3. We estimate the benefits in foregone treatment cost for a hypothetical, benchmark emergency room where traumatic head injuries constitute 1 out of 10 presentations, with one catastrophic, fatal head injury per 100 injury presentations. We exclude the treatment cost of the minor injuries which, while they may be expensive, are not preventable with helmet use. Nor do they cause death like head trauma would, however. Traumatic care costs include ongoing, longer-term care costs and catastrophic costs include lifesaving treatments that are usually the most expensive treatments available. Situations of failure where those most-expensive life-saving resources could be applied treating so many other injuries, added to the human cost of the life of a child, create a tragic loss the costs of which can not all be expressed on the spreadsheet. We estimate returns to public health from investing in helmets as the direct savings from preventing 10 traumatic head injuries and 1 death per 1000 presentations, using doctors or nurses to administer the program, because these figures mirror many of those found in several hundred state and not-for-profit hospitals. We then consider potential savings from prevented obesity and loss of earnings from the preventable death of a child.
Table 2. Morbidity, mortality and cost
Morbidity (per 1000)
Injury Level
Minor
Traumatic (head injury)
10
Catastrophic
1
Average cost per injury
Minor
€ 1,000
NOT INCLUDED
Traumatic (head injury)
€ 100,000
Catastrophic
€ 200,000
Cost per injury per 1000
Minor
€ 100,000
NOT INCLUDED
Traumatic (head injury)
€ 1,000,000
Catastrophic
€ 200,000
Total (per thousand)
€ 1,200,000
Foregone obesity cost
€ 1,000
€ 1,000,000
Foregone earnings
€ 1,000,000
x Catastrophic / 1000
€ 1,000,000
Total per thousand
€ 3,200,000
Savings
1000 helmets
€ 3,200,000
2000 helmets
€ 6,400,000
3000 helmets
€ 9,600,000
Technically, we would have to discount the obesity savings and earnings back to present value, but this would also imply adjusting future prices for possible inflation; exchange rates etc. We have foregone this level of complexity perhaps at a cost of the accuracy of our budget to predict exact costs and savings, but if we consider the results "if this amount of savings were achieved," the placeholder is useful to demonstrate the scope of possible, if not the exact and precise level of, return on investment in cycling injury prevention.
Table 3: Costs per helmet price from table 1.
# helmets
2000
Costs
Doctors
Low helmet price
€ 10,763
€ 21,026
€ 31,288
Mid helmet price
€ 15,763
€ 31,026
€ 46,288
High helmet price
€ 25,763
€ 51,026
€ 76,288
Nurses
Low helmet price
€ 10,578
€ 20,741
€ 30,903
Mid helmet price
€ 15,578
€ 30,741
€ 45,903
High helmet price
€ 25,578
€ 50,741
€ 75,903
Table 4: Savings per thousands of helmets
2000
Doctors
Low helmet price
€ 3,189,237
€ 6,378,974
€ 9,568,712
Mid helmet price
€ 3,184,237
€ 6,368,974
€ 9,553,712
High helmet price
Based on this cost-benefit analysis, the question is not whether we should implement the program or not, but at what level we can afford to distribute bicycle helmets to children seeking physical examinations to get into school. The answer is clear if we save only one life per thousand, even if we rule out savings from prevented obesity and the lost contribution from a lifetime of earnings. We should enact this program, using nurses, attempting to gain lowest possible prices, up to the point where savings equal zero. This analysis demonstrates that that break-even point is far enough away such that even not considering obesity savings or earnings, that we would have to give away many thousands of helmets before returns would equal costs. While the returns slowly fall the more we spend on helmets and the more we buy and distribute, the return on investment is in the range of a thousand times every euro spent. If we consider the public health savings from foregone obesity and lost productivity, this factor effectively triples. We can safely say that offering helmets to low-income consumers' children "dominates" the policy of standing by and letting them die (Owens, Qaseem, Chou and Shekelle, 2011, p. 177). While those savings accrue to future consumers, the sooner we begin the program, the more we can save against our own retirement costs and those of our children.
References
Blake, G., Velikonja, D., Pepper, V., Jilderda, I., and Georgieou, G. (2008, June). Evaluating an in-school injury prevention programme's effect on children's helmet wearing habits. Brain Injury. 22(6). pp. 501 -- 507. Retrieved from www.ncbi.nlm.nih.gov/pubmed/18465391
Commission de la Securite des Consommateurs (2006, March). Recommendation (summary) on the prevention of head injuries when cycling 03/06. Legal notice. Retrieved from http://www.securiteconso.org/notice517.html?id_article=517
Moyes, S. (2007). Changing pattern of child bicycle injury in the Bay of Plenty, New Zealand.
Journal of Paediatrics and Child Health, 43. pp. 486 -- 488. Retrieved from doi:10.1111/j.1440-1754.2007.01117.x
Owens, D., Qaseem, A., Chou, R., and Shekelle, P. (2011). High-Value, Cost-Conscious Health
Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. Annals of Internal Medicine, 154. pp. 174-180. Retrieved from www.g-i-n.net/newsletter/engine/...2011/literature-update-april-2011
Rahman, T., Cushing, R. And Jackson, R. (2011). Contributions of built environment to childhood obesity. Mount Sinai Journal Of Medicine, 78:1. pp. 49 -- 57. Retrieved from www.noo.org.uk/gsf.php5?f=10824&fv=11370
