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Motorcycle Trauma in the State of Illinois: Analysis of the Illinois Department of Public Health Trauma Registry
INJURY PREVENTION/ORIGINAL CONTRIBUTION
Motorcycle Trauma in the State of Illinois: Analysis of the Illinois Department of Public Health Trauma Registry From the Department of Emergency Medicine, University of Illinois at Chicago*, and the Illinois Department of Public Health.i
Elizabeth Orsay, MD* Janet A Holden, PhD* John Williams, MD* John R Lumpkin,MD, MPH*
Receivedfor publication June I5, 1994. Revisions received November 8, 1994, and February 27, 19q5. Acceptedfor publication March 13, 1995.
Study objective: Toassess the current morbidity and mortality of motorcycle trauma in the state of Illinois and, specifically, to assess the incidence and cost of head injury to motorcycle crash patients according to their helmet use.
Supported by a g~antfrom the Illinois Department of Transportation.
Design: Retrospective, cross-sectional examination of the Illinois Department of Public Health Trauma Registry, for which data are available from July 1, 1991, through December 31, 1992. Data are collected from all hospitals designated as Level I or Level II trauma centers in Illinois.
Copyright © by the American College of Emergency Physicians.
Participants: All patients involved in motorcycle crashes and subsequently taken to a Level I or Level II trauma center in Illinois and entered into the trauma registry during the period studied. Results: Head injury, spinal injury, helmet use, demographic data, hospital charges, days in ICU, and source of payment were selected as outcome measures. During the 18-month study period, 1,231 motorcycle trauma patients were entered into the trauma registry. Eighteen percent were helmeted and 56.0% were nonhelmeted. In 26.0% the helmet status at the time of the crash was unknown. Thirty percent of the helmeted patients sustained head injury and 4% sustained spinal or vertebral injury, compared with 51% and 8%, respectively, for nonhelmeted patients. Nonhelmeted patients were significantly more likely to sustain severe (Abbreviated Injury Score [AIS], 3 or more) or critical (AIS, 5 or more) head injury. Patients with these serious head injuries incurred almost three times the hospital charges and used a disproportionately larger share of ICU days than those with mild or no head injuries. There was a trend toward greater use of public funds or self-pay status (no insurance) for payment of hospital charges in nonhelmeted patients. Conclusion: Motorcycle helmet nonuse was associated with an increased incidence of serious head injury. Motorcycle trauma patients with severe or critical head injuries used a significantly greater proportion of ICU days and hospital charges than those with mild or no head injuries.
OCTOBER 1995
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ANNALS OF EMERGENCY MEDICINE
4 55
MOTORCYCLE T R A U M A Orsay et aI
[Orsay E, Holden JA, Williams J, Lumpkin, JR: Motorcycle trauma in the state of Illinois: Analysis of the Illinois Department of Public Health Trauma Registry. Ann EmergMedOctober 1995;26:455-460.]
INTRODUCTION Motorcycle crashes account for a disproportionate share of the deaths and disabilities that result from motor vehicle crashes. In 1991, there were 65 deaths per 100,000 motorcycles nationwide, compared with 18 per 100,000 passenger cars; the death rate per vehicle mile traveled among motorcycle riders is 21 times the death rate per vehicle mile traveled in passenger cars. >3 In Illinois in 1992, there were 3,228 motorcycle injuries and 104 fatalities. 4 Millions of dollars were spent for the acute health care expenses of injured motorcyclists in 1992 in Illinois, and many millions more will be spent to provide for their long-term health and rehabilitation. Illinois is one of only three states without any motorcycle helmet legislation. We analyzed data from the Illinois Department of Public Health (IDPH) Trauma Registry to more accurately assess the toll of motorcycle trauma in Illinois. This is the first study to evaluate the data from this trauma registry for head and spinal injuries resulting from motorcycle crashes, and it provides a more thorough analysis of the human and monetary costs of such injuries in our state.
Table 1.
Comparison of trauma registry cases by helmet status and demographic characteristics. No Helmet (n=689)
Helmet (n=222)
Unknown (n=320)
Mean age (years)
29.2
31.5
29.8
Sex (%) Male Female
87.2
87.8
85.6
Characteristic
12.8
12.2
14.4
Race (°/o) White Black Other Unknown
87.5 6.2 4.7 1.6
89.6 5.5 2.4 2.7
84.3 10.0
Position (%) Driver Passenger
84,2 15.8
85.1 14.9
88.4 11.6
Lecation (%) Urban Rural Unknown
4 56
61.8 34.4 3.8
53.2 41.8 5.0
4.1 1,6
56.5 37.3 6.2
MATERIALS
AND METHODS
The state of Illinois has a regionalized trauma care system that covers the entire state. The IDPH Trauma Registry was developed by and is maintained by the Illinois Department of Public Health. Data collection began in July of 1991, and reformation through December of 1992 is available for analysis. The registry contains medical and financial information on injured motorcyclists treated at any of 73 Level I or Level II trauma centers throughout the state of Illinois. The information is obtained and entered at the treating hospitals. Motorcycle trauma patients were identified by external cause of injury codes (International Classification of Disease, revision 9 [ICD-9] E-codes 811-823) and extracted from the trauma registry. The sample was then divided into three groups based on helmet status as recorded in the registry (present, absent, or unknovm/not recorded), and demographic variables were evaluated for the entire motorcycle trauma patient population. These included age, gender, race, position on the motorcycle (driver or passenger), location of the crash (urban or rural), and presence of significant spinal injury (defined as Abbreviated Injury Score [AIS] of 2 or more). The population was then divided into two groups based on presence or absence of significant head injury (AIS, of 2 or more) and compared with respect to number of days spent in the ICU, number of fatalities, and health care costs. The significant head injuries were also categorized as mild (AIS, 2 or more) or serious (AIS, 3 or more), and the serious category was subdivided into severe (AIS, of 3 more; eg, intracranial bleed or major skull fracture) and critical (AIS, 5 or more) head injury. Patients with no, mild, severe, and critical head injury were then evaluated with respect to helmet use.
