Monetised estimated quality-adjusted life year (QALY) losses for non-fatal injuries.

BACKGROUND: Quality-adjusted life years (QALYs) provide a means to compare injuries using a common measurement which allows quality of life and duration of life from an injury to be considered. A more comprehensive picture of the economic losses associated with injuries can be found when QALY estimates are combined with medical and work loss costs. This study provides estimates of QALY loss. METHODS: QALY loss estimates were assigned to records in the 2018 National Electronic Injury Surveillance System - All Injury Program. QALY estimates by body region and nature of injury were assigned using a combination of previous research methods. Injuries were rated on six dimensions, which identify a set of discrete qualitative impairments. Additionally, a seventh dimension, work-related disability, was included. QALY loss estimates were produced by intent and mechanism, for all emergency department-treated cases, by two disposition groups. RESULTS: Lifetime QALY losses ranged from 0.0004 to 0.388 for treated and released injuries, and from 0.031 to 3.905 for hospitalised injuries. The 1-year monetary value of QALY losses ranged from $136 to $437 000 among both treated and released and hospitalised injuries. The lifetime monetary value of QALY losses for hospitalised injuries ranged from $16 000 to $2.1 million. CONCLUSIONS: These estimates provide information to improve knowledge about the comprehensive economic burden of injuries; direct cost elements that can be measured through financial transactions do not capture the full cost of an injury. Comprehensive assessment of the long-term cost of injuries, including quality of life losses, is critical to accurately estimate the economic burden of injuries.

Products and activities associated with non-fatal traumatic brain injuries in children and adolescents - United States 2010-2013.

Background: Traumatic brain injury (TBI) is prevalent in children and adolescents ages <1-19 years, yet we have limited understanding of consumer products that are associated with TBIs in children and adolescents of varying ages. To address this gap, we combined two data sources to investigate leading products and activities associated with TBIs in children and adolescents in different developmental age groups (i.e. <1, 1-4, 5-9, 10-14, and 15-19 years). Methods: We analysed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), augmented with product information from the National Electronic Injury Surveillance System (NEISS), for the years 2010 through 2013. Results: From 2010 to 2013, children and adolescents aged <1-19 years accounted for 4.1 million non-fatal TBI-related emergency department visits. TBIs from home furnishings and fixtures, primarily beds, were highest among infants aged <1 year and children aged 1-4 years. TBIs from sports/recreation, especially bicycles and football, were highest among those aged 5-9 years, 10-14 years, and 15-19 years. Conclusions: The combined NEISS and NEISS-AIP data allow us to comprehensively examine products and activities that contribute to emergency department visits for TBIs in children and adolescents. Our findings indicate priority areas for TBI prevention and intervention.

Estimated total costs from non-fatal and fatal bicycle crashes in the USA: 1997-2013.

INTRODUCTION: Emergency department visits and hospital admissions resulting from adult bicycle trauma have increased dramatically. Annual medical costs and work losses of these incidents last were estimated for 2005 and quality-of-life losses for 2000. METHODS: We estimated costs associated with adult bicycle injuries in the USA using 1997-2013 non-fatal incidence data from the National Electronic Injury Surveillance System with cost estimates from the Consumer Product Safety Commission's Injury Cost Model, and 1999-2013 fatal incidence data from the National Vital Statistics System costed by similar methods. RESULTS: Approximately 3.8 million non-fatal adult bicycle injuries were reported during the study period and 9839 deaths. In 2010 dollars, estimated adult bicycle injury costs totalled $24.4 billion in 2013. Estimated injury costs per mile bicycled fell from $2.85 in 2001 to $2.35 in 2009. From 1999 to 2013, total estimated costs were $209 billion due to non-fatal bicycle injuries and $28 billion due to fatal injuries. Inflation-free annual costs in the study period increased by 137% for non-fatal injuries and 23% for fatal injuries. The share of non-fatal costs associated with injuries to riders age 45 and older increased by 1.6% (95% CI 1.4% to 1.9%) annually. The proportion of costs due to incidents that occurred on a street or highway steadily increased by 0.8% (95% CI 0.4% to 1.3%) annually. CONCLUSIONS: Inflation-free costs per case associated with non-fatal bicycle injuries are increasing. The growth in costs is especially associated with rising ridership, riders 45 and older, and street/highway crashes.

