Rural vs urban motor vehicle crash death rates: 20 years of FARS data

Data mining approach to explore emergency vehicle crash patterns: A comparative study of crash severity in emergency and non-emergency response modes

Emergency vehicle crashes, involving police vehicles, ambulances, and fire trucks, pose a serious traffic safety concern causing severe injury and deaths to first responders and other road users. However, limited research is available focusing on the contributing factors and their interactions related to these crashes. This research aims to address this gap by 1) identifying patterns of emergency vehicle crashes based on severity levels in both emergency and non-emergency modes and 2) comparing the associations by response modes for the related fatal, nonfatal injury, and no-injury crashes. Two national crash databases, Fatality Analysis Reporting System (FARS) and Crash Report Sampling System (CRSS), were utilized for police-reported emergency vehicle crashes from January 2016 to February 2020. Association rule mining (ARM) was employed to reveal the association between factors that strongly contributed to these crashes. The generated rules were validated using the lift increase criterion (LIC). The results showed the complex nature of risk factors influencing the severity of emergency vehicle crashes. The fatal consequences of speeding with no seatbelt usage were evident for emergency mode, whereas none of these risky driving attributes was observed for non-emergency mode. In addition, the analysis identified the risk of fatal emergency vehicle crashes involving pedestrians in dark-lighted conditions in both response modes. Regarding nonfatal injury severity, angle collisions were more likely to occur at urban intersections during emergencies, while rear-end crashes were more frequent on segments with a posted speed limit of 40-45 mph during non-emergency incidents. The outcomes also revealed that the no-injury crashes involving fire trucks exhibited different patterns depending on the response mode. The findings of this study can guide in making effective strategies to improve safe driving behavior of first responders. The identified associations provide insights into the factors that can be controlled to ensure safe operation of emergency vehicles on the road.

[Social inequalities related to road traffic mortality]

OBJECTIVE

To synthesize the social inequalities related to mortality from traffic accidents reported in scientific publications.

METHOD

A scoping review following the PRISMA-ScR guide was carried out. Using the MesH vocabulary, we systematically searched for articles in English, Portuguese and Spanish published in the EBSCO, Scielo, Scopus, Ovid, and PubMed databases.

RESULTS

We identified 47,790 records in the initial search, of which 35 articles met the selection criteria. Nine out ten publications are in high-income countries; there is a greater interest in analyzing mortality in occupants and drivers of vehicles and motorcyclists. Half of the publications use race-ethnicity and geolocation as socioeconomic position variables. The articles included in this review indicate that groups of people with low socioeconomic positions have higher mortality due to traffic accidents.

CONCLUSIONS

The highest mortality from traffic accidents occurs in people with low socioeconomic positions which suggests the development of road safety actions from a comprehensive, integrative perspective and linked to other political agendas to reduce their incidence by 2030. Although road traffic fatalities are higher in low and middle-income countries, few publications are available in these countries. It is necessary to strengthen the research capacities in these countries.

The influence of inferred traffic safety culture on traffic safety performance in U.S. States (1994-2014)

INTRODUCTION

Traffic safety performance (crash fatalities per billion vehicle miles traveled) is influenced by many factors related to the physical and social environment. The traffic safety culture in the local environment can influence behaviors that influence the risk of a fatal crash. However, if traffic safety culture is defined as "shared beliefs," it is not possible to directly observe the effect of culture on traffic safety performance.

METHOD

This study replicated the method proposed by Page (2001) to infer the effect of traffic safety culture on traffic safety performance for U.S. states between 1994 and 2014. This method infers the influence of traffic safety culture from the error between actual and predicted performance based on observable variables that measure the physical and social environment as well as behavioral hazards.

RESULTS

The results suggest that a positive traffic safety culture can have a protective effect by producing a lower-than-expected fatality rate. Conversely, a negative traffic safety culture can have an exacerbating effect by producing a larger-than-expected fatality rate.

CONCLUSION

The derived metric for estimating traffic safety culture had strong concurrent validity by correlating with the ranking of states based only on total crash fatality rate.

PRACTICAL IMPLICATIONS

Consistent with Page (2001), the analysis also identified common risk factors across states including per capita alcohol consumption and unemployment rate.