Table 2.
Age distribution by helmet status. Age (Years)
No. Without Helmets (%)*
No. With Helmets (%)t
16 and younger 17-21 22-34 35-44 45-54 55 and older
33 (4.8) 144 (20.9) 315 (45.7) 35 (19.6) 43 (6.2)
12 (5.4)
19 (2.8)
11 (5.0)
Total
689 (100.0)
222 (100.0)
37 (16.7) 98 (44.1) 34 (15.3) 30 (13,5)
Mean _+SD:"29.2_+10.8; t31.5_+12.5. P<.O01. P<.05.
ANNALS OF EMERGENCY MEDICINE
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MOTORCYCLE TRAUMA
Orsay et a~
The cost variables were hospital charges and primary payer source, which was categorized as public, private, or self-pay funds. Hospital charges were used as an estimate of health care costs. The hospital charges included charges billed to the patient by the institution. Professional fees, rehabilitation costs, and charges for subsequent inpatient or outpatient 'visits were not included. Descriptive and statistical analyses were done with the use of DBase IV and EpiInfo database and statistical packages. A P value of .05 or less was considered statistically significant. RESULTS
A total of 1,231 motorcycle trauma patients was entered into the trauma registry during the 18-month period from July 1, 1991, through December 31, 1992. Of these, 689 (56.0%) were nonhelmeted and 222 (18.0%) were helmeted. In 320 (26.0%), helmet status at the time of the crash was unknown. Among these three groups of patients, there were no statistically significant differences with regard to age, gender, race, position on the motorcycle (driver or passenger), or location of the crash (urban or rural) (Table 1). After elimination of those patients for whom the helmet status was unknown, 911 injured motorcyclists remained for analysis. Although the mean age of the helmeted patients was only moderately greater than that of the nonhelrneted patients (31.5 versus 29.2 years), this difference was significant because of the distribution of ages in the two groups (Table 2). Both groups were overwhelmingly male and white, and there was no difference in hehnet use between drivers and passengers (Table 1). Information on specific injuries was entered into the database for 819 patients. Striking differences (P<.001) were found :in the incidences of head injury (Table 3).
Motorcyclists with head injury were more than twice as likely not to have been wearing a helmet than those without head injury (odds ratio [OR], 2.41; 95% confidence interval [CI], 1,7 to 3.45, P<.001). Furthermore, motorcyclists with serious head injury (AIS, 3 or more) were more than twice as likely not to have been wearing a helmet than those with mild or no head injury (OR, 2.33; 95% CI, 1.38 to 4.11, P<.001). Of the 28 motorcyclists who suffered critical head injuries (AIS, 5 or more) only 3 (10.7%) were helmeted; however, this difference did not meet the criterion for significance (OR, 2.8; 95% CI, .84 to 14.64, P=.08). Forty-one patients died, 10 of whom were helmeted and 31 of whom were not (NS). Of patients who sustained significant spinal injury (n=58), 13.8% were helmeted, compared with 25.5% of patients who did not sustain such injuries (n=761). These spinal injuries ranged from simple vertebral fractures to fractures with complete transection of the spinal cord. Spinal injury was more likely to be associated with lack of helmet use (%2=3.97; P=.046; OR, 2.14; 95% CI, 0.98 to 5.31). A disproportionate share of ICU days were used by the seriously head-injured motorcyclists. Although only 9.4% of the helmeted patients sustained a serious head injury, these patients used 28.1% of the helmeted patients' ICU days. This disparity was even more pronounced for the nonhelmeted patients: the 19.4% of nonhelmeted patients who sustained a serious head injury used more than half (702, or 58.9%) of the nonhelmeted patients' ICU days (Figure 1). Figure 1,
Percentage of motorcycle trauma patients sustaining serious head injuries (AIS of 3 or more), along with percentages of hospital charges and ICU days used by these patients.
70-
% of Patients []
Injury Group No head injury Significant head injury (AIS, 3 or more) Mild head injury (AIS, 2 or mot#) Total
26:4
50-
No. Without Helmets (%)
No. With Helmets (%)
302 (48.9) 120 (19.4)
141 (69.8) 19 (9.4)
195 (31.6)
42 (20.8)
617 (99.9)
202 (100.1)
P<,O01.
