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"Topic Choice and Database Research" Please respond to the following: DISCUSSION TOPIC NOT AN ESSAYShare your topic selection for Assignment 1 here. Discuss why you chose the topic and what you hope t

"Topic Choice and Database Research" Please respond to the following: DISCUSSION TOPIC NOT AN ESSAY

  • Share your topic selection for Assignment 1 here. Discuss why you chose the topic and what you hope to address/prove in your essay.
  • Next, create a brief research evaluation checklist to help you determine what makes a good source for your essay. This can be a list of questions, a list of criteria that the source must meet, or anything in between.
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(((((((USE THE THREE ARTICLES LISTED BELOW)))))))))

Article 1:

Title:

Freedom Riders.

Authors:

Sullum, Jacob jsullum@reason.com

Source:

Reason. Nov2005, Vol. 37 Issue 6, p40-46. 7p. 1 Color Photograph.

Document Type:

Article

Subject Terms:

*MOTORCYCLE helmets -- Law & legislation*MOTORCYCLISTS*MOTOR vehicle drivers*UNITED States legislators*LEGISLATION*LEGISLATIVE bills*U.S. states

Abstract:

This article explores why U.S. states require adults to wear seat belts but most do not require them to wear motorcycle helmets. During the last few decades motorcycle activists have been remarkably successful in bringing that message to state legislators and members of Congress. In 1976, responding mainly to state resentment of federal mandates, Congress repealed legislation enacted in 1967 that had made federal highway funds contingent on adoption of helmet laws. At that point every state but California had passed a helmet law (although the Illinois law had been overturned by the state Supreme Court). Freed of the federal requirement, 27 states repealed their helmet laws or limited their coverage to minors (usually meaning riders under 18) during the next few years. Some of those states reinstated helmet requirements for adults in the 1980s and early '90s, including a few that acted after Congress again started tying highway funds to helmet laws in 1991. In 1995, largely in response to lobbying by the Motorcycle Riders Foundation, Congress again eliminated the helmet law mandate, and since then half a dozen states have repealed helmet requirements for adults (one of which, Louisiana, restored universal coverage last year). As of July 2005, 30 states still allowed adult motorcyclists the freedom to decide for themselves what, if anything, to wear on their heads. But the insurance industry, safety groups, and the National Highway Traffic Safety Administration continue to push universal helmet laws, which are periodically introduced by legislators even in states, such as Illinois and Minnesota, that have long allowed adults to ride without a helmet. Meanwhile, helmet law opponents are lobbying for repeal in California, West Virginia, and elsewhere. Resistance to helmet laws hasn't been easy, and it hasn't necessarily involved convincing legislators of anything but the motorcyclists' determination.

Full Text Word Count:

3919

ISSN:

0048-6906

Accession Number:

18511023

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Freedom Riders 

Contents

1.     "Motorcyclists Believe in Freedom"

2.     "A Case of Not-So-Subtle Political Intimidation"

3.     Buckle Up and Shut Up

4.     "We're Passionate About Our Motorcycles"

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How motorcyclists won the right to feel the wind in their hair--and why drivers still have to buckle up

ON A MONDAY afternoon in June 1999, Richard Quigley was riding his Harley near Capitola, California, when a local police officer pulled him over for violating the state's helmet law. There ensued a half-hour debate with the officer and his supervisor about whether Quigley's headgear--a trucker's cap emblazoned with "United States Freedom Fighter" into which he had inserted a rigid plastic disc--qualified as a "safety helmet." Quigley, a 61-year-old with a ponytail and a ZZ Top-style beard who directs Bikers of Lesser Tolerance of California and once ran for Congress on the Libertarian ticket, later caned the encounter "interesting, informative and fun!"

Richard Quigley's idea of fun, whether riding a motorcycle without a helmet or arguing with the police about it, may not be the same as yours or mine. But his enthusiasm for fighting California's helmet law, a battle in which he has been engaged for seven years "on the streets and in the courts" helps explain a public policy puzzle: While almost every state requires adults to wear seat belts, most do not require them to wear motorcycle helmets, even though riding a motorcycle is much more dangerous than driving a car. The story behind this anomaly is both inspiring and discouraging--inspiring because it shows that a highly motivated minority can make a successful stand for freedom, discouraging because it shows that politics is more important than principle in determining why certain laws aimed at protecting people from their own risky behavior become widely accepted while others remain controversial.

In 2003 there were 5.4 million registered motorcycles in the U.S., compared to about 136 million registered cars. Despite their relatively small numbers, motorcyclists have been far more effective than drivers at resisting traffic safety paternalism. After some initial grumbling, most motorists got used to buckling up and are now unlikely to put up much resistance as states move toward primary enforcement, allowing police to pull people over for not wearing seat belts (as opposed to issuing citations after stopping them for other reasons). By contrast, going back to the 1971 founding of the American Brotherhood Against Totalitarian Enactments (ABATE) by the staff of Easyriders magazine, motorcyclists have been willing to invest the time, effort, and money required to fight helmet laws. Call it the Quigley Factor.

