quadriplegia. 

The estimate exceeds $1.3 million to avert an injury resulting in complete 

or partial paraplegia. 

Minor Injuries 

Physician ratings of functional impairment were not available for 

minor injuries. Data from the National Highway Traffic Safety 
108 Cost of Injury in the United States 

Table 26 

Societal Willingness-to-Pay Estimates to Avoid Selected Injuries 

by Nature of Injury, 1985 

Amount 

Nature of Injury (thousands*) 

Severe Head Injury 

Total impairment $2,900-3,200 

Partial impairment 550-1,500 

Quadriplegia 

Complete 2,600 

Partial 2,200 

Paraplegia 

Complete 1,800 

Partial 1,350 

Very Severe Burn 3,600 

Minor Injury 4 

Death 2,000 

Source: Miller, Brinkman, and 

Luchter, 1988 

* After-tax dollars 

Administrations National Accident Sampling System (NASS) indicated 

that an average of 2 days were spent in the hospital and another 2.8 days 

of ability to perform work or housework were lost (Miller et al., 1988) 

Perhaps another 4.8 days of progressively less severe activity limitation 

and mild pain might follow. The three impairment scales described 

above suggest an average functional loss of 37 percent for 9.6 days, or a 

total of .01 life years lost. The societal willingness-to-pay amount to 

avoid a minor injury is estimated at $4,000. 
Willingness to Pay 109 

Conclusion 

Much of this report discusses the cost of injury to society. This 

chapter focuses on a methodology that combines individuals’ assessment 

of the amount they are willing to spend on injury risk reduction with the 

potential savings to society. This assessment yields values of $2 million 

to avoid death. To avoid moderate to critical injuries, the estimates range 

from $30,000 to $1.5 million. To avoid severe head injuries involving 

total impairment, quadriplegia, or very severe burns, willingness-to-pay 

estimates range from $2.6 million to $3.2 million. 

There is support in the economics profession for employing the 

willingness-to-pay method rather than the human capital approach 

when a dollar value is placed on health and safety benefits in cost-benefit 

analyses or resource allocation models (Bailey, 1980; Menzel, 1986; 

Mishan, 1988; National Safety Council, 1987; Thompson, 1980). 

Regulatory analyses performed by several federal agencies have 

employed the willingness-to-pay approach. Included are the Consumer 

Product Safety Commission, Occupational Safety and Health 

Administration, Federal Highway Administration, Coast Guard, Federal 

Aviation Administration, Nuclear Regulatory Commission, and 

Environmental Protection Agency. The Department of Agriculture has 

also used the approach in cost-benefit analysis. 

The American public would be willing to invest $300 billion a year 

to prevent all injury deaths and $800 billion to prevent all nonfatal 

injuries, for a total of $1.1 trillion. It is clear that the human capital 

approach yields significantly lower estimated values of human life than 

does the willingness-to-pay method. Both sets of estimates are presented 

in this report to provide the reader with the best and most current 

estimates available employing each approach. 
Chapter 5 

Potential Savings from Injury Prevention 

The premature deaths, disabilities, and costs resulting from injury, 

including large public sector expenditures, highlight the need to reduce 

the burden of injury in the United States. The application of current 

knowledge can substantially reduce the incidence or severity, and 

accompanying cost, of injury. This chapter provides examples of 

estimated savings to society of selected injury control interventions for 

which reasonable estimates of effectiveness and cost can be made. When 

effects of an intervention are known, but data are insufficient on cost or 

current extent of implementation, the missing data are noted. 

The precision of the estimates varies depending on research design 

and the generalizability of research findings. Scientists often disagree on 

these issues. However, in cases with large effects, or small effects based 

on large samples, it is unlikely that additional research would reverse the 

conclusion that a given intervention did or did not produce savings. In 

many cases, better data would increase the precision of the estimates. 

Background 

Some progress has been made in reducing injuries in the United 

States. Automobile occupant fatalities per million miles driven were 

reduced about 40 percent by the Federal Motor Vehicle Safety Standards 

authorized by the Motor Vehicle Safety Act of 1966 (Robertson, 1984). In 

New York City, where most children’s deaths from falls result from 

crawling out of windows in multistoried buildings, health department 

initiated programs and regulations helped reduce such fatal falls of 

children from about 50 per year in the 1960s (Bergner, Mayer, and 

Harris, 1971) to about 4 per year in the 1980s (Bergner, 1982). 

Numerous interventions to reduce the incidence and severity of 

injury have been identified (e.g., Haddon, 1970; Dietz and Baker, 1974; 

Robertson, 1983; Baker, O’Neill and Karpf, 1984; Waller, 1985), but many 

have yet to be implemented. Delay in the application of interventions 

known to be effective has a long history. In the 19th century, railroad 

workers had a very high injury mortality rate because of dependence on 

time tables to avoid the collision of trains on the same track, lack of 

uniform braking of all cars, and use of flexible chains to join cars. 

Despite the availability of automatic signaling systems, automatic 

braking systems, and automatic coupling systems in the 1870s (Adams, 
112 Cost of Injury in the United States 

1879), most railroads did not adopt the technology until it was required 

by Congress near the turn of the century (Robertson, 1983). Fatalities per 

thousand rail workers were reduced 80 percent from 1890 to 1920 

(Swain, 1980). 

In recent years, argument over the cost of applying interventions 

has been a major factor in delay of implementation. Determination of the 

net savings to society if any one intervention were implemented depends 

on estimates of level of incidence reduced, the cost of injury severity 

reduced, the estimated cost of implementing or increasing the 

intervention, and the extent to which the intervention would be applied. 

Unfortunately, for most interventions that have been suggested or 

implemented to some degree, data on all these elements are unavailable. 

Savings Estimation Method 

The current review of the literature on injury control interventions 

suggests that, most often, the cost of the intervention is not known or 

reported. Researchers who evaluate the effects of interventions seldom 

include cost estimates of the interventions. 

It is also difficult to find data on the extent of implementation of 

many interventions. For example, a controlled experiment in which 

parents in an experimental group were counseled regarding infant falls 

from tables, beds, etc. suggests that these falls can be reduced about 41 

percent by physician warnings and counseling (Kravitz, 1973). To 

estimate the savings that could be realized’ from expanding such 

counseling, however, data is needed on the current extent of counseling 

by physicians. No survey of physicians to determine the extent of such 

counseling and its cost is known. 

The following data are necessary to calculate savings: 

a. Number of injuries of given severity to which an 

intervention applies; 

b. Cost of injuries by severity; 

c. Proportion of each severity level reduced by the 

intervention; 

d. 

level; 

e. Cost of applying or incrementing the intervention; and 

f. Net savings =d-e. 

Reduced costs = Sum of ai x bi x ci where i = each severity 

It should be noted that this is not cost-benefit analysis. Certain costs 

and benefits that are not translatable into dollars are not included. On 

the cost side, for example, some interventions include alteration in 

transportation of teenage children that changes the daily routine of 
Potential Savings from Injury Prevention 113 

families. On the benefit side, for example, the human capital approach 

does not include reduced pain and suffering, and on the cost side, 

substitution of economic productivity with caregiving by family 

members. The willingness-to-pay approach includes the assumptions 

that people perceive risks accurately and evaluate them in economic 

terms. Even were the latter true, the public’s assessment of many risks is 

at variance with reality (Slovic, Fischhoff, and Lichtenstein, 1987). 

Nevertheless, with assumptions explicit, application of a particular 

method to a variety of interventions sheds light on the relative merits of 

the interventions in economic terms. 

Table 27 presents savings estimated for several interventions by the 

human capital and willingness-to-pay methods, separately, using data 

from Chapters 2 and 4. Although some of the uncertainties and ranges of 

estimates are discussed in this chapter, the literature cited should be 

consulted for a more complete view of the strengths and limitations of 

the studies relative to their use here. More detail on the methodology is 

found in Appendix B. 

Table 27 

Estimated Cost and Savings of Interventions 

to Reduce Injury and Severity 

Intervention 

Cost (millions) Savings (millions) 

Willing- WillingHuman ness Human ness 

Capital to Pay Program Capital to Pay 

Child pedestrian injury campaign $112 $234 $54 $58 $180 

Bicycle helmet promotion 255 356 72 183 284 

Driver education elimination -700 * -2,067 + -163 * 863 ** 2,230 ** 

License age 17 1,446 4,267 0 1,446 ** 4,267 ** 

Motorcycle helmet use laws 393 l,500 296 97 1,200 

Reduced ignition of cigarette paper 187 1,100 0 187 ** 1,100 ** 

Air bags 8,650 23,491 4,000 4,650 19,491 

Side crash protection 916 3,529 2,000 0 1,529 

Automatic vehicle lights 391 1,154 620 0 ** 534 ** 

* Represents reduced cost 

** Excludes savings in property damage 
114 Cost of Injury in the United States 

Implementation Strategies 

Implementation strategies can be categorized into four general 

approaches: 

* Persuade individuals to reduce risky behavior or protect 

themselves and others; 

Require that people refrain from risky behaviors or 

increase protection by administrative rule or law;

Change vehicles or environments to increase automatic 

protection (that is, the individual at immediate risk does 

not have to be changed to be protected); and

Improve post-injury emergency and rehabilitative 

treatment services. 

Generally, automatic protection is most successful and persuasion 

least successful, particularly if the persons at risk must take very 

frequent action for protection, such as the use of child restraints and 

safety belts in cars (Robertson, 1975). There seems to be a preference for 

education and other behavior-change approaches without resort to law, 

probably because they are thought to be less controversial or less costly, 

but such assumptions are subject to challenge by research. Laws may 

reduce risk if sufficiently enforced, but several nonlegal factors are 

related to both compliance with law and degree of enforcement 

(Robertson, 1983). The success of automatic approaches requires 

technical competence in design and quality control in implementation, 

after political, social, and economic barriers are overcome. 

Persuaded Behavior Change 

The research on three attempts at behavior change by persuasion is 

complete enough to allow a savings estimate - a campaign against childpedestrian injuries tested in three cities, a bicycle helmet promotion 

tested on a large scale in Australia, and high school driver education, 

which has been the subject of numerous studies. 

Campaign Against Child-Pedestrian Injuries 

Based on research regarding child ‘dart-out’ behavior resulting in 

pedestrian injuries, a campaign using an animated character, “Willy 

Whistle,” in schools and on television was studied in three cities. The 

researchers estimate a 20 percent reduction in dart-out injuries to 

pedestrians under age 15 and a 12 percent reduction in all childpedestrian injuries. The one-time developmental and research cost of the 

campaign was $472,000. The success of the campaign is dependent on 
Potential Savings from Injury Prevention 115 

use in school classrooms and on television. The television time (e.g., 380 

showings in Los Angeles valued at $150,000) was contributed by local 

stations as a public service (Blomberg, Preusser, Hale, and Leaf, 1983). 

Apparently only Miami, Florida has used the program consistently. 

The Miami schools spend $95,000 per year to implement the program in 

135 elementary schools, about $704 per school. If that cost is 

generalizable to the 76,000 elementary schools in the U.S., the annual cost 

of full implementation would be about $53.5 million per year, excluding 

any contributed television time. Limiting the use of the program to 

schools in neighborhoods that have a history of child-pedestrian injuries 

would reduce the cost. Since the effect of the program used only in 

schools without any television may be less than in the original 

experiment, the savings may be less with only school use. 

There were 978 deaths to pedestrians under age 14 in 1985. Using 

ratios of deaths and hospitalizations to incidence of medically treated 

child-pedestrian injuries from a large regional study (Barancik, 

Chatterjee, Greene-Cradden, et al., 1986), investigators estimate the 

medically treated incidence and hospital admissions per fatality. A 12 

percent reduction in child-pedestrian injuries would result in about 117 

fewer fatal injuries, 1,413 fewer hospitalizations, and 2,289 fewer 

medically treated and released cases. 

The cost of these injuries in human capital terms would be about 

$112 million, and by willingness-to-pay estimates, $234 million for fatal 

injuries alone. The human capital savings exceed the estimated cost of 

the program by about $58 million. Savings employing willingness-topay estimates less the cost of the program, would be about $180 million. 

The latter approach excludes nonfatal cases, for which the cost was not 

comparably calculated. 

A film entitled “And Keep on Looking,” dealing with a wider range 

of child-pedestrian situations for 9-12 year olds, has been field tested and 

a 20 percent reduction in injuries estimated (Pruesser and Lund, 1988). 

A videotape combining the “Willy Whistle” and the new film is being 

considered for distribution to urban and suburban schools by the 

National Highway Traffic Safety Administration. If these tapes are used, 

they may provide substantial results at less cost per school than the 

Miami program, but the cost per school has not been established. 

Bicycle Helmet Promotion 

Head injuries to bicyclists can be reduced substantially by helmet 

use (Thompson, Rivara, and Thompson, 1989). A promotional campaign 

to increase use of bicycle helmets in Victoria, Australia during 1982-85 

resulted in a 20 percent reduction in head injury to bicyclists (Wood and 

Milne, 1988). The campaign included: 
116 Cost of Injury in the United States 

1,000 helmets sold through the schools at two-thirds retail 

cost; 

Required helmet wearing while cycling in school 

activities; 

Poster distribution to all schools, physicians, and helmet 

retail outlets; 

Distribution of promotional materials to cycling clubs; 

A television and radio campaign that cost $A160,000 

(Australian dollars); and 

Government rebates of $A225,000 to purchasers of about 

25,000 helmets. 

Although the total cost of this effort is not calculable, a reasonable 

estimate of the program cost, given the identified cost, is $A500,000. The 

cost to consumers of helmet purchases must be added to that amount. 

The helmets known to have been sold through the rebate program cost 

consumers about $A900,000 after subtracting the rebates. The total cost, 

not counting unrebated helmet purchases, was about $A1.4 million in a 

population of 3.9 million. To implement the program in the U.S. 

population of about 245 million, converting Australian dollars to U.S. 

dollars at the 1985 conversion rate, 1.208, would cost about $72 million, 

assuming comparable rates of bicycle use. 

The total incidence and severity of head injuries to bicyclists is 

unknown. Head injuries have ranged from 49 percent to 67 percent of 

hospital admissions of bicyclists in three studies (summarized in Friede, 

Azzara, Gallagher, and Guyer, 1985). Assuming that these estimates are 

reasonably accurate, and applying the ratios of hospitalizations and 

deaths to incidence from a large regional study (Barancik et al., 1986), a 

20 percent reduction in bicyclist head injuries would result in 178 fewer 

fatalities, 2,463 fewer hospitalized injuries, and 16,602 fewer injuries 

treated and released. Deducting the $72 million cost of the program, the 

savings of the Australian bicycle helmet program in the U.S. would be 

about $183 million in human capital terms or at least $284 million by 

willingness-to-pay estimates. The latter estimate is for fatality reduction 

alone since the nonfatal injury cost was not calculated in a way usable 

here. The validity of these estimates depends on the extent to which 

cultural differences affect public acceptance of such programs and on the 

extent to which the direct conversion of Australian and U.S. dollars 

distorts differential effects of incentives in countries with different wage 

structures. 
Potential Savings from Injury Prevention 117 

Driver Education 

One of the most widespread attempts to educate people to reduce 

injury by altering behavior is driver education in the public schools. 

According to the latest survey (1982-83), 998,363 students were enrolled. 

Costs per pupil varied widely among the states, but the median was $163 

(National Safety Council, 1985). Therefore, high school driver education 

cost approximately $162.7 million in that year, not counting time 

diverted from academic subjects. The 1985 cost was probably not very 

different from the 1982-83 cost since any decline in numbers taking the 

course in the two years after the most recent survey would be at least 

partly offset by inflation in cost per pupil. 

Unfortunately, the scientific evidence indicates that expenditures on 

driver education in the public schools had an adverse rather than an 

ameliorative effect on injury rates. Al though carefully controlled 

experiments find that driver education has little or no effect on 

individual risk in the aggregate (Shaoul, 1975; Lund, Williams, and 

Zador, 1986), it results in a large increase in licensure in an age group 

that has a very high crash rate (Shaoul, 1975). An increase of 8 licensed 

16- and 17-year-olds per 10 students was found in a 27-state study 

(Robertson and Zador, 1978). In Connecticut, when driver education was 

eliminated from the public schools in nine school districts, there was a 75 

percent decline in licensure of 16 and 17-year-old drivers of those taking 

high school driver education compared to comparable districts that 

retained the course (Robertson, 1980). 

A 75 percent reduction in licensure of the 998,363 students enrolled 

nationally in 1982-83 would reduce the number of fatal crashes by about 

595 per year based on the national rate of 7.95 fatal crashes per 10,000 

licensed drivers aged 16-17. There were 1.64 deaths per fatal crash of 16-

year-old drivers, so about 976 deaths can be attributed to early licensure 

due to driver education. 

Since 16-year-old drivers have a fatal crash rate per mile about 11.4 

times that of drivers aged 35-39 (Robertson, 1983), near the average age 

of their parents, there would be about 91 percent fewer deaths if parents 

drove their children the same number of miles that the children drive 

themselves. Therefore, adjusted for substitution of parental driving, the 

reduction from eliminating driver education would be approximately 

0.91 x .75 x 976 or 666 deaths per year. If the distribution of nonfatal 

injury severity relative to deaths is similar to the distribution for all 

crashes, severity of injuries reduced would be distributed by the 

Abbreviation Injury Scale (AIS) as follows: AIS 1 - 69,657, AIS 2 - 5,974, 

AIS 3 - 1,325, AIS 4 - 213, AIS 5 - 71, fatal - 666. 
118 Cost of Injury in the United States 

The estimated savings of crash injuries prevented would be 

approximately $700 million in human capital terms or $2.1 billion by 

willingness-to-pay estimates had there been no driver education in 

public schools. Adding the savings from eliminating the program, the 

total savings would be about $863 million per year in human capital 

terms or $2.2 billion by willingness-to-pay estimates, not counting 

property damage. 

Laws Addressing Individual Behavior 

Estimates of savings from the effects of laws on individual behavior 

are not possible for many laws because the cost of enforcement is 

unknown. Estimates are attempted below for two cases -- legal driving 

age and motorcycle helmet use, for which the cost of enforcement is 

considered to be minimal. 

Legal Driving Age 

Driver education would have no adverse effect if the legal minimum 

driving age were raised to 18 (Robertson and Zador, 1978). Since no state 

has a minimum licensing age of 18, the exact effect of such a policy 

cannot be estimated. Research comparing fatal crash involvement of 16-

year-old drivers in New Jersey with a licensing age of 17 (except for an 

agricultural license at age 16) and Connecticut with a licensing age of 16 

indicates that about a 65-85 percent reduction in fatalities involving 16-

year-old drivers would ensue from a minimum licensing age of 17 

(Williams, Karpf, and Zador, 1983). Although the study found that the 

fatal crash rate involving 17-year-old drivers in New Jersey was slightly 

higher than in Connecticut, the fatal crash rate of drivers in the combined 

17-29 age group was comparable among the states. Also, there were no 

offsetting rates of 16-year-olds killed as pedestrians or bicyclists. 

In 1985, 2,014 people in the United States were killed in crashes 

involving 16-year-old drivers. Applying the same adjustments for parent 

substitution for 16-year-old drivers as in the case of driver education, 

about 1,375 deaths (0.91 x 0.75 x 2,014) would have been avoided if the 

legal driving age had been 17 in 1985. Assuming that the ratio of 

nonfatal to fatal injury distribution when these drivers are involved is 

similar to that for drivers in all age groups, the reduction in injury 

distribution of a 75 percent decrease in crashes by drivers less than 17 

years old would be approximately as follows: AIS 1 - 143,808, AIS 2 -

12,344, AIS 3 - 2,736, AIS 4 - 440, AIS 5 - 146, fatal - 1,375. Since it is 

unlikely that every trip of a 16-year-old driver would be substituted by a 

parent or other adult, this is a conservative estimate. 

A total savings of $1.4 billion in human capital terms or $4.3 billion 

by willingness-to-pay estimates would result from a minimum licensing 
Potential Savings fromInjury Prevention 119 

age of 17. This does not account for time spent by parents or others 

transporting teenagers under age 17 or the savings in property damage. 

A survey of teenagers in Michigan, New Jersey, and New York, with 

very different rates of licensure, found very little effect of licensure on 

lifestyle. The increase in percent of teenagers with jobs, comparing 

employment at age 15 and 16, was highest in New Jersey, where 

licensure at 16 was prohibited except in agriculture (Preusser, Williams, 

and Lund, 1985). 

Law enforcement expenditure would probably not have to be 

increased much, if any, to achieve the reduction. Most law enforcement 

would be achieved by parents who are unlikely to allow unlicensed 

drivers to use family vehicles. 

Motorcyclist Helmet Use Laws 

Laws requiring motorcyclists to use helmets reduce motorcyclist 

deaths by about 24-30 percent (Robertson, 1976; Watson, Zador, and 

Wilks, 1980; Hartunian, Smart, Willemain, and Zador, 1983). Data on 

nonfatal head injuries are sparse, but one study indicates that the 

increase in such injuries after repeal of a helmet law paralleled the 

increase in deaths (McSwain and Lummis, 1980). The nonfatal head 

injury to death ratio was 3:l. 

The number of motorcyclist fatalities in states without helmet laws 

in 1985 was 2,714. Therefore, based on a 24 percent reduction from the 

law, it is estimated that 651 fewer deaths and 1,953 fewer head injuries 

would have occurred had these states had helmet use laws. The 

reduction in injuries and deaths multiplied times their cost, results in an 

estimated cost reduction of $393 million in human capital terms or $1.5 

billion by willingness-to-pay estimates. 

Such a reduction is particularly significant because it would 

disproportionately reduce public expenditures. A detailed analysis of 

the cost of treatment and rehabilitative care of motorcyclists in a major 

trauma center found that 63 percent of the costs were borne by the 

taxpayers, mainly through Medicaid (Rivara, Dicker, Bergman, Dacey, 

and Herman, 1988). This is in contrast to all motor vehicle injuries, for 

which about 19 percent of treatment and rehabilitative costs are paid by 

Medicare and Medicaid (U.S. National Highway Traffic Safety 

Administration, 1983). 

Helmet use rates in states without laws range from 42 to 59 percent 

(Williams, Ginsburg, and Burchman, 1979). Assuming that about 50 

percent of the owners of registered motorcycles in the states without 

laws would have to purchase a helmet, the cost of the helmets would be 

approximately $296 million (based on a median price per helmet of $170 

in 1989, although some were available for less than $100). Assuming that 
120 Cost of Injury in the United States 

the helmet would be used in subsequent years, the annualized cost 

would be a fraction of that amount. Since virtually all motorcyclists use 

helmets in states where there are laws, the increment in law enforcement 

cost is considered nil. Therefore, if motorcyclist helmet use were 

required in states without such laws, the savings, subtracting the cost of 

the helmets, would be about $97 million in human capital terms or $1.2 

billion by willingness-to-pay estimates in the first year. Savings would 

increase in subsequent years because helmets would not have to be 

repurchased each year by most riders. 

An earlier analysis of the net human capital losses from motorcycle 

helmet repeal, using more detailed age distributions but a lower estimate 

of helmet costs, put the net cost of repeal of helmet laws at $160 million 

in 1980 (Hartunian et al., 1983). 

Product Design and Environmental Changes 

Numerous potential changes in product design and environments 

have been studied. For many, the cost and effectiveness varies by degree 

since various levels of protection are possible. The examples below --

cigarette design; automobile air bags, side crash protection, and 

automatic lights and head restraints; and offshore drilling equipment --

are analyzed briefly at one specified level of protection each. 

Reduced Ignition Potential of Cigarettes 

The most frequent cause of housefires is a cigarette dropped on 

bedding or upholstered furniture where it smolders and later produces a 

killing smoke or fire, often after occupants of the household are asleep. 

In response to The Cigarette Safety Act of 1984, a Technical Study Group 

on Cigarette and Little Cigar Safety produced a report on the feasibility 

and the cost of modifying cigarette design to reduce the likelihood of 

ignition by dropped cigarettes (Technical Study Group, 1987). 

Experimental cigarettes manufactured on equipment now used by 

the industry were tested on fabric, standardized as to padding and 

geometry. The numbers of ignitions in 20 tests varied from 0 to 20 for 

cigarettes with 41 combinations of type of tobacco, tobacco density, 

paper porosity, citrate added, circumference, and second paper 

wrapping. Lower ignitions were associated with low tobacco density, 

lower circumference, lower paper porosity, and no citrate added. 

Subsequent tests on commercially available furniture with fabric 

and substrate similar to the standardized mockup produced an 

exceptionally strong correlation (r=0.86) to results with the mockup. 

Although the Technical Study Group cautiously called for more work to 

establish performance criteria, the results of these studies indicate that 
Potential Savings from Injury Prevention 121 

reliable tests of cigarettes for potential ignition are feasible and standards 

for cigarette manufacture could be based on performance in such tests. 

Various costs and savings related to the modification of identified 

characteristics of cigarettes were estimated by a group at the National 

Bureau of Standards for the Technical Study Group (Ruegg, Weber, 

Lippiatt, and Fuller, 1987). A combination of modifications to cigarettes 

could achieve up to a 75 percent reduction in cigarette-related fire 

injuries, but several would result in increased cost of manufacture and 

lost revenues to farmers and in taxes. Reduced paper porosity, a 

modification that was assumed to generate no cost, produced a 30 

percent reduction in ignitions. A 30 percent reduction in cigaretteignited fires in 1985 would have avoided about 450 deaths and 2,100 

injuries as well as millions of dollars in property damage. The cost of 

these deaths and injuries is estimated to be $187 million in human capital 

terms or $1.1 billion by willingness-to-pay estimates (excluding reduced 

property damage cost). 

Air Bags 

After 20 years of regulatory battles and court decisions, a federal 

standard now specifies limits for forces on the head, chest, and legs in 

frontal crashes of automobiles at 30 miles per hour into a barrier. The 

standard is being phased in during the 1987-1990 model years. 

Manufacturers have indicated that, to comply with the standard, some 

vehicles will have driver-side airbags and safety belts in the right-front 

seat. Others will have the automatic safety belts in driver and right-front 

passenger positions. Automatic safety belts vary in effectiveness 

depending on design and ease of detachability (Graham and Henrion, 

1988; O’Neill, 1988). 

Estimates of the effect and cost of various forms of compliance with 

an automatic restraint standard have been the subject of controversy for 

two decades. The official regulatory analysis indicates fatality reductions 

of 40-50 percent for fully used lap-shoulder belts, 35-50 percent for fully 

used automatic belts, and 45-55 percent for air bags with full lap 

shoulder belt use (U.S. National Highway Traffic Safety Administration, 

1984). Since full belt use will not be accomplished, even with belt use 

laws and automatic belts, the actual effectiveness depends on projections 

of belt use generally and particularly among people at high risk. The 

effect on fatalities of increased use as the result of safety belt use laws is 

not nearly as high as predicted by estimated effectiveness of belts 

(Williams and Lund, 1988). 

Eventually, as the relative effectiveness of the various technologies 

in actual use becomes known, the use of air bags will likely increase. Use 

of full front-seat air bags, assuming no belt use, is estimated to reduce 
-- 

122 Cost of Injury in the United States 

deaths by about 6,190 (range 3,780-8,630); AIS 1 injuries, by about 

255,770 (no range indicated); and AIS 2-5 injuries, by about 110,360 

(range -- 73,660-147,560) (U.S. NHTSA, 1984). Since the midpoint of the 

range is the best estimate, it is used to estimate savings of approximately 

$8.7 billion in human capital terms or $23.5 billion by willingness-to-pay 

estimates. 

Increased belt use would reduce these estimates to the extent that 

there is overlap in the injuries reduced by air bags and those reduced by 

belts. Belt use laws have increased belt use from 10-20 percent to 40-60 

percent with an accompanying reduction in deaths of 5-15 percent 

(Williams and Lund, 1988). Some of that reduction is in side crashes and 

ejections that would not overlap with the effect of airbags. 

Since about 10 percent of the U.S. fleet is replaced with new vehicles 

each year, the savings from a modification of vehicles over their average 

lo-year use is about the same as the cost of injuries in a given year minus 

the cost of modifying a cohort of new vehicles of a given model year. 

The charges for air bags by manufacturers have varied from $300 per car 

for full-front-seat air bags as an option by General Motors in the mid 

1970s to $800 per car for driver-side air bags in certain recent models of 

several manufacturers. Like all vehicle components, the cost per unit is 

greatly reduced as a function of the number manufactured. The National 

Highway Traffic Safety Administration estimated $364 per car for fullfront air bags, including lifetime energy costs of the added weight of the 

vehicle (U.S. NHTSA, 1984). Multiplied times the number of new cars 

sold in 1985 (11.04 million), the cost of full-front air bags on all cars 

would be about $4 billion. Thus, subtracting the cost of the air bags, fullfront airbags in each model year would save about $4.7 billion in human 

capital terms or more than $19.5 billion by willingness-to-pay estimates. 

Side Crash Protection 

The National Highway Traffic Safety Administration is presently 

receiving comments on a proposed rule to increase protection to 

occupants of passenger cars hit from the side, which accounted for 32 

percent of car occupant fatalities in 1985 (U.S. NHTSA, 1988d). The 

NHTSA analysis presents effects and costs of various degrees of 

protection. At the highest level of proposed protection, estimated injury 

reduction would be approximately: AIS 3-5 - 4,735, fatal - 1,200. 

Since NHTSA did not estimate any benefits for reduction in AIS 1 

and AIS 2 injuries, the savings of $916 million in human capital terms or 

$3.5 billion by willingness-to-pay estimates are conservative. The ‘worst 

case’ cost estimate of the proposed side protection is $185 per car, 

including lifetime fuel costs, or a total cost, if applied to new cars sold in 
Potential Savings from Injury Prevention 123 

1985, of about $2 billion. Therefore, while it seems there would be no net 

savings in human capital terms at that level of protection, the savings by 

willingness-to-pay estimates, less the cost of increased side protection at 

the specified level, would be approximately $1.5 billion. 

Automatic Vehicle Lights 

Increased conspicuity of motor vehicles has been found an 

important factor in multiple-vehicle crash rates. Evaluations of the 

effects of the daytime use of headlamps, parking lamps, or redesigned 

systems have produced estimates of reductions in daytime, multiplevehicle crashes of 7-38 percent (Stein, 1985). Sweden experienced a 11-13 

percent reduction in such crashes when daytime headlamp use was 

required by law, despite the fact that 50 percent of drivers were using 

headlamps in daytime before the law (Transport Canada, 1986). 

While crash reductions can be largely accomplished by requiring the 

driver to turn the lights on by law as was done in Sweden, there is 

substantial potential for adverse reaction from people whose batteries 

die when they forget to turn the lights off at the end of a trip. An 

automatic relay that turns the lights off when the ignition is turned off 

would alleviate this problem. 

Although the current use of headlamps in daylight in the U.S. is 

unknown, it is unlikely to exceed 5 percent. Therefore, even considering 

the differences in weather and hours of daylight year-round between 

Sweden and the United States, the 11-13 percent reduction in crashes in 

Sweden, given a 50 percent prelaw headlamp use, seems a minimum to 

expect from automatic use were such a policy adopted in the United 

States. 

Assuming that the nonfatal severity to death ratio in daytime 

multiple-vehicle crashes is similar to all crashes, a 12 percent reduction in 

daytime multiple-vehicle collisions in 1985 would reduce injuries 

approximately as follows: AIS 1 - 38,907, AIS 2 - 3,337, AIS 3 - 740, AIS 4 -

119, AIS 5 - 40, fatal - 372. This amounts to $391 million in human capital 

terms or $1.2 billion by willingness-to-pay estimates, excluding property 

damage and pedestrian injuries that might be avoided by greater vehicle 

conspicuity. 

Transport Canada estimates the lifetime cost per vehicle of 

automatic reduced intensity highbeams at $40 for cars and light trucks, 

including increased fuel use. Applied to the 15.5 million cars, light 

trucks, and vans sold in 1985, the lifetime cost of the lights would be 

about $620 million. Since the lifetime use of a given model year is about 

equal to that of the full fleet in one year, automatic lights on all new 

vehicles in a given model year, if only 12 percent effective, would 

produce no savings in human capital terms but would save about $534 
�

124 Cost of Injury in the United States 

million by willingness-to-pay estimates, after subtracting the cost of the 

lights. Using a human-capital cost method and including savings in 

property damage excluded here, Transport Canada concludes that the 

savings from automatic headlamps would be greater than the costs 

(Transport Canada, 1986). 

Automatic Head Restraints 

The federal standard for head restraints can be met by adjustable 

restraints or by high seat backs that automatically reduce neck injury in 

rear-end crashes. Despite the fact that high seat backs are probably less 

expensive and certainly more effective in reducing neck injuries, about 

70 percent of new cars are equipped with adjustable restraints. High seat 

backs were found to reduce injuries by 17 percent compared to 10 

percent for adjustable restraints and were said to cost $28 less per car 

(Kahane, 1982). Recently, the National Highway Traffic Safety 

Administration has revised its cost estimate, indicating little difference in 

the cost of the two types of restraints on average, but the cost is said to 

vary from $20 to $40 for adjustable restraints and $20 to $37 for high seat 

backs depending on materials used (U.S. NHTSA, 1988c). 

A reduction of about 64,000 neck injuries in rear-end motor vehicle 

collisions occurred annually with a mix of 70 percent adjustable 

restraints and 30 percent high seat backs. If there were 100 percent high 

seat backs, the reduction would be about 85,000, a difference of 21,000. 

In 1981, neck injuries were estimated to cost about $670 per case, not 

counting pain and suffering (Kahane, 1982). Therefore, 100 percent 

installation of high seat backs would save approximately $14 million per 

year in injury cost, assuming no difference in the cost of the two types of 

seat on average. 

Power Makeup Equipment in Offshore Drilling 

In oil drilling, pipes are connected and disconnected by large tongs 

that work similarly to wrenches. Workers who handle the tongs 

experience a variety of injuries. Worker proximity to the mechanical 

energy in such operations can be altered by the use of ‘power makeup 

equipment.’ Comparison of sites with such equipment to those without, 

both before and after the installation of the equipment, indicates a 

reduction of 42 percent in related worker injuries per hours worked. The 

reduced cost of the injuries would pay for the equipment in 6 years 

(Mohr and Clemmer, in press). 

Since the extent of such equipment use throughout the industry is 

unknown, the total savings to society if the equipment were installed at 

all offshore drilling sites cannot be estimated. Nevertheless, the case 

illustrates the principle that injury reducing equipment in industry can 
Potential Savings fromInjury Prevention 125 

pay for itself in reduced injury costs and should be considered an 

investment rather than a cost. 

Data Needed for Estimation of Savings 

A list of some interventions for which data on effects have been 

estimated, but data on other aspects of savings analysis are unknown, is 

presented in Table 28. Many of the references for this section are in the 

table and are not repeated in the text. Although a large-scale literature 

review was conducted to find examples of interventions with known 

effectiveness, some may have been missed. 

Missing Implementation and Cost Data 

Counseling by physicians has been found to promote injuryreducing behaviors such as child restraint use and purchase of smoke 

detectors. In the study of pediatric counseling regarding infant falls from 

tables, beds, etc., counseling was associated with a 41 percent reduction 

in such falls compared to a control group that did not receive counseling. 

The extent and cost of the counseling and the severity and cost of the 

injuries are unknown. 

