Delays in Emergency Care and Mortality During Major U.S. Marathons(nejm.org)
nejm.org
Delays in Emergency Care and Mortality During Major U.S. Marathons
https://www.nejm.org/doi/full/10.1056/NEJMsa1614073
58 コメント
If delays of 4.4 minutes drive this effect, shouldn’t there also be massive swings in mortality every day (rush hour), and at the end of the weeks?
Yes, but I’m not sure what that would matter. I suppose they needed to control for time of day among marathons, but often they are all early on weekend days.
The point is to study the causal impact of having marathons vs not. Comparing that effect to other times of week which does not contain a marathon is not useful for much.
It could tell you if hosting a marathon is about as costly as having X more rush hours’ worth of mortality or something, but does not relate to the causal effect of the marathon.
For an example to compare, think about studying the impact on crime of heatwaves in a winter month. Someone could say, but won’t there be spikes of crime from heat in summer months? Yes, but why is it relevant — the point is to know the effect of the heatwave.
The point is to study the causal impact of having marathons vs not. Comparing that effect to other times of week which does not contain a marathon is not useful for much.
It could tell you if hosting a marathon is about as costly as having X more rush hours’ worth of mortality or something, but does not relate to the causal effect of the marathon.
For an example to compare, think about studying the impact on crime of heatwaves in a winter month. Someone could say, but won’t there be spikes of crime from heat in summer months? Yes, but why is it relevant — the point is to know the effect of the heatwave.
Effect size and comparison to other causes matters, because every study will be used as evidence for some political argument.
This study ("Marathons kill people!") will be used to argue for banning marathons in cities by people why are inconvenienced by the road closures.
A comparison to other common and accepted causes of traffic delays - or positive health impact of marathons - will prevent this misuse.
A similar thing happens with wind turbines killing birds. Yes they do. But radio towers, power pylons, agriculture, pesticide use, cars each kill 100x more, building windows 1000x more, and cats 10000x more. Yet it is still a popular argument used by people who are against renewable energy for other reasons, while nobody argues for banning skyscrapers.
This study ("Marathons kill people!") will be used to argue for banning marathons in cities by people why are inconvenienced by the road closures.
A comparison to other common and accepted causes of traffic delays - or positive health impact of marathons - will prevent this misuse.
A similar thing happens with wind turbines killing birds. Yes they do. But radio towers, power pylons, agriculture, pesticide use, cars each kill 100x more, building windows 1000x more, and cats 10000x more. Yet it is still a popular argument used by people who are against renewable energy for other reasons, while nobody argues for banning skyscrapers.
I agree in general and even said exactly this in my comment (comparing effect size in terms of X rush hours’ worth of mortality).
But in the specific case of policy adoption towards marathons, I don’t agree that comparison matters much for interpretation.
Banning marathons is totally different than taking action to reduce generic or rush hour traffic. Marathons are a purely recreational thing for society, nobody has any sincere need for them, certainly no needs to be colocated with dense urban areas.
Rush hour traffic is an emergent effect of necessary daily commuters and operations of a city.
Disentangling what part of it is needed, what can be reduced, and how to politically coordinate it is an entirely different situation.
In this sense, if banning marathons prevents even a tiny effect size on mortality, it’s obviously worth it, no matter if it is only saving 0.1 rush hours’ worth of mortality, or 0.01, or 0.001. Comparing with rush hour effect size adds virtually nothing to the process.
But in the specific case of policy adoption towards marathons, I don’t agree that comparison matters much for interpretation.
Banning marathons is totally different than taking action to reduce generic or rush hour traffic. Marathons are a purely recreational thing for society, nobody has any sincere need for them, certainly no needs to be colocated with dense urban areas.
Rush hour traffic is an emergent effect of necessary daily commuters and operations of a city.
Disentangling what part of it is needed, what can be reduced, and how to politically coordinate it is an entirely different situation.
In this sense, if banning marathons prevents even a tiny effect size on mortality, it’s obviously worth it, no matter if it is only saving 0.1 rush hours’ worth of mortality, or 0.01, or 0.001. Comparing with rush hour effect size adds virtually nothing to the process.
> If banning [something] prevents even a tiny effect size on [bad outcome] it’s obviously worth it
The same logic is why we now shuffle around in our socks at the airport. It is a terrible recipe for making policy.
