Introduction

Motorcycles have long been widely used as versatile modes of transportation in many countries owing to their light weight and agility. However, motorcyclists are exposed to the external environment despite traveling at high speeds and experiencing substantial gravitational forces [1]. Therefore, motorcyclist traffic accidents (M-TAs) pose a higher risk of severe injuries than other types of TAs. To address these risks, various technological advances and legal regulations have been implemented [2-4].

Speed is a critical factor influencing the severity of injuries in TAs, affecting both motorcyclists and other victims. Shadmani et al. [5] reported a close correlation between speed and road-related fatalities. Soole et al. [6] reported that average speed enforcement is particularly effective in reducing speed and the incidence of severe TAs while improving traffic flow. Nightingale et al. [7] reported that implementing a 20 mile/hour speed limit effectively reduced road speeds without causing traffic congestion, thereby enhancing road safety. However, the implementation of these policies may vary across different societies because TA characteristics are influenced by various factors, including regional road conditions, local driving culture, economic status, and legal regulations. Furthermore, the effectiveness of reducing urban speed limits remains a topic of debate, with some reports indicating that a 20 mile/hour speed limit on city roads reduces traffic volume but does not significantly affect the frequency or severity of TAs [8].

In South Korea, the Safe-Speed-5030 policy, which aims to lower urban road speed limits, was officially implemented on April 17, 2021, following a 2-year grace period [9,10]. This policy involves decreasing speed limits by 10 km/hour and setting a 50 km/hour limit for main roads and a 30 km/hour limit for side roads. Car-exclusive roadways and highways are exempt from this policy and motorcycles are legally prohibited from entering these roads. Therefore, the policy is expected to lower M-TAs on roads where speed limits have been reduced because motorcyclists experience greater impact forces than vehicle drivers in the event of a TA. However, most studies conducted after the implementation of Safe-Speed-5030 primarily focused on traffic flow, and nationwide analyses evaluating the clinical outcomes of M-TAs are lacking. Furthermore, this policy generated significant public controversy and dissatisfaction with increasing calls for its repeal [11]. Nonetheless, any modifications or repeals of specific policies should be supported by scientific evidence.

This study aimed to investigate the effect of the Safe-Speed-5030 policy on the incidence and clinical outcomes of M-TAs and to provide foundational data to inform future policy decisions.

Methods

Ethics statement: The study was approved by the Institutional Review Board (IRB) of Yeungnam University Hospital (IRB No: 2022-04-050). The requirement for informed consent was waived by the IRB.

1. Study participants

This study employed a before-and-after design to assess the impact of Safe-Speed-5030 on M-TAs in South Korea. We focused on examining M-TAs in the seven largest cities in South Korea: Seoul, Busan, Incheon, Daegu, Daejeon, Gwangju, and Ulsan. The combined population of these cities is 22,544,933, accounting for 43.5% of the country’s total population (Seoul, 9,708,247; Busan, 3,401,072; Incheon, 2,943,491; Daegu, 2,428,228; Daejeon, 1,469,431; Gwangju, 1,454,154; and Ulsan, 1,140,310) [12]. The study participants included M-TAs who visited regional emergency medical centers (equivalent to US Level I) and local emergency medical centers (equivalent to US Level II) in these cities. In total, 16 regional emergency medical centers were involved (Seoul, 6; Busan, 1; Incheon, 2; Daegu, 2; Daejeon, 2; Gwangju, 2; and Ulsan, 1) with 52 local emergency medical centers (Seoul, 24; Busan, 8; Incheon, 8; Daegu, 4; Daejeon, 3; Gwangju, 4; and Ulsan, 1) [13]. In total, 29,325 M-TAs were included in this study.

2. Data collection

In South Korea, data on patients visiting regional and local emergency medical centers are automatically transmitted in real-time to the National Emergency Medical Center (NEMC) database. After data collection, the quality control manager at the NEMC and each emergency medical center verify the data accuracy and reidentify any entries with questionable reliability. This system, known as the National Emergency Department Information System (NEDIS), is not publicly accessible, and access requires approval from the NEMC following a formal review [13]. This study was conducted using NEDIS data (No. 2022-11-01) on patients who were involved in M-TAs and visited the emergency medical centers under study.

