Risk Factors and Inequities in Transportation Injury and Mortality in the Canadian Census Health and Environment Cohorts (CanCHECs).

BACKGROUND: Road traffic injury contributes substantially to morbidity and mortality. Canada stands out among developed countries in not conducting a national household travel survey, leading to a dearth of national transportation mode data and risk calculations that have appropriate denominators. Since traffic injuries are specific to the mode of travel used, these risk calculations should consider travel mode. METHODS: Census data on mode of commute is one of the few sources of these data for persons aged 15 and over. This study leveraged a national data linkage cohort, the Canadian Census Health and Environment Cohorts, that connects census sociodemographic and commute mode data with records of deaths and hospitalizations, enabling assessment of road traffic injury associations by indicators of mode of travel (commuter mode). We examined longitudinal (1996-2019) bicyclist, pedestrian, and motor vehicle occupant injury and fatality risk in the Canadian Census Health and Environment Cohorts by commuter mode and sociodemographic characteristics using Cox proportional hazards models within the working adult population. RESULTS: We estimated positive associations between commute mode and same mode injury and fatality, particularly for bicycle commuters (hazard ratios for bicycling injury was 9.1 and for bicycling fatality was 11). Low-income populations and Indigenous people had increased injury risk across all modes. CONCLUSIONS: This study shows inequities in transportation injury risk in Canada and underscores the importance of adjusting for mode of travel when examining differences between population groups.

Comparison of the number of pedestrian and cyclist injuries captured in police data compared with health service utilisation data in Toronto, Canada 2016-2021.

INTRODUCTION: Pedestrian and cyclist injuries represent a preventable burden to Canadians. Police-reported collision data include information on where such collisions occur but under-report the number of collisions. The primary objective of this study was to compare the number of police-reported collisions with emergency department (ED) visits and hospitalisations in Toronto, Canada. METHODS: Police-reported collisions were provided by Toronto Police Services (TPS). Data included the location of the collision, approximate victim age and whether the pedestrian or cyclist was killed or seriously injured. Health services data included ED visits in the National Ambulatory Care Reporting System and hospitalisations from the Discharge Abstract Database using ICD-10 codes for pedestrian and cycling injuries. Data were compared from 2016 to 2021. RESULTS: Injuries reported in the health service data were higher than those reported in the TPS for cyclists and pedestrians. The discrepancy was the largest for cyclists treated in the ED, with TPS capturing 7.9% of all cycling injuries. Cyclist injuries not involving a motor vehicle have increased since the start of the pandemic (from 3629 in 2019 to 5459 in 2020 for ED visits and from 251 in 2019 to 430 for hospital admissions). IMPLICATIONS: While police-reported data are important, it under-reports the burden. There have been increases in cyclist collisions not involving motor vehicles and decreases in pedestrian injuries since the start of the pandemic. The results suggest that using police data alone when planning for road safety is inadequate, and that linkage with other health service data is essential.

Motor vehicle collision (MVC) emergency department (ED) visits and hospitalisations in Ontario during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic policy response dramatically changed local transportation patterns. This project investigated the impact of COVID-19 policies on motor vehicle collision (MVC)-related emergency department (ED) visits and hospitalisations in Ontario. METHODS: Data were collected on MVC-related ED visits and hospitalisations in Ontario between March 2016 and December 2022. Using an interrupted time series design, negative binomial regression models were fitted to the pre-pandemic data, including monthly indicator variables for seasonality and accounting for autocorrelation. Extrapolations simulated expected outcome trajectories during the pandemic, which were compared with actual observed outcome counts using the overall per cent change and mean monthly difference. Data were modelled separately for vehicle occupants, pedestrians and cyclists (MVC and non-MVC injuries). RESULTS: There was a 31.5% decrease in observed ED visits (95% CI -35.4 to -27.3) and a 6.0% decrease in hospitalisations (95% CI -13.2 to 1.6) among vehicle occupants, relative to expected counts during the pandemic. Results were similar for pedestrians. Among cyclist MVCs, there was an increase in ED visits (12.8%, 95% CI -8.2 to 39.4) and hospitalisations (46.0%, 95% CI 11.6 to 93.6). Among non-MVC cyclists, there was also an increase in ED visits (47.0%, 95% CI 12.5 to 86.8) and hospitalisations (50.1%, 95% CI 8.2 to 101.2). CONCLUSIONS: We observed fewer vehicle occupant and pedestrian collision injuries than expected during the pandemic. By contrast, we observed more cycling injuries than expected, especially in cycling injuries not involving motor vehicles. These observations may be attributable to changes in transportation patterns during the pandemic and increased uptake of recreational cycling.

