Spatial analysis of the association of alcohol outlets and alcohol-related pedestrian/bicyclist injuries in New York City

Comparing alcohol involvement among injured pedalcycle and motorcycle riders across three national public-use datasets

BACKGROUND

Annually since 2008; over 38% of fatally injured motorcycle riders and 20% of pedalcyclists involved in traffic crashes were under the influence of alcohol, yet public health surveillance of alcohol involvement in these injuries is underdeveloped. This study determined alcohol involvement among fatally and non-fatally injured pedalcycle and motorcycle riders and compared findings across three national public-use datasets.

METHODS

Using the 2019 National Emergency Medical Services Information System (NEMSIS), the Fatality Analysis Reporting System (FARS), and National Electronic Injury Surveillance System (NEISS) datasets, we identified alcohol involvement in fatal and non-fatal injuries to pedalcycle and motorcycle riders (≥21 years). Alcohol involvement was positive based on the clinician's evaluation of alcohol at the scene (NEMSIS) or within the ED record (NEISS); or when Blood Alcohol Content (BAC) values were ≥.01 (FARS). Pedalcycle and motorcycle injuries were identified across datasets using: 1) ICD10 codes for pedalcycle (V10-V19) or motorcycle (V20-V29) within the cause of injury and EMS respondent's impression of the encounter variables (NEMSIS); 2) product codes for bicycles or moped/power-assisted cycle/minibike/two-wheeled, powered, off-road vehicles (NEISS); and 3) American National Standard Institute's classifications for pedalcycle and motorcycle in the person and vehicle type variables (FARS). The descriptive epidemiology was compared across datasets.

RESULTS

There were 26,295 pedalcyclist and 50,122 motorcycle rider injuries resulting in an EMS response within NEMSIS data; 10.2% and 8.5% of these injuries respectively involved alcohol. These estimates were greater than the 7.3% of pedalcyclist and 6.1% of moped/power-assisted cycle/minibike/two-wheeled, powered, off-road vehicle injuries involving alcohol among patients who presented to an ED within the NEISS dataset. Based on FARS data, alcohol was involved in 27.0% of pedalcyclist and 42.0% of motorcyclist fatal injuries. Regardless of the data source, pedalcyclist and motorcycle fatal and non-fatal injuries were more likely to involve alcohol among middle-aged adults compared to older and early aged adults, and for men compared to women, with proportions that were generally 3-8% higher for men.

CONCLUSIONS

Measures for pedalcycle and motorcycle injuries and alcohol involvement vary substantially across national public-use datasets. Standardized, valid, and feasible methods are needed to accurately inform injury prevention efforts.

Prevalence of indications of alcohol and drug use among patients treated for injurious falls by Emergency Medical Services

Objective

To describe the distribution of alcohol and drug involvement in injurious falls by location and subtype of fall.

Methods

Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset we identified 1,854,909 patients injured from falls requiring an Emergency Medical Services (EMS) response and determined the fall location (e.g. indoors or on street/sidewalk) and the EMS clinician's notation of alcohol or drug involvement. We analyzed substance involvement by fall subtype, location of fall and patient demographics.

Results

Overall, for 7.4% of injurious falls there was a notation of substance use: 6.5% for alcohol alone, 0.6% for drugs and 0.3% for alcohol and drugs. 21.2% of falls that occurred on a street or sidewalk had a notation of substance use; alcohol use alone for 18.5% of falls, drugs alone for 1.7% of falls and alcohol and drugs for 0.9% of falls. Substance use prevalence was highest, at 30.3%, in the age group 21 to 64 years, for falls occurring on streets and sidewalks, without syncope or heat illness as contributing factors; alcohol use alone for 26.3%, drugs alone for 2.6%, and alcohol and drugs for 1.4%. Reported substance use involvement was more frequent for men compared to women for each location type.

