Sunday, October 18, 2015

2015 Injury and Fatality Study is Interesting

The Trust for American Health released a June 2015 report titled The Facts Hurt, A State-by-State Injury Prevention Policy Report. It is a detailed comparison of the states. It provides a great quantity of data and information, but frankly leaves the reader with a few questions. 

The report notes that "drug overdose" is "the leading cause of injury death in the United States" at "44,000 per year." This exceeds "motor vehicle-related deaths in 36 states and Washington D.C." More troubling is that the trend for overdose death is increasing, and the "rates have significantly increased in 26 states and Washington D.C." in the past four years. Half of those deaths "are related to prescription drugs," and the overdose "deaths have more than doubled in the last 14 years."

The relevance is apparent. Injuries are expensive in terms of medical treatment costs and productivity losses. In 2010 the total of these two for all types of injuries was $189 billion dollars, measured over the lifetime of the injury. If the entire 2010 American working age population (18-65) paid an equal share of that, it would be almost $1,000 per working-age American ($189 billion divided by 194 million). That is significant. 

One focus of the report is the rate of death in various states. The authors have color-coded the U.S. map to illustrate the states categorized into three groups based upon the volume of "injury-related death" per 100,000 people in the state. Five states, California, Connecticut, Hawaii, Massachusetts, New Jersey, and New York are coded as "green" states, with a rate of less than 50 per 100,000. 

Sixteen states are "red," with a rate of more than 70. These are Alabama, Alaska, Arizona, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, Oklahoma, Tennessee, Utah, West Virginia, and Wyoming.  The remaining 29 states are "brown" with a rate of between 50 and 70.

West Virginia is the highest on the map at 97.9 deaths by injury, per 100,000. The second highest is New Mexico with 92.7. New York is the lowest at 40.3, with the next lowest Massachusetts at 42.9. This methodology minimizes population disparity as an influence in the comparison.

Florida is a "brown" state. The reported death by injury rate is 61.3 per 100,000. The average for all 50 states is 64.8 (64.6 if the District of Columbia is included), so Florida is below average. The median (the value in the middle of the range) is Indiana at 63.7, which Florida is also below. The range is significant at 57.6 (defined by the difference between the highest, West Virginia with 97.9 and the lowest, New York with 40.3). 

Comparing Florida in this way could lead to the conclusion that Florida is doing well as regards safety. It is below average, below the median, and its total is further (36.6 versus 21) from the worst (97.0) than from the best (40.3). But, 61 people dying of injuries cannot be ignored and should not be minimized. Certainly, some might conclude that injury-related death is inevitable in some measure. However, the real focus should be decreasing the volume. In that focus perhaps an acceptable goal would be zero?

Another focus of the report is safety, and injury prevention. The report identifies "10 key injury-prevention indicators" which it suggests are a path to fewer injuries and thus fewer fatalities. The report annotates the number, out of ten, of these indicators with which each state has achieved. 

The ten listed are:

1. "Does the state have a primary seat belt law?"
2. "Does the state require mandatory ignition interlocks for all convicted drunk drivers?"
3. "Does the state require car seats for children up to at least the age of 8?"
4. "Does the state have Graduated Driver Licensing laws?" (restricting teen driving)
5. "Does the state require bicycle helmets for all children?"
6. "Does the state have fewer homicides than the national goal of 5.5 per 100,000?"
7. "Does the state have a child abuse and neglect victimization rate at or below the national rate of 9.1 per 1,000 children?"
8. "Does the state have fewer deaths from unintentional falls than the national goal of 7.2 per 100,000 people?"
9. "Does the state require mandatory use of data from the prescription drug monitoring program by at least some healthcare providers?"
10. "Does the state have laws in place to expand access to, and use of, nalaxone, an overdose rescue drug, by laypersons?"

Curiously, only number 10 of the "indicators" has anything to do with overdose death, the leading cause of deaths according to the report.  The leading cause of death might be anticipated to relate directly to more of the selected indicators.

Using this ten point evaluation method, the states are graded. Notably, 1-5 and 9-10 are questions of the presence of some process or requirement that is tied to safe (or safer) outcomes. Enactment of those requirements would arguably result in greater safety regarding specific activities, driving, biking, prescription drug use, etc. 

Questions 6, 7, and 8 however are outcome measures, that is statistical results. Achieving those results are deemed by the study as indicative of a likelihood of safer outcomes. These three are not concrete action items, but independent component goals for safety in their respective contexts. In order for those outcomes to be achieved, concrete actions would have to be taken to achieve those outcome statistics.

Unfortunately, the report notes that "twenty-nine states and Washington D.C. scored a five or lower." New York scored the best with "nine out of a possible 10." Florida was among "four states (that) scored the lowest . . . with two out of 10." These four are Florida, Iowa, Missouri and Montana. Their respective rates are Iowa 56.4 (13th), Florida 61.3 (22), Missouri 72.4 (36) and Montana 85.1 (47). 

Some might question whether the ten indicators selected by the study are the most indicative of success in minimizing injury-related death. New York's achievement of the lowest rate per 100,000 people, in conjunction with its score of 9 out of 10 on the selected indicators could argue in favor of the relevance of the indicators. However, conversely, the lowest scoring states regarding the ten indicators might by that logic be expected to be the worst performing, and that is not the case. Iowa in fact is near the best performing despite its score of only two on the ten criteria.

One wonders if the indicator list is an accurate representation of the probability of death. The incongruity of New York and Iowa is worthy of further thought. This at least suggests that other indicators or factors may play significant roles. in injury safety. If so, what other indicators might also be key or at least worthy of consideration?

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