Trends in Fatal and Non-Fatal Injuries in the United States: Analyzing Incidence and Costs from 2015 to 2022

doi:10.21203/rs.3.rs-4942035/v1

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Research Article

Trends in Fatal and Non-Fatal Injuries in the United States: Analyzing Incidence and Costs from 2015 to 2022

https://doi.org/10.21203/rs.3.rs-4942035/v1

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Background

In addition to the emotional toll on patients, families, and communities, injury is financially costly for the United States healthcare system. Costs associated with injury can be medical or non-medical, with medical costs limited to acute medical care and non-medical costs including work or quality of life losses. The objective of this study is to characterize recent incidence and cost trends for fatal and non-fatal injuries in the United States.

Methods

This descriptive retrospective study analyzes data published by the Centers for Disease Control and Prevention (CDC) Web-Based Injury Statistics Query and Reporting System (WISQARS) database from 2015–2022. The top ten injury types across all age groups by total cost in three injury outcome categories were compared, with the top three types in each category further discussed.

Results

Unintentional drug poisoning was the costliest fatal injury at $1.13T in 2022, a 123% increase from its total cost in 2015 ($503B). Suicide by drug poisoning was the only fatal injury type to decrease in total cost. Unintentional falls were the costliest non-fatal hospitalization-and-release and emergency department-and-release injury at $474B and $931B in 2022, respectively. Relative to fatal injuries, a greater proportion of costs were attributed to medical care in the non-fatal injury categories.

Conclusions

There is considerable heterogeneity in the trends of injury outcomes (i.e. fatal, non-fatal) and specific injury types (i.e. unintentional falls, firearm suicides), driven by changes in incidence and per-injury cost. Unintentional drug overdose and unintentional falls are the costliest fatal and non-fatal injuries, respectively, by wide margins. Recent injury incidence and cost trends highlight increased mortality, as well as increased hospitalization with decreased emergency department utilization for non-fatal injuries.

injury costs

injury incidence

fatal injury

non-fatal injury

medical costs

value of statistical life

healthcare utilization

Unintentional and violence-related injuries are among the top 10 causes of death for all age groups in the United States, with unintentional injury contributing to more years of potential life lost than any other cause of death in 2020(1, 2). Incidence of many injury types in the United States such as those related to firearms(3, 4, 5) and drug overdose(3, 6, 7) continue to increase markedly despite public health intervention(8, 9). In addition to the considerable emotional toll for patients, families, and communities(10, 11, 12), injury is financially costly on both an individual and system level(2, 3, 13, 14, 15, 16, 17). For instance, the average cost of medical spending, lost work, quality of life losses, and avoidable death from suicide and self-harm in the United States is over $500 billion per year(13).

Costs associated with injury can be medical or non-medical, with medical costs limited to acute medical care received upon sustaining the injury(3, 18). Non-medical costs, however, extend to the value of statistical life lost in cases of fatal injury and work and quality of life losses in cases of non-fatal injury(3). Value of statistical life (VSL) is a model developed to support public policy decision-making that represents a group’s implied valuation of mortality risk and, by extrapolation, how much a given amount of life is worth(3, 19, 20). Similarly, quality-adjusted life years (QALYs) represent the financial value of a given number of years spent in perfect health, and can be used in conjunction with an injury’s severity and medical course to quantify quality of life losses(3, 21). The total annual cost of a specific injury type is a product of the injury’s incidence and average per-person cost.

The Centers for Disease Control and Prevention (CDC) Web-Based Injury Statistics Query and Reporting System (WISQARS) provides several databases on injury type, incidence, and cost(1).This data is published on an annual basis, with a new “Cost of Injury” page published in December 2021 that includes VSL and quality of life loss cost data(2, 3, 14). Previous studies analyzing recent fatal and non-fatal injury focus on injury incidence and mortality(4, 6, 22, 23), with some detailing costs of specific injury types(13, 14, 18, 24). However, no studies have analyzed and discussed incidence and cost trends in the costliest injury types.

