Accid. Am/. & Prev. Vol. 22. No. 1. pp. 67-78. 1990 oool-4575/w $3.00 + .

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BICYCLE ACCIDENTS AND INJURIES: A PILOT

STUDY COMPARING HOSPITAL- AND
POLICE-REPORTED DATA

JANE C. STUTTS
University of North Carolina,HighwaySafety ResearchCenter, ChapelHill, North Carolina,
U.S.A.
JOSEPH E. WILLIAMSON and THEODORE WHITLEY
East CarolinaUniversity,Schoolof Medicine,Greenville,North Carolina,U.S.A.
and
FRANK C. SHELDON
Beaufort County Hospital, Washington,North Carolina,U.S.A.
(Received 11 November 1988; in revised form 29 July 1989)

Abstract-Bicycle accident and injury data collected by two different samples of North Carolina
hospital emergency rooms during the summers of 1985 and 1986 are examined and compared
with state police-reported bicycle accident data for the same time periods. Of the 649 emergency
room treated bicyclists, 62% were children aged 5-14 and 70% were male. Nineteen percent of
the riders suffered moderate or worse injuries (AIS 2 2), and 6% were hospitalized. In contrast,
less than half of the police-reported accidents involved riders under 15 years of age, 85% of the
riders were male, and two-thirds suffered moderate or worse injury. Whereas virtually all of the
police-reported accidents involved a motor vehicle, less than a fifth of the emergency room cases
did. Only 10% of the emergency room cases were duplicated on the state accident files. It is
estimated that 800 children ages O-19 are hospitalized annually in North Carolina for bicycle-
related injuries, and an additional 13,300 children receive emergency room treatment.

INTRODUCTION

The traditional source of information on bicycle-related injuries and deaths is police

accident data. North Carolina state accident files show 32 bicyclists killed and an ad-
ditional 1,245 injured in 1986 (NC DOT 1987). Nationwide, the National Safety Council
(1986) reported 1,000 bicycle fatalities and 40,000 injuries.
These numbers clearly do not reflect the full extent of the bicycle accident problem.
In their landmark study of bicycle-motor vehicle accidents, Cross and Fisher (1977)
estimated that only a third of all bicycle-motor vehicle accidents are reported to the
police and that half of the unreported accidents are injury producing. Cross (1978) further
concluded that 95% of all bicycling injuries do not result from collisions with motor
vehicles.
One estimate of the overall magnitude of the bicycle accident problem comes from
the U.S. Consumer Product Safety Commission, which operates the National Electronic
Injury Surveillance System (NEISS). The NEISS is based on a representative sample of
U.S. hospital emergency rooms. Using this data, the Commission has estimated that
550,000 persons receive emergency room treatment each year for bicycle-related injuries
(U.S. Consumer Product Safety Commission 1984).
The present study examines the characteristics of emergency room-reported bicycle
accidents and compares these with accidents reported on police accident files. The emer-
gency room data were also used in conjunction with North Carolina Hospital Discharge
Data to estimate the number of children hospitalized and the number receiving emer-
gency room treatment each year in North Carolina due to bicycle-related injuries.

