Motor vehicle occupant injury and related hospital expenditures in children aged 3 years to 8 years covered versus uncovered by booster seat legislation.

BACKGROUND: Although most states have infant restraint laws, booster seat legislation for older children has not been implemented universally despite evidence of effectiveness. We examined injury and expenditures for motor vehicle traffic (MV) occupant injury among 3 year to 8 year olds covered versus uncovered by booster seat legislation. METHODS: Age, state of residence/hospitalization, and month of injury were used to examine injury, deaths, and expenditures due to MV occupant injury in children covered versus uncovered by booster seat legislation. Data sources included Kids Inpatient Database 2003 and Web-based Injury Statistics Query and Reporting System. Statistical analyses used chi, Fisher's exact, and analysis of variance. Odds ratios were calculated with 95% confidence intervals (CI). RESULTS: Children covered by booster seat legislation were less likely to be hospitalized for MV occupant injury than uncovered children (odds ratio, 0.78; 95% CI, 0.69-0.88). MV occupant injury constituted a smaller proportion of total injury expenditures in children covered (4.9%) versus uncovered (6.9%) by booster seat legislation. Covered children residing in areas with zip code incomes above the median had 26% lower MV occupant/total injury (p = 0.001) compared with 13% lower MV occupant/total injury for those below the median income (p = 0.0712). The proportion of injury dollars spent for MV occupant injury was higher in self-pay children for covered (7.8%) and uncovered (8.9%) children. CONCLUSIONS: This study suggests that booster seat laws are associated with a lower proportion of injury expenditures for MV occupant injuries in booster seat-aged children. Observed income disparities raise questions regarding whether access to booster seats, quality of affordable seats, and proper use and/or enforcement strategies impede legislative effectiveness.

A retrospective benefit-cost analysis of the 1997 stair-fall requirements for baby walkers.

Based on estimates from the U.S. Consumer Product Safety Commission (CPSC), there were about 25,000 baby walker-related injuries treated annually in U.S. hospital emergency departments during the early 1990s. This amounted to about 8 injuries for every 1000 baby walkers in use. Most injuries resulted from falls down stairs. After CPSC initiated a regulatory proceeding in 1994, the CPSC staff worked with industry to address the stair-fall hazard. This cooperative effort resulted in requirements designed to prevent stair-fall injuries that became effective in 1997 as part of a revised voluntary safety standard. This study presents a retrospective benefit-cost analysis of the 1997 stair-fall requirements. The benefits were defined as the reduction in the costs of injuries resulting from the use of the safer walkers. The costs were defined as the additional resource costs associated with making baby walkers safer. The study found that the stair-fall requirements were highly effective in reducing the risk of stair-fall injury, and that the benefits of the requirements substantially exceeded the costs. The expected net benefits (i.e., benefits minus costs) amounted to an average of about $169 per walker, over the walker's expected product life. Given current U.S. sales of about 600,000 baby walkers annually, the present value of the expected net benefits associated with 1 year's production amounts to over $100 million annually. A sensitivity analysis showed that the major findings were robust with respect to variations in underlying assumptions.

Medicaid-based child restraint system disbursement and education and the vaccines for children program: comparative cost-effectiveness.

OBJECTIVE: Low-income children are disproportionately at risk for preventable motor-vehicle injury. Many of these children are covered by Medicaid programs placing substantial economic burden on states. Child restraint systems (CRSs) have demonstrated efficacy in preventing death and injury among children in crashes but remain underutilized because of poor access and education. The objective of this study was to evaluate the cost-effectiveness of Medicaid-based reimbursement for CRS disbursement and education for low-income children and compare it with vaccinations covered under the Vaccines For Children (VFC) program. METHODS: A cost-effectiveness analysis was performed of Medicaid reimbursement for CRS disbursement/education for low-income children based on data from public and private databases. Primary outcomes measured include cost per life-year saved, death, serious injury, and minor injury averted, as well as medical, parental work loss, and future productivity loss costs averted. Cost-effectiveness calculations were compared with published cost-effectiveness data for vaccinations covered under the VFC program. RESULTS: The adoption of a CRS disbursement/education program could prevent up to 2 deaths, 12 serious injuries, and 51 minor injuries per 100,000 low-income children annually. When fully implemented, the program could save Medicaid over $1 million per 100,000 children in direct medical costs while costing $13 per child per year after all 8 years of benefit. From the perspective of Medicaid, the program would cost $17,000 per life-year saved, $60,000 per serious injury prevented, and $560,000 per death averted. The program would be cost saving from a societal perspective. These data are similar to published vaccination cost-effectiveness data. CONCLUSION: Implementation of a Medicaid-funded CRS disbursement/education program was comparable in cost-effectiveness with federal vaccination programs targeted toward similar populations and represents an important potential strategy for addressing injury disparities among low-income children.

