Productivity losses from non-fatal traumatic brain injuries in the United States

Abstract

Background

Non-fatal traumatic brain injuries (TBIs) are commonly caused by falls, motor vehicle crashes and assaults, affecting millions of Americans each year. Yet there is limited information on the costs that non-fatal TBIs impose on affected individuals, families, employers and communities. This study used new data opportunities in a nationally representative survey to estimate annual productivity losses due to non-fatal TBI among US adults.

Methods

In 2025, authors combined survey response data from the 2023 National Health Interview Survey with supplementary information from previous studies and other nationwide data sources to estimate the cost of inability to work, absenteeism, presenteeism and household productivity loss from non-fatal TBI. Productivity losses were assessed using the human capital approach, which values lost time due to illness or injury using average observed wages in the population.

Results

Non-fatal TBI causes productivity losses among US adults each year exceeding an estimated US$19.1 billion (95% prediction intervals 7.5 to 35.6 billion) (2023 US$). The cost of inability to work comprises the greatest productivity losses (US$8.7 billion), followed by presenteeism (US$6.7 billion), absenteeism (US$3.5 billion) and household productivity loss (US$168 million).

Discussion and conclusions

The economic cost of lost productivity due to non-fatal TBI among adults is substantial. Public health strategies that prevent TBI have enormous potential to both alleviate suffering and create cost savings for the US economy by avoiding preventable work and personal time losses.

BACKGROUND

Traumatic brain injuries (TBI) are a significant public health concern in the USA. Leading traditional sources of surveillance for injuries and illness are widely acknowledged to undercount TBI for a variety of reasons—many such injuries do not receive medical attention, deaths may occur after an extended period of disability and not reflect TBI as the underlying cause, and medical coding standards can inhibit accurate accounting of TBI events—but TBI causes at least 70 000 deaths and over 200 000 hospitalisations each year.^{1 2} TBI severity and long-term effects vary widely, but during just the first year following a non-fatal TBI, patients incur, on average, approximately US$4500 (treated and released from an emergency department) to US$51 000 (hospitalised) in medical costs for combined acute and follow-up care. ^{3 4} Over 60% of working-age individuals who experience TBI and receive inpatient rehabilitation are unemployed for 2 years following their injury.⁵

Existing estimates of TBI-related lost productivity were carefully conducted but address only work absenteeism (missed work days) among people whose employer-sponsored insurance claims documented TBI treated in an emergency department.^{4 6} This does not adequately address known TBI medical coding issues and neglects other critical elements of the economic cost of lost productivity such as work-limiting disability, presenteeism (reduced productivity while at work) and lost non-market household productivity (such as cooking, cleaning or gardening).⁷ This study used new data opportunities in a nationally representative survey to estimate annual productivity losses due to non-fatal TBI among US adults.

METHODS

Following previously reported methods, the authors estimated TBI-attributable annual productivity losses in terms of inability to work, absenteeism, presenteeism and inability to perform household production using the human capital approach, which values lost time using observed average wages for the population.7 The authors analysed 2023 National Health Interview Survey (NHIS) data on adults who reported non-fatal TBI from head injuries,⁸ identified through an affirmative response to at least one of the two survey questions: (1) ‘during the past 12 months, as a result of a blow or jolt to the head, have you been knocked out or lost consciousness, been dazed or confused, or had a gap in your memory?’, or (2) ‘during the past 12 months, as a result of a blow or jolt to the head, have you had headaches, sensitivity to light or noise, balance problems, or changes in mood or behaviour?’ (online supplemental table S1).^{8 9}

The proportion of adults with TBI who were unable to work (‘what is the main reason you were not working for pay at a job or business last week?’ selected responses: health reasons or disability) was estimated from the NHIS survey-weighted responses using a logistic regression model (Stata V.18 logit with postestimation margins) to compare non-pregnant adults with and without TBI and controlling for selected sociodemographic and health factors (age, sex, race/ethnicity, education level, family income, marital status, metropolitan area type, census region, health insurance in the past year, categorical perceived health status (poor through excellent), cigarette smoking status, influenza vaccine status and overweight/obesity status) (online supplemental table S2).⁸ The same modelling approach was used to assess the proportion of adults with TBI who had household productivity losses using a survey question on whether respondents had been hospitalised (‘during the past 12 months, have you been hospitalised overnight?’)⁸ in combination with data from the nationwide Healthcare Cost and Utilisation Project indicating that survived patients with a primary diagnosis of TBI were hospitalised on average for 6.22 days.¹⁰