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.

Heterogeneous Costs of Alcohol and Drug Problems Across Cities and Counties in California.

BACKGROUND: Estimates of economic and social costs related to alcohol and other drug (AOD) use and abuse are usually made at state and national levels. Ecological analyses demonstrate, however, that substantial variations exist in the incidence and prevalence of AOD use and problems including impaired driving, violence, and chronic disease between smaller geopolitical units like counties and cities. This study examines the ranges of these costs across counties and cities in California. METHODS: We used estimates of the incidence and prevalence of AOD use, abuse, and related problems to calculate costs in 2010 dollars for all 58 counties and an ecological sample of 50 cities with populations between 50,000 and 500,000 persons in California. The estimates were built from archival and public-use survey data collected at state, county, and city levels over the years from 2009 to 2010. RESULTS: Costs related to alcohol use and related problems exceeded those related to illegal drugs across all counties and most cities in the study. Substantial heterogeneities in costs were observed between cities within counties. CONCLUSIONS: AOD costs are heterogeneously distributed across counties and cities, reflecting the degree to which different populations are engaged in use and abuse across the state. These findings provide a strong argument for the distribution of treatment and prevention resources proportional to need.

Perils of police action: a cautionary tale from US data sets.

OBJECTIVE: To count and characterise injuries resulting from legal intervention by US law enforcement personnel and injury ratios per 10 000 arrests or police stops, thus expanding discussion of excessive force by police beyond fatalities. DESIGN: Ecological. POPULATION: Those injured during US legal police intervention as recorded in 2012 Vital Statistics mortality census, 2012 Healthcare Cost and Utilization Project nationwide inpatient and emergency department samples, and two 2015 newspaper censuses of deaths. EXPOSURE: 2012 and 2014 arrests from Federal Bureau of Investigation data adjusted for non-reporting jurisdictions; street stops and traffic stops that involved vehicle or occupant searches, without arrest, from the 2011 Police Public Contact Survey (PPCS), with the percentage breakdown by race computed from pooled 2005, 2008 and 2011 PPCS surveys due to small case counts. RESULTS: US police killed or injured an estimated 55 400 people in 2012 (95% CI 47 050 to 63 740 for cases coded as police involved). Blacks, Native Americans and Hispanics had higher stop/arrest rates per 10 000 population than white non-Hispanics and Asians. On average, an estimated 1 in 291 stops/arrests resulted in hospital-treated injury or death of a suspect or bystander. Ratios of admitted and fatal injury due to legal police intervention per 10 000 stops/arrests did not differ significantly between racial/ethnic groups. Ratios rose with age, and were higher for men than women. CONCLUSIONS: Healthcare administrative data sets can inform public debate about injuries resulting from legal police intervention. Excess per capita death rates among blacks and youth at police hands are reflections of excess exposure. International Classification of Diseases legal intervention coding needs revision.

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates.

BACKGROUND: Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries. METHODS: The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated. RESULTS: The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung. CONCLUSIONS: Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems.

Finding Like-Minded Partners to Span the Continuum of Care.

This is an era of profound industry transformation, characterized by such forces as acceleration away from inpatient-centered care and toward alternative payment models, rising rates of chronic disease, and an aging population. Add to this mix physician and nurse shortages and a newfound understanding that today's patients are informed consumers, and the reality becomes clear: Healthcare providers must be adaptable, agile, and innovative to survive. Sometimes, the best way forward in transformative times is collaboration with other like-minded organizations.For INTEGRIS, an integrated, not-for-profit health system based in Oklahoma City, Oklahoma, partnering has always been a part of the corporate culture and a vital strategy in fulfilling its mission to improve the health of the people and communities it serves. In earlier days, collaborations often took the form of partnerships with community organizations to go beyond the hospital's walls and reach deeply into the community to address the underlying health needs of its population.However, the concept of partnerships has expanded to meet today's strategic business needs. INTEGRIS, for example, evaluates most partnerships in terms of population health management and the system's continuum of care. Care settings are viewed as being of three distinct types: community-based, acute, and post-acute. When it comes to health-and, increasingly, wellness-the goal of the system is to connect patients to whatever service they need, at whatever stage of life, whether that service is fully or partly owned by INTEGRIS or provided through partner affiliations.This network of partnerships involves the patient, the community, physicians, other clinicians and providers, insurers, regional collaborators, and others. INTEGRIS's partnership strategies have evolved over the years, and its partnerships have produced synergy and alignment to decrease costs, increase revenue, and better serve customers with the right care, in the right setting, at the right time.

