Elsevier

Injury

Volume 35, Issue 11, November 2004, Pages 1116-1127
Injury

Risk of disability due to car crashes: a review of the literature and methodological issues

https://doi.org/10.1016/j.injury.2003.12.016Get rights and content

Abstract

With improving rates of survival following road traffic injuries in many countries, healthy years of life lost due to crashes increasingly reflect the prevalence of disabling sequelae. This review examines the epidemiological evidence regarding the risk of disability due to car crashes, published between 1980 and 2002. Studies of sequelae limited to specific domains (e.g. head injury, whiplash, psychiatric morbidity) were excluded. Of the 19 studies meeting the criteria for review, most focused on the prevalence of disability following crashes but not the association between them. Prevalence estimates of post-crash disability varied from 2 to 87%. The potential sources of heterogeneity included differences in study settings and period, duration of follow-up, and definitions of exposure and outcome. Methodological problems that compounded the difficulties in interpretation and generalisability of study findings included selection biases and use of non-representative samples, idiosyncratic outcome measures, inadequate adjustment for confounding, and the prevailing medico-legal or compensation context. The findings highlight the need for well-designed population-based epidemiological studies using validated outcome measures and appropriate comparison groups to determine the independent risk of disability due to car crashes. The review also revealed a critical need for data from low- and middle-income countries, the setting for over 90% of the estimated global burden of road traffic injury.

Introduction

Despite well-publicised declines in traffic fatality rates in many industrialised countries, the impact of crashes on the loss of healthy years of life remains largely speculative.41 This reflects a lack of reliable data on non-fatal outcomes following crashes even in countries where detailed mortality statistics are assembled annually.62 In much of the world, routinely collected data on crash-related disability are non-existent or inaccessible.47

Assessors of the research evidence concur that a significant proportion of crash survivors experience long-term morbidity, but there is little agreement about the magnitude of this risk.7., 8., 32., 35., 38., 43., 44., 50. Furthermore, previous commentaries have primarily focused on psychiatric sequelae, whiplash-associated disorders, or injuries to the head and extremities.

With the global burden of road traffic injuries projected to rank as the third leading cause of disability-adjusted life years by 2020,41 it is vital to review the epidemiological evidence and identify gaps in knowledge regarding the magnitude and determinants of post-crash disability. This should help inform public policy, preventive interventions and health services. It may also change our perception of priorities.41

We conducted a systematic review of the epidemiological literature investigating the risk of disability due to car crashes. The review was restricted to car occupants as the patterns and consequences of injuries vary by the road user group.26., 36., 59. In addition to constituting the commonest road casualty group in most industrialised countries, injured car occupants are of increasing concern in many rapidly motorising low- and middle-income countries. Furthermore, an initial scan of the literature revealed car occupants to be the focus of much of the published literature on road crash-related disability. The specific objectives of the review were to critically appraise the evidence quantifying the risk of disability to crashes in this road user group, examine the methodological strengths and weaknesses of relevant studies, and determine the implications for future research into road traffic crash-related disability more generally.

Section snippets

Methods

We sought studies published between January 1980 and December 2002 that examined the risk of disability following involvement in a car crash. Pre-1980 publications were excluded due to important changes in crash-related injury since the introduction of seat-belt legislation. In the absence of a universally accepted objectively defined measure, outcomes related to current concepts of disability (e.g. functional limitations, psychosocial consequences, reduced quality of life) were considered

Results

Of the approximately 750 studies identified from the combined search strategy, 68 were considered potentially relevant based on the title or abstract and the full-text retrieved for detailed evaluation.

Discussion

Of the 19 studies reviewed, only one investigated the extent to which involvement in crashes increased the risk of disability among car occupants, independent of other causes.30 Most studies focused on the prevalence of disability following crashes but not the association between them. Period effects (e.g. seat-belt legislation, changes in the vehicle fleet such as age and presence of airbags, and characteristics of road networks), selection biases, idiosyncratic outcome measures, residual

Acknowledgements

We gratefully acknowledge the assistance of information specialists at the Ministry of Transport, Ministry of Health, Land Transport Safety Authority and Accident Compensation Corporation of New Zealand in searching institutional bibliographic databases. We also acknowledge the valuable feedback from the anonymous reviewers. This work was funded by a project grant from the Health Research Council of New Zealand.

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