Differences between occupational and non-occupational-related motor vehicle collisions in West Virginia: A cross-sectional and spatial analysis

BACKGROUND

Motor vehicle collisions comprise the majority of occupational-related fatalities in the United States and West Virginia has one of the highest occupational-related fatality rates in the nation. The purpose of this study was to compare work and non-work-related collisions, crash locations, and the characteristics of in-state and out-of-state drivers ≥18 years of age who were fatally injured in work-related collisions in West Virginia.

METHODOLOGY

Data were from the 2000-2017 Fatality Analysis Reporting System. Work and non-work-related crashes and characteristics in-state vs. out-of-state drivers were compared using binary and multivariable logistic regression analyses. Crash locations were compared via spatial analyses using kernel density estimations.

RESULTS

Among the 5,835 individuals fatally injured in crashes, 209 were designated 'at work'. The odds of being a work-related crash were 85% lower [Odds Ratio (OR) = 0.15; 95% confidence interval (CI): 0.04, 0.49] among those testing positive for alcohol, but 2.5 times greater (OR = 2.56; 95% CI: 1.16, 5.65) among those holding a commercial driver's license. The odds of being an in-state driver were 75% lower (OR = 0.25; 95% CI: 0.12, 0.53) among those wearing a safety belt, but 2.7 times greater among workers testing drug positive (OR = 2.67; 95% CI: 1.10, 6.52). In-state drivers were also less likely to be driving a large truck or be involved in single vehicle collisions and less likely to experience crashes on weekends, nights, or on highways. Spatial patterns of crash locations varied slightly between workers and non-workers.

CONCLUSIONS

Work-related crashes differed greatly from non-work-related crashes in West Virginia. Stark differences existed between in-state and out-of-state workers and their crashes. Various avenues for workplace safety interventions exist, including seatbelt initiatives and drug testing policies for non-commercial drivers, which could help mitigate West Virginia's elevated, occupational-related, traffic fatality rate.

The relationship between geographic location and outcomes following injury: A scoping review

INTRODUCTION

Globally, injury incidence and injury-fatality rates are higher in regional and remote areas. Recovery following serious injury is complex and requires a multi-disciplinary approach to management and community re-integration to optimise outcomes. A significant knowledge gap exists in understanding the regional variations in hospital and post-discharge outcomes following serious injury. The aim of this study was to review the evidence exploring the association between the geographic location, including both location of the event and place of residence, and outcomes following injury.

MATERIALS AND METHODS

A scoping review was used to investigate this topic and provide insight into geographic variation in outcomes following traumatic injury. Seven electronic databases and reference lists of relevant articles were searched from inception to October 2018. Studies were included if they measured injury-related mortality, outcomes associated with hospital admission, post-injury physical or psychological function and analysed these outcomes in relation to geographic location.

RESULTS

Of the 2,213 studies identified, 47 studies were included revealing three key groups of outcomes: mortality (n = 35), other in-hospital outcomes (n = 8); and recovery-focused outcomes (n = 12). A variety of measures were used to classify rurality across studies with inconsistent definitions of rurality/remoteness. Of the studies reporting injury-related mortality, findings suggest that there is a greater risk of fatality in rural areas overall and in the pre-hospital phase. For those patients that survived to hospital, the majority of studies included identified no difference in mortality between rural and urban patient groups. In the small number of studies that reported other in-hospital and recovery outcomes no consistent trends were identified.

CONCLUSION

Rural patients had a higher overall and pre-hospital mortality following injury. However, once admitted to hospital, there was no significant difference in mortality. Inconsistencies were noted across measures of rurality measures highlighting the need for more specific and consistent international classification methods. Given the paucity of data on the impact of geography on non-mortality outcomes, there is a clear need to develop a larger evidence base on regional variation in recovery following injury to inform the optimisation of post-discharge care services.

Magnitude of road traffic accident related injuries and fatalities in Ethiopia

Background

In many developing countries there is paucity of evidence regarding the epidemiology of road traffic accidents (RTAs). The study determines the rates of injuries and fatalities associated with RTAs in Ethiopia based on the data of a recent national survey.

Methods

The study is based on the secondary data of the Ethiopian Demographic and Health Survey conducted in 2016. The survey collected information about occurrence injuries and accidents including RTAs in the past 12 months among 75,271 members of 16,650 households. Households were selected from nine regions and two city administrations of Ethiopia using stratified cluster sampling procedure.

