Chapter 1: Motor Vehicle and Motorcycle Injury Rehabilitation: Findings from the Uniform Data System for Medical Rehabilitation

Abstract
The UDSMR collects and redistributes data from rehabilitation hospitals nationwide for use in evaluating the effectiveness and efficiency of their rehabilitation programs. It provides the most comprehensive data available on rehabilitation patients across diagnostic categories. This chapter provides UDSMR information on people injured in other motor vehicles and motorcycle crashes, including demographics, type of injury, length of stay, primary payers, and post-injury rehabilitation circumstances such as employment status, living situation, and functional independence.

Methods
The UDSMR has established a data repository and reporting system for medical rehabilitation facilities. Subscribing facilities receive quarterly reports of their own data as well as regional and national comparison data for use in evaluating the effectiveness and efficiency of their rehabilitation programs, as well as for hospital accreditation. In 2002, 783 comprehensive medical rehabilitation (CMR) facilities sent data to UDSMR. Of the CMR subscribers, 590 agreed to provide data for this study. Only cases containing E-codes were selected for analysis.
Five years of data (1998–2002) were combined into one dataset. The data were cleaned. For example, obvious miscoding in the E-codes was corrected and variables with missing data or codes out of range were excluded from the appropriate analyses. Because E-codes were indicated in multiple fields, each case was assigned to one unique etiology by a hierarchy scheme. Motorcycle injuries were primary, followed by other motor vehicle, suicide, assault, and other unintentional injury.

Results

Demographic Characteristics of People in Rehabilitation for Injury Due to Motor Vehicle and Motorcycle Crashes
Of the 15,046 rehabilitation patients who incurred injury in a motor vehicle crash, excluding motorcycles, during the 5-year period, 58 percent were male and 42 percent were female. The patients were 75.2 percent White, 14.3 percent African American, 6.4 percent Hispanic and 4.1 percent “Other.” Table 1 provides the age distribution of the patients.

Of the 1,437 rehabilitation patients who incurred injury in motorcycle crashes during the 5-year period, 85 percent were male and 15 percent were female. The patients were 84.4 percent White, 7.2 percent African American, 4.9 percent Hispanic, and 3.3 percent Other. Table 1 provides the age distribution of the patients. Seventy percent of the patients were ages 16–44. Consistent with the ages of the rehabilitation patients, in 1998, the mean age of a motorcycle owner was 38.1 years and the mean age of motorcyclists killed in fatal crashes in 2001 was 36.3 (NHTSA, 2003). The age pattern is similar to the age distribution of motorcycle crash victims found in the analysis of the Traumatic Brain Injury Model System (TBIMS) data in Chapter 3, although the broader rehabilitation group are a bit older than the TBI group. Some TBI cases in these two datasets overlap.

Table 1. Age Distribution of Rehabilitation Patients with Injury Incurred in Motor Vehicle and Motorcycle Crashes and Comparison to Traumatic Brain Injury Model System Data

Age Group

Motor Vehicle
Motorcycle

Comparison: (TBIMS) Motorcycle Cases (%)

Cases

Percent

Cases

Percent

<16

344

2.3

21

1.5

NA

1624

3526

23.4

284

19.8

26.9

2544

4884

32.5

708

49.3

51.1

4564

3435

22.8

381

26.5

20.7

>=65

2858

19.0

43

3.0

1.3

TOTAL

15047

100.0

1437

100.0

100.0

Type of Injury by Impairment Group and Cause
In this analysis injuries are presented in five categories: Motorcycle, Other Motor Vehicle, Suicide, Assault, and Other Unintentional (which includes falls). Other Motor Vehicle includes any highway vehicle other than a motorcycle. Rehabilitation patients injured in Other Motor Vehicle crashes comprise 18 percent of this dataset and motorcycle crashes comprise only 1.7 percent. The Motorcycle and Other Motor Vehicle categories include only on-road crashes, and for crashes occurring on roads the data does not distinguish between on-road and off-road motorcycle body types. The majority of the injury cases (71.2%) were in the Other Unintentional category.