The objective of this study is to characterize recent incidence and cost trends for fatal and non-fatal injuries in the United States and discuss potential causes of these trends. The authors hypothesize considerable heterogeneity in the incidence and costs of various injury types. The incidence and change in total cost of most injuries are not expected to outpace population growth. The COVID-19 pandemic is expected to greatly influence injury trends; injury volume related to social isolation (e.g. falls) and self-harm is expected to rise relatively drastically, while many unintentional injuries such as motor vehicle accidents are expected to be relatively less frequent and costly. Discussion of the findings in this study has implications for the medical and financial value of future public health interventions.

This descriptive retrospective study was performed to elucidate recent trends in injury incidence and costs at overall and per-injury levels. The study describes data published by the CDC intended for use by public health researchers. Given the publicly available, de-identified nature of the data, this study does not require institutional review board approval or consent for publication.

Data Overview

All fatal and non-fatal injury data, including incidence and cost of injury, were collected from the CDC’s WISQARS database(25). Since 2011, CDC’s WISQARS has reported injury incidence as well as per-injury average and population total medical and non-medical costs of injuries in the United States(3). This study considers an 8-year period from 2015 to 2022.

WISQARS data on annual injury volume and costs are informed by various sources(26, 27, 28, 29). Fatal injury incidence data is provided by the CDC’s National Center for Health Statistics annual mortality data files(27). Non-fatal injury incidence data is provided by the United States Consumer Product Safety Commission’s National Electronic Injury Surveillance System(28). Non-fatal quality of life loss financial data is provided by the Pacific Institute for Research and Evaluation(29). Value of statistical life and monetized quality of life loss is informed by the United States Health & Human Services’ Office of the Assistant Secretary for Planning and Evaluation(26).

Injury Classification

WISQARS reports data for fatal and non-fatal injury outcomes, with non-fatal injury outcomes being divided into two categories: injuries that resulted in hospitalization and release (1) and emergency department (ED) treat and release (2)(25). Injury types are further characterized by mechanism and intent(3). Mechanism serves as an overall descriptor of the injury (e.g. fall, firearm, overexertion). Intent classifications include unintentional, violence-related (i.e. homicide, suicide, etc.), or undetermined. An injury classification overview is included in Fig. 1. This study considers injury types as defined by fatality, intent, and mechanism. For instance, non-fatal unintentional falls with ED treatment and release and fatal homicide by firearm are both discrete injury types described in this study.

For fatal injuries, the following cost types are reported: medical costs and value of statistical life. Medical costs for injury deaths refer to medical care associated with the fatal event. For non-fatal injuries of all kinds, the following cost types are reported: medical costs, work loss costs, and quality of life loss costs. Total costs refer to the sum of medical and non-medical costs. Non-fatal costs are all calculated relative to the injury and one-year period following medical presentation. All costs are adjusted to 2021 USD(3, 25).

Statistical Analyses

Data collection and baseline calculations including rate of change for each injury type were performed using Microsoft Excel (2022 Microsoft Office; Redmond, WA). The top ten injury types by total cost in each of the three injury outcome categories were analyzed, with the top three types considered for further discussion.

Fatal Injury

The incidence and costs of the top ten fatal types by 2022 total cost are shown in Fig. 2a. Unintentional drug poisoning was the costliest injury at $1.13T in 2022, a 123% increase from its total cost in 2015 ($503B). Nearly all costs were related to value of statistical life loss, with just $721M stemming from medical costs, an average of $7.2k per fatality. Unintentional motor vehicle occupant injuries and firearm suicides and homicides represented the next most costly fatal injuries, respectively, with firearm homicide costs increasing the most since 2015 (+ 54%). Suicide by drug poisoning was the only fatal injury type listed to decrease in cost during the study period. Unintentional falls were associated with the greatest medical costs at $1.8B total or $38k per fatality. The average change in cost from 2015–2022 across the ten injuries listed was + 28%.