Drownings associated with children wandering into unsupervised 

swimming pools occurred 65 percent less frequently in Honolulu, where 

pool fencing is required, than in Brisbane, Australia which had no such 

requirement. The cities have similar weather and pool to household 

ratios. While the cost per pool of fencing can be easily obtained, the 

extent of installed fencing of pools in the U.S. is unknown as is the 

distribution and cost of drownings and near drownings associated with 

the lack of fencing. 

Motor vehicle fatalities and other health problems related to alcohol 

are lower in correlation with increased alcohol taxes, but taxes have not 

been raised to keep pace with inflation. Restoring the 1950 taxes on 

alcohol adjusted for inflation would increase the revenues generated by 

$20 billion per year (Hacker, 1987). Since both the severity distribution 

of injuries attributable to alcohol and the cost of administering the taxes 

are unknown, an estimate of the savings from increased alcohol taxes is 

not attempted here. 

Although relatively nonsevere injuries must occur in substantial 

numbers to equal the cost of one very severe injury, such seemingly 

mundane injuries as fractures and other injuries from sliding into bases 

while playing softball are not without significant cost. A recent study 

estimated a cost of $1,223 per sliding injury. Use of breakaway bases 

reduced such injuries by 95 percent at a cost of $48 per base (Janda, 

Wojtys, Hankin, and Benedict, 1988). Without an estimate of the extent 
126 Cost of Injury in the United States 

of the injuries and the use of breakaway bases nationally, however, 

savings from the universal use of breakaway bases cannot be calculated. 

Administration and Enforcement Costs 

Motor vehicle occupant deaths of infants (per 100,000 population in 

that age group) declined 37 percent from 1980 to 1984 in association with 

the enactment of child-restraint use laws. The reduction in 1980-84 for 

children aged 14 was 25 percent and for children aged 5-9, 11 percent 

(Robertson, 1987). Head injuries to children less than 4 years old in one 

emergency room declined 26 percent from before to after the childrestraint-use law in California; changes in less severe injuries were 

statistically insignificant (Agran, Dunkle, and Winn, 1987). 

Motor vehicle occupant deaths of young children (per 100,000 

population in that age group) declined about 30 percent from 1968 to 

1979 (Baker et al., 1984) in association with motor vehicle safety 

standards and the 55 mile-per-hour speed limit. This trend should not 

have continued into the 1980s because the effects of those policies were 

fully realized by 1980. Child-restraint laws no doubt account for some of 

the reductions in child occupant deaths in the 1980s. One analyst 

attributes 153 fewer child deaths in 1985 to the laws (Partyka, 1989). The 

reductions were found despite numerous exemptions in state laws. An 

analysis of state laws requiring child-restraint use found that 39 percent 

of the children O-5 years old killed in the year preceding the law were not 

covered by the law because of age or other exemptions (Teret, Jones, 

Williams, and Wells, 1986). If the exemptions had not retarded restraint 

use, an estimated additional 98 children ((153/0.61)-153) would not have 

died in 1985. 

It is not possible to estimate savings from eliminating the exceptions 

in child-restraint laws because data on the number of child seats that 

would have to be purchased and the cost of law enforcement are 

unknown. Many areas have child-seat loan programs that allow reuse of 

seats, but the extent of reduction in cost attributable to these programs is 

unknown. 

The cost of the administration of laws has seldom been studied. The 

cost of police enforcement varies depending on whether police are 

reassigned from other duties that are more or less beneficial or whether 

the police force is expanded. Certain laws such as administrative license 

suspension for driving while intoxicated (DWI), mandatory jail sentences 

for DWI, and required use of safety belts have been found to have some 

effect on fatalities. Administrative license suspension for DWI expanded 

to the 75 percent of states without such a policy would save $1.7-$4.6 

billion, less the cost of administration. Mandatory jail sentences 
Potential Savings from Injury Prevention 127 

Table 28 

Examples of Injury Control Countermeasures with Known Effectiveness: 

Data Needed for Savings Analysis 

Effect (% Percent Severity cost of Cost of 

Intervention reduction) Unapplied* Distribution Injuries Intervention 

Pediatric counseling 

on infant falls 

(Kravitz, 1973) 

Fenced swimming 

pools (Pearn et 

al., 1979) 

Alcohol taxes 

(Cook, 1981) 

Breakawav bases for 

softball (Janda 

et al., 1988) 

Administrative liccense suspension 

for DWI (Zador et 

al., 1988) 

First offense mandatory jail sentence for DWI 

Zador et al., 

1988) 

Belt use laws 

(Williams and 

Lund, 1988) 

Gun registration and 

waiting period 

(Medoff and 

Magaddino, 1983) 

Repeal right-turnon-red laws (Zador 

et al., 1982) 

Required smoke 

detectors in homes 

(McLoughlin et al., 

1985) 

41% Unknown Unknown Unknown Unknown 

of treated 

falls 

65% Unknown Unknown Unknown Unknown 

child pool 

drownings 

7% Varies Unknown Unknown Unknown 

auto fatals by state 

per 10% 

increase in 

liquor price 

95% Unknown see ref. $1,223 $48 extra 

sliding 

injuries per

injury 

per base 

5% 75% Estimated $1.7-$4.6 Unknown 

of all by ratio billion 

fatals per death 

2% 76% Estimated $700- Unknown 

of all by ratio $1,857 

motor- per death million 

vehicle 

fatals 

7% 20% Estimated $342- Unknown 

front occu- by ratio $906 

pant fatals per death million 

24% Unknown Unknown Unknown Unknown 

suicides 

57% Unknown Unknown Unknown Unknown 

pedestrian 

injuries at 

such sites 

25% Unknown Unknown Unknown Unknown 

fatal 
128 Cost of Injury in the United States 

Table 28 (Cont.) 

Effect (% Percent Severity cost of cost of 

Intervention reduction) Unapplied’ Distribution Injuries Intervention 

Window barriers in 90% Unknown Unknown Unknown 

high-rise buildings 

(Bergner, 1982) 

Amber timing Potential Optimally Derivable Derivable 

at intersections 12-70% unknown from NASS 

(Zador et al.,1984) all such 

crashes 

Flashing lights at 80% Unknown Unknown Unknown 

rural stop signs fatal 

(Hagenauer 

et al, 1982) 

Pedestrian-friendly 30% Unknown Derivable Derivable 

vehicle front ends fatal from NASS 

(Ashton, 1982) 

Reflective tape on 18% Unknown Unknown Unknown 

outline of large night- time 

trucks (Burger et car into 

al., 1986) truck crashes 

Breakaway utility 30% Unknown Derivable Unknown 

poles near roads fatal of from NASS 

(McFarland et al., such crashes 

1979) 

Remove u tilitv 38% Unknown Derivable Unknown 

poles from roads fatal of from NASS 

(McFarland et al.,) such crashes 

1979) 

Remove trees 50% Unknown Derivable Unknown 

from roadsides fatal of from NASS 

(McFarland et al., such crashes 

1979) 

Impact attenuators 50-75% Unknown Derivable Unknown 

at fixed objects fatal from NASS 

(McFarland et al., of such 

1979) crashes 

Breakaway signs 40-70% Unknown Derivable Unknown 

(McFarland et al., fatal from NASS 

1979) of such 

crashes 

Improve guardrail 55% Unknown Unknown Unknown 

ends (McFarland et fatal of 

al., 1979) such crashes 

Need 

updated 

figures 

Unknown 

Unknown 

Unknown 

Unknown 

Need updated 

figures per 

pole 

Need updated 

figures per 

pole 

Need updated 

figures per 

tree 

Varies by 

type 

Varies by 

type 

Varies by 

type 
Potential Savings from Injury Prevention 129 

Table 28 (Cont.) 

Effect (% Percent Severity cost of cost of 

Intervention reduction) Unapplied+ Distribution In juries Intervention 

Transition guardrail at bridge ends 

(McFarland et al., 

1979) 

Upgrade substandard 

guardrail 

McFarland et al., 

1979) 

Concrete median 

barrier 

McFarland et al., 

1979) 

Widen bridges 

(McFarland et al., 

1979) 

Improve curve 

delineation 

(McFarland et al., 

1979) 

Channel left turns 

(McFarland et al., 

1979) 

Lighting freeways 

(McFarland et al., 

1979) 

Flashing lights and 

gates at rail-highway crossings 

(Pinnell et al., 

1982) 

Limited access to 

businesses on 

rural roads 

(Stover et al., 

1982) 

One-way urban 

streets 

(Parsonson et 

al., 1982) 

55% Unknown Unknown Unknown Varies by 

fatal of such 

crashes 

15% Unknown Unknown Unknown Varies by 

fatal of type 

such crashes 

85-90% Unknown Derivable Unknown Need updated 

fatal from NASS figures 

crossover 

head-on 

50% Unknown Unknown Unknown Varies by 

fatal of 

such crashes 

16% Unknown Unknown Unknown Need updated 

fatal of figures 

such crashes 

42% Unknown Unknown Unknown Need updated 

fatal of figures 

such crashes 

50% Unknown Derivable Unknown Need updated 

fatal of from NASS figures 

such crashes 

60-80% Unknown Unknown Unknown Unknown 

fatal 

33% Unknown Unknown Unknown Unknown 

fatal at 

appropriate 

sites 

10-50% Unknown Unknown Unknown Unknown 

pedestrian 

injuries 

* Percent of population for which interventions have not been implemented 

for DWI in the states without it would save $342-$906 million, but the 

unknown cost of administration and keeping prisoners would 

substantially offset those savings. Mandatory belt use in the states 

without it would save $700-$1,858 million, less the cost of enforcement 

and administration. 

The lack of data on administrative and enforcement costs, as well as 

arguments over the effectiveness of laws such as gun control laws, also 

impedes savings analysis. More than half the suicides and homicides in 
130 Cost of Injury in the United States 

the United States are committed with firearms. Controlling for age, 

income, religion, region, and occupational status, laws that require a 

license or waiting period for purchase of a firearm are associated with a 

reduction in suicides of 3 per 100,000 population (Medoff and 

Magaddino, 1983). 

Such laws have generally been found more effective than laws that 

prohibit carrying concealed weapons, presumably because they are more 

enforceable (Lester and Murrell, 1982). Another study estimated that if 

New Jersey’s law had been applied in all states in the 1960s, some 4,200-

6,400 fewer deaths would have occurred annually from suicide, 

homicide, and unintentional firearm injuries (Geisel, Roll, and Wettick, 

1969). The New Jersey law included licensure of dealers and purchasers; 

delay between purchase and acquisition; maintenance of records of sales; 

restrictions on sales to felons, drug addicts, alcoholics, mentally ill 

persons, and minors; and restrictions on carrying handguns in motor 

vehicles or as concealed weapons. The results of that study have been 

questioned because the correlation was reduced when controls for region 

of the country were introduced in the analysis (Magaddino and Medoff, 

1984). 

Recent research compared assaults and homicides in Seattle and 

Vancouver, the latter with stricter rules regarding gun ownership. Gun 

ownership is not allowed for ‘self-protection’ in Vancouver but is 

allowed in Seattle. The two cities, 140 miles apart, have similar weather, 

unemployment, education, household income, and burglary and robbery 

rates. Although aggravated assaults and homicide rates, excluding those 

in which guns were involved, were similar in the two cities, the firearm 

assault rate in Seattle was 7.7 times that in Vancouver and the firearm 

homicide rate was 5.1 times higher (Sloan, Kellerman, Reay, et al., 1988). 

Since the lack of uniformly strict state laws regarding gun licensure 

and waiting periods allows for interstate transportation of guns by 

unqualified owners from less to more strict states, it is likely that a 

uniform policy would have more effect than has thus far been 

demonstrated by comparing the experience of states with different laws. 

Research on the effect of allowing drivers to turn right on red at 

signalized intersections indicates an overall 57 percent increase in 

pedestrian collisions in states where the law allowed right turns 

compared to states with no change in the law during the same period. 

Studies of all intersection crashes attribute only about 1 percent to rightturn-on-red (Hagenauer,Upchurch, Warren, and Rosenbaum, 1982), but 

the studies include dubious assumptions regarding the validity of police 

reports on the color of lights at the time of the crashes before the officer 

arrived. If the right-turn-on-red laws were repealed, the number of 

intersections where the signs would have to be changed and the cost of 

such changes is unknown. 
Potential Savings from Injury Prevention 131 

Comparison of a county with a law requiring smoke detectors in 

homes to a county without that requirement suggests that the 

requirement is associated with a 25 percent reduction in deaths from 

housefires. About 67 percent of U.S. households had smoke detectors in 

1982 (U.S. Fire Administration, 1983), but the extent of coverage of 

smoke-detector legislation is unknown. 

Fatal falls of children crawling out windows of multistoried 

buildings were reduced 90 percent in New York City in association with 

programs promoting the use of window barriers and regulations 

requiring such barriers. The number of barriers needed in other cities is 

unknown. 

Motor Vehicle Environments 

The length of the yellow phase of traffic control lights among 

signalized intersections is associated with a substantial difference in 

crash rates, the degree depending on the length of the lights (Zabor, 

Stein, Shapiro, and Tarnoff, 1984). A review of other studies suggests 

less effect in before-after comparisons when lights are changed 

(Hagenauer et al., 1982). The lack of use of control groups of 

intersections without light changes does not allow estimation of changes 

in crash rates that would have occurred without the light changes. An 

all-red interval after a green in either direction at intersections has also 

been associated with reduced crash rates (Hagenauer et al., 1982). The 

distribution of the timing of yellow lights and the use of all-red phases is 

not known, nor is there a good estimate of the range of injury severity 

affected. 

Use of flashing lights at approaches to stop signs at rural 

intersections is associated with substantially reduced crash rates. One 

study found a 51 percent reduction in injuries and an 80 percent 

reduction in deaths at installation sites (Hagenauer et al., 1982). Better 

controlled research and a census of relevant sites are needed to assess the 

savings potential of the use of warning flashers. 

Comparison of injuries to pedestrians struck by the frontends of 

vehicles in England suggests that a 30 percent reduction in pedestrian 

fatalities could be achieved if all vehicles were designed to reduce the 

energy exchanges from points, edges, and characteristics related to the 

kinematics of the event. Since some of these changes would result in less 

use of materials, such as elimin.a tion of sharp points on the front corners 

of several large American cars, there could possibly be a lower cost of at 

least some vehicles as well as savings in injury costs. The extent of all the 

changes needed in U.S. vehicles has apparently not been studied in 

sufficient detail for savings analysis. 
132 Cost of Injury in the United States 

Comparison of large trucks with reflective tape defining the outline 

of the trucks and trucks without the tape indicates a 15 percent reduction 

of car-into-truck crashes associated with reflectorization. The extent of 

use of this approach is unknown, but trucks with striping are rarely seen 

on the roads. 

Fatal crashes that occur when vehicles cross into the paths of 

oncoming vehicles are reduced 85-90 percent by concrete barriers that 

are flared at the bottom to guide an errant vehicle back into its lane. 

While the cost of such installations per mile can be obtained, the number 

of miles of road at high-risk sites is unknown. 

Crash rates related to bridge width are a function of both bridge 

width and the width of the approaching road (Bissell, Pilkington, Mason, 

and Woods, 1982). Widening of bridges is associated with an average 50 

percent reduction in fatal crashes related to bridge width. Modifications 

of the road approach, such as diagonal shoulder markings, continuous 

guardrail tapered before the bridge structure and post-mounted 

delineators behind the guardrail, have also been demonstrated to reduce 

bridge crashes substantially. The number of bridges that could be 

widened or approach roads modified to achieve the maximum reduction 

in injury is unknown. 

As noted previously, motor vehicle crashes occur disproportionately 

on or near curves. Better delineation of curves (edge and center stripes, 

roadside and center reflectors, and the like) is associated with about 16 

percent reduction in fatal crashes on modified roads. The miles of road 

curvature lacking such delineation is unknown. Curved road sections 

with low or absent cross slopes are particularly hazardous when wet. At 

one such section on the Washington, DC beltway, Congressional staff on 

rainy days filmed cars spinning and some that had spun off the road, 

going over embankments or striking bridge abutments (Kelley, 1972). 

One study found an average 25 percent difference in crashes per mile 

between sites that had no cross slope and a 0.025 ft. downward slope per 

foot of road in an area with an average rainfall of 60 inches per year (Dart 

and Mann, 1970). The extent of the problem nationally and the injury 

reduction that would be realized from modification of cross slopes 

unknown. 

Pavement grooving has also been found to be effective in reducing 

crashes on wet roads, but the estimates vary widely among studies -- 27 

percent reduction in Louisiana, 69 percent in California, and 62 percent 

in Baltimore. One study in Ohio indicated increased crashes on grooved 

sections in dry weather, but the other studies did not find a significant 

effect on dry-pavement crashes (reviewed in Gallaway, Benson, Mounce, 

Bissell, and Rosenbaum, 1982). The injury severity distributions in these 

crashes and extent of surfaces that would produce benefits from 

grooving are unknown. 
Potential Savings from Injury Prevention 133 

At intersections, lanes that channel left-turning vehicles out of the 

path of through traffic are associated with a 42 percent reduction in fatal 

crashes compared to intersections without this feature. Channeling is 

more effective at unsignalized intersections (54% injury reduction) than 

at signalized intersections (36% injury reduction), (Hagenauer et al., 

1982). Identification of the numbers of high-risk intersections that would 

produce a savings from channeling has apparently not been done. 

About 50 percent fewer fatal crashes occur on lighted sections of 

urban freeways compared to unlighted sections. Studies of lighting on 

several major routes indicate that lighting less than 0.4 horizontal foot 

candles is ineffective at best and may increase crashes (Schwab, Walton, 

Mounce, and Rosenbaum, 1982). Also, the placement of light poles near 

the road may increase the crash rate and, if they do not break away on 

impact, the severity. 

Intersection crash rates at night are substantially lower at lighted 

compared to nonlighted intersections, 25 to 86 percent lower depending 

on such elements as type of intersection, type of crash, and number of 

lanes (Hagenauer et al., 1982), but data on relative severity and numbers 

of intersections involved by type are inadequate for estimation of 

savings. 

Studies of sight distance impaired by hedges, fences, and the like at 

intersections indicate substantial reduction of crash rates associated with 

greater sight distance (Hagenauer et al., 1982). However, the relative 

severity of associated injuries and the extent of the problem have not 

been adequately studied for savings estimates. 

Crashes of motor vehicles and trains at intersections of roadways 

and train tracks are often very severe. The effectiveness of warning 

devices such as flashing lights and gates has been estimated at 64 to 80 

percent reduction in severe and fatal injuries in such crashes (Pinnell, 

Mason, Berg, Coleman, and Rosenbaum, 1982). Separation of motor 

vehicle and rail traffic by overpasses is obviously even more effective. 

In 1973, the Highway Safety Act authorized federal assistance for 

improvements at rai lroad crossings. About $1.2 billion was expended to 

eliminate or modify 5,600 railroad crossings in the ensuing decade. The 

numbers of motor vehicle fatalities at such crossings declined from 1,128 

in 1974 to 542 in 1984 although exposure increased 4 percent (Dempsey, 

1985). If the deaths had continued at the 1974 rate, about 2,500 more 

people would have died and nonfatal injuries of unspecified severity 

would have declined 28 percent. The reduced deaths alone resulted in a 

savings of about $1 billion in human capital terms or approximately $5 

billion by willingness-to-pay estimates, the latter several times the 

expenditure for the improvements. Since the installations will continue 

to produce savings, the total return will be larger. 
134 Cost of Injury in the United States 

Crashes per mile on rural highways are strongly correlated to 

number of business accesses per mile. Often in a string of adjacent 

businesses, each has its own parking lot and entrance. The parking lots 

could be joined and the in-and-out traffic channeled to a single entrance. 

The data suggest that an average 33 percent reduction of fatalities could 

be achieved on roads with no access control if they were changed to 

partial access control (Stover, Tignor, and Rosenbaum, 1982). The 

number of road sections that would produce benefits from partially 

limited access is unknown. 

In urban areas, changing traffic flow on a street from two-way to 

one-way traffic frequently results in reduced crashes and pedestrian 

injuries, although the variation is wide, 10 to 50 percent. Efficiency of 

traffic flow is also usually a benefit (Parsonson, Nehmad, and 

Rosenbaum, 1982). To specify the savings involved, more research is 

needed on the types of streets that would produce benefits, their 

numbers, and the distribution of crash severities. 

In 1985, almost 12,000 motor vehicle fatalities occurred in collisions 

with fixed objects near roadsides -- trees or shrubbery (2,967), utility 

poles or signs (2,221), guardrails (1,129), and other objects (5,477). 

Research indicates that 50 to 75 percent of these fatalities could be 

prevented by removal of trees from roadsides, impact attenuators, 

breakaway poles and signs, and improved guardrails. The current cost 

of such modifications per modification can be obtained, but the number 

of sites that need modifying is unknown. 

Targeting Interventions 

As noted above, the cost of applying many interventions is 

dependent on the extent to which they are targeted to high-risk 

populations or sites. For example, research comparing sites of fatal 

crashes into fixed objects with sites one mile in the direction from which 

the vehicles traveled indicates the high-risk sites can be substantially 

identified by road characteristics. Twenty-five percent of the crash sites 

were within 500 feet of curves greater than 6 degrees with downhill 

grades greater than 2 percent. Only 8 percent of the comparison sites 

had such characteristics. There was no difference in number of objects 

along the road at the fatal and comparison sites (Wright and Robertson, 

1976). Use of such epidemiologic studies to set priorities would decrease 

the cost of many interventions relative to the cost of associated injuries. 

An example of one such successfully targeted intervention occurred 

on Queens Boulevard in New York City. Spot maps of pedestrian severe 

and fatal injuries during 1980-84 revealed clusters on this widest street in 

the city. Eighty-five percent of the persons injured were aged 65 and 

older suggesting that interventions related to walking speed and vision, 
Potential Savings from Injury Prevention 135 

as well as speed control and education, might be effective (Retting, 1988). 

In 1985, several countermeasures were introduced at a total cost of about 

$150,000: 1) timing of lights was changed to increase pedestrian crossing 

time; 2) pedestrian signals were placed on median islands; 3) roadway 

markings were increased to identify pedestrian walkways and traffic 

flow; 4) size of speed limit signs was increased and speed enforcement 

increased; and 5) presentations on pedestrian safety were given at senior 

citizen centers. The deaths and severe injuries in the targeted area were 3 

per year in the two years after these measures were introduced 

compared to 8 per year in the five years before. 

Feasibility 

Effectiveness and savings analysis ignores feasibility of 

implementation because of ideological factors and concentrated interests 

that may oppose certain interventions. Policies such as government 

subsidization of bicycle helmet purchases, while acceptable in Australia, 

may be difficult to implement in the U.S. Although the majority of 

motorcyclists are in favor of helmet use laws, a vocal minority have been 

successful in gaining repeal in many states (Baker, 1980). Seemingly 

overwhelming ideological opposition or lobbying power is not always as 

solid as it appears, however. No one familiar with Tennessee politics 

would have expected that state to be the first to enact a child-restraint 

use law, but it did, and other states followed. The gun lobby spent $6 

million in an attempt to defeat Maryland’s new gun control legislation 

but was overwhelmingly defeated in a referendum in the 1988 election. 

The incremental approach discussed here also neglects the question 

of the circumstances under which the injurious consequences of certain 

products are so severe relative to whatever uses they have that they 

should be banned. In the 1960s, about 700 people per year in the U.S. 

died on motorcycles. As a result of massive advertising of motorcycles 

aimed at a broad spectrum of the population (Sakiya, 1982), sales soared 

and motorcycle registrations increased from about 500,000 in the 1960s to 

5.6 million by 1984. Deaths on motorcycles rose from 700 to 4,600 per 

year. In the 1980s, racing motorcycles capable of speeds of 160 miles per 

hour were introduced for street use. These racing motorcycles have 

death rates about twice those of other motorcycles (Kraus, Zador, 

Arzemanian, Anderson, and Harrington, 1988). 

A marketing effort similar to that for motorcycles, but directed to 

children as well, led to a large increase in sales of so-called ‘all-terrain 

vehicles’ (ATVs) and an accompanying increase in deaths. In this case, 

however, the government acted while the deaths were in the hundreds, 

rather than the thousands, per year. The industry has agreed to stop 

marketing 3-wheeled ATVs, but the Consumer Product Safety 
136 Cost of lnjury in the United States 

Commission allowed continued marketing of 4-wheeled ATVs in a 

compromise to avoid extensive litigation, although 4-wheeled ATVs may 

be as unstable as 3-wheelers (Kitzes, 1989). The government has refused 

to act on numerous other product-related hazards (Berger and Rivara, 

1980; Christoffel and Christoffel, 1989; Robertson, 1989). 

Conclusion 

There is some uncertainty in each of the estimates of potential for 

injury reduction because of variation in sampling error and the lack, in 

some cases, of good experimental design. There is, however, no doubt 

that a substantial proportion of severe injuries could be reduced by a 

greater application of current knowledge. The potential savings, net of 

the cost of injury control programs, is in the billions of dollars for the 

interventions for which data are available. Usually, savings estimates are 

far more sensitive to differences caused by using the human capital or 

the willingness-to-pay method than to variation in estimates of 

effectiveness of a given intervention. For example, there is nearly a fourfold difference in savings from air bags estimated by the human capital 

method compared to the willingness-to-pay method. There is, however, 

no such variation in estimated effectiveness of air bags. 

Savings in the billions of dollars were found for air bags ($5-$19 

billion), a minimum licensing age of 17 ($1.4-$4.3 billion), and the 

elimination of driver education from the public schools ($0.8-$2.2 

billion). Tens of millions would be saved by reduced cigarette paper 

porosity ($187-$1,100 million), high seat backs in cars ($14 million), 

motorcycle helmet laws in states without them ($97-$1,200 million), 

bicycle helmet use promotion ($183-$284 million), and child-pedestrian 

programs ($58-$180 million). Estimated by the willingness-to-pay 

method, the savings from automatic headlamps on cars and light trucks 

($534 million) and increased side crash protection for cars ($1.5 billion) 

are large. Because of the exclusion of the cost of property damage, the 

estimated savings for eliminating high school driver education, increased 

licensing age, reduced cigarette ignition, and automatic headlamps are 

substantially understated. 

As noted in the discussion above of the estimates for driver 

education and licensing age, the savings from some programs or policies, 

if implemented, would reduce the savings from others. Several of the 

programs and policies mentioned are independent of one another, but 

there is overlap in those related to injuries in or by motor vehicles. For 

example, air bags would reduce some of the injuries that would also be 

reduced by changes to the road environment, and these changes would 
Potential Savings from lnjury Prevention 137 

contribute to a part of the reduction in motorcycle and bicycle injuries, 

which would also be reduced by increased helmet use. 

Although complete information needed to calculate the precise 

savings that would result from implementing numerous approaches is 

missing, the cost of preventable injuries is so large that implementation 

would have to be enormously expensive to contraindicate action. Cost 

could be reduced substantially by collection and use of better data on the 

clustering of injuries geographically in some cases and in particular 

populations in others. Better data on the extent of current 

implementation and cost of implementation would contribute to more 

rational choices among programs and policies. 
Chapter 6 

Long-Term Impact of Injury on Individuals, 

Families, and Society 

Personal Narratives and Policy Implications 

Every injury resulting in severe disability causes profound personal, 

familial, and social impacts over the long term. An injury episode is not 

only physical and physiological, but is a deeply personal event occurring 

in an extended interpersonal and social context. What happens to 

severely injured individuals in the United States is a result not only of 

the physical trauma itself and the quality and extent of the medical care 

that follows, but also of the long-term support available from a variety of 

sources: family, friends, community groups, health care and social 

service delivery systems, and legal, insurance, and political institutions. 

The ability of severely injured people to attain maximum physical 

recovery, to survive financially, and to reorganize their lives within new 

limitations is dependent on a society with laws and policies that 

constrain or enable secure, productive lives regardless of inhibited 

functional status. 

The case studies below illustrate what happens to people with 

severe disabilities in the various contexts that impinge directly upon 

their well-being in the months and years following an injury. Together, 

these case studies tell a story of the struggle to acquire the personal, 

therapeutic, legal, and financial aid that enables injured persons to 

survive, have basic needs met, and create for themselves lives that are 

meaningful in terms of work, love, mutual support, recreation, and 

personal growth. A major disability resulting from injury shatters an 

individual’s world. Basic routines and activities of daily living can no 

longer be taken for granted. One’s place and role in family, community, 

and society are no longer the same. One never returns to previous 

conceptions of ‘normal.’ Perhaps most importantly, following an injury, 

one’s entitlement to society’s resources such as jobs, housing, education, 

and transportation is no longer automatic. Severely injured people have 

a ‘betwixt and between’ or undefined social status regarding their roles 

as productive participants in community life and as autonomous, 

decision-making beings. “They are neither ill nor well, neither socially 

alive and active nor socially expunged and removed” (Murphy, Scheer, 

Murphy, and Mack, 1988). A sudden disability renders an individual’s 

access to medical and social services, work, and housing questionable. A 
140 Cost of Injury in the United States 

negotiation process over access begins immediately following the injury 

and continues sometimes for years. 

The most comprehensive finding of the present study is that all 

participants needed to negotiate with health care, legal, and insurance 

institutions in order to secure a place for themselves in society following 

an injury. Access to long-term rehabilitation, psychological support, 

appropriate attendant services, housing, medication, equipment, and 

employment opportunities all had to be negotiated, or even fought for, 

within the regulations and policies of particular agencies and 

institutions. Thus, documenting the personal, noneconomic costs 

resulting from an individual’s or family member’s injury involves 

discussion of the social institutions in which their lives are embedded, 

the solutions those institutions are able to provide, and the problems 

they sometimes create. 

Methods and Subjects 

The following pages describe what happened to ten individuals and 

some of their family members over a period of two to eighteen years 

following a severe injury. Interviewees were selected from health care 

and social service professional referrals. Only mentally alert, expressive, 

articulate individuals were selected as subjects for this study in order to 

gather detailed information on the full range of the injury’s ramifications. 

Thus, the ability to express oneself was the first criteria for subjects 

chosen. Second, subjects chosen had mechanisms of injury typical of 

those occurring in the U.S., and common residual disabilities as well. 

Third, the personal stories of the ten individuals, though unique and 

idiosyncratic, are similar to thousands of other injury and disability 

stories. Thus, the case studies were carefully chosen to be widely 

representative of injury and its aftermath. Moreover, study participants 

were ordinary citizens. None were wealthy or famous. All were forced 

to make difficult choices under tragic circumstances. Their stories 

illustrate the financial, social, and institutional constraints that influence 

the decisions and give shape to the opportunities of injured persons. The 

stories are a testament to the strength of the human spirit under great 

adversity. 

The case studies illustrate the following injury-causing episodes: 

automobile crash, motorcycle crash, near drowning, diving into shallow 

water, contact sport, brutal beating, fall following an illness, fall in the 

workplace, and crush following malfunctioning workplace equipment. 

The studies represent the following residual disabilities: quadriplegia, 

ventilator-dependent quadriplegia, both mild and severe brain damage, 

severe central nervous system damage, facial disfigurement, amputated 

and deformed fingers, functionless hand and arm, and general weakness 
Long-Term Impact 141 

and inability to walk. The names used are pseudonyms and identifying 

information has been eliminated in order to preserve anonymity. The 

case studies portray events and responses from the point of view of the 

injured person or a family member who was the major caregiver of the 

injured person. The studies are entirely subjective (see Appendix B for a 

full description of methods). 

Data were collected from five injury survivors, four parents of 

survivors, one spouse, and one sibling. The small study group does not 

adequately represent the ethnic diversity of the U.S. population or of the 

greater San Francisco Bay Area, the location of all the interviews. The 

study group, however, represents a range of economic, occupational, and 

educational backgrounds. The California study group possibly had 

more services available than in other places in the country. 

‘Invisible’ Survivors 

There are thousands of severely disabled individuals in the San 

Francisco Bay Area. Yet finding injury survivors or family members 

who fulfilled the study eligibility criteria and who would share their 

experiences with an empathetic researcher proved to be exceedingly 

difficult. Many scholars have noted how the disenfranchised and 

alienated are ‘invisible’ members of American society (e.g., Harrington, 

1962; Sheehan, 1976). In spite of the growing lobbying strength and 

visibility of the disability rights movement over the past decade, the 

disabled, as individuals, have muted voices. People with disabilities 

seldom seek publicity. Potential subjects and their families were difficult 

to locate, even with the help of informed, energetic professional contacts. 

Members of ethnic minorities with disabilities and their families were 

even harder to find and thus are under-represented. Appropriate 

subjects who had suffered from firearm injuries were not located. Most 

injured people known to medical or allied health personnel had moved 

numerous times since their acute care or rehabilitation hospitalizations, 

and providers did not know where to find them. The fact that locating 

expressive individuals (especially ethnic minorities) with disabilities was 

so challenging is an important finding in itself. If representatives of the 

disabled population cannot easily be found to share their personal 

experiences, it will continue to be difficult for their collective needs to be 

articulated to policymakers at the local, state, and federal levels. 

The goal of presenting a small number of case studies is to illustrate 

how survivors and their families interpreted what happened to them in 

the days, months, and years following a severely disabling injury. The 

subjects presented experiences, events, and concerns that have emerged 

as central to their lives two to eighteen years after the injury occurred. 

The aim is to present a range of injuries, disabilities, family dynamics, 
142 Cost of Injury in the United States 

economic situations, and concerns about health, work, productivity, and 

dependence. Health care, social service, government, and insurance 

industry professionals would, of course, have different stories to tell. 

Defining Disability 

Criteria used to define disability vary widely in the literature. 

Krause (1972) distinguishes among three kinds of disability: 

biopsychosocial, social role, and legal disability. Social role disability, 

the definition employed in this chapter, refers to health-related 

limitations in performing the social roles expected of an individual, such 

as going to school, performing work at a job, or doing housework (Nagi, 

1979; Rice and LaPlante, 1988). Similarly, the World Health Organization 

defines disability as “any restriction or lack (resulting from an 

impairment) of ability to perform an activity in the manner, or in the 

range, considered normal” (WHO, 1984). 

Biopsychosocial definitions are made by physicians and others 

qualified to judge physical and mental functioning by generally accepted 

standards. The legal definition of disability is used to determine an 

individual’s entitlement to benefits from government programs, 

especially Supplemental Security Income (SSI) and Social Security 

Disability Insurance (SSDI). The definition for SSDI is relatively 

stringent: “Persons awarded benefits must have been judged to be 

unable to engage in any substantial gainful activity in the national 

economy, not merely in their own usual occupation, by reason of a 

physical or mental impairment. . . . The impairment is medically 

determined and must be expected to last a year or to result in death’ 

(U.S. SSA, 1987b). The legal definition of disability is much more 

restrictive than the social role definition. 

