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A maternity hospital-based infant car-restraint loan scheme: public health and economic evaluation of an intervention for the reduction of road traffic injuries |
Kedikoglou S, Belechri M, Dedoukou X, Spyridopoulos T, Alexe D M, Pappa E, Stamou A, Petridou E |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology A maternity hospital-based infant car-restraint loan scheme for the reduction of road traffic injuries was examined. Women who had recently given birth were given a car restraint for 6 months at a modest fee.
Economic study type Cost-effectiveness analysis.
Study population The study population comprised a hypothetical cohort of pregnant women.
Setting The setting was the community. The economic study was carried out in Greece.
Dates to which data relate The effectiveness and resource use data were gathered from 1996 to 1998. Studies published between 1984 and 2000 were also used to estimate the number of infants death prevented with the programme. The price year was 2000.
Source of effectiveness data The effectiveness evidence was derived from a synthesis of published studies, a programme implanted in the authors' setting, and authors' opinions.
Modelling The authors stated that an economic model was constructed to examine the possibility of a countrywide loan programme for infant care restraint in a hypothetical cohort of 100,000 participating members. Limited information on the model was provided.
Outcomes assessed in the review The outcomes used in the model were:
the number of infants perishing in road accidents annually in Greece,
the total infant deaths from all types of injury annually in Greece,
the number of children aged 1 - 4 years perishing in road accidents annually in Greece,
the total deaths from all types of injury for children aged 1 - 4 years annually in Greece,
the number and percentage of infant road traffic injury deaths avoided with the use of car restraints,
the percentage of prospective families of infants that participate in the countrywide scheme,
the percentage of infant injury mortality avoided,
the number and percentage of childhood (1 - 4 years) road traffic injury deaths avoided with the use of car restraints,
the percentage of prospective families of children aged 1 - 4 years that participate in the countrywide scheme,
the percentage of childhood (1 - 4 years) mortality from injuries avoided,
the total infant and childhood (0 - 4 years) road traffic injury deaths avoided, and
life expectancy.
Study designs and other criteria for inclusion in the review The clinical data did not come from a systematic review of the literature. Instead, it appears to have been identified selectively. Much of the data were estimated from the programme implemented in the Greater Athens area from 1996 to 1998, which involved 188 families. Data on the annual infant and child (age 1 - 4 years) casualties in road accidents were estimated from the National Statistical Service of Greece for the years 1996 to 2000. Families participating in the programme had a higher level of education than other families living in the same area.
Sources searched to identify primary studies Criteria used to ensure the validity of primary studies Methods used to judge relevance and validity, and for extracting data Number of primary studies included Nine primary studies and the authors' database provided clinical data.
Methods of combining primary studies Investigation of differences between primary studies Results of the review The number of infants perishing in road accidents annually in Greece was 2.2 per 100,000.
The total infant deaths from all types of injury annually in Greece were 23.2 per 100,000.
The number of children aged 1 - 4 years perishing in road accidents annually in Greece was 14.6 per 100,000.
The total deaths from all types of injury for children aged 1 - 4 years annually in Greece were 31.8 per 100,000.
Fifty per cent of infant road traffic injury deaths were avoided with the use of car restraints.
Fifty per cent of prospective families of infants participated in the countrywide scheme.
The number of infant road traffic injury deaths avoided with the use of car restraints was 0.6.
The percentage of infant injury mortality avoided was 2.4%.
Fifty per cent of childhood (1 - 4 years) road traffic injury deaths were avoided with the use of car restraints.
Fifty per cent of prospective families of children aged 1 - 4 years participated in the countrywide scheme.
The percentage of childhood (1 - 4 years) road traffic injury deaths avoided with the use of car restraints was 2.9%.
The percentage of childhood (1 - 4 years) mortality from injuries avoided was 9.2%.
The total infant and childhood (0 - 4 years) road traffic injury deaths avoided were 3.5.
Life expectancy was 78 years for infants and 76 years for children aged 1 - 4 years.
A multiple regression model had shown that the prior maternal seat belt use was significantly associated with the purchase of a second-stage car restraint.
Methods used to derive estimates of effectiveness Some assumptions were made to derive effectiveness estimates.
Estimates of effectiveness and key assumptions It was assumed that 80% of the participating parents would purchase a second restraint for their child.
Measure of benefits used in the economic analysis The summary benefit measures used were the number of fatalities avoided and the life-years gained, which were estimated using a modelling approach. Annualised data were reported.
Direct costs The cost analysis was carried out using two different perspectives, that of society and that of the payers. The societal perspective ignored cost sharing (i.e. the fact that parents contributed resources by paying the rental fee). The payer perspective had to bear only the incremental costs of running the programme after the parents themselves contributed the rental fee. The health services included in the economic evaluation were inventory costs (associated with restraint use), maintenance costs, information dissemination costs and campaign costs. The unit costs and the quantities of resources used were presented separately for most cost items. All economic data (both costs and quantities of resources used) were collected during the implementation of the programme and were updated to the year 2000. The use of a discount rate was unclear. The authors stated that the costs were annualised.