The period from April 17, 2018 to April 16, 2019, was designated as the pre-implementation phase and the period from April 17, 2021 to April 16, 2022, was designated as the post-implementation phase of the Safe-Speed-5030 policy. Baseline data were collected, including sex, age, health insurance type, emergency center location, emergency center level, TA occurrence time, and arrival mode. Age was categorized into 14 groups (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, and ≥80 years). The TA occurrence time was categorized into four groups as follows: dawn (00:00–05:59), morning (06:00–11:59), afternoon (12:00–17:59), and night (18:00–23:59). Severity upon arrival was assessed using the Korean Triage and Acuity Scale (KTAS), an emergency patient triage system used in South Korea [14]. The KTAS classifies patients into five levels, ranging from 1 (most critical) to 5 (nonurgent). Clinical data were also collected, including vital signs upon arrival, mental status, final outcomes of emergency center management, intensive care unit (ICU) admission, need for emergency surgery, and overall hospital outcome.

3. Statistical analysis

The Pearson chi-square test was used to compare categorical variables, with variables presented as numbers and percentages. Furthermore, to evaluate the association between policy implementation and emergency surgeries, ICU admission, and unfavorable outcomes, we conducted univariable and multivariable logistic regression analyses using these dependent variables. An unfavorable outcome was defined as death or hospital discharge without the prospect of recovery. Multicollinearity among variables in the multivariable logistic regression analysis was assessed using the variance inflation factor. The variables included sex, age, health insurance type, emergency center location, emergency center level, time of TA occurrence, arrival mode, heart rate, systolic blood pressure, respiratory rate, body temperature, and mental status on arrival. The results of the logistic regression analyses were presented as odds ratios (ORs), adjusted ORs (aORs), and 95% confidence intervals (CIs).

Statistical analysis was conducted using IBM SPSS for Windows, ver. 21.0 (IBM Corp., Armonk, NY, USA), with statistical significance set at p<0.05.

Results

1. Baseline characteristics

Table 1 presents the baseline characteristics of the study participants. Following policy implementation, the number of cases decreased by 2,923 (18.1%), from 16,124 in the pre-implementation period to 13,201 in the post-implementation period. No significant sex differences were observed. Among regions, Ulsan exhibited the highest decrease (34.8%), whereas Busan (5.1%) and Incheon (3.0%) showed an increase. Accident occurrences declined across all time periods, with the highest proportion recorded in the morning (27.3% at dawn, 28.6% in the morning, 18.4% in the afternoon, and 9.5% at night).

Fig. 1 presents the distribution of the M-TAs by age group. The proportion decreased differently across age groups. The largest reductions were observed in the 75 to 79-year-old (50.7%) and 15 to 19-year-old (45.5%) groups, whereas the 40 to 44-year-old group showed a 13.1% increase.

2. Clinical characteristics

The clinical characteristics of the study participants are presented in Table 2. The overall number of patients decreased after policy implementation (34.6% for KTAS level 5, 23.2% for KTAS level 4, 3.1% for KTAS level 3, and 16.9% for KTAS level 2). However, the proportion of moderate-to-severe cases (KTAS levels 1–3) increased in the post-intervention period from 35.8% to 41.4%, and the number of most critical patients (KTAS level 1) increased by 2.6%. No differences were observed in heart rate, systolic blood pressure, or mental status upon arrival at the hospital. The number of emergency surgeries and ICU admissions decreased after policy implementation (61 emergency surgeries and 184 ICU admissions); however, the number of unfavorable outcomes increased slightly. In addition, the ICU admission rate remained unchanged, whereas the rates of emergency surgeries and unfavorable outcomes increased (0.1% for emergency surgeries and 0.3% for unfavorable outcomes).

Fig. 2 illustrates the clinical outcomes according to age group. While the overall number of emergency surgeries, ICU admissions, and unfavorable outcomes decreased, the trends varied across age groups. Among patients who underwent emergency surgeries, the number significantly decreased in the 15 to 19-year and ≥70-year age groups, while it increased in the 30 to 49-year and 60 to 64-year age groups. For ICU admissions, the number of patients significantly decreased in the 15 to 19-year and 70 to 79-year age groups, while it increased in the 30 to 44-year, 60 to 64-year, and ≥80-year age groups. Similarly, for unfavorable outcomes, the number significantly decreased in the 15 to 24-year and 75 to 79-year age groups while increasing in the 25 to 44-year, 65 to 74-year, and ≥80-year age groups.