Of the 22 impairment diagnoses, the most common diagnosis for motor vehicles, excluding motorcycle crashes, requiring rehabilitation was TBI (30.7%) followed by Other Multiple Trauma (18.8%) and TBI with Fracture and Amputation (10.1%) (Table 2). The hip/knee replacement group contained 10 percent and the Other Orthopedic group contained 9.1 percent of the cases. In comparison to Other Motor Vehicle crashes, the Motorcycle crash victims are very similar in the distribution of impairments requiring rehabilitation, sharing the same top five categories --TBI; Other Multiple Trauma; TBI with Fracture and Amputation; Other Orthopedic; and hip/knee replacement. These categories account for 79 percent of the Other Motor Vehicle and 81 percent of the Motorcycle cases. The Motorcycle group was slightly more likely to have TBI rehabilitation services than the Other Motor Vehicle and the Suicide patients, but less likely than the Assault cases. Other Unintended injury causes often had hip/knee replacements as this injury group often includes falls and other injuries occurring in older populations.

Table 2. Distribution of Impairment Group by Injury Cause for Patients in Rehabilitation

Impairment Group
Injury Cause
Other Motor Vehicle (excluding MCs)
Motorcycle
Attempted Suicide
Assault
Other Unintended
Total
Total Cases (%)
15,047
(22.8%)
1,437
(2.2%)
376
(0.6%)
2,145
(3.3%)
46,947
(71.2%)
65,952
(100%)
 
Percent
Traumatic Brain Injury (TBI)
30.7
36.5
31.6
48.0
8.8
15.8
Other Multiple Trauma
18.8
18.6
4.5
5.5
4.0
7.8
TBI + Fracture + Amputation
10.1
11.7
1.9
2.1
0.8
3.2
Other Orthopedic
9.1
7.6
0.8
2.5
13.0
11.6
Hip/Knee Replacement
10.0
6.4
1.9
3.3
46.6
35.6
SCI Paraplegia Complete
2.3
3.5
2.1
10.7
0.9
1.6
TBI + Spinal Cord Injury (SCI)
2.5
2.5
0.3
0.9
0.4
0.9
Other Specified
4.0
2.4
42.8
8.8
17.8
14.4
SCI Paraplegia Incomplete
1.5
2.2
1.3
5.3
0.8
1.1
Lower-Extremity Amputation
0.7
2.0
1.1
0.6
0.3
0.3
SCI + Fracture + Amputation
0.7
1.7
0.8
0.3
0.1
0.3
SCI Quadriplegia Incomplete
3.4
1.3
1.9
3.7
1.5
2.0
SCI Quadriplegia Complete
2.7
1.0
1.6
3.8
0.8
1.3
SCI Other
1.5
0.9
1.6
1.9
0.9
1.1
SCI Paraplegia Unspecified
0.7
0.8
0.8
1.3
0.3
0.4
SCI Quadriplegia Unspecified
0.5
0.3
0.3
0.6
0.2
0.3
Other Amputation
0.0
0.2
0.0
0.0
0.1
0.1
SCI Unspecified
0.1
0.1
0.3
0.2
0.1
0.1
Burns
0.1
0.1
4.3
0.5
1.0
0.8
Neck + Back Pain
0.3
0.1
0.3
0.0
1.0
0.8
Upper-Extremity Amputation
0.0
0.0
0.0
0.1
0.0
0.0
Other Pain
0.1
0.0
0.0
0.0
0.5
0.4
Total Percent
100.0
100.0
100.0
100.0
100.0
100.0


Rehabilitation Length of Stay
Table 3 describes the mean length-of-stay (LOS) for rehabilitation for five causes of injury and for 22 injury categories. These varied widely by impairment diagnoses. For Other Motor Vehicles, the LOS ranged from 68.4 for spinal cord injury - quadriplegia complete to 10.1 days for neck and back pain. For the Motorcycle group LOS ranged from 71.4 days for spinal cord injury - quadriplegia complete to 10.3 days for Other Orthopedic. By cause of injury, the total mean length of stay was lowest for Other Unintended (16.7), moderate for Motorcycle (23.8) and Other Motor Vehicle (23.9) and highest for Assault (27.5) and for Suicide (29.3).