Statistical analysis of costs The costs were treated deterministically.
Indirect Costs It was unclear whether the indirect costs were included in the analysis.
Sensitivity analysis A sensitivity analysis was carried out to examine the impact of some model inputs on the total costs. Limited information on the type of sensitivity analysis was reported.
Estimated benefits used in the economic analysis In a cohort of 100,000 participating newborns, 3.5 fatalities (2.9 for child from 1 to 4 years and 0.6 for infants) were avoided with the programme. Using the life-expectancy for Greece (76 years for children and 78 for infants), the cumulative number of life-years saved was 267.
Cost results In a cohort of 100,000 participating newborns, the total costs of the programme over no intervention were Euro 861,598.00.
The sensitivity analysis showed that the variables with the greatest impact on the costs were the purchase price of each restraint (Euro 45), the average duration of a child care restraint, and the personnel cost for upholstery maintenance.
Synthesis of costs and benefits Incremental cost-effectiveness ratios were calculated to combine the costs and benefits of the programme under examination in comparison with no intervention.
From the perspective of society, the incremental cost per fatality avoided was Euro 246,171 and the cost per life-year saved was Euro 3,225.
From the perspective of the insurance, the incremental cost per fatality avoided was Euro 31,885 and the cost per life-year saved was Euro 418.
The results of the sensitivity analysis were not reported.
Authors' conclusions The loan programme of infant car-restraints was cost-effective in comparison with no intervention in Greece. It also compared favourably with other health care interventions.
CRD COMMENTARY - Selection of comparators The selection of the comparator (no intervention) was appropriate as it represented standard care in the authors' setting. You should decide whether this is a valid comparator in your own setting.
Validity of estimate of measure of effectiveness The effectiveness evidence came from published data and the authors' experience with the programme implemented in Athens. Primary published studies appear to have been identified selectively and a systematic review of the literature was not carried out. Much of the evidence was obtained from the authors' programme of the infant car-restraint loan scheme. The methods used to extract and combine the primary estimates were not reported. The issue of uncertainty was not addressed. This represents a strong limitation to the validity of the study, owing to the use of a key assumption about the efficacy of the intervention.
Validity of estimate of measure of benefit The use of a generalisable benefit measure aids comparisons with the benefits of other health care interventions. The use of life-years saved is appropriate because it captures the main aspect of health, namely life expectancy, affected by the intervention examined in the study.
Validity of estimate of costs The authors carried out the analysis using two different perspectives. However, when a societal perspective was adopted the indirect costs were not taken into consideration. The unit costs were presented for most items, and some information on resource consumption was provided. The costs came from local data, while resource use referred to the sample of patients included in the study on the efficacy of the interventions. The price year was reported, which aids reflation exercises in other settings. The costs were treated deterministically, but some sensitivity analyses of the cost inputs were carried out.
Other issues The authors did not make extensive comparisons of their findings with those from other studies. In terms of the generalisability of the study results to other settings, the authors stated that personnel costs might be higher in other countries, owing to the low per capita income figures in Greece. The authors noted that individuals who participated in the programme were volunteers, which might produce a selection bias and thus affect the validity of the efficacy results. Also, the families included in the study appear to have been different from the Greek general population in terms of level of education and, subsequently, it could not have been appropriate to extrapolate the likelihood to participate in the programme found in this study to a countrywide loan scheme model. Further, the analysis of the data relied on parental reports, rather than on actual observation.
Implications of the study The study results supported the implementation of a loan programme of infant car-restraints. The analysis showed that a proportion of the parents were likely to use care restraints improperly, which affects the efficacy of the intervention.
Source of funding The infant car restraint loan scheme in Athens was supported by the National Ministry of Health And Welfare of Greece.
Bibliographic details Kedikoglou S, Belechri M, Dedoukou X, Spyridopoulos T, Alexe D M, Pappa E, Stamou A, Petridou E. A maternity hospital-based infant car-restraint loan scheme: public health and economic evaluation of an intervention for the reduction of road traffic injuries. Scandinavian Journal of Public Health 2005; 33(1): 42-49 Other publications of related interest Ekman R, Welander G, Svanstrom BL, et al. Long-term effects of legislation and local promotion of child restraint use in motor vehicles in Sweden. Accident, Analysis and Prevention 2001;33:793-7.
Johnston C, Rivara FP, Soderberg R. Children in car crashes: analysis of data for injury and use of restraints. Pediatrics 1994;93:960-5.
Petridou E, Skalkidou A, Lescohier I, et al. Car restraints and seating position for prevention of motor vehicle injuries in Greece. Archives of Disease in Childhood 1998;78:335-9.
Indexing Status Subject indexing assigned by NLM MeSH Accidents, Traffic /economics /prevention & Adult; Attitude to Health; Automobiles; Child; Child, Preschool; Cost-Benefit Analysis; Humans; Infant; Infant Equipment /economics; Parents /psychology; Regression Analysis; Safety; Seat Belts /economics; Surveys and Questionnaires; control AccessionNumber 22005000413 Date bibliographic record published 31/12/2005 Date abstract record published 31/12/2005 |
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