ANNALS OF EMERGENCY MED{CINE
58.9%
Hospital Charges
Incidence of head injury by helmet status.
OCTOBER 1995
Proportionof Sample
60-
Table 3.
[]
ICU Days
4030-
28.1%
lO o
With Helmets
Without Helmets
45 7
MOTORCYCLE T R A U M A Orsay et al
I
The average hospital charges for the seriously headinjured motorcyclists were almost three times those of motorcyclists without head injury: $q3,214 versus $15,528 (Figure 2). The greater proportion of hospital charges generated by motorcyclists who sustained severe or critical head injury was in line with the disproportionate ICU days used by these patients. Helmeted motorcyclists with serious head injuries represented only 9.4% of all helmeted motorcyclists in this sample, yet they generated 24.1% of the hospital charges for their group. The nonhelmeted motorcyclists with serious head injury represented 19.4% of all nonhelmeted patients but generated 43.2% of the hospital charges (see Figure 1). Source of payment differences between the two groups approached significance (P=.07). Of the helmeted patients, 66.2% had private insurance, compared with 57.7% of the nonhelmeted patients. Twenty-seven (12.7%) of the helmeted patients paid with public funds (public aid, Medicare, and others), compared with 96 (14.5%) of the nonhelmeted patients. Of the helmeted patients, 21.1% were in the self-pay category, compared with 27.8% of the nonhelmeted (Table 4). DISCUSSION
The toll of motorcycle trauma in states without helmet legislation has not yet been fully appreciated. States with low helmet-use rates (such as Illinois) may suffer the effects of motorcycle trauma more severely than states Figure 2.
Average hospital charges for seriously injured motorcycle trauma patients versus those for patients without head injury. Thousands of Dollars 50$43214
I
with comprehensive motorcycle helmet legislationand high rates of helmet use. This study represents the most comprehensive analysis of motorcycle trauma in the state of Illinois to date. Illinois is unique in that it has an organized trauma system that includes the entire state and an ongoing trauma registry covering this coordinated emergency medical system. The large database generated allows for a larger and more complete sample than can be gathered from a single or a selected few trauma centers. Our analysis of the data is consistent with previously published literature on motorcycle trauma. 5-22 We found that helmet use is associated with a decrease in both the incidence of head injuries and their severity. In contrast, nonhelmeted patients were more than twice as likely to sustain serious head injury. The cost of hospital care for a motorcyclist without head injuries in this study was about one third of that for a motorcyclist with a serious head injury. Our findings are corroborated by data previously published for states that have enacted helmet laws and, in some cases, repealed and later re-enacted helmet laws. 6,12,23,24 Opponents of helmet legislation often claim that motorcycle helmets actually increase the incidence of spinal injury. Examination of our data contradicts this belief. We found a statistically significant decrease in the incidence of significant spinal injuries (AIS of 2 or more) among helmeted patients. However, the significance of this association is marginal and, in reality, there may be no link at all. 6,25
There are important limitations to our database. The trauma registry contains information only on acutely, seriously injured patients treated at level I or level II trauma centers. Excluded are the minimally injured, those who never seek (or who refuse) care anywhere, those treated and released from an emergency department, and those treated and admitted to a hospital that is not a trauma center. Motorcyclists who die at the scene of the crash and
40-
Table 4.
Payer status by helmet status.
30
20-
$15,528
No Headlnjuw
458
Payer Status
Severe Head Injury
No. Without Helmets (%)
No. With Helmets (%)
Public funds Private insurance Self pay
96 382 184
(14.5) (57.7) (27.8)
27 141 45
(12.7) (66.2) (21.1)
Total
662
(100.0)
213
(100.0)
P-.07.