Ability and Desire to Work 

Regulations, Access, Disincentives 

of 

In a recent book about the personal, cultural, and social dimensions 

disability, Robert Murphy states: “Most disabled people would prefer 

to work, even at low-paying jobs, rather than live on the Social Security 

rolls, but if their earned income exceeds a very low limit, they lose both 

their pension and their government health insurance. This is a critical 

matter, as their medical expenses usually are much higher than those of 

ordinary people. Even if they are accepted by an employer’s private

plan, these generally do not pay for attendants and certain costly 

equipment. In this classic bind, many disabled people cannot afford to 

be employed! . . .. The system itself promotes dependency” (Murphy, 

1987, pp. 159-160). 
Long-Term Impact 143 

Social Security Disability Insurance (SSDI) provides benefits to 

eligible disabled persons (and their dependents) who have worked 

under and contributed to the Social Security system (2 million recipients 

in 1986). The amount of the benefit is directly related to the amount of 

time worked and money paid into the system. The maximum benefit 

available from SSDI in 1988 was $800 a month. Supplemental Security 

Income (SSI) is intended for eligible disabled persons who fall below a 

certain income/assets level (3.9 million recipients in 1986). The monthly 

SSI benefit in 1988 was $354. Many states supplement the SSI benefit; the 

California supplement in 1988 was $221 a month. In order to be 

determined disabled under Social Security law, individuals must have a 

physical or mental impairment expected to last for at least a year, which 

prevents them from doing any substantial gainful work. Partial 

disabilities, which are recognized in many benefit programs, are not 

sufficient to qualify one for SSDI or SSI. Social Security’s medical 

requirements are strict and only about one-fourth of the initial claims 

received each year are allowed. Persons considered severely disabled 

may be denied benefits if they are capable of substantial gainful work. 

Since 1972, Medicare coverage has been extended to disabled 

persons. Hospital insurance protection and optional supplementary 

medical insurance is provided to disabled individuals who have been 

entitled to SSDI benefits for at least 24 months. Most SSI recipients are 

also covered by Medicaid. In fiscal year 1985, nearly 3 million (2,936,000) 

individuals with permanent and total disabilities received Medicaid 

benefits (U.S. SSA, 1987a). The following case study illustrates the 

ramifications of the employment bind in which many people with 

disabilities find themselves. 

Alan Bensen -- Eighteen Years of Quadriplegia 

Approximately 200,000 people in this country live with paralysis as 

a result of spinal cord injuries. Each year it is estimated that there are 

approximately 2,500 new cases of paraplegia and 1,050 new cases of 

quadriplegia. About 56 percent of the injuries resulting in these 

disabilities are caused by motor vehicle crashes, 20 percent by falls, 12 

percent by firearms, 7 percent by sports and recreational activities, and 6 

percent by other sources (DeVivo, Fine, Maetz, and Stores, 1980 and 

extrapolated from Kraus, Franti, Riggins, Richards, and Borhani, 1975). 

In 1969, at the age of 18, Alan Bensen dove into a lake and broke his 

neck when he hit the bottom. He was instantly and permanently 

paralyzed below his collarbone, but maintained arm function. His 

friends pulled him out of the water and got him to a hospital. He spent a 

few weeks in intensive care at an acute care hospital and then was 

transferred to a rehabilitation hospital. He was hospitalized a total of 
144 Cost of Injury in the United States 

nine months. Mr. Bensen had graduated from high school the year 

before his injury and had spent the preceding year working in a factory, 

saving money, and deciding what to do next. Both of his parents were 

working in factories at the time of his injury. From the hospital, Mr. 

Bensen moved home with his parents. They worked different shifts and 

one of them was always at home to care for their son. Mr. Bensen lived 

at home for about a year, learning to function. His parents were his 

primary caregivers. They initiated a lawsuit against the owner of the 

lake property shortly after the injury. They lost the suit but owed no 

legal fees. The case ended in 1972. 

For seven years following the injury, Mr. Bensen had many 

hospitalizations and surgeries for various injury- and quadriplegiarelated medical problems. He recalled a period when he was 

hospitalized every few months. His problems were those common to 

quadriplegics - urinary tract infections and upper respiratory infections, 

including pneumonia. In 1971, he had an ileal diversion, the removal of 

his bladder. He also had surgery three times on his right arm and hand 

to allow the thumb to function so he could write and hold objects 

securely. Both types of surgery were elective. All his medical bills --

acute care, rehabilitation, outpatient, successive surgeries -- and his 

related costs -- attendant care, a wheelchair-accessible van, and medical 

supplies - were covered by medical insurance. His initial acute care and 

rehabilitation costs were covered by his mother’s employee insurance 

policy. By the time she retired, Medicare was covering Mr. Bensen’s total 

health care costs. Medicare payments began for Mr. Bensen in 1973. 

Education and Job Discrimination 

Mr. Bensen attended the state university as a full-time student from 

1973 to 1977, graduating with a B.A. degree. He lived in an apartment 

with an attendant and a roommate during most of his undergraduate 

education. Friends drove him to and from school and transferred him in 

and out of the car. While he was a student, he spent three to five hours a 

week at the university gym doing rehabilitation therapies and learning 

how to do more things independently. One of the therapists at the 

university taught him to drive. He began with hand controls in a 

borrowed car. Then he bought his own car and had hand controls 

installed. This was of limited value, he recalled, because he could not get 

himself in and out of the car and could not go anywhere unless transfers 

were arranged at both ends. A free van with a lift acquired from the 

Midwest state vocational rehabilitation department during his senior 

year enabled him to become independently mobile. He was fortunate 

that the department had a surplus in the budget and was eager to spend 

the extra money. 
�

Long-Term Impact 145 

Mr. Bensen stayed out of school for the next three years while he 

considered options and applied to law schools. He drove in his van, 

with a friend, around the country to look at a few law schools. He 

eventually decided to come home and apply to the state university law 

school, which accepted him. He began there in 1980 and finished in 

1983. He applied for many more jobs than his peers and was aware of 

discrimination because he was in a wheelchair (see Murphy, 1987 and 

Vash, 1981 for a discussion of job discrimination experienced by the 

disabled). He finally got a job in a small town (pop. 750) in another state. 

He went there for seven months in 1984. He recalls that there was 

absolutely nothing to do there aside from his work, and in addition, no 

public buildings were accessible to him. He decided to move to the San 

Francisco area and live with a friend. 

Mr. Bensen contacted all the county offices around San Francisco 

to learn about subsidized housing for the disabled. He moved into the 

suburban apartment in which the interview was conducted early in 1985. 

He studied for the California bar exam and passed on the first attempt, in 

the summer of 1985. Again, he spent a long time looking for a job. First, 

he had a half-time job for a few months. Then he got the public sector 

law job he held at the time of the interview. For two years he worked at 

that job full-time. 

Increasing Medical Vulnerability 

Mr. Bensen said that he had recently cut his work schedule back to 

four days a week, taking Wednesdays off because he was getting 

physically sick working ten hours a day, five days in a row. He simply 

did not have the physical stamina to continue at that pace. At age 38, 

Mr. Bensen had recently become aware of his increasing vulnerability to 

a variety of health problems. The scoliosis in his lower back was getting 

worse, and he felt he would eventually need to have his lower spine 

fused. He would probably go back to the Midwest for the surgery 

because he does not have a doctor in California and he knows and trusts 

the doctors back home. 

Attendant Services That Work 

Mr. Bensen’s SSDI payments began in 1970. Through his SSI 

eligibility, Mr. Bensen simultaneously became eligible for both In-Home 

Support Services (attendant services) and Medical (California Medicaid). 

The In-Home Support Services Program pays for his morning and 

evening attendants, 170 hours a month, or five to six hours a day. He 

hires his own attendants by running ads in local papers and interviewing 

applicants. Mr. Bensen has lived with a woman friend, on and off, for 

-_ 
146 Cost of Injury in the United States 

many years. They met in his home town. She works as a teacher and 

also as his paid attendant during the evenings and on the weekends. The 

attendants help him get up, out of bed, dressed, and assist him with a 

range of motion exercises. The personal assistance service system works 

efficiently for him. 

Classic Bind: Employment or Benefits 

Mr. Bensen’s SSDI payments started at $135 a month and had risen 

to $651 a month when he was dropped from the program in April 1987. 

Current federal regulations stipulate that one can be employed for only 

fifteen months -- the Trial Work Period - while covered by SSDI, at which 

point the payments are terminated. Mr. Bensen was appealing this 

ruling to the Social Security Administration at the time of the interview. 

He said appeals are sometimes resolved at that level. If not, he will 

consider appealing to the federal courts. 

Catch 22: Disabled or Employable 

time 

Federal regulations have created a dilemma for Mr. Bensen . At the 

of the interview, he was receiving $675 a month in social security 

payments due to be terminated in two months. He said: “They don’t 

consider me disabled any longer because I have been working for more 

than 15 months.” The rules place him in a bind and force him to make a 

major decision. If he continues to work, the social security payments will 

stop, and he will have to keep working because it is almost impossibl.e to 

re-start the payments. He said, “Most people worry about getting on the 

system. You don’t hear too much about how they try to kick you off of 

it.” Mr. Bensen was extremely anxious about this dilemma, noting again 

that he did not have a lot of physi.cal stamina and was always vulnerable 

to medical problems. Working full-time was too hard for him. Yet, 

without social security payments, he would need to work full-time to 

survive financially. The anxiety and fear expressed by Mr. Bensen are 

pervasive among persons with severe disabilities. 

System Promotes Dependence and Poverty 

Federal regulations stipulate that a disabled individual can continue 

to receive social security benefits only if earning less than $300 a month. 

At the time of the interview, Mr. Bensen was trying to assess whether to 

work fewer hours at his job and pay for all his attendant care, van 

expenses, and other health-related costs out of pocket, so that he could 

deduct them, in order to pull his net earnings to just below the $300 a 

month ceiling. If Mr. Bensen decides to continue working full-time, thus 

losing his social security benefits, he will also lose his Medicare/Medical 
Long-Term Impact 147 

benefits because his income and assets are approaching those ceilings as 

well. He was not sure when those benefits would terminate, but he 

knew it was within the year. Medicare and Medical pay all his doctor 

bills and cover all his medical supplies. He could survive without those 

benefits only if his income were to increase substantially. He is caught in 

a bind created by government regulations. He wants to work as much as 

he is able, yet doing so may jeopardize both his financial and medical 

security. 

Health care benefits and economic status are linked by federal 

regulations. In order to be eligible for Medicare benefits, a disabled 

individual under 65 must be receiving SSI or SSDI. And to qualify for 

Medicaid, one must be indigent (Murphy, 1987). Moreover, De Jong and 

Wenker (1983) frame the broader problem that a persistent feature of 

American publicly subsidized health and social service benefits is that 

they are inexorably and traditionally tied to an individual’s earned 

income. These facts wreak havoc on a person’s desire and ability to be a 

part of the workforce, to contribute to society, and to garner self-esteem 

in the economic marketplace. Mr. Bensen is a vital member of society 

who is being jeopardized by his ability to earn a living. 

Olivia Evans -- Loss of a Hand, Loss of Free Choice 

Mrs. Evans had been employed as a housekeeper at a community 

hospital for thirteen years when she was injured on the job. One evening 

in 1984, as she was routinely preparing to open the door to the laundry 

chute in the basement of the hospital, the latch became jammed. As she 

struggled with the door, she caught her right thumb in the latch and 

could not release it. It took three men to get her hand out. Later she 

learned there had been three tons of pressure on the door, and 

subsequently on her hand. She was in excruciating pain and was taken 

immediately to the hospital emergency room. There were multiple 

fractures in her thumb. She was treated and released. Ten days later she 

had a hematoma in her forearm and was still in severe pain. A month 

later (December 1984), though still in pain, she returned to work. In 

April 1985, her orthopedist recommended that she stop working because 

she had developed many more hand problems: swelling, greatly 

reduced strength (she could not hold a coffee cup), and much more pain. 

She finally quit her job. In May 1985, Mrs. Evans had hand surgery to 

release some of the tendons in an a ttempt to reduce the pain and 

swelling. She wore a cast for six weeks. When it was removed , her hand 

was not healed. Moreover, pains were shooting up through her arm and 

into her neck and head. Her doctor sent her to a hand rehabilitation 

therapist and she received hand therapy for two years. 
148 Cost of Injury in the United States 

By the end of 1985, Mrs. Evans had developed other symptoms that 

were a direct result of the injury. She could not move her right elbow, 

shoulder, or neck, lacked range of motion in the right arm, and had 

severe pain all through her right side. She began wearing splints at night 

to restore circulation to the right arm and reduce the numbness. She said 

that the left hand, due to overcompensation, had developed problems in 

the seven months before the interview. As a result, she was wearing 

splints on both hands at night, which she reported were extremely 

uncomfortable and prevented her from sleeping well. The hospital that 

had employed Mrs. Evans paid for all of her care: the emergency room 

surgery, subsequent doctor bills, subsequent surgery, and all hand 

therapy. They also paid her workers’ compensation, 75 percent of her 

regular wages, from the time she stopped working until January 1987. 

Discrimination Against People in Pain 

Following the surgery, when Mrs. Evans was still complaining of 

severe pain, her surgeon said to her, “There is nothing wrong with your 

hand, it’s all in your head. I want you to see a psychiatrist." She was 

humiliated and extremely angry that the physician thought she was 

imagining pain. She nevertheless went to a psychiatrist, who reassured 

her that the problem was in her hand, not her head. The hand therapists 

were familiar with the post-injury syndrome she suffered and they 

confirmed it as a physical, not a mental, problem. She resented the 

doctor’s attitude so much that she decided to see a lawyer who brought a 

suit against the company that provided the laundry chutes to the 

hospital. She said her anger at her orthopedic surgeon pushed her to 

take legal action. The lawyer discovered that four people had previously 

been injured by the chute door. The lawsuit was still in progress at the 

time the interview was conducted. Mrs. Evans had no idea what the 

settlement might be. If she wins, she will receive 66 percent of the 

settlement. 

Private Disability Plans Exist for Profit, Not for People 

In 1986, the insurance carrier determined through its vocational 

rehabilitation service that Mrs. Evans could return to work. Officials 

informed her that she would have to switch occupations since she could 

no longer perform heavy work. She had been a seamstress in the 1960s, 

but she could not do the fine needle work anymore because of her injury. 

The insurance carrier expected her to find work related to sewing and 

expected her to look for a job by going to six potential places of 

employment a day until she found a job. After she had searched for a job 

for four weeks, the carrier found her a job as a bridal consultant at a 

boutique, designing, not sewing, the clothing. 
Long-Term Impact 149 

As a hospital housekeeper, Mrs. Evans had earned $10.25 an hour 

with full health care and retirement benefits. She lived two miles from 

her work and drove there in about five minutes. The bridal consulting 

job began in January 1987 with a 45-minute commute, $7.00 an hour, and 

no benefits. At the time of the interview (May 1988), she had received a 

$1.00 an hour raise. 

Suffering of Children 

Mrs. Evans’s husband died more than 10 years before the injury. 

She said, “The loss of my hand was in some ways worse than the loss of 

my husband. It was like another death in the family.” At the time of the 

injury, her children were aged 10 and 18. She reported that the injury 

brought about definite, negative changes in the family. The children 

became depressed because they were not accustomed to seeing their 

mother helpless and unable to function. They needed to help dress and 

bathe her. “All the housework fell on them. They had to open bottles, 

peel potatoes, everything,” Mrs. Evans said. “The children were sort of 

confined to school, home, and school again. We didn’t have money for 

anything, not even the movies.” She felt her children suffered through 

her injury even more than she did and said, “I feel I robbed my children 

of three years. They had to do for me, rather than me doing for them.” 

She said she also went through her life savings following the injury. She 

borrowed $20,000 from a private party to cover her bills. At the time of 

the interview she was struggling to pay off that loan. 

Private disability insurance is designed to get people through the 

system as quickly and efficiently as possible. In forcing individuals to 

quickly accept jobs, the industry does not consider the pain and suffering 

of the injured person, nor the appropriateness and wage level of 

employment secured. This policy undermines personal autonomy and 

self -respect. 

Especially Vulnerable 

Alone, Poor, and Unable to Work 

The 1980 census revealed that 12,320,000 citizens between the ages 

of 16 and 64 had impairments that limited or prevented them from being 

gainfully employed. This was 8.5 percent of the total labor force. The 

median income of the disabled population was about 62 percent that of 

the nondisabled population in 1980. Correspondingly, one out of ten 

able-bodied people lived below the poverty line in 1980, and one in four 

people with disabilities were in the poverty group. This difference is 

due mainly to the fact that 58.2 percent of disabled men and 76.5 percent 

of disabled women are completely out of the labor force and must 
150 Cost of Injury in the United States 

depend on public assistance for economic survival (Bowe 1983; Murphy 

1987). The following case study shows how Mrs. Goode became a 

statistic in this group. 

Bernice Goode -- Problems of a Hidden Disability 

Each year, more than 75,000 people in the United States sustain 

brain injuries that result in permanent disability (Kraus et al., 1984; 

Kraus, 1985b). What happens to a brain-injured person who cannot 

work and who is not permanently cared for by a family member? 

Because of her injury, Mrs. Goode was unable to work. Yet, after many 

years in the labor force, she was denied social security benefits when 

officials could not adequately define the disability of this woman who 

spoke articulately and was not physically impaired. She nearly became 

homeless and destitute as a result of falling through the cracks in the 

system. A resourceful and compassionate rehabilitation counselor came 

to her rescue by creatively ‘packaging’ Mrs. Goode’s organic impairment 

so she could receive benefits from the Social Security Administration. 

Only then was Mrs. Goode able to live alone and begin to participate in 

community life. 

In 1984, Mrs. Goode, at the age of 45, was severely beaten by a male 

acquaintance. She was at home, asleep. Her adult daughter was visiting 

from out of town. When the man arrived at about 2:00 a.m., Mrs. 

Goode’s daughter let him in the house and began talking with him. Mrs. 

Goode arose from bed and joined them in the kitchen. She reported that 

the man was on drugs and became violent. In a split second, Mrs. Goode 

decided to draw the man’s attention to herself to keep him from 

attacking her daughter. She went outside the apartment door, where he 

followed and beat and kicked her until she was unconscious. Her face 

was lacerated and her left arm was badly hurt. She does not remember 

being taken by ambulance to the nearest hospital. Mrs. Goode had been 

working as a Licensed Vocational Nurse for 14 years at one hospital. She 

enjoyed her job and felt worthwhile and productive in her caretaking 

role. She was earning $8 an hour at the time of the injury. 

Mrs. Goode was in a coma for about a week in the hospital intensive 

care unit. She was hospitalized for two and a half weeks and discharged 

with mild brain damage and a severely bruised left arm and hand. She 

returned home and her daughter stayed with her for another month. 

Mrs. Goode recalled that she could not function on her own during that 

period. She could not use her left hand and arm at all. She experienced 

memory loss and severe vertigo -- nausea and dizziness when standing 

up or moving rapidly or spontaneously -- which she continued to suffer 

from at the time of the interview, four years later. When her daughter 

left, Mrs. Goode’s sister invited her to live at the sister’s home, realizing 
Long-Term Impact 151 

that Mrs. Goode could not be left alone. Friends helped her pack her 

belongings, put some possessions in storage, and make the 500-mile 

move to her sister’s apartment. Mrs. Goode lived with the sister for one 

year, until the landlord told them that the lease specified one tenant only 

and that Mrs. Goode would have to leave. 

For the first three months of her stay at her sister’s home, Mrs. 

Goode took the bus three times a week to the Veterans Administration 

Hospital for physical therapy on her left arm. She received outpatient 

therapy for three months -- heat therapy and range-of-motion exercises. 

When she was discharged, her arm and hand were functional again. Her 

second husband was retired from the military, so she received the 

treatments as a dependent, free of charge. She was not divorced, but had 

not seen this husband since 1982 and did not know where he was living. 

Not Sick Enough for Benefits 

Mrs. Goode received disability insurance payments from her job for 

one year after the injury. When the disability insurance was terminated, 

which was at the same time she was forced to leave her sister’s home, she 

applied for Social Security benefits. She was denied a claim. Officials 

informed her that she was able to work; they could not see that anything 

was wrong with her. She was not physically handicapped in any 

obvious way, and she was able to carry on an ordinary conversation and 

follow routine instructions without any apparent difficulty. She applied 

for benefits a second time and was denied again. She then managed to 

qualify for welfare, but only for one month. She received $204 for that 

month. She also succeeded in getting $80 a month in food stamps, 

which continued until December 1986. 

When she was forced to move out of her sister’s apartment and 

there were no more disability insurance checks, an elderly woman of 77 

invited Mrs. Goode to live with her. The woman asked for $150 a month 

rent, but when Mrs. Goode’s welfare payment stopped after one month, 

the woman allowed Mrs. Goode to continue to live with her without 

paying because she wanted a companion. For over a two-year period, 

Mrs. Goode’s only income was the $80 a month in food stamps. If she 

had not been offered free housing, she would have been on the street. 

She stressed that she came veryclose to being destitute and homeless. 

Extreme Despair, Declining Mental Health Lead to Eligibility 

Because she had been denied Social Security benefits, Mrs. Goode 

looked in the yellow pages of the telephone directory and found a social 

security lawyer. The lawyer, together with the rehabilitation counselor 

and psychiatrist to whom he referred her, succeeded in accumulating 

enough evidence of disability to ensure Mrs. Goode’s eligibility for 
152 Cost of Injury in the United States 

benefits. That process took two years. Mrs. Goode was entitled to Social 

Security benefits as the result of a psychiatric evaluation, for which the 

psychiatrist and rehabilitation counselor pressed. Mrs. Goode had 

become severely depressed and withdrawn. The rehabilitation counselor 

noted that Mrs. Goode was not entitled to benefits until she “almost went 

completely crazy.” Before that time, she was considered too functional to 

qualify for benefits. When she became more disoriented, the health 

professionals were able to classify her condition to fit the eligibility 

requirements of the Social Security Administration. Her type of organic 

impairment, alone, was not enough to qualify her for benefits, even 

though she could not remember things, could not function at a job, and 

was extremely dizzy and nauseous all the time. The rehabilitation 

therapist, in conjunction with the psychiatrist, prescribed medications to 

control Mrs. Goode’s anxiety as well as the dizziness and nausea brought 

on by the vertigo. In 1987, SSDI payments began at $435 a month, with 

SSI at $88 a month. At the time of the interview (1988), she received 

SSDI at $518 a month and SSI at $77 a month. The food stamp money 

ended when the SSDI payments began. 

Functioning “Just Barely” 

In May of 1987, the elderly woman with whom Mrs. Goode lived 

died and left the house to her adopted daughter. The daughter and 

other family members had keys and were coming in at all hours of the 

night, upsetting Mrs. Goode terribly. The rehabilitation counselor 

arranged for Mrs. Goode to move to nearby government-subsidized 

housing in June 1987. Mrs. Goode felt lucky to have a studio apartment 

for $220 a month at the time of the interview. The rent is adjusted 

annually in conjunction with the Social Security payments. Mrs. Goode 

reported that she finally felt settled and that her medications were under 

control. She felt she was functioning, “but just barely.” She became a 

Jehovah’s Witness about six months after the injury and said her religion, 

along with Bible study and church activities, gave her the strength to go 

on living. She planned to be more involved in church activities in the 

future. Through the rehabilitation counselor, she began peer counseling 

with other brain-damaged adults. This opportunity to continue to help 

other people as she did in her former employment was important to Mrs. 

Goode. 

People with hidden disabilities, such as certain types of brain 

damage, are discriminated against by federal programs simply because 

the lack of functional ability is not apparent to system officials. To be 

eligible for benefits, disability must be obvious, and in the case of Mrs. 

Goode, allowed to increase in severity. Federal guidelines stipulate 
Long-Term Impact 153 

extreme illness and destitution in order for an individual to qualify for 

benefits. 

Trauma to the Self 

Burns and Disfigurement 

Approximately 60,000-90,000 people are hospitalized in the United 

States each year for the treatment of bum injuries. With medical 

advances in burn care, people are surviving severe burns covering over 

70 percent of the body surface. Burn patients undergo multiple 

operations for skin grafting and repeated admissions to hospitals for 

reconstructive surgery, and they live with permanent scarring. A severe 

burn is considered by many to be the most devastating injury a person 

can survive (Locke, Rossignol, Boyle, and Burke, 1986). 

Numerous studies of severely burned patients point to the deep and 

complicated emotional reactions that accompany burns (for example, 

Andreasen, Noyes, Hartford, et al., 1972; Bernstein, 1975; Hamburg, 

Artz, Reiss, Amspacher, and Chambers, 1953; Noyes, Andreasen, and 

Hartford, 197l). Facial disfigurement caused by a severe bum potentially 

alters consciousness more drastically and creates more serious emotional 

problems than other forms of disability because the face represents 

oneself, one’s essential being, more than any other part of the body. A 

burned and unrecognizable face creates a metamorphosis in a profound 

sense, as one’s identity is deeply threatened by the physical 

transformation. The following case presents one woman’s struggle and 

method for coping with that horrible transformation. 

Laura Frank -- Loss of Her Face, Loss of Her Self 

Pulling up to a stop sign, with her boyfriend in the driver’s seat of 

the car, was the last thing Ms. Frank, aged 35 at the time, remembered 

about the night in 1977 when her injury occurred. She was told later that 

a car rammed hers, and that the explosion from the gas tank knocked 

both Ms. Frank and her friend unconscious. A passerby pulled her 

friend out. She was left in the car for a time because the flames obscured 

her. Someone finally saw her and pulled her out. She recalled waking 

the following morning in a hospital bed, surrounded by doctors and 

nurses who told her where she was and what had happened. Until they 

spoke to her, she thought a nuclear bomb had dropped. 

Thirty-five percent of Ms. Franks face, upper body, arms, and 

hands were burned. She was hospitalized for two and a half months, 

during which time she received the standard excruciatingly painful 

treatment for bums. She recalled, “After breakfast every day, they gave 

me my morphine, and then took me in for the tubbings, the baths that 
Cost of Injury in the United States 

every burn patient gets to promote healing and prevent infection. Every 

time they put me in the wheelchair to take me down there, and pulled 

the sheet over me, it was like knives in my shoulder.” During the same 

period, she underwent surgery several times for skin grafts and had the 

fingers on her right hand amputated. She was right-handed. The initial 

skin grafts on her face were not successful and had to be done again. 

Afraid of, Devastated by Frightening Image of Self 

Ms. Frank was afraid to look in the mirror. During her initial 

hospitalization, she avoided all shiny surfaces and managed never to see 

her reflection. In retrospect, she stated that it was a real disservice that 

the social service, psychiatry, and nursing staffs never confronted, 

supported, or guided her in dealing with facial disfigurement. On the 

day the nurse drove her home, she went into the bathroom and saw 

herself for the first time. She began screaming hysterically. For the first 

time, she wanted to die. She did not recognize her own face. She stated 

that if the nurse had not been there, she would have gone “stark raving 

mad.” The next day, in the tub room at the hospital, she lost control of 

her emotions as never before. She recalled crying, screaming, and 

wanting to die. At that moment, she recalled, she came close to a 

psychotic breakdown. The hospital staff got her out of the tub and in to 

see a psychiatrist. That was the first time the hospital offered her 

psychological counseling of any sort. 

When she was first discharged from the hospital, Ms. Frank went to 

live with her boyfriend. After a month, he told her he wanted to date 

other women, and that he could not take the responsibility of her burns 

and care. She was absolutely devastated by his behavior: “I felt I would 

never have another relationship. Who would even want to look at me let 

alone hold me and kiss me ? How was I ever going to be part of life 

again. I had a lot of anger and grief.” She had no family in California 

and moved in with a woman friend with whom she lived from June 1977 

until April 1978. For the first four or five months after hospitalization, 

Ms. Frank also had a live-in nurse who dressed her, fed her, and drove 

her to the hospital for the daily tub baths and occupational therapy 

treatments she still required. Those gradually were reduced to three 

times a week, then twice a week. 

Insurance and More 

Ms. Frank was a junior high school teacher of English and 

journalism. The insurance plan through her school district covered all of 

her initial hospitalization costs and all of her many subsequent surgeries. 

The insurance covered 80 percent of the outpatient burn and 

occupational therapy treatments, which went on for months after she 
Long-Term Impact 155 

was discharged. Some of the 20 percent of the remaining costs was paid 

by her boyfriend’s insurance. The rest came from her savings. She could 

not go back to work for the remainder of the academic year nor the next 

year, 1977-1978. The superintendent of her district, where she had been 

teaching for eight years, made the personal decision to pay one-half of 

her salary during that entire period. This payment was not stipulated by 

her contract. 

Support from Psychologist, Friends 

Ms. Frank then began to see a psychologist who helped her deal 

with her burn scars, confront her disfigurement, accept her right hand 

with no fingers, and regain her sense of self-worth. Because the 

psychologist with whom she worked did not have a Ph.D. degree, Ms. 

Frank’s medical insurance would not cover the therapy costs. Her 

friends got together and paid for her therapy, which went on for about a 

year. Ms. Frank said that her friends were extraordinarily supportive 

through the entire recovery process, and that she owes whatever 

emotional strength she found to their constant support. 

Reconstructive Surgery 

There were many surgeries. Ms. Frank had face reconstructive 

surgery in November 1977. In February 1978, she elected to have joint 

replacement surgery on her left fingers. She wanted to regain the use of 

those fingers, but later felt that the surgery did not help and may have 

hurt her in the long run. She then had more surgery on her eyes, her 

nose, and her right hand. That hand surgery enabled her to have a 

strong grip, and she resumed writing with her right hand. All surgeries 

were covered 100 percent by her insurance. She had lots of emotional 

support, always going home with a friend for a week or two following 

the surgeries. 

Healing -- A Horrible Appearance 

Ms. Frank went back to her teaching job in September 1978. She 

scheduled the surgeries over the school holidays. During the first two 

years of resumed teaching, she wore a heavy, tight mask over her entire 

face and a covering over her right arm. They are used to reduce the 

severity of the scarring while the grafts heal. She was terrified of what 

the students at school would think of her in her mask because she looked 

so awful. When it was time to take the mask off, she was terrified again 

of what everyone would think of her face. None of her fears were 

realized however; everyone was nice to her. After reentering school, Ms. 

Frank prepared an entire curriculum to educate staff and students about 

. 
156 Cost of Injury in the United States 

burns, burn treatments, and facial disfigurement. She said the program 

helped people cope with her, and her with them. She went on to teach in 

another junior high school and in a high school for another three years. 

Each time she changed schools, she presented her program on burn 

education. She decided she wanted to spend more time developing burn 

and disfigurement curriculum for the schools. 

Winning Lawsuit Changed Life 

During the same period, Ms. Frank was involved in litigation 

against the automobile company. The lawsuit was started immediately 

after the injury by a lawyer who was a friend. The suit was settled in 

1980. She received close to one million dollars in a lump sum payment. 

The settlement enabled her to buy a larger home. Ms. Frank wanted to 

develop a reentry curriculum to be used in schools for children or staff 

with burns and other disfiguring disabilities. The settlement enabled her 

to take time off from teaching to do this. She initially took a one-year 

leave of absence, but has not returned to teaching since. 

Ms. Frank’s curriculum development work began with a grant from 

a private foundation. In 1986, she began working as a paid staff member 

with the county rehabilitation medical center, creating reentry programs 

for disfigured children that are used now by school districts all over the 

state. She has added a “corrective cosmetic and total disfigurement 

center,” to give practical advice about how to make the most of one’s 

looks for those with severe burns and disfigurement caused by injury or 

illness. She was motivated to do this work by the absence of advice and 

care for coping with disfigurement. She said burn centers simply do not 

address the issue of community reentry or the severe self-image 

problems of burn victims. The lack of psychological counseling in the 

days and months following Ms. Frank’s injury proved to be profoundly 

devastating. Winning a sizable lawsuit enabled her to devote her life to 

making sure other disfigured individuals do not undergo emotional 

trauma due to lack of professional support. This case illustrates the fact 

that emotional and psychological support following an injury are 

absolutely necessary, and that the need for support may continue for 

years. 

Attendant Services 

Who is in Control? 

More than 7.7 million people or 3.3 percent of the United States 

population require some help from another person to accomplish 

normal, everyday tasks because of functional limitation. Age is a 

significant factor in determining the need for personal assistance. Only 
Long-Term Impact 157 

2.2 percent of the population aged 18-64 needs assistance, but more than 

16.8 percent of the population over age 64 requires such assistance 

(World Institute on Disability, 1988). 

Disabled individuals who associate themselves with the 

independent living movement measure independence -- that most 

cherished national value -- not by the number of tasks one can do by 

oneself, but by the quality of life one can have with appropriate 

assistance. In the context of this movement, aid is considered a civil 

right, an entitlement that permits the individual with a disability to 

participate in work, recreation, family, community, and political life. 

Attendant services are viewed as indispensable to participation in 

society and thus are considered an inalienable right. 

The two cases presented below represent extremes in the exercise of 

control. The first, Mr. Morgan, controls his services by hiring, training, 

firing, and determining the wages of his personal assistants. He 

perceives his attendants to be extensions of himself. They work for him, 

and their work enables him to consider, at age 23, an education, a career, 

and a productive future. The second case, Mrs. Chapman, is at the 

mercy of the personalities and behaviors of the attendants sent to care for 

Mr. Chapman by a social service agency . Rather than being freed by the 

attendants to participate more fully in the life they once had, the 

Chapmans have become limited to an existence of coping with the 

attendants themselves. These cases represent the extremes of a 

continuum and illustrate how attendant services can be an opportunity 

for the bolstering of self-esteem and the control of one’s destiny, or can 

seriously erode self-respect and autonomy. 

Bart Morgan -- His Whole Life Ahead of Him 

In 1981, at the age of 17, Bart Morgan was thrown off his motorcycle 

while speeding. He severed his spinal cord between the second and 

third vertebrae and was left quadriplegic, able to move only the fingers 

of his left hand and dependent on a ventilator to breathe. Mr. Morgan, 

who was in the Midwest visiting his father at the time, was hospitalized 

for three months and then transferred to a hospital in the San Francisco 

Bay Area where his mother and three siblings resided. He was 

hospitalized there for four months. He had numerous surgeries for 

infections in his neck resulting from the fracture and quadriplegia. 

During the entire seven months of hospitalizations, he was medically 

unstable and not sure if he would live. When his life was no longer in 

danger, he was transferred to a rehabilitation hospital where he stayed 

for almost a year, participating in an active rehabilitation program. He 

returned to his mother’s home in 1983 and has lived there since. He 
158 Cost of Injury in the United States 

requires 24-hour-a-day Licensed Vocational Nurse (LVN) care, which he 

will need for life. 

Medicaid Waiver Prevents Institutionalization 

The family’s private health insurance covered all of Mr. Morgan’s 

medical, rehabilitation, and LVN care costs until 1985, when the $1 

million coverage ran out. At that point, he applied and became eligible 

for a Medicaid waiver to cover his 24-hour LVN care, at $15.75 an hour. 

Medicaid waivers allow states to develop demonstration projects to 

serve people who would otherwise be in hospital or nursing home beds. 

Mr. Morgan is fortunate to be included in one of the few demonstration 

programs in the country. 

Learning to Live With Personal Assistants 

At the time of the interview, Mr. Morgan had been receiving 

Medicaid funded attendant services for two and a half years. For the 

year before that, his private insurance had paid for his attendants. Until 

approximately six months before the interview, Mr. Morgan’s time at 

home -- three and a half years - was spent mainly in learning to recruit, 

train, and get along with attendants. By the time of the interview, he had 

acquired as much autonomy as possible in his home environment by 

creating and managing a smoothly running schedule for himself using 

his attendants. 