Results

Of the 75,271 household members enumerated, 123 encountered RTAs in the reference period and rate of RTA-related injury was 163 (95% confidence interval (CI): 136–195) per 100,000 population. Of the 123 causalities, 28 were fatal, making the fatality rate 37 (95% CI: 25–54) per 100,000 population. The RTA-related injuries and fatalities per 100,000 motor vehicles were estimated as 21,681 (95% CI: 18,090–25,938) and 4,922 (95% CI: 3325–7183), respectively. Next to accidental falls, RTAs were the second most common form of accidents and injuries accounting for 22.8% of all such incidents. RTAs contributed to 43.8% of all fatalities secondary to accidents and injuries. Among RTA causalities, 21.9% were drivers, 35.0% were passenger vehicle occupants and 36.0% were vulnerable road users including: motorcyclists (21.0%), pedestrians (12.1%) and cyclists (2.9%). Approximately half (47.1%) of the causalities were between 15–29 years of age and 15.3% were either minors younger than 15 years or seniors older than 64 years of age. Nearly two-thirds (65.0%) of the victims were males.

Conclusion

RTA-related causalities are extremely high in Ethiopia. Male young adults and vulnerable road users are at increased risk of RTAs. There is a urgent need for bringing road safety to the country's public health agenda.

Time and place of death from automobile crashes: Research endpoint implications

BACKGROUND

Vehicle crashes are a leading cause of US injury and death. Early death, however, has almost entirely been studied in-hospital. The US Department of Transportation Fatality Analysis Reporting System (FARS) database captures both prehospital and in-hospital mortality.

METHODS

FARS location (prehospital, in-hospital) and time of death were reviewed (1978-2013), and a 2003-2005 subgroup of 55,537 early deaths (i.e., between 5 minutes and 4 hours after injury) was analyzed to quantify risk of death over time.

RESULTS

There has been an overall decrease in 1978-2013 US vehicle-related deaths (from 3.3 deaths per 100 million vehicle miles traveled to 1.1 and from 22.6 per 100,000 population to 10.4). Snapshots of the death data reveal an overall downward trend of total in-hospital and prehospital deaths. The proportion of hospital deaths decreased by 58%, whereas the proportion of deaths in the prehospital period increased to 56%. Subgroup analysis revealed a rate of mortality risk of 0.4% per minute for the first 30 minutes, 1% per minute for the next 60 minutes, and 0.2% per minute and plateauing thereafter.

CONCLUSIONS

Analysis of census FARS data of motor vehicle crash-related deaths showed an overall 35% decrease in mortality over a period of 36 years. The disproportionate reduction in in-hospital deaths is perhaps a testament to the effectiveness of trauma centers. However, there is a demonstrable need to focus on prehospital deaths with resuscitative and adjuvant therapy research and trauma system design. Quantifying risk of death over time should help focus emergency medical services, trauma system, and resuscitation goals.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Evaluating adverse rural crash outcomes using the NHTSA State Data System

INTRODUCTION

The population-based rate of motor vehicle crash mortality is consistently higher in rural locations, but it is unclear how much of this disparity might be due to geographic barriers or deficiencies in emergency medical services (EMS). We sought to analyze separately factors associated with the occurrence of a severe injury and those associated with death after injury had occurred.

METHODS

Data from all police-reported crashes in 11 states from 2005-2007 were obtained through the National Highway Traffic Safety Administration (NHTSA) State Data System (SDS). Logistic regression was used to estimate factors associated with (1) death; (2) severe (incapacitating or fatal) injury; and (3) death given severe injury. Models included covariates related to the person, vehicle, and event; county location was specified using Rural-Urban Continuum Codes (RUCC).

RESULTS

Older age, not wearing a belt, ejection, alcohol involvement, high speed, and early morning times were associated with increased risk of both severe injury and death. Controlling for these factors, and restricting analysis to persons who had suffered a severe injury, the adjusted odds ratio (aOR) associated with death was higher for counties classified rural (RUCC 6-7, aOR 1.23, 95% CI 1.16-1.31) or very rural (RUCC 8-9, aOR 1.31, 95% CI 1.18-1.46).