Traffic-Calming Measures and Road Traffic Collisions and Injuries: a Spatiotemporal Analysis.

Traffic-calming measures (TCMs) are physical modifications to the road network aimed at making the roads safer. Although studies have reported reductions in road crashes and injuries tied to the presence of TCMs, they have been criticized for their pre-post designs. This study aims to complement our knowledge of TCMs effectiveness by assessing their impact using a longitudinal design. The implementation of eight TCMs, including curb extensions and speed humps, was evaluated at the intersections and census tract levels in Montreal, Canada from 2012 to 2019. The primary outcome was fatal or serious collisions among all road users. Inference was performed using a Bayesian implementation of Conditional Poisson regression in which random effects were used to account for the spatiotemporal variation in collisions. TCMs were generally implemented on local roads, although most collisions occurred on arterial roads. Overall, there was weak evidence that TCMs were associated with study outcomes. However, subgroup analyses of intersections on local roads suggested a reduction in collision rates due to TCMs (median IRR: 0.31; 95% Credible Interval: 0.12 - 0.86). To improve road safety, effective counterparts of TCMs on arterial roads must be identified and implemented.

Is higher school neighbourhood Walk Score associated with greater child pedestrian safety near schools?

Walk Score is a common index used to estimate how suitable the built environment is for walking. Although Walk Score has been extensively validated as a measure of walkability and walking, there are limited studies examining whether commonly used constructs of walkability are associated with traffic safety in children. This study examined the association between Walk Score and child pedestrian injury controlling for observed walking exposure in school zones in Calgary, Toronto and Montreal, Canada. Results indicate that a higher Walk Score was associated with more child pedestrian injuries in all three cities, even after controlling for walking exposure. School travel planning should consider established individual pedestrian collision risk and individual factors rather than assuming a highly walkable environment is also a safe pedestrian environment.

Blame attribution analysis of police motor vehicle collision reports involving child bicyclists.

BACKGROUND: Injuries resulting from collisions between a bicyclist and driver are preventable and have high economic, personal and societal costs. Studying the language choices used by police officers to describe factors responsible for child bicyclist-motor vehicle collisions may help shift prevention efforts away from vulnerable road users to motorists and the environment. The overall aim was to investigate how police officers attribute blame in child (≤18 years) bicycle-motor vehicle collision scenarios. METHODS: A document analysis approach was used to analyse Alberta Transportation police collision reports from Calgary and Edmonton (2016-2017). Collision reports were categorised by the research team according to perceived blame (child, driver, both, neither, unsure). Content analysis was then used to examine police officer language choices. A narrative thematic analysis of the individual, behavioural, structural and environmental factors leading to collision blame was then conducted. RESULTS: Of 171 police collision reports included, child bicyclists were perceived to be at fault in 78 reports (45.6%) and adult drivers were perceived at fault in 85 reports (49.7%). Child bicyclists were portrayed through language choices as being irresponsible and irrational, leading to interactions with drivers and collisions. Risk perception issues were also mentioned frequently in relation to poor decisions made by child bicyclists. Most police officer reports discussed road user behaviours, and children were frequently blamed for collisions. CONCLUSIONS: This work provides an opportunity to re-examine perceptions of factors related to motor vehicle and child bicyclist collisions with a view to prevention.

Pilot study to evaluate school safety zone built environment interventions.

