Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic

Long-term impacts of the COVID-19 pandemic on racial and ethnic disparities in motor vehicle crash (MVC) injuries and death are poorly understood. This study aimed to characterize trends and investigate the heterogeneity of MVC-related disparities in North Carolina across several data sources. Crash reports, emergency department visit records, and death certificates from 2018 to 2021 were used to calculate monthly population-rates of MVC-related public health outcomes. We estimated trendlines using joinpoint regression and compared outcomes across racial and ethnic classifications. MVC and MVC-related injury rates declined in conjunction with NC's stay-at-home order, while rates of severe outcomes remained unimpacted. By December 2021 rates of MVC-related outcomes met or exceeded pre-pandemic levels, with the highest rates observed among non-Hispanic Black individuals. Racial and ethnic disparities in MVC-related outcomes remained prevalent throughout the COVID-19 pandemic. These results highlight the importance of a holistic approach to traffic injury surveillance when assessing the impact of MVCs.

Feasibility of linking violent death decedents to prior-month emergency department visits in North Carolina, 2019-2020

OBJECTIVE

Linking data between violent death decedents and other sources can provide valuable insight, highlighting opportunities for prevention of violent injury. This study investigated the feasibility of linking North Carolina Violent Death Reporting System (NC-VDRS) records with North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT) emergency department (ED) visit data to identify prior-month ED visits among this population.

METHODS

NC-VDRS death records from 2019 through 2020 were linked to NC DETECT ED visit data from December 2018 through 2020 using a probabilistic linkage approach. Linkage variables included date of birth, age, sex, zip code and county of residence, date of event (death/ED visit) and mechanism of injury. Potential linkable ED visits were filtered to those occurring in the month prior to death and manually reviewed for validity. Linked records were compared with the NC-VDRS study population to assess linkage performance and generalisability.

RESULTS

Among the 4768 violent deaths identified, we linked 1340 NC-VDRS records to at least one ED visit in the month prior to death. A higher proportion of decedents dying in medical facilities (ED/outpatient, hospital inpatient, hospice or nursing/long-term care facility) linked to a prior-month visit (80%) relative to those dying in other locations (12%). When stratified by place of death, linked decedents demographically resembled the overall NC-VDRS study population.

CONCLUSIONS

Though resource intensive, an NC-VDRS-to-NC DETECT linkage was successful in identifying prior-month ED visits among violent death decedents. This linkage should be leveraged to further analyse ED utilisation prior to violent death, expanding the knowledge base surrounding prevention opportunities for violent injuries.

Structural Racism and Pedestrian Safety: Measuring the Association Between Historical Redlining and Contemporary Pedestrian Fatalities Across the United States, 2010‒2019

Objectives. To examine the association between historical redlining and contemporary pedestrian fatalities across the United States. Methods. We analyzed 2010-2019 traffic fatality data, obtained from the Fatality Analysis Reporting System, for all US pedestrian fatalities linked by location of crash to 1930s Home Owners' Loan Corporation (HOLC) grades and current sociodemographic factors at the census tract level. We applied generalized estimating equation models to assess the relationship between the count of pedestrian fatalities and redlining. Results. In an adjusted multivariable analysis, tracts graded D ("Hazardous") had a 2.60 (95% confidence interval = 2.26, 2.99) incidence rate ratio (per residential population) of pedestrian fatalities compared with tracts graded A ("Best"). We found a significant dose‒response relationship: as grades worsened from A to D, rates of pedestrian fatalities increased. Conclusions. Historical redlining policy, initiated in the 1930s, has an impact on present-day transportation inequities in the United States. Public Health Implications. To reduce transportation inequities, understanding how structurally racist policies, past and present, have an impact on community-level investments in transportation and health is crucial. (Am J Public Health. 2023;113(4):420-428. https://doi.org/10.2105/AJPH.2022.307192).

