Written by John D Kraemer & Connor S Benton
Objective This study aims to quantify and describe the burden of fatal pedestrian crashes among persons using wheelchairs in the USA from 2006 to 2012.
Design The occurrence of fatal pedestrian crashes among pedestrians using wheelchairs was assessed using two-source capture-recapture. Descriptive analysis of fatal crashes was conducted using customary approaches.
Setting Two registries were constructed, both of which likely undercounted fatalities among pedestrians who use wheelchairs. The first used data from the Fatality Analysis Reporting System, and the second used a LexisNexis news search.
Outcome measures Mortality rate (per 100 000 person-years) and crash-level, driver-level and pedestrian-level characteristics of fatal crashes.
Results This study found that, from 2006 to 2012, the mortality rate for pedestrians using wheelchairs was 2.07/100 000 person-years (95% CI 1.60 to 2.54), which was 36% higher than the overall population pedestrian mortality rate (p=0.02). Men’s risk was over fivefold higher than women’s risk (p<0.001). Compared to the overall population, persons aged 50–64 using wheelchairs had a 38% increased risk (p=0.04), and men who use wheelchairs aged 50–64 had a 75% increased risk over men of the same age in the overall population (p=0.006). Almost half (47.6%; 95% CI 42.8 to 52.5) of fatal crashes occurred in intersections and 38.7% (95% CI 32.0 to 45.0) of intersection crashes occurred at locations without traffic control devices. Among intersection crashes, 47.5% (95% CI 40.6 to 54.5) involved wheelchair users in a crosswalk; no crosswalk was available for 18.3% (95% CI 13.5 to 24.4). Driver failure to yield right-of-way was noted in 21.4% (95% CI 17.7 to 25.7) of crashes, and no crash avoidance manoeuvers were detected in 76.4% (95% CI 71.0 to 81.2).
Conclusions Persons who use wheelchairs experience substantial pedestrian mortality disparities calling for behavioural and built environment interventions.
Reducing the public health burden from pedestrian crashes is a top road safety priority. Each year, nearly 5000 pedestrians are killed and another 76 000 are injured by crashes on public roadways in the USA.1 ,2 Although both domestic3 ,4 and international5 policies require pedestrian infrastructure to enable safe and effective use by persons with disabilities, pedestrian injury risk among this population has been little studied. Improved safety for pedestrians using wheelchairs is, however, an advocacy organisation priority, both because of direct injury risks and because safety hazards impede persons with disabilities from being able to fully use the communities in which they live and work.6
Existing research has principally focused on non-fatal injuries among pedestrians using wheelchairs. A recent study found an incidence rate of pedestrian injury among persons using wheelchairs between 2002 and 2010 of 31.3/100 000 person-years (py), with men having a 3.5-fold increased risk over women.7 Earlier research found broadly similar results, and the gender disparity has been identified consistently in prior research.8–12
Mortality, however, has been identified as needing further study.7 A National Highway Traffic Safety Administration (NHTSA) analysis of emergency department (ED) visits found approximately 1 death per 40 non-fatal crashes among pedestrians using wheelchairs between 1991 and 1995. However, ED records undercount fatalities, which often occur at the crash scene, and this study was based on a small sample of deaths.9 Another analysis examined news reports of pedestrian crashes involving wheelchair users and found that over half of reported crashes were fatal;10 however, news sources under-report non-fatal crashes.13 Further, causes of fatal pedestrian crashes among wheelchair users have not been deeply assessed, though low night-time conspicuity has been hypothesised through a well-designed case study and literature review.8 Others have hypothesised that built-environment factors, such as safe and accessible crossings, likely play a role in collisions.7
This study has two objectives. First, using two-source capture-recapture, it seeks to estimate and describe the pedestrian crash mortality burden among wheelchair users by examining overlapping capture between two incomplete data sources. Second, it describes environmental, driver-level and pedestrian-related characteristics of crashes that killed pedestrians who used wheelchairs.
This study extends prior research which suggests that improving pedestrian safety for people using wheelchairs should be a policy priority. Some improvements are general to road safety: reducing distracted driving and pedestrian activity, improving safe crossing behaviour, reducing incapacitated driving, and improving pedestrian infrastructure—all of which appear to have played a role in a significant number of fatal crashes identified in this study. Others are specific to pedestrian risks faced by wheelchair users: low conspicuity of the wheelchair and pedestrian infrastructure that is particularly ill-suited to pedestrians who use wheelchairs.
Modern approaches to disability conceive of it as an interaction between physical limitation and social or environmental factors.34 This approach is reflected in the U.S. through the Americans with Disabilities Act, which requires public settings to be accessible to persons with disabilities—including through safe pedestrian infrastructure3 ,35—and which favours full community integration for people with disabilities.36 Prior research has shown that pedestrian safety concerns limit the ability of wheelchair users to fully access their communities,37 in violation of these norms, underscoring a substantial justice dimension to the disparities identified in this research.
This study has identified a significant disparity in road crash mortality risk between pedestrians who use wheelchairs and those who do not. These findings underscore the need for policymakers and planners to fully incorporate disability accommodations into pedestrian infrastructure and for persons who use wheelchairs—and others with disabilities—to remain a salient population when road safety interventions are designed. Finally, additional research to better understand would be valuable to better understand what causes the disparities identified in this study.
About BMJ Open
BMJ Open is an online, open access journal, dedicated to publishing medical research from all disciplines and therapeutic areas. The journal publishes all research study types, from study protocols to phase I trials to meta-analyses, including small, specialist studies, and negative studies. Publishing procedures are built around fully open peer review and continuous publication, publishing research online as soon as the article is ready.