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Background. FUEL Your Life (FYL) is a worksite translation of the Diabetes Prevention Program (DPP). In a randomized controlled trial, participants in a phone coaching condition demonstrated greater weight loss compared to participants in a group coaching or self-study condition. The purpose of this article is to describe the differences in participant reach, intervention uptake, and participant satisfaction for each delivery mode. Method. Employees who were overweight, obese, or at high risk for diabetes were recruited from city–county governments. Process evaluation data were collected from health coach records, participant surveys, and research team records. Differences between groups were tested using Pearson chi-square test and one-way analysis of variance. Results. Employee reach of targeted enrollment was highest for the self-study condition. Overall, intervention uptake was highest in the phone coaching condition. Participants who received phone coaching had increased uptake of the participant manual and self-monitoring of food compared to participants who received group coaching or self-study. Discussion. FYL demonstrated that DPP could be effectively delivered in the worksite by three different modalities. When implemented in a self-study mode, reach is greater but intervention uptake is lower. Phone health coaching was associated with greater intervention exposure.

Purpose:Report the results of a randomized, controlled trial of Live Healthy, Work Healthy (LHWH), a worksite translation of the Chronic Disease Self-Management Program (CDSMP).Design:14 worksites were randomly assigned to LHWH, standard CDSMP (usual care) or no-intervention (control) group.Setting:The diverse set of work organizations centered around a rural community in SE US.Subjects:411 participants completed baseline data with 359 being included in the final analyses.Intervention:LHWH had been adapted to fit the unique characteristics of work organizations. This translated program consists of 15 sessions over 8 weeks and was facilitated by trained lay leaders.Measures:The primary outcomes including health risk, patient-provider communication, quality of life, medical adherence and work performance were collected pretest, posttest (6 mos.) and follow-up (12 mos.).Analysis:Analyses were conducted using latent change score models in a structural equation modeling framework.Results:79% of participants reported at least one chronic condition with an average of 2.7 chronic conditions reported. Results indicated that LHWH program demonstrated positive changes in a most outcomes including significant exercise (uΔ = 0.89, p < .01), chronic disease self-efficacy (uΔ = 0.63, p < .05), fatigue (uΔ = −1.45, p < .05), stress (uΔ = −0.98, p < .01) and mentally unhealthy days (uΔ = −3.47, p < .001).Conclusions:The translation of LHWH is an effective, low cost, embeddable program that has the potential to improve the health and work life of employees.

Introduction Couples’ voluntary HIV counselling and testing (CVCT) is a high‐impact HIV prevention intervention in Rwanda and Zambia. Our objective was to model the cost‐per‐HIV infection averted by CVCT in six African countries guided by an HIV prevention cascade framework. The HIV prevention cascade as yet to be applied to evaluating CVCT effectiveness or cost‐effectiveness. Methods We defined a priority population for CVCT in Africa as heterosexual adults in stable couples. Based on our previous experience nationalizing CVCT in Rwanda and scaling‐up CVCT in 73 clinics in Zambia, we estimated HIV prevention cascade domains of motivation for use, access and effectiveness of CVCT as model parameters. Costs‐per‐couple tested were also estimated based on our previous studies. We used these parameters as well as country‐specific inputs to model the impact of CVCT over a five‐year time horizon in a previously developed and tested deterministic compartmental model. We consider six countries across Africa with varied HIV epidemics (South Africa, Zimbabwe, Kenya, Tanzania, Ivory Coast and Sierra Leone). Outcomes of interest were the proportion of HIV infections averted by CVCT, nationwide CVCT implementation costs and costs‐per‐HIV infection averted by CVCT. We applied 3%/year discounting to costs and outcomes. Univariate and Monte Carlo multivariate sensitivity analyses were conducted. Results We estimated that CVCT could avert between 54% (Sierra Leone) and 62% (South Africa) of adult HIV infections. Average costs‐per‐HIV infection averted were lowest in Zimbabwe ($550) and highest in South Africa ($1272). Nationwide implementations would cost between 7% (Kenya) and 21% (Ivory Coast) of a country’s President’s Emergency Plan for AIDS Relief (PEPFAR) budget over five years. In sensitivity analyses, model outputs were most sensitive to estimates of cost‐per‐couple tested; the proportion of adults in heterosexual couples and HIV prevention cascade domains of CVCT motivation and access. Conclusions Our model indicates that nationalized CVCT could prevent over half of adult HIV infections for 7% to 21% of the modelled countries’ five‐year PEPFAR budgets. While other studies have indicated that CVCT motivation is high given locally relevant promotional and educational efforts, without required indicators, targets and dedicated budgets, access remains low.

Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy’s goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 recently diagnosed adult pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients in the study experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR=2.91, 95% CI=1.29, 6.72), hospitalization (AOR=8.66, 95% CI=2.60; 39.54), and coping costs (AOR=3.84, 95% CI=1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as a proxy indicator for catastrophic costs was estimated to be 73% (95% CI=58%, 84%). Pulmonary TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.

Sleep-related infant deaths continue to be a major, largely preventable cause of infant mortality, especially in Georgia. The Georgia Department of Public Health (DPH), as part of a multi-pronged safe infant sleep campaign, implemented a hospital initiative to (1) provide accurate safe infant sleep information to hospital personnel; (2) support hospitals in implementing and modeling safe sleep practices; and (3) provide guidance on addressing caregiver safe sleep concerns. A process evaluation was conducted to determine progress toward four goals set out by DPH: (1) all birthing hospitals have a safe infant sleep policy; (2) all safe infant sleep policies reference the AAP 2011 recommendations; (3) all safe infant sleep policies specify the type and/or content of patient safe sleep education; and (4) all hospitals require regular staff training on safe sleep recommendations. Data were collected via structured interviews and document review of crib audit data and safe sleep policies. All 79 birthing hospitals in the state participated in the statewide campaign. Prior to the initiative, 44.3% of hospitals had a safe sleep policy in place; currently, 87.3% have a policy in place. The majority (91.4%) of hospitals have provided safe sleep training to their staff at this time. Important lessons include: (1) Engagement is vital to success; (2) A comprehensive implementation guide is critical; (3) Piloting the program provides opportunities for refinement; (4) Ongoing support addresses barriers; and (5) Senior leadership facilitates success.

