Study quantifies cost-benefit of hospital-based program to keep youth out of prison

With violence plaguing inner-city youth at epidemic rates, the report of a new study in the November issue of The Journal of the American College of Surgeons illustrated a research-based approach to confronting this national problem.

The study showed that “Caught in the Crossfire,” a hospital-based peer intervention program, reduced involvement in the criminal justice system among youth aged 12 to 20. Additionally, this program proved to be cost efficient in comparison with the cost of a stay in a juvenile detention center.

In 2001, the US Surgeon General warned of an epidemic in youth violence, calling for a research-based approach to systematically confronting the problem. Despite the attention, this issue continues to be a major public health concern in the US, where intentional violent trauma is the second leading cause of death among youth between the ages of 15 and 24. Violence among youth is notably worse in some inner-city areas, including Oakland, CA, where this study took place.

“This study demonstrates that investing dollars in preventive intervention programs is not only a good public health practice, but it is a good economic practice as well,” said Daniel Shibru, MD, University of California, San Francisco. “The findings are particularly significant because it proves that peer intervention programs like ‘Caught in the Crossfire' can reduce retaliatory youth violence as well as their involvement in the criminal justice system, especially as they return to the same violent environments where their injuries occurred.”

This retrospective, comparative double cohort study included 154 patients treated at a university-based urban trauma center in Alameda County, CA. Patients were 12 to 20 years of age and were hospitalized for intentional violent trauma. The two groups evaluated included the enrolled group of 75 patients with a minimum of five interactions with an intervention specialist and the control group of 79 patients who were selected based on age, gender, ethnicity or race, type of injury and year of hospitalization. Follow-up review for both groups was conducted over a period of 18 months after the date of their initial hospitalization and injury to determine three outcomes: whether they had died, had been re-hospitalized for another intentional violent injury, or had been involved or reinvolved with the criminal justice system.

Participants in the hospital-based peer intervention program reduced risk of criminal justice involvement for at-risk youth six months after completion of the one-year program (relative risk=0.67; 95% CI, 0.45, 0.99; p=.04). Based on a logistic regression analysis of age, gender and ethnicity or race, the study showed that only age (under 17 years) had a confounding effect on the association between program participation and criminal justice involvement (relative risk=0.71; p=0.043). After successful treatment through the program, risk of subsequent violent criminal behavior was reduced by 7 percent compared to the control group (p=0.15). Risk of death, physical re-injury and re-hospitalization from intentional violence were similar between both groups.

After a significant association was established between program participation and subsequent criminal justice involvement, attributable risk calculations showed that 16 percent of risk reduction in criminal justice involvement can be attributed to the peer intervention program. To prevent a single adverse criminal outcome, six patients needed to be treated through the program.

The cost of the program, which treats 75 to 100 youth annually, is approximately $3,500 per patient per year. The annual cost for a juvenile detention center admission in Alameda County is $80,000 per person. Since six patients need to be treated through the program to see a 16 percent risk reduction in involvement in the criminal justice system, the intervention program's annual cost amounts to $60,000 less per patient than the cost of incarceration in the juvenile detention system. Annually, this program could produce a total cost reduction of approximately $750,000 to $1.5 million, assuming that each juvenile who is rearrested and reconvicted spends one year in a detention center.