Economics of alcohol-involved traffic crashes in the USA: an input-output analysis.

BACKGROUND: Preventing traffic crashes reduces crash costs paid by employers and employees. The related savings filter through the economy, impacting its performance. This study is the first to measure the impact of traffic crash reduction on a national economy. It focuses on impaired driving crashes. METHODS: We analysed the impact of the almost 50% alcohol-involved driving crash rate reduction from 1984-1986 to 2010 and the impact if such crashes in 2010 had not occurred. The analysis entered published estimates of costs that employers, consumers and governments paid because of US impaired-driving crashes as production costs and demand changes in Rutgers University's input-output model of the US economy. For example, reducing medical costs paid by employers lowers the cost of labour inputs to production while reducing vehicle repairs raises demand for other goods. Running the model at current and alternative crash rates revealed the impacts of crash reductions on economic output, gross domestic product (GDP), national income and employment. RESULTS: Alcohol-involved crash reductions since 1984-1986 increased economic output in 2010 by an estimated $20 billion, raised GDP by $10 billion, increased US income by $6.5 billion, and created 215 000 jobs. GDP gains from alcohol-involved crash reduction contributed 5% of the $200 million compounded average annual growth in US GDP from 1985 to 2013. Eliminating remaining alcohol-involved crashes would result in similar economic gains. CONCLUSIONS: Alcohol-involved crashes drag down the US economy. On average, each of the 25.5 billion miles Americans drove impaired in 2010 reduced economic output by $0.80. Those losses are preventable.

A fresh look at the costs of non-fatal consumer product injuries.

BACKGROUND: Products under the purview of the Consumer Product Safety Commission are involved in a large share of injuries and injury costs in the USA. METHODS: This study analyses incidence data from the National Electronic Injury Surveillance System (NEISS) and cost data based on the Injury Cost Model, integrated with the NEISS. We examined the magnitude of non-fatal consumer product related injury, the distribution of products involved in these injuries and the cost of these injuries. We compared these findings with an earlier identical study from 2000. RESULTS: In 2008-2010, 43.8% of the annual 30.4 million non-fatal injuries treated in hospital emergency departments involved consumer products. Of these consumer product related injuries, in 2009-2010, just three product groups accounted for 77% of the $909 billion annual cost: sports and recreation; home structures and construction materials; and home furnishings and fixtures. Sports and recreation was a leading cause of injury costs among 5-24-year-olds, particularly football, basketball, bicycling, baseball/softball and soccer. Since 1996, football surpassed basketball in becoming the number one cause of injury costs for children aged 10-19 years and the fifth ranked cause of product related injury costs overall. Among those over age 30 years, stairs and floors were a leading cause of consumer product related injury costs, in particular among those over age 70 years where they were responsible for over one-fifth of costs. CONCLUSIONS: The findings of this study highlight priority areas for intervention and generate questions for future research.

Nonfatal Firearm Injuries by Intent in the United States: 2016-2018 Hospital Discharge Records from the Healthcare Cost and Utilization Project.

