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Want to be safe? Move to the City. No, really.

Large cities in the U.S. are significantly safer than their rural counterparts, with the risk of injury death more than 20 percent higher in the country.

A study to be published online tomorrow in Annals of Emergency Medicine upends a common perception that urban areas are more dangerous than small towns ("Safety in Numbers: Are Major Cities the Safest Places in the U.S.?").

"Cars, guns and drugs are the unholy trinity causing the majority of injury deaths in the U.S.," said lead study author Sage Myers, MD, MSCE, of the University of Pennsylvania in Philadelphia, Pa. "Although the risk of homicide is higher in big cities, the risk of unintentional injury death is 40 percent higher in the most rural areas than in the most urban.

And overall, the rate of unintentional injury dwarfs the risk of homicide, with the rate of unintentional injury more than 15 times that of homicide among the entire population. This has important implications about staffing of emergency departments and trauma care systems in rural areas, which tend to be underserved as it is."

Analyzing 1,295,919 injury deaths that occurred between 1999 and 2006, researchers determined that the risk of injury death was 22 percent higher in the most rural counties than in the most urban. The most common causes of injury death were motor vehicle crashes, leading to 27.61 deaths per 100,000 people in most rural areas and 10.58 per 100,000 in most urban areas. Though the risk of firearm-related death showed no difference across the rural-urban spectrum in the entire population as a whole, when age subgroups were studied, firearm-related deaths were found to be significantly higher in rural areas for children and people 45 years and older; however, for people age 20 to 44, the risk of firearm-related death was significantly lower in rural areas.

Race was also a factor. Rural counties with large black populations had significantly lower risk of injury death than those with small black populations. The opposite was true for Latino populations: Rural counties with large Latino populations had significantly higher risk of injury death than rural counties with small Latino populations.

Surprisingly, rural counties with the highest levels of college-educated inhabitants and median income had significantly increased risk of injury death compared to rural counties with the lowest levels of each.

"By digging deep into the data, we may be able to tailor injury prevention efforts to the populations that need them, such as seniors in cities who are more likely to fall and rural children who are more likely to drown," said Dr. Myers. "This data is relevant to staffing issues as well. Injury-related mortality risk is highest in the areas least likely to be covered by emergency physicians and least likely to have access to trauma care, which argues for using a population-planning approach to improve emergency and trauma care systems in the U.S."

Julie Lloyd
202-728-0610 x. 3010
July 23, 2013
For more information, visit:
Annals of Emergency Medicine is the peer-reviewed scientific journal for the American College of Emergency Physicians, the national medical society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research, and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. For more information, visit

Julie Lloyd | EurekAlert!
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