BACKGROUND

Emergency room surveys examining bicycle accidents have been carried out in
Burlington, Vermont (Waller 1971); Boulder, Colorado (Watts, Jones, Crouch et al.
67
68 J. C. STUTTSet al.
1986); Eugene, Oregon (Regional Consultants, Inc. 1979); Minneapolis, Minnesota (Davis,
Litman, Crenshaw et al. 1980); Oklahoma City, Oklahoma (Ernster and Gross 1982);
King County, Washington (LeValley and Mueller 1985); and Philadelphia, Pennsylvania
(Selbst, Alexander and Ruddy 1987), along with a number of hospitals in Australia,
Great Britain and Sweden (see Stutts [1986] for a more complete review). All of the
studies clearly show the young disproportionately represented in bicycle accidents. Re-
ported percentages vary according to the nature of the study and characteristics of the
cycling environment, but the 5-14 year age group generally accounts for 70% or more
of the study population. Males also dominate by a ratio of at least 2: 1.
The emergency room studies are a particularly valuable source of information on
the nature of injuries encountered by bicyclists. By far the most frequently reported
injuries are abrasions, lacerations, and contusions. In 60%-70% of cases these are the
most serious injuries occurring. Fractures are cited in 15%-25% of cases and head
injuries in lo%-25%. (The wide range to the latter is due in part to varying definitions
of head injury.)
The majority of emergency room-reported bicycle accidents do not involve a motor
vehicle. Reported percentages vary widely, however, again reflective of the particular
characteristics of the bicycling environment. Numbers range from 13% reported in the
Minneapolis study (Davis et al. 1980) to 50% reported in the Boulder study (Watts et
al. 1986).
The best estimate of the percentage of emergency room bicycle accident cases
requiring hospital admission comes from an analysis of bicycle accident cases reported
to the Massachusetts Statewide Childhood Injury Prevention Project (Friede, Azzara,
Gallagher et al. 1985). Overall, 6% of 573 injured riders required hospitalization; for
those riders involved in collisions with motor vehicles, this figure increased to 27%.
Other percentages reported in the literature are 8% for the Boulder, Colorado study
(Watts et al. 1986) and 13% for the King County, Washington study (LeValley and
Mueller 1985). Both of the latter involved a higher than usual rate of bicycle-motor
vehicle collisions.
In addition to these emergency room based surveys of bicycle accidents and injuries,
other studies have involved retrospective examination of hospital records and/or self
reported accident involvement through population surveys. These are also reviewed in
the earlier report by Stutts (1986).

THE DATA

The emergency room survey data which form the basis for this investigation evolved
from the efforts of two of this paper’s authors (Williamson and Sheldon) to document
the extent and nature of emergency room treated bicycle injuries occuring in their
communities. Pilot data were collected during the summer of 1984 at their respective
hospital emergency rooms. Because of the large number of cases reported and the
tremendous difference when compared with North Carolina police reported accident
data, the two authors expanded their data collection efforts during the summer of 1985.
With slight modifications to the survey instrument, the study was then extended for one
more data collection period (summer of 1986) to increase the sample size for statistical
analysis purposes.
Because the emergency room surveys evolved in this manner, some limitations do
exist in their overall design and implementation. However, it is not felt that these impact
on the overall conclusions of the study. With this caveat in mind, following is a description
of the various data sources utilized in the investigation.

Emergency room survey data

Hospital emergency room data on bicycle related accidents and injuries were col-
lected in two separate surveys-the first conducted mid-May through mid-September
1985, and the second, 1 June through 30 September 1986. Ten North Carolina hospitals
participated in the first survey and 15 in the second (7 of the original 10 plus 8 additional).
 Comparison of hospital and police data on bicycle accidents 69
Hospitals were selected on the basis of their geographic distribution across the state as
well as their willingness to participate. Although there was a mix of urban and rural
hospitals, no attempt was made in this pilot effort to select a statistically representative
sample.
The survey forms were completed by the emergency room physician or nurse most
directly involved with the patient’s treatment, and in most instances were completed on
the spot. (In severe injury cases it was sometimes necessary to obtain some of the
interview information after the patient had stabilized.) Follow-up telephone contacts
with the emergency rooms uncovered no difficulties in completing the forms.
Questions on the one page survey dealt with characteristics of the rider (age, sex),
time and location of accident, cause of accident, motor vehicle involvement, helmet
usage, and nature of injury. For the 1986 survey the form was revised to include AIS
injury severity (see American Association for Automotive Medicine 1985) and more
detailed information on location of injury.
While no formal follow-up was made to assess the level of participation by the
hospitals, examination of the returns showed consistent reporting throughout the four-
month data collection periods by about half the hospitals. One-fourth of the hospitals
submitted cases over a period of one month or less, and the remaining one-fourth varied
in their level of reporting. At only one hospital was there an obvious bias to report only
the most severe cases, and these data were excluded from the analysis. Further exam-
ination of the survey returns also showed that the individual hospitals submitted cases
across all days of the week and times of day, indicating participation by most if not all
of their emergency room staffs.