The incidence and costs over for the top three fatal injuries (unintentional drug poisoning, unintentional motor vehicle accident, suicide by firearm) during the study period are depicted in Fig. 2b. All three injuries increase steadily in incidence, medical cost, and non-medical cost over the study period, with none of the injuries’ medical or non-medical costs experiencing year-over-year decreases greater than 4% at any point. Increases in total cost occurred despite relative stability or decreases in per-injury costs.

Non-fatal Injury: hospitalization and release

The incidence and cost breakdown of the top ten non-fatal hospitalization and release injury types by 2022 total cost are shown in Fig. 3a. Unintentional falls were the costliest injury at $474B in 2022, a 35% increase from its total cost in 2015 ($352B). Relative to fatal injuries, a greater proportion of costs were attributed to medical care in the non-fatal injury categories. Unintentional falls accounted for the greatest medical cost in every year studied, peaking at $92B in 2022. Unintentional motor vehicle occupant injuries, unintentional struck by/against injuries, and unintentional motorcyclist injuries, were the next most costly injuries, respectively, with unintentional motorcyclist injuries increasing the most in cost since 2015 of any non-fatal hospitalization and release injury listed (+ 57%). Only unintentional other specified (-5%), struck by/against assaults (-4%), and unintentional poisonings (-4%) decreased in total cost since 2015. Despite unintentional poisonings having the second highest incidence (329k poisonings in 2022), it ranks ninth in total cost. The average change in cost from 2015–2022 was + 26%.

The incidence and costs over for the top three non-fatal hospitalization and release injury types (unintentional falls, unintentional motor vehicle occupant injuries, unintentional struck by/against injuries) during the study period are depicted in Fig. 3b. While fall and motor vehicle medical and non-medical costs never decreased by more than 4% in a single year, unintentional struck by/against dropped by 12% (medical) and 19% (non-medical) between 2019 and 2020. Variation in per-injury costs was observed with no specific injury type experiencing > 8% change in the study period.

Non-fatal Injury: emergency department and release

The incidence and cost breakdown of the top ten non-fatal emergency department and release injury types by 2022 total cost are shown in Fig. 4a. Unintentional falls were the costliest injury at $931B in 2022, a 14% increase from its total cost in 2015 ($819B). As with the non-fatal hospitalization and release category, unintentional falls also accounted for the greatest medical cost in every year studied, with its highest cost coming in 2015 ($70B). Unintentional struck by/against injuries, unintentional motor vehicle occupant injuries, and struck by/against assaults were the next most costly non-fatal hospitalization and release injuries, respectively. A greater proportion of injury types decreased in cost relative to other injury categories, with unintentional struck by/against injuries (-8%), struck by/against assaults (-8%), unintentional overexertion (-22%), unintentional pedal cyclist injuries (-24%), and unintentional unknown/unspecified injuries (-26%) all decreasing in cost over the 8-year study period. The injury with the greatest proportion of total costs stemming from medical care was unintentional poisoning (> 70% of total costs in 2022). The average change in cost from 2015–2022 was − 1%.

The incidence and costs over for the top three non-fatal hospitalization and release injury types (unintentional falls, unintentional struck by/against injuries, unintentional motor vehicle occupant injuries) during the study period are depicted in Fig. 4b. All three injury types experienced marked decreases in costs from 2015–2020 relative to other top injury types, with subsequent cost rebounds from 2020–2022. Per-injury costs increased uniformly and steadily.