INTRODUCTION: In addition to the nearly 40,000 firearm deaths each year, nonfatal firearm injuries represent a significant public health burden to communities in the United States. We aimed to describe the incidence and rates of nonfatal firearm injuries. METHODS: We calculated nonfatal firearm injury estimates using the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, including the Nationwide Emergency Department Samples and the National Inpatient Samples. We used the International Classification of Diseases, 10th Revision, Clinical Modification to identify firearm injury episodes. Deaths in the emergency department (ED) or as inpatients were excluded. RESULTS: In addition to the 118,171 persons shot and killed by firearms from 2016-2018, 228,380 people were shot (ratio 1.9:1) and treated at a hospital ED or admitted to hospital, a rate of 23.4 nonfatal firearm injury episodes per 100,000 population. The number of nonfatal injury episodes varied by year: 2018 had the lowest at 69,692, compared to 84,776 in 2017 and 73,912 in 2016. Unintentional injury episodes were the most frequent, accounting for 58.5% (n = 81,217) and 38.9% (n = 34,820) of total nonfatal firearm hospital discharges from the ED and inpatients, respectively. Assault episodes were the next most frequent, at 36.3% (n = 50,482) of ED and 49.5% (n = 44,290) of inpatient discharges. The highest rate of nonfatal firearm injury by five-year age group was for 20- to 24-year-olds. With an annual rate of 73.53 per 100,000 population, the rates for ages 20-24 were more than 10 times higher than the rates for patients younger than 15 or 60 years and older. More than half (53.4%, n = 121,884) of hospital-treated, nonfatal firearm injury episodes were patients living in ZIP codes with a median household income in the lowest quartile, compared to 7.5% (n = 17,102) for patients residing in the highest income quartile ZIP codes, a sevenfold difference. CONCLUSION: For every person shot and killed by a gun in the US, two more are wounded. Unlike firearm deaths, which are predominantly suicides, most nonfatal firearm injury episodes are unintentional or with an assault intent. Having a reliable source of nonfatal injury data is essential to understanding the incidence of firearm injuries.

Isolated Posterior Medial Ankle Dislocation with Associated Os Trigonum Dislocation after Low-Energy Mechanism.

We describe a case of an isolated posteromedial ankle dislocation, without malleolar fracture, with associated dislocation of an os trigonal process after a low-energy tennis injury. We demonstrate that nonoperative treatment results in excellent functional outcome scores with minimal arthritic progression at 2 years of follow-up. We discuss pathoanatomic risk factors of pure dislocations and propose that an os trigonum is a risk factor for isolated dislocations of the ankle.

Incidence and Lethality of Suicidal Overdoses by Drug Class.

Importance: Prior lethality analyses of suicide means have historically treated drug poisoning other than alcohol poisoning as a lumped category. Assessing risk by drug class permits better assessment of prevention opportunities. Objective: To investigate the epidemiology of drug poisoning suicides. Design, Setting, and Participants: This cross-sectional study analyzed censuses of live emergency department and inpatient discharges for 11 US states from January 1, 2011, to December 31, 2012, as well as Healthcare Cost and Utilization Project national live discharge samples for January 1 to December 31, 2012, and January 1 to December 31, 2016, and corresponding Multiple Cause of Death census data. Censuses or national samples of all medically identified drug poisonings that were deliberately self-inflicted or of undetermined intent were identified using diagnosis and external cause codes. Data were analyzed from June 2019 to January 2020. Main Outcomes and Measures: Distribution of drug classes involved in suicidal overdoses. Logistic regressions on the state data were used to calculate the odds and relative risk (RR) of death for a suicide act that involved a drug class vs similar acts excluding that class. Results: Among 421 466 drug poisoning suicidal acts resulting in 21 594 deaths, 19.6% to 22.5% of the suicidal drug overdoses involved benzodiazepines, and 15.4% to 17.3% involved opioids (46.2% men, 53.8% women, and <0.01% missing; mean age, 36.4 years). Opioids were most commonly identified in fatal suicide poisonings (33.3%-47.8%). The greatest RR for poisoning suicide completion was opioids (5.20 times the mean for suicide acts that did not involve opioids; 95% CI, 4.86-5.57; sensitivity analysis range, 3.99-6.86), followed by barbiturates (RR, 4.29; 95% CI, 3.35-5.45), antidepressants (RR, 3.22; 95% CI, 2.95-3.52), antidiabetics (RR, 2.57; 95% CI, 1.94-3.41), and alcohol (conservatively, because 30% of death certifiers do not test for alcohol; RR, 2.04; 95% CI, 1.84-2.26). The updated toxin diagnosis coding in International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, used to code the 2016 data revealed that calcium channel blockers also had a high RR of 2.24 (95% CI, 1.89-2.61). Translated to attributable fractions, approximately 81% of suicides involving opioids would not have been fatal absent opioids. Similarly, 34% of alcohol-involved suicide deaths were alcohol attributable. Conclusions and Relevance: These findings suggest that preventing access to lethal means for patients at risk for suicide should extend to drugs with high case fatality rates. Blister packing and securely storing lethal drugs seems advisable.

