The Impact of Child Maltreatment on Health-Related Quality of Life and Quality-Adjusted Life Years

Background and Purpose: The relationship between child maltreatment (CM) and mental and physical health is well known. These effects, as well as reduced social, economic, and other well-being outcomes, may plausibly reduce the quality of life of adult survivors of CM throughout the lifespan. From the perspective of health economics, reduced health-related quality of life (HRQOL) is an important, nonpecuinary component which must be included when measuring the full burden of any injury (CM) or disease for economic evaluation. Although tools exist for measuring this burden (primarily the quality-adjusted life years (QALY)), to date, only one study has measured the burden of CM in QALYs. This study provides new data on the QALY impacts of CM from a national sample for improved economic evaluation.

Methods: A nationally representative sample of n=1864 adults ages 18-85 was collected in October 2013 using internet-based data collection. The survey measured exposure to 5 types of CM using the child trauma questionnaire (CTQ). The primary outcome measures were responses to 2 preference-based, validated metrics of HRQOL, the CDC’s Healthy Days (HRQOL-4) and the EuroQoL group’s “EQ-5D” questionnaires. The impact of CM on these metrics was found using multivariate regressions, controlling for sociodemographics, economic outcomes, and other adverse childhood experiences. For economic evaluation, the impacts were expressed as estimated QALY losses using following published valuation sets for the two HRQOL instruments, applied to a synthetic cohort.

Results: Based on the Healthy Days measures, having any past severe abuse/neglect was associated with 2.0 more physically unhealthy days per month, 3.9 additional mentally unhealthy days per month, and 2.2 additional days with activity limitations; the same exposure was associated with an 11 point reduction on 0-100 scale measured using the EQ-5D. In all 5 types of CM, impacts on quality of life were largest in terms of mental health.

Conclusion and Implications: The relationship between CM and quality of life is substantial and should be included in both formal economic evaluation, as well as discussions of the costs and toll of CM. Over the lifespan, the estimated cumulative impact from severe CM exceeds 7 QALYs, or the equivalent a living 7 fewer years in full health if never having experienced CM as a child. Based on a common, but conservative threshold in health economics of $100,000 per QALY for cost-effectiveness, the quality of life burden from CM exceeds $700,000. To date, these metrics have not been included in discussion of the burden of CM. On the basis of quality of life alone, substantial investments in prevention of CM appear to be warranted.