North Carolina state accident data

In order to compare the emergency room bicycle accident data with state police-
reported data, the police-reported bicycle accidents for the same time periods were listed
sequentially by date along with pertinent identifying information such as age and sex of
rider, accident location (county), time of accident, and injury severity. The emergency
room cases were then individually examined to determine whether or not they were
duplicated in the state files. In a few instances it was necessary to examine the actual
hard copies of the police accident reports, because this allowed for comparisons of the
emergency room accident description with the police officer’s narrative description and
diagram of the accident. Following this procedure it was possible to determine the
percentage of emergency room bicycle accident cases found on the state accident files
and the characteristics of these cases.

North Carolina hospital discharge data

A final database examined was 1980 North Carolina Hospital Discharge Data pro-
vided by the State Center for Health Statistics (1980 being the only year for which
statewide data is available). For purposes of the current study, information was obtained
on the total number of pediatric hospital discharges statewide by age group and by cause
of injury. The latter is reported using the “E code”, or “External Cause of Injury,”
which is a part of the International Classification of Diseases (ICD) (World Health
Organization 1975). Included in the system are codes for bicycle-motor vehicle and
bicycle-non-motor vehicle accidents. Hospital discharge data were available for an es-
timated 89% of all pediatric hospitalizations and “E code” information available for
67% of these cases (Runyan, Ketch, Margolis et al. 1985). The data were adjusted to
reflect statewide totals, assuming even distributions of the missing cases.

EMERGENCY ROOM SURVEY RESULTS

The survey results are based on a total of 649 emergency room reported bicycle
accident cases-244 from the 10 hospitals participating in the 1985 survey and 405 from
the 15 hospitals participating in the 1986 survey. For purposes of this analysis, the data
have been combined into a single dataset, except for the injury section where changes
70 J. C. STtJrrs et al.
and additions to the 1986 survey form necessitate separate analysis. A comparison of
variable response distributions for the 1985 and 1986 samples shows generally consistent
trends. For example, for the 1985 sample, 61% of the injured riders were aged 5-14,
compared with 63% for the 1986 sample. The sex distributions for the two samples were
identical: 70% male, 30% female. [See Stutts, Williamson and Sheldon (1989) for ad-
ditional sample comparisons.]
The analysis that follows focuses on bicyclist characteristics (age and sex), accident
characteristics and causative factors, and the nature and extent of injuries for this sample
of hospital emergency room-reported bicycle injuries.

Bicyclist characteristics
Figure 1 graphically depicts the age and sex distribution of the emergency room
treated bicyclists. Males aged lo-14 comprised by far the largest category, followed by
5-9 year-old males. Overall, 36% of the sample was aged lo-14 and an additional 26%
aged 5-9. Also, 70% were male, with the predominance holding at every age level.

Accident characteristics
Figure 2 shows where the emergency room-reported bicycle accidents occurred. The
largest number of accidents (30%) occurred on city streets at nonintersection locations.
Seven percent occurred at intersections and an additional 17% at driveway locations.
The large category of “other” includes accidents occurring off-road, in yards, on dirt or
private roads, in parking lots, etc.
Additional information about the accidents is summarized in Table 1. Overall, a
motor vehicle was involved in only 18% of the cases; however, for riders 15 years of
age and older, 29% were in bicycle-motor vehicle accidents. For those cases where a
motor vehicle was involved, the bicyclist was judged to be at fault just over half (55%)
of the time. Interestingly, there were no statistically significant differences in fault by
age of rider, although percentages at fault were slightly higher for the youngest and
oldest age groupings. For these and all other variables listed in the table, there were no
significant differences by rider sex.
Factors contributing to the accidents were riding against traffic (8.7%), riding more
than one on a bike (9.5%), and a mechanical defect of the bicycle (13.7%). While the
youngest riders were more likely to have been riding more than one on a bike, there
were no significant age or sex differences with respect to either wrong way riding or
bicycle mechanical defect.