"Motorcyclists Believe in Freedom"

"Motorcyclists believe in freedom, and we attack anything that is attacking our freedom," explains Robert Fletcher, coordinator of the Texas ABATE Confederation. "Helmet laws go against the grain of everything this country stands for," says New York Myke, ABATE of California's state director and owner of San Diego Harley Davidson. Just as abortion rights groups insist they do not favor abortion, motorcyclist groups are at pains to make it clear they do not oppose helmets. Jeff Hennie, vice president for government relations at the D.C.-based Motorcycle Riders Foundation, says, "What we're advocating is freedom of choice.… It should be the decision of the rider whether to put on extra safety equipment." He describes the attitude of helmet law opponents this way: "Let me decide what is right for me, instead of the government jamming regulations down my throat."

During the last few decades motorcycle activists have been remarkably successful in bringing that message to state legislators and members of Congress. In 1976, responding mainly to state resentment of federal mandates, Congress repealed legislation enacted in 1967 that had made federal highway funds contingent on adoption of helmet laws. At that point every state but California had passed a helmet law (although the Illinois law had been overturned by the state Supreme Court). Freed of the federal requirement, 27 states repealed their helmet laws or limited their coverage to minors (usually meaning riders under 18) during the next few years. Some of those states reinstated helmet requirements for adults in the 1980s and early '90s, including a few that acted after Congress again started tying highway funds to helmet laws in 1991. In 1995, largely in response to lobbying by the Motorcycle Riders Foundation, Congress again eliminated the helmet law mandate, and since then half a dozen states have repealed helmet requirements for adults (one of which, Louisiana, restored universal coverage last year).

As of July 2005, 30 states still allowed adult motorcyclists the freedom to decide for themselves what, if anything, to wear on their heads. But the insurance industry, safety groups, and the National Highway Traffic Safety Administration (NHTSA) continue to push universal helmet laws, which are periodically introduced by legislators even in states, such as Illinois and Minnesota, that have long allowed adults to ride without a helmet. Meanwhile, helmet law opponents are lobbying for repeal in California, West Virginia, and elsewhere.

To block or repeal helmet laws, activists must convince legislators to defy public opinion. While a 1978 Louis Harris poll found that 57 percent of Americans thought motorcyclists should be free to ride without helmets, a 2001 survey by the same organization found that 81 percent thought helmets should be required. Add to that the fact that the fatality rate per mile traveled is more than 25 times as high for motorcycles as it is for cars, and the success of helmet law opponents is even more impressive.

The main argument they've had to counter also plays a conspicuous role in debates over government efforts to discourage risky habits such as smoking, drinking, and overeating. As a 1991 report from the General Accounting Office put it, "society bears the cost, through tax-supported programs as well as insurance premiums, for the additional deaths and serious injuries resulting when motorcycle riders do not use helmets." The courts have almost uniformly approved this alarmingly open-ended rationale for regulation as part of the police power.

Having failed in the courts, helmet law opponents have fended off the "social cost" argument in state legislatures partly by noting that taxpayer expenses associated with injuries that might have been prevented by motorcycle helmets do not amount to much. Although riding a motorcycle is much riskier than driving a car, helmets are considerably less effective at preventing injuries than seat belts are. As NHTSA noted in a 1996 report to Congress, "Helmets cannot protect the rider from most types of injuries." Based on accident data from seven states, NHTSA estimated that motorists involved in crashes who wore seat belts were 20 percent less likely to be injured and 60 percent less likely to be killed than motorists who didn't. The figures for motorcyclists who wore helmets were 9 percent and 35 percent, respectively.

The lower rates are applied to a much smaller population, yielding estimates of lives saved, injuries prevented, and costs avoided that are far less impressive than the ones for seat belts, especially at the state level. NHTSA's numbers indicate that a universal helmet law would prevent about a dozen fatalities a year in Minnesota, for example. As Robert Illingworth of the Minnesota Motorcycle Riders Association bluntly put it in a 1992 interview with the Minneapolis Star Tribune, "We're talking about an insignificant amount of money and an insignificant amount of carnage."

"A Case of Not-So-Subtle Political Intimidation"

Even these modest projections are open to question. While NHTSA makes much of increased fatalities after states stop forcing adults to wear helmets, some of the additional deaths may be due to increased riding. Helmet law opponents argue that lifting the requirement makes riding more convenient, comfortable, and enjoyable, which encourages current riders to use their bikes more and spurs new registrations, many by motorcyclists who may be more prone to accidents because they are inexperienced or have not ridden in years.

A NHTSA study released in August illustrates the uncertainty about the impact of helmet laws. NHTSA found that motorcycle helmet use in Florida fell by about 50 percent after the state legislature repealed the requirement for riders 21 and older. Fatalities per 10,000 registered motorcycles in 2001 and 2002, the two years after the new law took effect, were 21 percent higher than in 1998 and 1999, the two years before the change.

