Book Review

Economic Consequences of Traumatic Spinal Cord Injury

N Engl J Med 1994; 330:1464May 19, 1994

Article

Economic Consequences of Traumatic Spinal Cord Injury
By Monroe Berkowitz, Carol Harvey, Carolyn G. Greene, and Sven E. Wilson. 202 pp. New York, Demos, 1993. $59.95. ISBN: 0-939957-44-2

More than 175,000 people in the United States are living with a traumatic spinal cord injury -- that is, one not caused by disease. They are typically male and well educated (the majority attended college). At the time of the injury they were young (half were between 16 and 30 years old) and employed. About one quarter are veterans. There are somewhat more paraplegics than quadriplegics in this population. Motor vehicle accidents are the leading cause of spinal cord injury, followed by falls and sports injuries, primarily diving injuries. Sports injuries are the most likely to result in quadriplegia rather than paraplegia.

Economic Consequences of Traumatic Spinal Cord Injury, the results of the first broad-based national survey of the population with spinal cord injury, provides such information. A detailed questionnaire (90 minutes in duration) was administered to 758 respondents, sampled from area populations, institutions, and membership lists of organizations for people with spinal cord injuries. The study was paid for by the Paralyzed Veterans of America and was intended to provide the group with information useful in its role as an advocate for veterans. Fortunately, the source of funding does not seem to have affected the objectivity of the report.

The book focuses on the direct and indirect monetary costs of traumatic spinal cord injuries. The authors use a straightforward cost-of-injury approach, but the analysis is impressive nonetheless. Indeed, it is a model of how to conduct such studies. The book is detailed, but quite readable. The authors highlight the results, but they also make clear their methods and the assumptions used in estimation. They let you into their statistical kitchen.

The authors find that, in 1988 dollars, the average victim of a spinal cord injury incurred initial hospital and medical costs of about $95,000. Another $8,000 was spent on modification of the home. The ongoing additional cost of medical services and personal assistance necessitated by the injury accounts for another $14,000 per year. These are the direct expenses. In addition, there are lost earnings. Although 84 percent of the respondents were employed at the time of the injury, only 33 percent were working at the time of the interview. Furthermore, the authors estimate that those working had a 33 percent drop in earnings from what they would have been making had they not been injured. Overall, the average loss of earnings per year for the typical person with a spinal cord injury was $12,000. The aggregate dollar cost of spinal cord injuries in 1988 was $3.4 billion in direct expenses and another $2.2 billion in lost earnings.

The authors are economists, so they focus on the financial costs of spinal cord injuries. But they recognize that the psychosocial costs -- the impact on the lives of people with spinal cord injuries and their families and friends -- are even more important. For example, although only 3 percent of the people with spinal cord injury are institutionalized, at least 40 percent need assistance dressing themselves, 36 percent need assistance in bowel care, and half need assistance for mobility outside the home. More than 75 percent changed their career paths because of the injury.

What most impressed the authors was the resiliency of the victims and their families as they adjusted to the trauma. The authors' next task is to try to use their data to understand what factors cause different people with the same degree of impairment to have widely different outcomes in terms of attitude, productivity, and ability to manage the activities of daily living.

David Hemenway, Ph.D.
Harvard School of Public Health, Boston, MA 02115