The economic benefits of child safety seat misuse reduction programs and design improvements for children in rear seats.

This study finds that the break-even point for child safety seat misuse reduction programs and vehicle and seat design improvements is dollars 121 a year per child seat in use, annual misuse reduction program cost is dollars 6, and Lower Anchors and Tethers for Children (LATCH) cost dollars 13 annually per seat in use (in 2004 dollars). To estimate societal injury cost savings we compared tow-away crash outcomes for children ages 0-4, traveling in child seats in the back of passenger vehicles in 1984-1986 vs. 1999-2005. Both injury frequency and severity were compared and entered into the calculation of mean injury costs. To analyze the economic benefits of child safety seat misuse reduction programs and vehicle and seat design improvements for children sitting in rear seats of passenger vehicles, we compared outcomes of tow-away crashes for children ages 0-4 traveling in a child safety seat in two different multi-year time periods: 1984-1986 and 1999-2005. We chose 1984-1986 as a baseline as those years featured large, high-quality samples of crash data during the time period before the ongoing misuse of child seats was recognized as a public policy problem. By the early 1990s, misuse was a policy issue and misuse reduction programs were springing up.

Children in taxis: an opportunity for pediatricians and emergency physicians to save lives?

OBJECTIVE: Child safety devices (infant seats, booster seats, and seat belts) are effective in curbing the risk of injury; however, there remains a pattern of parental nonuse or misuse of safety seats. The aim of this study was to assess the level of knowledge and compliance of parents with children presenting for emergency care of the National Highway and Traffic Association safety seat guidelines in private cars and taxicabs. METHODS: Two hundred forty-two caregivers of children (ages range, 2 weeks to 19 years) presenting for care in the pediatric emergency department of an urban university hospital were approached to complete an interviewer-administered questionnaire, and 225 participated. The questionnaire included knowledge, attitude, and behavior questions on protective equipment for various aged children. RESULTS: Eleven (47.8%) of 23 children 1 year or younger were reported to use infant seats often or always while riding in private cars, compared with 8 (22.2%) of 36 children 1 year or younger were reported to their use while in taxis (P < 0.05). Seventeen (85%) of 20 children older than 8 years were reported to have used seat belts often or always in private cars versus 10 (41.7%) of 24 in taxis (P < 0.01). One hundred fifty-four (99.3%) of 155 subjects knew the National Highway Traffic Safety Administration recommended position for the safety seat for their child. Most parents believed in the efficacy of child safety seats in preventing vehicle injuries and reported they would be more likely to use safety devices if they received information on their use in the emergency department. CONCLUSIONS: Data from this survey show that use of safety seats is lower in taxis than in private automobiles and that this is attributable to the inconvenience of carrying these seats to and from the taxi rather than financial considerations or lack of knowledge about their effectiveness. Strategies should be sought to increase availability of child safety devices in taxicabs. The emergency department, as well as the pediatrician's office or clinic, can be a locus for an educational intervention to parents and caregivers on child passenger safety.

Cost-outcome analysis of booster seats for auto occupants aged 4 to 7 years.