The key findings in this descriptive retrospective study of injury cost and incidence in the United States are that there is considerable heterogeneity in the trends of injury outcomes (i.e. fatal, non-fatal) and specific injury types (i.e. unintentional falls, firearm suicides). In the fatal injury category, unintentional drug poisoning, the top injury type in both incidence (99.6k fatalities) and cost ($1.13T total cost), rose in cost a striking 123% from 2015 levels. In both the non-fatal hospitalization and release and non-fatal ED and release categories, unintentional falls accounted for the greatest costs and incidence by wide margins. Total costs in the fatal and non-fatal outcome categories were dominated by non-medical costs, including value of statistical life, quality of life, and work losses. The average costs of the top ten fatal and non-fatal hospitalization and release injuries rose 28% and 26% during the 8-year study period, respectively, despite the United States population growing just 3.9% from 2015 to 2022(30).

Fatal Injuries

The fatal injury category displayed the highest average growth rate in total cost of any outcome studied at + 28% from 2015–2022. Total costs of unintentional drug poisonings in 2022 were more than twice that of the next most costly fatal injury (unintentional motor vehicle injuries) and increased 123% in total costs during this period, which was the highest of any injury type studied. Firearm-related suicides and homicides were the next most costly fatal injuries, with firearm homicides displaying the second-highest cost increase from 2015 at + 54%. All of the top three costliest fatal injury types grew at rates substantially higher than the United States population growth during the study period despite stability or decrease in per-injury costs, highlighting increased incidence as the key driver of fatal injury costs(30).

Unintentional drug poisonings, specifically fatal overdoses, are a recognized public health crisis in the United States(7, 31, 32, 33, 34). Incremental change in federal and state drug policies have struggled to address illicit substance use(33), with the continuation and exacerbation of overdose-related fatalities also largely due to increased usage of synthetic opioids(34). Per an analysis of drug overdose mortality among people experiencing homelessness by Fine et al, 2022, initial predominance of prescription opioids as the leading cause of fatal overdose in the early 21st -century was soon eclipsed by illicitly manufactured fentanyl and polysubstance overdose(31). Friedman et al, 2022 studied the demographics of drug overdose in the United States from 2010–2021 and found that beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population despite nationally decreasing adolescent drug use rates, again potentially attributable to the ubiquity and increased potency of synthetic opioids(7). Regarding escalating polysubstance abuse, the rate of drug overdose deaths involving both cocaine and opioids increased more quickly from 2011–2021 than the rate of cocaine-only overdose deaths(35). Recent discussion in the substance abuse space warns of a potential “fourth wave” of the opioid overdose crisis marked by co-ingestion of fentanyl alongside methamphetamine and/or cocaine(36).

Motor vehicle crashes had just under half as many fatalities in 2022 as unintentional drug poisoning and increased in total costs by 22% from 2015. Fatal motor vehicle crashes are nearly three times more common in males and are the leading cause of fatal work-related injury in the United States(37, 38, 39). Historically, fatal motor vehicle injury were either stable or declining from 1999–2010, with a subsequent increase in fatality rates from 2010–2019(40, 41). Interestingly, this recent bump diverges considerably from the fatality trends of comparable Organization of Economic Cooperation and Development (OECD) countries, with the United States fatality rates per one million residents more than twice as high Canada, Australia, and the United Kingdom in 2021(42, 43). Despite improvements in pre-hospital care greatly enhancing crash survivability in recent years(44), reasons behind the increase in fatality rates are hypothesized to be multifactorial(45, 46). Yellman et al, 2022 posits looser blood alcohol concentration driving allowances relative to peer countries, inconsistent restraint use, and distracted driving as key sources of international discrepancies and rising US fatality rates(45). A meta-analysis of the impact of cannabis legality on motor vehicle accident deaths by Marinello et al, 2023 displayed a 10% increase in fatalities in states with legal recreational cannabis markets(46). However, conflicting research demonstrates an opposite trend due to substitution effects away from alcohol consumption(47), and studies into the trend inflection of motor vehicle fatalities remain nascent and challenging(48, 49, 50). The findings in this study diverge from sentiment around decreased motor vehicle fatalities constituting one of the greatest public health achievements of the 20th century(51, 52).