BACKGROUND: School safety zones were created in 2017 under the City of Toronto's Vision Zero Road Safety Plan. This pilot study examined the effect of built environment interventions on driver speeds, active school transportation (AST) and dangerous driving. METHODS: Interventions were implemented at 34 schools and 45 matched controls (2017-2019). Drivers travelling over the speed limit of >30 km/hour and 85th percentile speeds were measured using pneumatic speed tubes at school frontages. Observers examined AST and dangerous driving at school arrival times. Repeated measures beta and multiple regression analyses were used to study the intervention effects. RESULTS: Most schools had posted speed limits of 40 km/hour (58%) or ≥50 km/hour (23%). A decrease in drivers travelling over the speed limit was observed at intervention schools post-intervention (from 44% to 40%; OR 0.79, 95% CI 0.66 to 0.96). Seventy-one per cent of drivers travelled >30 km/hour and the 85th percentile speed was 47 km/hour at intervention schools, with no change in either postintervention. There were no changes in speed metrics in the controls. AST increased by 5% (OR 1.22, 95% CI 0.97 to 1.54) at intervention schools. Reductions in dangerous driving were observed at all schools. CONCLUSIONS: Posted speed limits were >30 km/hour at most schools and high proportions of drivers were travelling above the speed limits. There were reductions in drivers exceeding the speed limit and in dangerous driving, and modest increased AST post intervention. Bolder interventions to slow traffic are required to effectively reduce speeding around schools, which may increase safe AST.

Child pedestrian and cyclist injuries, and the built and social environment across Canadian cities: the Child Active Transportation Safety and the Environment Study (CHASE).

INTRODUCTION: Traffic injury is a leading and preventable cause of child death and disability, with child pedestrians and cyclists particularly vulnerable. Examining built environment correlates of child pedestrian and cyclist motor vehicle collisions (PCMVC) in different settings is needed to promote an evidence-based approach to road safety. METHODS: We conducted a cross-sectional study across multiple urban/suburban environments in Canada (Calgary, Toronto, Montreal, Laval, Peel Region). All public elementary schools were included (n=1030). We examined the role of land use/social environments, road environments and traffic safety interventions on the rates of child PCMVC within 1000 m of schools. Multivariable negative binomial regression was conducted for all cities and by individual city. In a subset of schools (n=389), we examined associations when controlling for active school transportation (AST). RESULTS: Mean PCMVC rate per school ranged from 0.13 collisions/year in Peel to 0.35 in Montreal. Child PCMVC were correlated with land use, social and road environments and traffic safety interventions. In fully adjusted models, social and land use features remained the most important correlates. New immigrant population had the largest positive association with child PCMVC (incidence rate ratio (IRR): 1.26, 95% CI 1.06 to 1.50), while old housing (pre-1960) density was most protective (IRR: 0.83, 95% CI 0.77 to 0.90). AST was associated with PCMVC, but it had no effect on the relationships between PCMVC and other social/environmental correlates. CONCLUSION: The built environment and social factors influence rates of child PCMVC. Opportunities to reduce child PCMVC exist through modifications to city design and road environments and implementing traffic safety interventions.

Active school transportation and the built environment across Canadian cities: Findings from the child active transportation safety and the environment (CHASE) study.

Walking and bicycling to school (active school transportation, AST) has been in decline for decades in North America and globally with the rise of automobility. This cross-sectional study estimated associations between the built environment and AST in seven Canadian communities. We observed the travel behaviours of almost 118,000 students at 552 schools. Using beta regression, we modeled the proportion of children using AST, considering built environment and social environment factors around schools. Across all schools, the average proportion of children using AST was 54.3% (SD 18.9%), with variability among cities from a low of 39.5% (SD 22.1%) in Laval, Quebec to 69.7% (SD 18.1%) in Montreal, Quebec. Overall, several modifiable road design features were associated with AST, including the presence of school crossing guards, cycling infrastructure, Walk Score® and traffic signal density. There was variability in the directionality and statistical significance of associations with design variables across cities, suggesting that the local context and directed local interventions are important to support AST. Natural experiment studies are necessary to examine local approaches related to the built environment to increase AST and ensure appropriate new policy and program interventions are developed.