5-9 1 O-14 15-19 20-24 25-29 30-39 40+

Age Group
Fig. 1. Distribution of hospital emergency room cases by age and sex of rider (N = 649)
 Comparison of hospital and police data on bicycle accidents 71

Other fl
City street
L (non&terse&i on)
30.2%

Sidewalk + ’
5.9%

Intersection
7.4% /
\
r Driveway
.n+m

15.7%

Fig. 2. Distribution of hospital emergency room cases by location of accident (Iv = 649).

Helmet use for this sample of riders was low, less than 3% overall. Seven percent
of riders age 15 and older reported wearing a helmet at the time of their crash, versus
less than 1% of riders under age 15.
Information on alcohol involvement was included only in the 1986 survey but is of
particular interest. Whereas the overall rate of alcohol involvement reported was 5%,
the percentage is considerably higher for older bicyclists, as shown in Fig. 3. For riders
aged 15-19, the percentage of crashes involving alcohol was 9.4%, and for riders aged
20 and older, 23.2% (p < .Ol). Again, however, there was no significant difference in
alcohol involvement for male versus female riders.
Injury characteristics
Concerning injuries, a total of seven fatalities was reported-four in 1985 and three
in 1986. All involved collisions with a motor vehicle. Ages of the fatally injured riders
ranged from 6 to 20, and all but one was male. Two of the accidents occurred at
intersections, one at midblock, and four on state highway/rural road segments. All of
the fatally injured cyclists suffered a head injury (none wore a helmet). While the survey
questionnaire did not ask if the head injury was the cause of death, for four of the seven
fatalities it was clearly so, either because no other injuries were cited or because the
other injuries were minor. In the remaining three cases it was noted that the patient
died of “multiple trauma” or “multiple system failure,” and for these the head injury
may or may not have been the cause of death.

Table 1. Additional characteristics of emergency room reported bicycle accidents

Percent
Accident characteristic of cases Age effects

Motor vehicle involved 18.0% Riders >15 over twice as likely to be in collisions with
m.v.-29% vs. 13% for riders ~15 (p < .Ol)
Another bicycle involved 6.8% No significant age differences
Bicyclist at fault (bicycle- 62.9% No significant age differences
m.v. cases)*
Bicyclist riding against 8.7% No significant age differences
traffic
Bicyclist riding on bike 1.8% No significant age differences
path/lane*
More than one on bike 9.5% Higher for riders <15-13% vs. 3% for riders >15
(P < .05)
Bicycle mechanical defect 13.7% No significant differences
Helmet worn 2.7% Helmet use higher for riders >15-7% vs. 1% (p < .Ol)
Alcohol/drugs involved* 5.3% Strong age effect-see Fig. 3

*1986 data only.

U9 22:1-F
72 J. C. STUTB et al.

15-19 20-24 25-29 30-39 40+

Age Group
Fig. 3. Percentage of hospital emergency room cases involving alcohol by age category (1986 data).

For the 1986 survey, the reporting physician (or nurse) was asked to give an Ab-
breviated Injury Score (AIS) for the most severe injury. Examination of these results
indicates that 81% of the patients had minor (AIS 1) injuries, 12% moderate (AIS 2)
injuries, 4% serious (AIS 3) injuries, and 3% severe, critical, or life threatening (AIS
4 or greater) injuries. Male riders were nearly twice as likely as female riders to experience
an injury of AIS 2 or greater-22% for males vs. 12% for females (p < .Ol). The
percentage of cases experiencing moderate or worse (AIS 2 2) injury was also signifi-
cantly greater for the oldest age groups, for accidents involving a motor vehicle, accidents
reported to the police, and accidents involving alcohol or drugs (see Table 2).