Total costs of suicide by firearm grew at a similar rate to unintentional motor vehicle fatalities (+ 21%). The link between firearm access and suicide completion is well-established(53, 54, 55). However, recent increases in incidence and total costs are alarming and complex, and are thought to stem from legal, mental health, and socioeconomic factors(56, 57, 58). Per Martínez-Alés et al, 2021, state-level ownership rates largely explain differences in firearm suicide but only marginally explain the recent increases in firearm suicide rates(58). Background checks and mandatory waiting periods, which have been slow to gain legislative traction, are correlated with lower firearm suicide risk(56). Multiple studies have shown increases in firearm suicide mortality risk among younger birth cohorts, in line with research detailing concurrent increases in depression and suicidal behaviors among US adolescents(57, 59, 60). Suicide is the leading cause of death in teenagers in the US, with nearly 50% of suicides completed by 15–19 year-olds involving a firearm(57). In addition to rising adolescent firearm suicide rates, a second spike in mortality is being observed in the elderly, specifically “Baby Boomer” males > 64 years old(59, 61). Finally, ethnic minorities–specifically those of American Indian descent–and counties with higher poverty rates continue to experience the highest and fastest-growing firearm suicide rates(62, 63).

Non-fatal Injuries

The non-fatal outcome categories–hospitalization and release (1) and ED and release (2)–were both dominated in incidence and total costs by unintentional falls, with total costs that increased 35% and 14% from 2015 levels, respectively. The 2022 incidence of unintentional falls requiring hospitalization and release was 1.70M, with medical costs of $91.5B ($53.9k per injury). Unintentional falls with an ED and release outcome were associated with a 2022 incidence of 6.57M and medical costs of $58.3B ($8.9k per injury). Gross medical costs in both non-fatal categories far exceeded those displayed by any of the top fatal injuries as well as fatal unintentional falls, which had medical costs of $1.76B ($37.8k per fatality).

The exceptional costliness and accompanying rise in unintentional fall costs (overall and per-injury) and incidence relative to US population growth, particularly for falls requiring hospitalization, is alarming. Considerable public health and healthcare economics research has been performed on fall injuries, prevention, and management(18, 64, 65, 66, 67). Per Colón-Emeric et al, 2024, fall mortality has more than doubled in the US between 2000–2016, with falls accounting for 4.4% of all Medicare hospital expenditures and nearly 12% of spending for home health services and long-term care facilities(67). This reported increase in fall mortality fits the data described in this study, which reflect rising morbidity in the form of hospitalizations over ED-only encounters. Additionally, per Newgard et al, 2021, adults who experience non-fatal fall injuries have increased post-acute healthcare expenditures (median increase of $12,682), which is reflected in this study’s methodology of describing medical costs in the one-year period following injury(68). As to explanations behind increased incidence and associated costs of falls in the US, a rapidly-aging population is thought to be the main driver(18, 66, 69).

In a 2018 study that also used the CDC WISQARS database alongside the Medicare Current Beneficiaries Survey to analyze fall injury, Florence et al describe various characteristics of those experiencing non-fatal falls(18). The study reports significantly greater fall risk in elderly, female, Caucasian, and lower income adults, with additional risk posed by medical comorbidities including depression and diabetes(18). While there is substantial agreement across clinical practice guidelines on fall risk prevention and risk stratification, fall injuries are expected to continue increasing in coming years(64).

Unintentional motor vehicle injuries were found to be the second costliest non-fatal hospitalization and release injury and third costliest ED and release injury. In reverse order to motor vehicle injuries, unintentional struck by/against injuries were found to be the third costliest non-fatal hospitalization and release injury and second costliest ED and release injury. Despite sharing the same injury types across their top three costliest injuries, the rate of change in cost from 2015–2022 differed widely between the two non-fatal outcome categories; morbidity increases, which are reflected in this study’s findings of increased hospitalization and decreased ED-only costs for all top three injury types, are also demonstrated by the categories’ average cost change from 2015 (+ 26% hospitalization and release versus − 1% ED and release). This relative decline in ED and release injury incidence and costs persisted despite rebounds in 2021 and 2022 following the COVID-19 outbreak, trends exhibited by all three injury categories(6).