Over a decade ago, the Society for Prevention Research endorsed the first standards of evidence for research in preventive interventions. The growing recognition of the need to use limited resources to make sound investments in prevention led the Board of Directors to charge a new task force to set standards for research in analysis of the economic impact of preventive interventions. This article reports the findings of this group’s deliberations, proposes standards for economic analyses, and identifies opportunities for future prevention science. Through examples, policymakers’ need and use of economic analysis are described. Standards are proposed for framing economic analysis, estimating costs of prevention programs, estimating benefits of prevention programs, implementing summary metrics, handling uncertainty in estimates, and reporting findings. Topics for research in economic analysis are identified. The SPR Board of Directors endorses the “Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science.” Electronic supplementary material The online version of this article (10.1007/s11121-017-0858-1) contains supplementary material, which is available to authorized users.

Sleep-related infant deaths are a leading cause of infant mortality in Georgia, and these deaths are largely associated with unsafe sleep practices among caregivers. In early 2016, the Georgia Department of Public Health launched the Georgia Safe to Sleep Hospital Initiative, providing hospitals with safe infant sleep information and educational materials to be distributed to families and newborns. This study examined the knowledge and behaviors of a sample of Georgia parents after the implementation of the Hospital Initiative and identified the family characteristics and intervention components most closely associated with the knowledge and practice of safe infant sleep. The primary caretakers of all infants born in Georgia from August to October 2016 were invited to complete a web-based survey 1 month after hospital discharge. The final sample size included 420 parents of newborns, and the primary outcomes assessed included two measures of knowledge and four measures of infant sleep behaviors regarding infant sleep position and location. Most respondents demonstrated knowledge of the correct recommended sleep position (90%) and location (85%). Logistic regression revealed that receipt of information in the hospital was significantly correlated with safe sleep behaviors, and infant sleep habits tended to influence safe sleep practices. Additionally, Medicaid parents receiving bassinets from the hospital were 74% less likely to bed share (OR 0.26; 95% CI 0.007). Implementation of a statewide hospital initiative was associated with high levels of parental knowledge and behavior and may have been successful in reducing the practice of bed sharing among Medicaid parents. Electronic supplementary material The online version of this article (10.1007/s10900-017-0449-x) contains supplementary material, which is available to authorized users.

Across the U.S., states have adopted Complete Streets legislative statutes—state laws that direct transportation agencies to routinely design and operate roadways to provide safe access for all users, including pedestrians, bicyclists, motorists, and public transit users. To date, there has not been a systematic and comprehensive analysis of the content and provisions of these laws. In this study, Complete Streets state statutes were identified using legal research databases. Using established legal mapping methods, a qualitative analysis was conducted of state laws that were effective through December 2018. A codebook and open-source data set were developed to support the public use of the data. Eighteen states and Washington, DC, have adopted Complete Streets legislative statutes. A total of 21 have been adopted, with 76% (n=16) of laws adopted since 2007. While the laws vary in content, detail, and specificity, several common provisions were identified across statutes. Complete Streets legislative statutes may be essential to ensure that road networks throughout states are safe, connected, and accessible for all users. This study provides key insights into the legislative landscape of Complete Streets state laws and makes available a new data set that can support future evaluations of these laws.

Objective The aim of this study was to evaluate the effectiveness of the Fuel Your Life program, an adaptation of the Diabetes Prevention Program (DPP), utilizing implementation strategies commonly used in worksite programs-telephone coaching, small group coaching, and self-study. Methods The primary outcomes of body mass index and weight were examined in a randomized control trial conducted with city/county employees. Results Although the majority of participants in all three groups lost some weight, the phone group lost significantly more weight (4.9 lb), followed by the small groups (3.4 lb) and the self-study (2.7 lb). Of the total participants, 28.3% of the phone group, 20.6% of the small group, and 15.7% of the self-study group lost 5% or more of their body weight. Conclusions Fuel Your Life (DPP) can be effectively disseminated using different implementation strategies that are tailored to the workplace.

OBJECTIVES: This study estimated the incidence, direct medical and non-medical costs, and productivity losses due to morbidity and mortality across multiple strata for injuries that occurred in Jiangxi, China. STUDY DESIGN: Cross-sectional study. METHODS: Data came from the Jiangxi injury survey, a provincially-representative, population-based sample of 100,010 households. The major economic costs of injuries were divided into direct costs and indirect costs. Direct costs encompass medical costs and direct non-medical costs. Indirect costs refer to the productivity losses due to injury-related morbidity and mortality. RESULTS: In 2005, about one of 18 residents in Jiangxi, China, experienced an injury. Overall, fall, animal bite, and road traffic crash (RTC) injuries accounted for more than 66% of all injuries, while fall, RTC, drowning, and self-harm injuries accounted for 80% of fatal injuries. Average cost per case for a fatal injury was 163,389 RMB ($20,171) for lost productivity and 2800 RMB ($346) in direct medical & non-medical costs. A non-fatal injury resulting in hospitalisation or permanent disability on average caused 5221 RMB ($643) in direct costs and 18,437 RMB ($2276) in lost productivity and, an additional loss of three school days. A non-hospitalised non-fatal injury on average caused 303 ($37) RMB in direct costs and 491 RMB ($61) in lost productivity and, an additional loss of 0.5 school days. CONCLUSIONS: The unequivocal evidence of the substantial health and financial burden of injuries indicates to Chinese policy makers that more research and efforts are needed to find efficacious and cost-effective interventions targeting injury.Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Language: en

Objective Conduct a cost-effectiveness analysis of the Fuel Your Life (FYL) program dissemination. Methods Employees were recruited from three workplaces randomly assigned to one of the conditions: telephone coaching, small group coaching, and self-study. Costs were collected prospectively during the efficacy trial. The main outcome measures of interest were weight loss and quality-adjusted life years (QALYs). Results The phone condition was most costly ($601 to $589/employee) and the self-study condition was least costly ($145 to $143/employee). For weight loss, delivering FYL through the small group condition was no more effective, yet more expensive, than the self-study delivery. For QALYs, the group delivery of FYL was in an acceptable cost-effectiveness range ($22,400/QALY) relative to self-study (95% confidence interval [CI]: $10,600/QALY-dominated). Conclusions Prevention programs require adaptation at the local level and significantly affect the cost, effectiveness, and cost-effectiveness of the program.