The same logic is why we now shuffle around in our socks at the airport. It is a terrible recipe for making policy.
Of course if you take it out of context it fails to generalize. Why would you think it should generalize?
Nobody is saying this about [something] or [bad outcome], only about marathons that demonstrate causal impact of higher mortality rate due to traffic impact on emergency services.
It’s not a recipe. It’s weird to me that you’d even suggest such a non sequitur concept.
Nobody is saying this about [something] or [bad outcome], only about marathons that demonstrate causal impact of higher mortality rate due to traffic impact on emergency services.
It’s not a recipe. It’s weird to me that you’d even suggest such a non sequitur concept.
Banning marathons to save one life just because they’re recreational? Would you also ban all books because people have died driving to bookstores?
This is precisely proving my whole point.
The debate would be about the actual effect size as compared with the way society determines subjective value of things like marathons. It would have nothing at all to do with the relative effect size compared to some other benchmark like “rush hour.”
The debate would be about the actual effect size as compared with the way society determines subjective value of things like marathons. It would have nothing at all to do with the relative effect size compared to some other benchmark like “rush hour.”
Sure, presence of a non-zero effect, regardless of its size, can be theoretically interesting. Relativistic effects are often small, but they’re critical support for the theory of relativity. I’m not sure there’s an overarching theory here, but if you want to make that argument, be my guest.
On the other hand, the article has obvious policy implications, and those ought to depend, critically, on the size of the effect. If marathons are, in fact, massively risky, then maybe we should have them far, far away from hospitals. If the risk bops around a lot, and having a marathon shifts it from “quiet Sunday morning” to “run of the mill Tuesday” then no one needs to do anything.
On the other hand, the article has obvious policy implications, and those ought to depend, critically, on the size of the effect. If marathons are, in fact, massively risky, then maybe we should have them far, far away from hospitals. If the risk bops around a lot, and having a marathon shifts it from “quiet Sunday morning” to “run of the mill Tuesday” then no one needs to do anything.
> “If the risk bops around a lot, and having a marathon shifts it from “quiet Sunday morning” to “run of the mill Tuesday” then no one needs to do anything.”
I think you are assuming some kind of implied cost-benefit here that I don’t see, or at least why would it be delimited in units of effect size of other times of a week.
Even if the effect is as small as shifting quiet Sunday to run-of-the-mill Tuesday, it still seems obviously worth it to remove that. I’d say the same about parades and other things like this.
The debate would have no real connection to the effect size in units of other days’ traffic mortality spikes, ever.
The debate would be how do we value subjective recreation things like parades or marathons, to justify any effect size of mortality, and then how does that relate to the actual effect size.
Marathon vs. rush hour makes no difference to anyone. Why is rush hour the unit to care about? Marathon vs. no marathon assuming non-zero effect size of any kind is the discussion.
I think you are assuming some kind of implied cost-benefit here that I don’t see, or at least why would it be delimited in units of effect size of other times of a week.
Even if the effect is as small as shifting quiet Sunday to run-of-the-mill Tuesday, it still seems obviously worth it to remove that. I’d say the same about parades and other things like this.
The debate would have no real connection to the effect size in units of other days’ traffic mortality spikes, ever.
The debate would be how do we value subjective recreation things like parades or marathons, to justify any effect size of mortality, and then how does that relate to the actual effect size.
Marathon vs. rush hour makes no difference to anyone. Why is rush hour the unit to care about? Marathon vs. no marathon assuming non-zero effect size of any kind is the discussion.
I brought up rush hour because it’s an intuitive benchmark.
If my relative risk changes a thousandfold over the day, then I don’t really care about a ~1 point increase; by living in a city, I’ve already tacitly accepted more risk. On the other hand, if it normally swings from 0.9-1.1, then the damn things are a menace (though still not a huge one in absolute terms) and maybe we ought to do something.
If my relative risk changes a thousandfold over the day, then I don’t really care about a ~1 point increase; by living in a city, I’ve already tacitly accepted more risk. On the other hand, if it normally swings from 0.9-1.1, then the damn things are a menace (though still not a huge one in absolute terms) and maybe we ought to do something.
I still don’t agree. Why these thresholds?