3. Effect of reduced urban road speed limits on the medical outcomes of motorcyclists involved in traffic accidents

Table 3 presents the results of univariable and multivariable logistic regression analyses assessing the risk of emergency surgery, ICU admission, and unfavorable outcomes after policy implementation compared to the pre-implementation period. In the multivariable logistic regression analysis, the likelihood of undergoing emergency surgery did not differ significantly from that in the pre-implementation period (aOR, 1.093; 95% CI, 0.935–1.277). However, the risks of ICU admission and unfavorable outcomes were significantly higher after policy implementation (aOR, 1.147; 95% CI, 1.015–1.296 for ICU admission; and aOR, 1.502; 95% CI, 1.052–2.145 for unfavorable hospital discharge).

Discussion

To the best of our knowledge, this is the first study to investigate the effects of reduced urban road speed limits on the clinical outcomes of patients who were involved with M-TAs in South Korea. Compared to the period before implementation, the total number of M-TAs decreased by 10.0% after the policy was introduced, whereas emergency surgeries and ICU admissions decreased by 7.6% and 10.2%, respectively. However, ICU admissions and the likelihood of unfavorable outcomes increased following policy implementation.

In this study, ICU admissions showed no statistically significant change in the univariable logistic regression analysis but increased significantly in the multivariable analysis after adjusting for confounding variables. For unfavorable outcomes, both univariable and multivariable analyses showed a significant increase in the post-phase. In contrast to in-car TAs, in which the vehicle provides protection, individuals involved in two-wheeled-vehicle TAs are more likely to sustain severe injuries, even at the same collision speed. Furthermore, among two-wheeled-vehicle users, motorcyclists are at a greater risk of sustaining severe injuries than bicyclists because of the higher speeds involved. A previous study indicated that M-TAs account for approximately 5% of all road TAs in South Korea, with a death rate as high as 12% [1]. Vadeby and Forsman reported that reducing the speed limit by 10 km/hour led to 17 fewer deaths per year, particularly on narrow roads [15]. Chung and Song [16] reported that the severity of M-TAs increases when the speed exceeds 30 km/hour or when the speed of the opposing vehicle exceeds 50 km/hour, particularly on roads narrower than 6 m or on curved road sections. These findings suggest that reducing the urban road speed limits potentially contributes to a decline in the number of M-TAs. In this study, while the overall number of patients decreased, the number of the most critically injured patients (KTAS level 1) and the proportion of moderate-to-severe cases (KTAS levels 1–3) increased after policy implementation. Consequently, after implementation of the Safe-Speed-5030 policy, the relative decrease in patients with minor injuries led to an overall increase in the severity of patients presenting to emergency medical centers after experiencing an M-TA. These factors may have contributed to the increased risk of ICU admissions and unfavorable outcomes observed after policy implementation. Nadimi et al. [17] reported that motorcyclist characteristics have the greatest influence on traffic violations, with individuals who have committed prior offenses being more likely to repeat them. Therefore, aggressive, noncompliant motorcyclists who disregard traffic laws may be more likely to ignore the Safe-Speed-5030 policy, contributing to high-severity TAs under high-speed or hazardous driving conditions. Additional interventions such as periodic education programs targeting motorcyclists with frequent violations of TA involvement may be necessary to reduce the incidence of motorcyclist-related accidents and severe injuries.

This study demonstrated age-specific differences in the proportions of M-TAs, with an increase in the 40 to 44-year age group. Furthermore, the number of emergency surgeries, ICU admissions, and unfavorable outcomes increased in patients in their 30s and 40s. According to data from the Korean Ministry of Employment and Labor, delivery workers are most commonly in their 30s and 40s [18]. The recent increase in telecommuting has increased the number of delivery service workers, many of whom rely on motorcycles because of their speed, ease of parking, flexible maneuverability on narrow roads, and low transportation costs. Middle-aged individuals constitute the majority of delivery service workers, with increasing numbers potentially contributing to an increase in M-TAs within this age group. Choi et al. [19] reported that in domestic studies on work-related M-TAs, delivery service workers had a higher proportion of TAs. Delivery service workers prioritize speed and accessibility, increasing the likelihood of traffic violations such as aggressive driving and exceeding speed limits, and their frequent time on the road increases the probability of accidents [20,21]. Previous studies have indicated that 26% of M-TAs were related to speeding, with a significant likelihood of those involved using mobile phones while riding, and aggressive riders were more likely to use their phones while riding [22-24]. Motorcyclists may exhibit aggressive driving behaviors influenced by psychosocial factors, with studies reporting that 80% routinely violate traffic signals [25,26]. Constant time pressure in the delivery industry may further increase the likelihood of aggressive driving among delivery riders, potentially increasing the risk of severe collisions. Delivery service workers are particularly prone to increased accident rates and injury severity at night and on weekends because of the nature of their work. Considering the growing scale of the delivery industry, targeted interventions, such as educational programs and awareness campaigns for both service workers and employers, are necessary.