ANNALS OF EMERGENCYMEDICINE 26:4 QCTOBER1995
MOTORCYCLE T R A U M A Orsay et aI
are transported directly to a morgue are also not included. In addition, the registry contains only medical and financial data. Police crash reports, which contain information on estimated speeds, crash types, and road conditions, are not included. These variables could also affect the outcomes studied here. The IDPH Trauma Registry contained information on a total of 782 motorcycle crashes that resulted in treatment of motorcyclists at an Illinois level I or level II trauma center between July 1, 1991, and July 1, 1992. However, the Illinois Department of Transportation's 1991 Illinois Crash Facts and Statistics 26 reported a total of 4,587 motorcycle crashes in a similar 1-year period (January 1, 1991, to December 31, 1991). This total included 109 motorcycle fatalities. Our analysis represents the acute phase of treatment only: the characteristics of those patients whose needs required transfer to long-term health and rehabilitative care are also absent from the registry. The absence of these patients may have biased the data, as has been noted in other studies, 13,2r,29 to a degree that is not known. Furthermore, the data in the trauma registry are not consistent across the state. The state trauma system is divided into regions, each of which defines its own triage criteria to determine which patients are sent to a trauma center and which are sent to other hospitals. However, even with these restrictions, the IDPH Trauma Registry represents the most comprehensive and up-to-date database available. The number of motorcycle trauma patients with an unknown helmet status (26%) seems disturbingly high. Previously published medical literature also reported high rates for unknown helmet use, from 13% 5 to 65%. s Clearly, mor e complete information regarding helmet use would lead to a more thorough understanding of motorcycle trauma~ Taxpayers bear a significant proportion of the health care costs incurred by those who are insured through public funds or who have no insurance. A trend toward absence of private health insurance was noted among nonhelmeted motorcyclists. The same motorcyclists (nonhelmeted) were more likely to sustain the most costly type of trauma: serious head injury. If nonhelmeted patients had experienced the same rate of serious head injury as those who wore a helmet, 62 fewer such cases would have occurred. Given the average hospital charges for seriously head-injured motorcyclists of $43,214, as much as $1,716,532 m initial hospital charges would have been saved by the presence of helmets. Additional funds would have been saVed for those who subsequently required
OCTOBER 1995 26:4
ANNALS OF EMfiRGENCY MEDICINE
transfer to a rehabilitation facility. Millions more dollars would have been saved over the lifetimes of these nonhelmeted, head-injured patients. Motorcycle crash victims are usuaIly young, have no other medical illnesses, and can survive for many more years with a serious head injur;¢ Enormous costs are generated during their lifetimes for ongoing medical care and rehabilitative services. As startling as these figures are, they are based on only 62 fewer projected serious head injuries. The 1992 Illinois Traffic Crash Facts and Statistics reported 104 motorcycle fatalities and 3,228 injuries for that single year. ~ CONCLUSION
This evaluation of motorcycle-related injury from the IDPH Trauma Registry shows that lack of helmet use by motorcyclists is associated with an increased incidence of serious head injury. Motorcycle trauma patients with serious head injuries use a significantly greater proportion of ICU days and health care charges than those with mild or no head injury. REFERENCES 1. FlemingA (ed): FatafityFacts 1993. insurance Institute for HighwaySafety,July 1993. 2. FatalAccident Reporting System I991. Washington DC, US Departmentof Transportation, 1991. 3. 199I Motorcycle Fatal CrashFacts.Washington DC, National Centerfor Statistics and Analysis, US Departmentof Transportation, National HighwayTraffic Safety Administration, 1992. 4. 1992Illinois CrashFactsand Statistics. Illinois Departmentof Transportation, Division of Traffic Safety, 1992. 5. Offner PJ, Rivara FP, Meier RV: The impact of motorcycle helmet use. J Trauma1992;32:636642. 9. Muelleman RL, Minek EJ, Co]locottPE: Motorcyclecrash injuries and costs: Effects of a reenacted comprehensivehelmet use law. Ann EmergMad1992;21:266-271. 7. McSwain NE, BellesA: Motorcyclehelmets: Medical casts and the law. J Trauma 1990;30:1189-1199. 8. RomanoPS, Mcoughlin E: Helmet use and fatal motorcycle injuries in California, 1987-1988. J Head TraumaRehabfl 1991;2:21-37. 9. Sosin DM, Sacks JJ, Holmgran P: Head injury-associated deathsfrom motorcyclecrashes. JAMA 1990;264:2395-2399. 10. Sosin DM, SacksJJ: Motorcycle-helmetuse laws and head injury prevention. JAMA 1992;267:1649-1651. 11. May C, Morabito D: Motorcycle helmet use, incidence of head injury, and cost of hospitalizatic n. J EmergNuts 1989;15:839- 892. 12. CopesWS, Dickman FB, Champion HR, et al: Motorcycle injuries: An MTOSperspective, in 35th Annual Proceedings."Association for the Advancement of Automotive Medicine, October79, 1991. 13. Rutledge R, Stutts, J, Foil B, et al: The associationof helmet use with the outcomeof motorcycle crash injury when controlling for crash/injury severity. AccidAnal Prey 1993;25:347-353. 14. BraddockM, SchwartzR, Lapidus G, et al: A population-basedstudy of motorcycleinjury and cost. Ann EmergMad 1992;21:273- 277.
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15. Murdock MA, Waxman K: Helmet use improvesoutcomesafter motorcycleaccidents. West J Mad 1991;155:370-372. 16. Fleming NS, BeckerER:The impact of the Texas 1989 motorcyclehelmet law and headrelated fatalities, severeinjurLes,and overall injuries. Mad Care 1992;30:632-645.
I
Reprint no. 47/1166979 Address for reprints: Elizabeth Orsay, MD
17. Rivara FF,Dicker BG: The public cost of motorcycletrauma. JAMA 1988;260:221-223.
Program in EmergencyMedicine
18. ShankarBS. RamzyAI, SaderstromCA, et el: HeLmetusa, patternsof injury, medical outcome, and costs among motorcycledrivers in Maryland AccidAnalPrev1992;24:385-396,
Universityef Illinoisat Chicago
19, Kelly P, SansonT, StrangeT, at el: A prospectivestudy of the impact of helmet usageon motorcycletrauma. Ann EmergMed / 991;20:852-850.