Methodological considerations in MVC epidemiological research.

BACKGROUND: The global burden of MVC injuries and deaths among vulnerable road users, has led to the implementation of prevention programmes and policies at the local and national level. MVC epidemiological research is key to quantifying MVC burden, identifying risk factors and evaluating interventions. There are, however, several methodological considerations in MVC epidemiological research. METHODS: This manuscript collates and describes methodological considerations in MVC epidemiological research, using examples drawn from published studies, with a focus on the vulnerable road user population of children and adolescents. RESULTS: Methodological considerations in MVC epidemiological research include the availability and quality of data to measure counts and calculate event rates and challenges in evaluation related to study design, measurement and statistical analysis. Recommendations include innovative data collection (eg, naturalistic design, stepped-wedge clinical trials), combining data sources for a more comprehensive representation of collision events, and the use of machine learning/artificial intelligence for large data sets. CONCLUSIONS: MVC epidemiological research can be challenging at all levels: data capture and quality, study design, measurement and analysis. Addressing these challenges using innovative data collection and analysis methods is required.

State-of-the-art review: preventing child and youth pedestrian motor vehicle collisions: critical issues and future directions.

AIM: To undertake a comprehensive review of the best available evidence related to risk factors for child pedestrian motor vehicle collision (PMVC), as well as identification of established and emerging prevention strategies. METHODS: Articles on risk factors were identified through a search of English language publications listed in Medline, Embase, Transport, SafetyLit, Web of Science, CINHAL, Scopus and PsycINFO within the last 30 years (~1989 onwards). RESULTS: This state-of-the-art review uses the road safety Safe System approach as a new lens to examine three risk factor domains affecting child pedestrian safety (built environment, drivers and vehicles) and four cross-cutting critical issues (reliable collision and exposure data, evaluation of interventions, evidence-based policy and intersectoral collaboration). CONCLUSIONS: Research conducted over the past 30 years has reported extensively on child PMVC risk factors. The challenge facing us now is how to move these findings into action and intervene to reduce the child PMVC injury and fatality rates worldwide.

Spatial distribution of roadway environment features related to child pedestrian safety by census tract income in Toronto, Canada.

BACKGROUND: Investments in traffic calming infrastructure and other street design features can enhance pedestrian safety as well as contribute to the 'walkability' of neighbourhoods. Pedestrian-motor vehicle collisions (PMVCs) in urban areas, however, remain common and occur more frequently in lower income neighbourhoods. While risk and protective features of roadways related to PMVC have been identified, little research exists examining the distribution of roadway environment features. This study examined the relationship between roadway environment features related to child pedestrian safety and census tract income status in Toronto. METHODS: Spatial cluster detection based on 2006 census tract data identified low-income and high-income census tract clusters in Toronto. Police-reported PMVC data involving children between the ages of 5 and 14 years were mapped using geographical information system. Also mapped were roadway environment features (densities of speed humps, crossing guards, local roads, one-way streets and missing sidewalks). Multivariate logistic regression was used to examine the relationship between roadway environment features (independent variables) and cluster income status (dependent variable), controlling for child census tract population. RESULTS: There were significantly fewer speed humps and local roads in low-income versus high-income clusters. Child PMVC rates were 5.4 times higher in low-income versus high-income clusters. CONCLUSION: Socioeconomic inequities in the distribution of roadway environment features related to child pedestrian safety have policy and process implications related to the safety of child pedestrians in urban neighbourhoods.

Effect of reducing the posted speed limit to 30 km per hour on pedestrian motor vehicle collisions in Toronto, Canada - a quasi experimental, pre-post study.

