Reducing the Burden of Injury

ADVANCING PREVENTION AND TREATMENT

Richard J. Bonnie, Carolyn E. Fulco, and Catharyn T. Liverman, Editors

Committee on Injury Prevention and Control

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1999



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Reducing the Burden of Injury: Advancing Prevention and Treatment Reducing the Burden of Injury ADVANCING PREVENTION AND TREATMENT Richard J. Bonnie, Carolyn E. Fulco, and Catharyn T. Liverman, Editors Committee on Injury Prevention and Control Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1999

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Reducing the Burden of Injury: Advancing Prevention and Treatment NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the W.K. Kellogg Foundation, the John D. and Catherine T. MacArthur Foundation, and the Robert Wood Johnson Foundation. The views presented are those of the Institute of Medicine Committee on Injury Prevention and Control and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data Reducing the burden of injury : advancing prevention and treatment / Richard J. Bonnie, Carolyn E. Fulco, Catharyn T. Liverman, editors ; Committee on Injury Prevention and Control, Division of Health Promotion and Disease Prevention, Institute of Medicine. p. cm. Includes bibliographical references and index. ISBN 0-309-06566-6 (pbk.) 1. Accidents--United States--Prevention. 2. Wounds and injuries--United States--Prevention. I. Bonnie, Richard J. II. Fulco, Carolyn. III. Liverman, Catharyn T. IV. Institute of Medicine (U.S.). Committee on Injury Prevention and Control. HV676.A2 R44 1999 363.11'5--dc21 98-40288 Copyright 1999 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Reducing the Burden of Injury: Advancing Prevention and Treatment COMMITTEE ON INJURY PREVENTION AND CONTROL RICHARD J. BONNIE* (Chair), John S. Battle Professor of Law and Director, Institute of Law, Psychiatry, and Public Policy, University of Virginia DIANA D. CARDENAS, Professor, Department of Rehabilitation Medicine, University of Washington KATHERINE KAUFER CHRISTOFFEL, Director, Violent Injury Prevention Center, Children's Memorial Hospital, Chicago, and Professor of Pediatrics and Preventive Medicine, Northwestern University Medical School PHILIP J. COOK, ITT/Sanford Professor of Public Policy, and Director, Sanford Institute of Public Policy, Duke University SUSAN S. GALLAGHER, Director, Children's Safety Network, and Senior Scientist, Education Development Center, Inc., Newton, Massachusetts HERBERT G. GARRISON, Director, Eastern Carolina Injury Prevention Program, and Associate Professor of Emergency Medicine, East Carolina University School of Medicine BERNARD GUYER,* Professor and Chairman, Department of Maternal and Child Health, Johns Hopkins University School of Hygiene and Public Health HOPE HILL, Professor of Psychology, Howard University LENWORTH M. JACOBS, JR., Professor and Chairman, Department of Traumatology and Emergency Medicine, and Professor of Surgery, University of Connecticut School of Medicine; Director, EMS/Trauma Program, Hartford Hospital, Hartford, Connecticut ELLEN MACKENZIE, Director, Center for Injury Research and Policy, Department of Health Policy and Management, Johns Hopkins University School of Hygiene and Public Health SUE MALLONEE, Chief, Injury Prevention Service, Oklahoma State Department of Health, Oklahoma City ELIZABETH MCLOUGHLIN, Director of Programs, Trauma Foundation, San Francisco General Hospital, San Francisco, California GORDON REEVE, Corporate Epidemiologist, Occupational Health and Safety, Ford Motor Company, Dearborn, Michigan PATRICIA WALLER, Director, Transportation Research Institute, and Professor of Health Policy and Administration, University of Michigan School of Public Health ALLAN F. WILLIAMS, Senior Vice-President for Research, Insurance Institute for Highway Safety, Arlington, Virginia FLAURA WINSTON, Director, TraumaLink, Children's Hospital of Philadelphia, University of Pennsylvania CRAIG ZWERLING, Director, Injury Prevention Research Center, University of Iowa Board on Health Promotion and Disease Prevention Liaison ELENA O. NIGHTINGALE,* Scholar-in-Residence, Institute of Medicine * Member, Institute of Medicine.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Staff CAROLYN E. FULCO, Study Director CATHARYN T. LIVERMAN, Study Director SANDRA AU, Project Assistant/Research Assistant KATHLEEN STRATTON, Director, Division of Health Promotion and Disease Prevention