Disease management is gaining importance in workplace health promotion given the aging workforce and rising chronic disease prevalence. The Chronic Disease Self-Management Program (CDSMP) is an effective intervention widely offered in diverse community settings; however, adoption remains low in workplace settings. As part of a larger NIH-funded randomized controlled trial, this study examines the effectiveness of a worksite-tailored version of CDSMP (wCDSMP [n = 72]) relative to CDSMP (‘Usual Care’ [n = 109]) to improve health and work performance among employees with one or more chronic conditions. Multiple-group latent-difference score models with sandwich estimators were fitted to identify changes from baseline to 6-month follow-up. Overall, participants were primarily female (87%), non-Hispanic white (62%), and obese (73%). On average, participants were age 48 (range: 23–72) and self-reported 3.25 chronic conditions (range: 1–16). The most commonly reported conditions were high cholesterol (45%), high blood pressure (45%), anxiety/emotional/mental health condition (26%), and diabetes (25%). Among wCDSMP participants, significant improvements were observed for physically unhealthy days (uΔ = −2.07, p = 0.018), fatigue (uΔ = −2.88, p = 0.002), sedentary behavior (uΔ = −4.49, p = 0.018), soda/sugar beverage consumption (uΔ = −0.78, p = 0.028), and fast food intake (uΔ = −0.76, p = 0.009) from baseline to follow-up. Significant improvements in patient–provider communication (uΔ = 0.46, p = 0.031) and mental work limitations (uΔ = −8.89, p = 0.010) were also observed from baseline to follow-up. Relative to Usual Care, wCDSMP participants reported significantly larger improvements in fatigue, physical activity, soda/sugar beverage consumption, and mental work limitations (p < 0.05). The translation of Usual Care (content and format) has potential to improve health among employees with chronic conditions and increase uptake in workplace settings.

Background Students seeking degrees in healthcare in Ecuador participate in community improvement projects and provide free health services under the supervision of faculty health professionals. The aim of this study is to determine the impact of a community-based intervention delivered by nursing students on health-related quality of life (HRQoL) and perceived social support of a rural population in Ecuador. Methods A quasi-experimental non-equivalent control group design study was conducted in two rural communities in Tumbaco, Ecuador. Families from one rural community were invited to participate in the intervention, receiving 8 weekly home visits from nursing students. Families from a neighboring community were similarly recruited as wait-list controls. One member of each family was consented into the study; the final sample included 43 intervention participants and 55 control participants. HRQoL and perceived social support were assessed before and after the intervention in both groups. The SF-12 was used to measure HRQoL, including eight domain scores and two composite scores, and the Interpersonal Support Evaluation List was used as an indicator of perceived social support. Difference-in-differences (DD) analyses were conducted to mitigate the effects of any baseline differences in the non- equivalent control group design. Results When compared to the control group, the intervention group realized significant improvements in the physical component summary score of the SF-12 (4.20, p

Background Standardized methodologies for assessing economic burden of injury at the national or international level do not exist. Objective To measure national incidence, medical costs, and productivity losses of medically treated injuries using the most recent data available in the United States, as a case study for similarly developed countries undertaking economic burden analyses. Method The authors combined several data sets to estimate the incidence of fatal and non-fatal injuries in 2000. They computed unit medical and productivity costs and multiplied these costs by corresponding incidence estimates to yield total lifetime costs of injuries occurring in 2000. Main outcome measures Incidence, medical costs, productivity losses, and total costs for injuries stratified by age group, sex, and mechanism. Results More than 50 million Americans experienced a medically treated injury in 2000, resulting in lifetime costs of $406 billion; $80 billion for medical treatment and $326 billion for lost productivity. Males had a 20% higher rate of injury than females. Injuries resulting from falls or being struck by/against an object accounted for more than 44% of injuries. The rate of medically treated injuries declined by 15% from 1985 to 2000 in the US. For those aged 0–44, the incidence rate of injuries declined by more than 20%; while persons aged 75 and older experienced a 20% increase. Conclusions These national burden estimates provide unequivocal evidence of the large health and financial burden of injuries. This study can serve as a template for other countries or be used in intercountry comparisons.

Economic evaluation can help administrators and institutions make informed decisions on how to allocate resources in higher education. This essay describes methods for conducting one type of economic evaluation, benefit–cost analysis, using an example of an existing undergraduate education program, the Freshman Research Initiative at the University of Texas Austin., Institutions and administrators regularly have to make difficult choices about how best to invest resources to serve students. Yet economic evaluation, or the systematic analysis of the relationship between costs and outcomes of a program or policy, is relatively uncommon in higher education. This type of evaluation can be an important tool for decision makers considering questions of resource allocation. Our purpose with this essay is to describe methods for conducting one type of economic evaluation, a benefit–cost analysis (BCA), using an example of an existing undergraduate education program, the Freshman Research Initiative (FRI) at the University of Texas Austin. Our aim is twofold: to demonstrate how to apply BCA methodologies to evaluate an education program and to conduct an economic evaluation of FRI in particular. We explain the steps of BCA, including assessment of costs and benefits, estimation of the benefit–cost ratio, and analysis of uncertainty. We conclude that the university’s investment in FRI generates a positive return for students in the form of increased future earning potential.

Context: There is an established association between the provision of health care services and maternal mortality. Aims: The purpose of this research is to investigate Ecuadorians’ willingness to pay to prevent maternal death and disabilities due to complications of care during childbirth in the context of universal coverage. Methods and Materials: The study elicited a “contingent” market on morbidity and mortality outcomes, specific to Ecuador’s epidemiologic profiles between a hypothetical market that included a 50% reduction in the risk of maternal mortality from 100 to 50 per 100,000, and a market that included a 50% reduction in the risk of maternal morbidity from 4,000 to 2,000 per 100,000. Results: The average amount participants are willing to pay to prevent maternal mortality in the context of universal coverage, was of $176 a year (95% CI=$172, $179). The unadjusted mean WTP for a reduction in the maternal morbidity risk was $135 (95% CI=$132, $139). Translated into Value of statistical Life, participant´s from this study valued the prevention of one statistical maternal death at USD $352,000. Conclusion: Results suggest that the costs of maternal care do not outweigh the benefit of prevention, and that Ecuadorians are willing to pay a significant amount to reduce the risk of maternal mortality. Global Health implications: Reduction of maternal mortality will remain an important global developmental goal in the upcoming years. Having a monetary approximation on the value of these losses may have important implications in the allotting financial and technical resources to reduce it. Key words: Willingness to Pay • Maternal Mortality • Maternal Morbidity • Ecuador • Contingent Valuation Copyright © 2017 Roldos et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

OBJECTIVES To determine the yield of undetected active tuberculosis (TB), TB and human immunodeficiency virus (HIV) coinfection and the number needed to screen (NNS) to detect a case using active case finding (ACF) in an urban community in Kampala, Uganda. METHODS In a door-to-door survey conducted in Rubaga community from January 2008 to June 2009, residents aged ≥15 years were screened for chronic cough (≥2 weeks) and tested for TB disease using smear microscopy and/or culture. Rapid testing was used to screen for HIV infection. The NNS to detect one case was calculated based on population screened and undetected cases found. RESULTS Of 5102 participants, 3868 (75.8%) were females; the median age was 24 years (IQR 20-30). Of 199 (4%) with chronic cough, 160 (80.4%) submitted sputum, of whom 39 (24.4%, 95%CI 17.4-31.5) had undetected active TB and 13 (8.1%, 95%CI 6.7-22.9) were TB-HIV co-infected. The NNS to detect one TB case was 131 in the whole study population, but only five among the subgroup with chronic cough. CONCLUSION ACF obtained a high yield of previously undetected active TB and TB-HIV cases. The NNS in the general population was 131, but the number needed to test in persons with chronic cough was five. These findings suggest that boosting the identification of persons with chronic cough may increase the overall efficiency of TB case detection at a community level.