Most of the additional deaths after 2000 cannot be attributed to the legal change, since the national motorcycle fatality rate rose by 13 percent during the same period, possibly due to an increase in riders with little experience and in older motorcyclists with slower response times. And while NHTSA took into account the 33 percent increase in registrations that Florida saw after the helmet law was changed, it does not have reliable state-level data for miles ridden, so it could not determine whether people who already had motorcycles started using them more. The bottom line is that decreased helmet use may well have contributed to the rise in fatalities, but it's not clear to what extent. The effect certainly was not as dramatic as implied by press reports, which focused on raw numbers instead of rates, downplayed the national trend, and gave short shrift to other possible contributing factors.

In addition to questioning the effectiveness of helmet laws, motorcycle activists sometimes suggest (in an argument that belies their professed agnosticism on the question of whether it's smart to wear a helmet) that helmets make accidents more likely because they increase fatigue and impair hearing, peripheral vision, and awareness of air pressure changes. Once an accident occurs, they argue, the added weight increases the risk of neck and spine injuries. James Baxter, president of the National Motorists Association and a former lobbyist on motorcycle issues, says the arguments suggesting that helmet laws cause injuries "have never been too well documented," but they "provided enough of an excuse for some legislators who wanted to get out from under the issue."

Another important factor that helped helmet law opponents was the decision by motorcycle manufacturers to stay out of the fight. Although a 2004 NHTSA pamphlet lists the Motorcycle Industry Council as a supporter of "universal motorcycle helmet laws," a spokesman for the group, Mike Mount, says it encourages motorcyclists to wear helmets but takes no position on whether they should be legally required to do so. "They are cowed into silence," says Chuck Hurley, executive director of Mothers Against Drunk Driving (MADD), who until this year ran the National Safety Council's Air Bag & Seat Belt Safety Campaign. "The most you'll get out of them is that helmets are a good idea."

If motorcycle manufacturers worry about antagonizing their customers, legislators worry about provoking single-issue voters with long memories. The key to resisting motorcycle helmet laws was convincing legislators they would pay at the polls for trying to force helmets onto adults. The laws' opponents did so in ways both dramatic and mundane. They rode into state capitals, thousands at a time, to protest existing laws or forestall new ones. They packed legislative hearing rooms. They met with legislators, wrote letters, and got involved in party politics. They campaigned for politicians who supported the right to ride without a helmet and against politicians who didn't.

The Minnesota Motorcycle Riders Foundation acquired enough clout to elicit a 1990 pledge from Gov. Arne Carlson to veto any bill extending the state's helmet requirement to adults. A couple of years later, a state legislator who had sponsored an unsuccessful helmet bill complained to the Minneapolis Star Tribune: "It's a case of not-so-subtle political intimidation. These [motorcyclists] are people who really feel negatively about something. They are the ones who'll get out and work very hard against you in your district and bad-mouth you."

Each year in Texas, where the legislature freed riders 21 or older from the state's helmet requirement in 1997, Texas ABATE brings several thousand riders in motorcycle attire to the state Capitol in Austin, where they walk the halls, knock on doors, and explain their point of view. Before 2000, when the Florida legislature narrowed the state's helmet law, ABATE of Florida members would ride into Tallahassee bareheaded, with a pre-arranged police escort, and ride out wearing helmets. "It was very orderly," says James "Doc" Reichenbach, the group's president. "This was done very professionally."

The example of Florida, where the helmet requirement for adults was in effect for more than three decades, suggests the importance of another trait: persistence. Opponents of helmet laws across the country "just kept pounding away at this issue," says Baxter. "I think a lot of legislators just felt it wasn't worth the trouble to them personally to get in these people's faces and have them camping on their doorstep, working against them in elections, supporting their opponents."

Buckle Up and Shut Up

As Melissa Savage, an analyst with the National Conference of State Legislatures, told the Chicago Tribune in 2003, "You don't see anything like this sort of well-organized opposition to seat-belt laws." In response to the first state law requiring adults to buckle up, which was approved by New York in 1984, a few defiant motorists wore T-shirts with seat belt straps sewn into them to create the illusion that they were complying. Others vented their objections in angry letters to legislators and Gov. Mario Cuomo, who dismissed them, in a 1985 interview with the Los Angeles Times, as "NRA hunters who drink beer, don't vote, and lie to their wives about where they were all weekend." Ballot initiatives, later reversed by state legislators, temporarily repealed seat belt laws in Massachusetts, Nebraska, and North Dakota. But generally speaking, says the National Motorists Association's Baxter, "there was no strong opposition. The legislators did not feel they would be affected by the consequences of their vote. There was no downside."

When the New York law was passed, the idea of fining people for riding unbelted was controversial. A 1982 Gallup survey found that 75 percent of Americans opposed such laws, and a Gallup survey conducted two years later, shortly after New York's law was approved, found 65 percent were still against the idea. But the swing in public opinion continued as more states adopted seat belt laws, culminating with Maine in 1995. Today every state except New Hampshire requires adults to wear seat belts, and polls indicate a large majority of the public not only supports such laws but favors primary enforcement, currently permitted in only 20 states and D.C.