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Reducing the Burden of Injury: Advancing Prevention and Treatment Acknowledgments The committee's efforts were supported by the work and dedication of the project staff and consultants and numerous individuals named in Appendix A who shared their thoughts and expertise with the committee. The committee benefited from the project staff's direction and commitment to the study; Carolyn Fulco and Cathy Liverman contributed constructively to the committee's deliberations and provided necessary guidance in informing the committee of our responsibilities in developing the report. Sandra Au provided the committee with excellent attention to detail, exceptional concern for the study process, and dedication to the production of the report. Institute of Medicine summer intern, Ann St. Claire, in consultation with many individuals, produced an informative timeline of the development of the injury field and provided assistance with numerous other activities; we appreciate her efforts on our behalf. We also thank Kysa Christie for her diligent work on producing the camera-ready copy of the report. We are indebted to Kathleen Stratton for her insight, assistance, and guidance as we negotiated our way through various difficult issues, and especially to Elena Nightingale for her thoughtful comments that kept us true to our task. They both contributed constructively to the committee's deliberations and provided guidance to make the report responsive to the charge. Miriam Davis, consultant to the committee, provided exceptional background information and research for our deliberations and extensive written material for the committee's consideration. Lois Fingerhut, National Center for Health Statistics, provided considerable technical assistance and information on injury statistics and injury surveillance systems and we are very grateful for her help. Finally, we appreciate the careful editing by Florence Poillon who has enhanced the readability of the report, and to all the reviewers whose thoughtful comments have improved the quality of our work.

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Reducing the Burden of Injury: Advancing Prevention and Treatment This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: Susan Baker, Johns Hopkins University School of Hygiene and Public Health; Barbara Barlow, Columbia University, Harlem Hospital Injury Prevention Program; Enriqueta Bond, Burroughs Wellcome Foundation; James Ebert, Marine Biological Laboratory, Johns Hopkins University; Lois Fingerhut, National Center for Health Statistics; John Graham, Harvard University School of Public Health; Robert Haggerty, University of Rochester School of Medicine; David Hoyt, University of California, San Diego, Medical Center; Alexander Kelter, California Department of Health Services; Mark Moore, Harvard University; Barry Myers, Duke University; Fred Rivara, University of Washington; and Gerald Strauch, American College of Surgeons. While the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the institution. The committee expresses its appreciation to the sponsors of this study: the W.K. Kellogg Foundation, the John D. and Catherine T. MacArthur Foundation, and the Robert Wood Johnson Foundation.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Preface The Committee on Injury Prevention and Control was appointed by the Institute of Medicine in March 1997, with funding from the Robert Wood Johnson, W.K. Kellogg, and John D. and Catherine T. MacArthur foundations, and was directed to "make recommendations intended to further develop the field of injury prevention and control and to reduce the burden of injury in America." In carrying out this charge, the 17-member committee was standing on the shoulders of two predecessor committees of the Institute of Medicine (IOM) and the National Research Council (NRC), whose efforts laid the foundation for the field of injury prevention and treatment, as distinct spheres of specialization within public health and clinical medicine, more than a decade ago. Accordingly, the reports of these earlier committees—Injury in America (NRC, 1985) and Injury Control (NRC, 1988)—have been taken as the starting point for this work. William H. Foege, who chaired both of these committees, correctly observed that future historians would regard this formative period as a "turning point" for the field, ''when science began defining injury, measuring determinants [and] devising interventions" and public and private efforts were galvanized to address injury problems. Although much has been accomplished since the publication of Injury in America, the aspirations of the previous IOM-NRC committees have not yet been fully realized. Injury prevention and treatment encompass a vast terrain and touch on the interests of numerous disciplines and constituencies. To open the process to as many voices as possible, the committee convened a public hearing in Washington, D.C., conducted three scientific workshops, invited written comments and suggestions from hundreds of organizations and individuals, and conducted surveys of researchers and practitioners about the needs of the field. The level and intensity of the response provide compelling evidence of the growth and