A negative binomial regression model (Stata V.18 nbreg with postestimation margins) was used to estimate the average number of absenteeism days (‘days missed work, past 12 months’)⁸ among non-pregnant employed respondents with a TBI compared with those without, controlling for survey weights and the same selected factors (online supplemental table S2).⁸ Presenteeism is typically the most complex type of lost productivity to measure and was not addressed in the survey data; instead, authors multiplied the number of estimated work days in a year among employed respondents with a TBI—after subtracting the estimated number of absenteeism days among respondents with TBI—by an estimate from a study that observed presenteeism due to migraines or severe headaches and reported 3.06% lower productivity on the days that affected individuals were at work (online supplemental table S2).¹¹

All costs are 2023 US$. Productivity losses were estimated by age group (18–29, 30–44, 45–64 and ≥65) and sex (male, female). Lost productive days were assigned standard market economic values by age group and sex (males/females: age 18–29 years, US$126/99; age 30–44 years, US$327/203; age 45–64 years, US$354/197, age 65+years, US$89/33).^{12 13} Prediction intervals (PI) around point estimates were generated by multiplying modelled 95% CI estimates for input measures (eg, upper and lower 95% CIs for the modelled population prevalence of TBI and the modelled number of absenteeism days using survey-weighted data) by standard market values. This study used publicly available data and did not require Institutional Review Board review (45 CFR §46).

RESULTS

The estimated annual cost of productivity loss per adult with non-fatal TBI is US$2329 (PI US$1169–US$3575) (table 1), and the cost among all US adults was US$19.1 billion (PI US$7.5–US$35.6 billion) (table 2). The majority is due to inability to work (46% of total, or US$8.7 billion), followed by presenteeism (35%, US$6.7 billion), absenteeism (18%, US$3.5 billion) and household productivity loss (1%, US$168 million). Despite a greater loss of productive time due to TBIs among females compared with males (online supplemental table S3), the associated overall estimated cost, along with three cost components—absenteeism, presenteeism and inability to work—was higher for males, due to males receiving higher average wages (tables 1–2; online supplemental table S4). Inability to work due to TBI among males aged 45–64 years old comprised the largest cost component (US$2.4 billion, or 12% of total) (online supplemental table S5), and that group of adults had the highest productivity loss per affected person (US$2266) (online supplemental table S6) across age groups, sex and cost components.

Table 1.

Productivity losses per US adult with non-fatal TBI

Cost component	Male	Female	Total
Inability to work*	1386	812	1065
	(456–2310)	(268–1353)	(351–777)
Absenteeism†	538	333	423
	(182–998)	(112–616)	(143–785)
Presenteeism‡	1140	567	820
	(920–1373)	(467–671)	(665–982)
Household productivity loss§	13	26	21
	(6–20)	(13–40)	(10–31)
Total per adult cost¶	3077	1739	2329
	(1564–4701)	(861–2680)	(1169–3575)

All costs were estimated per adult aged ≥18 years who had TBI, In 2023 US$. Values In parentheses are 95% prediction Intervals, calculated based on the 95% CIs of model-based estimates. Each cost component was calculated as the sum of each cost component over all age groups.

^*Per person cost of Inability to work attributable to TBI was calculated by dividing the total cost of inability to work attributable to TBI by the number of adults aged ≥18 years who had TBI in 2023.

^†Per person absenteeism cost attributable to TBI was calculated by dividing the total absenteeism cost attributable to TBI by the number of adults aged ≥18 years who had TBI in 2023.

^‡Per person presenteeism cost attributable to TBI was calculated by dividing the total presenteeism cost attributable to TBI by the number of adults aged ≥18 years who had TBI in 2023.

^§Per person cost of household productivity loss attributable to TBI was calculated by dividing the total cost of household productivity loss attributable to TBI by the number of adults aged ≥18 years who had TBI in 2023.

^¶Total per adult cost was calculated as the sum of the per adult cost of absenteeism, presenteeism, household productivity loss and inability to work.

TBI, traumatic brain injury.

Table 2.

Productivity losses due to non-fatal TBI among US adults

Cost component	Male	Female	Total
Inability to work*	5.00	3.72	8.72
	(1.28–10.19)	(0.97–7.50)	(2.25–1.77)
Absenteeism†	1.94	1.52	3.46
	(0.51–4.40)	(0.41–3.42)	(0.92–7.82)
Presenteeism‡	4.11	2.60	6.71
	(2.58–6.06)	(1.69–3.72)	(4.27–9.78)
Household productivity loss§	0.05	0.12	0.17
	(0.02–0.09)	(0.05–0.22)	(0.06–0.31)
Total cost¶	11.11	7.95	19.06
	(4.39–20.73)	(3.11–14.86)	(7.50–35.59)

All costs were estimated In 2023 US$ (billion). Values In parentheses are 95% prediction Intervals, calculated based on the 95% CIs of model-based estimates. Each cost component was calculated as the sum of each cost component over all age groups.

