Discussion
Electric scooters have continued to rise significantly in prevalence and so too has the need for an effective approach to mitigate the medical and financial consequences of related injuries in today’s value-based healthcare environment. In this series, we investigate the epidemiology and morbidity of e-scooter injuries, characterize billing charges for e-scooter injury clinical encounters, and identify modifiable risk factors associated with higher billing charges. We report a high prevalence of substance use (58.7%) and low use of helmets (3.2%) in those sustaining any injury while riding e-scooters. Risk factors associated with independent increases in total billing charges included intoxication during e-scooter crash ($231 377 increase), intracranial bleeds ($75 528 increase) and TBI ($360 898 increase).
There has been a dramatic increase in e-scooter injuries with morbidity ranging from benign superficial abrasions to devastating severe traumatic brain injuries or death.12–15 17 22 The incidence of e-scooter injuries increased from 1.6 per 100 000 in 2014 to 2.6 per 100 000 in 2017 with a 77% rise specifically within the millennial cohort (aged 22–39 years).16
In addition, the introduction of e-scooters into major cities has caused some cities to resort to temporary e-scooter bans in order to develop the infrastructure to support e-scooter use.23 24 Solutions proposed to minimize scooter-related injuries have included increasing helmet use by mandating e-scooter companies to provide appropriate head protection,12 25 as well as minimizing pedestrian bystander injuries and scooter injuries from motor vehicle crashes by designating scooter-specific lanes similar to bike lanes.11 26 Ultimately, the solution to decreasing injuries will likely consist of a multifaceted approach incorporating new infrastructure, public education and formal legislation measures.
To date, no study has reported on the financial implications electric scooter injuries have on either the healthcare system or individual patients. The presently reported average $95 710 total billing charges for e-scooter injury clinical encounters are in stark contrast to the commonly advertised $1 activation fee for use of e-scooters.27 This total billing charge is indicative of the payment the non-profit medical system would need to receive to avoid accruing debt in relation to the clinical encounter. It is challenging to identify which party absorbs the majority of the financial burden for clinical encounters after e-scooter injuries. However, this burden is significant in all scenarios: patients may experience significant financial stress, medical insurances may respond by increasing cost of baseline plans and premium or the medical system may increase charges for other services. Regardless, the fact remains that one party ultimately absorbs the majority of the financial burden for an e-scooter injury encounter that may have been prevented with improved public health safety measures in place.
Risk factors associated with higher total billing charges included any substance use prior to e-scooter crash, ISS >10, intracranial bleeds, TBI and >2 subspecialty consultations. These were identified in the context of a 58.7% rate of any substance intoxication and 3.2% self-reported rate of helmet use during e-scooter crashes. Enforcing use of helmets while riding e-scooters may decrease both overall morbidity of sustained injuries as well as decrease rates of TBI.28 29 Unfortunately, it is unreasonable to expect e-scooter companies to have claim responsibility for helmet use, especially after riders choose to sign the waiver of responsibility on the mobile app prior to having access to e-scooters. It is thus not surprising to observe that social media promotion of e-scooters portrays riders wearing protective gear in a mere 6.79% of content with completely absent written content regarding protective gear.30 31 Investigations of e-scooter crashes, similar to those in non-motorized bicycle crashes, may serve as further evidence for publish health advocacy of improved regulations measures.12 25 32
Disincentivizing substance use while riding e-scooters is another concrete, and likely highly impactful, risk factor to target for mitigation of medical and financial consequences of e-scooter injuries. While there are clear legal mandates against operation of motor vehicles and bicycles while intoxicated, e-scooters are not defined in motor vehicle codes and thus are not explicitly covered in local operational law.33 Recent state-specific legislation proposals by e-scooter companies to legalize e-scooter use have incorporated clauses preempting local city authorities from regulating shared micromobility services in exchange for introduction of e-scooters into metropolitan areas.6 The mounting global literature reporting increasingly morbid e-scooter injuries is clear evidence of the need for improved public safety regulations.14 15 17 32 34–40 The issue at hand is complex with corporate social responsibility, medical ethics, public health ethics and government stewardship at play.41–44
Limitations
This study has several strengths and limitations. First, this paper addresses costs associated with admitted patients as this cohort of patients had the most reliable documentation of mechanism of injury due to the multiple independent documentation from specialty consultations. However, there were many more patients presenting to the ED and subsequently discharged that incurred costs associated with e-scooter related injuries. Use of ICD-10 diagnosis codes for identification of our patient population may have incorporated a selection bias towards more severe injuries. While this method successfully included most patients evaluated for scooter-related injuries, it relies on accurate assignment of diagnosis codes by providers. Providers may not be aware of the available ICD-10 code specification for e-scooter injuries or may not code injuries according to mechanism of injury. Additionally, patients with very minor injuries may not have disclosed to their provider the association of e-scooters with their injury. Thus, our patient population may be skewed towards more severe injuries that warranted patient interview and documentation by multiple providers. Second, abstraction of helmet use prior to injury relied on medical provider query of helmet use and subsequent medical record documentation. This may have led to under-representation of helmet use within the present cohort. However, incorporation of patient’s self-reported helmet use portends the risk of over-representation. Overall, the risk of over-representation or under-representation of helmet use was likely minimized, as the currently reported rates are similar to prior observational studies,14 the majority of patients had medical record documentation from more than one provider (increasing the likelihood of more inclusive documentation within the medical record), and the majority of patients had explicit documentation of answering negatively to the question of ‘were you wearing a helmet when you were injured’. Finally, use of total billing charges from a single institution limits the generalizability of results to patients evaluated at other institutions. However, this was minimized by focusing the investigations of financial burden towards relative differences in cost rather than absolute values. In the context of these strengths and limitations, this study provides useful insight into the financial burden of e-scooter injuries and therefore possible actionable changes that can be made on a policy level.