One reason for the nearly complete triumph of seat belt laws is the numbers cited to support them. NHTSA estimates that seat belt laws save thousands of lives each year, compared to a few hundred that could be saved if every state had a universal helmet law. "Those numbers are just so much larger than they are related to motorcycles that they get [legislators'] attention," says John Ulczycki, transportation safety director at the National Safety Council.

The people wielding the numbers have also made a difference. In contrast to the motorcycle industry's stance on helmets, automakers played an early and conspicuous role in the debate over seat belt laws, which they began pushing in 1983 as an alternative to the air bags the federal government was threatening to require. That strategy took on a new urgency in 1984, when Secretary of Transportation Elizabeth Dole said the federal air bag mandate would begin to take effect in 1986 but would be lifted if seat belt laws covering at least two-thirds of the U.S. population had been passed by April 1989. (As with the drinking age, which every state has raised to 21 because of a 1984 law that threatened to cut off highway funding if they didn't, the supposedly federalist Reagan administration did not hesitate to impose its preferred traffic safety policies on the states through indirect means.) The auto industry set up a lobby group, Traffic Safety Now, and invested some $100 million to push seat belt laws in the hope of meeting Dole's deadline.

Insurance companies also lobbied for seat belt laws, but they did not want the air bag mandate lifted. Ultimately the insurers got what they wanted: mandatory seat belts and mandatory air bags. Although seat belt laws covering more than two-thirds of Americans were passed by May 1986, the laws did not meet Dole's specifications, which included primary enforcement and a minimum fine of $25. In a 1986 ruling, the U.S. Court of Appeals for the D.C. Circuit upheld Dole's authority to issue the conditional air bag mandate but noted that "none of these [seat belt] laws… apparently complies with the secretary's specific requirements."

Although Traffic Safety Now no longer exists, the auto industry supports organizations such as the National Safety Council that lobby for primary enforcement of seat belt laws. Widespread seat belt use helps reduce automakers' liability for car accident injuries and deaths, including those involving air bags, which can be especially dangerous when used without belts. Insurers, always looking for ways to reduce claims, likewise support primary enforcement (which the Insurance Institute for Highway Safety hopefully calls "standard enforcement") and fund groups such as Advocates for Highway and Auto Safety.

As states move toward primary enforcement (which the transportation bill signed by President Bush in August encourages them to do with a promise of extra highway money), seat belt laws may arouse more resentment and concern, especially since traffic stops can lead to further hassles, such as interrogation and examinations by drug-sniffing dogs. Fear of racially tinged police harassment was the main reason New Jersey, the second state to adopt a seat belt law, did not follow New York's lead in allowing primary enforcement, and most states copied the New Jersey model. "Do I think racial profiling is an issue ?" says MADD's Chuck Hurley, who lobbied for stricter seat belt laws when he worked at the National Safety Council. "Yes, I do." But Hurley doubts primary enforcement of seat belt laws will noticeably worsen the problem, and he argues that it makes sense as a matter of consistency: If you can be pulled over for a broken tail light, why not for failing to buckle up? One answer is that the broken tail light poses a potential hazard to others, while the unbuckled seat belt does not. But unless they want to repeal existing seat belt requirements, says Hurley, politicians who oppose primary enforcement are left to argue, rather implausibly, that it's "the Maginot Line between enough government and too much government."

It does seem unlikely that motorists who have become accustomed to wearing seat belts during the last two decades will suddenly rebel when enforcement becomes stricter. The national seat belt use rate (based on daytime surveys of drivers and front-seat passengers) gradually rose from less than 15 percent in 1984 to 80 percent in 2004. A desire to comply with the law and fear of fines no doubt had much to do with that trend, as did publicity about the potentially life-saving benefits of buckling up. Motorists who developed the habit as children copying their parents may not give any thought to the legal requirement, let alone harbor moral objections to it.

"We're Passionate About Our Motorcycles"

Which brings us back to the Quigley Factor. Why do motorcyclists seem to care so much more about helmet laws than drivers care about seat belt laws, when the underlying principle is the same?

Motorcyclists may have been quicker to recognize the importance of the principle because riding a motorcycle is much more dangerous than most other modes of transportation and forms of recreation. If the government can save lives and taxpayer money by requiring helmets, it could save even more by banning motorcycles altogether. The National Motorists Association's Baxter suggests that motorcyclists' consciousness of their minority status also fed their determination to resist helmet laws. "They knew that if they didn't directly get involved, nobody else was going to," he says.

The way helmet laws are enforced tends to confirm motorcyclists' sense of themselves as a picked-on minority. To begin with, police in states that require adults to use helmets have the authority to stop a motorcyclist simply for failing to wear one, while police in most states still need some other reason to stop a motorist before they can cite him for not buckling up. Even in states with primary seat belt enforcement, a helmetless motorcyclist is more conspicuous than an unbuckled motorist, making him more vulnerable to traffic stops. "The police really don't spot the guy not wearing a seat belt as much as a guy not wearing a helmet," says Texas ABATE'S Fletcher. "You can see [the helmetless motorcyclist] three blocks away." Because he cannot credibly attribute his noncompliance to forgetfulness, says Baxter, "a motorcyclist who doesn't wear a helmet is a direct affront to the enforcement community," which makes a stop even likelier and raises the potential for a hostile encounter. And once he is stopped, a motorcyclist may be forced to park his vehicle and walk, unlike an unbelted driver, who can simply buckle up and continue on his way after getting a warning or a ticket.