CONCLUSIONS

Persons severely injured in crashes are more likely to die if they are in rural locations, possibly due to EMS constraints. As NHTSA-SDS data become more available and more uniform, they may be useful to explore specific factors contributing to this increased risk.

Safety in numbers: are major cities the safest places in the United States?

STUDY OBJECTIVES

Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum.

METHODS

A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored.

RESULTS

A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39).

CONCLUSION

Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order.

An examination of the environmental, driver and vehicle factors associated with the serious and fatal crashes of older rural drivers

Motor vehicle crashes involving rural drivers aged 75 years and over are more than twice as likely to result in a serious or fatal injury as those involving their urban counterparts. The current study examined some of the reasons for this using a database of police-reported crashes (2004-2008) to identify the environmental (lighting, road and weather conditions, road layout, road surface, speed limit), driver (driver error, crash type), and vehicle (vehicle age) factors that are associated with the crashes of older rural drivers. It also determined whether these same factors are associated with an increased likelihood of serious or fatal injury in younger drivers for whom frailty does not contribute to the resulting injury severity. A number of environmental (i.e., undivided, unsealed, curved and inclined roads, and areas with a speed limit of 100km/h or greater) and driver (i.e., collision with a fixed object and rolling over) factors were more frequent in the crashes of older rural drivers and additionally associated with increased injury severity in younger drivers. Moreover, when these environmental factors were entered into a logistic regression model to predict whether older drivers who were involved in crashes did or did not sustain a serious or fatal injury, it was found that each factor independently increased the likelihood of a serious or fatal injury. Changes, such as the provision of divided and sealed roads, greater protection from fixed roadside objects, and reduced speed limits, appear to be indicated in order to improve the safety of the rural driving environment for drivers of all ages. Additionally, older rural drivers should be encouraged to reduce their exposure to these risky circumstances.

Eleven years of occupational mortality in law enforcement: The census of fatal occupational injuries, 1992-2002

BACKGROUND

Occupational injury deaths remain high for Law Enforcement Officers (LEOs). This study describes and compares intentional and transportation-related fatality rates in US LEOs between 1992 and 2002.

METHODS

Workplace injury deaths among LEOs from 1992 to 2002 were categorized into "Intentional," "Transportation-related," and "Other," using the Census of Fatal Occupational Injuries. Occupations included in this analysis were sheriffs and bailiffs, police and detectives, non-public service guards, and correctional officers. Fatality rates were compared among law enforcement occupations, cause of death, and demographics with rate ratios and 95% confidence intervals.

RESULTS

During the 11-year period, 2,280 workers died from an occupational injury, for a fatality rate of 11.8 per 100,000 across all LEO occupations. Forty-seven percent were homicides (n = 1,072, rate 5.6 per 100,000), 36% transportation-related (n = 815, rate 4.2 per 100,000), 11% were due to other causes (n = 249, rate 1.3 per 100,000), and 5% were workplace suicides (n = 122, rate 0.6 per 100,000). The proportion of fatalities by cause of death differed significantly between occupations (P < 0.0001). Sheriffs and bailiffs experience a high risk for occupational injury death compared to other law enforcement occupations. Of the transportation-related fatalities, LEOs were operating a motor-vehicle in 58% of the incidents and 22% of the fatalities were struck by incidents.

CONCLUSIONS

Transportation-related deaths were nearly as common as homicides as a cause of occupational injury death among US LEOs. Struck by vehicle incidents remain an important and overlooked cause of death. This research points to opportunities for the prevention of transportation-related deaths in law enforcement.

Fatal crash trends for Australian young drivers 1997-2007: geographic and socioeconomic differentials

BACKGROUND

Little has been published on changes in young driver fatality rates over time. This paper examines differences in Australian young driver fatality rates over the last decade, examining important risk factors including place of residence and socioeconomic status (SES).

METHODS

Young driver (17-25years) police-recorded passenger vehicle crashes were extracted from New South Wales State records from 1997-2007. Rurality of residence and SES were classified into three levels based on drivers' residential postcode: urban, regional, or rural; and high, moderate, or low SES areas. Geographic and SES disparities in trends of fatality rates were examined by the generalized linear model. Chi-square trend test was used to examine the distributions of posted speed limits, drinking driving, fatigue, seatbelt use, vehicle age, night-time driving, and the time from crash to death across rurality and socioeconomic status.