What if the behavior in question wasn’t marathons but instead was attempts at the Guiness Book of World Records record for largest number of people twirling umbrellas in a line while blocking traffic?
Does that also need to show an effect size relative to rush hour or generic risk tolerance of some other situation? Why? Why would it be “worth” that particular amount of risk and not something much greater (if you love setting records) or much lower (if you think it’s totally pointless & blocking fire trucks for nothing).
What if the behavior in question wasn’t marathons but instead was attempts at the Guiness Book of World Records record for largest number of people twirling umbrellas in a line while blocking traffic?
Does that also need to show an effect size relative to rush hour or generic risk tolerance of some other situation? Why? Why would it be “worth” that particular amount of risk and not something much greater (if you love setting records) or much lower (if you think it’s totally pointless & blocking fire trucks for nothing).
Again, I brought up rush hour as a reference point (benchmark, calibration method, etc), not as a threshold. Surely you’ve seen the “Is four a lot?” meme (“Dollars? No. Murders? Yes”). That applies here in spades.
And yes, I think the bar for some random record attempt would be a bit higher. Some of the comments in this thread seem to think the marathon is valueless. I disagree. The Boston marathon is a big deal locally—-even non-runners get excited about it, so it does contribute to civic pride or whatever, More tangibly, the marquee marathons (Boston, NYC, etc) bring in a fair bit of tourist money.
If these things are unexpectedly very dangerous, then sure, let’s reconsider. If not, do you also want to replace Central Park with rounded, rubberized surfaces?
And yes, I think the bar for some random record attempt would be a bit higher. Some of the comments in this thread seem to think the marathon is valueless. I disagree. The Boston marathon is a big deal locally—-even non-runners get excited about it, so it does contribute to civic pride or whatever, More tangibly, the marquee marathons (Boston, NYC, etc) bring in a fair bit of tourist money.
If these things are unexpectedly very dangerous, then sure, let’s reconsider. If not, do you also want to replace Central Park with rounded, rubberized surfaces?
If the ambulance takes 4 minutes more to get to the hospital, don't we expect it to get on scene 4, or at least a few, minutes later?
Sure, but the exact same argument holds for regularly occurring traffic too.
My point is that I want to know whether the 0.7-6 fold increase in relative risk is occurring against a flat baseline or whether it’s just a blip riding atop giant fluctuations.
My point is that I want to know whether the 0.7-6 fold increase in relative risk is occurring against a flat baseline or whether it’s just a blip riding atop giant fluctuations.
ambulances don't typically sit at hospitals, they drive around and attempt to keep an area covered as best as possible.
To me, the central question is whether marathon running is more popular amongst parts of a community with more political clout, and whether this explains the how participants manage to impose inconveniences (and potentially more serious harms, as suggested in this paper) on the rest of the community by staging a marathon.
I always thought it was the sheer number of people that wanted to participate - 10,000 runners and at least twice that number of spectators (assuming that every runner has at least one person interested in watching, some bring a whole family).
I don't know what marathon traffic is like in most cities, but I've driven across San Francisco many times during the marathon and it's never been as bad as during normal rush-hour traffic.
(edit: I guess I understated the number of runners/spectators, the SF marathon claims 27,000 runners and 80,000 spectators)
I don't know what marathon traffic is like in most cities, but I've driven across San Francisco many times during the marathon and it's never been as bad as during normal rush-hour traffic.
(edit: I guess I understated the number of runners/spectators, the SF marathon claims 27,000 runners and 80,000 spectators)
This is maybe a tangent but if everything collapses when one road is closed that suggests a system lacking resiliency.
True, but you don't need a marathon to tell you that. Just go anywhere downtown at rush hour on a weekday. Every 5 minutes, some driver will enter the box before it's clear, and block the intersection both ways for everybody.
A couple months ago, a package truck crashed on the freeway a mile ahead of me, and traffic didn't move for over 3 hours. Our roads are not designed with redundancy as a primary concern.
A couple months ago, a package truck crashed on the freeway a mile ahead of me, and traffic didn't move for over 3 hours. Our roads are not designed with redundancy as a primary concern.
Not exactly what you meant, but I believe the interstate highway system was designed for redundancy for military mobility as a primary concern after WWII because of how easily rail could be taken out.