Chicago, Illinois60612-7354
1819 West Polk Street, M/C 724
20. Lloyd LE. Lauderda/eM, BetzTG: Motorcycledeathsand iniuries in Texas:Helmetsmake a difference. Tax Med 1987;81:30- 35. 21. McSwain NE Jr, PetrucelLiE: Medical consequencesof motorcycle helmet nonusage.J Trauma1984;24:233-236. 22. Bachulis BL, et el: Patternsof injury in helmetedand nonhelmetedmotorcyclLsts,Am J Surfl 1988;155:708-711. 23. Hertz ES: The Effects of Helmet Law Repeal on Motorcycle Fatalities: A Four YearStudy. Washington DO, US Departmentof Transportation, National HighwayTraffic Safety Administration, Septembert989. 24. Motorcycle helmet laws: Questionsend answers. Injury Prevention Network Newsletter, 1991;6:1-15. 25. OrsayEM, Muelleman RL, PetersonTD, et el: Motorcyclehelmets and spinal injuries: Dispelling the myth. Ann EmargMed1994;23:802-806. 26. I991 Illinois CrashFactsand Statistics. Illinois Departmentof Transportation, Division of Traffic Safety, 1991. 27. PayneSR,Waller J: Trauma registry and trauma center biases in injury research.J Trauma 1989;29:424-429. 28. PollockDA, McClain PW: Trauma registries: Current status and future prospects.JAMA 1989;262:2280-2283.
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Motorcycle Trauma in the State of Illinois: Analysis of the Illinois Department of Public Health Trauma Registry From the Department of Emergency Medicine, University of Illinois at Chicago*, and the Illinois Department of Public Health.i
Elizabeth Orsay, MD* Janet A Holden, PhD* John Williams, MD* John R Lumpkin,MD, MPH*
Receivedfor publication June I5, 1994. Revisions received November 8, 1994, and February 27, 19q5. Acceptedfor publication March 13, 1995.
Study objective: Toassess the current morbidity and mortality of motorcycle trauma in the state of Illinois and, specifically, to assess the incidence and cost of head injury to motorcycle crash patients according to their helmet use.
Supported by a g~antfrom the Illinois Department of Transportation.
Design: Retrospective, cross-sectional examination of the Illinois Department of Public Health Trauma Registry, for which data are available from July 1, 1991, through December 31, 1992. Data are collected from all hospitals designated as Level I or Level II trauma centers in Illinois.
Copyright © by the American College of Emergency Physicians.
Participants: All patients involved in motorcycle crashes and subsequently taken to a Level I or Level II trauma center in Illinois and entered into the trauma registry during the period studied. Results: Head injury, spinal injury, helmet use, demographic data, hospital charges, days in ICU, and source of payment were selected as outcome measures. During the 18-month study period, 1,231 motorcycle trauma patients were entered into the trauma registry. Eighteen percent were helmeted and 56.0% were nonhelmeted. In 26.0% the helmet status at the time of the crash was unknown. Thirty percent of the helmeted patients sustained head injury and 4% sustained spinal or vertebral injury, compared with 51% and 8%, respectively, for nonhelmeted patients. Nonhelmeted patients were significantly more likely to sustain severe (Abbreviated Injury Score [AIS], 3 or more) or critical (AIS, 5 or more) head injury. Patients with these serious head injuries incurred almost three times the hospital charges and used a disproportionately larger share of ICU days than those with mild or no head injuries. There was a trend toward greater use of public funds or self-pay status (no insurance) for payment of hospital charges in nonhelmeted patients. Conclusion: Motorcycle helmet nonuse was associated with an increased incidence of serious head injury. Motorcycle trauma patients with severe or critical head injuries used a significantly greater proportion of ICU days and hospital charges than those with mild or no head injuries.
OCTOBER 1995
26:4
ANNALS OF EMERGENCY MEDICINE
4 55
MOTORCYCLE T R A U M A Orsay et aI
[Orsay E, Holden JA, Williams J, Lumpkin, JR: Motorcycle trauma in the state of Illinois: Analysis of the Illinois Department of Public Health Trauma Registry. Ann EmergMedOctober 1995;26:455-460.]
INTRODUCTION Motorcycle crashes account for a disproportionate share of the deaths and disabilities that result from motor vehicle crashes. In 1991, there were 65 deaths per 100,000 motorcycles nationwide, compared with 18 per 100,000 passenger cars; the death rate per vehicle mile traveled among motorcycle riders is 21 times the death rate per vehicle mile traveled in passenger cars. >3 In Illinois in 1992, there were 3,228 motorcycle injuries and 104 fatalities. 4 Millions of dollars were spent for the acute health care expenses of injured motorcyclists in 1992 in Illinois, and many millions more will be spent to provide for their long-term health and rehabilitation. Illinois is one of only three states without any motorcycle helmet legislation. We analyzed data from the Illinois Department of Public Health (IDPH) Trauma Registry to more accurately assess the toll of motorcycle trauma in Illinois. This is the first study to evaluate the data from this trauma registry for head and spinal injuries resulting from motorcycle crashes, and it provides a more thorough analysis of the human and monetary costs of such injuries in our state.
Table 1.