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Reducing the Burden of Injury: Advancing Prevention and Treatment vitality of the injury field and of a heightened public awareness of injury problems. The committee encountered the customary pattern of special pleading for one cause or another (e.g., suicide, drunk driving, firearms, head injury), a reflection of a general drift toward interest-group politics in biomedical research and health policy making. Focusing attention on particular problems arouses public interest, brings more energy into the field, and probably hastens the application of advances in the laboratory to solutions of real-world issues or diseases. However, preoccupation with special causes can obscure common goals and lead to fragmentation of effort. While the committee applauds the energetic efforts of an increasing number of "interest groups" in the injury field to draw public attention to their particular concerns, what is most needed at this stage of the field's development is for all these groups to collaborate in a common effort to advance injury science and strengthen the nation's investment in injury prevention and treatment. The committee was constituted to reflect the disciplines ordinarily identified with the injury field (including biomechanics, psychology, epidemiology, and medicine) as well as a number of disciplines adjacent to the field, such as criminology, economics, and law. This committee's experience holds a lesson for the field as a whole. Certain ideas have been regarded as axiomatic in the injury field, including a general preference for "passive protection" and a general skepticism about behavioral strategies. Until recently, these biases have been accompanied by tendencies to neglect the use of incentives and to overlook or disregard the costs of regulatory interventions. Future success of the injury field depends on its ability to broaden its base—by recruiting researchers and collaborators from the behavioral and social sciences—and to incorporate and integrate different ideas and perspectives, while preserving its intellectual bearings and distinct grounding in public health. The historical record will show that this committee was conceived at a moment of confusion (if not crisis) in the field (Thompson, 1998). Two related questions had been raised. One is whether the priorities of injury policy makers, researchers, and practitioners have become distorted by an undue emphasis on firearms, and perhaps by a bias in favor of gun control. The second is whether prevention of violence is being overemphasized in comparison with the field's traditional focus on unintentional injuries. The committee explored these problems frankly and open-mindedly. We explored the similarities and differences between firearms and other mechanisms of injury, including the role of intentionality, and their implications for designing and implementing intervention strategies. We explored the relation between violence prevention and injury prevention. We also seriously considered proposals to refocus the preventive agenda of the injury field on unintentional injuries, leaving primary responsibility for assaultive injuries and suicide to criminal justice and mental health. In the end, however, the committee decided, unanimously, to reaffirm the views expressed in Injury in America and Injury Control regarding the scope and mission