Purpose The Strong African American Families–Teen (SAAF–T) program, a family-centered preventive intervention that included an optional condom skills unit, was evaluated to determine whether it prevented unprotected intercourse and increased condom efficacy among rural African American adolescents. Ancillary analyses were conducted to identify factors that predicted youth attendance of the condom skills unit. Methods Sixteen-year-old African American youths (N = 502) and their primary caregivers were randomly assigned to SAAF–T (n = 252) or an attention control (n = 250) intervention. SAAF–T families participated in a 5-week family skills training program that included an optional condom skills unit. All families completed in-home pretest, posttest, and long-term follow-up interviews during which adolescents reported on their sexual behavior, condom use, and condom efficacy. Because condom use was addressed only in an optional unit that required caregiver consent, we analyzed efficacy using complier average causal effect analyses. Results Attendance in both SAAF–T and the attention control intervention averaged 4 of 5 sessions; 70% of SAAF–T youth attended the condom skills unit. Complier average causal effect models indicated that SAAF–T was efficacious in reducing unprotected intercourse and increasing condom efficacy among rural African American high school students. Exploratory analyses indicated that religious caregivers were more likely than nonreligious caregivers to have their youth attend the condom skills unit. Conclusions Results suggest that brief condom skills educational modules in the context of a family-centered program are feasible and reduce risk for sexually transmitted infections and unplanned pregnancies.

It has been demonstrated that intimate partner violence (IPV) victimization is costly to employers, but little is known about the economic consequences associated with employing perpetrators. This study investigated propensity for partner abuse as a predictor of missed work time and on-the-job decreases in productivity among a small sample of male employees at a state agency ( N = 61). Results suggest that greater propensity for abusiveness is positively associated with missing work and experiencing worse productivity on the job, controlling for level of education, income, marital status, age, and part-time versus full-time employment status. Additional research could clarify whether IPV perpetration is a predictor of decreased productivity among larger samples and a wider variety of workplace settings. Employers and IPV advocates should consider responding to potential IPV perpetrators through the workplace in addition to developing victim-oriented policies and prevention initiatives.

Objectives. We sought to assess the difference in a preference-based measure of health among adults reporting maltreatment as a child versus those reporting no maltreatment. Methods. Using data from a study of adults who reported adverse childhood experiences and current health status, we matched adults who reported childhood maltreatment (n = 2812) to those who reported no childhood maltreatment (n = 3356). Propensity score methods were used to compare the 2 groups. Health-related quality-of-life data (or “utilities”) were imputed from the Medical Outcomes Study 36-Item Short Form Health Survey using the Short Form–6D preference-based scoring algorithm. Results. The combined strata-level effects of maltreatment on Short Form–6D utility was a reduction of 0.028 per year (95% confidence interval=0.022, 0.034; P Conclusions. Persons who experienced childhood maltreatment had significant and sustained losses in health-related quality of life in adulthood relative to persons who did not experience maltreatment. These data are useful for asessing the cost-effectiveness of interventions designed to prevent child maltreatment in terms of cost per quality-adjusted life years saved.

Background: The Georgia Charitable Care Network (GCCN) is a non-profit organization whose primary mission is to foster collaborative partnerships to deliver compassionate health care to low-income, uninsured individuals. Hypertension screening and management is a service provide by 90+ clinics in the GCCN statewide. Methods: With data from N=1661 patients who were screened and treated for hypertension at n=12 clinics in 2013, the impact of hypertension management on blood pressure levels, the incidence of coronary heart disease (CHD) and stroke, and utilization of emergency departments (EDs) were examined. The resulting changes in healthcare utilization were converted to changes in healthcare costs and compared to the expenditures for clinics providing screening and treatment services to the same population over a one-year period. Results: Patients with an initial diagnosis of hypertension or prehypertension experienced average reductions of 10.27 mmHg and 6.32 mmHg in systolic and diastolic blood pressure, respectively, during their follow-up visits. These changes were associated with 32.0% and 44.3% reductions in the relative risk of CHD and stroke, respectively. The savings from this reduction in blood pressure and avoided ED visits for 1661 hypertensive patients produced positive net benefits in 2013 US$, of more than $400,000, with a benefit-cost ratio of 1.6. Conclusions: For every dollar invested in GCCN clinics for hypertension screening and management, there is a benefit to the healthcare system through reduced costs of $1.60. GCCN clinics are a cost-saving delivery model for underserved communities with poor health status and high ED usage.

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. System- atic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child mal- treatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region’s per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region’s GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child mal- treatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

Introduction While smoke alarm installation programs can help prevent residential fire injuries, the costs of running these programs are not well understood. Method We conducted a retrospective cost analysis of a smoke alarm installation program in 12 funded communities across four states. Costs included financial and economic resources needed for training, canvassing, installing, and following-up, within four cost categories: (a) personnel, (b) transportation, (c) facility, and (d) supplies. Results Local cost per completed home visit averaged $214.54, with an average local cost per alarm installed of $115.02. Combined state and local cost per alarm installed across all four states averaged $132.15. For every 1% increase in alarm installation, costs per alarm decrease by $1.32. Conclusions As more smoke alarms are installed, the average installation cost per alarm decreases. By demonstrating effective economies of scale, this study suggests that smoke alarm programs can be implemented efficiently and receive positive economic returns on investment.

Summary Objectives: Falls in the older adults are a major public health concern. The growing population of adults 65 years or older, advances in medical care and changes in the costs of care motivated our study of the acute health care costs of fall-related injuries among the older adults in the United States of America. Design and settings: The MarketScan ® Medicare Supplemental database 1998 was used to estimate reimbursed costs for hospital, emergency department (ED), and outpatient clinic treatments for unintentional falls among older adults. Results: A fall on the same level due to slipping, tripping, or stumbling was the most common mechanism of injury (28%). Mean hospitalisation cost was US$ 17,483 (S.D.: US$ 22,426) in 2004 US$. Femur fracture was the most expensive type of injury (US$ 18,638, S.D.: US$ 19,990). The mean reimbursement cost of an ED visit was US$ 236 and US$ 412 for an outpatient clinic visit. Conclusion: The magnitude of the economic and social costs of falls in older adults underscores the need for active research in the field of falls prevention.

