Self-reported alcohol use is an independent risk factor for head and brain injury among cyclists but does not confound helmets' protective effect.

BACKGROUND: Head and brain injury accounts for most morbidity and mortality related to bicycle accidents, much of which can be mitigated by helmet use; but other factors, such as alcohol use and type of accident, also correlate with injury. OBJECTIVE: To examine the correlation between alcohol use, helmet use, riding environment, and rider characteristics, with the presence of head and severity of brain injury in a group of bicycle riders presenting to a regional trauma center after an accident. METHODS: Data were collected at the bedside and from the medical records for all bicycle accident victims presenting during a 2 ½-year period to a regional trauma center. Data were analyzed in Stata version 10 (StataCorp LP, College Station, TX) using chi-squared, analysis of variance, Kruskal-Wallis, or Wilcoxon rank-sum where appropriate. RESULTS: There were 427 patients enrolled, of which 82% were male, with a median age of 31 years. Two factors correlated with presence of head injury and severity of brain injury among bicycle riders presenting to the emergency department (ED) after an accident. For any head or brain injury, the odds ratios for helmet use and alcohol use were 0.5 (95% confidence interval [CI] 0.32-0.78) and 2.68 (95% CI 1.66-4.33). Of accidents presenting to the ED, helmeted riders were less likely to sustain a head or brain injury, and riders who reported alcohol use were more likely to sustain a head or brain injury. CONCLUSIONS: Helmet use was protective for head or brain injury in non-drinking cyclists, but had a confounding effect in drinking riders.

Research priorities for administrative challenges of integrated networks of care.

In 2006, the Institute of Medicine (IOM) advanced the concept of "coordinated, regionalized, and accountable emergency care systems" to address significant problems with the delivery of emergency medical care in the United States. Achieving this vision requires the thoughtful implementation of well-aligned, system-level structures and processes that enhance access to emergency care and improve patient outcomes at a sustainable cost. Currently, the delivery of emergency medical care is supported by numerous administrative systems, including economic; reimbursement; legal and regulatory structures; licensure, credentialing, and accreditation processes; medicolegal systems; and quality reporting mechanisms. In addition, many regionalized systems may not optimize patient outcomes because of current administrative barriers that make it difficult for providers to deliver the best care. However, certain administrative barriers may also threaten the sustainability of integration efforts or prevent them altogether. This article identifies significant administrative challenges to integrating networks of emergency care in four specific areas: reimbursement, medical-legal, quality reporting mechanisms, and regulatory aspects. The authors propose a research agenda for indentifying optimal approaches that support consistent access to quality emergency care with improved outcomes for patients, at a sustainable cost. Researching administrative challenges will involve careful examination of the numerous natural experiments in the recent past and will be crucial to understand the impact as we embark on a new era of health reform.