When Mr. Morgan was discharged from the rehabilitation hospital 

to his home, a rehabilitation counselor motivated him to become an 

activist in his own care and to take charge of both his current condition 

and his future life. Over time, that counselor became for Mr. Morgan a 

model of the independent living movement philosophy and a father 

figure as well. Mr. Morgan stressed that the counselor helped him grow 

up, learn about his body, and understand other people: “I learned from 

him that my nurse is an extension of me. If I go out there and fix myself 

lunch, the nurse helps me fix lunch. The dishes we use are our 

responsibility to wash and put away. It is real clear, and it is a common 

courtesy.” Mr. Morgan underscored the independent living philosophy 

as he further explained, “I was taught by the rehab counselor how to 

train my nurses. I had to learn how to be the boss, how to be diplomatic 

when personality conflicts arose between me and the staff, or between 

my mother and the staff. I’ve had 40 nurses since I came home. When I 

interview them, we go through everything so I don’t waste my time, 

their time, or the state’s money to train them.” 
Long-Term Impact 159 

Advocate for Assistants 

Mr. Morgan acts as an advocate for his nurses, “If you want good 

people, you have to pay for them.“. He interviewed representatives from 

several agencies who accepted Medicaid contracts before finding one 

that would pay the nurses a salary of $10 an hour. He stated that 

Medicaid pays the agency $15.75 an hour for the LVNs, but he had to 

negotiate the $10 an hour salary. There is no industry-wide or agencywide policy on attendant salaries. 

On to Education and Job 

In 1982, when Mr. Morgan turned 18, his SSI benefits began at $450 

a month. He used part of that money to pay rent, “to help out my mom,” 

who worked full-time as a supervisor in an electronics plant. The rest 

was his own spending money. He spent two years attending the local 

community college, taking general education courses. His education 

there was financed by the State Department of Rehabilitation. At the 

time of the interview, Mr. Morgan was working part-time as a peer 

counselor for other ventilator-dependent quadriplegics. He said he was 

lacking direction in his education and was ready for specific job training. 

He was searching for a state-financed program that would train him for 

computer work, which he physically could do (with the help of an 

attend nt) and in which he was quite interested. With his nursing care 

under control, Mr. Morgan had entered a period of frustration 

concerning the next hurdle in his life, job training and employment. Mr. 

Morgan needs a ventilato r to help him breathe. He can only move two 

fingers on his right hand. Yet he has learned to take control of his bodily 

functions and daily routine through his attendants. Now, his goal is to 

expand his horizons by entering the workplace -- with his attendants as 

extensions of himself. 

Vulnerability and Dependence After a Fall 

The tendency to fall is a serious problem associated with aging. 72 

percent of deaths due to falls in the U.S. occur in the 10 percent of the 

population that is aged 65 or older. About a third of this age group 

living at home will fall each year, and about 1 in 40 of them will 

subsequently be admitted to a hospital. Repeated falls are a common 

reason for admission of previously independent elderly individuals to 

long term care institutions (Rubenstein, 1983). This example illustrates 

the response of Mrs. Alice Chapman to the ramifications of her 

husband’s fall. Managing the care of her disabled spouse plunged Mrs. 

Chapman into a position of vulnerability and dependence on the social 

service system. 
160 Cost of Injury in the United States 

One year after he had a stroke, Mr. Chapman, aged 78, fell while 

walking in his kitchen and fractured his hip. From the time of his stroke 

until that moment, Mr. and Mrs. Chapman had lived in their 

comfortable, two-bedroom apartment, up a flight of stairs. As a result of 

the hip fracture, Mr. Chapman was hospitalized for about six weeks. He 

had his hip pinned surgically and then spent weeks in physical therapy 

attempting to relearn to walk. He complained of intolerable pain and 

did not resume walking. At the time of his hospital discharge, the 

hospital social worker informed Mrs. Chapman, who was able-bodied 

and relatively healthy, that her husband would now require a round-theclock attendant at home because of his inability to walk even to the 

bathroom. His generally weakened condition made him unable to care 

for his personal needs, which included the use of a catheter. 

The hospital discharge planner referred Mrs. Chapman to a local 

agency from which she hired for her husband one attendant to work 

Mondays through Fridays, and another for the weekends. Medicare 

does not cover attendant services, nor do ‘Medigap’ private insurance 

policies. Long term care insurance, which is now beginning to serve 

elderly people by paying for expenses that Medicare will not cover, has 

many restrictions and conditions on attendant service coverage and will 

not pay for it in most cases. Mrs. Chapman paid for 24-hour-a-day care. 

The Family Survival Project in San Francisco estimated the average cost 

of a live-in Nursing Assistant or Home Health Aide to be $110-120 a day 

in 1987. 

Alice Chapman's Story 

Since Mr. Chapman’s return from the hospital (three months prior 

to the interview), Mrs. Chapman’s once active and community-oriented 

life had shrunk to the narrow focus of dealing with her husband’s 

attendants and the uncertainty and crises they caused. The weekday 

attendant began work as soon as Mr. Chapman returned home. Mrs. 

Chapman reported that this attendant was a “prima donna.” He did not 

like their children to visit and said they were interfering in his care of 

Mr. Chapman. Whenever friends and family came by, the attendant was 

always there, standing by Mr. Chapman’s wheelchair saying, “Show 

them all how high you can pick your hand up,” or “He had this many 

units of urine today,” which made Mr. and Mrs. Chapman feel degraded. 

The weekend attendant, in contrast, was very cordial. The 

Chapmans felt comfortable with him. But after only two weekends, he 

telephoned Mrs. Chapman from jail, and asked her for $250 to get him 

out. He did not return to work, but the weekday attendant offered to 

work straight through until Mrs. Chapman found another attendant for 

the weekends. She reported, “He worked for nine straight days, and 
Long-Term Impact 161 

then he had a fit; he just went crazy and he became awful. He became 

abusive and was absolutely impossible. Meanwhile, I got somebody else 

from the agency for the weekends. I never liked him. My husband was 

terrified of him. On the first Sunday the new man was with us, he had 

just made up my husband’s bed and put him back in it, when my 

husband soiled it. He let out a blue streak of swearing at my husband. It 

was degrading and awful.” She finally found another weekend 

attendant. 

From Bad to Worse 

Things were getting worse with the weekday attendant. Mrs. 

Chapman reported, “I had a handyman over to fix things, and I decided I 

wanted my privacy so I had a lock put on my bedroom door. The 

attendant said to me: ‘Why are you doing that? Don’t you trust me? 

First your children interfere with everything I do, and now you don’t 

trust me.’ But the last straw was when I called the doctor, to talk to him 

about my husband’s condition. After we had talked for a few minutes, I 

said, ‘I’ll get the attendant on the line to talk to you about medications; he 

takes care of that.’ He had been listening on the extension phone 

anyway, and said, ‘I’m right here.’ They started to have a conversation, 

and I interjected something, and he yelled at me through the extension 

phone, so that the doctor was right there to hear. He said, 'Mrs. 

Chapman, how can you interfere ? The doctor is a busy man, and I’m 

handling this, I’m taking care of this.’ I hung up the phone, but I was 

boiling, absolutely boiling, so humiliated.” After he left, she took the 

attendant’s clothes and paycheck to the agency, and he never came back. 

The new weekend attendant began to work four days a week and a 

friend of his worked the other three days. Mrs. Chapman summed up 

her ordeal, “Until these two arrived, it was an absolute nightmare.” 

Even people who can afford to pay for attendant services cannot get 

the servicesIeasily or readily. The Chapmans’ situation illustrates the 

dangers of being dependent upon the private, for-profit marketplace. 

This case is a powerful example of why this country needs a long term 

care system that responds to people’s needs for appropriate assistance in 

the home. 

Impact On the Family 

Mothers and Children 

Twenty million children in the United States have a chronic physical 

or mental condition; 3.2 million of them are limited in daily activities 

because of the disability. Mothers serve as the primary caregivers for 

these children, whether or not the mothers are employed outside the 
162 Cost of Injury in thz United States 

home. Caregiving for disabled children has enormous emotional costs; 

the most negative consequences include depression, anxiety, frustration, 

and feelings of helplessness (U.S. House, 1988). When injury resulting in 

severe, permanent disability occurs, the entire family is affected. Though 

the injury physically impairs only one person, it has many impacts on all 

family members. The disability will change the schedules, daily 

activities, and responsibilities of those who live with or are responsible 

for the injured person. Roles and places of residence may be altered. 

The changes may be subtle or dramatic, and they may be permanent. 

Change is experienced by the individual as loss -- loss of predictable 

patterns of daily living, free time, recreational and employment 

opportunities, money, sleep, and independence. More frustrating, 

frightening, and disappointing is the loss of the injured person as a fully 

functioning family member. The primary caregiver of the injured person 

potentially experiences the most disruption, anger, guilt, and resentment 

of any family member. Change, loss, and the fact that there is never a 

return to ‘normal’ are the noneconomic, yet absolutely real, costs of 

injury to the family. 

Mothers’ Perspectives: Disability All-Consuming 

Four stories were told by mothers of severely injured children (all 

male). Two adult children, aged 18 and 21 at the time of their injuries, 

sustained severe brain damage, making them unable to be left alone 

safely and dependent on their families for the rest of their lives. One 

three-year-old suffered severe brain and central nervous system damage 

as a result of nearly drowning. He will be wheelchair-bound and unable 

to speak or care for himself in any way for the remainder of his life. A 

sixteen-year-old broke his neck in a school-sponsored wrestling match 

and became quadriplegic. He died 18 months later of complications 

resulting from the quadriplegia. All four mothers devoted their lives to 

caring for their disabled children with as much common sense and 

mental well-being as seems possible. 

Their stories illustrate the fact that money and services are critical to 

caring for a severely disabled child. No one in this study group was 

independently wealthy. Legal settlements enabled three of the families 

to survive what otherwise would have been financial difficulty or 

devastation from the injury. Moreover, the settlements made it possible 

for two of the parents to bring their children home to a changed and 

accessible environment, enabling the patient to be in familiar 

surroundings and be nurtured by family members. The three mothers 

each emphasized that they would have become bankrupt or completely 

unable to cope had they not been awarded a sizable sum of money. The 

fourth case is an example of the parental stress and lack of adequate care 
Long-Term Impact 163 

and treatment for the injured person that results from inadequate funds. 

Carolyn Vash writes of family members who become “casualties of the 

system” (Vash, 1981, pp. 59-60). This occurs when family member needs 

for practical or emotional support either are ignored by individuals in 

health care or social service agencies, or are not met because appropriate 

services do not exist. Of the four case studies in this group, two can be 

described as casualties of the system, one in an extreme form. 

Caring for Brain-Injured Adults 

It is estimated that each year in the United States, 410,000 people 

sustain brain injuries. While the great majority experience good 

recovery, approximately 17,600 do not. Of these, over 10,600 have a 

moderate recovery, 5,000 are left with severe impairment, and 2,000 

remain in a permanent vegetative state. Approximately half of these 

injuries are sustained in motor vehicle crashes, about 20 percent from 

falls, about 17 percent from assault (about 5 percent from firearms), 

about 10 percent from sports and recreation, and the rest from other 

blunt trauma (figures extrapolated from Kraus et al., 1984.) 

Two of the mothers’ stories share certain characteristics. At the time 

of the injuries, their sons were about the same age, 18 and 21, and were 

both employed and living on their own. Both became severely braindamaged. Though their mothers placed them in sheltered housing 

environments for a time, those situations were not entirely appropriate, 

and both young men eventually returned home to live with the family. 

Both sons have needed nearly constant supervision since the injury. 

Both mothers have been divorced for many years and have worked 

outside the home to support their families. They have borne the full 

burden of their sons’ disabilities without financial or emotional support 

from a spouse or ex-spouse. 

The two stories also differ in several critical ways. One mother, 

Mrs. Smith, has four other, healthy children who rallied round her and 

gave their full and constant physical and emotional support to their 

disabled brother. The other mother, Mrs. Jones, has one other child, a 

daughter, who married shortly after her brother was injured and moved 

to a different city. Thus, the burden of care was placed completely upon 

Mrs. Jones. Secondly, Mrs. Smith won a legal settlement that permitted 

her to buy a large, comfortable home so that the entire family could 

remain together and so that Bobby, the brain-damaged son, could live in 

a normal family environment. Mrs. Jones, without any familial support, 

initiated but did not win a lawsuit, and she has struggled to find 

housing, employment, and care for her son from the time of the injury to 

the present, 15 years later. Third, Mrs. Smith is a practicing registered 

nurse. Her professional knowledge enabled her to make informed 
�

164 Cost of Injury in the United States 

decisions about her son’s care that were also appropriate for the family. 

Looking back, she felt all her decisions were the right ones, and that her 

son’s best interests were served. She said that her medical knowledge 

made it possible to cope with the uncertainty of her son’s recovery. Mrs. 

Jones, a secretary and writer, had no medical training to guide her 

through the maze of decisions she had to make on her son’s behalf. She 

said repeatedly that she did not know anything about rehabilitation, 

brain damage, or community resources, and that nobody told her 

anything about these things. She felt her son suffered because of her lack 

of knowledge and that he did not recover as much as he might have, had 

he been given more aggressive early treatment and more consistent care 

over the years. 

Bobby Smith -- A Family Rallies Around 

In October 1985, Bobby Smith was working at a California ski resort; 

he has no recollection of what happened to him. Apparently, he backed 

into, and fell, 13 feet through a door at the top of a tramway. He was 21 

years old. He was alone at the time of the fall and was found perhaps 20 

or 30 minutes later, unconscious. ‘In extremis,’ he was taken to the 

nearest hospital, a small facility. He had an epidural hemorrhage. 

Doctors performed an emergency brain decompression, a nine-hour 

procedure. Bobby was in the hospital for two months. All 

hospitalization costs and surgeons’ fees were paid for by Bobby’s 

workers’ compensation. 

Bobby is the fourth of five children. At the time of his injury, he 

was living near the ski resort with one of his sisters. Two brothers were 

living in a large city, about a three-hour drive from the hospital. Mrs. 

Smith lived with her youngest child, a daughter who was still in high 

school, in an East Coast city. When the family was notified, the oldest 

brother, Alex, took over all caregiving and decision-making 

responsibilities until Mrs. Smith arrived from the East Coast. Alex said 

that his other brother, who was actually closest to Bobby, had a very 

hard time emotionally during the entire post-injury period and could not 

make any of the necessary practical decisions regarding Bobby’s care. 

Mrs. Smith said that when she arrived after Bobby’s two emergency 

surgeries, she thought he was going to die. He was on a respirator. 

Hospital staff asked her if they should discontinue the respirator, which 

she declined. “It really puts you in touch with your own mortality, and it 

is a terrible, terrible thing to have to face,” she said. 

Battling the Insurance Industry 

Bobby’s medical care was outstanding at the small hospital, Mrs. 

Smith thought. After Bobby had spent two months there, the family had 
Long-Term Impact 165 

to decide where to send him for rehabilitation. ‘That decision became 

our first battle with the insurance representative,” Mrs. Smith said. “He 

wanted to send Bobby to a hospital in Colorado, and we later learned 

that he owned a part of that hospital. He pushed us very hard, and even 

flew us out to see it.” But Mrs. Smith found that hospital no better than 

local rehabilitation facilities, and her biggest concern was keeping the 

family together during this crisis. She felt, along with all her children, 

that Bobby’s recovery depended upon his being near his family as much 

as upon his medical rehabilitation program. She decided to send him to 

a hospital in the San Francisco area where three of her children were 

living. She had planned to move to the area herself the following year 

when the youngest child graduated from high school. 

Family Life Revolves Around Patient 

Bobby was in the rehabilitation hospital for one year. During that 

time, Mrs. Smith flew out from the East Coast every month for six 

months until June, when her daughter finished school and they moved 

West. She began working full-time as a nurse on the night shift. She 

spent her days with Bobby in the hospital. Until she arrived, Alex went 

to the hospital every morning at 9:00 a.m., to be with Bobby for most of 

the day. He worked as a waiter in a restaurant during the evenings. 

When his mother finally moved to the area, he confessed his emotional 

exhaustion, and asked his mother to take over. Both Mrs. Smith and 

Alex are convinced that their presence and care for Bobby saved his life 

and enabled him to recover as much as he has. 

Hospital Liability and Restricted Treatment 

Bobby’s insurance covered all his medical bills at the rehabilitation 

hospital. He was medically unstable during periods. He was missing 40 

percent of his skull. He had a pressure shunt inserted. He had plastic 

plates inserted in his skull to control the pressure shifts. Mrs. Smith 

reported that the hospital staff was afraid to do active rehabilitation with 

him because he was so unstable. They had liability issues, she reported. 

If Bobby fell during physical therapy, for example, hospital staff were 

afraid that the family would initiate a lawsuit, so they did not do active 

therapies and did not encourage him to begin to do things for himself. 

As a result, the family felt Bobby was not getting enough rehabilitation. 

So Alex learned how to do much of the staffs work, including inserting 

feeding tubes before Bobby learned how to swallow, and initiating 

therapeutic exercises. Bobby was in the rehabilitation hospital for one 

year. 
166 C ost of Injury in the United States 

Post-Rehabilitation Experience 

The family had heard about a sheltered, transitional housing facility 

in the area for brain-injured people. They decided to place Bobby there, 

to try it out. Bobby lived in a condominium there and participated in a 

day treatment program complete with psychological nursing services 

and rehabilitation services. Bobby was the first patient in that facility. 

He was there for nine months. Mrs. Smith was commuting there once or 

twice a week, a two-hour ride on public transportation, while she was 

working full-time on the night shift. 

The facility staff concluded they could not do anything more for 

Bobby at the same time that the family decided to take him home. Bobby 

had become like a small child, but the family believed he could learn to 

do things for himself. The family wanted to control his re-education and 

did not want him living away from them. They had thought all along 

that they could provide the best care and a situation in which Bobby 

could learn and thrive. If they were not with him, they felt his functional 

abilities would deteriorate and that he would suffer emotionally. They 

were renting a four-bedroom house in San Francisco with only one 

bathroom, which was upstairs and too small for a wheelchair. 

Winning a Lawsuit Freed the Family to Have a Home 

On the day of the injury, Bobby’s lawyer referred Alex to other 

lawyers who began a lawsuit against the company that built the door 

through which Bobby fell. They settled out of court nearly two years 

later, in July 1987. The settlement is an annuity that pays Bobby a 

monthly check of $5,057. It will pay $7.5 million over Bobby’s lifetime. 

The settlement freed the family to decide to care for Bobby permanently. 

They would never have had the money for a home without the legal 

settlement. 

Liability Paranoia 

As soon as Bobby returned home from the transitional facility, Mrs. 

Smith took him to a neurologist with the goal of taking him off 

medications. The family realized he was overmedicated both at the 

rehabilitation hospital and at the transitional facility. They referred to 

this fact as a “catch 22.” It is well known that certain kinds of patients, 

especially those who are brain-damaged or mentally ill, are frequently 

heavily medicated because of liability concerns. Sedated patients are not 

likely to run off or injure themselves, but they are not able to achieve 

maximum rehabilitation, either. Bobby was wheelchair-bound while at 

the transitional facility. He was having seizures, a common result of 

brain damage, about once a month. After the neurologist reduced his 
Long-Term ong-Term Impact 167 

seizure medication by half, he still had about one seizure a month, but 

was able to function much more effectively. 

Gambling on Good Health 

SSDI payments began for Bobby in September 1987. Mrs. Smith 

applied when he came home, and received one year in additional 

retroactive payments. He receives $97 a month. He will be eligible for 

Medicare after receiving SSDI for 24 months, and Medicare will pay 80 

percent of his medical bills for life. The “catch” or “gamble,” as Mrs. 

Smith and Alex expressed it, is that they currently have no health 

insurance for Bobby. The family is taking a calculated risk that Bobby 

will not fall, have another brain injury, or have a major acute illness in 

the two-year period before Medicare payments begin. All the family 

members save as much money as they can against the possibility of a 

catastrophic illness for Bobby. 

The entire family has become involved with the community braininjured support network. They find support group meetings very 

helpful. Mrs. Smith was recently asked to serve on the board of the 

network. She feels lucky when she compares her experience to other 

stories she hears about brain injury. She emphasized that the whole 

family was grateful to be working and able to support themselves and 

Bobby. The settlement enabled them to buy the perfect house for their 

needs and to keep the family intact. Bobby’s condition has improved 

over the years. Their risk is that he will incur a major medical expense 

before the Medicare payments begin. Again, winning a lawsuit greatly 

enhanced the quality of life for every member of this family. Federal 

regulations regarding the two-year waiting period for Medicare 

payments could potentially undo their security. 

Stan Jones -- Falling Through the Cracks in the System 

In July 1973, the automobile in which eighteen-year-old Stan Jones 

was the passenger was hit by a speeding car driven by a teenager with 22 

moving traffic violations on his record. Stan was thrown from the 

vehicle and instantly knocked unconscious. Aside from the head injury, 

he suffered only minor cuts and bruises. Police witnessed the crash and 

rushed him to a hospital. 

No Private Insurance 

Stan was a patient at a trauma center for several months, and in a 

coma for the first six to eight weeks. Because the family had no private 

insurance, he was placed in a city-run convalescent hospital where “he 

was with old, demented men mainly,” Mrs. Jones said. She felt that was 
168 Cost of Injury in the United States 

a terrible situation, and that Stan would “definitely go crazy there.” After 

several months, she found another placement for him in a suburban 

convalescent and rehabilitation hospital where he stayed for ten months. 

For the first four months following the injury, Stan could not eat; he 

could not speak for ten months. When Stan was moved to the suburban 

rehabilitation hospital, Mrs. Jones moved also to be nearer to him. She 

felt he did not get enough rehabilitative therapies there because he had 

behavioral problems resulting from the brain damage. He was very 

disruptive, causing the staff to prefer to leave him alone. Mrs. Jones said 

that during the first year after the injury, no one told her where to go for 

adequate rehabilitation for her son. She made every decision in a 

vacuum and, without appropriate information or education, learned 

how to interact with and care for her son. All of Stan’s acute care and 

rehabilitation costs were covered by Medical. 

Impact on a Sibling 

The family also consisted of a daughter, one year younger than 

Stan, who was out of town at the time of injury. “Our family was not 

able to pull together after this,” Mrs. Jones said. “My daughter recoiled 

from the whole thing; she did it for her own survival. She married a year 

after the injury, in response to it. That marriage lasted four years. She 

pulled back emotionally from me and from her brother.” 

Ramifications ications on Employment

Divorced for many years, Mrs. Jones had worked as a secretary and 

raised the children on her own. She did not work at all for the first six 

months after her son’s injury. Then, when she got a new job, she could 

not concentrate and was fired. She said that she would have quit 

anyway. Her doctor arranged for her to receive disability insurance for a 

time and told her that it was best if she did not attempt to resume work. 

Effects of Brain Damage 

In the middle of 1974, Stan was discharged from the rehabilitation 

hospital to home. By then he could walk, dress himself, and talk, but he 

could not be left alone. He was hallucinating some of the time. He 

would close the curtains of the house and play records. He had trouble 

getting into the shower; he was very hypersensitive, and the water 

irritated him. Mrs. Jones stressed that no one told her that his behavior 

was due to the brain damage. Nobody told her what to expect; she had 

to “learn everything from scratch.” She was overwhelmed. At the time 

of the interview, 15 years post-injury, his behavior is still unpredictable. 
�

Long-Term lmpact 169 

He will scream out regarding something he does not like or something 

that upsets him. He has limited judgment and control. 

No Appropriate Housing or Treatment 

After two years of having Stan at home with her, Mrs. Jones realized 

she could not care for him adequately, or cope with the situation 

emotionally, so she placed him in a half-way house for mentally ill 

people. This was the best setting she could find for him, but it was not 

entirely appropriate. He lived there for 18 months, but he kept trying to 

leave by walking away. She emphasized how, at every stage, her son 

“fell through the cracks of the treatment and care system.” There are no 

appropriate institutional settings for brain-damaged people. 

In 1977, Mrs. Jones remarried and remained in the marriage until 

1980. The husband arranged for Stan’s eligibility and placement in a 

federally subsidized (Section 8) housing project. Stan moved into an 

apartment shared with a couple who were supposed to be his attendants. 

He lived there from 1977 to 1981. 

A Glimmer of Improvement 

Through the half-way house, Stan received a grant from a private 

foundation for an aide to go to his apartment to teach him the basic skills 

he needed to live independently. The aide worked with Stan for two and 

a half years, until the money from the grant was terminated. Mrs. Jones 

felt this was extremely worthwhile and benefited her son greatly. 

During this period, his functional skills improved. His gait almost 

returned to normal. His voice tone became more normal. He began to 

run for exercise and to read a bit. The private foundation also paid for 

Stan to attend a local private college once a week for two years. He went 

to a learning center there to work on regaining cognitive skills. Mrs. 

Jones felt this was very helpful. During that period, she spent much time 

with her son, “bombarding him with verbal stimulation, and just being 

with him.” 

In 1981, Mrs. Jones and Stan bought and moved into the house in 

which they currently reside. It is small and run-down, but adequate for 

their needs. Stan has a separate entrance to a small apartment 

downstairs, giving him a feeling of independence. Also in 1981, Mrs. 

Jones went back to full-time secretarial work, which she continued for six 

and a half years. 

No Package for the Problem 

While she worked, Mrs. Jones had various attendants come to the 

home to care for Stan because he could never be left alone. She always 

-_ 
170 Cost of Injury in the United States 

had difficulty finding attendants who would remain on the job. She has 

spent most of her time and energy organizing systems of care for her 

son. When a caregiver leaves, she begins all over again. The past 15 

years have been one long attempt to cope with his care. ‘There was no 

package for this problem,” she said. Professionals simply could not help 

her out. Although the state and county, through MediCal, paid for Stan’s 

round-the-clock attendant care for the first two years, there was no major 

legal settlement to aid her in hiring the help she needed for his care 

when those payments ceased. She became a casualty of the system with 

no financial backing of her own to pay privately for services. Though 

she owns her own home, she and her son live quite marginally. Stan’s 

emotional and behavioral problems have become worse over the years 

because of his early lack of emotional care in the days following the 

injury. Stan realizes and is angry about how dependent he is on his 

mother. At the age of 34, he suffers emotionally because of his 

dependence and lack of productivity. Mrs. Jones is both fed up with 

having the full burden of his care and emotionally exhausted. But she 

stated that she would never abandon him. At the time of the interview, 

she had no financial resources to draw on beyond those to cover her 

most basic food and shelter costs, and there were no appropriate 

community services available free of charge for her son’s care or 

rehabilitation. She felt that her situation was truly hopeless. 

Lawsuit Nightmare 

The day after the injury occurred, an attorney friend referred Mrs. 

Jones to another lawyer who began a lawsuit. She said, ‘The entire 

situation was a nightmare. I had no idea what I was doing.” She hired a 

“top firm” but felt, in retrospect, that the attorney did not do an adequate 

job. She sued the California Department of Motor Vehicles and the city 

of San Francisco (in two separate offices) on negligence charges. The 

lawsuit went on for 11 years. Mrs. Jones won in the court of appeals but 

then lost in the California Supreme Court. In 1980, there was a $16,000 

settlement from one of the automobile insurance companies. The 

lawyers received $8,000 of that as their fee. Later, she received $4,000 

more. She used some of the money for a tutor for Stan, bought a car for 

herself, and saved some of the money. The $8,000 enabled her to put a 

down payment on the current residence. The legal proceedings finally 

ended in 1984. She received nothing. She felt that more money would 

have enabled her to give Stan a lot more rehabilitation in the first years 

after the injury and to place him in a private residential facility with 

vocational training. He would have become much more independent 

had he had that opportunity. 
Long-Term Impact 171 

Mrs. Jones has none of the support needed to cope adequately with 

her son’s injury: respite and emotional support from family or friends, 

insurance to provide rehabilitation opportunities, and a legal settlement 

to improve the quality of family life are all lacking. Stan is an example of 

the disabled person who can benefit tremendously from a specially 

trained attendant. This service was temporarily provided to Stan by a 

private foundation, but could be part of the publicly funded long term 

care system. 

Caring for Severely Disabled Children 

Joe Campbell -- Trauma, Devotion, Death 

In April 1984, Joe Campbell, aged 16, attended a school-sponsored 

wrestling match. Toward the end of the day, with the coach gone for a 

few minutes, Joe began playing around with a boy 70 pounds heavier 

than he. The boys did some moves for which they were not well trained. 

They both fell and Joe screamed. He had broken his neck and was 

instantly paralyzed from the neck down. The coach ran in and 

performed first aid. Paramedics took Joe to the nearest hospital where 

he remained for two days. He was then transferred to a rehabilitation 

hospital where he stayed for 14 months. He died 4 months later. 

Joe was the youngest of three boys in the family. The others were 

19 and 20 and were living at home at the time of his injury. Mrs. 

Campbell, a deeply religious Christian woman, worked two days a week 

at a church-sponsored nursery school. Mr. Campbell worked for a chain 

retailer; his gross income at the time of his son’s injury was less than 

$25,000 a year. 

Long Hospitalization 

Joe had 23 doctors who cared for him after he was injured. Mrs. 

Campbell felt that they all were good, and that her son received 

consistently excellent care from the entire health care team throughout 

his hospitalization. His medical problems were profound. He had 

pressure sores from his inability to move. He developed skin rashes, 

allergic reactions to different medications. He was on a respirator for the 

first seven months of his hospitalization. His inability to talk because of 

the respirator was extremely frustrating for family members, who 

desperately wanted to communicate with him. 

Insurance Coverage 

Joe’s medical care was covered by three insurance carriers. First, 

there was a group plan through her husband’s employer. But his union 
172 Cost of Injury in the United States 

had negotiated only $150,000 maximum coverage. Mrs. Campbell told 

me she suffered a tremendous amount of anxiety when she was told 

initially that the $150,000 would probably cover only six months of Joe’s 

care. After only three weeks, the hospital bills were $45,000, and she 

started to panic. The second insurance carrier was through the national 

letter carriers. Her husband had worked years before for the U.S. Post 

Office. Over the years, she had continued to pay the premium at $1,600 a 

year. That policy was the one that covered most of Joe’s care, in spite of 

its one-year clause. At the end of one year, the insurance had paid about 

$400,000. Then, MediCal covered Joe’s hospitalization for two additional 

months, until the family was able to bring him home. On the day of the 

wrestling match, Joe had paid $7 for $10,000 of insurance. With the 

loopholes Mrs. Campbell searched for and discovered, that third carrier 

contributed $20,000 toward Joe’s care. But even three policies did not 

cover all his medical expenses. 

Insurance Not Enough 

The family needed more money for Joe’s medical care than the 

insurance could provide, and Mrs. Campbell was advised to begin a suit 

against the local wrestling association. The settlement came to $100,000. 

The lawyer got a third of the settlement in fees, plus a few hundred 

dollars in expenses. Joe had just turned 18 by the time the settlement 

came through, and Medical, which had been covering his medical costs, 

received half of the net of the settlement. The family ended up with 

$33,000. They did not receive the settlement until April 1987, after Joe 

had died. The grand total of Joe’s medical care: $604,576.11. 

The Complexity of Going Home 

The family had to significantly remodel their home in order for Joe 

to be able to live as a wheelchair-dependent quadriplegic. They had a 

ramp built to the front entrance of the house and they needed to rebuild 

a bathroom, which required plumbing changes throughout the house. In 

addition, they added a room for Joe, off the kitchen. The total cost of the 

remodelling was $23,000. Mrs. Campbell explained that there was an 

enormous amount of red tape with the city planning department. She 

worked with an architect from the city housing department, a service 

subsidized by the city. In order to pay for the construction, she 

borrowed $17,000 from her parents. $7,000 of that was paid back to them 

from the legal settlement. Her parents refused to accept any more 

money. In addition, she used all the money in Joe’s savings account; 

they borrowed against their life insurance; an aunt gave them $1,000, and 

the church set up a “homecoming fund” for Joe and raised $7,000 toward 

the cost of the construction. 
Long-Term Impact 173 

Disrupting the Family 

Joe’s homecoming proved to be a major adjustment for the family. 

The younger brother very reluctantly gave up his room for Joe. The 

older brother, who was closest to Joe, was studying accounting at the 

time of the injury. He quit his course and has become depressed and 

without direction since. Joe was home for three months before he died. 

During that time, Mrs. Campbell had full responsibility for his care and 

was completely exhausted by it. In her attempt to hire an attendant, she 

interviewed scores of people, finding most of them inappropriate. She 

finally managed to hire a man for eight hours a day, five days a week, 

but he disappeared after the first month. She continued to interview 

others after that, but did not find anyone satisfactory. She did all his care 

herself, with some help from her husband. Her other sons did not help 

her out in any way. Joe’s physical care was all-consuming, and the 

‘bowel and bladder” program had to go on every four hours. She did the 

1:00 a.m. shift and her husband helped at 5:00 a.m., before he went to 

work, so she could sleep until 8:00 a.m. 

Joe came home in June 1985. In September, he began school again at 

the public high school. He attended for four days, then got pneumonia, 

both bacterial and viral. Mrs. Campbell drove him to the hospital in the 

middle of the night, when he had great difficulty breathing. She was not 

sure he was going to make it through the night. But he lived in the 

hospital for three weeks. During that time, the family knew he was 

going to die. When he died three weeks later, Mrs. Campbell felt there 

was nothing left unsaid, and that her son “went home to God.” During 

the final weeks of Joe’s life, family members and close friends from 

church met in the hospital and planned his memorial service. Mrs. 

Campbell said this was extremely therapeutic and healing. She 

organized and hosted the memorial, attended by 200 people from all 

walks of Joe’s short life: school, sports, hospital, doctors, and church. 

Insurance from three carriers was not enough to cover Joe’s catastrophic 

injury, and the family needed to win a lawsuit to help pay for Joe’s 

medical and related expenses. Most people are unaware of the 

enormous cost of a catastrophic injury. 

Jason Stuart -- Youngest Child, Most Profound Disabilities 

In 1982, three-year-old Jason walked out his kitchen door onto the 

back patio while his mother was not watching and fell into the 

swimming pool located several steps from the back door. At the time, 

Mrs. Stuart was married and had a six-year-old daughter and a fivemonth-old daughter. She and her husband ran a trucking and 

transportation business from their home. Mr. Stuart was out of the 

house when Jason fell into the pool and Mrs. Stuart was very busy with 
174 Cost of Injury in the United States 

the business telephones. The six-year-old came screaming to her that 

Jason was in the pool. Mrs. Stuart found him floating on top of the water 

and estimated that he had been there at least 20 minutes. She jumped in, 

dragged him out, and ran screaming with him to the front of the house. 

Her neighbor, who happened to be a physician, came running out and 

attempted to resuscitate the child. Another neighbor called an 

ambulance. The child was pronounced Dead On Arrival at the nearest 

hospital. When they revived him some minutes later, hospital staff 

informed Mrs. Stuart that though he was technically alive, he would 

probably be blind, deaf, and permanently comatose. 

Mother Initiates Rehabilitation 

After Jason was hospitalized for seven weeks, Mrs. Stuart was told 

she could take home her still-comatose son. She had heard from a friend 

about a physician-designed rehabilitation program called Patterning, in 

which the coma victim is bombarded with stimuli. The program 

requires hundreds of volunteers. Its goal is to stimulate all the senses 

and bring the injured person out of the coma. Jason’s doctors strongly 

discouraged Mrs. Stuart from trying this program and they were very 

pessimistic about Jason’s prognosis. But Mrs. Stuart made the decision 

that she would do everything possible to revive her child and she began 

the Patterning program. She went to a local office, found out what she 

needed to do, and proceeded to gather all the materials (flash cards, 

pictures, other visual stimuli), which she paid for out o f pocket. She also 

arranged for 125 volunteers a week to come to her house to run the 

program. For six months, from 7 a.m. to 8 p.m., she had volunteers who 

came to her home, touched and massaged Jason, read to him, flashed 

picture/word cards in front of him, and in many other ways stimulated 

the child constantly. During that period, she woke up every hour and a 

half during every night in order to turn the child over, preventing him 

from getting pressure sores. 