OBJECTIVES: The purpose of this work was to analyze the societal return on investment in booster seats and in laws requiring their use in the United States. Booster seats reduce crash-related injury. Their use is mandatory for vehicle occupants aged 4 to 7 years in most of the United States. This study estimates the injury cost savings attributable to booster seat use. METHODS: Seat cost came from pricing on the Web and at retailers. Costs of passing and enforcing a legal mandate were estimated as a percentage of the costs of seat use. Injury risk when belted absent a seat was computed from national probability samples of crashes in the last years before booster seats entered into general use (1993-1999). Published estimates were used of the percentage of reduction in injuries achieved with booster seats, the mix of diagnoses reduced, and injury cost by diagnosis. The computations used a 3% discount rate. We studied the net cost per quality-adjusted life year saved, benefit-cost ratio, and net savings per seat. RESULTS: A booster seat costs 30 dollars plus 167 dollars for maintenance and time spent on installation and use. This investment saves 1854 dollars per seat, a return on investment of 9.4 to 1. Even lower bound estimates in sensitivity analysis indicated that society would benefit from the use of booster seats. Seat laws offer a return of 8.6 to 1. CONCLUSIONS: Belt-positioning booster seats offer a sound return on investment. Booster seat use laws should be passed, publicized, and enforced nationwide.

An emergency department intervention to increase booster seat use for lower socioeconomic families.

OBJECTIVES: To evaluate the effectiveness of booster seat education within an emergency department (ED) setting for families residing in lower socioeconomic neighborhoods. METHODS: This was a prospective, randomized study of families with children aged 4 to 7 years and weighing 40 to 80 lb who presented to a pediatric ED without a booster seat and resided in lower socioeconomic communities. Subjects were randomly assigned to one of three groups: 1) received standard discharge instructions, 2) received five-minute booster seat training, and 3) received five-minute booster seat training and free booster seat with installation. Automobile restraint practices were obtained initially and by telephone at one month. RESULTS: A total of 225 children were enrolled. Before randomization in the study, 79.6% of parents reported that their child was usually positioned in the car with a lap/shoulder belt and 13.3% with a lap belt alone. Some parents (16.4%) had never heard of a booster seat, and 44.9% believed a lap belt was sufficient restraint. A total of 147 parents (65.3%) were contacted for follow-up at one month. Only one parent (1.3%) in the control group and four parents (5.3%) in the education group purchased and used a booster seat after their ED visit, while 55 parents (98.2%) in the education and installation group reported using the booster seat; 42 (75.0%) of these parents reported using the seat 100% of the time. CONCLUSIONS: Education in a pediatric ED did not convince parents to purchase and use booster seats; however, the combination of education with installation significantly increased booster seat use in this population.

A maternity hospital-based infant car-restraint loan scheme: public health and economic evaluation of an intervention for the reduction of road traffic injuries.

AIMS: The results of an infant car-restraint loan scheme and evaluate its cost-effectiveness are presented. METHODS: The intervention programme was initiated in 1996. Car-restraints, donated by manufacturers, were lent for a six-month period to eligible prospective parents for a modest fee. Specially trained health visitors performed in-person interviews with the participating parents. The data were collected and recorded on a pre-coded questionnaire. Cross-tabulations and multiple logistic regression were performed to analyse the data. Subsequent purchase of a next-stage car restraint, suitable for older children (up to four years of age) was considered as a proxy measure of the success of the programme. This information, along with the detailed operational and financial data collected during the implementation phase of the programme, was used to develop a model to assess the cost-effectiveness of a countrywide intervention. RESULTS: During a two-year period 188 families participated in a survey. On return of the infant car restraint, 92% of the participants reported proper use of the device and 82% had already purchased the second-stage car restraint. Parental age, gender, or educational status was not predictive of positive parental road safety practices for the newly born, whereas history of parental seat-belt use--as a proxy of personal road safety behaviour--was positively correlated with the likelihood of purchasing a second-stage car-restraint device. The cost-effectiveness ratio varies between 418.00 euro and 3,225.00 euro per life-year saved, depending on whether the modest administrative fee is considered. CONCLUSIONS: On the basis of plausible assumptions, a loan programme of infant car-restraints was shown to be particularly cost effective.

Child and family safety device affordability by country income level: an 18 country comparison.