Table 3. Average Length of Stay by Impairment Group and Injury Cause for Patients in Rehabilitation

 

Impairment Group

Injury Cause

Motorcycle

Other Motor Vehicle

Attempted Suicide

Assault

Other Unintended

Total

 

Average Length of Stay (Days)

SCI Quadraplegia Complete

71.4

68.4

--

67.9

64.2

66.4

TBI + SCI

50.1

40.5

--

40.7

45.8

42.5

SCI Quadriplegia Incomplete

42.8

46.3

--

43.3

42.7

44.1

SCI Paraplegia Complete

41.5

41.4

--

40.0

40.5

40.8

SCI Paraplegia Incomplete

38.1

31.1

--

30.0

28.1

29.7

SCI+Fracture+Amputation

29.9

25.7

--

--

29.1

27.3

TBI

28.7

27.9

35.5

24.0

21.6

25.2

Other Specified

28.4

22.2

26.3

25.2

17.4

13.6

SCI Paraplegia Unspecified

24.4

31.1

--

27.6

31.0

30.6

TBI+Fracture+Amputation

21.6

21.7

--

23.8

20.4

21.5

Other Multiple Trauma

13.7

14.4

17.9

16.3

13.8

14.2

Lower-Extremity Amputation

13.3

16.8

--

10.9

16.6

25.6

Hip/Knee Fracture Or Replacement

11.2

12.8

--

12.1

14.2

15.5

SCI Other

10.8

19.5

--

20.0

19.1

19.1

Other Orthopedic

10.3

13.5

--

13.1

13.6

13.5

Upper-Extremity Amputation

NA

--

NA

--

11.3

12.2

Other Pain

NA

10.4

NA

--

12.8

12.6

SCI Unspecified

--

27.9

--

--

23.2

24.1

SCI Quadriplegia Unspecified

--

49.0

--

34.6

37.8

41.5

Other Amputation

--

--

NA

NA

22.7

22.3

Neck And Back Pain

--

10.1

--

--

13.0

12.7

Burns

--

35.6

24.8

14.5

16.0

16.9

 

TOTAL

23.8

23.9

29.3

27.5

16.7

18.9

-- Indicates fewer than 10 cases.
* Indicates no injury cases in the category.

Primary Payer by Cause of Injury, 1998–2002
The most commonly reported payer for people injured as a result of a motor vehicle crash was private insurance (40.2%), followed by public funding –(Medicaid or Medicare) (26.1%) and no-fault insurance (19.9%) (see table 4.) For motorcycle crash injuries private insurance was more likely to be the payer (63%). Public funding accounted for 19.5 percent of the cases, followed by no-fault automobile insurance (6.9%), Other/ Unknown (5.5%), self-pay (2.4%), unreimbursed (1.6%) and Workers’ Compensation (1%). The distribution is similar to Motor Vehicle Crashes, but is dissimilar from Suicide, Assault, and Other Unintended injuries that have public funding sources ranging from 49.5 percent to 76.7 percent.

Table 4. Distribution of Primary Payer by Cause of Injury

 

Primary Payer

Injury Cause

Motorcycle

Other Motor Vehicle

Attempted Suicide

Assault

Other Unintended

 

Percent

Private Insurance

63.0

40.2

34.3

25.7

15.9

Public Funding (Medicare or Medicaid)

19.5

26.1

49.5

53.7

76.7

No-Fault Auto

6.9

19.9

0.5

0.2

0.5

Other/Unknown

5.5

5.6

7.2

6.4

2.0

Self-Pay

2.4

2.0

4.0

3.4

0.5

Unreimbursed

1.7

2.5

3.7

8.6

0.6

Workers' Compensation

1.0

3.7

0.8

2.0

3.9

TOTAL

100

100

100

100

100

Pre- and Post-Measures
Data were gathered from patients via telephone surveys at one-year post–injury and at subsequent anniversaries of the injury throughout the duration of the study. Not all facilities followed up with patients after discharge from the rehabilitation facility. Table 5 lists the number and percentage of cases with follow-up data available. This very small subset of the original number of cases may not be a representative sample. However, for the most part, facilities either conduct follow-up interviews or not, so the results are more affected by facility bias than nonrespondent bias.