RESULTS

Young driver fatality rate significantly decreased 5% per year (p<0.05); however, stratified analyses (by rurality and by SES) showed that only the reduction among urban drivers was significant (average 5% decrease per year, p<0.01). The higher relative risk of fatality for rural versus urban drivers, and for drivers of low versus high SES remained unchanged over the last decade. High posted speed limits, fatigue, drink driving and seatbelt non-use were significantly associated with rural fatalities, whereas high posted speed limit, fatigue, and driving an older vehicle were significantly related to low SES fatality.

CONCLUSION

The constant geographic and SES disparities in young driver fatality rates highlight safety inequities for those living in rural areas and those of low SES. Better targeted interventions are needed, including attention to behavioral risk factors and vehicle age.

Identification of differences between rural and urban safety cultures

The prevailing risk of traffic fatalities is much larger in rural areas compared to urban areas. A number of explanations have been offered to explain this including road design, emergency medical service proximity, and human factors. This research explored the potential contribution of rural driver attitudes that may underlie the increased fatal crash risk in rural environments. This analysis examined differences between rural and urban drivers in terms of self-reported risk taking for driving behaviors associated with fatal crashes and attitudes toward safety interventions using a large-scale survey. The results suggested that rural drivers engage in riskier behavior, such as not wearing seatbelts, because they have lower perceptions of the risks associated with such behaviors. Results also suggested that vehicle type (e.g., pickup trucks versus passenger vehicles) may be related to seatbelt compliance and frequency of driving under the influence of alcohol. Rural drivers perceived the utility of government-sponsored traffic safety interventions to be lower than their urban counterparts. This study provides insights into the role of the human factor in rural fatal crashes and provides policy suggestions for developing safety interventions that are designed with respect to the psychosocial factors that define the rural culture.

Outcomes of Blunt Trauma Victims Transported by HEMS from Rural andUrban Scenes

OBJECTIVE

Mortality differences exist between victims of urban and rural trauma; however, it is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, length of hospital stay, and discharge status of adult blunt trauma victims transported by HEMS from rural and urban scenes to regional trauma centers.

METHODS

Retrospective review of all adult (age >/= 15) HEMS transports in 2001; 271 urban and 141 rural blunt trauma patients were identified from HEMS transport records and the trauma registries at three level one trauma centers. Demographic data, scene and hospital interventions, as well as discharge status of the two groups were examined.

RESULTS

Total mileage [27 +/- 12 vs. 119 +/- 64, p < 0.001], total flight times (minutes) [30 +/- 10 vs. 79 +/- 40, p < 0.001], and scene times (minutes) [16 +/- 8 vs. 21 +/- 14, p < 0.001] were significantly longer for rural flights. There were no significant differences between the groups with regard to age, gender, receiving hospital, and initial HEMS vitals. Injury Severity Score, ICU length of stay (LOS), total hospital LOS, and hospital mortality did not differ between the two groups. After controlling for age, gender, and ISS, there were no significant mortality differences between the two groups (p = 0.074).

CONCLUSIONS

Despite longer flight and scene times for rural patients, adjusted in-hospital mortality rates were similar for patients transported from urban and rural scenes. Factors prior to HEMS arrival may contribute to increased mortality rates of rural blunt trauma victims documented nationally.

The Resuscitation Outcomes Consortium Epistry-Trauma: design, development, and implementation of a North American epidemiologic prehospital trauma registry

Injury is a major public health problem generating substantial morbidity, mortality, and economic burden on society. The majority of seriously injured persons are initially evaluated and cared for by prehospital providers, however the effect of emergency medical services (EMS) systems, EMS clinical care, and EMS interventions on trauma patient outcomes is largely unknown. Outcome-based information to guide future EMS care has been hampered by the lack of comprehensive, standardized, multi-center prehospital data resources that include meaningful patient outcomes. In this paper, we describe the background, design, development, implementation, content, and potential uses of the first North American comprehensive epidemiologic prehospital data registry for injured persons. This data registry samples patients from 264 EMS agencies transporting to 287 acute care hospitals in both the United States and Canada.

Outcomes of pediatric trauma patients transported from rural and urban scenes

OBJECTIVES

Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes.

METHODS

Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records.