Table 2. Percent of emergency room cases with moderate or

worse (AIS 2 2) injury by population subgroup (1986 data)

Percent with
Population Sample mod. or worse
subgroup n (AIS 2 2) injury

Sex
Male 285 22.2
Female 120 11.7
Age
o-4 21 0.0
5-9 114 15.7
10-14 143 20.3
15-19 56 17.9
20-24 21 19.1
25-29 18 22.2
30-39 16 31.3
40+ 16 43.8
Admitted to hospital?
Yes 25 92.0
No 367 13.7
Motor vehicle involved?
Yes 32.3
No 3:; 16.9
Reported to police?
Yes 52 42.3
No 344 15.7
Alcohol/drugs involved?
Yes 21 33.3
No 37.5 18.5
 Comparison of hospital and police data on bicycle accidents 73
Concerning location and type of injury, results of the 1985 survey indicated that
14% of the riders suffered a head injury and 25% some form of fracture or dislocation.
The most common injuries were abrasions and lacerations, affecting 71% and 45%,
respectively. For this 1985 sample, 32 of 227 nonhelmeted riders (14.1%) suffered a
head injury, as compared with 2 of 15 (13.3%) helmeted riders. (Numbers of helmeted
riders were too small to permit statistical analysis of helmet effectiveness.)
Injury information for the 1986 survey was coded differently, with separate codes
for location of injury(ies) and AIS injury severity (most severe injury only). Twenty-
four percent of the 1986 sample had some sort of injury to the head and 17% an injury
to the face (see Table 3). Note, however, that for this sample injuries to the head can
include lacerations, abrasions, etc. and do not necessarily imply a “head” injury in the
same sense as reported for the 1985 sample. (Because of this no analysis of helmet
effectiveness was attempted.) Most frequent were injuries to the extremities: 42% of
riders experienced injuries to the knee, lower leg or foot, and 36% injuries to the elbow,
lower arm, or hand.
Examining the AIS information available for the 1986 data, injuries to the head
were associated with higher AIS scores, although results were not statistically significant
(p = .06). (Head injury was present in 22% of cases involving only minor injury and
33% of cases involving moderate or greater injury.) Injuries to the shoulder and arm
were also associated with higher AIS scores. Examination of survey hard copies showed
that the latter frequently involved fractures or dislocations.
Finally, the percentage of cases requiring hospital admission was quite consistent
for the two samples-5.8% in 1985 and 6.3% in 1986. The overall hospitalization rate
of 6.1% is essentially identical to that reported by Friede et al. (1985) based on a larger
representative sample of bicycle accidents reported to the Massachusetts-based Statewide
Childhood Injury Prevention Program.

COMPARISON OF EMERGENCY ROOM AND POLICE DATA

The North Carolina Division of Motor Vehicles reports that, in 1986, 1245 bicyclists
were injured in police-reported traffic accidents and an additional 32 bicyclists were
killed [NC DOT 19871. These figures are up considerably from the previous year, when
1125 bicyclists were reported injured and 22 killed.
An examination of the 1985 police-reported data is contained in Stutts (1986). The

Table 3. Location of emergency room treated bicycle

injuries (1986 data)

Total injuries reported

Injury location (N = 692)

Head
(;$3)*
Face
(;;.8)
Neck
(3.7)
Thorax 30
(7.4)
Abdomen, lower back 27
(6.7)
Shoulder, upper arm
$6)
Elbow, lower arm, hand 147
(;;-4)
Hip, upper leg
(6.4)
Knee, lower leg, foot 170
(;.I)
Other
(9.9)

*Percent of riders (N = 404) with injury at given

location.
74 J. C. STUTTS et al.