Conclusions

Overall, 1-in-5 injurious falls on streets and sidewalks and requiring EMS attention involved substance use, and these numbers likely underestimate the true burden. As cities seek to expand nightlife districts, design strategies to protect pedestrians from falls should be enacted.

Clinical Trauma Severity of Indoor and Outdoor Injurious Falls Requiring Emergency Medical Service Response

Background

Injurious falls represent a significant public health burden. Research and polices have primarily focused on falls occurring indoors despite evidence that outdoor falls account for 47-58% of all falls requiring some medical attention. This study compared the clinical trauma severity of indoor versus outdoor injurious falls requiring Emergency Medical Services (EMS) response.

Methods

Using the 2019 National Emergency Medical Services Information System (NEMSIS) dataset, we identified the location of patients injured from falls that required EMS response. We classified injury severity using 1) the Revised Trauma Score for Triage (T-RTS): ≤ 11 indicated the need for transport to a Trauma Center; 2) Glasgow Coma Scale (GCS): ≤8 and 9-12 indicated moderate and severe neurologic injury; and 3) patient clinical acuity by EMS: Dead, Critical, Emergent, Low.

Results

Of 1,854,909 encounters for patients with injurious falls, the vast majority occurred indoors (n=1,596,860) compared to outdoors (n=152,994). The proportions of patients with moderate or severe GCS scores, were comparable between those with indoor falls (3.0%) and with outdoor falls on streets or sidewalks (3.8%), T-RTS scores indicating need for transport to a Trauma Center (5.2% vs 5.9%) and EMS acuity rated as Emergent or Critical (27.7% vs 27.1%).Injurious falls were more severe among male patients compared to females: and males injured by falling on streets or sidewalks had higher percentages for moderate or severe GCS scores (4.8% vs 3.6%) and T-RTS scores indicating the need for transport to a Trauma Center (7.3% vs 6.5%) compared to indoor falls. Young and middle-aged patients whose injurious falls occurred on streets or sidewalks were more likely to have a T-RTS score indicating the need for Trauma Center care compared to indoor falls among this subgroup. Yet older patients injured by falling indoors were more likely to have a T-RTS score indicating the need for Trauma Center than older patients who fell on streets or sidewalks.

Conclusions

There was a similar proportion of patients with severe injurious falls that occurred indoors and on streets or sidewalks. These findings suggest the need to determine outdoor environmental risks for outdoor falls to support location-specific interventions.

Neighborhood Alcohol Outlet Density, Historical Redlining, and Violent Crime in NYC 2014-2018

Alcohol outlets tend to cluster in lower income neighborhoods and do so disproportionately in areas with more residents of color. This study explores the association between on- and off-premise alcohol outlet density and history of redlining with violent crime in New York City between 2014 and 2018. Alcohol outlet density was calculated using a spatial accessibility index. Multivariable linear regression models assess associations between the history of redlining, on-premise and off-premise alcohol outlet density with serious crime. Each unit increase in on- and off-premise alcohol density was associated with a significant increase in violent crime (β = 3.1, p < 0.001 on-premise and β = 33.5, p < 0.001 off premise). In stratified models (redlined vs not redlined community block groups) the association between off-premise alcohol outlet density and violent crime density was stronger in communities with a history of redlining compared to those without redlining (β = 42.4, p < 0.001 versus β = 30.9, p < 0.001, respectively). However, on-premise alcohol outlet density was only significantly associated with violent crime in communities without a history of redlining (β = 3.6, p < 0.001). The violent crime experienced by formerly redlined communities in New York City is likely related to a legacy of racialized housing policies and may be associated with state policies that allow for high neighborhood alcohol outlet density.