RESULTS

Total mileage, flight times, and scene times were significantly longer for rural flights (P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients.

CONCLUSIONS

Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.

From surveillance to action: early gains from the National Violent Death Reporting System

OBJECTIVES

Drawing from the experiences of individual state programs that currently participate in the National Violent Death Reporting System (NVDRS), this article reviews some of the practical benefits that may accrue from the introduction of violent death surveillance systems.

DESIGN

As a state-based surveillance system that uses multiple data sources and relies upon multiple stakeholders, the NVDRS program has fostered an array of initiatives within and among individual state programs. State-based initiatives highlighted in this article were selected on the basis of a purposive sampling strategy intended to illustrate key aspects of program development.

SETTING

The NVDRS state programs are in Alaska, California, Colorado, Georgia, Kentucky, Maryland, Massachusetts, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin.

RESULTS

The NVDRS has helped to build alliances and collaborative efforts between key stakeholders, facilitated the recognition of violent death as a public health problem through outreach and media attention, acted as a catalyst for new projects, enhanced surveillance of special populations and utility for evaluation, and identified key circumstances that will target interventions in state prevention planning.

CONCLUSIONS

The NVDRS has implemented data collection efforts and is beginning to produce and analyze findings. In the process of implementing the data collection system and publicizing findings, state NVDRS programs are realizing other gains that strengthen their surveillance efforts. The use of data for prevention purposes will be the ultimate indicator of program success.

Road traffic mortality in Estonia: Alcohol as the main contributing factor

Traffic fatalities are the leading cause of death among the young and middle-aged population in Estonia. The objective of this study was to reveal the pattern of traffic fatalities among the population aged 15 - 64 years and to determine the role of alcohol in their fatalities. The data were collected from post-mortem reports at the Estonian Bureau of Forensic Medicine from 2000 to 2002. Alcohol-related deaths were those with a blood alcohol concentration (BAC) equal or above 0.05 g/100 ml. Out of 512 victims, 401 were males and 111 were females. The greatest group were car occupants (58%) followed by pedestrians (31%). The portion of alcohol-related deaths was 70% among men and 44% among women. The mean BAC and percentage of alcohol-related deaths was significantly higher in pedestrian than in driver fatalities. Alcohol intoxication was identified as the most powerful contributing factor to traffic fatalities. The results provide more evidence for politicians to tackle alcohol abuse and unsafe traffic environments.

Rural-urban disparities in health-related quality of life within disease categories of Veterans

CONTEXT

Compared to their urban counterparts, rural veterans have been found to have lower health-related quality of life.

PURPOSE

To determine whether these disparities persist when examining disease categories of rural and urban veterans.

METHODS

We obtained survey data on 748,216 veterans who were current or anticipated Veterans Health Administration patients. Using International Classification of Diseases (ICD)-9CM codes, we determined whether these veterans had diagnoses that fell into any of 30 physical health disease categories, and we used ZIP codes to determine whether veterans lived in rural or urban settings. We compared rural to urban prevalence of disease categories as well as urban to rural health-related quality-of-life physical health component summary scores (PCS) and mental health component summary scores (MCS) for each disease category.

FINDINGS

Physical diagnoses were significantly more prevalent in the rural veteran population for most disease categories examined. For every disease category examined, PCS were significantly lower for veterans who lived in rural, compared to urban, settings (P < .001 for all); rural veterans also experienced lower MCS for all disease categories although differences were modest. Differences persisted after controlling for sociodemographic factors.

CONCLUSIONS

Compared to the urban veteran population, within disease categories, the rural veteran population experiences higher disease prevalence and lower physical and mental quality-of-life scores. Policymakers should anticipate greater health care demands from the rural veteran population and work to meet that demand.

Crossing county lines: the impact of crash location and driver's residence on motor vehicle crash fatality

INTRODUCTION

Studies have demonstrated that the fatality risk for motor vehicle crashes (MVCs) is higher in rural than urban areas. The purpose of this study was to quantify the risk of a fatal outcome associated with a crash by the urban/rural classification of the driver's county of residence and the county of crash before and after adjusting for potentially confounding factors.

METHODS

County of crash and driver's county of residence were classified as urban or rural for 514,648 Utah crash participants. Multivariate regression analysis was used to assess the impact of rural versus urban crash location on fatality outcomes for both urban and rural drivers.