1986 data were similarly examined for the present study. The combined results show
that: (i) less than half of the police-reported accidents involve riders under the age of
15, compared with two-thirds of the emergency room-reported cases; (ii) almost 85%
of the riders in the police-reported data are male, compared with 70% in the emergency
room data; and (iii) police-reported accidents involve more serious injuries to the rider,
with 2% of the riders killed, 26-27% seriously injured, and 41-42% moderately injured.
To test whether these differences might be due to differences in the time periods covered
by the two samples (May-September for the emergency room sample vs. the full year
for the police-reported data), the police data were examined only for the same months
covered by the emergency room data, with identical results.
Whereas motor vehicles are a factor in only about one-fifth of the emergency room
cases, virtually all of the police-reported cases involve collisions between bicycles and
motor vehicles. Also, over 95% of the police-reported cases occur either on local (city)
streets or on rural highways; less than 3% are reported occurring at off-road locations
such as parking lots, driveways, etc. In contrast, off-road locations comprised a major
portion of the emergency room sample accidents.
A more direct approach used to compare the emergency room and police-reported
bicycle accidents involved a case-by-case matching of the two samples. As noted in the
Data section, cases were considered a match if they occurred on the same date, at
approximately the same time, in the same city and/or county, and involved a rider of
the same age and sex. Where questions arose, actual hard copies of the accident reports,
including the accident narrative and diagram, were viewed and compared with infor-
mation on the emergency room reports.
Following this procedure, 68 of the 649 reported emergency room cases (10.5%)
were found documented on state accident files. All but one of these 68 documented
cases involved a motor vehicle. Out of the total 649 cases, 112 involved a motor vehicle,
so that the rate of reporting of bicycle-motor vehicle accidents to the state files was
671112 or 59.8%.
The above information is summarized in Table 4. These results clearly indicate that
a substantial percentage of bicycle-motor vehicle accidents are not appearing on police
accident files. As would be anticipated, virtually no non-motor-vehicle bicycle accidents
appear on the files, even though many of these do occur on public roadways and result
in injuries serious enough to require hospital treatment.

STATEWIDE PROJECTIONS OF CHILDHOOD BICYCLE INJURIES

It was noted earlier that 6.1% of the emergency room bicycle accident cases required
hospital admission. This information was combined with the 1980 Hospital Discharge
Data from the State Center for Health Statistics to produce estimates of the numbers
of children receiving emergency room treatment statewide for bicycle-related injuries.
Table 5 shows the reported number of North Carolina hospital discharges for bicycle-
related injuries by age group. The unadjusted numbers at the top of the table are low,
since they do not take into account the fact that discharge data were only available for

Table 4. Comparison of emergency room reported and police reported

bicycle accidents

Located on state
accident file?

Emergency room cases Yes No Total

Motor vehicle involved 112

(Z.8) (Z.2) (17.3)
Non-motor-vehicle involved 536 537
(A.2) (99.8) z8.7)
Overall 581
(& (89.5)
 Comparison of hospital and police data on bicycle accidents 75
Table 5. North Carolina pediatric hospital discharges for bicycle-related injuries (1980 State Center
for Health Statistics)

Aee

Cause of injury o-4 5-9 10-14 15-19 Total

Unadjusted data*
Bicycle-motor vehicle

Bicycle-non motor vehicle

$3)
180
$6)
144
390.6) (k)
394
Pi.0) (85.7) (80.4) (Z.4) (81.9)
Total 210 179 481
(6.2) (43.7) (37.2) g.9,
Adjusted datat
Bicycle-motor vehicle 5.0 50.3 58.7 31.9 145.9
Bicycle-non motor vehicle 45.3 301.9 241.5 72.1 660.7
Total 50.3 352.2 300.2 104.0 806.6

*Discharge data available for 89% of all pediatric hospitalizations. Cause (E-code) information
available for 67% of reported cases.
tAssumes an even distribution for missing cases.
$Column percents.