Database selection matters: A case study in child restraint use and injury patterns using North Carolina motor vehicle traffic crash report and trauma registry data

OBJECTIVE

While proper restraint use is protective against motor traffic vehicle crash (MVTC)-associated morbidity and mortality, it is inconsistently measured across health and MVTC data sources. This project addresses this gap by assessing differences in child restraint measures between two North Carolina (NC) datasets and comparing the utility of these sources to evaluate patterns of child restraint use and associated health outcomes.

METHODS

We analyzed 2018 NC MVTC and NC Trauma Registry (NCTR) data for children ≤15 years old, both separately and as linked MVTC-NCTR records. We calculated mean and standard deviation for continuous variables and frequency and proportion for categorical variables. Among linked records, we compared reported restraint use and performed age-adjusted logistic regression to estimate associations between restraint use and severe injury.

RESULTS

A lower proportion of pediatric MVTC victims were reported as unrestrained in the MVTC (14.7%) versus NCTR (25.8%) data. Among linked MVTC-NCTR records, only 41.3% featured perfect concordance of restraint information between datasets. Among linked records, child restraint was reported for 31.3% of children, while the NCTR data allowed more granular coding of child restraint (30.3% overall), including child booster seat (13.5%), child car seat (8.7%), infant car seat (4.8%), and unrestrained in child car seat (3.4%). Age-adjusted regression analyses of the linked data revealed that lap/shoulder seatbelt use was significantly associated with lower likelihood of severe injury compared to being unrestrained whether informed by MVTC (OR = 0.39; 95% CI: 0.16, 0.93) or NCTR (OR = 0.38; 95% CI: 0.15, 0.96) data. While the association between reported use of a child car seat and severe injury was not statistically significant in the MVTC data (OR = 0.50; 95% CI: 0.19, 1.32), child car seat use reported in the NCTR data revealed a significant association (OR = 0.16; 95% CI: 0.03, 0.93).

CONCLUSIONS

Linked crash and trauma center data allow for identifying important patterns of restraint use among pediatric passengers in MVTCs. Dataset-dependent differences in measuring restraint use have critical public health implications and illustrate the importance of careful dataset selection prior to analysis, as the use of different data sources may impact overall study conclusions.

Examining the Effect of Pedestrian Crashes on Vulnerable Populations in North Carolina

BACKGROUND

Over the last several years, pedestrian fatalities have increased in North Carolina; however, fatalities represent a small proportion of the total number of nonfatally injured pedestrians. Therefore, we linked statewide motor vehicle crash (MVC) and emergency department (ED) visit data to better understand the circumstances and characteristics of pedestrians treated in North Carolina emergency departments (EDs) for injuries related to crashes.

METHODS

We linked information for pedestrians and bicyclists from 2017 North Carolina police-reported MVCs to population-based ED visit data using hierarchical deterministic methods.

RESULTS

We linked 45% of pedestrian crash records to ED visit records (N = 1383 incident ED visits). The rate of pedestrians treated in North Carolina EDs for their injuries was 13.6 ED visits per 100,000 person years. For pedestrian injuries treated in North Carolina EDs, rates (per 100,000 person years in parentheses) were higher among men (15.5) and Black pedestrians (22.7) than women (10.6) and White pedestrians (8.2). Sociodemographic characteristics associated with serious injuries included age, sex, race/ethnicity, and expected source of payment for the ED visit. Crash characteristics associated with serious injuries included posted speed limit, ambient light, number of lanes, and striking vehicle type.

LIMITATIONS

The study involved the use of secondary data, not collected specifically for pedestrian injury surveillance.

CONCLUSIONS

Pedestrian injuries and fatalities place a considerable burden on the population of North Carolina, especially among persons of color and older adults. Injury prevention programs are actively addressing this problem, but more needs to be done.

The impact of the COVID-19 pandemic on the utilization of emergency department services for the treatment of injuries

CONTEXT

The global COVID-19 pandemic has had a major impact on the utilization of healthcare services; however, the impact on population-level emergency department (ED) utilization patterns for the treatment of acute injuries has not been fully characterized.

OBJECTIVE

This study examined the frequency of North Carolina (NC) EDs visits for selected injury mechanisms during the first eleven months of the COVID-19 pandemic.