ATV and bicycle deaths and associated costs in the United States, 2000-2005.

OBJECTIVE: We determined the rate and costs of recent U.S. all-terrain vehicle (ATV) and bicycle deaths. METHODS: Fatalities were identified from the National Center for Health Statistics Multiple Cause-of-Death public-access file. ATV and bicycle deaths were defined by International Classification of Diseases, 10th Revision codes V86.0-V86.9 and V10-V19, respectively. Lifetime costs were estimated using standard methods such as those used by the National Highway Traffic Safety Administration. RESULTS: From 2000 through 2005, 5,204 people died from ATV crashes and 4,924 from bicycle mishaps. A mean of 694 adults and 174 children died annually from ATV injuries, while 666 adults and 155 children died from bicycle injuries. Death rates increased among adult ATV and bike riders and child ATV riders. Males had higher fatality rates for both ATVs and bicycles. Among children, total costs increased 15% for ATV deaths and decreased 23% for bicycle deaths. In adults, ATV costs increased 45% and bike costs increased 39%. CONCLUSIONS: Bicycle- and ATV-related deaths and associated costs are high and, for the most part, increasing. Promotion of proven prevention strategies, including helmet use, is indicated. However, enforcement of helmet laws is problematic, which may contribute to observed trends.

Consumer Products Contributing to Fall Injuries in Children Aged <1 to 19 Years Treated in US Emergency Departments, 2010 to 2013: An Observational Study.

Consumer products are often associated with fall injuries, but there is limited research on nonfatal unintentional falls in children that examines both the child's age group and the involvement of consumer products and activities. We combined 2 data sources to investigate products and activities that contribute to fall injuries in children at different developmental ages (ie, <1, 1-2, 3-4, 5-9, 10-14, and 15-19 years). We analyzed data from the National Electronic Injury Surveillance System-All Injury Program for the years 2010 through 2013 and augmented it with product information from the National Electronic Injury Surveillance System. Between 2010 and 2013, children aged <1 to 19 years accounted for 11.1 million nonfatal unintentional fall-related emergency department visits. Fall injuries associated with home furnishings/fixtures were highest among children in age groups <1 year, 1 to 2 years, and 3 to 4 years. In the home furnishings/fixtures product group, beds were the leading contributor to falls. Fall injuries associated with sports/recreation were highest among children in age groups 5 to 9 years, 10 to 14 years, and 15 to 19 years. In this product group, monkey bars and basketball were the leading contributors to falls. Our findings indicate priority areas for falls injury prevention and intervention.

Trends in Drug Poisoning Deaths Among Adolescents and Young Adults in the United States, 2006-2015.

OBJECTIVE: Despite the rising toll of drug poisoning deaths in the United States, the extent of the problem among adolescents and young adults ages 15-24 years has received relatively little attention. We examined sociodemographic characteristics and state trends in drug poisoning deaths among adolescents and young adults from 2006 to 2015 and estimated the costs of drug poisoning mortality in this population. METHOD: We used the National Vital Statistics System's Multiple Cause of Death files from 2006 to 2015. We analyzed trends using Joinpoint regression analysis and calculated total costs of drug poisoning deaths, including medical costs, work loss costs, and quality of life loss, based on widely used cost estimates. RESULTS: Drug poisoning death rates (per 100,000 population) in adolescents and young adults increased from 8.1 in 2006 to 9.7 in 2015. The rates increased significantly for Whites (1.7% per year) and Asian/Pacific Islanders (4.3% per year) from 2006 to 2015 and for Blacks (11.8% per year) from 2009 to 2015. By U.S. region, the rates increased significantly in the Midwest (4.4% per year) from 2006 to 2015 and in the Northeast (11.0% per year) from 2009 to 2015. Trends varied by age group, intent for drug poisoning, drug category (i.e., opioids, pharmaceutical drugs excluding opioids, illicit drugs excluding opioids, and unspecified drugs), urbanization level, and state. The estimated costs of drug poisoning deaths among adolescents and young adults totaled approximately $35 billion in 2015. CONCLUSIONS: Trends in drug poisoning deaths and estimated costs inform state-specific prevention and intervention efforts.