Table 5. Rehabilitation Cases with Follow-Up Data by Cause of Injury

 
Injury Cause
 

Motorcycle

Other Motor Vehicle

Attempted Suicide

Assault

Other Unintended

Total

Followed Cases

328

3,335

68

336

11,027

15,094

% with Follow-Up Data

22.8

22.2

18.1

15.7

23.5

29.7


Living Status
Patients were asked at time of discharge where they would be living. Of those injured in Other Motor Vehicles crashes, 94 percent lived in private homes both before and after rehabilitation. A similar but slightly higher proportion was found for motorcycle crash injury victims - 97 percent of those with known pre- and post-measures. (n=328). For attempted suicide, Assault, and Other Unintended Injuries, the percents were 75 percent, 92 percent, and 89 percent respectively.

Vocational Status at Time of Rehabilitation Discharge
Table 6 shows that across all injury categories, more than 50 percent of patients in the workforce changed their vocational status to nonworking or disabled at the time of rehabilitation discharge. Of the previously employed people injured in Other Motor Vehicle crashes, 64 percent were not working or disabled. This number was similar -- 62 percent (51.1% and 10.6% respectively) -- for motorcycle crash victims at the time of discharge.

Table 6. Post-Rehabilitation Vocational Status, by Cause of Injury, for Patients Employed at the Time of Admission

Post-Vocational Status
Cause of Injury

Motorcycle

Other Motor Vehicle

Attempted Suicide

Assault

Other Unintended

Total Cases

237

1541

24

134

1506

 

Percent

Employed

32.5

27.1

12.5

15.7

32.0

Not Working

51.1

54.1

70.8

69.4

41.6

Disability

10.6

9.9

12.5

9.7

8.2

Student

0.8

1.9

0.0

2.2

0.5

Other

5.1

7.0

4.2

3.0

17.7

Total

100

100

100

100

100


Functional Independence Measure Scores at Time of Discharge
FIM1 scores are standardized scales used in medical rehabilitation units to measure ability to function independently. The FIM System is comprised of 13 motor activities and 5 cognitive skills in the areas of self-care, sphincter control, transfers, locomotion, and social cognition. Each of the 18 items is rated on a seven-level ordinal scale, with Level 7 representing “Complete Independence” and Level 1 describing “Total Assistance.” The sum of the item scores describes the severity of an individual’s disability and reflects the amount of assistance required for an individual to complete daily activities.

Table 7 presents the mean FIM motor score for Motorcycle and Other Motor Vehicle injury for 20 diagnostic groups, arrayed for Motorcycle crash injury patients from the highest (most independent) motor score, to the lowest (requiring most assistance). The possible score range is from 13 for complete mobility loss to 91 for full mobility. Many of the patients had a near-total recovery, with mean FIM scores in the 70s. The lowest average FIM motor score is seen for SCI Quadriplegia Complete in both the Motorcycle and the Other Motor Vehicle Categories.

Table 7. Post-Rehabilitation Average FIM Motor Score by Motorcycle versus Other Motor Vehicle Injury by Diagnosis Group

Impairment Group

Motorcycle

Other Motor Vehicle

Diagnosis Group

Number of Cases

Avg FIM Motor Score

Number of Cases

Avg FIM Motor Score

Upper-Extremity Amputation

29

76.4

6

66.3

SCI Other

13

75.6

225

66.3

Other Orthopedic

109

72.0

1,365

68.4

TBI

523

69.0

4,605

67.9

Hip/Knee FX/Replacement

92

69.0

1,501

70.0

SCI Paraplegia Incomplete

31

67.5

223

66.2

Other Multiple Trauma

268

66.9

2,830

66.5

SCI Paraplegia Unspecified

12

64.7

103

59.8

TBI + Fracture + Amputation

168

64.6

1,522

64.7

Other Specified

34

63.0

607

63.0

SCI Paraplegia Complete

51

59.4

349

59.1

SCI Quad Incomplete

19

52.7

516

51.4

SCI + Fracture + Amputation

24

50.9

109

56.5

TBI + SCI

36

50.3

376

55.7

SCI Quadriplegia Complete

15

29.1

400

29.0

SCI Unspecified

*

*

22

69.1

SCI Quadriplegia Unspecified

*

*

71

42.9

Lower-Extremity Amputation

*

*

100

70.0

Neck + Back Pain

*

*

46

71.0

Other Pain

*

*

18

65.7


Table 8 presents the mean FIM cognitive scores for Motorcycle and Other Motor Vehicle. These must have a different scale than motor, with a range from 5 to 35. The mean scores range from a low of 23.3 for TBI to 34.4 for SCI Paraplegia Unspecified. Spinal cord injuries and amputations would not be expected to impair cognitive functioning and presumably strike people of similar demographics as those who experience TBIs. Thus, absent TBI, mean cognitive scores for TBI victims would have been about 33 to 34 for Motorcyclists and 32 to 33 for Other Motor Vehicle injury victims. Importantly, patients may continue to recover and rehabilitate after discharge from inpatient rehabilitation, which can improve their ultimate FIM levels.