BACKGROUND: Pedestrian related deaths have recently been on the rise in Canada. The effect of changing posted speeds on the frequency and severity of pedestrian motor vehicle collisions (PMVC) is not well studied using controlled quasi-experimental designs. The objective of this study was to examine the effect of lowering speed limits from 40 km/h to 30 km/h on PMVC on local roads in Toronto, Canada. METHODS: A 30 km/h speed limit on local roads in Toronto was implemented between January 2015 and December 2016. Streets that remained at a 40 km/h speed limit throughout the study period were selected as comparators. A quasi-experimental, pre-post study with a comparator group was used to evaluate the effect of the intervention on PMVC rates before and after the speed limit change using repeated measures Poisson regression. PMVC data were obtained from police reports for a minimum of two years pre- and post-intervention (2013 to 2018). RESULTS: Speed limit reductions from 40 km/h to 30 km/h were associated with a 28% decrease in the PMVC incidence rate in the City of Toronto (IRR = 0.72, 95% CI: 0.58-0.89). A non-significant 7% decrease in PMVC incidence rates were observed on comparator streets that remained at 40 km/h speed limits (IRR = 0.93, 95% CI: 0.70-1.25). Speed limit reduction also influenced injury severity, with a significant 67% decrease in major and fatal injuries in the post intervention period on streets with speed limit reductions (IRR = 0.33, 95% CI: 0.13-0.85) compared with a 31% not statistically significant decrease in major and fatal injuries on comparator streets (IRR = 0.69, 95% CI: 0.37-1.31). The interaction term for group and pre-post comparisons was not statistically significant (p = 0.14) indicating that there was no evidence to suggest a pre-post difference in IRRs between the intervention and comparator streets. CONCLUSIONS: Declines in the rate of PMVC were observed on roads with posted speed limit reductions from 40 km/h to 30 km/h, although this effect was not statistically greater than reductions on comparator streets.

Spatial distribution of pedestrian-motor vehicle collisions before and after pedestrian countdown signal installation in Toronto, Canada.

BACKGROUND: Pedestrian countdown signals (PCS) have been installed in many cities over the last 15 years. Few studies have evaluated the effectiveness of PCS on pedestrian motor vehicle collisions (PMVC). This exploratory study compared the spatial patterns of collisions pre and post PCS installation at PCS intersections and intersections or roadways without PCS in Toronto, and examined differences by age. METHODS: PCS were installed at the majority of Toronto intersections from 2007 to 2009. Spatial patterns were compared between 4 years of police-reported PMVC prior to PCS installation to 4 years post installation at 1864 intersections. The spatial distribution of PMVC was estimated using kernel density estimates and simple point patterns examined changes in spatial patterns overall and stratified by age. Areas of higher or lower point density pre to post installation were identified. RESULTS: There were 14 911 PMVC included in the analysis. There was an overall reduction in PMVC post PCS installation at both PCS locations and non-PCS locations, with a greater reduction at non-PCS locations (22% vs 1%). There was an increase in PMVC involving adults (5%) and older adults (9%) at PCS locations after installation, with increased adult PMVC concentrated downtown, and older adult increases occurring throughout the city following no spatial pattern. There was a reduction in children's PMVC at both PCS and non-PCS locations, with greater reductions at non-PCS locations (35% vs 48%). CONCLUSIONS: Results suggest that the effects of PCS on PMVC may vary by age and location, illustrating the usefulness of exploratory spatial data analysis approaches in road safety. The age and location effects need to be understood in order to consistently improve pedestrian mobility and safety using PCS.

Recent trends in child and youth emergency department visits because of pedestrian motor vehicle collisions by socioeconomic status in Ontario, Canada.