Motorcycles are more affordable than vehicles, can be operated at an earlier age, and lack advanced driver-assistance systems. These factors make motorcyclists vulnerable to hazardous situations and contribute to both personal financial losses and societal productivity decline in the event of accidents. South Korea has implemented regulations to improve motorcycle safety, including mandatory helmet use, daytime running lights, and designated lane rules. However, structural limitations such as the inability to fully separate bus lanes and low compliance with safety gear regulations among riders have hindered regulation effectiveness [27-29]. Under these circumstances, the Safe-Speed-5030 policy, implemented with the goal of reducing the incidence of M-TAs and improving outcomes, had a limited impact on medical outcomes but was associated with a reduction in the overall number of patients. This suggests some effectiveness of the policy. However, the Safe-Speed-5030 policy has also been accompanied by significant public dissatisfaction. Previous studies have indicated that lowering the speed limit from 30 miles/hour to 25 miles/hour reduced the average speed by only 0.3%, suggesting that the effect on travel time is minimal on urban roads [30-32]. Therefore, rather than abandoning the Safe-Speed-5030 policy, refining and supplementing it is more appropriate. Furthermore, we believe that additional measures such as dedicated separated motorcycle lanes, lane widening, variable speed limits, and removal of roadside structures are needed to further reduce M-TAs and improve patient outcomes.

This study had several limitations. First, the emergency medical institutions in South Korea are classified into three levels. NEDIS collects data only from regional and local emergency medical centers. Therefore, the M-TA data were limited to cases from these centers, which should be considered when interpreting the results of this study. Patients with major trauma are primarily transported to regional and local emergency medical centers. Therefore, the objective of this study to investigate clinical outcomes in M-TAs remains valid. Second, the severity and outcomes of M-TAs may be influenced by various factors such as impact energy and the type of opposing vehicle. However, owing to the limitations of the NEDIS data and practical constraints, the collection of all the relevant variables was not feasible. Further research incorporating more variables is necessary. Third, the study was conducted in South Korea. Regional differences in TA patterns and medical systems may affect the influence of similar policies. Therefore, the generalizability of these findings should be considered with caution. More extensive research, including international studies, is required. Fourth, the post-phase of this study was the coronavirus disease 2019 (COVID-19) pandemic period, which may have affected traffic density. Traffic density has been reported to have increased or decreased during the COVID-19 pandemic [33,34]. In addition, reductions in traffic density may reduce TA occurrence but increase severe casualties owing to factors such as the tendency of drivers to speed [35]. Therefore, it has not yet been clearly confirmed whether traffic density decreased due to the COVID-19 pandemic and thus decreased severe M-TAs. However, M-TA occurrence is affected by various complex factors, such as changes in traffic density. Further studies considering these factors are required.

Following implementation of the Safe-Speed-5030 policy, the overall number of patients who had experienced M-TAs and the resulting emergency surgeries and ICU admissions decreased. However, the number of critically injured patients and unfavorable outcomes increased, and there was no improvement in clinical outcomes. Considering the partial effectiveness of the policy, revising its implementation is more appropriate than abandoning it entirely. Further policy measures are required to improve the outcomes of patients who are involved in M-TAs.

Article information

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Acknowledgments

We would like to thank Yeungnam University Medical Research Center for their assistance with the statistical analysis.

Funding

This work was supported by a grant from the Chunma Medical Research Foundation in Korea in 2023.

Author contributions

Conceptualization, Formal analysis, Methodology, and Visualization: SB, JHK. Data curation, Funding acquisition, and Supervision: JHK. Writing-original draft: SB. Writing-review & editing: JHK.

Fig. 1.

Distribution of motorcyclists involved in traffic accidents by age group.

Fig. 2.

Distribution of clinical outcomes of motorcyclists involved in traffic accidents by age group. (A) Emergency surgeries, (B) intensive care unit admissions, and (C) unfavorable outcomes.

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References

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