Differences in prevalence, injury, and utilization of services between female and male victims of intimate partner violence (IPV) have been noted. However, there are no studies indicating approximate costs of men’s IPV victimization. This study explored gender differences in service utilization for physical IPV injuries and average cost per person victimized by an intimate partner of the opposite gender. Significantly more women than men reported physical IPV victimization and related injuries. A greater proportion of women than men reported seeking mental health services and reported more visits on average in response to physical IPV victimization. Women were more likely than men to report using emergency department, inpatient hospital, and physician services, and were more likely than men to take time off from work and from childcare or household duties because of their injuries. The total average per person cost for women experiencing at least one physical IPV victimization was more than twice the average per person cost for men.

In programs of therapeutic foster care, youth who cannot live at home are placed in a foster home in which foster parents are trained to provide a structured environment for learning social and emotional skills. Youth in the program are monitored at home, in school, and in leisure activity; program personnel work closely with foster parents, and may collaborate with teachers, probation officers, employers, and others in the youth's environment to ensure prosocial learning and behavior. Evaluations have examined the effects of therapeutic foster care on violence among children with severe emotional disturbance and among adolescents with chronic delinquency. Two studies of therapeutic foster care for children with severe emotional disturbance yielded inconsistent results; evidence to date is insufficient to determine effectiveness. Three studies of therapeutic foster care for adolescents with chronic delinquency by one research team indicated that this intervention can reduce subsequent violence in this population. The Task Force on Community Preventive Services (the Task Force) recommends therapeutic foster care for the reduction of violence among adolescents with chronic delinquency.

In early childhood home visitation programs, parents and children are visited at home during the child's first 2 years of life by trained personnel who provide some combination of information, support, or training about child health, development, and care. Home visitation has been used to meet a wide range of objectives, including improvement of the home environment, family development, and the prevention of child behavior problems. The Task Force on Community Preventive Services (the Task Force) has conducted a systematic review of scientific evidence of the effectiveness of early childhood home visitation for preventing violence, with a focus on violence by and against juveniles. The Task Force recommends early childhood home visitation for preventing child abuse and neglect, on the basis of strong evidence of effectiveness. The Task Force found insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited children, violence by visited parents (other than child abuse and neglect), or intimate partner violence in visited families. This report gives additional information about the findings, including diverse outcome measures and results in study population subsamples, describes how the reviews were conducted, provides information that can help in applying the intervention locally, and recommends additional research.

To assess the total medical costs and productivity losses associated with the 1993 waterborne outbreak of cryptosporidiosis in Milwaukee, Wisconsin, including the average cost per person with mild, moderate, and severe illness, we conducted a retrospective cost-of-illness analysis using data from 11 hospitals in the greater Milwaukee area and epidemiologic data collected during the outbreak. The total cost of outbreak-associated illness was 96.2 million US dollars: 31.7 million US dollars in medical costs and 64.6 million US dollars in productivity losses. The average total costs for persons with mild, moderate, and severe illness were 116 US dollars, 47 US dollars, and 7,808 US dollars, respectively. The potentially high cost of waterborne disease outbreaks should be considered in economic decisions regarding the safety of public drinking water supplies.

Background Rising health care costs and limited resources necessitate trade-offs between resources allocated toward prevention and those toward treatment. Information from opinion polls suggests citizens favor spending a higher proportion of all health care dollars on prevention rather than treatment. Objectives To assess the policy implications of willingness to pay (WTP) for use in cost-benefit analysis (CBA) as a method for capturing individual preferences for prevention and treatment in the context of resource allocation decisions. Methods The authors recruited a random sample of 1456 US residents age 18 years and greater by telephone using random-digit dialing. The survey was designed as a 3-stage (phone-mail-phone) process and was conducted between December 1998 and March 1999. For all persons completing the survey (N = 1104), the authors 1st collected respondents’ opinions about the costs and effectiveness of prevention versus treatment programs in general. Half of respondents were then asked to state their WTP for a hypothetical prevention scenario and half were asked to state their WTP for a hypothetical treatment scenario. Both scenarios were specific to the same health context and included an identical reduction in mortality risk. Results WTP for treatment was significantly greater than WTP for prevention, $665 and $223, respectively. Prior opinions on the relative effectiveness afforded by preventive and treatment interventions moderately influenced the WTP estimates for persons randomized to either scenario. Prior opinions on costs had no significant effect on WTP estimates for either scenario. WTP significantly increased with age and household income in the full sample but was not significantly affected by gender or educational attainment. Conclusions The aggregated WTP responses from the prevention and treatment scenarios presented in our study would imply that treatment is more strongly preferred by society than prevention when the health context is the same and benefits of each are held constant. A better understanding is needed of the discrepancy between citizens’ stated preferences for prevention (e.g., through polling) and our findings that they were willing to pay substantially more for treatment than for prevention.

The Guide to Community Preventive Service's methods for systematic reviews were used to evaluate the effectiveness of various approaches to increasing physical activity: informational, behavioral and social, and environmental and policy approaches. Changes in physical activity behavior and aerobic capacity were used to assess effectiveness. Two informational interventions ("point-of-decision" prompts to encourage stair use and community-wide campaigns) were effective, as were three behavioral and social interventions (school-based physical education, social support in community settings, and individually-adapted health behavior change) and one environmental and policy intervention (creation of or enhanced access to places for physical activity combined with informational outreach activities). Additional information about applicability, other effects, and barriers to implementation are provided for these interventions. Evidence is insufficient to assess a number of interventions: classroom-based health education focused on information provision, and family-based social support (because of inconsistent findings); mass media campaigns and college-based health education and physical education (because of an insufficient number of studies); and classroom-based health education focused on reducing television viewing and video game playing (because of insufficient evidence of an increase in physical activity). These recommendations should serve the needs of researchers, planners, and other public health decision makers.