Another reason helmet laws provoke more resistance than seat belt laws is the comfort factor: While buckling up is relatively painless for most people, wearing a motorcycle helmet that weighs a few pounds and covers most of your head can be tiring and sweaty. "If it's really hot, I absolutely don't wear one," says ABATE of Florida's Reichenbach. "You sit at a stoplight, especially in Florida, you're sitting there in zoo percent humidity, and the sun is beating down on you, and that heat's coming up off the road, which is like 140, 150 degrees.… We've had people literally pass out at stoplights wearing helmets."

The view of helmets as confining and stifling meshes with the sentiment that forcing people to wear them ruins what is for many riders a visceral experience of freedom. "We're passionate about our motorcycles," says ABATE of California's Myke. "This is something that's more of a way of life than a hobby or a sport. It really goes to the core of our being.… Riding a motorcycle is my celebration of freedom." Few motorists feel the same way about driving, which for most of us is a workaday means of getting around, not an important part of our identities.

Hennie, head of the Motorcycle Riders Foundation, says it's hard for the uninitiated to understand how a method of transportation could acquire so much meaning. "If you've never ridden a motorcycle," he says, "there's no way to describe the feeling of freedom. It's got to be the next best thing to being able to fly. When you start putting restrictions on that freedom, people take it personally."

In the final analysis, not enough people took seat belt laws personally. For the most part, whatever objections they harbored were overcome by force of law and force of habit. By contrast, substantial numbers of motorcyclists have complained loudly, conspicuously, and persistently about helmet laws for more than three decades. "Apparently," says the National Safety Council's Ulczycki, "legislators are easily convinced that the perceived rights of motorcyclists to injure themselves are more important than the public good." Aside from the tendentious definition of "the public good," this gloss is misleading on two counts: Resistance to helmet laws hasn't been easy, and it hasn't necessarily involved convincing legislators of anything but the motorcyclists' determination. Politicians didn't have to understand their passion to respect it. And therein lies a lesson for the world's busybodies and petty tyrants.