OBJECTIVE: To compare availability, urban price, and affordability of child/family safety devices between 18 economically diverse countries. DESIGN: Descriptive: urban price surveys by local safety organisations or shoppers. SETTING: Retail stores and internet vendors. MAIN OUTCOME MEASURES: Prices expressed in US dollars, and affordability measured by hours of factory work needed to buy a child safety seat, a belt-positioning booster seat, a child bicycle helmet, and a smoke alarm. RESULTS: Prices of child and family safety devices varied widely between countries but the variation for child safety seats and bicycle helmets did not relate strongly to country income. Safety devices were expensive, often prohibitively so, in lower income countries. Far more hours of factory work were required to earn a child safety device in lower income than middle income, and middle income than higher income, countries. A bicycle helmet, for example, cost 10 hours of factory work in lower income countries but less than an hour in higher income countries. Smoke alarms and booster seats were not available in many lower income countries. CONCLUSIONS: Bicycles and two-axle motor vehicles were numerous in lower and middle income countries, but corresponding child safety devices were often unaffordable and sometimes not readily available. The apparent market distortions and their causes merit investigation. Advocacy, social marketing, local device production, lowering of tariffs, and mandatory use legislation might stimulate market growth. Arguably, a moral obligation exists to offer subsidies that give all children a fair chance of surviving to adulthood.

How readable are child safety seat installation instructions?

OBJECTIVES: To measure the required reading level of a sample of child safety seat (CSS) installation instructions and to compare readability levels among different prices of CSSs to determine whether the lower cost seats to which low-income parents have greater access are written to a lower level of education. METHODS: A CD-ROM containing CSS installation instructions was obtained from the National Highway Traffic Safety Administration. Pricing information was obtained for available models from an Internet-based company that provides comparative shopping information. Paper copies of the instruction sets were generated, and their readability levels were determined using the SMOG test. A second rater was used in addition to the primary investigator to assess interrater reliability of the SMOG as applied to the instruction sets. RESULTS: The readability of instruction sets ranged from the 7th- to 12th-grade levels, with an overall mean SMOG score of 10.34. No significant associations were found to exist between readability and seat prices; this was observed whether the data were treated as continuous or categorical. CONCLUSIONS: CSS instruction manuals are written at a reading level that exceeds the reading skills of most American consumers. These instruction sets should be rewritten at a lower reading level to encourage the proper installation of CSSs.

Effects of improved access to safety counseling, products, and home visits on parents' safety practices: results of a randomized trial.

OBJECTIVE: To present the results of an intervention trial to enhance parents' home-safety practices through pediatric safety counseling, home visits, and an on-site children's safety center where parents receive personalized education and can purchase reduced-cost products. DESIGN: Pediatricians were randomized to a standard- or an enhanced-intervention group. Parents of their patients were enrolled when the patient was 6 months or younger and observed until 12 to 18 months of age. SETTING: A hospital-based pediatric resident continuity clinic that serves families living in low-income, inner-city neighborhoods. PARTICIPANTS: First- and second-year pediatric residents and their patient-parent dyads. INTERVENTIONS: Parents in the standard-intervention group received safety counseling and referral to the children's safety center from their pediatrician. Parents in the enhanced-intervention group received the standard services plus a home-safety visit by a community health worker. OUTCOMES: Home observers assessed the following safety practices: reduction of hot-water temperature, poison storage, and presence of smoke alarms, safety gates for stairs, and ipecac syrup. RESULTS: The prevalence of safety practices ranged from 11% of parents who stored poisons safely to 82% who had a working smoke alarm. No significant differences in safety practices were found between study groups. However, families who visited the children's safety center compared with those who did not had a significantly greater number of safety practices (34% vs 17% had > or 3). CONCLUSIONS: Home visiting was not effective in improving parents' safety practices. Counseling coupled with convenient access to reduced-cost products appears to be an effective strategy for promoting children's home safety.

Developing a special needs restraint loaner program for transporting medically fragile children.

Pediatric orthopaedic patients require special consideration for their transportation needs. A hospital-based program to fulfill these needs promotes patient safety and allows accessibility of needed devices to elective and nonelective patients. Nurses can be an integral part of this process. This article presents the process of establishing a special needs restraint program including the legalities, acquisition of equipment, and training of appropriate personnel.