Five months after the injury, the child emerged from the coma. Mrs. 

Stuart continued the Patterning program for another month. She felt his 

recovery was owed entirely to the stimulation he received from the 

program, which she stressed she carried out against her doctor’s wishes. 

At six months after the injury, she decided to terminate the program. 

She felt at the time that it could continue to benefit the child, but she was 

too exhausted to recruit and train the manv volunteers needed. 

Extent of Disability 

With severe central nervous system damage, including brain 

damage, the child was not able to learn to do the normal, developmental 

tasks of a three-year-old. He could do nothing for himself when he 
Long-Term Impact 175 

emerged from the coma, and now, six years later at age nine, still cannot 

do anything. He cannot sit up unaided, though he can hold his head up. 

He cannot control his movements and thus cannot feed himself. He is 

confined to a wheelchair when he is awake. Ironically, his vision and 

hearing are within normal limits and he can comprehend simple 

commands and sentences when someone speaks to him. 

Insurance and Legal Issues 

Eight months after the injury, Mrs. Stuart’s insurance broker 

informed her that her health insurance carrier would no longer cover the 

huge medical expenses of the child and that the family would be 

switched to another carrier, which would give Jason the same coverage. 

For six months, the new carrier did not pay for any treatment or 

rehabilitation services for Jason, so he did not receive physical or speech 

therapy. Mrs. Stuart claimed that Jason would be less disabled today 

had he received those services in the early months following the injury. 

Mrs. Stuart retained a lawyer and sued the insurance carrier. She won 

the case and settlement back payments began in 1986. 

About a year after the injury, Mr. and Mrs. Stuart became aware 

that they could collect from their home owner’s insurance policy. Mrs. 

Stuart learned this after receiving misinformation for quite some time. In 

1986, she finally received $500,000 for Jason’s care, paid to him in 

monthly installments. The money is used for his needs, at her discretion. 

The bulk of it is in trust for him. 

Catch 22 of Therapy 

When he turned four, Jason began to attend the public school every 

week day, from 8:00 a.m. to 1:00 p.m. in a program for handicapped 

children. Jason has been in that school program for five years. Mrs. 

Stuart claimed the greatest strength of the school program was, and has 

always been, the speech therapy program in which Jason receives a lot of 

verbal stimulation. Over the years, he has learned to nod yes and no, 

and to recognize pictures, words, and commands. Although the school 

district technically provides a physical therapy program, the physical 

therapists cannot actually touch Jason during any exercises at all because 

of school district liability concerns. Mrs. Stuart deeply regrets this. She 

believes her child would have greatly benefited from ‘hands on’ physical 

therapy, which he does not receive. Like Mrs. Smith and Mrs. Jones, 

Mrs. Stuart also explained that she was caught in a “catch 22 situation” 

regarding physical therapy for Jason. To participate in the school district 

program, one cannot hire, even privately, a physical therapist. The 

reason given is that the school district does not want to duplicate 

services. She is legally prevented from getting physical therapy for the 
176 Cost of Injury in the United States 

child if she wants to continue sending him to school. At the time of the 

interview, she had been fighting this policy with the school district for 

some time. She was convinced that Jason’s overall physical condition 

was deteriorating because he could not get physical therapy. She said 

Jason had become much more stiff, especially in the past two years, and 

that his scoliosis (a common problem for wheelchair-bound individuals) 

had become more pronounced. 

Divorce 

In 1985, Mr. and Mrs. Stuart divorced, a common occurrence among 

parents of severely injured children (for example, see Nixon and Pearn, 

1977, regarding near drowning). Mr. Stuart gave his wife no emotional 

support and his disabled son no physical help at all after the injury. He 

simply could not cope with his son’s condition. Mrs. Stuart said that one 

day her husband walked downstairs with his suitcase and announced he 

was leaving. She had no idea he had planned to leave. She knew he 

could not cope with Jason’s condition but was shocked that he would 

leave her and the children. The oldest child, then seven and a half, fell 

apart emotionally. 

The family business had gone bankrupt several months after the 

injury. The divorce was settled with Mr. Stuart paying $500 a month in 

alimony and $1,200 a month for child support. This was not enough for 

the family. To meet the $1,500-a-month mortgage payments and other 

household expenses, Mrs. Stuart took on one, then two, then three parttime jobs. The alimony payments stopped about one year before the 

interview when Mrs. Stuart started a new relationship. 

Remarriage 

Mrs. Stuart remarried three months before the interview was 

conducted. At that time, Mr. Stuart wanted to stop the child support 

payments. Mrs. Stuart was furious at him for this and was determined 

that the payments continue. She was prepared to take him to court if the 

payments should stop. Her second husband works as an auto mechanic 

and brings home $480 a week. Mrs. Stuart said she would not give up 

the child support without a huge fight. 

Emotional Toll on Siblings 

Mrs. Stuart spoke about the emotional burden the injury placed on 

her two other children. Her eldest daughter was seriously affected by 

Jason’s near drowning (Nixon & Pearn, 1977, report that emotional 

trauma typically follows the near drowning of a family member). Mrs. 

Stuart reported that about six months after the injury, the six-year-old 
Long-Term Impact 177 

confessed to her mother that the drowning was her fault. Her mother 

had told her to watch Jason. She felt guilty when she realized she had 

not been watching him and he fell into the pool. Mrs. Stuart tried 

repeatedly to explain that it was not her fault or responsibility. At 

present, that daughter, at age 12, is resentful of any help she has to give 

Jason. Mrs. Stuart felt she had neglected the oldest child over the years. 

The youngest child, now six, is more compassionate, Mrs. Stuart said, 

and she reads to her brother. But Mrs. Stuart worries that she may be 

learning-disabled. The father rarely comes to see the children and the 

oldest child misses him greatly. 

Severe disability of a child, including a grown child, usually means 

that the mother must devote her life to the child’s care. Extensive 

medical insurance and large legal settlements are essential to ensure that 

the family financially survives the catastrophe. A severe injury has 

profound, long-term ramifications on all family members. Individual 

responses are highly variable, yet divorce and the emotional instability 

of uninjured children are typical results. 

Conclusion 

is 

A number of findings are consistent across these ten cases. Money 

central to the well-being of the injured person and the family. The cost 

of serious injury goes far beyond initial medical treatment and includes 

housing, disability-related equipment, and long-term rehabilitation, 

education, and vocational training. For most individuals, the ability to 

financially survive a catastrophic injury depends on winning a large 

legal settlement in addition to having good private insurance coverage. 

Yet, even with a legal settlement and excellent medical coverage, it is 

realistic to be continually fearful of the cost of potential medical 

complications, follow-up surgical procedures, and future rehabilitation, 

housing, education, or job-training. The needs do not stop with medical 

stabilization; they continue for years or for a lifetime. 

The consequences of severe injury have a far-reaching impact that 

goes beyond the economic cost. Profound disability affects all aspects of 

the survivors’ existence for the rest of their lives, however long they may 

be. The disability disrupts, changes, and dominates family life forever. 

One family member, usually the mother or spouse, becomes the primary 

caregiver and devotes her life to the well-being of the injured person by 

calling upon all the personal and community resources of which she is 

aware. Emotionally surviving the burden of injury and disability 

depends on a supportive network for both the injured person and the 

primary caregiver from family, friends, health care professionals, and 

community groups. 
178 Cost of Injury in the United States 

Government benefits are set up on an either/or basis: disabled or 

employable; sick or healthy; indigent or ineligible for funds. Such 

inflexible criteria may not fit individual needs or unusual situations. 

Federal regulations are insensitive to the fact that many severely 

disabled people want to work and are capable of doing so. SSI and 

Medicaid have complex and variable eligibility criteria and are designed 

to provide benefits to the disabled at or below the poverty level. Services 

for the disabled are not consistently available across the country. In 

California they are more diverse, more individually tailored, and easier 

to acquire than in other places, especially in rural areas. 

All people interviewed for this project thought there should be a 

“safety net,” that is, they felt they should be able to rely on the “social 

service system” when a catastrophic injury occurs. They all expressed a 

“right” to more help with such extraordinary problems. They thought 

the social service system should be more comprehensive, more flexible, 

more supportive, and finally, more generous. Yet, in spite of their great 

need for the resources of society, all individuals illustrated characteristic 

American values: a determination to be self-reliant, a need to remain 

independent, and a profound responsibility toward disabled family 

members, regardless of the emotional and financial burden of that 

responsibility. 
Recommendations 

Injury in the United States has an enormous impact on society. The 

lifetime direct and indirect costs of injuries occurring in the United States 

in a single year amount to $158 billion and over 10 million lost life years. 

The consequences of disabling injury are economically and personally 

devastating for individuals, families, and the community. 

The case studies presented in this report vividly describe how the 

lives of injured persons and their families are significantly and 

permanently changed. The high cost associated with injury, including 

the first and later year costs, demonstrate that the long-term economic 

effect of severe injury is a significant burden on society. All sectors of 

the nation’s economy share the burden, including federal, state, and local 

governments and the private sector. Injury is a major public health 

problem that needs to be addressed by a variety of strategies. 

Prevention, control, treatment, and rehabilitation planning are required 

to reduce the number of deaths and nonfatal injuries as well as the 

associated high costs. Both new injury research and the application of 

existing knowledge deserve high national priority. 

The estimated lifetime cost of injury in the United States reported 

herein is the best estimate based on existing data. The conduct of the 

present study involved use of information from numerous sources, but 

in many cases estimates were necessarily made on the basis of limited 

data. The recommendations presented herein address the following 

injury issues: 

Injury prevention and control, 

Coding and measurement, 

Data needs, and

Treatment and rehabilitation.

Injury Prevention and Control 

The science of injury control has improved markedly in the past 

twenty-five years. The effectiveness of passive protection, 

environmental modification, and performance standards for consumer 

products has been documented in specific circumstances of injury. 

However, the enormous burden of injury demands that additional 

resources be devoted to injury prevention research and control 

evaluation. 
�

180 Cost of Injury in the United States 

Resources Needed for Injury Prevention Research 

In Injury in America, the Committee on Trauma Research report 

published by the National Academy of Sciences (Committee, 1985) 

identifies significant research needs in the areas of injury epidemiology, 

prevention, biomechanics, and treatment and concludes that in light of 

the magnitude of the injury problem, increased efforts are warranted. 

One of the major recommendations of that report is for the establishment 

of a Center for Injury Control at the U.S. Centers for Disease Control 

(CDC) to support research and prevention in the identified problem 

areas. The results of the research reported herein shed further light on 

the magnitude of injury cost, the impact on individuals and families, and 

the burden on public resources, which continue to dwarf efforts to 

diminish these impacts. A new focus on the problem of injury in the 

United States is needed at this time. Increased investment in the 

prevention of injury will pay substantial dividends. 

RECOMMENDATION: Direct greater resources to the prevention of injuries and the mitigation of their results through the 

application of existing knowledge and the development and 

evaluation of new strategies. Establish and fund a Center for 

Injury Control within CDC to provide a focal point for 

national injury prevention activities. Provide additional 

resources to existing agencies that currently pursue the 

prevention and control of injury resulting from motor vehicles, 

fires, consumer products, and occupational hazards. 

Evaluation of Injury Control Interventions 

Numerous interventions for injury control have never been 

evaluated or have been studied on a scale too small to produce reliable 

results. For most interventions, there are insufficient data to estimate 

cost effectiveness. Evaluation is necessary to identify and replicate 

successful interventions, and to avoid adverse effects. Well-designed 

studies of the costs and benefits of alternative injury control 

interventions are needed. 

RECOMMENDATION: Conduct research and controlled 

experiments to evaluate the effectiveness and savings of a wide 

range of injury control interventions and implement programs 

shown to be cost effective. 

Many injury prevention measures have been shown to be effective 

in reducing the frequency and severity of injury but have not been 

systematically applied. These interventions relate to changes in the 

-_ 
Recommendations 181 

physical environment and in behavior. The barriers to the 

implementation of these intervent ions need to be investigated. Injury 

prevention research should evaluate why measures that have been 

proven to be effective are not implemented or are discontinued. 

RECOMMENDATION: Conduct research to evaluate the 

societal barriers to the application of injury prevention 

strategies that have been proven to be effective. 

Coding and Measurement Issues 

A major limitation of existing data sources for injury surveillance 

and epidemiologic research is the lack of uniform information on the 

cause, type, and severity of injuries. Discharge data on hospitalizations 

involving injury routinely include codes for the diagnosis of the specific 

nature or type of injury (e.g., fracture or sprain), but are less likely to 

include codes for cause (e.g., motor vehicle crash or fall), although 

classification systems exist for describing the cause of injury. 

Cause of Injury 

The International Classification of Disease-g-Clinical Modification 

(ICD-9-CM) External Cause of Injury and Poisoning Codes (E-codes) 

have generally been used to classify cause of injury. Although 

information on cause of injury is critical in the design and evaluation of 

injury control -programs, cause of injury codes are not routinely 

incorporated in the National Health Interview Survey, the National 

Hospital Discharge Survey, or in statewide hospital discharge abstract 

systems. Requiring the uniform and routine collection of this 

information would greatly enhance the utility of these data bases. To 

ensure the success of this effort, however, the cause of injury should be 

coded in a data field separate from the description of the nature or type 

of the injury. Coding the cause in one of the limited number of fields 

used for describing the nature of the injury is not appropriate because it 

leads to underutilization of the cause of injury codes, especially if 

multiple injuries and/or comorbidities are present. 

The Committee to Review the Status and Progress of the Injury 

Control Program at the Centers for Disease Control (1988) states: 

“Incorporation of E-codes into hospital records and hospital discharge 

data bases is essential for determining the causes and incidence of 

injuries. Data systems that monitor injury incidence and prevalence 

and the morbidity and mortality associated with injury, as well as the 

causes of injury, are critical to the development of effective 

interventions” (Committee, 1988, p. 50). 
182 Cost of Injury in the United States 

RECOMMENDATION: Require the use of both cause and 

nature or type of injury codes for all hospital discharge data 

systems and for all data bases having the potential of 

providing national injury estimates. Require a separate field 

for the cause of injury code. 

Standardization of Injury Coding 

Four additional coding conventions are employed by various 

federal and state agencies and private organizations. 

�  ICD-N and ICD-E codes. The most widely used coding 

convention is the International Classification of Diseases (ICD-9-CM), 

Nature of Injury Code (N-code). The N-codes classify injury and 

poisoning (Codes 800-999) according to the nature or type of injury and 

the body part injured (e.g., sprains and strains and fractures of neck and 

trunk, lower limb). Currently, the sample surveys conducted by the 

National Center for Health Statistics (NCHS) -- the National Health 

Interview Survey, the National Hospital Discharge Survey, the National 

Ambulatory Care Survey, and the National Medical Care Utilization and 

Expenditure Survey -- employ the N-codes in classifying the nature of 

injury. The Health Care Financing Administration requires the use of Ncodes for reimbursement purposes. In current plans for the 10th 

revision, the ICD will not employ the ‘N-code’ and ‘E-code’ terminology. 

Chapters replacing these codes will be entitled “Injuries, Poisonings, and 

Certain Consequences of External Injuries” and “External Causes of 

Mortality and Morbidity” (Israel, 1989). 

�  ANSI Z16.2 codes. The Z16.2 coding system of the American 

National Standards Institute (ANSI) is used by insurers to code injuries 

for Workers’ Compensation. The basic data on workplace injury are 

derived from the Supplemental Data System of the U.S. Department of 

Labor and the Detailed Claims Information data base of the National 

Council on Compensation Insurance, as well as numerous state data 

bases. The scheme is designed for coding from records that lack the 

diagnostic detail required for ICD coding. A serious gap in the scheme is 

its failure to code the nature of internal injuries or neurological injuries. 

�  NEISS codes. The National Electronic Injury Surveillance 

System (NEISS) operated by the U.S. Consumer Product Safety 

Commission employs a less diagnostically demanding coding scheme 

than the ICD to record injury-related visits and admissions to a sample 

of hospitals. The scheme includes more detailed cause codes than the 

ICD-E codes. A strength of this scheme is the ability to code from 

emergency room records that often lack the detail needed for ICD-N 

coding. A deficiency in the NEISS system is the lack of identification of 

products by manufacturer and model. 
Recommendations 183 

� OIC codes. The National Accident Sampling System operated by 

NHTSA uses Occupant Injury Codes (OIC)which generally are more 

detailed than ICD codes and differentiate injuries according to threat to 

life. Nature or type of injury codes are not recorded. 

RECOMMENDATION: Standardize coding of injuries by 

multiple coding of nature and cause of injury for all data bases 

intended to provide national estima tes of injury. Agency needs 

for specific information can be met by the addition of 

customized codes. 

Injury Severity Measurement 

Injury severity determination provides an important tool for 

classifying injuries according to their potential threat to life or residual 

impairment. Classification of injuries by severity is central for 

monitoring patterns of injury and evaluating alternative strategies for 

prevention and treatment. Injury severity determination serves trauma 

care systems by assisting prehospital triage, clinical management, 

outcome evaluation, and medical research on injury. 

A variety of scores and scales have been developed over the years to 

determine injury severity (Cales, 1986; MacKenzie, 1984; Gustafson, 

1983). Included are the Abbreviated Injury Scale (AIS), the Injury 

Severity Score (ISS), the Trauma Index, the IPCAR Score, the IllnessInjury Severity Index, the Trauma Score, the Glasgow Coma Scale, the 

CRAMS Scale, the Therapeutic Intervention Scoring System (TISS), the 

Acute Physiology and Chronic Health Evaluation (APACHE), and the 

Hospital Trauma Index, to name a few. 

Although significant advances have been made in severity of injury 

scaling in the past three decades, substantial limitations persist. The 

Abbreviated Injury Scale (AIS) is the most widely recognized severity 

scoring system based on anatomic descriptors. A major drawback to 

incorporating the AIS in large population-based data systems, however, 

has been the need to review the entire medical record for adequate 

scoring. The recent development of computer software that translates 

ICD-9-CM codes into AIS severity scores affords the opportunity to 

classify injuries according to AIS severity using computerized hospital 

discharge abstracts. This conversion is, however, based on many 

assumptions due to the lack of specificity in the ICD-9CM nature of 

injury codes. Modest changes to the ICD classification would enhance 

the compatibility of the ICD and AIS classification systems and provide 

population-based injury information specific to severity as measured by 

the AIS. 
184 Cost of Injury in the United States 

RECOMMENDATION: Ensure tke compatibility of tke ICD 

and AIS systems for classifying anatomic description of injury 

to permit tke computerized conversion from ICD to AIS for 

assigning severity scores on national data bases. 

Impairment Classification Systems 

The AIS is primarily a measure of severity based on potential threat 

to life. There is no comparable measure based on expected levels of 

impairment. Impairment-based severity scales are critical, however, in 

determining the direct and indirect costs of injury and in evaluating the 

impact of alternative therapies and programs on the prevention of 

disability. 

Injury often leads to impairments that reduce the capacity for 

functioning. Impairment is a chronic physiological, psychological, or 

anatomical abnormality of bodily structure or function caused by injury 

or disease (Rice and LaPlante, 1988). The World Health Organization 

has proposed a classification entitled International Classification of 

Impairments, Disability, and Handicap (ICIDH) (WHO, 1980). The 

ICIDH is an extension of the taxonomic approach of the widely used 

International Classification of Diseases (ICD). The WHO (1980) manual 

treats impairment as a classification of disturbances at the level of the 

organ, disability as a taxonomy of individual limitations, and handicap 

as a classification of circumstances that place individuals with disabilities 

at a disadvantage relative’ to their peers when viewed from societal 

norms. 

The purpose of the ICIDH is to provide a framework for the 

organization of information about the consequences of disease and 

injury. There is substantial disagreement on the extent to which the 

ICIDH has achieved this goal (Haber, 1989). Moreover, the use of the 

ICIDH as a classification system in the United States has been limited. 

The classification of impairment can be used as a measure of 

societal impact as it directly measures the reduction in the ability of 

disabled people to live at full capacity. There have been several 

approaches to the development of injury impairment factors in this 

country (Hirsch, 1983; Luchter, 1987). 

RECOMMENDATION: Conduct research on tke development 

and evaluation of a valid and useful classification sysiem for 

impairments tkat will meet tke needs of researchers, program 

administrators, and rehabilitation specialists. 
Recommendations 185 

Data Needs 

The present study has utilized currently available data on cost, 

incidence, severity, and consequences in an effort to identify the 

magnitude and range of lifetime costs of injury in the United States. The 

data were found to be lacking in many respects. More complete and 

accurate measurement of the incidence of injury and related cost is 

required to target injury prevention and control programs in the future. 

The present research points the way to the following recommendations 

on methods to obtain better data to improve this measurement. 

Injury Surveillance 

Timely injury data are needed to identify important shifts in rates 

and patterns of injury, to identify newly emerging problems, and to form 

the basis for planning, analysis, and evaluation of injury control efforts. 

Information on injuries and events relating to injury may be obtained 

from a variety of sources. Examples of national databases designed for 

the surveillance of specific types of injury include: the Fatal Accident 

Reporting System (FARS), the National Accident Sampling System 

(NASS), the National Electronic Injury Surveillance System (NEISS), and 

the Survey of Occupational Injuries and Illnesses. These surveillance 

systems have provided important and useful information for monitoring 

the epidemiology of specific types of injury. Criticisms have 

nevertheless been raised regarding the completeness of coverage, the 

scope of content, and the high cost of these systems (Panel on 

Occupational Safety and Health Statistics, 1987; U.S. GAO, 1988). 

Other sources that provide data on injuries, although not designed 

specifically for the purpose of injury surveillance, are surveys from the 

National Center for Health Statistics and mortality data from the national 

vital statistics system. Two specific surveys of relevance are the National 

Health Interview Survey (NHIS) and the National Hospital Discharge 

Survey (NHDS). These surveys can provide uniform data on all injuries 

regardless of cause or nature, but their utility for surveillance is limited 

by their mode of collection. As large national surveys, they are collected 

and tabulated on an annual basis with data appearing approximately 9-

12 months after the end of the data collection year. Such a design does 

not lend itself to some surveillance needs. 

Mortality data from the national vital statistics system are also 

general purpose statistics that can provide information on injuries. 

These data, based on information reported on death certificates, are of 

two types: final and provisional. Final data, based on counts of all 

deaths in the United States, include both external causes and nature of 

injury information, as well as place of injury. The fact that final data are 

tabulated only once a year limits their usefulness for surveillance. 
186 Cost of Injury in the United States 

In contrast, provisional mortality data are tabulated monthly, with 

an approximate four-month lag from the time of death to the publication 

of aggregate statistics in the Monthly Vital Statistics Report (MVSR) of the 

National Center for Health Statistics. Provisional data include cause of 

injury codes but not type of injury. A special adaptation of provisional 

mortality data for surveillance purposes is the Mortality Surveillance 

System (MSS) introduced into the Monthly Vital Statistics Report in 1989 

(U.S. NCHS, 1989a). This is a graphic presentation and brief expository 

text of trends in selected causes of death, including injury, by age, sex, 

and month. The presentation is designed to graphically identify major 

departures of mortality patterns from the underlying trend and seasonal 

pattern in mortality, with a reasonably short time delay. 

Some state medical examiner and hospital discharge record systems 

have the potential for providing timely, detailed mortality and morbidity 

data for the most severe injuries. With the increasing availability of 

statewide hospital discharge abstract databases, new opportunities exist 

for developing timely and cost efficient surveillance systems. Currently, 

28 states maintain databases that contain, at a minimum, the items 

incorporated in the Uniform Hospital Discharge Data Set (UHDDS). 

When linked to death certificate data, hospital discharge abstracts 

provide population-based data on a significant subset of all injuries --

namely, those that are serious enough to result in death or 

hospitalization. An important advantage of these statewide databases is 

that they include all hospital discharges and provide data specific to the 

state and its local communities. 

No single national database is likely to be adequate for the 

comprehensive surveillance of injury. An effective, cost-efficient 

strategy of surveillance will depend on a combination of methods for 

gathering information from a variety of sources. Coordination of these 

efforts is essential to ensure uniform definitions and comprehensive 

surveillance of all types of injuries regardless of their severity or cause. 

RECOMMENDATION: Develop a national coordinated program of injury surveillance for the quick identification and 

control of outbreaks of specific injuries and for epidemiologic 

research on injuries. For this effort, rely on the integration of 

uniformly collected data derived from multiple sources at both 

the national and local levels. To compensate for the time lag 

inherent in national data bases, states in which the medical 

examiner and/or hospital discharge data have the necessary 

quality and currency could monitor their data as an early 

warning system. Provide resources to achieve these objectives. 
Rewmmendations 187 

Population-Based Data on Injury 

The National Health Interview Survey (NHIS) conducted by the 

National Center for Health Statistics is a continuing, nationwide, 

household interview survey. A probability sample of households in the 

civilian noninstitutionalized population of the United States is surveyed 

each week by interviewers from the Bureau of the Census. The survey 

provides data on the incidence of injury and acute conditions, limitation 

of activity, persons injured, hospitalizations, disability days, physician 

visits, and the prevalence of selected chronic conditions. It contains no 

data on circumstances or cause of injury. The NHIS ‘core’ set of 

questions has remained virtually unchanged from year to year. 

To provide data on special topic areas in addition to the basic NHIS 

data, supplements to the NHIS have been conducted annually. Topics 

covered by the supplement vary from year to year. A special 

supplement on injury conducted in 1970-72 and 1975 focused on the 

cause of injury. In 1985, the Health Promotion and Disease Prevention 

Supplement included questions on occupant restraints, smoke detectors, 

and hot water temperature settings. In 1987, a supplement conducted on 

cancer risk factors included questions on occupational exposure. In 

addition, a 1988 supplement on occupational health included an 

extensive set of questions on work injuries and work-related health 

conditions. The 1990 Health Promotion and Disease Prevention 

supplement will repeat the questions on the 1985 supplement and add 

questions about adolescent use of helmets and other guards when 

engaged in sports. A comprehensive NHIS supplement on injury should 

be conducted to collect detailed information on the cause of injury, the 

involvement of consumer products, whether the injury was job related, 

the nature of the resulting disability, and the medical care and 

rehabilitation services provided. 

RECOMMENDATION: Expand core NHIS questions relevant 

to injury to describe the circumstances of injury. In addition, 

conduct a comprehensive supplement to the NHIS on incidence, 

medical care, rehabilitation, and disability related to injury. 

Provide adequate finds for the expansion of the core NHIS 

questions and for the conduct of a comprehensive injury 

supplement. 

Longitudinal Studies 

Longitudinal data sets are increasingly essential to provide dynamic 

descriptions of injury and the short- and long-term consequences on 

individual injured persons, their families and friends, the community, 

and society. Injury refers to damage inflicted on a body by some 
188 Cost of Injury in the United States 

traumatic, usually external, force. Injured individuals may undergo 

physical, mental, economic, and emotional changes that prevent, disrupt, 

or permanently change their ability to carry on their usual activities. 

They may incur large and repeated medical and rehabilitation expenses. 

They may develop impairments, disabilities, and handicaps that require 

personal assistance in daily living and major changes in the means of 

livelihood. Injury may also entail loss of income, social status, or social 

contacts. It is essential that dynamic descriptions of injuries and their 

consequences be fully understood and documented as a basis for the 

formulation of policy in the areas of prevention, treatment, 

rehabilitation, and research. Very few longitudinal studies of severely 

injured persons have been conducted to provide improved estimates of 

lifetime costs. 

Injured Persons in the General Population 

The major national source of population-based data on injury is the 

National Health Interview Survey (NHIS). Conducted continuously 

since 1957, the NHIS provides national data annually on the incidence of 

unintentional injury, the prevalence of acute and chronic conditions and 

impairment, the extent of disability, the utilization of health care 

services, and other health-related topics. The National Center for Health 

Statistics conducts targeted population surveys (TPS), which are followup studies of NHIS respondents who report specific conditions at the 

time of the household interview or represent a certain demographic 

characteristic. Examples of TPS are the Post-Polio Survival Survey, an 

epidemiologic study of 800 persons identified during the 1987 NHIS as 

being at risk for post-polio syndrome, and the Work Injury Followback 

Survey, a followback study of about 200 persons reporting occupational 

injuries during the two-week reference period prior to the NHIS 

interview. 

A sample of injured persons in the NHIS could be selected and 

followed periodically to track the physical and economic consequences 

of injury. Precedent for this approach is the Longitudinal Study of Aging 

(LSOA), a family1 of surveys based on the Supplement on Aging (SOA) to

the 1984 National Health Interview Survey. The SOA provides 

comprehensive information on family structure, housing, use of 

community and social supports, occupation and retirement, functional 

limitations, and conditions and impairments. All respondents are 

followed through death records from the National Death Index, 

acquisition of cause of death codes from the death certificates, and 

linkage with Medicare files from the Health Care Financing 

Administration (HCFA). Subsamples have been selected for reinterviews in 1986, 1988, and 1990 to measure changes in functioning, 
Recommendations 189 

provision of help, living arrangements, and use of medical and nursing 

home care. The LSOA provides an excellent means of monitoring the 

long-term impact of injuries, especially falls, on disability impairment 

and mortality of 1 elderly people. 

RECOMMENDATION: Conduct, with adequate finding, a 

follow-up survey of respondents to the proposed NHIS Injury 

Supplement to determine the long-term physical and economic 

consequences of injury in the general population. Oversample 

respondents with severe injury resulting in long-term 

disability. 

Patients Treated in Trauma Centers 

The modern trauma center is the locus for treatment of and the 

primary source of data on moderately to severely injured persons in the 

United States. Trauma centers provide a full array of services with a 

complete team of qualified personnel available on a 24-hour basis. 

RECOMMENDATION: Develop a series of well-designed, 

closely coordinated studies of the long-term physical, psychological, and economic consequences of patients treated in 

several trauma centers throughout the nation. 

Cost Data 

For almost all types of medical care expenditure (e.g., hospital care, 

physician services, drugs and appliances, and rehabilitation), current 

data are unavailable from national data sources. Data from the 1980 

National Medical Care Utilization and Expenditure Survey (NMCUES) 

conducted by the National Center for Health Statistics are used in this 

report by inflating per person or per visit 1980 costs to 1985 levels on the 

basis of the relevant medical care component of the Consumer Price 

Index. The NMCUES is a national probability sample of the noninstitutionalized population. About 10,000 households were sampled and five 

interviews conducted over a period of 15 months to obtain information 

on medical care utilization, expenditure, and other health-related 

information. 

The National Medical Expenditure Survey (NMES) was conducted 

by the National Center for Health Services Research and Health Care 

Technology Assessment (NCHSR and HCTA) in 1987 and 1988. NMES 

consisted of six rounds of data collection covering an 18-month period. 

The household sample consisted of 14,000 households including 

oversamples of Blacks, Hispanics, low-income people, and people with 

functional impairments. Data collected includes expenditures and 
190 Cost of Injury in the United States 

sources of payment for all major forms of medical care, 

sociodemographic and economic characteristics of respondents, 

insurance coverage of respondents, and access to medical care. This 

survey will be a rich source of cost data for injury as well as for other 

illnesses and conditions. The data were not yet available for use in the 

present study. 

RECOMMENDATION: Conduct, with adequate finding, a 

national medical expenditure suwey periodically, preferably 

every five years, to provide current expenditure data for the 

nation. 

Occupational Injury 

Occupational injury is a major cause of illness and premature death 

in the United States. The Bureau of Labor Statistics (BLS) is responsible 

for collecting statistics on occupational injury and illness. It has been 

alleged that the number of occupational injuries reported by the BLS is 

seriously underreported because employers have a strong incentive not 

to report injuries. A recent study by the Panel on Occupational Safety 

and Health Statistics (1987) of the National Academy of Sciences 

Committee on National Statistics concludes that the BLS data systems are 

inadequate for providing the Occupational Safety and Health 

Administration (OSHA) with the data it needs for maintaining an 

effective program for prevention of workplace injury and illness. The 

Committee also concludes that there is no single agreed upon estimate 

for the number of occupational fatalities in the United States. Because of 

the inadequate data available on occupational injuries and fatalities, 

separate cost estimates for these injuries are not made herein. 

The Panel report includes 24 important recommendations relating 

to the revision and improvement of existing BLS data systems, use of 

other data systems, and confidentiality issues relating to survey data on 

individual establishments. The first recommendation is that the “BLS 

annual survey should be modified to permit the collection of detailed 

data on severe occupational injuries categorized as injuries resulting in 

death, hospitalization, or outpatient surgery” (Panel, 1987, p. 103). 

RECOMMENDATION: Implement the recommendations of 

the National Academy of Sciences Panel on Occupational 

Safety and Health Statistics of the Committee on National 

Statistics as soon as possible to provide improved and 

accurate data on occupational injuries and fatalities. 
Recommendations 191 

Firearm Injury Data 

Firearms are the second leading cause of injury death in the United 

States. In the past, firearm injuries were considered the sole 

responsibility of the police, with no role allocated to public health 

departments. Although the National Crime Survey collects information 

on firearms involved in crimes, no existing source provides the necessary 

information on all firearm deaths: homicide, suicide, and unintentional 

death. The Fatal Accident Reporting System (FARS) data base, 

administered by the NHTSA, provides an excellent model of such a 

system. The FARS collects information on fatal motor vehicle crashes 

categorized by the characteristics of the accident, the vehicle/driver, and 

the persons involved. The FARS uses some or all of the following data 

sources: police, hospital, medical examiner/coroner, and EMS reports; 

state vehicle registration, driver licensing, and highway department files; 

and vital statistics documents and death certificates (U.S. National 

Highway Traffic Safety Administration, 1988a). A system on firearm 

fatalities, comparable to FARS, would become a primary resource for 

documenting the firearm problem, and for designing prevention 

strategies. 

RECOMMENDATION: Require that firearm injuries, in 

addition to being reportable to the police, be reportable to 

health departments. Place greater emphasis on coding the type 

of firearm on the death certificate. Develop a national fatal 

firearm injury reporting system, comparable to FARS, with 

sufficient data for documenting the firearm problem and 

designing prevention strategies. 

Treatment and Rehabilitation 

Medical care provided to injured persons places a financial strain on 

the health care system. To relieve the enormous economic burden of 

disability on the society and on individuals and families, treatment and 

rehabilitation research and program development are essential. 

Trauma Care 

Communications systems are needed for medical management at 

the site of injury and for rapid delivery of the patient to the hospital for 

prompt medical care. When a severely injured person arrives at the 

hospital or trauma center, an experienced team of specialists with 

necessary back-up facilities, such as a blood bank, is required to avoid 

unnecessary morbidity, mortality, and residual disability. Since the 

1970s, trauma care has become increasingly specialized. Guidelines for 
192 Cost of Injury in the United States 

trauma center designation developed by the American College of 

Surgeons have permitted systems of regional trauma care to be designed 

and implemented. Recently, economic pressures on trauma centers due 

to uncompensated care have threatened the viability of such systems and 

centers. While trauma centers treat the most severely injured patients, 

hospitals with no trauma service continue to treat less severely injured 

patients. Studies are needed to examine the economic and treatment 

issues involved in trauma systems in order to assure that trauma care is 

provided most efficiently and effectively. The talents of epidemiologists, 

statisticians, biomedical engineers, trauma and rehabilitation physicians, 

behavioral scientists, and health economists will aid in this process. 

RECOMMENDATION: Conduct collaborative interdisciplinary research to identify and evaluate factors in trauma care 

that produce optimal results. 