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

BACKGROUND: Injuries are a leading cause of death and acquired disability, and result in significant medical spending. Prior estimates of injury-related cost have been limited by older data, for certain population, or specific mechanisms. FINDINGS: This study estimated the incidence of hospital-treated nonfatal injuries in the United States (US) in 2013 and the related comprehensive costs. Injury-related emergency department (ED) visits and hospitalizations were identified using 2013 Healthcare Cost and Utilization Project (HCUP) data. Models estimated the costs of medical spending and lost future work due to injuries in 2013 U.S. dollars. A total of 31,038,072 nonfatal injury-related hospitalizations and ED visits were identified, representing 9.8 per 100 people. Hospital-treated nonfatal injuries cost an estimated $1.853 trillion, including $168 billion in medical spending, $223 billion in work losses, and $1.461 trillion in quality of life losses. CONCLUSIONS: Approximately one in 10 individuals in the US is treated in the hospital for injury each year, with high corresponding costs. These data support priority-setting to reduce the injury burden in the US.

Issues in using state hospital discharge data in injury control research and surveillance.

This study evaluates the quality of injury-related coding in state hospital data and their usefulness to injury researchers. Using 1997 hospital discharge records from 19 states, hospitalized non-fatal injury-related cases were identified by first selecting all cases that met broad criteria for injury, and then dropping cases that appeared incorrectly coded as injuries and cases related to medical care. Based on our criteria, 1,129,980 non-fatal hospitalized cases were identified as probable acute injuries. Three-quarters were coded with a traditional injury diagnosis in the primary diagnosis field, and 90% had a traditional injury diagnosis somewhere in the first six diagnosis fields. Of cases with an injury diagnosis code in the first three diagnosis fields, 88.1% were E coded. E coding completeness varied by state, with some states reporting high rates of E coding by using non-specific E codes. Other challenges included E-coded cases where no injury diagnosis was reported and apparent miscoding of the E code. We conclude that it is possible to combine multiple states' data if researchers are aware of the challenges they may encounter. In order to capture all injury-related cases, it is important to scan secondary diagnosis fields.

Creating a learning culture for quality and leadership. Panel discussion.

Today's fast-changing health care environment requires adept and knowledgeable leadership. Leaders must develop consistent standards across the organization to ensure quality and operational excellence. This will require the adoption of new skill sets and behaviors by clinicians and other employees. Leaders, too, will need to develop new skills and behaviors to effectively implement positive change. Health Forum convened a group of health care executives and industry experts July 13 in San Francisco to examine how hospital leaders can build and disseminate a consistent quality culture throughout the organization. Health Forum would like to thank all of the participants for their open and candid discussion, as well as GE Healthcare for sponsoring this event.

The costs of unintentional home injuries.

BACKGROUND: Unintentional home injuries impose significant, but little reported, costs to society. The most tangible are medical and indirect costs. A less-tangible cost is the value of lost quality of life due to impairment or death. METHODS: A societal perspective was adopted in estimating unintentional home injury costs. All costs associated with the injuries are included in the analysis-costs to victims, families, government, insurers, and taxpayers. The costs are incidence based, meaning all costs that will result from an injury over time are counted in the year that the injury occurs. RESULTS: Unintentional home injuries cost U.S. society at least $217 billion in 1998. The cost of fatal unintentional injuries alone was $34 billion, with nonfatal injuries accounting for the remaining $183 billion. The largest cost was the value of lost quality of life at $162 billion. Medical costs and indirect costs were $22 billion and $33 billion, respectively. CONCLUSIONS: These estimates indicate that unintentional home injuries, especially falls, are a major problem in the United States. Falls are a particular problem in need of more attention.