Introduction: Resources for public health (PH) are scarce and policymakers face tough decisions in determining their funding priorities. The difficulty of making these decisions is compounded by current PH accounting systems, which are ill-equipped to link fiscal resources to PH outcomes. This paper examines the types of revenues and expenditures, health services, and health outcomes that are being tracked at the local and state PH levels. The authors provide recommendations for strengthening the ability of local and state governments to link expenditures to PH outcomes, both within and across jurisdictions.Framework and Next Steps: The source of revenue data for most local jurisdictions is the accounting systems used for the budgeting and auditing of fiscal activities, and these are primarily linked to specific PH programs. In contrast, expenditure data are mostly generic and typically span multiple PH programs with no link to specific PH activities. Many challenges exist to then link PH activities to health outcomes data, which are often collected through separate reporting systems at the local, state, and national levels. Policy change at the state level and implementation strategies that are standardized across local health departments are required to assess the costs and health outcomes of PH activities.Conclusion: Information linking PH expenditures to health outcomes of PH services could greatly inform the decision-making process. This information will allow investments in PH to be better understood and will provide a strong foundation for the PH services and systems research community to understand variation and drive improvement. Ultimately, these data could be used to improve accountability at the local and state PH department levels.

In adopting evidence-based practices (EBP), program administrators most frequently focus on program effectiveness. But there is growing recognition of the importance of program cost and of economic analysis for allocating scarce resources for prevention and intervention programs.1 Economic analysis includes the assessment of programmatic costs using a micro-costing approach (precise individual resource valuation) to value the resources required to implement programmatic processes and activities so that programs can be compared to each other.2–5 Differences in program cost are typically driven by differences in program length, staff requirements to implement the program and materials. However, another key source of program cost is the implementation strategy. Program administrators must consider the costs to adopt or implement a program. Translation or implementation science focuses on the processes by which EBP are implemented. Less rigorous implementation procedures often fail to yield implementation with fidelity, which is needed to achieve program outcomes.6 More rigorous strategies are more expensive, but there is evidence that they are needed to achieve implementation with fidelity.7,8 Thus, the consideration of implementation costs is an important area of study. That is, just as intervention scientists have studied how much intervention is needed for behavior change, implementation scientists must study how much implementation is necessary to achieve fidelity. To date, however, few studies have considered costs in implementation research,9 and fewer still have specifically focused on the costs of implementing EBP in the field of child maltreatment (CM) prevention.10 To our knowledge there are no studies that have calculated implementation costs for variants on a model and then related those costs to implementation outcomes. This paper presents a calculation of marginal implementation costs for 2 variants of a training program for the SafeCare® model, an evidence-based parenting model for child maltreatment prevention. SafeCare® has been disseminated to child welfare systems across 20 U.S. states. The SafeCare® dissemination model includes a “train-the-trainer” component in which staff external to the purveyor (the National SafeCare® Training and Research Center [NSTRC]) are trained over time to train local staff. The training of trainers is notoriously difficult and often fails because of the lack of follow-up support.11 In the study reported here, we trained trainers under 2 different models to examine the impact of trainee and client outcomes. A first step in understanding the impact of the 2 models is to calculate marginal cost differences in the 2 training models. The 2 training models differed primarily in their provision of support to new trainers following completion of the train-the-trainer program. Trainers were randomly assigned into 1 of 2 models for training, standard or enhanced. In the “standard” approach, the model includes a 5-day workshop with skill demonstration and proficiency improvement through role-playing activities and live training sessions. The model includes some ongoing support from NSTRC training staff, and in turn, trainers provide some support to the providers they train. The second model, the “enhanced” approach, provided extensive ongoing consultation from NSTRC training staff for 6 months upon completion of the trainer training workshop. In this paper, we present data collected to determine marginal cost differences between the 2 models. Although we do not present data on implementation and client outcomes, this paper serves as an example of how data collection on this topic can be accomplished and how marginal costs are computed.

Context: Because human and financial resources are limited, health efforts must focus on prevention strategies that yield the most benefit for the investment. Many current strategies identified in the literature offer opportunities to promote health at a reasonable cost. Objective: To present a literature-based review of evidence demonstrating that prevention can be an effective and wise use of resources through CDC’s An Ounce of Prevention … What Are the Returns? Second Edition. Design: Systematic review of cost-effectiveness literature for a selected group of prevention strategies. Setting: Prevention strategies relevant to the U.S. population. Results: Data indicate that the health conditions considered can be addressed through prevention strategies that are either cost effective or cost saving. Conclusions: An Ounce of Prevention … What Are the Returns? Second Edition can be used to conveniently access information on prevention strategies, the diseases and injuries they address, and their cost effectiveness. It also complements other comprehensive prevention guides. However, limitations of the available cost-effectiveness studies indicate that standardized procedures should be followed for studies of all recommended prevention strategies. Researchers must standardize review procedures to improve both the quality and comparability of studies.

▪ Abstract Cost-effectiveness analysis, an analytic tool that expresses as a ratio the cost of obtaining an additional unit of health outcome, can help decision makers achieve more health protection for the same or less cost. We characterize the state of the cost-effectiveness analysis literature by reviewing how this technique is applied to various clinical and public health interventions. We describe the results of cost-effectiveness analyses for over 40 interventions to reduce cancer, heart disease, trauma, and infectious disease. The cost-effectiveness ratios for these interventions vary enormously, from interventions that save money to those that cost more than $1 million per year of life gained. The methods used to derive the cost-effectiveness ratios also vary considerably, and we summarize this variation within each health area. Greater uniformity of analytical practice will be necessary if cost-effectiveness analysis is to become a more influential tool in debates about resource allocation.

Alcohol use poses a major threat to the health and well being of rural African American adolescents by negatively impacting academic performance, health, and safety. However, rigorous economic evaluations of prevention programs targeting this population are scarce.Cost-effectiveness analyses were conducted of SAAF-T relative to an attention-control intervention (ACI), as part of a randomized prevention trial. Outcomes of interest were the number of alcohol use and binge drinking episodes prevented, one year following the intervention. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs) were used to determine the cost-effectiveness of SAAF-T compared to the ACI intervention.For the 473 participating youth completing baseline and follow-up assessments, the incremental per participant costs were $168, while the incremental per participant effects were 3.39 episodes of alcohol use prevented and 1.36 episodes of binge drinking prevented. Compared to the ACI intervention, the SAAF-T program cost $50 per reduction in an alcohol use episode and $123 per reduced episode of binge drinking. For the CEACs, at thresholds of $100 and $440, SAAF-T has at least a 90% probability of being cost-effective, relative to the ACI, for reductions in alcohol use and binge drinking episodes, respectively.The SAAF-T intervention provides a potentially cost-effective means for reducing the African American youths' alcohol use and binge drinking episodes.

