a b s t r a c t

Background: There has been a marked increased in moped use over the past few years. In addition, there has been an increase in moped-related injuries presenting to the emergency department (ED). The objective of this study is to characterize moped-related injuries presenting to US EDs and obtain national estimates of moped injury in- cidence over time.

Methods: Data regarding moped injuries were queried from the National Electronic Injury surveillance System from calendar year 2007 to 2015. Data included diagnosis, body part injured, ED disposition, and patient demo- graphics.

Results: There were an estimated 114 729 moped-related injuries treated in US EDs from 2007 to 2015 (95% con- fidence interval, 102 156-127 302). In addition, there was an increase in the number of moped injuries annually (B = 762.1, P b .01). The average number of moped injuries yearly was 12 748. The mean age was 34 years. Pa- tients between ages 19 and 38 years represented 42% of the study population. Men (74%) and whites (55%) accounted for most of the injured population. Most injuries were stabilized in the ED and discharged home (85%). Approximately 9% of injuries were admitted to the hospital, and fractures constituted 59% of all diagnoses admitted to the hospital. Contusions (27%) and fractures (24%) accounted for most diagnoses. The most common body part injured was the head (16%).

Conclusions: Moped injuries have increased since 2007 and mopeds are associated with severe injuries. Education and reexamination of current moped laws may decrease the number and severity of moped-related injuries.

Introduction

In the United States, mopeds, defined as 2-wheeled motorized vehi- cles with an automatic transmission and an engine displacement of less than 50 cc, are becoming a popular Mode of transportation, with sales increasing by up to 60% [1,2]. Several studies have acknowledged the in- herent risk of injury associated with mopeds [3-5]. In South Carolina, the number of moped fatalities has increased yearly from calendar year 2007 to 2011 [3]. Studies have also demonstrated that alcohol is as- sociated with significantly more moped-related accidents compared with other motor vehicle accidents [4,5].

? Meetings: This study was presented at the 2015 SAEM annual national conference in San Diego, CA, on May 13th, 2015.

?? Funding source: None.

? Financial disclosures: All authors have no financial disclosures relevant to this article

to disclose.

?? Conflicts of interest: All authors have no conflicts of interest relevant to this article to

disclose.

* Corresponding author at: Emergency Medicine, Weill Cornell Medical College, 1320 York Ave, New York, NY 10021. Tel.: +1 212-746-5454.

E-mail address: [email protected] (S. Bandzar).

Although mopeds have become more popular in recent years, most research dates back to the late 1980s and it is unclear if these data rep- resent current national trends and characteristics of moped-related in- juries. The National Electronic Injury Surveillance System database contains a wealth of information regarding moped injuries presenting to US emergency departments (EDs) across the nation. The purpose of this study is to investigate the characteristics of moped- related injuries presenting to the ED by using a national database. This study also aims to explore the implications of these findings, which will help guide Injury prevention efforts.

Methods

The NEISS database is a stratified sample of approximately 100 EDs in the United States and its territories which operate 24 hours a day and have at least 6 beds. The Consumer Product Safety Commission monitors injuries in these US hospital EDs using the NEISS database. The NEISS database was established in 1972 and has undergone revi- sions in its sampling frame in calendar years 1978 and 1990. Participat- ing US hospital EDs submit data from their electronic medical records to the NEISS database. These data include associated consumer products and characteristics of the presenting injury. The data are uploaded

http://dx.doi.org/10.1016/j.ajem.2016.07.052 0735-6757/

S. Bandzar et al. / American Journal of Emergency Medicine 34 (2016) 2000-2002

from participating hospital via a NEISS database coder. The NEISS coders assign a product code to consumer products associated with pre- senting injuries and record other aspects of the injury via a free-text narrative. The NEISS database coders are trained professionally to de- crease inconsistencies. Prior studies have demonstrated the accuracy of the NEISS in identifying injuries [6,7]. This study received institutional review board exemption.

18000

16000

16269

15613

14685

14000

13730

12562

12000

10000

8000

10739 10748

10564

9820

6000

4000

2000

0

2007 2008 2009 2010 2011 2012 2013 2014 2015

Calendar Year

Number of Moped Injuries

Data from the NEISS database pertaining to the moped injuries were retrospectively analyzed from calendar years 2007 to 2015. The ana- lyzed data from the database included the following: patient age, diag- nosis, sex, race, body part affected by injury, ED disposition, and locale of injury. A short, free-text narrative was also a part of each patient case and described the injury from the attending physician’s perspective. The NEISS uses a complex statistical design that extrapolates national estimates based on samples from the participating EDs.