Typically it’s not one road... it’s a large portion of a city. For instance, in the town I live when a marathon happens I have to drive out of town, then back in, to get to the other side of town.
It's never just one road... they're long distance marathons not foot races.
Or just whether the events are imposed on the communities or welcomed by them.
There is also likely an opportunity to reduce the harm while still holding marathons.
There is also likely an opportunity to reduce the harm while still holding marathons.
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People can just run in a circle in a park, so yes.
The shorter the course, the fewer people that can participate simultaneously.
When I said "marathons" above, I was talking about the event still being quite similar to what they are right now.
When I said "marathons" above, I was talking about the event still being quite similar to what they are right now.
Looking forward to all the contortions people will suggest so that we can do literally anything except not ban cars on crowded marathon days, which is the obvious and easiest solution.
It seems easier to ban crowded marathon days. If the choice is between marathons and cars, the local people are most likely to pick cars.
26.2 miles can be laid out anywhere in a rural or suburban area. Those of us that run on country roads know that space is never a problem. There is no need for it to be run in the heart of a city other than vanity and trying to leech money from the attendees.
Not everything is about need. I don't see too many residents of NY or Boston clamoring to get rid of their respective marathons because they're inconvenient. You could say the same thing of other notable sports and other events.
It's true they bring in money and it's also true that most residents are sort of proud of them even if they don't participate. But I'm not sure how any of those things are so horrible.
It's true they bring in money and it's also true that most residents are sort of proud of them even if they don't participate. But I'm not sure how any of those things are so horrible.
Heck, it’s possible that urban marathons, by promoting fitness (etc), have a net positive effect on health despite this.
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I’d argue just not hosting marathons near dense urban centers or important traffic routes is an even easier and more effective thing to do.
I wonder if they properly controlled for the Boston Marathon bombing. Although there were amazingly few direct casualties given the circumstances, the extra strain on the hospital system may have had substantial second order effects.
They did not include 2013 in their analysis.
They also typically found ~11 hospitalizations of Medicare recipients for heart attacks on a study day and included ~12,000 hospitalizations, so 1 day wouldn't impact the data that much anyway.
They also typically found ~11 hospitalizations of Medicare recipients for heart attacks on a study day and included ~12,000 hospitalizations, so 1 day wouldn't impact the data that much anyway.
How’s this compare to weekday rush hour, though?
It looks like the study doesn’t have data that would enable them to determine that. The marathon event presents a known day where there is disruption, which they can see in ambulance transport times. They then can see in Medicare data patient outcomes based on days. Looks like they’d need much more granular data on admission times, etc from the Medicare data set which probably is not possible.
That said you can probably infer from everything we know that if ambulance transport times are longer during rush hour then patient outcomes are also worse.
That said you can probably infer from everything we know that if ambulance transport times are longer during rush hour then patient outcomes are also worse.
In theory that data exists. The NEMSIS data set includes transport timestamps and locations (allowing you to determine some sort of "rush hour impact score"), and enough identifying information follow up with the pt's outcome.
There's no unified dataset linking the two though, so it would be a fair bit of work.
https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDiction...
There's no unified dataset linking the two though, so it would be a fair bit of work.
https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDiction...
They article says on marathon days it took 4.4 minutes to get to the hospital, with similar number of incidents as on regular days. That's believable. That would also be true if there was a parade or a big football game.
No, it doesn’t. It says it took 4.4 minutes _longer_.
right, sorry, that was a typo, you are of course correct it was 4.4 minutes longer. doesn't change my thought, does it?
> 2757 deaths in 11,074 hospitalizations
That seems like a high death rate for hospitalizations, does it not? Would be interesting to see the breakdown of admissions and cause of death.
That seems like a high death rate for hospitalizations, does it not? Would be interesting to see the breakdown of admissions and cause of death.
It's probably for emergency only admits, and probably also includes DOAs. Which would make it more understandable.
This is amazing research.
Why can't these people run far away from cities and suburbs ? There are plenty of remote roads. Sort of like Dakar.
They could possibly do this but the logistics would be messy. For large marathons, people travel to the destination from all over the world and book hotels in the city where they can easily get to the start location. Also, seeing the city while running the marathon, however inconvenient to others, is part of the attraction of the location.