Rehabilitation 

Rehabilitation is the process by which biologic, psychologic, and 

social functions are restored or developed to permit an injured person to 

achieve maximal personal autonomy. Rehabilitation is achieved both 

through functional change in the injured person and through changes in 

the physical and social environment. More persons survive major 

injuries today than in the past and need functional restoration of 

cognition, sensation, movement control, and mobility after brain, spinal 

cord, and musculoskeletal injuries. Rehabilitation units have developed 

improved procedures for amputation, prosthetics, and management of 

multiple musculoskeletal injury and neurotrauma. Progress has been 

made in reconstructive surgical procedures for improved function and 

correction of deformities. The Independent Living Movement provides 

community resources and role models for people living with disabilities. 

Resources are currently devoted to the development of expensive, 

high-tech rehabilitation devices that are not used because they are not 

affordable or reliable enough to meet the needs of the average person 

living with disabilities. Additional research and development resources 

must be devoted to the design and production of affordable, reliable 

assistive devices. 

RECOMMENDATION: TION: Greatly expand research for the 

development and evaluation of cost-effective model systems of 

rehabilitation and for the design and production of affordable 

and reliable assistive devices to serve the needs of people with 

disabilities. Involve people with disabilities in the decisionmaking process. 
Appendix A 

Injury Diagnoses 

Classification of ICD-9-CM Codes (E800-E999)* 

by Cause and Intent 

Cause and Intent 

Motor Vehicles 

Traffic and non-traffic accidents 

Suicide and self-inflicted injury by 

crashing of motor vehicle 

Injury by crashing of motor vehicle, 

undetermined whether accidentally or 

purposely inflicted 

Falls 

Accidental falls

Suicide and self-inflicted injuries by

jumping from high place

Assault by pushing from a high place

Falling from high place, undetermined

whether accidentally or purposely 

inflicted 

Firearms 

Accident caused by firearm missile 

Suicide and self-inflicted injury by 

firearms and explosives 

Assault by firearms and explosives 

Injury due to legal intervention by 

firearms 

Injury by firearms, undetermined whether 

accidentally or purposely inflicted 

Poisonings 

Accidental poisoning by drugs, medicinal 

substances, and biologicals; other 

solid and liquid substances, gases, 

and vapors 

ICD-9 E-Code 

E810-E825 

E958.5 

E988.5 

E880-E888 

E957 

E968.1 

E987 

E922 

E955 

E965 

E970 

E985.0-E985.4 

E850-E869 
194 Cost of Injury in the United States 

Suicide and self-inflicted poisoning by

solid or liquid substances, gases in

domestic use, or other gases and vapors

Assault by poisoning

Injury due to legal intervention by gas

Poisoning by solid or liquid substances,

gases in domestic use, or other gases,

undetermined whether accidentally or

purposely inflicted

Fire/Burns 

Accidents caused by fire and flames, 

hot substance or object, caustic or 

corrosive material, and steam 

Suicide and self-inflicted injury by 

burns, fire, or scald 

Assault by fire or hot liquid 

Injury by burns, fire, or scald, 

undetermined whether accidentally or 

purposely inflicted 

DrowningslNear Drownings 

Accidental drowning and submersion, 

including accident to watercraft 

causing submersion, or other accidental 

submersion or drowning in water transport 

accident 

Suicide and self-inflicted injury by 

submersion 

Assault by submersion 

Submersion, undetermined whether 

accidentally or purposely inflicted 

Other 

Railway accidents 

Road vehicles accidents (other than motor 

vehicles) 

Water transport accidents causing injury 

other than submersion or drowning 

Air and space transport accidents 

Vehicle accidents not elsewhere classifiable 

Accidents due to natural and environmental 

factors 

E950-E952 

E962 

E972 

E980-E982 

E890-899, E924 

E958.1, E958.2 

E968.0, E968.3 

E988.1, E988.2 

E830, E832, E910 

E954 

E964 

E984 

E800-E807 

E826-ES29 

E831, E833-E838 

E840-E845 

E846-E849 

E900-E909 
Accidents caused by suffocation and foreign 

bodies 

Other accidents, including falling objects, 

striking against or struck by objects or 

persons, caught in between objects; 

accidents caused by machinery, cutting or 

piercing instruments, or caused by 

explosion of pressure vessel 

Accidents caused by explosive material, 

electric current, exposure to radiation 

Overexertion and strenuous movements 

Other and unspecified environmental and 

accidental causes 

Late effects of accidental injury 

Suicide and self-inflicted injury by 

hanging, strangulation, and suffocation, 

cutting and piercing instruments, extremes 

of cold, electrocution, crashing of 

aircraft, caustic substances (except 

poisoning), other specified and 

unspecified means; 

Late effects of self-inflicted injury 

Homicide and injury purposely inflicted by 

other persons, including fight, brawl, 

rape, assault by corrosive or caustic 

substance (except poisoning), hanging 

and strangulation, and cutting and 

piercing instruments 

Child battering and other maltreatment 

Assault by other means, including striking 

by blunt or thrown object, criminal 

neglect, and other specified and unspecified 

means 

Late effects of injury purposely inflicted 

by other person 

Appendix A 195 

E911-E915 

E916-E921 

E923, E925, E926

E927

E928

E929

E953,E956,E958.3

E958.4,E958.6-

E958.9

E959

E960,E961,E963,

E966

E967

E968.2,E968.4,

E968.8,E968.9

E969
196 Cost of Injury in the United States 

Legal intervention by explosives, blunt 

object, cutting and piercing instrument, 

other specified and unspecified means 

(excluding firearms, or gas) E971,E973-976 

Late effects of injuries due to legal 

intervention; E977 

Legal execution E978 

Undetermined whether accidentally or purposely 

inflicted: hanging, strangulation, or 

suffocation, injury by explosives, cutting 

and piercing instruments, or other and 

unspecified means (except bums, fires, 

scalds, and motor vehicle crashes) 

Late effects of injury, whether accidentally 

or purposely inflicted 

Injury resulting from operations of war 

Late effect of injury due to war operations 

E983,E985.5, 

E985.6,E986,E988.0, 

E988.3,E988.4, 

E988.6-E988.9 

E989 

E990-E998 

E999 

*Excludes misadventures to patients during surgical and medical care 

(E870-E879), drugs, medicinal and biological substances causing adverse 

effects in therapeutic use (E930-E949). For hospitalized injuries, 

E-codes E929, E959, E977, E989 are excluded. 
The lifetime 

two components: 

and lifetime cost 

here. 

Direct Cost 

Appendix B 

Methodology 

Estimation of Lifetime Cost 

(Chapter 2) 

cost of injury for 1985 is estimated as the product of 

incidence (the number of new injuries occurring in 1985) 

per person. The model of per person cost is discussed 

The direct cost of injury is the value of resources that could be 

allocated to other uses in the absence of injury, such as expenditures for 

hospitals and nursing home care, physician and other professional 

services, rehabilitation, community-based services, drugs and medical 

equipment. Also included are related expenditures for insurance 

administration costs, vocational rehabilitation, and home 

modifications. The direct cost represents actual expenditures for goods 

and services. In this model, direct cost is calculated as the sum of 

discounted cost in each year (arbitrarily truncated at 99 years) times 

the survival probability of the individuals as follows: 

99 

PVDC = n=y 

 (n-y+l)

y,s 

where: 

PVDC = present discounted value of direct costs per 

person 

n age of the individual 

Y = age at which the individual was injured 
198 Cost of Injury in the United States 

i 

P (n) = probability that a person of sex s with injury i 

y,s acquired at age y will survive to age n 

S sex of the individual 

DC(n) = direct costs incurred in year n following injury 

r real discount rate 

Morbidity Cost 

The morbidity cost is represented by wages lost by people who 

either are unable to work at all because of injury and disability or 

cannot work at a level of full effectiveness; for persons too sick to 

perform their usual housekeeping services an imputed value of these 

services is included. Calculating the morbidity cost involves applying 

average earnings by age and sex to work-loss years for those currently 

employed, attaching a dollar value to housekeeping services lost 

because of illness, and applying labor force participation rates and 

earnings to persons who are too sick to be employed. In this model, 

morbidity due to injury is calculated as the number of days of restricted 

activity times average daily earnings, real or imputed, adjusted to 

reflect the probability that the person will survive, as follows: 

- PV -

morbidity 

99 

 (n)D (n) [$ (n) E,(n) Yf (n) Ef(g 

. 

c x 

365 “-’ 

where: 

1 . 

PVmorbidity = present discounted value or earnings 

losses due to injury per person 

D(n) days of restricted activity during the 

year of a person currently age n 

n probability that a person of sex s with 

injury i acquired at age y will survive to 

age n 
Appendix B 199 

n age of the individual 

Ys(n) mean annual earnings of an employed 

person of sex s and age n 

Es(n) = proportion of the population of sex s 

and age n that are employed in the 

labor market 

Yhs(n) mean annual imputed value of 

homemaking services of a person of sex s 

and age n 

Ehs(n) proportion of the population of sex s 

and age n that are keeping house 

g = rate of increase of labor productivity 

Y age at which the individual was 

injured 

r real discount rate 

For fatal and hospitalized injuries, restricted ac tivity time and 

earnings were calculated on an annual (no t daily) basis. 

Mortality Cost 

Premature mortality is the current monetary value of future output 

lost due to premature death. The estimated cost or value to society of 

all deaths is the product of the number of deaths and the expected 

value of an individual’s future earnings with sex and age taken into 

account. This method of derivation takes into consideration life 

expectancy for different age and sex groups, changing pattern of 

earnings at successive ages, varying labor force participation rates, 

imputed value for housekeeping services, and the appropriate discount 

rates to convert a stream of costs into its present worth. Mortality due 

to injury is calculated as the earnings that the individual would have 

had in the absence of injury, as follows: 
200 Cost of Injury in the United States 

PV 

mortality = 

p E,(n) + h (n) 1 x 

(l+r) “-’ S 

where: 

= present discounted value of loss due to 

i 

Y 

S 

n 

Es(n) 

g 

r 

injury death per person 

= probability that a person of sex s and age y 

will survive to age n 

= type of injury 

= age at which the individual was injured 

= sex of the individual 

= age of the individual 

= mean annual earnings of an employed person 

ofsexsandagen 

= proportion of the population of sex s and age n 

that are employed in the labor market 

= mean annual imputed value of homemaking 

services of a person of sex s and age n 

= proportion of the population of sex s and age n 

that are keeping house 

= rate of increase of labor productivity 

= is the real discount rate 
Appendix B 201 

Methods and Assumptions of Cost and Savings Analysis 

(Chapter 5) 

Most of the assumptions and methods in the cost and savings 

analysis are specified in the text. This appendix notes the steps in the 

analysis. 

The analysis of savings that could be accomplished by injury 

control programs included the following steps: 

1. Search the scientific literature for research that demonstrates 

the effect of programs on injuries. Use only research that deals with 

programs that have not been fully implemented and that demonstrates 

an effect on injury rates. Studies of attitudes and behavior thought to 

be related to injury were excluded unless actual effects on injury rates 

were found. Where several studies were done and the results differed, 

a judgment was made about the scientific validity of the research. For 

example, the results of a controlled experiment were given more weight 

than a quasi-experiment (comparison group without random 

assignment) which, in turn, was given more weight than a before-after 

study. 

2. Obtain information on the cost of implementing a given program. 

As noted in the text, this was possible on only a fraction of the 

identified programs. In some cases, such as costs of law enforcement to 

implement a law, the incremental costs are unknown. In others, the 

extent of implementation of programs that have been implemented 

partially, such as physician’s counseling, is unknown. 

3. Estimate the distribution of injury severity that would be 

reduced by the program. In most cases, this was accomplished by 

assuming that the program would affect the known distribution of 

severity of injuries relative to fatal injuries, as noted in the text in each 

case. In certain instances, special computer tabulations were done to 

obtain the injury estimates. These included the number of people killed 

in crashes where a driver was a certain age and the number of 

motorcyclists killed in states without helmet laws, both tabulated 

from the Fatal Accident Reporting System file for 1985. The estimated 

proportionate reduction in injuries of specified severity to be expected 

from implementation or increase in a given program was then 

multiplied by the number of injuries of a given severity that the 

program could be expected to reduce. 

4. Where the necessary elements could be reasonably estimated, 

costs of the injuries that could be prevented by a given program were 

estimated by multiplying the number of injuries of a given severity 

expected to be reduced by the costs of the injuries of that severity. Two 

costs are employed -- the human capital costs reported in Chapter 2, 

and the willingness-to-pay costs reported in Chapter 4. The following 
202 Cost of Injury in the United States 

computer program run in BASIC can be used to estimate savings of motor 

vehicle occupant injuries in a given area (such as a state) where the 

deaths in a given category are known: 

10 DATA 104.588,8.97,1.99,0.32,.1065,1 

20 DATA 1570,30423,40014,170543,741039,401302 

30 DATA 3000,31000,115000,375000,1525000,2000000 

40 DIM RATIOD(6),COST1(6),COST2(6),INJ(6),SAV1(6), 

SAV2(6) 

50 FOR I=1 to 6 

60 READ RATIOD(I) 

70 NEXT I 

80 FOR I=1 to 6 

90 READ COST1 (I) 

100 NEXT I 

110 FOR I=1 to 6 

120 READ COST2(1) 

130 NEXT I 

140 INPUT DEATHS 

150 LPRINT “DEATHS=“,DEATHS 

160 FOR I=1 to 6 

170 INJ(I)=RATIOD(I)*DEATHS 

180 SAVl(I)=INJ(I)*COSTl(I) 

190 SAV2(I)=INJ(I)*COST2(1) 

200 TOTl=TOTl+SAVl(I) 

210 TOT2=TOT2+SAV2(1) 

220 LPRINT I,INJ(I),SAVl(I),SAV2(1) 

230 NEXT I 

240 TOTl=TOT1/1000000 

250 TOT2=TOT2/1000000 

260 LPRINT “HUMAN CAPITAL= $“,TOTl,“MILLION, 

WILLINGNESS TO PAY=$“,TOT2,“MILLION” 

270 TOTl=0 

280 TOT2=0 

290 GOT0 140 

300 END 

For example, if 600 car occupants died in a given state and a beltuse law would reduce those deaths 7 percent, the number of deaths to be 

reduced would be 600 x .07 or 42. Enter 42 at the ? prompt when the 

program is run and the estimated savings will be printed. 

5. Potential savings of each of these types of costs are estimated by 

subtracting the cost of implementing or incrementing a given 
Appendix B 203 

intervention from the estimated costs of the injuries that could be 

reduced by the intervention. 

Methodology for Case Studies 

(Chapter 6) 

In-depth interviews were conducted with injury survivors and 

their family members in order to discover the impact of injury and 

disability on individuals and families. The anthropological technique 

of open-ended interviewing was employed. This interpretive analytic 

technique is widely used in the social sciences when the goal of the 

project is to collect richly textured information from a small number of 

subjects. With this technique, the group under investigation may not be 

widely representative of the larger population, but the investigator is 

able to gain a deeper knowledge of meanings in that group. 

Anthropological interpretation generalizes in a different way from 

survey or other positivist approaches. It describes individuals 

systematically and accurately in order to highlight patterns and 

principles. Findings come not through explicit statements about specific 

variables or generalities, but rather through concrete portrayal of 

individual events and lives. This was not a survey and no survey 

techniques were used. Because the aim of this anthropological part of 

the project was not to test a hypothesis, no variables were isolated or 

tested. The goal was to interpret data collected about the meaning of 

injury and disability over the long term. 

The interviewer was interested in hearing what the subjects 

perceived as meaningful events and experiences and the way in which 

they interpreted what happened. Thus, facts were not checked nor 

were any external measures of validity employed. Two to three hours 

were spent with each subject. All interviews were informal in style and 

were intended to be relatively nondirective. No precise preworded 

questionnaire was used, though an interview topic guide, shown below, 

was followed. Questions were designed to get people to talk about 

what was meaningful to them, rather than to have specific queries 

answered. A detailed questionnaire would have forced survivors and 

families to structure their answers according to researchers’ priorities 

rather than their own. The guiding principle was to encourage people 

to talk about what had happened to them from their own point of 

view. 

Interviews elicited information on the following topics: details of 

how the injury occurred; the acute care and rehabilitation experience; 

use of medical, legal, and social services; impact of the injury on family 

dynamics and employment; feelings about disability, recovery, loss, 
204 Cost of Injury in the United States 

and disruption; the changed self; and expressed needs over the postinjury years. Thus, interviews centered on the important events -- as 

perceived by the subject -- that had happened since the injury, and the 

meaning of those events to the injured person or family member. 

Interviews were undertaken in a spirit of friendliness and honesty. 

Data obtained in this manner were spontaneous, thoughtful, and 

usually self-reflective. Information about injury and disability was 

anchored in the occurrences of everyday life and the social and 

economic forces that impact the individual’s immediate environment. 

All interviews, conducted between January and June 1988, were taperecorded and the tapes were fully transcribed. 

Interview Guide for Case Studies 

Demographic Background 

1. Age 2 . Principal source of income 

3. Level of education 

4. Religious affiliation 

5 . Current occupation 

6. 

7. 

Marital status

Who live with currently. Where live currently.

The Injury 

1. How did the injury happen.? Where? When? Describe. 

2 . What happened immediately following? Who arrived on 

the scene? When? What did they do? 

Post-Injury Acute Care Hospitalization 

1. How long hospitalized? 

2 . Types of treatment? 

3 . Total costs? How covered? 

Rehabilitation and Other Post-Hospital Treatment 

1 . 

2 . 

3 . 

4. 

Kinds of home care, outpatient rehabilitation therapies since

injury? Costs? How covered?

How long did formal rehabilitation services last?

What about other types of treatment services? Costs? How

covered?

What about related social/psychological services since

injury? What services received, for how long, costs, how

covered.
Appendix B 205 

5 . Were you satisfied with your rehabilitation? Want(ed) 

more? Why? 

Legal Issues 

1. Was a lawsuit involved? Settled in or out of court? Award? 

2 Workers’ compensation involved? Describe. 

Employment 

1 . Describe any job/career changes since injury. Lose job? 

Modify/change jobs? Over what time period? Alter type of 

work, amount of work, or work schedule? Resulting salary 

changes? 

Living Standard 

1. Could you describe to me in what ways your standard of living 

has changed each year since the injury? 

Household Arrangements 

1. Who assists with physical care? To what extent? 

2. Who is responsible for scheduling these activities? 

3. Who cooks, cleans house, shops, home repairs, etc.? 

4. How have these activities changed since injury? 

5 . What activities have you had to give up since injury? 

Perceptions of Adjustment 

1. How have you been feeling since the injury? (Probes for 

physical and emotional factors) 

2 . What is your day like? Describe from beginning to end. 

3 . What kinds of changes have you noticed? 

4 . Do you feel any basic changes in your life have occurred? 

Describe. 

5 . What are your plans for the future? 

6 . What does your family think about this? 

Attitudes Toward Disability and Dependence 

1. How are your abilities limited now? How has this changed 

since injury? 

2. What do you do, can you do, about these limitations? How 

has this changed over time? 

3 . How is it for you to depend on (family, other caregiver) for 

aspects of personal hygiene? Aspects of daily routine? 

Recreation? Financial security? Social interaction? Other? 

(How is it to have patient dependent upon you for the above?) 
206 Cost of Injury in the United States 

Overall Adjustment 

1. What new household routines have been established since 

injury? 

2. What devices or home reconstructions would make life easier, 

safer? 

3. Who takes over tasks patient can no longer perform? 

4. Have you established any new routines to make patient care 

easier on other family members? What? 

5 What arrangements have to be made for continuing with all 

forms of therapy and treatment? 

6 . What financial, or insurance coverage arrangements have you 

had to make, if any? 
Appendix C 

Detailed Tables 

Table C-3

United States Civilian Population Estimates, 1985

Age Group Both Sexes Males Females 

Total 237,055,667 

0-4 17,995,333 

5-14 33,919,333 

15-24 38,765,000 

2544 72,926,667 

45-64 44,890,000 

65-74 17,027,333 

75+ 11,532,667 

114,626,333 122,429,667 

9,208,000 8,788,000 

17,367,667 16,551,667 

19,254,667 19,511,000 

35,824,667 37,102,000 

21,423,000 23,466,333 

7,484,667 9,542,333 

4,064,000 7,469,000 

* Estimates derived from annualizing 1984,1985 and 1986 estimates 
208 Cost of Injury in the United States 

Table C-2 

Motor Vehicles: Number and Rate of Injured Persons by Sex, Age, and 

Class of Injury, 1985 

Total Fatalities** Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 5,372 2,266.1 45,923 19.4 523,028 220.6 4,803 2,026.l 

O-4 112 * 622.7 1,195 6.6 8,853 49.2 102 * 566.8 

5-14 328 * 965.8 2319 6.8 42,277 124.6 283 * 834.3 

15-24 1,763 4548.4 14,296 36.9 164,892 425.4 1,584 4,086.2 

2,064 2,830.5 15,062 20.7 185,156 253.9 1,864 2556.0 

45-64 793 1,767.6 6,891 15.4 77,590 172.8 709 1579.4 

6574 203 * 1,190.2 3,016 17.7 25,642 150.6 174 * 1,021.9 

75+ 109 * 943.1 3,144 27.3 18,619 161.4 87* 754.4 

Male 2,459 2,145.2 32,454 28.3 311,496 271.7 2,115 1,845.1 

O-4 70 * 757.9 696 7.6 5,090 55.3 64 * 695.0 

5-14 189 * 1,089.8 1,481 8.5 27,787 160.0 160 * 921.3 

15-24 763 3,963.2 10,696 55.6 105,411 547.5 647 3360.2 

1,036 2,890.5 11,424 31.9 116,105 324.1 908 2534.6 

45-64 254 1,187.3 4,687 21.9 38,677 180.5 211 * 984.9 

65-74 70 * 935.1 1,687 22.6 10,305 137.7 58 * 774.9 

75+ 77 * 1,892.3 1,783 43.9 8,121 199.8 67 * 1,648.6 

Female 2,913 2379.3 13,469 11.0 211,532 172.8 2,688 2,195.5 

0-4 42 * 480.9 499 5.7 3,763 42.8 38 * 432.4 

5-14 138 * 835.7 838 5.1 14,490 87.5 123 * 743.1 

15-24 1,000 5,125.7 3,600 18.5 59,481 304.9 937 4,802.4 

2544 1,029 2,772..6 3,638 9.8 69,051 186.1 956 2576.7 

45-64 539 2,297.4 2,204 9.4 38,913 165.8 498 2,122.2 

65-74 133 * 1390.3 1,329 13.9 15,337 160.7 116 * 1,215.6 

75+ 32 * 426.5 1,361 18.2 10,498 140.6 20 * 267.8 

* Figure has low statistical reliability or precision (relative standard error exceeds percent) ** Excludes 6,452 deaths occuring in later years due to injuries incurred in 1985 
Appendix C 209 

Table C-3 

Falls: Number and Rate of Injured Persons by Sex, Age, and Class of 

Injury, 1985 

Total Fatalities** Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 12,289 5,184.l 

0-4 1,316 7,313.4 

5-14 2,484 7,322.6 

15-24 1,825 4,707.6 

2,591 3,552.2 

1,755 3,909.5 

1,058 6,215.2 

1,261 10,931.7 

Male 5,633 4,914.2 

O-4 692 7,516.7 

5-14 1,266 7,292.l 

15-24 1,071 5,560.6 

1,405 3,922.7 

716 3,341.7 

248 * 3309.0 

235 * 5,778.7 

Female 6,656 5,436.8 

O-4 624 7,099.9 

5-14 1,217 7,354.6 

15-24 754 3,865.6 

1,185 3,194.5 

45-64 1,039 4,428.0 

65-74 811 8,494.9 

75+ 1,026 13,735.0 

12,866 5.4 783,357 330.5 11,493 4,848.2 

132 0.7 34,944 194.2 1,281 7,118.5 

79 0.2 59,697 176.0 2,424 7,146.4 

535 1.4 52,363 135.1 1,772 4,571.1 

1,384 1.9 124,131 170.2 2,465 3380.1 

1,815 4.0 143,156 318.9 1,610 3,386.5 

1,728 10.1 108,549 637.5 948 5,567.5 

7,193 62.4 260,518 2,259.0 993 8,610.3 

7,002 6.1 317,980 277.4 5,308 4,630.7 

91 1.0 20,050 217.7 672 7,298.0 

61 0.4 38,409 221.2 1,228 7,070.6 

462 2.4 36,217 188.1 1,034 5370.1 

1,151 3.2 77,140 215.3 1,327 3,704.2 

1,312 6.1 62,577 292.1 652 3,043.5 

1,022 13.7 31,645 422.8 215 * 2,872.5 

2,903 71.5 51,942 1,278.l 180 * 4,429.l 

5,864 4.8 465,377 380.1 6,185 5,051.9 

41 0.5 14,894 169.5 609 6,929.9 

18 0.1 21,288 128.6 1,196 7,225.9 

73 0.4 16,146 82.8 738 3,782.5 

233 0.6 46,991 126.7 1,138 3,067.2 

503 2.1 80,579 343.4 958 4,082.4 

706 7.4 76,904 805.9 733 7,681.6 

4,290 57.4 208,576 2,792.6 813 10,885.0 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

** Excludes 3,604 deaths occuring in later years due to injuries incurred in 1985 
210 Cost of Injury in the United States 

Table C-4 

Firearms: Number and Rate of Injured Persons by Sex, Age, and Class 

of Injury, 1985 

Total Fatalities” Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 268 * 112.9 31,556 13.3 65,129 27.5 171 * 72.1 

O-4 0 * 1.7 104 0.6 199 * 1.1 0 * 0.0 

5-14 24 * 71.6 590 1.7 2,684 * 7.9 21 * 61.9 

15-24 60 * 155.6 6,879 17.7 28,420 73.3 25 * 64.5 

2544 164 * 225.1 13,140 18.0 26,018 35.7 125 * 171.4 

45-64 12 * 27.7 6398 14.3 6,047 13.5 0 * 0.0 

65-74 4 * 20.9 2547 15.0 1,010 * 5.9 0 * 0.0 

75+ 3 * 23.0 1,898 16.5 749 * 6.5 0 * 0.0 

Male 216 * 188.5 26,366 23.0 56,718 49.5 133 * 116.0 

o-4 0 * 1.4 61 0.7 71 * 0.8 0 * 0 

5-14 20 * 113.1 464 2.7 2,186 * 12.6 17 * 97.9 

15-24 52 * 271.9 5,894 30.6 25,456 132.2 21 * 109.1 

2544 129 * 358.7 1 0,831 30.2 22,672 63.3 95 * 265.2 

45-64 10 * 47.6 5,217 24.4 4,970 23.2 0 * 0 

65-74 3 * 40.9 2,202 295 862 * 11.5 0 * 0 

75+ 2 * 54.1 1,697 41.8 500 * 12.3 0 * 0 

Female 52 * 42.1 5,190 4.2 8,411 6.9 38 * 31.0 

O-4 0 * 1.9 43 0.5 128 * 1.5 0 * 0 

5-14 5 * 27.9 126 0.8 498 * 3 4 * 24.2 

15-24 8 * 40.7 985 5 2,964 * 15.2 4 * 20.5 

2544 36 * 96.1 2,309 6.2 3,346 9 30 * 80.9 

45-64 2 * 9.6 1,181 5 1,077 * 4.6 0 * 0 

65-74 0 * 5.2 345 3.6 148 * 1.6 0 * 0 

75+ 0 * 6.0 201 2.7 249 * 3.3 0 * 0 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

** Excludes 1,030 deaths occuring in later years due to injuries incurred in 1985 
Appendix C 211 

Table C-5 

Poisonings: Number and Rate of Injured Persons by Sex, Age, and 

Class of Injury, 1985 

Total Fatalities Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 1,702 718.2 11,894 5.0 218,554 92.2 1,472 621 .O 

339 1,884.3 93 0.5 24,986 138.8 314 1,744.9 

5-14 266 * 784.9 94 0.3 11,132 32.8 255 * 751.8 

15-24 137 * 353.2 1,518 3.9 50,386 130.0 85 * 219.3 

25-44 547 749.9 5,942 8.1 66,942 91.8 474 650.0 

45-64 256 * 570.1 2,690 6.0 31,223 69.6 222 * 494.5 

65-74 100 * 585.2 772 4.5 14,870 87.3 84* 493.3 

75+ 58 * 501.2 785 6.8 19,019 164.9 38* 329.5 

Male 688 600.5 7,621 6.6 97,754 85.3 583 508.6 

157 * 1,706.9 52 0.6 14,121 153.4 

5-14 130 * 747.4 43 0.2 4,771 27.5 

15-24 41 * 212.9 1,025 5.3 20,975 108.9 

25-44 220 * 612.7 4,241 11.8 32,270 90.1 

45-64 91 * 426.5 1,484 6.9 13,886 64.8 

65-74 43 * 573.2 389 5.2 5,516 73.7 

75+ 7 * 162.5 387 9.5 6,216 153.0 

143 * 1553.0 

125 * 719.7 

19 * 98.7 

183 * 510.8 

76 * 354.8 

37 * 494.3 

0 * 

Female 1,014 828.3 4273 3.5 120,800 98.7 889 726.1 

182 * 2,069.9 41 0.5 10,865 123.6 

5-14 136 * 824.2 51 0.3 6,361 38.4 

15-24 96 * 491.5 493 2.5 29,411 150.7 

2544 327 * 882.4 1,701 4.6 34,672 93.5 

45-64 165 * 701.2 1,206 5.1 17337 73.9 

65-74 57 * 594.6 383 4.0 9354 98.0 

75+ 51 * 685.5 398 5.3 12,803 171.4 

171 * 1,945.8 

130 * 785.4 

66 * 338.3 

291 * 784.3 

146 * 622.2 

47 * 492.5 

38 * 508.8 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

0-4 

o-4 

0.0 

o-4 
212 Cost of Injury in the United States 

Table C-6 

Fire/Burns: Number and Rate of Injured Persons by Sex, Age, and 

Class of Injury, 1985 

Total Fatalities ** Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 1,463 617.2 5,671 2.4 54,397 22.9 1,403 591.8 

145 * 804.1 811 45 11,885 66.0 132 * 733.5 

5-14 168 * 4965 485 1.4 4,940 14.6 163 * 480.6 

15-24 370 955.4 442 1.1 8,937 23.1 361 931.3 

494 677.8 1,150 1.6 16,119 22.1 477 654.1 

45-64 129 * 287.2 1,118 2.5 7,818 17.4 120 * 267.3 

65-74 106 * 621.8 676 4.0 2,196 * 12.9 103 * 604.9 

75+ 50 * 437.8 989 8.6 2,505 * 21.7 47 * 407.5 

Male 797 695.6 3,438 3.0 38,946 34.0 755 658.7 

0-4 

5-14 

1524 

45-64 

65-74 

75+ 

59 * 642.9 464 5.0 7,736 84.0 51 * 553.9 

46 * 265.8 266 1.5 3,892 22.4 42 * 241.8 

179 * 931.9 290 1.5 7,142 37.1 172 * 893.3 

366 1,021.0 787 2.2 11,992 33.5 353 985.4 

108 * 502.5 756 3.5 5,896 27.5 101 * 471.5 

21 * 277.7 387 5.2 1,399 * 18.7 19 * 253.9 

18 * 452.2 488 12.0 890 * 21.9 17 * 418.3 

Female 666 543.7 2,233 1.8 15,451 12.6 648 529.3 

85 * 972.9 347 3.9 4,149 47.2 81 * 921.7 

5-14 122 * 738.7 219 1.3 1,048 * 6.3 121 * 731 .o 

15-24 191 * 978.7 152 0.8 1,795 * 9.2 189 * 968.7 

25-44 128 * 346.3 363 1.0 4,127 11.1 124 * 334.2 

45-64 21 * 90.7 362 1.5 1,922 * 8.2 19 * 81 .O 

65-74 85 * 891.7 289 3.0 797 * 8.4 84 * 880.3 

75+ 32 * 430.0 501 6.7 1,615 * 21.6 30 * 401.7 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

** Excludes 39 deaths occuring in later years due to injuries incurred in 1985 

0-4 

O-4 
Appendix C 213 

Table C-7 

Drownings/Near Drownings: Number and Rate of Injured Persons by 

Sex, Age, and Class of Injury, 1985 

Total Fatalities” Hospitalized Nonhospitalized 

Age Rate per Rate per Rate per Rate per 

and Number 100,000 100,000 100,000 Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 38 * 15.9 6,171 2.6 5,564 2.3 26 * 11.0 

0-4 29 * 159.6 720 4.0 1,993 * 11.1 26 * 144.5 

5-14 1 * 3.7 589 1.7 672 * 2.0 0 * 0.0 

15-24 2 * 5.6 1,461 3.8 722 * 1.9 0 * 0.0 

25-44 3 * 4.2 1,858 2.5 1,195 + 1.6 0 * 0.0 

45-64 2 * 3.4 845 1.9 678 * 1.5 0 * 0.0 

65-74 1 * 3.2 388 2.3 157 * 0.9 0 * 0.0 

75+ 0 * 4.0 310 2.7 148 * 1.3 0 + 0.0 

Male 35 * 30.4 4,951 4.3 3,928 3.4 26 * 22.7 

0-4 28 * 299.7 462 5.0 1,132 * 12.3 26 * 282.4 

5-14 1 * 6.1 458 2.6 605 * 3.5 0 * 0.0 

15-24 2 * 9.6 1,317 6.8 526 * 2.7 0 * 0.0 

3 + 7.2 1,613 4.5 967 * 2.7 0 * 0.0 

45-64 1 * 5.6 652 3.0 547 + 2.6 0 * 0.0 

65-74 0 * 4.0 254 3.4 49 * 0.7 0 * 0.0 

75+ 0 * 7.3 195 4.8 103 * 2.5 0 + 0.0 

Female 3 * 2.3 1,220 1.0 1,636 * 1.3 0 * 0.0 

0-4 1 * 12.7 258 2.9 861 * 9.8 0 * 0.0 

5-14 0 * 1.2 131 0.8 67 * 0.4 0 * 0.0 

15-24 0 * 1.7 144 0.7 196 * 1.0 0 + 0.0 

25-44 0 * 1.3 245 0.7 228 * 0.6 0 * 0.0 

45-64 0 * 1.4 193 0.8 131 * 0.6 0 * 0.0 

65-74 0 + 2.5 134 1.4 108 * 1.1 0 * 0.0 

75+ 0 * 2.1 115 1.5 45 * 0.6 0 * 0.0 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

