Reducing Mortality From Motor Vehicle Crashes in Rural Communities

Injuries are the leading cause of pediatric mortality, and motor vehicle crashes are the most common cause of injury.¹  Efforts to ameliorate morbidity and mortality from these crashes have been focused on both prevention and optimizing care for those who are injured. Although preventive measures in the United States have decreased the number of pediatric deaths, our rate of improvement is lower than that of 19 comparable industrialized nations.²  In addition, although the advent of regional trauma centers has improved outcomes after an injury, the systems of care are not yet leveraged to their full potential and often are not readily accessible to those in rural areas.

In this issue of Pediatrics, Mokdad et al³  highlight the disparities in outcomes between children injured in motor vehicle crashes in urban versus rural areas using the Fatality Analysis Reporting System database (years 2010–2017). The authors document higher mortality rates in rural counties and demonstrate lower mortality rates in counties with a regional trauma center. These findings are consistent with decades of literature revealing similar results from the United States and internationally.^4–6  It is well known that children injured by motor vehicles in rural counties sustain more severe injuries than those in urban areas.⁵  The explanation for this is likely multifactorial and includes opportunities for intervention, including restraint misuse, presence of gravel roads, red light camera legislation, and a higher percentage of larger vehicles, such as trucks, than automobiles.^7–9  It is, unfortunately, not surprising that these rural pediatric patients also have a higher mortality rate compared with their urban counterparts. The question remains whether this disparity in outcomes primarily results from their greater degree of injury or from limitations in their postinjury care, including emergency medical services response time and presence of a regional trauma center. This question is important so that we can direct and implement the most effective interventions to help address this disturbing disparity in outcomes.

Mokdad et al³  make a compelling argument that the proximity to a regional trauma center is a significant contributor to the disparity in outcomes. Impressively, they teased out county-level data and superimposed the nation’s regional trauma centers in the data. They report that injured children in counties with an adult trauma center had a 41% lower mortality rate, whereas those injured in counties with a dedicated pediatric trauma center had a 44% lower mortality rate, independent of urban or rural status. Furthermore, they note the relative paucity of trauma centers: only 11% and 3% of counties have an adult or pediatric trauma center, respectively. These data, coupled with the historic underuse of existing trauma centers,¹⁰  lend credence to their conclusion that increased access and use of trauma centers could be a significant target for improvement measures.

However, there are potentially confounding issues to consider when assessing the reported magnitude that trauma centers can have on pediatric deaths resulting from motor vehicle crashes (eg, 41% and 44% lower mortality rate). First, it is not clear from the report that deaths at the scene were excluded from analysis. From their data, among children who died, fatalities at the scene in rural counties approached 58%, whereas those in urban areas were 31%. The presence or absence of a regional trauma center would arguably have no impact on scene mortality rates, so these patients should have been excluded from the analysis. Second, the validity of the results would have been strengthened if there were better model adjustments for injury severity when comparing urban and rural and trauma center and non–trauma center differences. Although such data are not available in Fatality Analysis Reporting System, including standard injury severity scores would have reduced the multitude of variables that likely confounded the analysis of trauma center efficacy.

Given the high proportion of pediatric deaths that occur at the scene of motor vehicle crashes and the inherent difficulties in creating more trauma centers, particularly in sparsely populated areas, it may be that focusing efforts on prevention remains the more fruitful option. For example, the authors cite a staggeringly low seat belt compliance rate of 54% in rural areas, a target ripe for improvement. Although we are not out to minimize the transformative impact that trauma regionalization has had on improving outcomes and reducing long-term morbidity, opportunities remain to extend the efficiency and reach of existing centers. For example, the use of telemedicine to extend regionalized pediatric trauma centers beyond their physical location has been proposed for several years but is being adopted only slowly.^11–13  Telemedicine is increasingly used in all disciplines of medicine, and has been studied among pediatric trauma patients with positive impacts.^14–17  The use of telemedicine in the emergency department for children has been associated with greater provider and patient satisfaction, a more appropriate mode of transportation compared with telephone consultations, and a decrease in medical errors.^18,19