PHOTO (COLOR)

~~~~~~~~

By Jacob Sullum

Senior Editor Jacob Sullum (jsullum@reason.com) is a syndicated columnist and the author of Saying Yes: In Defense of Drug Use (Tarcher/ Penguin).

Copyright of Reason is the property of Reason Foundation and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Article 2:

Title:

Quality-Adjusted Life-Years and Helmet Use Among Motorcyclists Sustaining Head Injuries.

Images

Authors:

Lee, Hsin-YiChen, Yeh-HsinChiu, Wen-TaHwang, Jing-ShiangWang, Jung-Der

Source:

American Journal of Public Health. Jan2010, Vol. 100 Issue 1, p165-170. 6p. 3 Charts, 1 Graph.

Document Type:

Article

Subject Terms:

*MOTORCYCLING injuries*MOTORCYCLE helmets*QUALITY-adjusted life years*QUALITY of life*MOTORCYCLISTS*HEAD injuries

Geographic Terms:

TAIWAN

Abstract:

Objectives. We estimated loss of quality-adjusted life expectancy (QALE) among motorcyclists in Taiwan who sustained head injuries while wearing or not wearing a helmet. Methods. Patients with head injuries (n=3328) were grouped into categories representing good and poor outcomes (moderate disability or death) at discharge. After linkage with the National Mortality Registry, survival functions were determined and extrapolated over a 50-year period on the basis of the survival ratio between patients and age- and gender-matched reference populations, as calculated from available Taiwan vital statistics. Survival functions were then multiplied by scores from quality-of-life measures. Results. Percentages of good and poor outcomes were 87.2% and 12.8%, respectively, in the helmeted group and 66.4% and 33.6% in the nonhelmeted group. The mean QALE for helmeted motorcyclists, calculated by weighting percentages of good and poor outcomes, was 31.7 quality-adjusted life-years (QALYs), with an average loss of 5.8 QALYs. For nonhelmeted motorcyclists, the mean QALE was 25.9 QALYs, with a loss of 10.7 QALYs. Conclusions. Helmet use could save approximately 5 QALYs among motorcyclists sustaining head injuries. Future cost-effectiveness analysis can calculate the incremental cost-effectiveness ratio for regulation of helmet use. (Am J Public Health. 2010;100:165-170. doi:10.2105/AJPH.2008.159004) [ABSTRACT FROM AUTHOR]

Copyright of American Journal of Public Health is the property of American Public Health Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Full Text Word Count:

4377

ISSN:

0090-0036

Accession Number:

47519843

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Quality-Adjusted Life-Years and Helmet Use Among Motorcyclists Sustaining Head Injuries 

Contents

METHODS

Extrapolation of Long-Term Survival

Quality-of-Life Values

Calculation of Quality-Adjusted Life Expectancy

RESULTS

DISCUSSION

Study Limitations and Strengths

Conclusions

TABLE 1 — Frequency Distributions in the Helmeted (n=2879) and Nonhelmeted (n=449) Patient Groups and Between-Group Comparisons: Taiwan, 2001-2007

TABLE 2 — Comparison of Characteristics Among Patients With Head Injuries Who Were Interviewed (n=190), Who Could Not Be Contacted (n=390), and Who Refused to Be Interviewed (n=20): Taiwan, 2001-2007

TABLE 3 — Life Expectancy and Quality-Adjusted Life Expectancy (QALE) in Years, by Outcome at Discharge and Helmet Use: Taiwan, 2001-2007

References

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Section:

RESEARCH AND PRACTICE

Objectives. We estimated loss of quality-adjusted life expectancy (QALE) among motorcyclists in Taiwan who sustained head injuries while wearing or not wearing a helmet.

Methods. Patients with head injuries (n=3328) were grouped into categories representing good and poor outcomes (moderate disability or death) at discharge. After linkage with the National Mortality Registry, survival functions were determined and extrapolated over a 50-year period on the basis of the survival ratio between patients and age- and gender-matched reference populations, as calculated from available Taiwan vital statistics. Survival functions were then multiplied by scores from quality-of-life measures.

Results. Percentages of good and poor outcomes were 87.2% and 12.8%, respectively, in the helmeted group and 66.4% and 33.6% in the nonhelmeted group. The mean QALE for helmeted motorcyclists, calculated by weighting percentages of good and poor outcomes, was 31.7 quality-adjusted life-years (QALYs), with an average loss of 5.8 QALYs. For nonhelmeted motorcyclists, the mean QALE was 25.9 QALYs, with a loss of 10.7 QALYs.

Conclusions. Helmet use could save approximately 5 QALYs among motorcyclists sustaining head injuries. Future cost-effectiveness analysis can calculate the incremental cost-effectiveness ratio for regulation of helmet use. (Am J Public Health. 2010;100:165-170. doi:10.2105/AJPH.2008.159004)

Motorcycles have become one of the most popular means of transportation in many developing countries, particularly in Asia, because of their convenience, affordability, and relatively high fuel efficiency.[ 1][ 2] However, relative to car drivers, motorcyclists are more easily injured, and are more often killed as a result of even minor collisions with other, larger vehicles.

According to traffic accident data from Taiwan's National Police Agency,[ 3] more than 1100 motorcyclists were killed on the country's roads in 2007, accounting for 59.7% of all traffic accident deaths. Furthermore, 57.1% of all motorcycle-related fatalities involved injuries to the head, thereby indicating a distinct correlation between motorcycle-related injury and head injury.

In a recent review of traffic accidents involving motorcyclists, Liu et al.[ 4] concluded that if motorcyclists are wearing a helmet at the time of the crash, their risk of death is reduced by 42%, and their risk of head injury is reduced by 69%. These findings have been corroborated in many other studies indicating that, after implementation and enforcement of laws requiring motorcyclists to wear helmets, there are clear reductions in motorcycle-related head injuries, the severity of such injuries, and the overall length of patient hospital stays.[ 5-7] Nevertheless, relatively few studies have set out to investigate the long-term effects of helmet protection among motorcyclists sustaining head injuries.

Many countries with national health insurance systems have been increasingly faced with a heavy financial burden, essentially as a result of an aging population and new forms of technology (e.g., gene therapy, positron emission tomography). Most of these countries have adopted economic analyses as a means of containing costs associated with medical care and increasing overall cost-effectiveness by improving the health outcomes achieved per dollar spent.[ 8] One of the most basic methods used to achieve such improvements is that of evaluating the cost per quality-adjusted life-year (QALY) gained from different health care services, an approach applied to ensure that preventive measures are competitive by saving more lives than would treatment after an illness occurs. The fundamental concept involves adjusting the survival function with the mean quality of life at each time point t and then summing this adjusted value over a lifetime. The resulting measure, "quality-adjusted life expectancy" (QALE), is expressed in the following equation[ 9-13]:

 Multiple line equation can not be convered into text.

where St|x denotes the survival function for condition x at time t and Qolt|x denotes the quality-of-kfe function for condition x at time If an age- and gender-matched referent can be simulated from the vital statistics for every case of condition x, one should be able to calculate the QALE for a general referent (in the present case, if a head injury had not occurred).

The difference between the QALE for head injury cases and referents just noted would be the expected loss of QALE for an average head injury case. In this study, we sought to quantify QALE and expected loss of QALE among motorcyclists in Taiwan who sustained head injuries while wearing or not wearing a helmet and to determine life-years saved as a result of helmet use in such cases.

METHODS

Our primary data source was the Head Injury Registry,[ 14] a system designed to monitor the epidemiology of traumatic head injuries in Taiwan. The registry includes in the definition of head injuries: brain concussions, contusions, skull bone fractures, brain damage with clear neurological deficits, clinically observable cognitive deficits, posttraumatic amnesia, neurological sequelae, and any evidence of intracranial hemorrhage. Head-injured motorcyclists are defined as motorcycle riders or passengers who, after having sustained direct or indirect trauma to the head, exhibit one or more of the aforementioned diagnoses.

Data on head injuries were recorded by experienced neurosurgeons from each of the hospitals included in the study and extracted by a research assistant from the Injury Prevention Center at Taipei Medical University to ensure consistent data quality. The procedure for ascertaining each case involved a careful review of inpatient medical records, examination of surviving motorcyclists with head injuries admitted to the hospital, review of death certificate data to determine the number of patients who died during the course of their treatment, and review of the deaths that occurred outside the hospital (e.g., at the scene of the accident) through the National Mortality Registry. Registry certificates were issued once a forensic examination indicated that brain injury was the primary cause of death.

Data on 3328 patients hospitalized as a result of motorcycle-related head injuries were collected from 22 major hospitals in Taipei City and 4 hospitals in Hualien County between 2001and 2007. The Glasgow Outcome Scale15 was used to categorize head injury outcome at the time of hospital discharge as follows: death, persistent vegetative state, severe disability (conscious but dependent), moderate disability (disabled but independent), or good recovery.

Although our primary aim was to investigate the difference between helmeted and nonhelmeted motorcyclists in terms of loss of QALYs, the outcome of the patient at discharge was considered to be the most important prognostic factor. Thus, in accordance with the Glasgow Outcome Scale, we divided our head injury cohort into 2 categories: those with good outcomes (good recovery) and those with poor outcomes (ranging from moderate disability to death). We used these categories to subsequently estimate and extrapolate survival functions and quality-of-life functions.

Extrapolation of Long-Term Survival

After verifying the survival status of patients by cross linking them with the updated database of the National Mortality Registry at the end of the follow-up period (December 31, 2007), we used the Kaplan-Meier method to estimate survival functions based on 2001 to 2007 follow-up data. Because a high percentage of these patients were still alive at the end of follow-up (survival rates were 92.6% and 85.5% for the helmeted and non-helmeted groups, respectively), we estimated the lifetime survival function by incorporating life expectancy data from the general population of Taiwan.[ 11-13] ,[ 16]

We assumed that head injuries might produce excess mortality, which could be quantified from following-up the cohort for a short period of time (5 years). If this excess mortality appeared to be a constant hazard in the chronic stage (1 or 2 years after the head injury), the long-term survival of our cohort could be projected from a survival function for an age-and gender-matched reference population.[ 11] ,[ 12] The survival function of this reference population can be generated, via the Monte Carlo method, from national vital statistics life tables.[ 12]

Also, we were able to obtain expected and mean quality-of-life values at each study time point by conducting a cross-sectional survey among the patients; these data served to adjust the survival curve.[ 13] In previous studies involving simulation[ 11] and mathematical16 methods, we have shown that this is a valid means of predicting life expectancy, even when the censored rate is above 50%; it has also been corroborated by several real-world examples.[16 -19]

Quality-of-Life Values

We used the Eurool 5-dimensional (EQ-5D) questionnaire, a preference-based, generic, self-reported instrument,[ 20][ 21] to estimate quality-of-life values for helmeted and nonhelmeted motorcyclists who sustained head injuries. This instrument has been extensively used as an outcome measure[ 22-24]; the Chinese version was developed in Taiwan, along with the value categorization used in this study.[ 25]

The 5 dimensions encompassed in the questionnaire are mobility, self-care, usual activities, pain-discomfort, and anxiety-depression, with 3 levels of severity (no problems, some or moderate problems, and severe or extreme problems). The resulting utility value is coded from 0 to 1 (on the basis of the 5-dimensional classification), where 1 indicates optimal health.[ 21]

Using computer-generated random numbers, we selected a cross-sectional sample of 600 surviving patients from the Head Injury Registry. Telephone contact numbers were obtained from the members of this sample when they were admitted to the hospital; survivors were subsequently contacted by telephone after their discharge to determine their willingness to participate in our study. In cases in which patients were unable to answer the questionnaire, their family members were invited to provide the necessary information.

Between January and March 2008, 190 patients were successfully interviewed (response rate: 31.7%). Excluding the 20 patients who refused to be interviewed, most of the others who did not respond had changed their telephone number or could not be reached after 3 calls. To examine the representativeness of the interviewed sample, we conducted a supplementary analysis in which we compared selected characteristics (e.g., age, gender, severity of injury) of those who were interviewed, those who could not be reached, and those who refused to be interviewed.