BACKGROUND: Children in lower-income households have higher injury rates. Trends in emergency department (ED) visits by children 0-19 years because of pedestrian motor vehicle collisions (PMVCs) in Ontario, Canada (2008-2015) by socioeconomic status were examined. METHODS: PMVC ED data were obtained from the Institute for Clinical Evaluative Sciences for children age 0-19 years over the period 2008-2015. Age-adjusted rates were calculated using Ontario census data. Household income quintiles were determined from the Registered Persons Database. Poisson regression was used to model ED visit rates by year, age and income quintile. RESULTS: The frequency of child PMVC ED visits in Ontario decreased from 1562 in 2008 to 1281 in 2015. Age-adjusted rates were unchanged over time (IRR 1.00, 95% CI 0.99 to 1.00); however, rate disparities by income status persisted with an IRR of 0.52 (0.50 to 0.55) comparing the highest with the lowest income level. CONCLUSIONS: Exposure to traffic may play a role in rate disparities by income status in child PMVC; however, less safe traffic environments in lower income areas may also be strong contributors. These findings highlight the potential impact of roadway safety modifications in lower income areas to mitigate disparities in injury rates by socioeconomic status.

The built environment and active transportation safety in children and youth: a study protocol.

BACKGROUND: Active transportation, such as walking and biking, is a healthy way for children to explore their environment and develop independence. However, children can be injured while walking and biking. Many cities make changes to the built environment (e.g., traffic calming features, separated bike lanes) to keep people safe. There is some research on how effective these changes are in preventing adult pedestrians and bicyclists from getting hurt, but very little research has been done to show how safe various environments are for children and youth. Our research program will study how features of the built environment affect whether children travel (e.g., to school) using active modes, and whether certain features increase or decrease their likelihood of injury. METHODS: First, we will use a cross-sectional study design to estimate associations between objectively measured built environment and objectively measured active transportation to school among child elementary students. We will examine the associations between objectively measured built environment and child and youth pedestrian-motor vehicle collisions (MVCs) and bicyclist-MVCs. We will also use these data to determine the space-time distribution of pedestrian-MVCs and bicyclist-MVCs. Second, we will use a case-crossover design to compare the built environment characteristics of the site where child and youth bicyclists sustain emergency department reported injuries and two randomly selected sites (control sites) along the bicyclist's route before the injury occurred. Third, to identify implementation strategies for built environment change at the municipal level to encourage active transportation we will conduct: 1) an environmental scan, 2) key informant interviews, 3) focus groups, and 4) a national survey to identify facilitators and barriers for implementing built environment change in municipalities. Finally, we will develop a built environment implementation toolkit to promote active transportation and prevent child pedestrian and bicyclist injuries. DISCUSSION: This program of research will identify the built environment associated with active transportation safety and form an evidence base from which municipalities can draw information to support change. Our team's national scope will be invaluable in providing information regarding the variability in built environment characteristics and is vital to producing evidence-based recommendations that will increase safe active transportation.

Annual Trends in Follow-Up Visits for Pediatric Concussion in Emergency Departments and Physicians' Offices.

OBJECTIVE: To assess whether children and youth with concussion receive follow-up visits in accordance with the recommended guidelines. STUDY DESIGN: We conducted a retrospective, population-based study using linked health administrative data from all concussion-related visits to emergency department and physician offices by children aged 5 through 18 years (range, 5.00-18.99) in Ontario between 2003 and 2013. We analyzed the percentage of children and youth seen for follow-up. The Mann-Kendall test for trends was used to assess a monotonic increasing trend over time in concussion follow-up visits. RESULTS: A total of 126 654 children and youth were evaluated for an index concussion visit. The number of children and youth assessed for concussion follow-up (N = 45 155) has increased significantly over time (P < .001). In 2003, 781 of 7126 patients (11.0%; 95% CI, 10.3-11.7) with an index visit for concussion had a follow-up assessment. By 2013, 6526 of 21 681 (30.1%; 95% CI, 29.5-30.7) patients received follow-up care. CONCLUSIONS: The proportion of children and youth receiving follow-up after an acute concussion has significantly increased between 2003 and 2013. Nevertheless, more than two-thirds of all patients do not seek medical follow-up or clearance as recommended by current concussion guidelines, suggesting that ongoing efforts to improve and monitor compliance with recommended guidelines by patients and physicians are important.

The decline in active school transportation (AST): A systematic review of the factors related to AST and changes in school transport over time in North America.