RESULTS

Before adjusting for confounding factors the relative risk of fatality in a rural versus urban crash was 9.7 (95% CI: 8.0-11.7) for urban drivers and their passengers compared to 1.8 (95% CI: 1.3-2.6) for rural residents. Adjustment for behavioral, road, and crash characteristics reduced risk estimates to 2.8 (95% CI: 2.2-3.5) and 1.2 (95% CI: 0.8-1.7), respectively.

CONCLUSION

Urban and rural drivers may have distinct risk factors for MVC fatality in rural areas. Interventions to reduce the risk of fatality in rural areas should evaluate the needs of both urban and rural drivers.

Is the number of traffic fatalities in American hospitals decreasing?

Fatality Analysis Reporting System (FARS) data from 1977 to 2002 record a decreasing number of traffic fatalities taken to a hospital compared with traffic fatalities not taken to a hospital. In this study, we calculated the proportions of decedents reportedly taken to a hospital each year in each state, and the proportions surviving at least 1h. We also used death certificate data from the National Center for Health Statistics (NCHS) for 1979-1999 to categorize the proportion of motor vehicle fatalities in each state by hospital patient status. The annual number of traffic fatalities decreased slightly over the period of observation. The proportion of decedents recorded in FARS as transported to a hospital fell from about 73 to 43%. However, this proportion decreased abruptly at certain times in some states, suggesting previous misclassification. The proportion surviving at least 1h remained relatively constant. NCHS data showed a decline in the proportion declared dead in hospitals from 62 to 51%, including a decline in the proportion declared dead on arrival (DOA) from 20 to 8%. Along with occasional misclassification in some states, the decrease in cases transported only to be pronounced DOA could explain why FARS data show a decrease in deaths after hospital transport.

Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study

OBJECTIVE

The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors.

METHODS

The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively.

RESULTS

During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics.

CONCLUSIONS

Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.

Temporal trends, gender, and geographic distributions in child and youth injury rates in Sweden

OBJECTIVE

Sweden has the lowest child injury mortality rate in the world, 5.2/100 000 for children under 15. This paper describes temporal trends in Sweden, as well as gender related and geographic differences.

DESIGN

The Swedish Cause-of-Death Register (1987-2001) and the Hospital Patient Register (1987-2002) were used to compare rates for the country as a whole and for discharges aged 0-20 by municipality, using the SEATS time series analysis program.

RESULTS

There was a decrease in the rate of fatal unintentional injuries from 7 to 4 per 100 000 for girls and from 16 to 10 per 100 000 for boys since 1987. The gap between girls and boys was reduced and boys now have almost the same mortality rate as girls for violence related deaths. Road and other unintentional injuries show a general decrease whereas the pattern for falls varies by age and sex. Self inflicted injuries increased for both sexes, but more for girls. Substantial differences in injury rates between municipalities were also found-up to six times for girls and eight times for boys.

CONCLUSION

Substantial declines in injury fatalities over time were found, but these were different for boys and girls. There remain substantial differences between municipalities. These data, published in a child injury atlas, have prompted substantial interest among media and the authorities.

Fatal motor vehicle crashes in rural and urban areas: decomposing rates into contributing factors

OBJECTIVES

Motor vehicle crash fatality rates have been consistently higher in rural areas than in urban areas. However, the explanations for these differences are less clear. In this study the decomposition method was used to explore the factors associated with increased fatal crash involvement rates in rural communities.

DESIGN

Using national databases, the fatal crash incidence density was decomposed into the product of three factors: the injury fatality rate, the crash injury rate, and the crash incidence density.

RESULTS

As expected, the fatal crash incidence density was more than two times higher in rural than in urban areas. This was driven primarily by the injury fatality rate, which was almost three times higher in rural areas.

CONCLUSIONS

Further research should examine the relative roles of crash severity and the timely receipt of definitive medical care after a crash.