Data were analyzed using SAS (University Edition) software (SAS, Cary, NC). Survey Procedures (PROC SURVEYFREQ) were used to ac-

2001

count for the NEISS’s complex statistical design. Sample weights from the NEISS database were used in all analyses to extrapolate national es- timates and to adjust for the inverse probability of selection for each in- jury depending on several factors including the volume of the ED. Relationships were examined using linear regression and ?² tests and by calculating Relative risk with 95% confidence intervals (CIs). A P value less than .05 was considered statistically significant. injury rates were calculated using census data from calendar year 2010 from the US Census Bureau [8].

The patient cases from the NEISS database were categorized by gen- der, sex, age, locale of injury, type of injury, and ED disposition. One case was excluded from the study because the consumer product associated with the injury was mistakenly labeled. The NEISS categories for types of moped injuries included the following: (1) contusion, (2) fracture,

(3) internal organ damage, (4) strain or sprain, and (5) laceration. NEISS categories for the patient’s disposition from the ED included the following: (1) treated and released, (2) admitted to hospital for evalua- tion, (3) transferred to another hospital, and (4) other. The “other” cat- egory included patients who were held for observation or Left without being seen by a physician. NEISS categories for locale of injury included the following: (1) home, (2) public street/highway, (3) other public property, (4) not reported, and (5) other. The “other” category included other places of recreation (ie, schools) and farms. NEISS categories for injured body parts included the head, trunk, shoulder, leg, and knee. Other injured body parts consisted of less than 5% of the total number of injuries.

Results

From calendar years 2007 to 2015, there were 114 729 injuries at-

tributable to mopeds (95% CI, 102 156-127 302). The number of moped-related injuries by year is shown in Fig. 1. A linear model of the total number of moped-related injuries regressed on year yielded a slope B = 762.1 (P b .01).

The average number of moped injuries annually was 12 748. The mean age was 34 years (median, 30; range, 85). Patients between the ages of 19 and 38 years represented approximately 42% of the study population (47 615 of estimated 114 729). There was a higher percent- age of moped-related injuries that occurred in men (74%) and in whites (55%). However, 33% of the cases did not record a race. Among the pa- tients for whom the location of their injury was recorded (77%), most injuries occurred on the street (65%). Most injuries treated in the ED were stabilized and released (85%). Approximately 9% of the injuries were admitted to the hospital for further evaluation. Of the injuries ad- mitted to the hospital for further evaluation, fractures and head trauma accounted for 59% and 24% of all admissions, respectively. Approximate- ly 15% of hospital admissions were patients younger than 23 years.

The most common body part to be injured was the head (16%). The next common body parts to be injured were the knee (13%), shoulder

Fig. 1. Estimated number of moped-related injuries by calendar year.

(11%), and leg (8%) as seen in Table 1. Moped users older than 18 years had the highest frequency of neck injuries when compared with other age groups (RR, 4.11; 95% CI, 3.41-4.81).

The most common diagnosis was a contusion (27%). The most com- mon location for a contusion was the knee (18%). When the data were stratified by age, contusions represented the most frequent diagnosis in patients between the ages 0 to 38 years when compared with other age groups (RR, 1.67; 95% CI, 1.64-1.71). Specifically, contusions repre- sented 35% of all injuries in patients between the ages of 0 and 18 years. In patients between the ages of 19 and 38 years, contusions accounted for 29% of all injuries.

Fractures and sprains/strains accounted for 24% and 14% of all moped-related injuries seen in the ED, respectively. The most common fractured body parts were the shoulder (16%) and leg (14%). The fre- quency of fractures was highest for patients between the ages of 39 and 86 years when compared with ages 0 to 18 years (RR, 2.61; 95% CI, 2.53-2.70). The frequency of sprains/strains was highest in patients between the ages of 19 and 38 years when compared with other age groups (RR, 1.90; 95% CI, 1.84-1.96).

There are several limitations to this study. Approximately 30 years ago, McHugh et al recommended that all moped operators wear a hel- met, wear brightly colored clothing to increase visibility on the road, and not ride double on mopeds which seat one person [9]. Because of limited number of study variables in the NEISS database, it was not pos- sible to determine if these recommendations were implemented. The NEISS database lacks details including the following: if safety equipment was used, if moped operators were driving under the influence of alco- hol, what type of moped was used, the time of day during the accident, and if the moped operator was wearing easily visible colors if they col- lided with another vehicle.

Discussion

Previous studies that have investigated moped injuries date back to the 1970s and 1980s and used small, local hospital data sets [1,9]. It is unclear if these data represent current national trends and characteris- tics of moped-related injuries. This study is the first study to investigate the epidemiology of moped-related injuries using nationally represen- tative data.