89% of all North Carolina pediatric hospitalizations, and E code information only avail-
able for an estimated 67% of these cases (Runyan et al. 1985). Incorporating these
adjustments to the data produces the estimate of just over 800 children under the age
of 20 hospitalized annually in North Carolina for bicycle-related injuries. Approximately
350 of these children are in the 5-9 year age category and an additional 300 in the lo-
14 year age category. Only 18% of the bicycle-related hospitalizations are shown as
resulting from a motor vehicle collision.
Using the 6.1% hospitalization rate cited earlier, it was estimated that over 13,000
children under the age of 20 are treated each year in North Carolina hospital emergency
rooms for bicycle-related injuries, including 5,800 children aged 5-9 and an additional
5,000 children aged 10-14.
Going one step further, one could project that 17,000-18,000 North Carolinians of
all ages receive emergency room treatment each year for bicycle-related injuries (this
on the basis that one-fourth of our emergency room sample involved riders age 20 and
older). This latter estimate agrees well with the U.S. Consumer Product Safety Com-
missions’s projection of 550,000 bicycle-related emergency room cases (all ages) occur-
ring annually in the U.S. (U.S. CPSC 1984). On a purely population basis, North Carolina
could expect to entertain 2.6% or 14,300 of these cases. Given the particular popularity
of bicycling in North Carolina, it is not unreasonable to assume a figure considerably
higher than this.

DISCUSSION AND RECOMMENDATIONS

This study is part of a continued effort towards a more accurate assessment of bicycle
accidents occurring in North Carolina. In the past, the primary source of information
on the bicycle accidents and their resulting injuries has been state motor vehicle accident
files. Such data do not present an accurate account of the full range of accidents and
injuries occurring to bicyclists. This is true even for the relatively small percentage of
accidents involving a motor vehicle.
Hospital records represent an alternative source of information on bicycle-related
accidents and injuries. Retrospective analyses of hospital data have yielded considerable
information regarding the numbers of bicyclists being injured and the significance of
bicycle injuries compared with other types of injuries. However, examinations of bicycle-
related accidents and injuries based solely upon hospital emergency room or admissions
records clearly cannot provide detailed information on the circumstances surrounding
the accident, and it is this information that is critical to the development of effective
countermeasures for reducing the frequency and severity of bicycle accidents.
76 J. C. Sm et al.