Comparison of trauma registry cases by helmet status and demographic characteristics. No Helmet (n=689)
Helmet (n=222)
Unknown (n=320)
Mean age (years)
29.2
31.5
29.8
Sex (%) Male Female
87.2
87.8
85.6
Characteristic
12.8
12.2
14.4
Race (°/o) White Black Other Unknown
87.5 6.2 4.7 1.6
89.6 5.5 2.4 2.7
84.3 10.0
Position (%) Driver Passenger
84,2 15.8
85.1 14.9
88.4 11.6
Lecation (%) Urban Rural Unknown
4 56
61.8 34.4 3.8
53.2 41.8 5.0
4.1 1,6
56.5 37.3 6.2
MATERIALS
AND METHODS
The state of Illinois has a regionalized trauma care system that covers the entire state. The IDPH Trauma Registry was developed by and is maintained by the Illinois Department of Public Health. Data collection began in July of 1991, and reformation through December of 1992 is available for analysis. The registry contains medical and financial information on injured motorcyclists treated at any of 73 Level I or Level II trauma centers throughout the state of Illinois. The information is obtained and entered at the treating hospitals. Motorcycle trauma patients were identified by external cause of injury codes (International Classification of Disease, revision 9 [ICD-9] E-codes 811-823) and extracted from the trauma registry. The sample was then divided into three groups based on helmet status as recorded in the registry (present, absent, or unknovm/not recorded), and demographic variables were evaluated for the entire motorcycle trauma patient population. These included age, gender, race, position on the motorcycle (driver or passenger), location of the crash (urban or rural), and presence of significant spinal injury (defined as Abbreviated Injury Score [AIS] of 2 or more). The population was then divided into two groups based on presence or absence of significant head injury (AIS, of 2 or more) and compared with respect to number of days spent in the ICU, number of fatalities, and health care costs. The significant head injuries were also categorized as mild (AIS, 2 or more) or serious (AIS, 3 or more), and the serious category was subdivided into severe (AIS, of 3 more; eg, intracranial bleed or major skull fracture) and critical (AIS, 5 or more) head injury. Patients with no, mild, severe, and critical head injury were then evaluated with respect to helmet use.
Table 2.
Age distribution by helmet status. Age (Years)
No. Without Helmets (%)*
No. With Helmets (%)t
16 and younger 17-21 22-34 35-44 45-54 55 and older
33 (4.8) 144 (20.9) 315 (45.7) 35 (19.6) 43 (6.2)
12 (5.4)
19 (2.8)
11 (5.0)
Total
689 (100.0)
222 (100.0)
37 (16.7) 98 (44.1) 34 (15.3) 30 (13,5)
Mean _+SD:"29.2_+10.8; t31.5_+12.5. P<.O01. P<.05.
ANNALS OF EMERGENCY MEDICINE
26:4
OCTOBER 1995
MOTORCYCLE TRAUMA
Orsay et a~
The cost variables were hospital charges and primary payer source, which was categorized as public, private, or self-pay funds. Hospital charges were used as an estimate of health care costs. The hospital charges included charges billed to the patient by the institution. Professional fees, rehabilitation costs, and charges for subsequent inpatient or outpatient 'visits were not included. Descriptive and statistical analyses were done with the use of DBase IV and EpiInfo database and statistical packages. A P value of .05 or less was considered statistically significant. RESULTS
A total of 1,231 motorcycle trauma patients was entered into the trauma registry during the 18-month period from July 1, 1991, through December 31, 1992. Of these, 689 (56.0%) were nonhelmeted and 222 (18.0%) were helmeted. In 320 (26.0%), helmet status at the time of the crash was unknown. Among these three groups of patients, there were no statistically significant differences with regard to age, gender, race, position on the motorcycle (driver or passenger), or location of the crash (urban or rural) (Table 1). After elimination of those patients for whom the helmet status was unknown, 911 injured motorcyclists remained for analysis. Although the mean age of the helmeted patients was only moderately greater than that of the nonhelrneted patients (31.5 versus 29.2 years), this difference was significant because of the distribution of ages in the two groups (Table 2). Both groups were overwhelmingly male and white, and there was no difference in hehnet use between drivers and passengers (Table 1). Information on specific injuries was entered into the database for 819 patients. Striking differences (P<.001) were found :in the incidences of head injury (Table 3).
Motorcyclists with head injury were more than twice as likely not to have been wearing a helmet than those without head injury (odds ratio [OR], 2.41; 95% confidence interval [CI], 1,7 to 3.45, P<.001). Furthermore, motorcyclists with serious head injury (AIS, 3 or more) were more than twice as likely not to have been wearing a helmet than those with mild or no head injury (OR, 2.33; 95% CI, 1.38 to 4.11, P<.001). Of the 28 motorcyclists who suffered critical head injuries (AIS, 5 or more) only 3 (10.7%) were helmeted; however, this difference did not meet the criterion for significance (OR, 2.8; 95% CI, .84 to 14.64, P=.08). Forty-one patients died, 10 of whom were helmeted and 31 of whom were not (NS). Of patients who sustained significant spinal injury (n=58), 13.8% were helmeted, compared with 25.5% of patients who did not sustain such injuries (n=761). These spinal injuries ranged from simple vertebral fractures to fractures with complete transection of the spinal cord. Spinal injury was more likely to be associated with lack of helmet use (%2=3.97; P=.046; OR, 2.14; 95% CI, 0.98 to 5.31). A disproportionate share of ICU days were used by the seriously head-injured motorcyclists. Although only 9.4% of the helmeted patients sustained a serious head injury, these patients used 28.1% of the helmeted patients' ICU days. This disparity was even more pronounced for the nonhelmeted patients: the 19.4% of nonhelmeted patients who sustained a serious head injury used more than half (702, or 58.9%) of the nonhelmeted patients' ICU days (Figure 1). Figure 1,
Percentage of motorcycle trauma patients sustaining serious head injuries (AIS of 3 or more), along with percentages of hospital charges and ICU days used by these patients.