METHODS

Data were obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), NC's legislatively mandated statewide syndromic surveillance system for the years 2019 and 2020. Frequencies of January - November 2020 NC ED visits were compared to frequencies of 2019 visits for selected injury mechanisms, classified according to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) injury diagnosis and mechanism codes.

RESULTS

In 2020, the total number of injury-related visits declined by 19.5% (N = 651,158) as compared to 2019 (N = 809,095). Visits related to motor vehicle traffic crashes declined by a greater percentage (29%) and falls (19%) declined by a comparable percentage to total injury-related visits. Visits related to assault (15%) and self-harm (10%) declined by smaller percentages. Medication/drug overdose visits increased (10%), the only injury mechanism studied to increase during this period.

CONCLUSION

Both ED avoidance and decreased exposures may have contributed to these declines, creating implications for injury morbidity and mortality. Injury outcomes exacerbated by the pandemic should be addressed by timely public health responses.

Selected characteristics and injury patterns by age group among pedestrians treated in North Carolina emergency departments

OBJECTIVE

The objective of this study was to describe pedestrian demographic characteristics, crash characteristics, selected health outcomes, and injury patterns by age using linked North Carolina (NC) crash-emergency department (ED) visit data for the period October 1, 2010, to September 30, 2015.

METHODS

This was a descriptive epidemiologic study. To examine both crash and health outcomes, NC pedestrian crash records were linked to statewide NC ED visit records using hierarchical deterministic methods. Pearson chi-square tests were used to compare the frequencies of pedestrians treated in NC EDs by sex, race/ethnicity, crash location, rurality, estimated driver speed at impact, ambient light, hospitalization/death, location of injury, and nature of injury, stratified by the following age groups: 0-14, 15-24, 25-64, and ≥65 years.

RESULTS

Most pedestrians treated in NC EDs were male (57.5%), except among adults ≥65 years old (47.5%). Over half of all injured pedestrians aged 0-14 (52.6%) and 15-24 (50.5%) years were Black/African American, and 70.8% of injured pedestrians ≥65 years were white. Among pedestrians aged 25-64 years, no single racial/ethnic group was the majority. Though most pedestrians were injured on trafficways (71.7%) and at speeds ≤35 mph (80.1%), adults ≥65 years were less likely to be involved in on-trafficway crashes (51.0%) and pedestrians aged 15-24 years were more likely to be involved in >35 mph crashes (22.9%) compared to other age groups. Most pedestrians were injured under daylight conditions (56.9%). Regarding selected health outcomes, the highest frequency of hospitalization/death was for pedestrians aged ≥65 years (26.3%), compared to those aged 0-14 years (18.8%) and 15-64 years (12.4%). In terms of location of injury, 0- to 14-year-olds had the highest proportion of head injuries (39.5%), and adults ≥65 years of age had the highest proportion of spinal column/vertebral column (12.6%) and upper extremity injuries (33.2%). For nature of injury, 0- to 14-year-olds had the highest proportion of traumatic brain injuries (11.4%) and superficial wounds and contusions (62.8%). Adults aged ≥65 years had the highest proportion of open wounds/amputations and fractures (16.1%). Adults aged 25-64 years had the highest proportion of strains/sprains/dislocations (18.7%).

CONCLUSIONS

There were considerable differences in demographic characteristics, crash characteristics, frequency of hospitalization/death, and injury patterns by age group. It is important to design streets and implement transportation policies and programs that improve safety for all pedestrians.

Begin risk assessment for falls in women at 45, not 65

The clinical and epidemiological literature provides guidelines for fall prevention starting at age 65; however, the focus on age ≥65 is not evidence based. Therefore, this study examined state-wide North Carolina emergency department visit data to examine the characteristics of falls across the age spectrum, identify the age at which the incidence of fall-related emergency department visits started to increase and determine whether these trends were similar for men and women. We determined that incidence rates of fall-related emergency department visits began to increase in early middle age, particularly for women. Since fall risk assessment and prevention activities should be initiated prior to an injurious fall, we recommend beginning these activities before age 65.