** Excludes 116 deaths occuring in later years due to injuries incurred in 1985 
214 Cost of Injury in the United States 

Table C-8 

Other: Number and Rate of Injured Persons by Sex, Age, and Class of 

Injury 

Total Fatalities** Hospitalized Nonhospitalized 

Age Rate per Rate per 

and Number 100,000 100,000 

Rate per 

100,000 

Rate per 

Number 100,000 

Sex (thousands) Persons Number Persons Number Persons (thousands) Persons 

Total 35,726 15,070.8 28,487 12.0 696,707 293.9 35,001 14,764.9 

O-4 2,130 11,835.8 1,308 7.3 29,576 164.4 2,099 11,664.l 

5-14 6,917 20,393.8 806 2.4 

15-24 8,592 22,163.4 4,281 11.0 

83,647 246.6 

158,362 408.5 

6,833 20,144.9 

8,429 21,743.8 

12200 16,729.2 9,288 12.7 258,758 354.8 11,932 16361.6 

4,423 9,853.4 5,844 13.0 110,326 245.8 4,307 9,594.6 

913 5363.6 2,750 16.2 27,536 161.7 883 5,185.8 

551 4,775.2 4,210 36.5 28,502 247.1 518 4,491.6 

Male 22,288 19443.8 20,972 18.3 494,752 431.6 21,772 18,993.9 

O-4 1,451 15,756.3 744 8.1 17,094 185.6 1,433 15,562.6 

5-14 4332 24942.6 3.4 60359 347.5 4,271 24291.7 

15-24 5,918 30,735.9 3,411 17.7 122,687 637.2 5,792 30,081 .O 

7,787 21,737.7 7,565 21.1 192,908 538.5 7,587 21,178.l 

45-64 2,283 10,655.1 4,585 21.4 75,067 350.4 2,203 10,283.3 

65-74 326 * 4,356.8 1,810 24.2 15,280 204.2 309 * 4,128.4 

75+ 191 * 4,690.7 2,273 56.0 11357 279.5 177 * 4355.3 

Female 13,438 10,976.5 7,515 6.1 201,955 165.0 13,229 10,805.4 

O-4 679 7727.0 564 6.4 12,482 142.0 666 7278.5 

5-14 2,586 15,620.8 222 1.3 23,288 140.7 2,562 15,478.8 

15-24 2,674 13,702.8 870 4.5 35,675 182.8 2,637 13,515.5 

4,413 11,893.l 1,723 4.6 65,850 177.5 4,345 11,711 .o 

45-64 2,141 9,121.7 1,259 5.4 35,259 150.3 2,104 8,966.0 

65-74 587 6,153.6 940 9.9 12,256 128.4 574 6,015.3 

75+ 360 4,821.0 1,937 25.9 17,145 229.5 341 4,565.5 

* Figure has low statistical reliability or precision (relative standard error exceeds 30 percent) 

*+ Excludes 1,853 deaths occuring in later years due to injuries incurred in 1985 
Appendix C 215 

Table C-9 

Motor Vehicles: Lifetime Cost* of Injury by Age, Sex, and Type of 

Cost, 1985 

Age Amount (millions) Per Injured Person 

and Indirect cost Indirect Cost 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $48,683 $12,270 $19,085 $17,328 $9,062 $2,304 $3,583 $330,843 

O-4 1,004 207 539 258 8,963 1,869 4,864 215,084 

5-14 3,107 817 1,553 737 9,485 2,512 4,775 264,858 

15-24 16,107 3,890 5,259 6,957 9,135 2,224 3,007 401,696 

25-44 20,652 4,370 8,620 7,662 10,005 2,132 4,206 444,497 

45-64 5,939 1,828 2,534 1,577 7,485 2,325 3,222 211,640 

65+ 1,874 1,158 579 137 6,017 3,793 1,898 21,429 

Male 33,328 6,765 12,912 13,652 13,554 2,788 5,321 370,618 

O-4 628 124 342 162 8,993 1,798 4,945 232,365 

5-14 2,145 511 1,131 503 11,336 2,724 6,025 288,666 

15-24 11,379 2,243 3,639 5,497 14,912 2,981 4,836 426,407 

2544 14,987 2,625 6,106 6,256 14,472 2,563 5,962 488,672 

45-64 3,511 799 1,537 1,175 13,801 3,199 6,157 230,665 

65+ 679 463 157 60 4,622 3,226 1,093 16,488 

Female 15,355 5,506 6,173 3,676 5,271 1,899 2,129 

O-4 377 83 198 96 8,913 1,987 4,730 191,172 

5-14 962 306 422 234 6,952 2,222 3,068 225,039 

15-24 4,728 1,647 1,620 1,460 4,727 1,653 1,626 329,752 

25-44 5,665 1,745 2,514 1,406 5,507 1,703 2,453 316,971 

45-64 2,429 1,030 997 402 4,505 1,918 1,856 170,558 

65+ 1,195 695 77 7,263 4,295 2,611 27,864 

* Discounted at 6 percent 

** Based on 52,375 deaths, including 6,452 deaths occuring in later years due to injuries sustained in 1985 
216 Cost of Injury in the United States 

Table C-10 

Falls: Lifetime Cost* of Injury by Age, Sex, and Type of Cost, 1985 

Age Amount (millions) Per Injured Person 

and Indirect Cost Indirect Cost 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality” 

Total $37,279 $14,689 $21,049 $1,541 $3,033 $1,197 $1,715 $93,554 

O-4 1,161 612 520 28 882 465 395 192,473 

5-14 2,626 1,042 1,556 29 1,057 420 626 165,944 

15-24 6,456 1,006 5,170 280 3,538 551 2,834 235,831 

25-44 10,994 2,019 8,259 716 4,244 780 3,190 342,264 

45-64 6,243 2,288 3,573 383 3,558 1,305 2,038 131,459 

65+ 9,799 7,722 1,972 105 4,226 3343 10,547 

Male 21,041 5,445 14,335 1,261 3,735 968 2,548 138,042 

690 341 328 21 996 493 474 226,150 

5-14 1,820 632 1,165 24 1,437 499 920 152,833 

15-24 4,792 661 3,881 250 4,476 618 3,626 248,858 

25-44 8,224 1,265 6,332 627 5,852 901 4,510 371,720 

45-64 3,539 1,003 2,237 298 4,943 1,403 3,131 153,627 

65+ 1,976 1,543 391 42 4,096 3,225 817 9,800 

Female 16,239 9,245 6,714 280 2,440 1,390 1,010 38,136 

5-14 

15-24 

2544 

65+ 

471 271 192 8 755 

806 411 390 5 662 

1,663 344 1,289 30 2,205 

2,770 755 1,927 89 2,337 

2,705 1,285 1,335 84 2,603 

7,823 6,178 1,581 63 4,260 

337 

637 

1,237 

3,373 

308 

321 

1,709 

1,626 

1,286 

137,748 

278,119 

164,677 

220,582 

87,053 

11,105 

* Discounted at 6 percent 

** Based on 16,470 deaths, including 3,604 deaths occuring in later years due to injuries sustained in 1985 

O-4 

O-4 
Appendix C 217 

Table C-11 

Firearms: Lifetime Cost* of Injury by Age, Sex, and Type of Cost, 1985 

Age Amount (millions) Per Injured Person 

and Indirect costs Indirect costs 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $14,410 $911 $1,418 $12,080 $53,831 $3,860 $6,006 $370,706 

108,386 11,566 39,586 217,900 

12,087 1,606 2,039 268,924 

69,720 6,834 7,372 468,860 

47,746 2,510 4,483 504,781 

148,516 14,891 37,769 237,665 

31,123 20,940 35,767 20,779 

57,053 4,132 5,554 384,424 

148,146 10,541 62,799 235,216 

12,242 1,674 1,960 265,249 

70,078 6,896 6,620 484,188 

52,450 2,774 4,448 530,351 

150,637 14,858 32,220 247,444 

23,732 22‘258 15,122 18,739 

40,338 2,749 7,855 300,035 

77,694 12,135 26,711 193,337 

11,430 1,313 2,377 287,707 

67,363 6,418 12,390 378,732 

30,791 1,580 4,606 382,152 

138,946 15,047 63,374 194,140 

72,358 16,421 106,595 35,524 

0-4 

5-14 

15-24 

2544 

Male 

0-4 

5-14 

15-24 

65+ 

33 2 8 23 

293 38 48 207 

4,204 365 394 3,445 

7,838 379 677 6,782 

1,848 90 228 1,530 

193 37 63 93 

12,328 784 1,054 10,491 

20 1 

241 32 

3,669 320 

6,740 326 

1,535 74 

125 30 

4 14 

38 171 

3,041 

523 5,890 

160 1,301 

21 74 

365 1,589 

3 8 

11 36 

86 404 

154 892 

68 229 

42 19 

Female 2,081 128 

13 2 

5-14 53 6 

15-24 535 45 

2544 1,098 53 

45-64 314 16 

65+ 68 7 

* Discounted at 6 percent 

** Based on 32,586 deaths, including 1,030 deaths occuring in later years due to injuries sustained in 1985 

O-4 
218 Cost of Injury in the United States 

Table C-12 

Poisonings: Lifetime Cost *of Injury by Age, Sex, and Type of Cost, 

1985 

Age Amount (millions) Per Injured Person 

and Indirect Cost Indirect Cost 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $8,537 $1,703 $2,441 $4,394 $5,015 $1,007 $1,444 $369,402 

168 148 0 20 495 437 0 212,671 

5-14 108 77 0 30 405 291 0 321,663 

15-24 1,484 321 734 10,839 2,370 3,167 483,760 

25-44 4,761 510 1,299 2,952 8,706 943 2,401 496,835 

45-64 1,429 272 536 621 5,582 1,072 2,116 230,877 

65+ 374 177 36 3,734 2,402 1,138 23,154 

Male 5,589 726 1,599 3,265 8,119 1,066 2349 428,358 

5-14 

15-24 

25-44 

45-64 

65+ 

Female 2,948 

96 

52 

3,452 

870 

177 

83 0 

36 0 

133 277 

246 900 

119 365 

107 57 

12 

15 

532 

2,306 

14 

608 531 0 232,417 

398 281 1 352,238 

22,973 3,329 6,927 518,891 

15,728 1,144 4,182 543,726 

9,523 1,328 4,059 260,066 

3,583 2,200 1,162 17,450 

5-14 

15-24 

25-44 

45-64 

65+ 

72 

56 

1,129 2,907 968 834 264,252 

65 0 8 398 356 0 187,626 

41 0 15 411 301 0 295,885 

188 152 202 5,652 1,968 1,591 410,720 

264 399 646 3,998 811 1,224 379,924 

152 171 235 3,394 932 1,047 194,959 

267 121 23 3,804 2,494 1,127 28,821 

* Discounted at 6 percent 

** Based on 11,894 deaths 

0-4 

0-4 

0-4 
Appendix C 219 

Table C-13

Fires/Burns: Lifetime Cost* of Injury by Age, Sex, and Type of Cost,

1985

Age Cost* (millions) Cost per Injured Person 

and Indirect Indirect 

Sex Total Direct Morbidity Mortality TotaI Direct Morbidity Mortality** 

Total $3,832 $920 

326 137 

5-14 267 80 

15-24 785 155 

25-44 1,607 301 

45-64 642 118 

65+ 205 129 

Male 2,801 608 

0-4 188 77 

5-14 176 49 

15-24 630 114 

25-44 1,233 227 

45-64 489 86 

65+ 86 55 

Female 1,030 312 

o-4 138 60 

5-14 91 32 

15-24 155 41 

25-44 374 74 

45-64 153 32 

65+ 120 74 

$1,548 $1,364 $2,619 $631 $1,062 $238,841 

14 175 2,253 953 100 215,188 

42 144 1,583 478 252 296,928 

417 212 2,118 420 1,128 479,831 

743 563 3,252 610 1,507 489,644 

286 238 4,977 921 2,238 205,653 

44 32 1,313 832 288 19,302 

1,237 955 3,513 766 l,559 274,804 

3 108 3,173 1,316 50 231,852 

42 86 3,816 1,062 912 321,624 

366 . 150 3,509 638 2,041 516,360 

582 424 3,371 622 1,594 539,050 

228 174 4,541 806 2,134 219,468 

17 14 2,187 1,427 446 15,895 

310 408 1,548 470 468 182,844 

11 67 1,615 702 134 192,905 

0 58 741 259 4 266,932 

52 62 811 214 271 410,137 

161 139 2,914 579 1,260 382,530 

58 63 7,182 1,506 2,766 175,315 

27 18 1,021 636 235 23,076 

* Discounted at 6 percent 

** Based on 5,710 deaths, including 39 deaths occuring in later years due to 

injuries sustained in 1985 

0-4 
220 Cost of Injury in the United States 

Table C-14 

Drownings/Near Drownings: Lifetime Cost* of Injury by Age, Sex, 

and Type of Cost, 1985 

Age Cost” (millions) Cost per Injured Person 

and Indirect Indirect 

Sex Total Direct Morbidity Mortality Total Direct Morbidity Mortality** 

Total $2,453 $78 $107 $2,268 $64,993 $2,466 $3,339 $360,707 

O-4 183 26 0 157 6,376 917 6 218,365 

5-14 201 8 2 190 159,021 11,270 3,720 323,347 

15-24 767 11 28 728 351,406 15,023 38,738 498,496 

25-44 1,039 17 48 974 340,247 14,344 39,999 524,131 

45-64 236 12 23 202 155,285 17,200 34,058 209,934 

65+ 27 5 5 16 26,516 16,205 17,851 23,221 

Male 2,117 56 76 1,986 60,704 1,873 2,526 391,884 

o-4 122 15 0 108 4,434 539 6 232,785 

5-14 163 7 2 155 153,160 11,115 2,584 337,383 

15-24 700 8 22 670 379,937 15,570 41,662 508,823 

25-44 928 14 35 879 359,571 14,753 35,745 544,861 

45-64 191 10 16 166 159,460 17,738 28,614 215,934 

65+ 13 3 2 9 21,788 16,834 11,479 

Female 335 22 31 282 117,372 13,302 19,171 231,221 

O-4 61 11 0 50 54,257 12,820 0 192,542 

5-14 38 1 1 36 190,483 12,674 13,975 274,276 

15-24 67 3 6 58 196,748 13,557 30,892 404,045 

25-44 111 3 13 95 234,848 12,611 58,042 387,650 

45-64 45 2 7 36 139,839 14,952 56,790 186,060 

65+ 14 2 4 7 33,584 15,580 24,182 29,788 

* Discounted at 6 percent 

** Based on 6,287 deaths, including 116 deaths occuring in later years due to 

injuries sustained in 1985 
Appendix C 221 

Other: Lifetime Cost* of Injury by Age, Sex, and Type of Cost, 1985 

Age Cost* (millions) Cost per Injured Person 

and Indirect Indirect 

Sex Total Direct Morbiditv Mortalitv Total Direct Morbiditv Mortality** 

Total $42,421 $14,235 $19,272 $8,914 $1,187 $399 $540 $293,817 

04 1,252 677 303 273 588 318 142 200,418 

5-14 3,097 1,964 865 268 448 284 125 243,540 

15-24 9,340 3,187 4,028 2,125 1,087 371 469 460,224 

25-44 18,931 5,127 9,034 4,770 1,552 421 741 483,403 

45-64 7,634 2,149 4,131 1,353 1,726 487 935 216,622 

65+ 2,167 1,131 910 126 1,480 776 625 17,602 

Male 30,790 9,524 13,831 7,435 1,381 428 621 331,363 

04 788 432 188 168 543 298 130 212,363 

5-14 2,178 l,329 645 204 503 307 149 300,406 

15-24 7,025 2,313 2,944 1,768 1,187 391 498 478,829 

25-44 14,744 3,707 6,932 4,105 1,893 476 891 507,116 

45-64 5,294 1,318 2,853 1,123 2,319 578 1,252 228,878 

65+ 761 426 269 66 1,473 831 524 15,551 

Female 11,631 4,711 5,441 1,479 866 351 405 187,187 

04 464 245 115 104 361 169 183,764 

5-14 919 635 220 64 246 85 151,472 

15-24 2,315 874 1,084 357 327 406 385,946 

25-44 4,187 1,420 2,102 665 322 476 375,074 

45-64 2,340 832 1,278 230 389 598 171,707 

65+ 1,406 705 642 59 747 679 20,647 

* Discounted at 6 percent 

** Based on 30,343 deaths, including 1,853 deaths occuring in later years due to 

injuries sustained in 1985 
222 Cost of Injury in the United States 

Table C-16 

Mortality, Including Deaths in Later Years, by Age, Sex, and Cause of 

Injury, 1985 

Age

and Motor Fire- Poison- Fires/ DrownSex Total Vehicles Falls arms ings Burns ings* Other 

Total 155,665 52,375 16,470 32,586 11,894 

0-4 4,434 1,199 147 104 93 

5-14 5,992 2,782 172 770 94 

15-24 33,896 17,320 1,189 7,348 1,518 

25-44 51,279 17,238 2,089 13,435 5,942 

45-64 27,854 7,450 2,913 6,437 2,690 

65+ 31,910 6,386 9,960 4,492 1,557 

Male 111,867 36,836 9,136 27,289 7,621 

0-4 2,618 696 91 61 52 

5-14 3,986 1,741 154 644 43 

15-24 26,502 12,892 1,005 6,280 1,025 

25-44 40,327 12,803 1,686 11,102 4,241 

45-64 20,245 5,092 1,943 5,256 1,484 

65+ 18,189 3,612 4,257 3,946 776 

Female 43,798 15,539 7,334 5,297 4,273 

O-4 1,816 503 56 43 41 

5-14 2,006 1,041 18 126 51 

15-24 7,394 4,428 184 1,068 493 

25-44 11,252 4,435 403 2,333 1,701 

45-64 7,609 2,358 970 1,181 1,206 

65+ 13,721 2,774 5,703 546 781 

5,710 6,287 30,343 

811 720 1,360 

485 589 1,100 

442 1,461 4,618 

1,150 1,858 9,867 

1,157 961 6,246 

1,665 698 7,152 

3,477 5,067 22,441 

464 462 792 

266 458 680 

290 1,317 3,693 

787 1,613 8,095 

795 768 4,907 

875 449 4,274 

2,233 1,220 7,902 

347 258 568 

219 131 420 

152 144 925 

363 245 1,772 

362 193 1,339 

790 249 2,878 

* Includes Near Drownings 
Appendix C 223 

Table C-17 

Life Expectancy in Years, by Age and Sex, 1985 

Age Total Male Female 

Under 1 

14 

5-9 

10-14 

15-19 

20-24 

25-29 

30-34 

35-39 

4044 

4549 

50-54 

55-59 

60-64 

65-69 

70-74 

75-79 

80-84 

85+ 

74.6 71.2 78.1 

73.1 69.7 76.5 

68.7 65.3 72.1 

63.8 60.3 67.2 

58.9 55.5 62.3 

54.2 50.9 57.4 

49.5 46.3 52.6 

44.8 41.7 47.7 

40.1 37.1 42.9 

35.5 32.5 38.2 

31.0 28.1 33.6 

26.6 23.9 29.1 

22.6 20.1 24.9 

18.8 16.5 20.8 

15.4 13.3 17.1 

12.3 10.5 13.6 

95 8.1 10.5 

7.2 61 . 78 .

6 0. 51 . 6 4.

Source: National Center for Health Statistics: Vital

Statistics of the United States, 1985, Vol. II, Sec. 6, Life

Tables. DHSS Pub. No. (PHS) 88-1104. Public Health

Service, Washington. U.S. Government Printing Office, 1988
224 Cost of Injury in the United States 

Table C-18 

Present Value of Lifetime Earnings by Age, Sex, and Discount Rate, 

1985

Males Females 

Age 4 Percent 6 Percent 4 Percent 6 Percent 

Under 1 421,235 208,631 341,274 173,738 

l-4 454,561 236,117 368,388 196,515 

5-9 519,459 293,977 420,790 244,559 

10-14 602,092 374,790 487,557 311,678 

15-19 689,576 468,782 552,141 384,026 

20-24 745,680 541,021 578,481 425,804 

25-29 749,695 568,546 558,019 424,982 

30-34 717,630 565,043 513,796 402,176 

35-39 653,498 532,289 454,897 364,873 

40-44 561,016 471,190 388,555 319,090 

45-49 450,452 389,462 319,279 268,529 

50-54 331,478 294,646 249,422 214,826 

55-59 213,719 194,878 181,151 159,614 

60-64 108,880 101,085 117,333 105,272 

65-69 42,879 39,713 67,346 61,103 

70-74 19,176 17,802 36,593 33,574 

75-79 9,383 8,789 18,847 17,531 

80-84 4,698 4,457 9,164 8,655 

85+ 1,442 1,408 2,311 2,257 
Appendix C 225 

Table C-19 

Selected Economic Variables Used in Estimating Mortality Cost by 

Age and Sex, 1985 

Percent Mean Annual Value of 

of Population Mean Annual Housekeeping Services** 

Not in Labor Force 

Age me MaleEarningcemale Ma? LaborF>Tmle Male Female 

15-19 44.9 41.5 $6,706 $6,353 20-24 85.0 71.8 19357 16,030 

25-29 94.1 75.5 25,771 19,702 

 94.4 74.1 30,950 

3539 94.8 75.6 36,075 22,077 

40-44 935 75.4 38,856 21,642 

45-49 932 73.0 21,252 

 905 65.4 37,497 20,476 

55-59 82.0 55.7 19,878 

62.6 40.3 35,409 

6569 24.6 13.3 33,412 19,552 

70-74 12.9 5.5 27,898 16,529 

75-79 a.4 3.0 13,988 

80-84 5.5 1.5 19,418 11,824 

3.5 1.0 16,212 9,999 

4,706 11,715 

7,862 5,091 123% 

2,871 8,491 5,327 13,130 

8,911 5,446 

2,989 8,202 5,475 12,920 

2,989 7,469 5,475 12,108 

2,989 7,469 5,475 12,108 

7,338 5,682 12,029 

5,682 12,029 

7,155 5,712 11,793 

2,276 5,094 4,067 8,397 

3,464 2,766 5,710 

899 1,607 3317 

1,139 1,878 

 Mean annual 

contributions 

earnings for year-round 

to social insurance 

full-time workers, including supplements, consisting mainly of employer’s 

Values are imputed by multiplying hours spent in each type of domestic activity by the wages for corresponding 

occupations 

Source: U.S. Bureau of the Census, Current Population Reports, Series P-60, No. 156, “Money Income of Households, 

Families, and Persons in the United States, 1985.” Tables 34 and 36. U.S. Government Printing Office, 

Washington, D.C. 

U.S. Department of Labor, Bureau of Labor Statistics, Employment and Earnings, January Table 
226 Cost of Injury in the United States 

Figure C-1 

Present Value of Lifetime Earnings, by Age, Sex, and Discount Rate, 

1985 

Under 1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 4549 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ 

Males-4 Percent 

-Males-6 Percent 

Females-4 Percent 

-~-mm Females-6 Percent 
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�

Glossary 

Government Agencies and Programs 

Centers for Disease Control (CDC)

Consumer Product Safety Commission (CPSC)

Department of Health and Human Services (DHHS)

Department of Transportation (DOT)

National Center for Health Statistics (NCHS)

National Highway Traffic Safety Administration (NHTSA)

National Institutes of Health (NIH)

Old Age Survivor Disability Insurance (OASDI)

Social Security Administration (SSA)

Social Security Income (SSI)

Veterans Administration (VA)

Workers’ Compensation (WC)

Sources of Data 

Annual Survey on Occupational Injuries. An annual survey of 

establishments in the private sector conducted by the Bureau of 

Labor Statistics to collect statistics on occupational injuries and 

illnesses. A sample of approximately 280,000 establishments is 

selected from 5 million establishments with 11 or more employees. 

Information is provided on all work-related fatalities and illnesses 

and occupational injuries that involve loss of consciousness, 

restriction of work or motion, transfer to another job, or medical 

treatment beyond first aid. Data are reported by industry on lost or 

restricted workdays, nonfatal cases that do not involve lost 

workdays, days away from work, and fatalities by cause. 

Fatal Accident Reporting System (FARS). Data from traffic fatalities are 

collected from police reports, hospitals, medical examiners and 

coroners, Emergency Medical Services reports, state registration, 

driver licensing, highway department files, and death certificates. 

FARS is administered by the National Highway Traffic Safety 

Administration. Data are collected on time and location of the 

accident, age and sex of each person involved, alcohol involvement, 

and injury severity. 

National Accident Surveillance System (NASS). A national random 

sample of police reports of motor vehicle crashes administered by 

the National Highway Traffic Safety Administration. 
248 Cost of Injury in the United States 

National Council on Compensation Insurance (NCCI). A random 

sample of nearly 500,000 Workers’ Compensation cases in 16 states 

including detailed information on nature of injury, cost per case, 

and lost workdays. Claims have been tracked since 1979, and 

payments are reported at six months and every twelve months 

thereafter. 

National Electronic Injury Surveillance System (NEISS). Data on 

patients sustaining injuries associated with consumer products 

collected from a national random sample of hospital emergency 

departments, administered by the Consumer Product Safety 

Commission. 

National Health Interview Survey (NHIS). A continuing nationwide 

sample survey in which data on health status, acute and chronic 

conditions, and medical care use are collected through personal 

household interviews, administered by the National Center for 

Health Statistics. About 50,000 households with 125,000 persons are 

interviewed annually. In addition to a core set of questions 

repeated each year, supplement questionnaires on current health 

topics change each year in response to the need for data on special 

topics. 

National Hospital Discharge Survey (NHDS). A continuing nationwide 

sample survey of about 500 short-stay hospitals, administered by 

the National Center for Health Statistics. Within each sample 

hospital, a systematic random sample of discharges is selected and 

data are abstracted from about 200,000 medical records. Data are 

collected on admissions, length of stay, diagnoses, and procedures. 

National Medical Care Utilization & Expenditure Survey (NMCUES) A 

nationwide sample survey conducted in 1980 by the National 

Center for Health Statistics in which 10,000 households 

encompassing 17,000 individuals were interviewed five times at 

approximately 3-month intervals. Data were collected on health 

conditions, services, charges, sources and amounts of payments. 

National Mortality Detail File (NMDF). Data from death certificates for 

all residents who die in the United States each year, administered 

by the National Center for Health Statistics. Included are 

demographic characteristics of the decedent and cause of death. 

National Nursing Home Survey (NNHS). A periodic sample survey of 

nursing homes, administered by the National Center for Health 

Statistics. The 1985 survey data were obtained on the medical 

conditions and expenses of 6,023 discharges and 5,243 residents in 

1,079 facilities. 
Glossary 249 

Survey of Income and Program Participation (SIPP). A nationwide 

sample survey conducted by the Bureau of the Census that began in 

1983. The sample includes approximately 21,000 households 

interviewed every 4 months for 2 and 2/3 years. Each February a 

new panel of households goes into the field and members of each 

panel go through interviews or waves. Data are collected on 

demographics, housing, income and wealth, health status, and 

health expenses. 

Economic Terms 

Cost-of-illness studies. Studies that quantify the cost associated with a 

particular illness, based on either the prevalence or incidence of the 

illness. Most studies attempt to measure both direct and indirect 

costs. 

Currently employed. A term used in the NHIS to characterize persons 18 

years of age and over who reported that at any time during the 2-

week period covered by the interview they either worked or had a 

job or business. 

Direct cost. The actual dollar expenditures related to illness or injury, 

including amounts spent for hospital and nursing home care, 

physician and other medical professional services, drugs and 

appliances, and rehabilitation. 

Discount rate. A rate used to convert a future stream of dollars into the 

present value equivalent. The higher the discount rate, the lower 

the present value of a given stream of dollars. 

Human capital. An approach to valuing life in which productivity is 

based on market earnings and an imputed value for housekeeping 

services. 

Indirect cost. The value of lost output due to the reduced productivity 

caused by illness, disability, or injury. This includes the value of 

lost workdays and housekeeping days due to illness and disability, 

and losses due to premature death. 

Labor force participation rate. The proportion or percent of the 

population employed at a given point in time. 

Later year cost. The cost in later years associated with injuries sustained 

in 1985. 

Life expectancy. The average number of years of life remaining to a 

person at a particular age based on a given set of age- and sexspecific death rates. 
250 Cost of Injury in the United States 

Life years lost. The number of years that an individual would have been 

productive in the absence of injury or impairment, based on the 

number of years of life expectancy remaining at the age of death. 

Lifetime cost. The present discounted value of costs occurring in all 

future years. 

Lifetime earnings. The present discounted value of earnings in future 

years for the remainder of an individual’s life. 

Market earnings. Wages and salaries earned in the labor market 

including supplements such as employer’s contributions to social 

insurance. 

Morbidity cost. The value of lost productivity by individuals unable to 

perform their usual activities due to injury or disability, or those 

who cannot perform at a level of full effectiveness. 

Mortality cost. The value of lost productivity due to premature death 

resulting from injury. This is calculated as the present discounted 

value of future market earnings plus an imputed value for 

housekeeping services. 

Productivity loss. The value of output 

disability. 

not produced due to injury or 

Restriction of activity. A term used in the NHIS for categorizing 

limitations resulting from injury which encompasses four types of 

restriction: bed days, work-loss days, school-loss days, and cutdown days. 

Transfer payment. A payment that represents a transfer of funds from 

one payer to another and does not represent new goods or services 

produced. Insurance settlements, for example, are funds 

transferred from the insurance company to the hospital or 

individual to pay for medical services that have already been 

counted elsewhere. 

Value of housekeeping services. An imputed value calculated by 

assigning the prevailing wage rate for performance of tasks similar 

to those performed by housekeepers. For example, time spent 

cooking might be valued using the prevailing wage rate for a cook. 

Willingness to pay. An approach to valuing human life based on what 

an individual would be willing to pay for a change that reduces the 

probability of illness or death. It encompasses both the direct and 

indirect cost of illness. 
Glossary 251 

Work-loss day. A term used in the NHIS for a day on which a currently 

employed person aged 18 years or over missed more than half a day 

from a job or business. 

Injury Terms 

Abbreviated Injury Scale (AIS). A six-point threat-to-life scale that 

categorizes injury severity based on the nature of the damage to 

different body regions, defined as follows: AIS 1 -- minor; AIS 2 --

moderate; AIS 3 - serious; AIS 4 -- severe; AIS 5 -- critical; AIS 6 -

maximum. 

Cause of death. Every death is attributed to one underlying condition, 

based on information reported on the death certificate and utilizing 

the international rules for selecting the underlying cause of death 

from the reported conditions. 

Condition. A health condition is a departure from a state of physical 

and mental well-being. For NHIS, there are two types of condition: 

acute, which lasts less than three months and involves a physician 

visit or restricted activity; and chronic, which lasts three months or 

more. 

Death rate. A measure derived by dividing the number of deaths in a 

population in a given period by the resident population at the 

middle of that period. 

Disability. Any restriction or lack of ability to perform an activity in the 

manner, or in the range, considered normal. 

Drowning. A death resulting from suffocation within 24 hours of 

submersion in water. 

E-codes. International Classification of Diseases external cause of injury 

codes, developed by the World Health Organization. E-codes 

include injuries caused by motor vehicles, falls, firearms, drownings 

and near drownings, fires and burns, poisonings, and other causes. 

Epidemiology. The study of the distribution and determinants of healthrelated states and events in populations, and the application of this 

study to control health problems. 

Fatality. An injury that results in death. 

Fire/burn injury. Damage to tissue caused by thermal, chemical, 

electrical, radiation energy, or by inhalation of smoke and toxic 

fumes caused by a fire. 

Firearm injury. Damage to tissue caused by bullets fired from a firearm. 

-_ 
252 Cost of injury in the United States 

Hospital discharge. The completion of any continuous period of stay of 

one night or more in a hospital as an inpatient. 

Hospitalized injury. An injury that results in hospitalization with 

survival to discharge. 

Impairment. A chronic physiological, psychological, or anatomical 

abnormality of bodily structure or function caused by disease or 

injury. 

Incidence. The number of instances of illness commencing, or of persons 

falling ill or sustaining injury, during a given period in a specified 

population. More generally, the number of new events, e.g., new 

cases of injury in a defined population. 

Incidence rate. A measure of the rate at which new events occur in a 

population, derived by dividing the number of injuries reported 

during a defined period of time by the number of persons in the 

stated population in which the cases occurred. 

Injury. Damage to tissue caused by the exchange of kinetic, thermal, 

chemical, electrical or radiation energy at levels intolerable to tissue, 

or the deprivation of oxygen due to suffocation. 

Injury control. An organized effort to prevent injuries or to minimize 

their severity. 

Intent. The state of mind of persons involved in an injury episode which 

forms the basis for categorizing an injury as unintentional 

(traditionally termed accidental), as homicide/assault, or as 

suicide/self-inflicted. 

Intentional injury. An injury which is judged to have been purposely 

inflicted, either by the self or another. 

International Classification of Diseases (ICD) codes. A classification of 

the nature (N-Codes) and external cause of illness and injuries (ECodes), developed by the World Health Organization. 

Motor vehicle injury. An injury sustained by a motor vehicle occupant, 

pedestrian, motorcyclist or bicyclist in motor vehicle crash. 

N-codes. International Classification of Diseases of the nature of the 

injury and body part affected, developed by the World Health 

Organization. N-codes include, for example, head injury, spinal 

cord injury, fractures, abdominal/thoracic injuries, and others. 

Near drowning. Survival for at least 24 hours after suffocation from 

submersion in water. 
Glossary 253 

Nonhospitalized injury. An injury requiring medical attention without 

hospitalization, or resulting in one or more days of restricted 

activity without medical attention. 

Prevalence. The number of instances of a given disease or disability in a 

given population at a designated time, regardless of the course of 

the disease or disability. 

Prevalence rate. The total number of all individuals who have a disease 

or disability at a particular time (or during a particular period) 

divided by the population at risk of having that disease or disability 

at this point in time or midway through the period. 

Severity score. A measure of the seriousness of an injury, usually related 

to probability of survival. 

Survival rate. The proportion of survivors in a group, e.g., of patients, 

studied and followed over a period. 