Active travel to school has declined during the last 50years in North America. During the last decade, the children's active school transportation (AST) literature has grown. This systematic review provides an updated examination of AST correlates, and discusses why school travel mode (STM) share may have changed over time. AST trends are described and a systematic literature review of AST correlates in North America for the period 1990-2016 was conducted. Strength of association between correlates and AST, and relationship direction are assessed and reported. Graphical presentation of correlates included in ≥5 studies were included. Sixty-three studies were identified and reviewed. Distance to school was most strongly associated with AST. Individual, parental and societal correlates had moderate positive associations with AST including: child age, lower parental education, income and other income related factors, race and positive perceptions of AST. Longitudinal studies were few in number, as were studies about exceptional populations, policy, and interventions. AST intervention should focus on key AST correlates. Social and environmental diversity calls for local solutions to school travel challenges. Changes in AST correlates over time should be considered for evaluating existing policy approaches, and to support development of new policy, regulation, design, and program interventions.

Annual and Seasonal Trends in Ambulatory Visits for Pediatric Concussion in Ontario between 2003 and 2013.

OBJECTIVE: To investigate annual and seasonal trends in physician office and emergency department (ED) visit rates for pediatric concussion in Ontario between 2003 and 2013. STUDY DESIGN: A retrospective, population-based study was conducted using linked health administrative data from all concussion-related visits to ED and physician office by children aged 5 through 18 years. Time series analysis was used to assess whether periodic components exist in the monthly number of concussion-related visits. RESULTS: Over the 11-year study period, there were 176 685 pediatric visits for concussion in EDs and physician offices in Ontario. Standardized concussion-related visits showed a 4.4-fold (95% CI 4.37-4.45) increase per 100 000 from 2003 to 2013, with nearly 35 000 total visits in 2013. Concussion-related visits demonstrated a steep increase from 2010 onward. The greatest increases in standardized visits were in females (6.3-fold, 95% CI 6.23-6.46 vs 3.6-fold, 95% CI 3.56-3.64 in males) and 13-18.99 year olds (5.0-fold, 95% CI 4.93-5.08 vs 4.1-fold, 95% CI 3.99-4.27 in 9-12 years and 2.3-fold, 95% CI 2.23-2.42 in 5-8 years). A strong seasonal variability (R2autoreg = 0.87, P < .01) in the number of concussion-related visits was present, with most occurring in fall and winter. CONCLUSIONS: Pediatric concussion-related ED and physician office visit rates have greatly increased in the last decade, particularly since 2010. Prevention strategies may be targeted at those most at risk and at seasonal-related activities carrying the greatest risk of concussion.

Installation of speed humps and pedestrian-motor vehicle collisions in Toronto, Canada: a quasi-experimental study.

BACKGROUND: Evidence related to the effectiveness of speed humps on reducing pedestrian-motor vehicle collisions (PMVC) has been conflicting. The purpose of this study was to determine the association between speed hump installation and changes in PMVC rates in Toronto, Canada. METHODS: Speed humps were mapped along with police-reported pedestrian collisions from 2000-2011 and built environment roadway characteristics. A quasi-experimental study identified collision counts before and after speed hump installation, modeled using repeated measures Poisson regression adjusted for season and roadway characteristics. Stratified analyses were conducted by age group and injury severity. RESULTS: There were 27,827 PMVC, with 1344 collisions along 409 roadways with speed humps. PMVC incidence rates/meters of road/month decreased after installation of speed humps (IRR 0.78 95 % CI 0.66, 0.91). Winter, collector roads (versus local), pre-amalgamated city centre and increased land use mix were associated with more collisions. The association between speed humps and PMVC rates decreased more for children (IRR 0.57, 95 % CI 0.41, 0.79) than for adults (IRR 0.80, 95 % CI 0.68, 0.95). CONCLUSIONS: Speed humps are an easily replicated method of traffic calming which have a significant protective effect on PMVC on the roadways where they are installed, particularly for children. There is a need for an area-wide analysis to determine the effects of the installation of speed humps to ensure that PMVC are not being displaced to surrounding roadways.