Characteristics of sports and recreation-related emergency department visits among school-age children and youth in North Carolina, 2010-2014

BACKGROUND

Sports and recreational activities are an important cause of injury among children and youth, with sports-related traumatic brain injuries (TBIs) being of particular concern given the developing brain. This paper reports the characteristics of sport and recreation-related (SR) emergency department (ED) visits among school-age children and youth in a statewide population.

METHODS

This study included all injury-related visits made to all North Carolina 24/7 acute-care civilian hospital-affiliated EDs by school-age youth, 5-18 years of age, during 2010-2014 (N = 918,662). Population estimates were based on US decennial census data. Poisson regression methods were used to estimate incidence rates and rate ratios.

RESULTS

During the five-year period, there were 767,075 unintentional injury-related ED visits among school-age youth, of which 213,518 (27.8%) were identified as SR injuries. The average annual absolute number and incidence rate (IR) of SR ED visits among school-age youth was 42,704 and 2374.5 ED visits per 100,000 person-years (95% confidence interval [CI], 2364.4-2384.6), respectively. In comparison to other unintentional injuries among school-age youth, SR ED visits were more likely to be diagnosed with an injury to the upper extremity (Injury Proportion Ratio [IPR] = 1.28; 95% CI, 1.27-1.29), the lower extremity (IPR = 1.14; 95% CI, 1.13-1.15), and a TBI or other head/neck/facial injury (IPR = 1.12; 95% CI, 1.11-1.13). Among ED visits made by school-age youth, the leading cause of SR injury was sports/athletics played as a group or team. The leading cause of team sports/athletics injury was American tackle football among boys and soccer among girls. The proportion of ED visits diagnosed with a TBI varied by age and sex, with 15-18 year-olds and boys having the highest population-based rates.

CONCLUSIONS

Sports and recreational activities are an important component of a healthy lifestyle, but they are also a major source of injury morbidity among school-age youth. Physical activity interventions should take into account sex and age differences in SR injury risk.

Snakebites Treated in North Carolina Emergency Departments, October 2013-September 2015

INTRODUCTION

North Carolina (NC) is home to more than 30 species of indigenous venomous and nonvenomous snakes. Snakebites can cause debilitating and potentially fatal injuries. However, there is a lack of current information available describing the incidence of snakebites in NC. Therefore, we performed this study of snakebites treated in NC emergency departments (EDs) using the statewide syndromic surveillance system, the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT).

METHODS

This was a descriptive epidemiologic study characterizing NC ED visits collected by NC DETECT between October 1, 2013 and September 30, 2015 with an assigned International Classification of Diseases, 9th Revision, Clinical Modification code or keyword indicating a snakebite.

RESULTS

Over the 2-year period, the absolute count of snakebite-related ED visits was 2080 visits with an incidence rate of 10.4 visits per 100 000 person-years (95% confidence interval: 10.0-10.9). The frequency of snakebite was highest during the summer months and evening hours. Men had higher incidence rates of snakebite-related ED visits than women, and residents of the Coastal Plain geographic region of NC had higher incidence rates than persons in other regions.

CONCLUSIONS

The current study indicated that snakebites are common injuries treated at NC EDs, with a strong seasonal and geographic component. Additional research is needed to further characterize the circumstances associated with snakebites for the development of preventive measures and public health education.

Use of syndromic surveillance data to monitor poisonings and drug overdoses in state and local public health agencies

BACKGROUND

The incidence of poisoning and drug overdose has risen rapidly in the USA over the last 16 years. To inform local intervention approaches, local health departments (LHDs) in North Carolina (NC) are using a statewide syndromic surveillance system that provides timely, local emergency department (ED) and Emergency Medical Services (EMS) data on medication and drug overdoses.

OBJECTIVE

The purpose of this article is to describe the development and use of a variety of case definitions for poisoning and overdose implemented in NC's syndromic surveillance system and the impact of the system on local surveillance initiatives.

DESIGN, SETTING, PARTICIPANTS

Thirteen new poisoning and overdose-related case definitions were added to NC's syndromic surveillance system and LHDs were trained on their use for surveillance purposes. Twenty-one LHDs were surveyed on the utility and impact of these new case definitions.