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Reducing the Burden of Injury: Advancing Prevention and Treatment of the injury field. Despite important differences associated with intentionality, the committee strongly endorses the continued integration of all injury prevention activities within a common framework of research and program development. The injury field has much to contribute to scientific understanding of firearm injuries and to the prevention of violence, complementing the contributions made by criminal justice, mental health, and other approaches. The public health investment in these areas should be strengthened, not abandoned or diminished. Strengthening "the injury field" is but one element of a strategic plan for reducing the burden of injury in America. Achieving a safer society requires coordinated efforts by many public and private agencies in numerous spheres of research and social action. Public health agencies and affiliated constituencies comprise only a segment of the vast array of agencies and groups aspiring to build a safer America. The challenge set forth in Injury in America was to establish injury prevention and treatment as a recognized interdisciplinary field of scientific study. For the most part, this goal has been achieved. The challenge confronting us today is to enhance the impact and effectiveness of the field. Doing so requires a broad matrix of collaboration with other agencies and constituencies, and careful priority setting within the field in order to focus efforts and resources on areas of research and action that optimize the specialized contribution of public health. This report takes its place alongside several other recent IOM-NRC reports highlighting the need to rejuvenate and strengthen the infrastructure of public health (IOM, 1988, 1996). Our society's failure to invest in injury prevention is symptomatic of a more general tendency to underinvest in programs designed to prevent social problems. This is ultimately a political challenge that must be addressed by "marketing" the virtues of prevention in the forum of public opinion. "A key struggle for [public health leaders] is making the benefits of community-based, population-wide public health activities and initiatives more recognizable" (IOM, 1996). Another key challenge in public health is to take maximum advantage of the changing incentives in the emerging structure of health care delivery and financing. In large capitated systems with limited enrollee turnover, successful prevention can result in larger profit margins downstream. Partnerships between public health agencies and managed care organizations offer rich opportunities for institutionalizing injury prevention and assessing outcomes (Lasker and Committee on Medicine and Public Health, 1997; Mechanic, 1998). This report emphasizes, as did Injury in America and Injury Control , that the nation's current investment in injury research is not commensurate with the magnitude of the problem. Throughout the report, the committee has recommended additional funding for surveillance, research, and program evaluation supported by a variety of federal agencies. Abundant opportunities for scientific advances in all aspects of the field fully justify a substantially higher level of funding for injury research. Trauma research (basic and applied) should receive a higher share (compared with current allocations) of increases in the National

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Reducing the Burden of Injury: Advancing Prevention and Treatment Institutes of Health (NIH) budget, and funding outside NIH (e.g., Centers for Disease Control and Prevention, Agency for Health Care Policy and Research) for extramural research in all aspects of injury prevention and treatment should be increased. The committee also concluded that there is a yawning gap between what we already know about preventing or ameliorating injuries and what is being done in our communities, workplaces, and clinics. Thousands of lives could be saved every year if interventions already known to be successful were more widely implemented. Funding for prevention program support, emergency medical services and trauma systems, and public health infrastructure should be significantly increased. Although the committee has not attempted to develop cost estimates for its recommendations, carrying them out will clearly require the investment of new funds. The committee has provided adequate support for the programmatic goals and objectives of its recommendations; additional funds and resources must be forthcoming from the Congress for the relevant federal agencies and the states. Echoing Dr. Foege's prefatory claim in Injury in America, adequate investment in injury research and program implementation "could yield an unprecedented public health return." It is time for the country to make the necessary investment. Richard J. Bonnie, LL.B. Chair Committee on Injury Prevention and Control REFERENCES IOM (Institute of Medicine). 1988. The Future of Public Health. Washington, DC: National Academy Press. IOM (Institute of Medicine). 1996. Healthy Communities: New Partnerships for the Future of Public Health. Washington, DC: National Academy Press. Lasker RD, Committee on Medicine and Public Health. 1997. Medicine and Public Health: The Power of Collaboration. New York: New York Academy of Medicine. Mechanic D. 1998. Topics for our times: Managed care and public health opportunities. American Journal of Public Health 88(6):874–875. NRC (National Research Council). 1985. Injury in America: A Continuing Public Health Problem. Washington, DC: National Academy Press. NRC (National Research Council). 1988. Injury Control: A Review of the Status and Progress of the Injury Control Program at the Centers for Disease Control. Washington, DC: National Academy Press. Thompson B. 1998. The science of violence: Guns, politics, and the public health. Washington Post Magazine. March 20.