At-risk-measure Sampling in Case-Control Studies with Aggregated Data

Transient exposures are difficult to measure in epidemiologic studies, especially when both the status of being at risk for an outcome and the exposure change over time and space, as when measuring built-environment risk on transportation injury. Contemporary "big data" generated by mobile sensors can improve measurement of transient exposures. Exposure information generated by these devices typically only samples the experience of the target cohort, so a case-control framework may be useful. However, for anonymity, the data may not be available by individual, precluding a case-crossover approach. We present a method called at-risk-measure sampling. Its goal is to estimate the denominator of an incidence rate ratio (exposed to unexposed measure of the at-risk experience) given an aggregated summary of the at-risk measure from a cohort. Rather than sampling individuals or locations, the method samples the measure of the at-risk experience. Specifically, the method as presented samples person-distance and person-events summarized by location. It is illustrated with data from a mobile app used to record bicycling. The method extends an established case-control sampling principle: sample the at-risk experience of a cohort study such that the sampled exposure distribution approximates that of the cohort. It is distinct from density sampling in that the sample remains in the form of the at-risk measure, which may be continuous, such as person-time or person-distance. This aspect may be both logistically and statistically efficient if such a sample is already available, for example from big-data sources like aggregated mobile-sensor data.

Fatal pedestrian crashes on interstates and other freeways in the United States

INTRODUCTION

More than 800 pedestrians die annually in crashes on interstates and other freeways in the United States, but few studies have examined their characteristics.

METHOD

Data from the Fatality Analysis Reporting System on pedestrians fatally injured during 2015-2017 were analyzed. Chi-square tests compared characteristics of pedestrians killed on interstates and other freeways with those that died on other roads, and across crash types among freeway deaths. Land use characteristics of locations where pedestrians were killed while crossing freeways in a large state (California) were identified using Google Earth.

RESULTS

A larger proportion of pedestrians killed on freeways died on dark and unlit roads (48% vs. 32%), were male (78% vs. 68%), or were ages 20-44 (55% vs. 32%) compared with pedestrians killed on other roads. Crossing (42%) was the most common crash type among pedestrian deaths on freeways, followed by disabled-vehicle-related crashes (18%). Pedestrians who died while crossing more often had blood alcohol concentrations ≥ 0.08 g/dL (40%) than those in disabled-vehicle-related (22%) or other crashes (34%). Deaths in crossing crashes were more likely than other freeway deaths to occur on urban roads (81%), at speed limits ≤50 mph (13%), or between 18:00 and 23:59 (49%), and 58% of crossing crashes analyzed for land use were located between residential and other (e.g., commercial, recreational) uses. Over a third (37%) of deaths in disabled-vehicle-related crashes occurred at speed limits ≥70 mph.

CONCLUSIONS

A surprising proportion of pedestrian deaths occur on controlled-access roads not designed for walking. Countermeasures for these crashes need to be implemented to see meaningful reductions in pedestrian fatalities overall. Practical applications: Improving roadway and vehicle lighting, requiring reflective warning devices for marking disabled vehicles, constructing pedestrian overpasses and underpasses in areas frequently crossed, and promoting alternative means of traveling between residential and commercial areas could help.

Geospatial characteristics of non-motor vehicle and assault-related trauma events in greater Phoenix, Arizona

BACKGROUND

Injury-causing events are not randomly distributed across a landscape, but how they are associated with the features and characteristics of the places where they occur in Arizona (AZ) remains understudied. Clustering of trauma events and associations with areal sociodemographic characteristics in the greater Phoenix (PHX), AZ region can promote understanding and inform efforts to ameliorate a leading cause of death and disability for Arizonans. The outcomes of interest are trauma events unrelated to motor vehicle crashes (MVC) and the subgroup of trauma events due to interpersonal assaults.

METHODS

A retrospective, ecological study was performed incorporating data from state and national sources for the years 2013-2017. Geographically weighted regression models explored associations between the rates of non-MVC trauma events (n/10,000 population) and the subgroup of assaultive trauma events per 1000 and areal characteristics of socioeconomic deprivation (areal deprivation index [ADI]), the density of retail alcohol outlets for offsite consumption, while controlling for race/ethnicity, population density, and the percentage urban population.