RESULTS/CONCLUSIONS

Ninety-one per cent of survey respondents (n = 29) agreed or strongly agreed that their ability to access timely ED data was vital to inform community-level overdose prevention work. Providing LHDs with access to local, timely data to identify pockets of need and engage stakeholders facilitates the practice of informed injury prevention and contributes to the reduction of injury incidence in their communities.

Use of diagnosis codes for detection of clinically significant opioid poisoning in the emergency department: A retrospective analysis of a surveillance case definition

BACKGROUND

Although fatal opioid poisonings tripled from 1999 to 2008, data describing nonfatal poisonings are rare. Public health authorities are in need of tools to track opioid poisonings in near real time.

METHODS

We determined the utility of ICD-9-CM diagnosis codes for identifying clinically significant opioid poisonings in a state-wide emergency department (ED) surveillance system. We sampled visits from four hospitals from July 2009 to June 2012 with diagnosis codes of 965.00, 965.01, 965.02 and 965.09 (poisoning by opiates and related narcotics) and/or an external cause of injury code of E850.0-E850.2 (accidental poisoning by opiates and related narcotics), and developed a novel case definition to determine in which cases opioid poisoning prompted the ED visit. We calculated the percentage of visits coded for opioid poisoning that were clinically significant and compared it to the percentage of visits coded for poisoning by non-opioid agents in which there was actually poisoning by an opioid agent. We created a multivariate regression model to determine if other collected triage data can improve the positive predictive value of diagnosis codes alone for detecting clinically significant opioid poisoning.

RESULTS

70.1 % of visits (Standard Error 2.4 %) coded for opioid poisoning were primarily prompted by opioid poisoning. The remainder of visits represented opioid exposure in the setting of other primary diseases. Among non-opioid poisoning codes reviewed, up to 36 % were reclassified as an opioid poisoning. In multivariate analysis, only naloxone use improved the positive predictive value of ICD-9-CM codes for identifying clinically significant opioid poisoning, but was associated with a high false negative rate.

CONCLUSIONS

This surveillance mechanism identifies many clinically significant opioid overdoses with a high positive predictive value. With further validation, it may help target control measures such as prescriber education and pharmacy monitoring.

Enhancing Tabletop X-Ray Phase Contrast Imaging with Nano-Fabrication

X-ray phase-contrast imaging is a promising approach for improving soft-tissue contrast and lowering radiation dose in biomedical applications. While current tabletop imaging systems adapt to common x-ray tubes and large-area detectors by employing absorptive elements such as absorption gratings or monolithic crystals to filter the beam, we developed nanometric phase gratings which enable tabletop x-ray far-field interferometry with only phase-shifting elements, leading to a substantial enhancement in the performance of phase contrast imaging. In a general sense the method transfers the demands on the spatial coherence of the x-ray source and the detector resolution to the feature size of x-ray phase masks. We demonstrate its capabilities in hard x-ray imaging experiments at a fraction of clinical dose levels and present comparisons with the existing Talbot-Lau interferometer and with conventional digital radiography.

Motionless electromagnetic phase stepping versus mechanical phase stepping in x-ray phase-contrast imaging with a compact source

X-ray phase contrast imaging based on grating interferometers detects the refractive index distribution of an object without relying on radiation attenuation, thereby having the potential for reduced radiation absorption. These techniques belong to the broader category of optical wavefront measurement, which requires stepping the phase of the interference pattern to obtain a pixel-wise map of the phase distortion of the wavefront. While phase stepping traditionally involves mechanical scanning of a grating or mirror, we developed electromagnetic phase stepping (EPS) for imaging with compact sources to obviate the need for mechanical movement. In EPS a solenoid coil is placed outside the x-ray tube to shift its focal spot with a magnetic field, causing a relative movement between the projection of the sample and the interference pattern in the image. Here we present two embodiments of this method. We verified experimentally that electromagnetic and mechanical phase stepping give the same results and attain the same signal-to-noise ratios under the same radiation dose. We found that the relative changes of interference fringe visibility were within 3.0% when the x-ray focal spot was shifted by up to 1.0 mm in either direction. We conclude that when using x-ray tube sources, EPS is an effective means of phase stepping without the need for mechanical movement.