Population characteristics of traffic accident-related deaths in Japan and Ireland, 1950-2000

To compare epidemiological characteristics of traffic accidents in Japan and Ireland, we analyzed mortality and the negative effect on life expectancy between 1950 and 2000 and generated a multivariate model. The characteristics were similar in the two countries: The time trends showed an increase in mortality followed by a decrease. The mortality rates were about 13 and 5/100,000 for males and females, respectively, in 2000. Correlation coefficients for sex were over 0.9. Age distribution obeyed the natural logarithm regularity. The negative effect on life expectancy was about 0.34 year for males, and 0.13 year for females. The economic level was positively associated with mortality, whereas "number of vehicles owned" was associated negatively. In conclusion, we can take advantage of the broad consistencies in these two countries when we draw up an intervention strategy. Any preventive strategy should be directed to the young, particularly males.

Trauma system evaluation using the fatality analysis reporting system

BACKGROUND

The Fatality Analysis Reporting System (FARS) has recorded detailed data on fatal traffic crashes since 1975. At least three prior studies have used declining mortality rates derived from FARS as evidence of regional trauma system effectiveness.

METHODS

FARS and census data were obtained at no cost through the Internet. Previously published studies were replicated graphically including data from additional years before and after the previously reported time periods, and with rates also calculated for control populations.

RESULTS

The association of trauma system organization with observed decreases in mortality rates was less convincing when all available data were displayed and other potential factors were considered. Death after traffic crashes, and especially death in hospitals, is becoming less frequent throughout the country.

CONCLUSION

FARS is an excellent resource available to all injury researchers, but provides little evidence that some regions have decreased traffic mortality more than others because of trauma systems.

Deaths due to injuries among employed adults: the effects of socioeconomic class

BACKGROUND

Few studies have investigated socioeconomic status (SES) and external causes of death (ie, deaths attributable to injuries). These deaths are of particular interest because they are potentially preventable and they represent the second leading cause of years of life lost under age 75.

METHODS

We studied 261,723 deaths from external causes in 27 states from 1984 to 1997 among employed persons age 20-64. Numerator data came from occupation on the death certificate. Occupation-specific denominator data came from the U.S. Census. A Nam-Powers SES score was assigned to each occupation based on its relative income and education in the U.S. Census.

RESULTS

After adjusting for age, sex, year and race, SES was strongly associated with mortality from all external causes combined for men (rate ratios = 2.9, 2.3, 1.5, and 1.0 by ascending SES quartile), and to a lesser extent for women (rate ratios = 1.6, 1.0, 1.1, and 1.0). A similar pattern was seen for each of the specific external causes (motor vehicle deaths, suicide, homicide, injuries other than by motor vehicle, and medical complications).

CONCLUSIONS

We estimate 41% of deaths from external causes are attributable to having a SES below the top quartile (both sexes combined).

Head injury-related road crash mortality in rural Western Australia

BACKGROUND

The aim of the present paper was to assess the incidence of, and identify factors associated with road crash (RC)-related fatal head injuries in rural and metropolitan Western Australia.

METHODS

Examination of demographics, driving behaviour and RC characteristics for RC fatalities involving a head injury (Abbreviated Injury Scale (AIS) > or = 2) between 1 January 1998 and 31 December 1999 was carried out using the State Coronial Database.

RESULTS

There were 328 deaths. The median age was 28 years and 74.1% of cases were male. Seventy per cent died at the scene. Of scene survivors, 89% were transferred to a metropolitan hospital before dying. Sixty per cent of total RC and 65% of at-scene deaths occurred in rural areas. Single-vehicle crashes comprised 45% of total crashes, of which 72.8% occurred in rural locations. Poor driver behaviour was identified in 53% of deaths. Ethanol was implicated in 29.8% of deaths, other intoxicating drugs were implicated in 19.2%, speeding was implicated in 19.5%, and lack of safety restraints/devices was implicated in 22%. Poor driver behaviour was identified in 72% of single-vehicle deaths, compared with 38% of multivehicle crashes (P < 0.001). Rural people comprised 61% of rural crash victims. Ninety-one per cent of rural victims died in rural crashes. The incidence of RC death associated with head injury in the rural population is 13.4 deaths/100 000 per year, more than double that for the metropolitan population (6.4 deaths/100 000 per year; P < 0.001).

CONCLUSION

The rural population of Western Australia is overrepresented in head injury-related RC deaths. Single-vehicle crashes where unsafe driving behaviour is implicated comprise a large proportion of these. Strategies to reduce unsafe driving practices aimed at rural drivers are necessary.