70-
% of Patients []
Injury Group No head injury Significant head injury (AIS, 3 or more) Mild head injury (AIS, 2 or mot#) Total
26:4
50-
No. Without Helmets (%)
No. With Helmets (%)
302 (48.9) 120 (19.4)
141 (69.8) 19 (9.4)
195 (31.6)
42 (20.8)
617 (99.9)
202 (100.1)
P<,O01.
ANNALS OF EMERGENCY MED{CINE
58.9%
Hospital Charges
Incidence of head injury by helmet status.
OCTOBER 1995
Proportionof Sample
60-
Table 3.
[]
ICU Days
4030-
28.1%
lO o
With Helmets
Without Helmets
45 7
MOTORCYCLE T R A U M A Orsay et al
I
The average hospital charges for the seriously headinjured motorcyclists were almost three times those of motorcyclists without head injury: $q3,214 versus $15,528 (Figure 2). The greater proportion of hospital charges generated by motorcyclists who sustained severe or critical head injury was in line with the disproportionate ICU days used by these patients. Helmeted motorcyclists with serious head injuries represented only 9.4% of all helmeted motorcyclists in this sample, yet they generated 24.1% of the hospital charges for their group. The nonhelmeted motorcyclists with serious head injury represented 19.4% of all nonhelmeted patients but generated 43.2% of the hospital charges (see Figure 1). Source of payment differences between the two groups approached significance (P=.07). Of the helmeted patients, 66.2% had private insurance, compared with 57.7% of the nonhelmeted patients. Twenty-seven (12.7%) of the helmeted patients paid with public funds (public aid, Medicare, and others), compared with 96 (14.5%) of the nonhelmeted patients. Of the helmeted patients, 21.1% were in the self-pay category, compared with 27.8% of the nonhelmeted (Table 4). DISCUSSION
The toll of motorcycle trauma in states without helmet legislation has not yet been fully appreciated. States with low helmet-use rates (such as Illinois) may suffer the effects of motorcycle trauma more severely than states Figure 2.
Average hospital charges for seriously injured motorcycle trauma patients versus those for patients without head injury. Thousands of Dollars 50$43214
I
with comprehensive motorcycle helmet legislationand high rates of helmet use. This study represents the most comprehensive analysis of motorcycle trauma in the state of Illinois to date. Illinois is unique in that it has an organized trauma system that includes the entire state and an ongoing trauma registry covering this coordinated emergency medical system. The large database generated allows for a larger and more complete sample than can be gathered from a single or a selected few trauma centers. Our analysis of the data is consistent with previously published literature on motorcycle trauma. 5-22 We found that helmet use is associated with a decrease in both the incidence of head injuries and their severity. In contrast, nonhelmeted patients were more than twice as likely to sustain serious head injury. The cost of hospital care for a motorcyclist without head injuries in this study was about one third of that for a motorcyclist with a serious head injury. Our findings are corroborated by data previously published for states that have enacted helmet laws and, in some cases, repealed and later re-enacted helmet laws. 6,12,23,24 Opponents of helmet legislation often claim that motorcycle helmets actually increase the incidence of spinal injury. Examination of our data contradicts this belief. We found a statistically significant decrease in the incidence of significant spinal injuries (AIS of 2 or more) among helmeted patients. However, the significance of this association is marginal and, in reality, there may be no link at all. 6,25
There are important limitations to our database. The trauma registry contains information only on acutely, seriously injured patients treated at level I or level II trauma centers. Excluded are the minimally injured, those who never seek (or who refuse) care anywhere, those treated and released from an emergency department, and those treated and admitted to a hospital that is not a trauma center. Motorcyclists who die at the scene of the crash and
40-
Table 4.
Payer status by helmet status.
30
20-
$15,528
No Headlnjuw
458
Payer Status
Severe Head Injury
No. Without Helmets (%)
No. With Helmets (%)
Public funds Private insurance Self pay
96 382 184
(14.5) (57.7) (27.8)
27 141 45
(12.7) (66.2) (21.1)
Total
662
(100.0)
213
(100.0)
P-.07.