^*Absenteeism cost attributable to non-fatal TBI was calculated by multiplying the age group- and sex-specific total missed workdays due to absenteeism attributable to TBI for those who were employed, by the age group- and sex-specific market economic value from Grosse et al,¹² which was inflation-adjusted to US$ 2023.

^†Presenteeism cost attributable to TBIs was calculated by multiplying the age group- and sex-specific total presenteeism days loss attributable to TBI for those who were employed, by the age group- and sex-specific market economic value from Grosse et al,¹² which was inflation-adjusted to US$ 2023.

^‡Cost of household productivity loss attributable to TBIs was calculated by multiplying the age group- and sex-specific total days of hospital stay overnight or longer, attributable to TBI, by the age group- and sex-specific non-market economic value from Grosse et al,¹² which was inflation-adjusted to US$ 2023.

^§Cost of inability to work attributable to TBIs was calculated by multiplying the age group- and sex-specific total adults who had inability to work attributable to TBI, by the age group- and sex-specific market economic value from Grosse et al,¹² which was inflation-adjusted to US$ 2023.

^¶Total cost was calculated as the sum of the cost of absenteeism, presenteeism, household productivity loss and inability to work.

TBI, traumatic brain injury.

DISCUSSION

Estimated productivity loss from TBI among US adults exceeds US$19 billion annually, or approximately US$2300 per affected person. The largest share of the inability to work cost, 46%, may suggest that TBI may lead to higher productivity losses due to short-term disability compared with TBI-related absenteeism or presenteeism. This study’s estimated cost of absenteeism and inability to work due to TBI is modestly lower than previous estimates that addressed only TBIs treated in hospital emergency departments.⁶ There is considerable variation in outcomes for individuals with non-fatal TBI; many experience functional improvement at 1–2 years postinjury, followed by a decline in functioning and decreased independence by 5 years.⁵ Factors such as functional status, older age, non-White race, lower preinjury productivity, public healthcare payer source, longer length of inpatient rehabilitation stay and lower discharge functional status have been shown to negatively affect improvements over time.¹⁴ Although inpatient rehabilitation can support return to work after TBI, many individuals do not receive this or other follow-up after the injury. Rehabilitation care following TBI is affected by patients’ functional recovery level, independence, geographic availability and financial resources—including insurance coverage.¹⁵ Prevention strategies, including home safety modifications to prevent falls, particularly for older adults, always using seatbelts in motor vehicles and preventing interpersonal violence, can reduce non-fatal TBI among adults. Strategies to ensure individuals who experience TBI receive recommended medical care and follow-up after the injury to support return to work are critical in minimising the loss of productive time.

Limitations

NHIS survey data, including TBI-and productivity-related survey responses, may be subject to recall bias. The use of the human capital approach may overestimate the cost of productivity losses compared with the friction cost approach and may not accurately reflect the value of time because it incorporates observed differences in earnings based on sex. There is some evidence that post-TBI headaches comprise similar severity and functional impairment as migraines, and in the absence of available data on average reduced productivity while at work (or presenteeism) among people with TBI, this study applied a presenteeism estimate derived from people with migraines or severe headaches.^{11 16 17} However, postconcussion syndrome entails not only headache, but also dizziness, decreased concentration, memory problems, irritability, fatigue, sensory sensitivity and judgement problems, as well as depression and anxiety, which undoubtedly also impact presenteeism.^18–20 Estimating household productivity loss due to non-fatal TBI by relying solely on overnight hospitalisations and the length of hospital stay, and excluding sick days spent at home, undoubtedly underestimates such losses.¹⁰ This study identified respondents’ inability to work based on data specific to not working in the previous week due to disability, which may have overestimated the cost of inability to work attributable to TBI.

CONCLUSIONS

The economic cost of TBI attributable to the lost productivity among US adults is substantial. Public health strategies that prevent TBI have enormous potential to alleviate suffering and create cost savings for the US economy by avoiding preventable work and personal time losses.

Supplementary Material

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Productivity losses from non-fatal traumatic brain injuries (TBIs) are substantial in the USA; however, existing estimates tend to underestimate these losses.

WHAT THIS STUDY ADDS

• This study estimates the annual productivity losses from non-fatal TBIs among US adults in 2023.

HOW MIGHT THIS STUDY AFFECT RESEARCH, PRACTICE OR POLICY

• A comprehensive understanding of productivity losses resulting from non-fatal TBIs can inform prevention strategies and ultimately help reduce the economic burden of these injuries.