To provide this information, additional data collection activities are needed, either
at the time of treatment or later, through follow-up contacts. The emergency room
survey studies cited earlier are examples of this type of approach. The present investi-
gation goes beyond these studies by also examining police-based data and drawing com-
parisons between the emergency room and police results. Thus, it is more able to address
the question, “What do police reports fail to tell us about the nature and magnitude of
the bicycle accident problem?”
Further research is needed to better define the nature and magnitude of the bicycle
accident problem. Police reported statistics, though frequently cited, represent only a
small portion of the bicycle accident “iceberg.” Unfortunately, the amount of highway
safety dollars allocated to bicycle safety and to bicycle-related research has reflected a
similar underappreciation of the bicycle accident problem.
Yet bicycles are a major source of injury, particularly to young people. The Con-
sumer Product Safety Commission (1984) has identified bicycles as the leading cause of
sports or recreational injuries seen in hospital emergency rooms. In children, bicycle
crashes are one of the leading if not the leading cause of hospitalized head injuries (Ivan,
Choo, and Ventureyra 1983).
Interest in cycling continues to grow. The Metropolitan Statistical Bulletin (1981)
reported that there were 62-65 million bicycles in the United States, or one for every
two registered passenger cars. In recent years, the increasing emphasis on physical fitness,
the growth of bicycle commuting, and the growing popularity of bicycle riding have all
contributed to a bicycling boom. One outcome of this growth is that the population of
riders injured and killed in accidents has aged. What used to be primarily a “kids’ ”
problem is today affecting more and more adults.
What can be done to alleviate this situation? We have already cited the need for
more research to examine the characteristics of bicycle accidents-both those involving
a motor vehicle and those not involving a motor vehicle. Hospital-based studies and
survey studies are two recommended approaches. Certainly the current study could and
should be replicated on a larger and more representative sampling of cases.
Efforts might also be directed at improving police-based reporting of bicycle acci-
dents. In North Carolina, only bicycle accidents involving a motor vehicle are routinely
reported to the Division of Motor Vehicles (DMV) to become part of the state’s traffic
records system. However, police officers frequently do investigate and file reports on
non-motor-vehicle bicycle accidents that occur on the roadway, particularly if they in-
volve injury. Although not forwarded to the DMV, these reports may be kept on file
at the local level and may even be retrievable by computer. A project aimed at collecting
and examining data on all police investigated bicycle accidents would appear of value.
Ultimately, it may be recommended that local law enforcement agencies file and submit
reports to DMV on bicycle only as well as bicycle-motor vehicle accidents.
Concerning hospital-based sources of information on bicycle accidents and injuries,
in response to the growing recognition of injuries as a major public health problem,
there is a trend across the United States towards implementing trauma registries and
other large scale injury surveillance systems. In North Carolina, a statewide trauma
registry is being developed to monitor the care of severely injured patients treated at
the state’s major trauma centers. Parallel efforts are underway to develop a statewide
plan for emergency room based injury surveillance. Such systems, when operational,
have the potential for yielding information on large numbers of bicycle-related injuries,
as well as how these injuries compare with other forms of trauma.
In addition to these research efforts, there are actions that can be taken now to
reduce the frequency and severity of bicycle accidents. Most important is to encourage
helmet usage by all cyclists, young and old, riding on the road or off. Head trauma is
the leading cause of death in fatal bicycle accidents. Weiss (1986) notes that “pediatricians
and family physicians have a unique opportunity to provide education to families and
communities about the importance of using helmets. ” In Madison, Wisconsin, a multi-
pronged mass media campaign was carried out to increase helmet use by that city’s large
population of older cyclists (Berchem 1987); and a Seattle, Washington medical center
 Comparison of hospital and police data on bicycle accidents 71

has prepared a guide for local communities interested in developing a children’s bicycle
helmet safety program (Harborview Injury Prevention Center 1987).
Secondly, schools should adopt as part of their physical education curriculum in-
struction in bicycle safety, if possible including on-road training. Considering the pop-
ularity of bicycling as a lifetime sport, the lack of attention devoted to its instruction in
the public schools appears unjustified. Effective bicycle education programs have already
been developed. These programs, which differ from earlier programs in their strong on-
road component and emphasis on teacher training, have been successfully implemented
in a number of public school systems, including 60% of the elementary schools in Mon-
tana, a growing number of schools throughout Florida, as well as in Great Britain and
the Australian states of Victoria and New South Wales (Williams 1981; Burden 1989;
R. Boyd, 1987; and H.N. Boyd 1987). The greatest need at this stage is for some
mechanism for placing such programs in the schools and the funding to make it possible.
Ideally, this should be accomplished at the state level, although individual communities
and/or school systems could also take the initiative.
There are other steps that communities can take to lower their bicycle accident
count. Enforcement of traffic laws, even for the very youngest riders on the street, has
been shown to significantly reduce the frequency of bicycle-motor vehicle accidents
(Hunter and Stutts 1981). Attention should be directed at educating older cyclists not
to mix drinking and riding. Communities might also adopt a pin-map approach to ex-
amining their own patterns of bicycle accidents to determine if any specific problem
locations need attention.
Obviously there is much that can and should be done. As in other areas of injury
prevention, many different people from many different areas of interest need to become
involved-educators, physicians, law enforcement officers, transportation engineers,
researchers, and state and local government officials. The present investigation, which
has pooled the resources of many, is a step in this direction.

Acknowledgements-Funding for this project was provided by the North Carolina Governor’s Highway Safety
Program and the Centers for Disease Control. Appreciation is expressed to Melissa Marion with the North
Carolina DOT Bicycle Program for her role in instigating the project.

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