Unintentional injury. An injury which is judged to have occurred 

without anyone intending that harm be done. 
Index* 

Abbreviated Injury Scale (AIS),15,31,34,183,251

Acquired immune deficiency syndrome, 106

Acute injury, defined, 33

Acute Physiology and Chronic Health Evaluation (APACHE), 183

Administrative rule

cost of, 126-31,201

reduction of injury by, 114,126-31

See also Laws

Adolescents 

incidence of injury among, 9,11,19,23-25,27,117,118 

and motor vehicle injury reduction measures, 117-19 

Adults 

cost for, 39,40,43,46-47,52,55,83 

incidence of injury among, 9,11,19-21,23-25,27 

leading causes of death of, 62 

payment sources for, 87,88 

See also Elderly 

Adverse effects, N-code for, 32 

Age, xxii, 8-11 

and attendant care, 156-57 

cause of injury by, 12,22-32 passim, 159,208-14 

cost of injury by, xxiii, xxvi, xxxvi, 39-65 passim, 82,83,215-21,225 

incidence of injury by, 9,11,19-29 passim, 34-35,159 

of injury death, 9,19-29 passim, 34,41,43,62,117,159,222 

leading causes of death by, 62 

legal driving, 117,118-19,136 

life expectancy by, 223 

lifetime earnings by, 42,43,52,57,224,226 

payment sources by, 87,88-90,96,98 

See also Adolescents; Adults; Children; Elderly 

Agencies. See Federal agencies; National...; Private sector; Programs; 

Public sector 

AHA. See American Hospital Association 

AIDS. See Acquired immune deficiency syndrome 

Air bags, x1,19,121-22,136-37 

Air transport accidents, 44 

AIS. See Abbreviated Injury Scale 

*'Passim’ indicates repeated mention throughout the pages referenced 
256 Cost of Injury in the United States 

Alcohol, as risk factor, 19,23,25,27,57,125,126-29

‘All-terrain vehicles’ (ATVs), 135-36

Ambulance service

cost of, 73,77,80 

payment for, 88 

American College of Surgeons, 192 

American Hospital Association, 77 

American National Standards Institute (ANSI), 182 

“And Keep on Looking,“ 115 

Anthropological interpretation, 203 

Antidepressants, poisoning by, 25 

Assaultive injury, 11,14,163 

See also Firearm injury 

Assault weapons, 23 

Attendant care 

in case studies, 145-46,154,158-59,160.61,169-70,171,173

cost of, 78,82,159,160

disabled persons’ access to (general), 140,156-57

payment for, 88

Attitudes 

discriminatory, 145,148 

and savings related to injury, 201 

See also Emotional responses 

Australia, bicycle helmets in, 115-16,135

Auto injury. See Motor vehicle injury

Auto insurance, 74,78,92,100

Automatic head restraints, automobile, 124,136

Automatic protection, defined, 114

Automatic vehicle lights, 123-24,136

Back injury, 82

Barbiturates, poisoning by, 25

Beating injury, 150-51

Behavioral change, reduction of injury by, 114-20,180

Benefit payments, 54,92

in case studies, 145,146,147,151-53

from private sector, 98 (see also Private insurance)

from public sector, xxiii, 92,98,99,142-43,147,151-53,178 (see also

Social Security)

Bicycle helmets, 115-16,135,136,137

Biopsychosocial disability, 142

Bites, animal /insect, 11

Black Lung Trust Fund, 98
Index 257 

Blind, SSI payments to, 98

Blomquist method, 102

Boating, and drownings, 27

Brain injury, 150-53,262,163-71,174.75

Braking deficiencies, motor vehicle, 19

Bridge width, and injury reduction, 132

Bureau of Labor Statistics (BLS), 190

Bureau of the Census, 74-75,79,97

Burns. See Fires and burns

California data, 27, 141

Cancer 

life years lost for, 2,68 

mortality cost for, 2 

Cardiovascular disease 

life years lost for, 2,68 

mortality cost for, 2,62 

research on, 68 

Caregivers/Caregiving 

in case studies, 144,145-46,149,150-51,154,162-77 

family, 113,144,149,161-77 

See also Attendant care 

Case studies, 143-78, 203-6

‘Casualties of the system,’ 163,170

‘Catch 22’ situation, in case studies, 166-67,175-76

Causes of death, 251

leading, xxiii, xxiv, 62-65,66,67-69 

leading injury, xxi, xxvii, 9,11,19,35 

Causes of injury, 11-13 

by age, 12,22-32 passim, 159,208.14 

cost by, xxvii-xxxi, 43-58 passim, 62,63,64,79,82,215-21 

E-code, 14,29,31-32,181,182,193-96,251 

by gender, 12,20,22,24,28,208-14 

hospitalized, 11,17,19,21,23-25,27,31-32 

incidence by, 9-11,13,14,19-34 passim, 43,208.14 (see also 

individual causes) 

injury death by, xxi, xxvii, 9,11,19-29 passim, 35,43,46,48,62,117, 

118,134,159,222 

leading, xx-xxi, xxv, xxvii, xxx, 9,11,19,35,191 

nonhospitalized injury by, xxi, 11,19,21,23,25,27 

other, xxx, 11,13,44,214,221 (see also Sports and recreational 

activities) 

recommendations re, 181-82 
258 Cost of Injury in the United States 

reduction of injury by, 19,21,25,27,11 l-37 passim

See also Drownings and near drownings; Fall injury; Firearm injury;

Fires and bums; Motor vehicle injury; Poisonings

Center for Injury Control, 180

Centers for Disease Control (CDC), xvii, 38,180,181

Central nervous system disorders, 106,162,174-75

Cerebrovascular diseases, mortality costs of, 62

Children caregivers/caregiving for disabled, 161-63,171-77

incidence of disabled, 161

incidence of injury among, 9,11,21,23,25,27,111

payment for, 87

reduction of injury among, 21,111,114-15,125,126,131,135,136

Child-restraint use law, 126,135

Chronic care facilities, falls in, 21

Cigarette Safety Act (1984),120

Cigarettes, 27,120-21,136

Civilian population estimates, 29,207

Classification systems impairment, recommendations re, 184

See also Coding 

Class of injury, xxxi-xxxii 

by cause, 11,17-34 passim, 159,208-14 

cost by, 48-52,53 

incidence by, 8-16 passim, 208-14 

See also Hospitalized injury; Injury death; Nonhospitalized injury 

Clinics, payment for, 91

Clothing ignition burns, 27

Coal excise tax, 98

Coast Guard, 109

Coding recommendations re, xviii, 5,181-84

See also International Classification of Diseases codes 

Committee on Trauma Research, 66-68,180 

Committee to Review the Status and Progress of the Injury Control 

Program, 181 

Community support networks for disabled persons, 155-56,167,192 

See also Independent Living Movement 

Concrete barriers, in roadways, 132 

Condition, defined, 251 

Congress, xvii, 112 

Consumer price index (CPI), 72,189 

Consumer Product Safety Commission, 109,135-36,182 

Control. See Injury prevention and control 

Cost-benefit analysis, 112-13 

Cost-of-illness studies, 70-81,249 
h&?x 

Cost of injury, xxvi, 

in case studies, 143-78 

data on, 

estimation methods for, 

greatest, xxv, xxvi, xxx, 

highest per injury fatality, xxxiii, 62 

payment sources for, see Payment sources 

reduction of, see Savings from injury reduction 

type of, see Direct cost; Indirect cost 

See also Lifetime cost; Per person cost 

Cost of injury reduction programs, 114-37 passim

CRAMS Scale, 183

Crime victim’s compensation, 100

Currently employed, defined, 249

Curves, and motor vehicle injury, 19,132

Cutting injury, 

Dart-out injury, 114-15

Data 

on cost, 

on incidence, 27-35 

limitations of, 

on payment sources, 94-100 

recommendations re, xviii-xix, 

on savings from prevention, 

Death. See Death rate; Fatality; Injury death 

Death rate, 251 

by age, 43 

of males, 39 

mortality cost and, 46 

See also Leading causes 

Debt, bad, 88

Department of Agriculture, 109

Department of Labor, 182

Dependence

in case studies, 

Social Security system promoting, 

Diagnosis, 193-96 

of hospitalized injury, 

N-code, 

and payment source, 95 

See also Coding; Severity of injury 
�

260 of Injury in the United States 

Direct cost, xxxv, passim, 

by age, passim 

by cause, 

defined, xxxiv, 70 

estimation of, passim, 197-98 

by gender, 39,48055 passim 

payment sources for, xxiii, 87-100 

See also Attendant care; Medical attention 

Disability, 

biopsychosocial, 142 

case studies of, 

and cost, xxxv, 

(see also Morbidity costs) 

defining, 142 

incidence of, 149 

legal, 142 

payment sources for, xxiii, passim 

permanent, (see also Spinal cord injury) 

recommendations re classification of, 184 

social role, 142 

Disability rights movement, 141,157 

Discount rates, 

Discrimination 

in case studies, 145,148 

See Employment 

Diving, spinal cord injury from, 

Divorce, 176 

Driver education, 

Driving age, legal, 117,118-l 9 

Driving injury. See Motor vehicle injury 

Driving while intoxicated 

See also Alcohol 

Drownings and near drownings, xxix-xxx, 

in case studies, 

cost of, xxx, 

incidence of, xxix, 

reduction of, 27,125 

risk factors in, 

Drugs 

illegal traffickers’ assault weapons, 23 

legal, see Prescription drugs 

Earnings. See Lifetime earnings 
�

Index 

E-codes, 

Education 

in case studies, 

driver, 

See also Schools 

Elderly 

attendant care for, 157 

cost for, 

incidence of injury among, passim, 34,159 

payment sources for, 

reduction of injury among, 134-35 

Emergency care 

cost of, 

payment for, 88 

reduction of injury by improving, 114 

Emotional responses 

to bum injury, 153,154 

to caring for disabled children, 

in case studies, 146-57 passim, 164-77 passim 

See also Suffering 

Emotional support. See Psychological support 

Employment 

in case studies, 144-59 passim, 

current (defined), 249 

disability affecting, 140-59 passim, 

discrimination over, 145 

health insurance related to, 

losses in, (see also Productivity loss) 

and reemployment costs, 

of teenagers, 119 

See also Labor force participation rate; Workers’ Compensation 

Enforcement cost, of injury reduction measures, 

Environmental changes, injury reduction with, 

181 

Environmental Protection Agency, 109 

Epidemiology, 251 

Equipment, disabled persons’ access to, 140,144 

Estimation method cost, 

incidence, 27-34 

payment, 94-100 

savings, 

Ethnic minorities, in case studies, 141 

Exertion injury, 11 
262 Cost of in the United States 

Expenditures. See Cost of injury; Cost of injury reduction programs; 

Funding 

Extremity injury 

cost of, 

incidence of, 15-17 

See also Head injury 

Fall injury 

in case studies, 

cost of, xxvii-xxviii, 

incidence of, xxvii, xxx, 9-22 passim, 43,209 

as leading cause of nonfatal injury, xxi, xxvii, xxx, 

permanent disability from, 

reduction of, 

risk factors in, 

Families 

caregiving by, 

in case studies, 

cost estimates excluding, 82 

long-term impact of injury on, xxv, 

parental driving in, 117,119 

 Accident Reporting System 

Fatality, 251 

causes of, see Causes of death 

cost of, see Mortality cost 

fates worse than, 

injury, see Injury death 

severe injury preferable to, 107 

See also Death rate 

Fates worse than death, 

Federal agencies and disability (general), 

injury research expenditures by, l-2,66-69 

payment by, xxiii, passim, 

willingness-to-pay method used by, 109 

See also Social Security 

Federal Aviation Administration, 109 

Federal Highway Administration, 109 

Federal Motor Vehicle Safety Standards, 111 

Females 

cost of injury for, 

disabled unemployed, 

incidence of injured, 
injury death rate for, 

See also Gender 

Firearm injury, xxviii, 251 

case studies and, 141 

cost of, xxviii, 

incidence of, xxviii, 

permanent disability from, 143,163 

recommendation re data on, 191 

reduction of, 129-30 

risk factors in, 23 

Fires and burns, xxix, 14,251 

in case study, 153-56 

cost of, 

as fates worse than death, 

incidence of, xxix, 

as preferable to death, 107 

reduction of, 

risk factors in, 

willingness-to-pay method and, 

First year cost, xxii-xxiii, xxxvii, 

Flame burns, 27

Food stamps, 151,152

Foreign bodies, N-codes for, 32

‘Free care,’ 95-96

Funding

injury research, xxiv, xxxvii, 

for prevention and control, 

for treatment, 2

See also Payment sources

Gang warfare, 23

Gases, poisonings by, 25

Gender

cause of injury by, 

cost of injury by, xxiii, passim, 

of disabled unemployed, 149-50

incidence of injury by, -xxii, 

injury death by, 

life expectancy by, 223

lifetime earnings by, 

General Motors, 122 

Glasgow Coma Scale, 183 

Gun control laws, 
Cost in the United States 

Gun injury. See Firearm injury

Handguns, 23

Hand loss, in case study, 147-49

Hangings, 

Head injury

in case studies, 167-71

cost of, 

as fate worse than death, 105,106

incidence of, 

payment sources for, 100

as preferable to death, 107

reduction of, 

willingness-to-pay method and, 

See also Brain injury

Head restraints, automatic, 124,136

Health Care Financing Administration, 182,188

Health care priorities, l-2

See also Recommendations 

Health Care Technology Assessment (HCTA), 189 

Health conditions, defined, 251 

Health Promotion and Disease 

Prevention Supplement, 187 

Heart diseases, 68 

mortality cost of, 62

See also Cardiovascular disease

Helicopter transport 

cost of, 

payment for, 88 

Helmets 

bicycle, 

Motorcycle, 

Highway accesses, and injury reduction, 134

Highway Safety Act 133

Hitting injury, 11

Homicide, 

Hospital discharge, 252

Hospital discharge data, 

See National Hospital Discharge Survey 

Hospitalization 

cost of initial, 76 

leading causes of, xxii 

See also Hospitalized injury 
Hospitalized injury, xxxii, 

by age, 

in case studies, 143-60 passim, 164-74 passim 

by cause, xxi, 

cost estimation methods for, 

cost of, 

data sources on, 

diagnosis and severity of, 

by gender, 

injury reduction campaigns and, 115,116 

intent of, 14 

payment for, 

recommendation re, 191-92 

See also Emergency care; Surgery 

Hospital Trauma Index, 183

Housefires, 25,131

Housekeeping services, value of, 

Housing

in case studies, 

disabled persons’ access to (general), 140 

Human capital method, 

savings measured by, 113-24 passim, 

vs. willingness-to-pay method, 

See also Productivity loss 

ICD codes. See International Classification of Diseases codes

Illness-Injury Severity Index, 183

Impairment, 252

permanent, 

recommendations re classification of, 184 

See also Disability; Injury 

Implementation, of interventions, 

feasibility of, 135-36 

Incidence/Incidence rate, xx, xxvi-xxx, 

by age, passim, 34035,159 

by cause, passim, 43,208.14 (see individual 

causes) 

data sources and methods 

determining, 27-35 

of disability, 149 

by gender, xxii, 

method based on, 

Independent Living Movement, 
266 Cost of in the United States 

Indirect cost, 

by age, 42-43 

by cause, 215-21 

defined, 70 

See also Morbidity cost; Mortality cost; Productivity loss 

Individuals 

in case studies, 

laws addressing behavior of, 

long-term impact of injury on, xxv, xli-xlii, 

203-6 

payment by, 

persuaded behavior change of, 114-18 

willingness-to-pay approach and, 

See also Age; Families; Gender; Per person cost 

In-Home Support Services, 145 

Injury, 

causes of, see Causes of injury 

class/type of, see Class of injury 

cost of, see Cost of injury 

data on, see Data fatalities from, see Injury death 

incidence of, see Incidence/Incidence rate 

intent of, see Intent reduction of, see Reduction of injury 

severity of, see Severity of injury 

Injury death, xxi, xxxi-xxxii, 

age of, passim, 

causes of, xxi, xxvii, passim, 

cost estimation methods for, 

cost of, xxxiii, (see Mortality costs) 

data sources on, 

defined, 29 

in emergency room, 73 

vs. fates worse than death, 106 

by gender, 

in hospital, 73-74 

injury reduction campaigns and, 115,116 

intentional, xxii, 

leading causes of, xxi, xxvii, 

payment for, 

reduction of, 

135,201 

at the scene, 73 

unintentional, 21-23 

See also Death rate 
 in America (Committee on Trauma Research), 66-68,180 

Injury prevention and control, 

by cause, 

funding for, 

injury death reduced by, 

programs for, passim, 201-3 

recommendations re, xviii, 

research on, 

savings from, see Savings from injury reduction 

willingness-to-pay method and, passim, 

Injury Prevention Center, The Johns Hopkins University, xvii

Injury Severity Score 183

Injury surveillance

recommendation re, 185-86 

See also Data 

Institute for Health Aging, University of California, xvii 

Insurance 

administration cost of, 

auto, 

in case studies, 148-60 passim, 164-75 passim

disability, 

health, 

home owner’s, 175

life, 

long term care, 160

See also Workers’ Compensation

Intent, 252 

of injury, 

See also Intentional injury; Unintentional injury 

Intentional injury, 

deaths, xxii, 

self-inflicted, 

International Classification of Diseases codes, 

and codes, 183-84 

E-codes, 

ICIDH and, 184 

N-codes, 

recommendations re, 

International Classification of Impairments, Disability, and Handicap 

(ICIDH), 184 

Interventions. See Injury prevention and control; Reduction of injury 

Interviewees, 
268 of in the United States 

Interviewing, 

open-ended, 203 

‘Invisible’ survivors, 

IPCAR Score, 183 

Jail sentences, for DWI, 126-29

The Johns Hopkins University, Injury Prevention Center, xvii

Labor force participation. See Employment; Productivity loss; Workers’ 

Compensation 

Labor force participation rate, 249 

by age, 

and cost, 

of males, 

Later year cost, xxii-xxiii, xxxvii, 

estimation of, 

Laws 

administration and enforcement cost of, 

reduction of injury by, 

See also Liability issues 

Lawsuits 

in case studies, passim, 175,177 

See also Legal cost 

Leading causes of death, xxiii, xxiv, 

of hospitalization, xxii 

of injury, xx-xxi, xxv, xxvii, xxx, 

of injury death, xxi, xxvii, 

of nonfatal injury, xxi, xxvii, xxx, 

Left-turn lanes, injury reduction with, 133

Legal cost, excluded from studies, 82

Legal disability,. 142

Legality. See Laws; Lawsuits; Legal disability; Liability issues

Liability issues

health care practitioner, 

product, 82 

Licenses 

gun, 130 

motor vehicle, 

Life, value of, willingness-to-pay method and, 

Life expectancy, 223,249 

and cost, 

Life insurance, 
Lifetime costs, xxii, xxvi, xxxiv, 

by age, 39-65 passim, 

by cause, xxvii-xxx, 43-55 passim, 82,215.21 

by class (general), (see individual injury types) 

estimation of, 

by gender, xxiii, passim, 215-21,225 

measurement of, (see Human capital method; 

Willingness-to-pay method) 

payment for, see Payment sources 

research funding by, xxxviii, 

See also Direct cost; Indirect cost 

Lifetime earnings, 46,250 

by age, 

by discount rate, 224,226 

estimation of, 

by gender, 

Life years lost, xxiv, 

as cost, 

Lifting injury, 11 

Lights 

roadway illumination, 133 

traffic signal, 

vehicle, 123024,136 

Local government, as payment source, 

Longitudinal studies, recommendation re, 

Longitudinal Study of Aging 188-89

Long term care institutions, 159

See Nursing homes 

Long-term impact of injury, xxv, xli-xlii, 

on families, xxv, xli-xlii, 

203-6 

on individual, xxv, 

on society, 

Lower extremity injury, incidence of, 15-17 

Machinery and tools, injury involving, 17 

Males 

cost of injury for, 

disabled unemployed, 

incidence of injured, 

injury death rate for, 

See also Gender 
2 70 of in the United States 

Market earnings, 250 

See also Lifetime earnings 

Marketing, product, 

Maryland 

data from, 

gun control law in, 135 

Measurement 

recommendations re, xviii, 

See also Estimation method; Human capital method; 

Willingness-to-pay method 

Medicaid, 

in case studies, 158,159 

Medical, 

Medical attention 

in case studies, 

cost of, xxiii, xxxiv, 

payment for, 

without hospitalization, see Nonhospitalized injury 

See also Hospitalization; Physician; Prescription drugs; Surgery 

Medicare, 

in case studies, 

Medications. See Prescription drugs 

Mercy killing, 106 

Methodology 

in case studies, 

cost estimation, 

incidence estimation, 27-34 

payment estimation, 94-100 

savings estimation, 

See also Human capital method; Measurement; Willingness-to-pay 

method 

Miami, Florida, injury reduction program, 

Minor injury 

willingness-to-pay method and, 107-8 

See also Nonhospitalized injury 

Morbidity. See Disability; Injury 

Morbidity cost, xxxv, passim, 83,250 

by age, 

by cause, 

defined, xxxiv 

estimation of, 

by gender, 

productivity loss as, xxiii, 
�

Index 271 

Mortality 

‘late,’ 

See also Death rate; Fatality; Injury death 

Mortality cost, xxxvi, 

by age, 

by cause of injury, 

defined, xxxiv 

estimation of, 

by gender, 

by leading causes of death, 62-69 passim 

productivity loss as, 

and research expenditures, 

Mortality Surveillance System 186

Mothers, as caregivers for disabled children, 161-77

Motorcycle helmets, 

Motor vehicle injury, xxvii, 208,252

in case studies, 

cost of, xxv, xxvii, xxx, 

FARS data on, 191

incidence of, xxvii, 9-20 passim, 

as leading cause of injury death, xxi, xxvii, 

permanent disability from, 

reduction of, passim, 202

risk factors in, passim

Motor Vehicle Safety Act (19661,111

National Academy of Sciences, 180

National Accident Sampling System 183,185

National Ambulatory Care Survey, 182

National Association of Rehabilitation Facilities, 77

National Bureau of Standards, 121

National Cancer Institute, 

National Center for Health Services Research 189

National Center for Health Statistics 

188,189 

National Council on Compensation Insurance 

National Crime Survey, 191 

National Death Index, 188 

National Electronic Injury Surveillance System 182,185 

National Health Interview Survey 

181-89 passim 

National Heart, Lung, and Blood Institute, 
272 Cost of in the United States 

National Highway Traffic Safety Administration xvii, 74, 

National Hospital Discharge Survey 

and cause of injury, 32,181 

and hospitalized injury, 

and injury incidence, 27 

and payment sources, 

National Institute of Mental Health Statistical Reporting System, 88 

National Medical Care Utilization and Expenditure Survey 

(NMCUES), 189 

and cost of injury, 

N-codes used by, 182 

and payment sources, 

National Medical Expenditure Survey 189-90

National Mortality Detail File, 

National Nursing Home Survey (NNHS), 

National Research Council Committee on National Statistics, 190

National Uniform Data System for Mental Rehabilitation, 

N-codes, 

Near drownings. See Drownings and near drownings

Neck injury, 

Neoplasms

mortality costs of, 62 

research on, 68 

See also Cancer 

New Jersey gun control law, 130 

New York City 

road design interventions in, 134-35 

window barrier regulations in, 

Nonhospitalized injury, xxi, xxxiii, 

by age, 

by cause, xxi, 

cost estimation methods for, 

cost of, 

by gender, 

injury reduction campaigns and, 115,116 

by intent, 

Nonmedical expenditures, xxiii, xxxiv, 

Nuclear Regulatory Commission, 109

Nursing homes

cost of, 81

falls in, 21

payment for, 
Occupant Injury Codes 183 

Occupational injury, 190 

See Workers’ Compensation 

Occupational Safety and Health Administration 109,190 

Offshore drilling, power makeup equipment in, 

Old Age, Survivors, and Disability Insurance (OASDI), 92 

One-way traffic, injury reduction with, 

Open-ended interviewing, 203 

Opiates, poisonings by, 25 

Osteoporosis, falls related to, 21 

Outpatient care 

payment for, 

See also Physical therapy 

Pain 

in case studies, 149 

quantification of, xxv 

reduction of, 113 

Panel on Occupational Safety and Health Statistics, 190

Paraplegia, 

Parental driving, 117,119

Patterning program, 174

Pavement grooving, injury reduction by, 132

Payment sources, xxiii, xxxvii-xxxix, 

by age, 

in case studies, 144-77 passim

by class of injury, 

for direct cost, xxiii, 87-100

disability and survivor benefit, xxiii, 

passim

estimation methods for, 94-100

private, 87-100 passim (see Private insurance; Settlements)

public sector, xxiii, 87-100 passim, (see also

Medicaid; Medical; Medicare; Social Security), 178

transfer payment, see Transfer payments

See also Insurance

Pedestrian injury, 

Permanent impairment, 

See also Spinal cord injuries 

Per person cost 

by cause, xxvii-xxx, 

estimation of, 82 
274 of in the United States 

by gender, 38-39 

See Age; Gender 

Persuaded behavior change, in reduction of injury, 114-18 

Pharmacy services. See Prescription drugs 

Physical therapy 

in case studies, 

cost for, 

Physician 

cost of, 

injury reduction with counseling by, 

payments for, 91 

Piercing injuries, 

Poison control centers, 25 

Poisonings, xxviii-xxix 

cost of, 

incidence of, xxviii-xxix, passim, 211

risk factors in, 25

Police enforcement costs, of injury reduction measures, 126-31

Pools, swimming, 125,173.74

Population-based data, 29,207

recommendations re, 

See also Age; Gender; Incidence/Incidence rates 

Post-Polio Survival Survey, 188 

Poverty 

of disabled persons, 14647,149 

Social Security system promoting, 146-47 

Power makeup equipment, in offshore drilling, 

Prescription drugs (and ‘other items’) 

in case studies, 152,16667 

cost estimation of, 

disabled person’s to (general), 140 

falls correlated with, 21 

payment for, 

poisoning by, 25 

Prevalence/Prevalence rate, 253 

method using, 

Prevention. See Injury prevention and control 

Private insurance, 

in case studies, 

Private sector 

dependence of interviewees on, 161 

passim 

payment by, 87-100 passim (see Private insurance; Settlements) 

See also Families; Individuals; Workers’ Compensation 

Product design, injury reduction with, 120-25 
�

Productivity loss, xxxvii, 

estimation of, 

as morbidity cost, xxiii, 

as mortality cost, 

in work-loss days, 

in work years lost, 

Product liability, 82 

Product marketing, 135-36 

Programs 

injury reduction, passim, 201-3

payment by, 87-100 passim

rehabilitation, 174 (see also Independent living movement)

See also Federal agencies; individual programs

Property damage cost, 85 

savings in, 

studies including, 

Psychological reactions. See Emotional responses 

Psychological support 

in case studies, 

disabled persons’ access to (general), 141,156 

Public sector 

payment by, xxiii, 87-100 passim, (see also 

Medicaid; Medical; Medicare; Social Security), 178 

See also Federal agencies; State government 

Quadriplegia, 75 

in case studies, 

willingness-to-pay model and, 

Railroad crossings, injury reduction and, 

Railroad worker injury, 11 

Railway transport accidents, 44

Recommendations, 

coding and measurement issues, xviii, 

data needs, xviii-xix, 

injury prevention and control, xviii, 5,179.81 

treatment and rehabilitation, xix, 

Reduction of injury, xxv, 

by cause, 

cost of programs for, 114-37 passim 

implementation of interventions for, 
276 Cost of Injury in the United States 

savings from, see Savings from injury reduction 

See also Injury prevention and control 

Reemployment cost, 

Reflectorization, on trucks, 132 

Rehabilitation, 179,192 

in case studies, passim

cost of, 

disabled persons’ access to long-term (general>, 140

for hospitalized injury (general), 17

payment for, 

recommendations re, xix, 

reduction of injury by improving, 114

vocational, 

See also Physical therapy

Rehabilitation Services Administration, 80 

Rehospitalization 

cost estimations of, 77 

data on, 

Remarriage, interviewee, 176 

Research, 70,179 

data, see Data 

funding for, xxiv, xxxvii, l-2,65-69 

methods, see Methodology 

prevention and control, 68,179.81,201 

recommendations for, 

willingness-to-pay, 101 

Restriction of activity, 250 

Right turns on red, 130 

Risk factors, 

alcohol as, 

reduction of, see Reduction of injury 

Road design, and motor vehicle injury, 

Safety belts, 

San Francisco Bay Area, interviews in, 141

Savings from injury reduction, xxxix-xl, l-37

data needed for, 

estimation methods for, 

specific figures, 115-24 passim, 

Scalds, 27 

Schools 

driver education in, 

pedestrian injury reduction campaign in, 114-15 
Seat backs, auto, 

Seattle gun ownership rules, 130

‘Self pay,’ 96

See also Uninsured costs 

Self-protection, firearm deaths from, 23 

Settlements, 

in case studies, passim �

See also Insurance 

Severity of injury, xx, 7,106 

and cost, 

data on, 

hospitalized, 

measurement of, 

recommendations on measurement of, 183-84 

reduction of, 

willingness to pay and, 

See also Disability; Hospitalized injury; Injury death; 

Nonhospitalized injury 

Severity score, 253

Sex. See Gender

Side crash protection, 122023,136

Smoke detectors, 

Social role disability, 142

Social Security, 

in case studies, 

See also Medicaid; Medicare; Social Security Disability Insurance;

Supplemental Security Income

Social Security Disability Insurance 

in case studies, 

Society 

long-term impact of injury on, 

morbidity cost for, 54 

mortality cost for, 

savings to from prevention, xxxix-xl, l-37 

willingness to pay of, 

See also Private sector; Productivity loss; Public sector 

Softball-base injury, 125-26 

Space transport accidents, 44 

Speed, motor vehicle, 

Spinal cord injury 

in case studies, 

causes of, 

cost of, 

incidence of, 17-18
�

278 Cost of Injury in the United States 

payment sources for, 100 

as preferable to death, 107 

See also Paraplegia; Quadriplegia 

Sports and recreational activities, injuries in, 

SSDI. See Social Security Disability Insurance

SSI. See Supplemental Security Income

Stabbings, 11

State government injury reduction laws of, 

as payment source, (see also Medical) 

Stroke, 68 

See also Cardiovascular disease 

Stumbling injury, 11 

Suffering in case studies, 

quantification of, xxv 

reduction of, 113 

Suffocations, 

Suicides, 

Supplement on Aging 188-89 

Supplemental Security Income 

in case studies, 

Surgery, in case studies, 

Surveillance, injury 

recommendation re, 185-86 

See also Data 

Survey of Income and Program Participation 97 

Survey of Occupational Injuries and Illnesses, 185 

Survival rate, 253 

Survivor benefit payments, xxiii, passim 

Survivors 

‘invisible,’ 

long-term effects on, 

See also Individuals

Sweden, automobile headlamp use in, 123

Swimming, and drownings, 27

Targeted population surveys 188

Targeting interventions, 134-35

Taxes

alcohol, 125 

coal excise, 98 

Technical Study Group on Cigarette and Little Cigar Safety, 

Teenagers. See Adolescents 

Television, injury reduction campaign on, 114-15 
Index 

Tennessee, child-restraint use law in, 135

Therapeutic Intervention Scoring System 183

Tranquilizers, poisonings by, 25

Transfer payments, xxxviii-xxxix, 

source of, 

See also Benefit payments; Settlements 

Transport Canada, 

Trauma care recommendations re, 

See also Hospitalized injury; Trauma center 

Trauma center 

in case studies, 167-68 

recommendations re, 

Trauma Index, 183 

Trauma-related injury 

brain, 163 

cost of, 84 

data re incidence of, 

See also specific injuries 

Trauma Score, 183 

Treatment, 179 

in case studies, 

cost for, 

funding for, 2 

for hospitalized injury (general), 

payment for, 

recommendations, xix, 

reduction of injury by improving, 114 

See also Medical attention; Physical therapy; Rehabilitation; 

Trauma care 

Trial Work Period, 146

Trucks, reflectorization on, 132

Twisting injury, 11

Type of cost. See Direct cost; Indirect cost

Type of injury. See Class of injury

Uniform Hospital Discharge Data Set 186

Uninsured care, 

Unintentional injury, 

University of California, Institute for Health Aging, xvii

Upper extremity injury

incidence of, 15-17 

See also Head injury 
280 Cost of in the United States 

Value of housekeeping services, 

Vancouver gun ownership rules, 130

Vapors, poisonings by, 25

Veterans Administration (VA), 

Vocational rehabilitation cost, 

Water transport accidents, 

Willingness-to-pay method, xxxix, 

to avoid specific and minor injury, 104-8 

human capital method vs., 

to reduce fatal injury risk, 101-4 

to reduce nonfatal injury risk, 104 

savings measured by, 113-23 passim, 

See also Reduction of injury 

 Whistle,” 114-15

Window barriers, falls reduced by, 

Workers’ Compensation, passim

American National Standards Institute codes used for, 182

in case studies, 148

data re, 72

Work Injury Followback Survey, 188

Work-loss days, 

Work years lost, 

World Health Organization, 142,184

Years of potential life lost 38 

See also Life years lost 
Biographical Sketches 

Alison S. Jones, B.A., Research Associate, Department of Health 

Policy and Management, School of Hygiene and Public Health, The 

Johns Hopkins University, Baltimore, MD, has investigated topics such 

as cost containment impact on the poor and uninsured, the impact of 

rural hospital closure on Medicare beneficiaries residing in rural 

counties, and the effects of competition on the market for physician 

services. She is currently a Ph.D. candidate in Health Economics. 

Sharon R. Kaufman, Ph.D., Research Anthropologist, Institute for 

Health Aging, University of California, San Francisco, is a medical 

anthropologist whose research includes studies of development in late 

life; the culture of American medicine; and chronic illness, disability, and 

rehabilitation. She is the author of The Ageless Sources in 

Late Life. 

Gregory de Lissovoy, Ph.D., M.P.H., Assistant Professor, Department of Health Policy and Management, School of Hygiene and Public 

Health, The Johns Hopkins University, Baltimore, MD, teaches health 

care financial management and health economics. His research interests 

include medical technology assessment, alternative delivery systems, 

and home health care. 

Ellen J. MacKenzie, Ph.D., Associate Professor of Health Policy and 

Management and Assistant Director of the Health Services Research and 

Development Center, School of Hygiene and Public Health, The Johns 

Hopkins University, Baltimore, MD, maintains research interests in 

severity measurement, the long-term impact of traumatic injuries, and 

the evaluation of emergency medical services. 

Wendy Max, Ph.D., Assistant Professor of Economics, California 

State University, Hayward, CA, and Affiliated Faculty Member, Institute 

for Health Aging, University of California, San Francisco, is a health 

economist. She conducts research on Alzheimer’s disease, the cost of 

injury, and the economics of aging. 

Elizabeth Associate Director, Trauma Foundation, San Francisco General Hospital, San Francisco, CA, has worked for 

the prevention of injury since 1973, when she became director of burn 

prevention at the Shriners Burns Institute in Boston. She evaluates burn 

prevention education and laws related to residential smoke detectors 

and flammable fabrics and is involved in the public debate on 

motorcycle helmet laws. 

Ted R. Miller, Ph.D., Senior Research Associate, The Urban 

Institute, Washington, D.C., has 18 years of experience in economics and 

public policy analysis. He has written extensively on issues related to 
Cost of in the United States 282 

safety and insurance, including the cost of the value of travel 

time, and the value of life. 

Ida VSW Red, M.A., M.S.L.S., Senior Public Policy Analyst, 

Department of Social and Behavioral Sciences and Resource Director, 

Institute for Health Aging, University of California, San Francisco, 

manages the research library and the publications program of the 

Institute. She is coeditor of Nation’s and coordinating editor 

of Fiscal Austerity and Long Term Care of the Elderly. 

Dorothy P. Rice, (Hon.), Professor in Residence, Department 

of Social and Behavioral Sciences, with joint appointments at the Institute 

for Health Aging and the Institute for Health Policy Studies, 

University of California, San Francisco, served from 1977 to 1982 as 

director of the National Center for Health Statistics. Previously she 

served as deputy assistant commissioner for research and statistics of the 

Social Security Administration. Her major interests are health statistics, 

the impact of an aging population, cost-of-illness studies, and the 

economics of medical care. 

Leon S. Robertson, Ph.D., Lecturer at Yale University and 

President, Research, a research firm in Branford, CT, has served 

on the faculties of Harvard University Medical School and Wake Forest 

University, was Senior Behavioral Scientist in the Insurance Institute for 

Highway Safety, and taught injury epidemiology in the Summer Session 

in Epidemiology at the Universities of Minnesota and Michigan for many 

years. He is coauthor of 5 books and author of Injuries: Causes, Control 

Strategies and Public Policy, as well as more than 100 articles and chapters 

in the scientific literature. 

David S. Salkever, Ph.D., Professor, Department of Health Policy 

and Management, School of Hygiene and Public Health, The Johns 

Hopkins University, Baltimore, MD, has carried out research in a variety 

of areas in health economics over the past 20 years. His cost-related 

research includes studies of determinants of hospital cost inflation and 

cost control programs, cost-effectiveness in ambulatory care settings, the 

indirect cost of adult and children’s chronic health problems and 

disabilities, and the direct and indirect cost of chronic back pain. 

Gordon Smith, M.B., Ch.B., M.P.H., Assistant Professor, Department of Health Policy and Management, School of Hygiene and Public 

Health, The Johns Hopkins University, Baltimore, MD, is a member of 

The Johns Hopkins Injury Prevention Center faculty with a joint 

appointment in Epidemiology. He specializes in injury epidemiology 

and disease surveillance systems with research interests in alcohol and 

injury risk, drowning, injury in developing countries, and occupational 

injury. He is also a member of the World Health Organization Task 

Force to revise the External Cause Code for ICD-10.