Also, we asked patients who had sustained their injury in 2007 to recall their health condition at the time of their discharge from the hospital, given that their injuries had occurred within a short period before their interview (less than 1.2 years) and recall bias would thus be minimal. As a result, these patients could contribute 2 or more data points of quality of life to our study. We used smoothing methodology to estimate differences in duration of time after occurrence of head injury, and we assumed that the utility value for all hypothetical referents was 1 throughout the survival of the sample patient.

Calculation of Quality-Adjusted Life Expectancy

After calculating lifetime survival functions for the groups with good and poor outcomes, we adjusted these values according to the corresponding quality-of-life function and the period of time after the occurrence of the head injury to calculate QALE on the basis of an 80-month follow-up period and 50 years of extrapolation.13 Given that the mean age of our cohort was approximately 37 years and the average life expectancy of the Taiwanese population in 2007 was 78.4 years, we believed that a 50-year extrapolation could approximate lifelong utility loss among patients sustaining a head injury.

To facilitate our analyses, we used the software program MC-QAS (http://www.stat.sinica.edu.tw/jshwang), built on the R statistical package. The validity of this program in extrapolating long-term survival data has been established in previous studies, including those focusing on permanent disability from occupational injuries,[ 17] HIV infection,[ 16] and cancer.[ 19] We calculated average QALE values for helmeted and nonhelmeted motorcyclists by weighting the respective percentages of good and poor outcomes and then summing these percentages.

RESULTS

The basic characteristics of the 3328 members of our cohort are summarized in Table 1. There were no significant age or gender differences between helmeted and nonhelmeted motorcyclists. However, the rate of helmet use was much higher in urban Taipei City (71.3%) than in rural Hualien County (28.7%).

Nonhelmeted motorcyclists had longer average intensive care unit stays and worse outcomes at discharge than helmeted motorcyclists. No significant demographic or helmet use differences were observed among patients who were interviewed, those who could not be reached, and those who refused to be interviewed (Table 2 ), although the proportion of good outcomes at discharge appeared to be slightly lower among respondents than among nonrespondents. Finally, Taipei City residents made up a higher percentage of the interviewed group (70.5%) than they did of the other groups (approximately 50%).

An independent-sample t test showed that the mean utility score for poor outcomes was 0.7 (SD=0.3; P<.01), significantly lower than the mean utility score for good outcomes (0.9; SD=0.2). Patients with good outcomes were also found to have a longer QALE than those with poor outcomes, as illustrated in Figure 1.

Life expectancies and QALE values, by discharge outcome and helmet use, are summarized in Table 3. After the proportions of the 2 outcome categories were weighted among helmeted and nonhelmeted motorcyclists (Table 1), the QALE of the typical helmeted motorcyclist after 50 years of extrapolation was 31.7 QALYs, representing a loss of 5.8 QALYs relative to a hypothetical age- and gender-matched reference group. Among non-helmeted motorcyclists, the estimated QALE after 50 years of extrapolation was 25.9 QALYs, with a greater loss (10.7 QALYs) relative to the reference group.

DISCUSSION

Although previous studies have documented the protective effects of helmets in reducing mortality and improving short-term outcomes among motorcyclists,[ 4-7][ 26] relatively few of these studies have focused on the long-term health benefits of wearing a helmet. One of the major challenges faced in such research is that most patients who have sustained head injuries survive for long periods. If a head injury cohort is not followed for a sufficiently long period, the result is often a high censored rate (above 50%), and the research team would not be able to obtain the lifetime survival function for estimation of QALE required by the conventional method.[ 27] To the best of our knowledge, ours is the first study of its kind to estimate the lifelong utility losses of helmeted and nonhelmeted motorcyclists sustaining head injuries. To determine the validity of our basic assumption, a constant excess mortality rate associated with head injuries, we initially estimated the QALE of patients with head injuries according to outcome at discharge. This strategy helped ensure the homogeneity of our subcohorts, with a stable survival ratio relative to the reference population after the first several years of follow-up.

The percentage of good outcomes was higher among helmeted motorcyclists (87.2%) than among nonhelmeted motorcyclists (66.4%), and thus the weighted average QALE loss in the helmeted group was below that of the nonhelmeted group (5.8 versus 10.7). In other words, use of a helmet can save an average of approximately 5 QALYs among individuals sustaining head injuries as a result of motorcycle accidents.

In an earlier study, Tsauo et al.[ 28] found that the average QALE loss for a single head injury case was 4.8 QALYs, lower than the values we found (Table 3). The difference in these findings may be attributable to a pair of factors. First, there was a 12-year gap in the data periods used in the 2 studies. The QALE loss in our study relative to the reference population might have been slightly increased because there was a 2-year increase in the average life expectancy of the general population[ 29] at the time of our study as compared with the average at the time of the Tsauo et al. study.

Second, Tsauo et al.[ 28] included only cases occurring within Taipei City, where the rate of good outcomes at discharge (88.2%) tends to be higher than that of our cohort from Taipei and Hualien. Although they did not report the percentage of helmet use in their study population, the rate of good outcomes in their study is comparable to the rate among helmeted motorcyclists in our study (87.2%) and much higher than that among nonhelmeted motorcyclists (66.4%), whose life expectancy would presumably be shorter.

Study Limitations and Strengths

One of the major limitations of our study was the low response rate (31.7%). As mentioned, to examine the representativeness of the sample, we compared the characteristics of respondents and nonrespondents. Although nonrespondents were more common in Hualien County, there were no significant between-group differences in terms of age, gender, number of days spent in intensive care units or general wards, helmet use rat

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