Short-term shifts in injury incidence due to the COVID-19 pandemic are characterized and discussed by He et al, 2022(6). He et al notes increased mortality but decreased morbidity in 2020(6), trends replicated and extended to 2022 in this study. The specific discrepancy in non-fatal hospitalization and ED trends are thought to be mainly due to delayed seeking of emergency care by patients and caretakers fearful of contracting COVID-19 from healthcare settings(6, 70, 71). Secondarily, healthcare resources may have also been re-prioritized and stretched to an extent that reduced and delayed accessibility to emergency care(72). Such delays in care may have also increased mortality of patients with severe injuries, leading to the growing fatality trends described in this study(73).

While this study characterizes broad incidence and cost trends in a variety of fatal and non-fatal injury types, the study was limited by lack of specificity around injury demographics and etiology. For instance, age and gender demographics were not included in this study, nor were any underlying injury causes (i.e. driving while impaired or speeding for motor vehicle injuries). Relatedly, injury type groupings by the CDC are subjective and also feature an “Other” type not detailed in this study. This study also does not hypothesize specific consequences of medical and non-medical injury expenditures, including their effect on health insurance premiums, economic productivity, and patients’ or families’ future quality of life. Finally, this study provides no public health prevention or management guidance for the injuries characterized.

Despite these limitations, the CDC WISQARS continues to be a reliable injury surveillance database with adaptable features and recent updates(74). Future studies in the injury cost and surveillance fields should use studies including this one to elucidate cost-effective prevention and management strategies. Additional research should also be performed to further characterize and potentially mitigate injury-related costs, particularly non-medical costs related to work and quality of life losses.

This study elucidates recent incidence and cost trends for fatal and non-fatal injuries and highlights considerable heterogeneity in the trends of injury outcomes (i.e. fatal, non-fatal) and specific injury types (i.e. unintentional falls, firearm suicides). Unintentional drug overdose and unintentional falls are the costliest fatal and non-fatal injuries, respectively, by wide margins. Recent injury incidence and cost trends are characterized by increased mortality, as well as increased hospitalization with decreased emergency department utilization for non-fatal injuries. The findings in this study provide insight into US healthcare utilization and should be used to design cost-effective injury prevention and management strategies.

Ethics approval and consent to participate: Not applicable. Given the publicly available, de-identified nature of the data, this study does not require institutional review board approval or consent for publication.

Consent for publication: Not applicable. Manuscript does not contain data from any individual person.

Availability of data and materials: The datasets generated and/or analysed during the current study are available in the Centers for Disease Control and Prevention (CDC) Web-Based Injury Statistics Query and Reporting System (WISQARS) repository, which can be located at https://wisqars.cdc.gov/

Competing interests: The authors declare that they have no competing interests.

Funding: Not applicable. No funding to report in support of this study or manuscript.

Authors’ contributions: SW drafted the manuscript and performed initial literature review, data analysis, and crafting of the discussion. AS performed data analysis and created manuscript figures. KS presented the initial study idea and provided study direction, data recommendations, and manuscript edits. AL provided manuscript edits and guidance related to data analysis, project scope, and manuscript structure.

Acknowledgements: Not applicable.

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No competing interests reported.

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Trends in Fatal and Non-Fatal Injuries in the United States: Analyzing Incidence and Costs from 2015 to 2022

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Data Overview

Injury Classification

Statistical Analyses

Results

Fatal Injury

Non-fatal Injury: hospitalization and release

Non-fatal Injury: emergency department and release

Discussion

Fatal Injuries

Non-fatal Injuries

Conclusions

Declarations

References

Additional Declarations

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Version 1