In this study, there was a statistically significant increase in the an- nual number of moped injuries from calendar years 2007 to 2015 (P b

.01). During the study period, there were an estimated 114 729 injuries associated with mopeds. Most of these injuries occurred in riders be- tween the ages of 19 and 38 years, in men, and in whites. In 2012, this demographic was shown to have the highest number of automobile ac- cidents associated with alcohol intoxication [10,11]. In addition, there have been concerns regarding this population operating mopeds while

2002 S. Bandzar et al. / American Journal of Emergency Medicine 34 (2016) 2000-2002

Table 1 National estimates (N), percentage distribution, and injury rates per 100 000 of population in the United States for various characteristics of moped-related injuries seen in US hospi-

tal EDs from calendar years 2007 to 2015

had a fracture [9]. In this study, head injuries accounted for 24% of the total hospital admissions. The relative decrease in frequency of head in- juries since 1984 may be attributed to helmet usage. Thus, wearing a

helmet is strongly encouraged to prevent detrimental head injuries.

Characteristic N Percent of total (%) Injury rate

Total	114 729	100	37.2
Age (y)
0-18	23 507	20	7.6
19-38	47 615	42	15.4
39-58	32 602	28	10.6
59-78	10 174	9	3.3
79-86	798	1	0.3
5 most common body parts injured
Head	18 161	16	5.9
Knee	12 534	11	4.1
Shoulder	12 498	11	4.0
Leg	9599	8	3.1
Trunk	7663	7	2.5
5 most common diagnoses
Contusion	31 221	27	10.1
Fracture	27 625	24	8.9
Strain or sprain	15 557	14	5.0
Internal organ damage	13 157	11	4.3
Laceration	11 295	10	3.7
ED disposition Treat and release	97 302	85	31.5
Admit	10 750	9	3.5
Transfer	3954	3	1.3
Othera	2723	3	0.9
Locale of injury
Street	74 958	65	24.3
Not recorded	26 316	23	8.5
Home	8224	7	2.7
Other public property	3573	3	1.2
Otherb	1658	1	0.5
Sex
Male	84 451	74	27.4
Female	30 278	26	9.8
Race
White	63 413	55	20.5
Not specified	37 319	33	12.1
Black	8989	8	2.9
Hispanic	3844	3	1.2
Otherc	1163	1	0.4

^a Patient cases that did not specify an ED disposition and patients that were held for observation, left the ED against medical advice, and died in the ED were assigned to the category “other.”

^b Locations that did not equal at least 5% of the total number of cases during the study period were assigned to the category “other.” These locations included places of recreation (ie, schools) and farms.

^c Races that did not equal at least 5% of the total number of cases during the study pe- riod were assigned to the category “other.” These races include Asians and Alaskan Natives.

inebriated [12]. Studies have demonstrated that a substantial propor- tion of moped injuries are associated with an operator being intoxicat- ed. These reports also demonstrated that intoxicated moped operators are often repeat offenders [12].

This may be attributable to the fact that some states (ie, North Caro- lina and Virginia) in the United States do not require licensure to oper- ate a moped. Therefore, mopeds have become a more attractive mode of transportation for those with suspended licenses because of high-risk behaviors or without licenses [1]. In other countries, strict legislative changes pertaining to moped registration and licensure have been im- plemented within the last 5 years and have been associated with re- duced number and severity of moped-related injuries [13].

In this study, the most commonly injured body parts were the head, trunk, shoulder, and legs. In 1984, McHugh et al. demonstrated that head injuries were present in 83% of all moped-related injuries in pa- tients admitted to a local hospital in North Carolina and 24% of patients

However, fractures still remain high with 24% of patients in the cohort suffering from a fracture and 59% of the total number of admissions at- tributable to fractures.

In 1984, approximately 75% of moped-related injuries that were ad- mitted to a hospital consisted of patients younger than of 23 years [9]. In this cohort, only 15% of hospital admissions were patients younger than 23 years. Most admissions were patients aged between 23 and 45 years. It is unknown why there has been a shift from the younger generation to older patients in regard to hospital admissions. Further studies are war- ranted to determine if alcohol consumption is associated with this shift. McHugh et al [9] proposed many recommendations in 1984 in an ef- fort to prevent possible moped accidents and injuries. One of these rec- ommendations was to increase the number of states requiring a driver’s license, or in states without licensing requirements, to assess a moped operator’s knowledge of the “rules of the road.” Thirty years later, some states (ie, North Carolina and Virginia) still do not require a driver’s license to operate a moped and do not require assessing a moped operator’s knowledge of the “rules of the road.” In Finland, legis- lative changes requiring moped operators to take a theoretical written examination and vehicle handling test, and participate in practical driv- ing lessons were associated with a statistically significant decrease in both the number and severity of moped-related injuries [13]. In an ef- fort to reduce recidivism and prevent injuries, health care systems and legal systems are encouraged to collaborate and reexamine the current

laws regarding moped registration and licensure.

Conclusions

Moped injuries have increased in recent years and are a source of se- rious injury. Further research is warranted to evaluate specific interven- tions to reduce the number and severity of moped injuries.

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