Table 8 Post-Rehabilitation Average FIM Cognitive Score by Motorcycle versus Other Motor Vehicle Injury by Diagnosis Group

Diagnosis Group

Motorcycle

Other Motor Vehicle

Number of Cases

Avg FIM Cognitive Score

Number of Cases

Avg FIM Cognitive Score

SCI Paraplegia Unspecified

12

34.4

103

32.6

SCI Other

13

34.2

225

32.7

Lower Extremity Amputation

29

34.1

100

32.6

SCI+Fracture+Amputation

24

34.0

109

31.5

Other Orthopedic

109

33.8

1,365

32.6

SCI Paraplegia Complete

51

33.8

349

33.2

SCI Paraplegia Incomplete

31

33.6

223

33.4

SCI Quadriplegia Incomplete

19

33.4

516

32.8

SCI Quadriplegia Complete

15

33.3

400

31.9

Hip/Knee FX/Replacement

92

33.2

1,501

33.1

Other Multiple Trauma

268

32.7

2,830

32.3

Other Specified

34

31.3

607

29.4

TBI + SCI

36

29.1

376

28.1

TBI+Fracture+Amputation

168

26.6

1,522

26.7

TBI

523

23.3

4,605

23.9

SCI Unspecified

*

*

22

33.1

Burns

*

*

18

33.4

SCI Quadriplegia Unspecified

*

*

71

32.2

Neck+Back Pain

*

*

46

32.0

Other Pain

 

 

18

32.1


Discussion
The UDSMR provides the most comprehensive data available on rehabilitation patients across diagnostic categories, and provides one of the largest datasets of motor vehicle and motorcycle-related rehabilitation data available. These data are the only existing source for impairment across a range of causes. It also provides limited pre- and post-measures. With these data we can understand the distribution of cases that the rehab PPS rules apply to. One shortcoming of these data is that they often lack cause codes; some facilities refused us access to their data. Therefore the cause-coded cases accessible to us may not be representative.

The data also do not distinguish between on-road and off-road motorcycles such as motocross motorcycles for crashes occurring on roads]. However, crashes occurring with off-road motorcycles are believed to be a very small proportion of on-road motorcycle crashes. An analysis of the Fatality Analysis Reporting System (FARS) finds that off-road vehicles account for only 1.2 percent of on-road motorcycle fatalities.


1Note: The specific FIM scores are as follows, from worst to best. A score of "1" means "total assistance," in which the person puts forth less than 25 percent of the effort necessary to do a task. A score of "2" means "maximal assistance," in which the person puts forth less than 50 percent of the effort necessary to do a task, but at least 25 percent. If someone gets an FIM score of "1" or "2", the person is classified as having "complete dependence," because the person puts forth less than half the energy, requires maximal or total assistance, or even worse -- the activity is not performed at all.

An FIM score of "3" means "moderate assistance," in which the person puts forth between 50 percent and 75 percent of the effort necessary to do a task. A score of "4" means "minimal contact assistance," in which the person puts forth 75 percent or more of the effort necessary to do a task, and requires no more help than touching. A score of "5" means "supervision or setup," in which the person only needs someone to standby and cue or coax him/her (without physical contact) so the task can be done. A score of 5 can also be obtained if a helper is needed to set up items or assistive devices for the person. If someone gets an FIM score of 3, 4, or 5, he/she is classified as having "modified dependence," because the person can at least put forth half or more of the energy to complete the task.

A FIM score of "6" means "modified independence," in which no helper is needed and the person needs an assistive device. A score of 6 can also be obtained when no help is needed but the person takes considerable time to do a task or may complete the task in an unsafe manner. A score of "7" means "total independence," in which no helper is needed and the person performs the task safely, within a reasonable amount of time, and without assistive devices, aids, or changes. If someone gets an FIM score of 6 or 7,the person is classified as being "independent," because another person is not needed to complete the activity.