ANNALS OF EMERGENCYMEDICINE 26:4 QCTOBER1995
MOTORCYCLE T R A U M A Orsay et aI
are transported directly to a morgue are also not included. In addition, the registry contains only medical and financial data. Police crash reports, which contain information on estimated speeds, crash types, and road conditions, are not included. These variables could also affect the outcomes studied here. The IDPH Trauma Registry contained information on a total of 782 motorcycle crashes that resulted in treatment of motorcyclists at an Illinois level I or level II trauma center between July 1, 1991, and July 1, 1992. However, the Illinois Department of Transportation's 1991 Illinois Crash Facts and Statistics 26 reported a total of 4,587 motorcycle crashes in a similar 1-year period (January 1, 1991, to December 31, 1991). This total included 109 motorcycle fatalities. Our analysis represents the acute phase of treatment only: the characteristics of those patients whose needs required transfer to long-term health and rehabilitative care are also absent from the registry. The absence of these patients may have biased the data, as has been noted in other studies, 13,2r,29 to a degree that is not known. Furthermore, the data in the trauma registry are not consistent across the state. The state trauma system is divided into regions, each of which defines its own triage criteria to determine which patients are sent to a trauma center and which are sent to other hospitals. However, even with these restrictions, the IDPH Trauma Registry represents the most comprehensive and up-to-date database available. The number of motorcycle trauma patients with an unknown helmet status (26%) seems disturbingly high. Previously published medical literature also reported high rates for unknown helmet use, from 13% 5 to 65%. s Clearly, mor e complete information regarding helmet use would lead to a more thorough understanding of motorcycle trauma~ Taxpayers bear a significant proportion of the health care costs incurred by those who are insured through public funds or who have no insurance. A trend toward absence of private health insurance was noted among nonhelmeted motorcyclists. The same motorcyclists (nonhelmeted) were more likely to sustain the most costly type of trauma: serious head injury. If nonhelmeted patients had experienced the same rate of serious head injury as those who wore a helmet, 62 fewer such cases would have occurred. Given the average hospital charges for seriously head-injured motorcyclists of $43,214, as much as $1,716,532 m initial hospital charges would have been saved by the presence of helmets. Additional funds would have been saVed for those who subsequently required
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ANNALS OF EMfiRGENCY MEDICINE
transfer to a rehabilitation facility. Millions more dollars would have been saved over the lifetimes of these nonhelmeted, head-injured patients. Motorcycle crash victims are usuaIly young, have no other medical illnesses, and can survive for many more years with a serious head injur;¢ Enormous costs are generated during their lifetimes for ongoing medical care and rehabilitative services. As startling as these figures are, they are based on only 62 fewer projected serious head injuries. The 1992 Illinois Traffic Crash Facts and Statistics reported 104 motorcycle fatalities and 3,228 injuries for that single year. ~ CONCLUSION
This evaluation of motorcycle-related injury from the IDPH Trauma Registry shows that lack of helmet use by motorcyclists is associated with an increased incidence of serious head injury. Motorcycle trauma patients with serious head injuries use a significantly greater proportion of ICU days and health care charges than those with mild or no head injury. REFERENCES 1. FlemingA (ed): FatafityFacts 1993. insurance Institute for HighwaySafety,July 1993. 2. FatalAccident Reporting System I991. Washington DC, US Departmentof Transportation, 1991. 3. 199I Motorcycle Fatal CrashFacts.Washington DC, National Centerfor Statistics and Analysis, US Departmentof Transportation, National HighwayTraffic Safety Administration, 1992. 4. 1992Illinois CrashFactsand Statistics. Illinois Departmentof Transportation, Division of Traffic Safety, 1992. 5. Offner PJ, Rivara FP, Meier RV: The impact of motorcycle helmet use. J Trauma1992;32:636642. 9. Muelleman RL, Minek EJ, Co]locottPE: Motorcyclecrash injuries and costs: Effects of a reenacted comprehensivehelmet use law. Ann EmergMad1992;21:266-271. 7. McSwain NE, BellesA: Motorcyclehelmets: Medical casts and the law. J Trauma 1990;30:1189-1199. 8. RomanoPS, Mcoughlin E: Helmet use and fatal motorcycle injuries in California, 1987-1988. J Head TraumaRehabfl 1991;2:21-37. 9. Sosin DM, Sacks JJ, Holmgran P: Head injury-associated deathsfrom motorcyclecrashes. JAMA 1990;264:2395-2399. 10. Sosin DM, SacksJJ: Motorcycle-helmetuse laws and head injury prevention. JAMA 1992;267:1649-1651. 11. May C, Morabito D: Motorcycle helmet use, incidence of head injury, and cost of hospitalizatic n. J EmergNuts 1989;15:839- 892. 12. CopesWS, Dickman FB, Champion HR, et al: Motorcycle injuries: An MTOSperspective, in 35th Annual Proceedings."Association for the Advancement of Automotive Medicine, October79, 1991. 13. Rutledge R, Stutts, J, Foil B, et al: The associationof helmet use with the outcomeof motorcycle crash injury when controlling for crash/injury severity. AccidAnal Prey 1993;25:347-353. 14. BraddockM, SchwartzR, Lapidus G, et al: A population-basedstudy of motorcycleinjury and cost. Ann EmergMad 1992;21:273- 277.
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Reprint no. 47/1166979 Address for reprints: Elizabeth Orsay, MD
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Program in EmergencyMedicine
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Universityef Illinoisat Chicago
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Chicago, Illinois60612-7354
1819 West Polk Street, M/C 724
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