RESULTS

The 63,451 non-MVC traumas within a 3761 mile2 study area encompassing PHX and 22 surrounding communities, an area with nearly 60% of the state's population and 54% of the trauma events in the AZ State Trauma Registry for the years 2013-2017. Adjusting for confounders, ADI was associated with the rates of non-MVC and assaultive traumas in all census block groups studied (mean coefficients 0.05 sd. 0.001 and 0.07 sd. 0.002 for non-MVC and assaultive trauma, respectively). Alcohol retail outlet density was also associated with non-MVC and assaultive traumas in fewer block groups compared to ADI.

CONCLUSION

Socioeconomic deprivation and alcohol outlet density were associated with injury producing events in the greater PHX area. These features persist in the environment before and after the traumas occur. Ongoing research is warranted to identify the most influential areal predictors of traumatic injury-causing events in the greater PHX area to inform and geographically target prevention initiatives.

Alcohol Outlet Density and Area-Level Heavy Drinking Are Independent Risk Factors for Higher Alcohol-Related Complaints

Alcohol outlet density has well-documented associations with social and health indicators such as crime and injury. However, significantly less is known about the relationships among alcohol-related complaints. Bayesian hierarchical Poisson regression with spatial autocorrelation was used to model the association between on- and off-premises alcohol outlet density and area-level prevalence of current drinkers and heavy drinking, and graffiti density-an indicator of physical disorder-in association with calls from civilians reporting illegal use, alcohol sales, and other alcohol-related activities (hereafter alcohol-related complaints). Complaints were separated into two groups based on whether they occurred at (a) clubs/bars/restaurants or (b) elsewhere. Alcohol-related complaints and graffiti were collected from NYC Open Data. Alcohol density data are from ESRI Business Analyst and information on the prevalence of drinking from the New York City Community Health Survey. The unit of analysis consisted of ZIP codes in New York City (n = 167), and the design was a cross-sectional analysis of aggregated data between 2009 and 2015. In multivariable models, a one-unit increase in off-premises alcohol outlet density was associated with a 47% higher risk of alcohol-related complaints at clubs, bars, and restaurants [rate ratio (RR = 1.46, 95% CI = 1.21, 1.77)]. Area-level prevalence of heavy drinking was associated with a 59% higher risk of alcohol-related complaints at the club, bars, and restaurants (RR = 1.59, 95% CI = 1.34, 1.86) and a 40% higher risk of complaints elsewhere (RR = 1.40, 95% CI = 1.20, 1.63). In New York City, area-level heavy drinking prevalence is a strong independent mechanism that links alcohol outlet density to alcohol-related complaints. Area-level heavy drinking should be investigated as a predictor of other public health problems such as drug overdose mortality.

Density of Medical Marijuana Dispensaries and Current Marijuana Use among Young Adult Marijuana Users in Los Angeles

Background: While tobacco and alcohol studies have focused on density of outlets as a determinant of consumption, research has begun examining the effects of medical marijuana (MM) dispensaries on marijuana use. Objectives: Examine the relationship between density of MM dispensaries and frequency of marijuana use among young adult medical marijuana patients (MMP) and nonpatient users (NPU). Methods: Young adult marijuana users (n = 329) aged 18- to 26-year old were sampled in Los Angeles in 2014-2015 and separated into MMP (n = 198) and NPU (n = 131). In 2014, 425 operational MM dispensaries were identified within the City of Los Angeles. Sequential multilevel Poisson random effect models examined density of MM dispensaries per square mile and 90 d marijuana use among MMP and NUP at the ZIP code level while controlling for demographic, behavioral, and community characteristics. Results: Density of MM dispensaries was not related to 90 d use of marijuana (days of use or hits per day) among either MMP or NPU. MMP reported significantly greater days of marijuana use in the past 90 d compared to NPU but no differences were found for hits per day. African-Americans reported significantly greater hits per day compared to whites. Hispanics reported significantly fewer hits per day compared to non-Hispanics. Conclusion: Concentration of MM dispensaries surrounding young adult marijuana users in Los Angeles was unrelated to days of marijuana use irrespective of having a MM recommendation or not. Rather, individual factors related to consumer choices and behaviors were more important in determining recent marijuana use among MMP and NPU.