Estimating the benefits of preventing child maltreatment (CM) is essential for policy makers to determine whether there are significant returns on investment from interventions to prevent CM. The aim of this study was to estimate the benefits of preventing CM deaths in an Ecuadorian population, and to compare the results to a similar study in a US population. The study used the contingent valuation method to elicit respondents’ willingness to pay (WTP) for a 1 in 100,000 reduction in the risk of CM mortality. After adjusting for differences in purchasing power, the WTP to prevent the CM mortality risk reduction in the Ecuador population was $237 and the WTP for the same risk reduction in the US population was $175. In the pooled analysis, WTP for a reduction in CM mortality was significantly impacted by country (p = 0.03), history of CM (p = 0.007), payment mechanism (p < 0.001), confidence in response (p = 0.014), and appropriateness of the payment mechanism (p < 0.001). These findings suggest that estimating benefits from one culture may not be transferable to another, and that low- and middle-income countries, such as Ecuador, may be better served by developing their own benefits estimates for use in future benefit-cost analyses of interventions designed to prevent CM.

Home visiting programs in the United States seek to improve maternal and child health, child development, and family economic self-sufficiency by supporting and educating families with young children. Today, home visiting is seen as an important strategy for high-risk families who may be difficult to engage in other services. The Patient Protection and Affordable Care Act (ACA) of 2010 included $1.5 billion over five years for states to operate the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. It also required a national evaluation of the programs. This document describes the design of that evaluation — the Mother and Infant Home Visiting Program Evaluation (MIHOPE). MIHOPE was launched in 2011 by the Administration for Children and Families and the Health Resources and Services Administration within the U.S. Department of Health and Human Services. The evaluation is being conducted by MDRC in partnership with Mathematica Policy Research, James Bell Associates, Johns Hopkins University, the University of Georgia, and Columbia University.MIHOPE will include the following components:-An analysis of state needs assessments will describe the communities that states chose to target with MIECHV program services.-An implementation study will collect information on the services provided by local programs as well as the factors that helped shape those programs.-An impact analysis will estimate the effects of home visiting programs on family outcomes, both overall and for key subgroups of families.-An economic analysis will assess program costs and savings.The study will include approximately 5,100 families with a pregnant woman or a child under 6 months old. Families who enroll in the study will be randomly assigned to a home visiting group or to a comparison group that can use other services available in their community. Families will be spread across about 85 local programs in about 12 states. Sites must be operating one of four national models of home visiting: Early Head Start-Home Visiting Option, Healthy Families America, Nurse-Family Partnership, or Parents as Teachers. These four models were chosen because they are being implemented using MIECHV program funds in at least 10 states.Data for the implementation and impact studies will be collected from a variety of sources, including interviews with parents; observations of the home environment; observed interactions of parents and children; direct assessments of children’s development; observations of home visitors in their work with families during home visits; logs, observations, and interviews with home visitors, supervisors, and program administrators; program model documentation from program developers, grantees, and local sites; and administrative data on child abuse, health care use, maternal health, birth outcomes, and employment and earnings.The study will produce a report to Congress in 2015 that includes information on families and sites included in the evaluation as well as information on how states made decisions about how to spend home visiting funds. Later reports will provide more information on program implementation, the effects of home visiting programs for families, and the features of programs that are associated with larger effects.

Introduction: Intimate partner violence (IPV) is a widespread social structural problem that affects a great proportion of Ecuadorian women. IPV is a sexually, psychologically, or physically coercive act against an adult or adolescent woman by a current or former intimate partner. Not-for-profit groups in Ecuador report that 70% of women experience 1 of the forms of IPV sometime during their lifetime, but population-based surveys suggest that 41% of Ecuadorian women are exposed to emotional violence, 31% physical violence, and 12% sexual violence by their spouse or partner over their lifetime. Despite the high prevalence, the response of the Ecuadorian government has been insufficient to reduce the number of victims and to provide adequate legal and health services for the prevention and treatment of IPV. Given the power of economic data to influence policy making, the goal of this study is to produce the first estimate of the economic impact of IPV in Ecuador and to identify the policy paths in which these estimates would have the greatest impact for Ecuador. Methods: Using a bottom-up method for estimating the economic burden of IPV and a national prevalence of IPV based on a population-based survey in the 2003–2004 year, the total economic burden is estimated at approximately $109 million adjusted to the 2012 United States (U.S.) currency rate. Results: Based on a prevalence of 255,267 women who were victims of IPV in the 2003–2004 year, the total economic burden is estimated at approximately $109 million adjusted to the 2012 the U.S. currency rate. The largest cost category contributing to the economic burden was the costs of healthcare services to treat injuries associated with IPV events. Conclusion: The asymmetry between the economic burden of IPV and the amount of government resources devoted to IPV prevention efforts suggests the need for a greater role to be played by the government and other factors in society in the area of IPV prevention. [West J Emerg Med. 2013;14(4):347–353.]

Although assessing the costs of an intervention to prevent child maltreatment is straightforward, placing a monetary value on benefits is challenging. Respondents participating in a statewide random-digit-dialed survey were asked how much they would be willing to pay to prevent a death caused by child maltreatment. Our results suggested that society may value preventing a death from child maltreatment at $15 million. If a child maltreatment intervention is effective enough to save even 1 life, then in many cases, its benefits will outweigh its costs.

Purpose. To quantify the relationship between body mass index (BMI) and rates of medically attended injuries by mechanism (overall, fall, motor vehicle, and sport-related) and by nature (strain/sprain, lower extremity fracture, and dislocations), and between BMI and injury treatment costs. Design. Cross-sectional analysis. Setting. The noninstitutionalized population of the United States. Subjects. The 1999–2000, 2000–2001, and 2001–2002 waves of the Medical Expenditure Panel Survey, a large, nationally representative dataset, were combined to create the analysis sample. The final sample included 42,304 adults. Measures. Medically attended injury rates by mechanism and nature of injury and related treatment costs. Analysis. Logistic regressions were used to separately estimate the odds of sustaining any injury by mechanism or by nature for overweight (25 ≤ BMI ≤ 29.9) and three categories of obese individuals compared with those who were normal weight. A second set of regressions tested whether, given that an injury occurred, obese individuals had greater injury treatment costs. Results. Slightly more than one in five adults sustain an injury each year that requires medical treatment. The odds of sustaining an injury are 15% (overweight) to 48% (Class III obesity) greater among those with excess weight. Conditional on sustaining an injury, BMI did not have a significant impact on injury treatment costs. Conclusion. Our findings show a clear association between BMI and the probability of sustaining an injury. If increasing BMI is causing the rise in injury rates, then the incidence of injuries, including those related to falls, sprains/strains, lower extremity fractures, and joint dislocations, are likely to increase as the prevalence of obesity increases.