If the actual marathon course is somewhere remote from the city, it's unlikely such a place would have the hotel space for all the runners, and transporting them to/from the site would be a massive undertaking in itself. Chicago has about 45,000 runners every year. Then there are all the volunteers who need to get to and from stations around the course.
I'm not saying any of this to discount the argument that marathons impose a huge inconvenience, only that moving them elsewhere isn't so cut and dried a solution.
If the actual marathon course is somewhere remote from the city, it's unlikely such a place would have the hotel space for all the runners, and transporting them to/from the site would be a massive undertaking in itself. Chicago has about 45,000 runners every year. Then there are all the volunteers who need to get to and from stations around the course.
I'm not saying any of this to discount the argument that marathons impose a huge inconvenience, only that moving them elsewhere isn't so cut and dried a solution.
>people travel to the destination from all over the world and book hotels in the city where they can easily get to the start location.
Or at the end. The Boston Marathon actually starts pretty much 26 miles to the west of downtown in a suburb/exurb. So runners do need transportation to get to the start. It's not really accessible by public transit but I imagine there are buses in addition to people just getting rides from friends/family.
It is held on a (state) holiday and a lot of Boston companies give the day off. (And companies out by the start like EMC do as well because their parking lots are used.)
Or at the end. The Boston Marathon actually starts pretty much 26 miles to the west of downtown in a suburb/exurb. So runners do need transportation to get to the start. It's not really accessible by public transit but I imagine there are buses in addition to people just getting rides from friends/family.
It is held on a (state) holiday and a lot of Boston companies give the day off. (And companies out by the start like EMC do as well because their parking lots are used.)
Because part of the fun is running in places you otherwise could not (like through Manhattan during the NYM)
Not sure why you are being downvoted, but some races do, mostly ultramarathons and trail runs. I can see some city folks who don’t have a car being upset and in the spirit of this study, disruptions to their respective remote infrastructure.
Seconds count. We already know that speed bumps kill 9 for every 1 life they save, due to ambulance delays. Ambulances are heavy and can't go over speed bumps very quickly. The 1 life they save is from someone not going so fast.
I'm not so sure that's a thing we "known". I didn't have any luck tracking down the origin of that stat (it looks like it may be from a study in Boulder CO, but other than the same sentence referencing it that seems to show up in a bunch of articles, I can't find actual study).
I'd be very surprised if that was actually a rigorously proven stat.
I'd be very surprised if that was actually a rigorously proven stat.
You may be right. It's been a while. I remember reading a news article some place where they had the stats before they put them in, and found out after that ambulance times were delayed and the death rate went up, and then they tore them all out at great expense. The other ones I remember seeing are more like the one linked below. I think they proved the speed bumps result in ambulance delays, and assume deaths based on a rate. I also recall not being able to find any solid data that the speed bumps save lives.
Absent some solid evidence, I just don't buy it (based on a fair bit of experience as a paramedic). Speed bumps don't slow you down that much, and "seconds" really aren't that important.
Interesting, I have a few friends who were formerly EMTs and when I spoke to some former paramedic acquaintances, they seemed to believe the speed bumps were detrimental in certain specific medical cases, things like cardiac arrest and aortic aneurysms.
I'm in SoCal and some of these neighborhoods are just full of speed bumps, so maybe it's all of those seconds adding to minutes? Also there are different types of speed bumps, some don't slow you down at all and others you go 5mph and feel like you're ruining your suspension. Or maybe there's some other confounding factor? Do you only have a few where you live?
I'm in SoCal and some of these neighborhoods are just full of speed bumps, so maybe it's all of those seconds adding to minutes? Also there are different types of speed bumps, some don't slow you down at all and others you go 5mph and feel like you're ruining your suspension. Or maybe there's some other confounding factor? Do you only have a few where you live?
There are a bunch of references in this article though I can't find that exact statistic:
http://www.edmecka.com/Forms/tfc_calm.pdf
Oh, on page 158 they claim it is more like 40 lives lost per 1 life saved in Austin, TX.
http://www.edmecka.com/Forms/tfc_calm.pdf
Oh, on page 158 they claim it is more like 40 lives lost per 1 life saved in Austin, TX.
That's not based on any actual evidence though... Just a bunch of (somewhat dubious) assumptions piled into a theoretical analysis.
Would like a source for this.