Alcohol Outlets, Neighborhood Retail Environments, and Pedestrian Injury Risk

BACKGROUND

Alcohol outlet density has been associated with increased pedestrian injury risk. It is unclear whether this is because alcohol outlets are located in dense retail areas with heavy pedestrian traffic or whether alcohol outlets contribute a unique neighborhood risk. We aimed to compare the pedestrian injury rate around alcohol outlets to the rate around other, similar retail outlets that do not sell alcohol.

METHODS

A spatial analysis was conducted on census block groups in Baltimore City. Data included pedestrian injury emergency medical services (EMS) records from January 1, 2014 to April 15, 2015 (n = 848); locations of alcohol outlets licensed for off-premise (n = 726) and on-premise consumption (n = 531); and corner (n = 398) and convenience stores (n = 192) that do not sell alcohol. Negative binomial regression was used to determine the relationship between retail outlet count and pedestrian injuries, controlling for key confounding variables. Spatial autocorrelation was also assessed and variable selection adjusted accordingly.

RESULTS

Each additional off-premise alcohol outlet was associated with a 12.3% increase in the rate of neighborhood pedestrian injury when controlling for convenience and corner stores and other confounders (incidence rate ratio [IRR] = 1.123, 95% confidence interval [CI] = 1.065, 1.184, p < 0.001). The attributable risk was 4.9% (95% CI = 0.3, 8.9) or 41 additional injuries. On-premise alcohol outlets were not significant predictors of neighborhood pedestrian injury rate in multivariable models (IRR = 0.972, 95% CI = 0.940, 1.004, p = 0.194).

CONCLUSIONS

Off-premise alcohol outlets are associated with pedestrian injury rate, even when controlling for other types of retail outlets. Findings reinforce the importance of alcohol outlets in understanding neighborhood pedestrian injury risk and may provide evidence for informing policy on liquor store licensing, zoning, and enforcement.

Neighbourhood alcohol environment and injury risk: a spatial analysis of pedestrian injury in Baltimore City

OBJECTIVES

The purpose of this study was to investigate the contribution of neighbourhood disorder around alcohol outlets to pedestrian injury risk.

METHODS

A spatial analysis was conducted on census block groups in Baltimore City. Data included pedestrian injury EMS records from 1 January 2014 to 15 April 2015 (n=858), off-premise alcohol outlet locations for 2014 (n=693) and neighbourhood disorder indicators and demographics. Negative binomial regression models were used to determine the relationship between alcohol outlet count and pedestrian injuries at the block group level, controlling for other neighbourhood factors. Attributable risk was calculated by comparing the total population count per census block group to the injured pedestrian count.

RESULTS

Each one-unit increase in the number of alcohol outlets was associated with a 14.2% (95% CI 1.099 to 1.192, P<0.001) increase in the RR of neighbourhood pedestrian injury, adjusting for traffic volume, pedestrian volume, population density, per cent of vacant lots and median household income. The attributable risk was 10.4% (95% CI 7.7 to 12.7) or 88 extra injuries. Vacant lots was the only significant neighbourhood disorder indicator in the final adjusted model (RR=1.016, 95% CI 1.007 to 1.026, P=0.003). Vacant lots have not been previously investigated as possible risk factors for pedestrian injury.

CONCLUSIONS

This study identifies modifiable risk factors for pedestrian injury previously unexplored in the literature and may provide evidence for alcohol control strategies (eg, liquor store licencing, zoning and enforcement).