[Trauma craneal no accidental en niños: costo económico directo de la atención médica en un hospital de tercer nivel].

INTRODUCTION: Abusive head trauma (AHT) is an extreme form of physical abuse that is produced by abruptly shaking an infant or toddler. OBJECTIVE: To describe the direct economic cost of care during hospitalization of 14 children with confirmed diagnosis of AHT in a pediatric hospital. METHOD: Analysis of the cost of disease in patients with AHT attended to between 2001 and 2010. Partial direct economic cost of medical care (days of hospital stay, laboratory tests and imaging studies, surgical procedures and subspecialist consultations) was calculated adjusting for inflation, with year 2001 taken as base year. Patients were classified in three groups (moderate, severe and fatal AHT). Descriptive and sensitivity analysis was carried out. RESULTS: Patients with severe AHT generated higher medical care costs ($105,794.88 ± 33,201.91) in comparison with the group of moderate ($37,012.95, ± 7,154.87) and fatal AHT ($18,595.04 ± 6424.47) (p <0.05). Total cost was $665,467.98 Mexican pesos ($71,249.25 international dollars). CONCLUSIONS: Total cost for the 14 patients was an elevated figure, as in other parts of the world. The direct economic cost is closely related to the severity of the clinical presentation.

INTRODUCCIÓN: El trauma craneal no accidental (TCNA) es una forma extrema de abuso físico que se produce por la sacudida brusca de un lactante o preescolar. OBJETIVO: Describir el costo económico directo de la atención durante la hospitalización de 14 niños con diagnóstico confirmado de TCNA en un hospital pediátrico. MÉTODO: Análisis del costo de la enfermedad en pacientes con TCNA, atendidos entre 2001 y 2010. Se realizó análisis descriptivo y de sensibilidad. Se calculó costo económico directo parcial de la atención médica (días de estancia hospitalaria, exámenes de laboratorio y gabinete, procedimientos quirúrgicos y consultas por subespecialista), ajustado por la inflación, se tomó como año base 2001. Los pacientes se clasificaron en tres grupos: TCNA moderado, severo y fatal. RESULTADOS: Los pacientes con TCNA severo generaron mayor costo en la atención médica ($105 794.88 ± 33 201.91), en comparación con el grupo con TCNA moderado ($37 012.95 ± 7154.87) y fatal ($18 595.04 ± 6424.47) (p < 0.05). El costo total fue de 665 467.98 pesos mexicanos (71 249.25 dólares internacionales). CONCLUSIONES: El costo total de los 14 pacientes fue una cifra elevada como en otras partes del mundo. El costo económico directo se relaciona estrechamente con la gravedad del cuadro clínico.

Lifetime Cost of Abusive Head Trauma at Ages 0-4, USA.

This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids' Inpatient Database, and previous studies. Unit costs were derived from published sources. From society's perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2-9.2 million) for a death. It averages $2.6 million (95% CI $1.0-2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5-16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

Pediatric Ophthalmologists' Experiences With Abusive Head Trauma.

PURPOSE: To estimate the number of cases of abusive head trauma seen by pediatric ophthalmologists and analyze factors associated with physician subpoenas and court testimonies. METHODS: Pediatric ophthalmologists were surveyed about their experiences with abusive head trauma. The survey was sent to 875 active members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). RESULTS: The response rate was 15% (132 surveys). The median pediatric ophthalmologist is consulted 10.0 (interquartile range [IQR] = 4.0 to 19.0) times per year to evaluate patients for abusive head trauma and sees 2.5 (IQR = 1.0 to 6.0) patients with probable abusive head trauma each year. Pediatric ophthalmologists were equally likely to be subpoenaed (4.6% vs 4.8%, P = .84) or to testify (1.9% vs 1.7%, P = .79) whether they did or did not perform retinal photography. Physicians were equally likely to be subpoenaed (4.8% vs 7.1%, P = .92) or to testify (2.2% vs 0.0%, P = .17) whether a child abuse team was involved in patient care or not. Geographic location had no statistical significance on how frequently pediatric ophthalmologists were subpoenaed (P = .17) or testified in court (P = .12). When a pediatric ophthalmologist was subpoenaed to court, the median number of missed clinic days was 1.0 (IQR = 1.0 to 2.0), with an estimated cost of $3,000 (IQR = $1,750 to $4,750) in lost revenue. CONCLUSIONS: Obtaining retinal imaging, having a child abuse team, and geographic location had no significant relationship with how often pediatric ophthalmologists were subpoenaed or testified in court.

The medical cost of abusive head trauma in the United States.

OBJECTIVES: Health consequences of shaken baby syndrome, or pediatric abusive head trauma (AHT), can be severe and long-lasting. We aimed to estimate the multiyear medical cost attributable to AHT. METHODS: Using Truven Health MarketScan data, 2003-2011, we identified children 0 to 4 years old with commercial or Medicaid insurance and AHT diagnoses. We used exact case-control matching based on demographic and insurance characteristics such as age and health plan type to compare medical care between patients with and without AHT diagnoses. Using regression models, we assessed service use (ie, average annual number of inpatient visits per patient) and inpatient, outpatient (including emergency department), drug, and total medical costs attributable to an AHT diagnosis during the 4-year period after AHT diagnosis. RESULTS: We assessed 1209 patients with AHT and 5895 matched controls. Approximately 48% of patients with AHT received inpatient care within 2 days of initial diagnosis, and 25% were treated in emergency departments. AHT diagnosis was associated with significantly greater medical service use and higher inpatient, outpatient, drug, and total costs for multiple years after the diagnosis. The estimated total medical cost attributable to AHT in the 4 years after diagnosis was $47,952 (95% confidence interval [CI], $40,219-$55,685) per patient with AHT (2012 US dollars) and differed for commercially insured ($38,231 [95% CI, $29,898-$46,564]) and Medicaid ($56,691 [95% CI, $4290-$69,092]) patients. CONCLUSIONS: Children continue to have substantial excess medical costs for years after AHT. These estimates exclude related nonmedical costs such as special education and disability that also are attributable to AHT.

Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis.

OBJECTIVES: To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program. METHODS: A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs. RESULTS: There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes. CONCLUSIONS: Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.