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Reducing the Burden of Injury: Advancing Prevention and Treatment Contents   EXECUTIVE SUMMARY 1 1 THE INJURY FIELD 18 Study Background 18 Origins of the Injury Field 20 Injury as a Public Health Problem 23 The Mission and Boundaries of the Injury Field 23 Vocabulary of the Injury Field 28 Development of the Injury Field 30 Organization of the Report 36 2 MAGNITUDE AND COSTS 39 Overall Burden of Injury: Mortality Rates 44 Overall Burden of Injury: Morbidity 48 Patterns of Injury in the Population 49 The Cost of Injury 53 3 SURVEILLANCE AND DATA 60 Coding Issues 62 Existing Data Sources 64 Data Linkages 78 Summary 78 4 PREVENTION RESEARCH 82 Research Accomplishments 83

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Reducing the Burden of Injury: Advancing Prevention and Treatment Research Opportunities 95 Summary 106 5 CASE STUDIES ON PREVENTION 115 Motor Vehicle Injuries 115 Firearm Injuries 124 Summary 134 6 TRAUMA CARE 138 Overview of Trauma Care Systems 139 Role of Trauma Systems in Primary Prevention, Surveillance, and Research 146 Growth in Trauma Care Systems 148 Outcomes of Trauma Care Systems 150 Research on Treatment Outcomes and Clinical Effectiveness 152 Costs of Trauma Care Systems 156 Financing of Trauma Systems 159 Advent of Managed Care 164 Summary 167 7 STATE AND COMMUNITY RESPONSE 178 Strengthening the Public Health Infrastructure 186 Training and Technical Assistance 194 Integrating Research and Practice 197 Public Awareness and Advocacy 198 Summary 201 8 FEDERAL RESPONSE 204 National Highway Traffic Safety Administration 205 Consumer Product Safety Commission 212 Occupational Safety and Health Administration 217 National Institute for Occupational Safety and Health 223 National Institutes of Health 227 Maternal and Child Health Bureau 230 Office of Justice Programs 234 National Center for Injury Prevention and Control 239 Coordination and Leadership 251 9 CHALLENGES AND OPPORTUNITIES 258 Coordination and Collaboration 260 Strengthening Capacity for Research and Practice 262 Integrating the Field 264 Nurturing Public Support 265 Promoting Informed Policy Making 266

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Reducing the Burden of Injury: Advancing Prevention and Treatment   APPENDIXES A Acknowledgments 273 B Timeline 284 C Public Meeting Agenda 296 D Acronyms 300   INDEX 305 TABLES, FIGURES, AND BOXES Tables 1.1 Mission and Vocabulary of the Injury Field 30 2.1 Leading Causes of Injury Death, Trends, 1985–1995 46 2.2 Leading Causes of Years of Potential Life Lost 54 3.1 U.S. Federal Data Systems for Injury Surveillance, Research, and Prevention Activities 66 4.1 Examples of Effective Unintentional Injury Prevention Interventions 87 6.1 Chronology of Trauma System Legislation 144 6.2 Essential Criteria to Identify Regional Trauma Systems 150 7.1 State and Local Government Agencies and Organizations 184 8.1 Federal Agencies Involved in Injury Prevention and Treatment 206 9.1 Leading Causes of Death and Disability in the United States 263 Figures 1.1 Years of potential life lost 19 1.2 Haddon matrix 22 2.1 Ten leading causes of death, 1995 42 2.2 Burden of injury: United States, 1995 44 2.3 Leading causes of injury death by manner of death, United States, 1995 45 2.4 Age-adjusted death rates for leading causes of injury: United States, 1985–1995 47 2.5 Hospital discharge rates for injury by age and sex: United States, 1993–1994 51 5.1 Motor vehicle traffic injury deaths in the United States, 1950–1996 116 6.1 Reimbursement profile for all service areas 163 Boxes 1 The Federal Response 11 2 Summary of Recommendations 15 4.1 Harlem Hospital Injury Prevention Program 85

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Reducing the Burden of Injury: Advancing Prevention and Treatment 4.1 Harlem Hospital Injury Prevention Program 85 5.1 Brief Overview of Federal Firearm Laws and Regulations 127 6.1 The Continuum of Care 140 6.2 Levels of Trauma Centers 141 7.1 Child Passenger Safety Seats: An Example of the Lessons Learned 179 7.2 Examples of Nonprofit Organizations 181 7.3 Examples of Professional Organizations 183

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Reducing the Burden of Injury: Advancing Prevention and Treatment Reducing the Burden of Injury

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