The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, 2010-2011

BACKGROUND

Traumatic brain injuries (TBIs) are a leading cause of injury morbidity and mortality in the United States. An estimated 1.7 million TBIs occur each year, and TBIs may lead to severe lifelong disability and death; even mild-to-moderate TBIs may have long-term consequences. North Carolina's population-wide data on TBIs are limited, so it is important to analyze the available data regarding TBI-related emergency department (ED) visits.

METHODS

Statewide data on TBI-related ED visits were obtained from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), an electronic public health surveillance system. Counts and rates were produced by sex, age, county of residence, disposition, mode of transport, and mechanism of injury.

RESULTS

In 2010-2011, there were 140,234 TBI-related ED visits in North Carolina, which yields a rate of 7.3 ED visits per 1,000 person-years. The rate was higher for men (7.9 visits per 1,000 person-years) than for women (6.8 visits per 1,000 person-years). Rates were highest in individuals aged 0-4 years (13.1 visits per 1,000 person-years), 15-19 years (10.6 visits per 1,000 person-years), 75-79 years (11.3 visits per 1,000 person-years), 80-84 years (17.9 visits per 1,000 person-years), and 85 years or older (30.6 visits per 1,000 person-years). TBI-related ED visits were principally the result of falls (39.0%), being struck by a person or object (17.6%), or motor vehicle traffic-related crashes (14.1%).

LIMITATIONS

This study utilizes data collected primarily for administrative purposes, such as hospital billing.

CONCLUSION

TBIs are a common cause of ED visits in North Carolina. These descriptive statistics demonstrate needs for statewide ED surveillance to monitor the incidence of TBIs and for the development of prevention strategies.

Epidemiology of injury and violence in North Carolina

Injury and violence are significant public health problems in the state, on par with other leading causes of deaths. This article reviews the leading causes of injury-associated deaths, hospitalizations, and emergency department visits for North Carolina residents; outlines data resources and policy implications; and facilitates further discussion on injury epidemiology and surveillance needs.

Addressing the escalating public health issue of falls among older adults

The rate of older adult falls has increased dramatically in North Carolina. With screening and intervention, many falls can be prevented. To improve best practices, the Carolina Geriatric Education Consortium and other members of the North Carolina Falls Prevention Coalition have committed resources to train health care professionals in screening and assessment and to develop infrastructure to disseminate evidence-based interventions.

Strain-dependent vascular remodeling phenotypes in inbred mice

We have recently established a mouse model of arterial remodeling in which flow in the left common carotid artery of FVB mice was interrupted by ligation of the vessel near the carotid bifurcation, resulting in a dramatic reduction of the lumen as a consequence of a reduction in vessel diameter and intimal lesion formation. In the present study we applied this model to various inbred strains of mice. Wide variations in the remodeling response with regard to reduction in vessel diameter, intimal lesion formation, lumen area, and medial hypertrophy were found. On carotid artery ligation SJL/J mice revealed the most extensive inward remodeling leading to an approximate 78% decrease in lumen area while lumen narrowing in FVB/NJ mice was largely due to extensive neointima formation as a result of smooth muscle cell (SMC) proliferation. Significant positive remodeling in the contralateral right carotid artery with a >20% increase in lumen area was observed in SM/J and A/J mice. An in vitro comparison of growth properties of SMC isolated from FVB/NJ mice and a strain that exhibited very little SMC proliferation (C3H/HeJ) demonstrated accelerated growth of SMC from FVB/NJ following serum stimulation. In vivo, SMC proliferation in the FVB/NJ strain was preceded by a 37% loss of medial SMC occurring within the 2 days after ligation, however, cell death was not detectable in C3H/HeJ mice. These findings suggest that the mechanisms leading to lumen narrowing in the vascular remodeling process are genetically controlled.