Background Child maltreatment causes substantial morbidity and mortality in the U.S. Morbidity associated with child maltreatment can reduce health-related quality of life. Accurately measuring the reduction in quality of life associated with child maltreatment is essential to the economic evaluation of educational programs and interventions to reduce the incidence of child maltreatment. The objective of this study was to review the literature for existing approaches and instruments for measuring quality-of-life for child maltreatment outcomes. Methods We reviewed the current literature to identify current approaches to valuing child maltreatment outcomes for economic evaluations. We also reviewed available preference-based generic QOL instruments (EQ-5D, HUI, QWB, SF-6D) for appropriateness in measuring change in quality of life due to child maltreatment. Results We did not identify any studies that directly evaluated quality-of-life in maltreated children. We identified 4 studies that evaluated quality of life for adult survivors of child maltreatment and 8 studies that measured quality-of-life for pediatric injury not related to child maltreatment. No study reported quality-of-life values for children younger than age 3. Currently available preference-based QOL instruments (EQ-5D, HUI, QWB, SF-6D) have been developed primarily for adults with the exception of the Health Utilities Index. These instruments do not include many of the domains identified as being important in capturing changes in quality of life for child maltreatment, such as potential for growth and development or psychological sequelae specific to maltreatment. Conclusion Recommendations for valuing preference-based quality-of-life for child maltreatment will vary by developmental level and type of maltreatment. In the short-term, available multi-attribute utility instruments should be considered in the context of the type of child maltreatment being measured. However, if relevant domains are not included in existing instruments or if valuing health for children less than 6 years of age, direct valuation with a proxy respondent is recommended. The choice of a proxy respondent is not clear in the case of child maltreatment since the parent may not be a suitable proxy. Adult survivors should be considered as appropriate proxies. Longer-term research should focus on identifying the key domains for measuring child health and the development of preference-based quality-of-life instruments that are appropriate for valuing child maltreatment outcomes.

Injuries are the number one killer of children and young adults in the United States (Centers for Disease Control and Prevention [CDC], 2005). More than 28 million injuries serious enough to require emergency medical care occur annually (CDC, 2005). The lives of millions of others have been dramatically affected by injuries to themselves or someone they love. Injury leads to pathological conditions and impaired physiological functioning that can affect any part, organ, or system of an individual and can have both short-term and long-term effects (Sattin, 1992). Due to the potential extensive nature of injuries, outcomes depend on a broad continuum of multidisciplinary care. Injury has been described, until recently, as the “neglected disease” because it occurs in such great numbers but has been tacitly accepted as a normal occurrence of living in a modern society (Committee on Trauma, and Committee on Shock, Division of Medical Sciences, National Academy of Sciences/National Research Council [Committee on Trauma], 1966). However, the 1985 report Injury in America noted that a public health approach similar to that used for other diseases could lead to signifi cant reduction in injuries (Committee on Trauma Research, Commission on Life Sciences, National Research Council and the Institute of Medicine [Committee on Trauma Research], 1985). Injuries can be viewed as a problem in medical ecology—that is, as a relationship between a person (the host), an agent, and the environment (Haddon, 1970; Haddon & Baker, 1981; Sattin, 1992). The underlying agent of injury is not a microbe or carcinogen but energy, most often in the form of mechanical force (Haddon, 1970). The dose of energy received; the dose’s distribution, duration, and rapidity; and the individual’s response to the transfer of the energy can deter

In this study, we investigate the association between exposure to adverse childhood experiences and long-term disability using receipt of Social Security Disability Insurance (SSDI) benefits as a proxy for disability as a measure of economic impact. Survey data were obtained over an eight-month period (ending in March 2014) from a convenience sample of patients attending two private psychology practices, and parishioners attending a local church in western Nebraska. Data were collected using the Adverse Childhood Experiences (ACE) Study questionnaire, which collects information on eight areas of exposure (e.g., abuse and household dysfunction). Respondents were also asked for the status of SSDI applications and several demographic questions. The Student’s t-test and the two-sample test of proportions were used to test for statistically significant differences in total ACE score and individual ACE Study questions, respectively, by receipt of SSDI. The response rate was 64% (n = 96 out of 150) and respondents were mostly female (75%) with an average age of 48.2 years (range: 19–92). The mean total ACE score was significantly larger, indicating more adverse exposures, for respondents who received SSDI benefits (p = 0.037) compared to those who did not receive benefits. Exposure to sexual abuse (p = 0.014), neglect (p = 0.046), and a household member with mental illness (p = 0.012) were significantly associated with receipt of SSDI. Respondents who received SSDI were significantly more likely to report more exposure to adverse childhood experiences, particularly child maltreatment. These results suggest that the economic impact of child maltreatment may be underestimated if the long-term effect on the ability to work is not included. No previous studies have been conducted to determine the association of adverse childhood experiences and costly SSDI benefits. Investigating this association will provide policy makers with an understanding of the true economic burden of these events and, ultimately, lead to more resources to prevent these exposures.

Introduction Case detection by passive case finding (PCF) strategy alone is inadequate for detecting all tuberculosis (TB) cases in high burden settings especially Sub-Saharan Africa. Alternative case detection strategies such as community Active Case Finding (ACF) and Household Contact Investigations (HCI) are effective but empirical evidence of their cost-effectiveness is sparse. The objective of this study was to determine whether adding ACF or HCI compared with standard PCF alone represent cost-effective alternative TB case detection strategies in urban Africa. Methods A static decision modeling framework was used to examine the costs and effectiveness of three TB case detection strategies: PCF alone, PCF+ACF, and PCF+HCI. Probability and cost estimates were obtained from National TB program data, primary studies conducted in Uganda, published literature and expert opinions. The analysis was performed from the societal and provider perspectives over a 1.5 year time-frame. The main effectiveness measure was the number of true TB cases detected and the outcome was incremental cost-effectiveness ratios (ICERs) expressed as cost in 2013 US$ per additional true TB case detected. Results Compared to PCF alone, the PCF+HCI strategy was cost-effective at US$443.62 per additional TB case detected. However, PCF+ACF was not cost-effective at US$1492.95 per additional TB case detected. Sensitivity analyses showed that PCF+ACF would be cost-effective if the prevalence of chronic cough in the population screened by ACF increased 10-fold from 4% to 40% and if the program costs for ACF were reduced by 50%. Conclusions Under our baseline assumptions, the addition of HCI to an existing PCF program presented a more cost-effective strategy than the addition of ACF in the context of an African city. Therefore, implementation of household contact investigations as a part of the recommended TB control strategy should be prioritized.

Objective: To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged ⩾65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury. Methods: Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall. Results: In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled $0.2 billion dollars for fatal and $19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% ($12 billion) were for hospitalizations, 21% ($4 billion) were for emergency department visits, and 16% ($3 billion) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2–3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs. Conclusions: Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.