The population consumption model, alcohol control practices, and alcohol-related traffic fatalities

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Existing Regulatory Approaches to Reducing Exposures to Chemical- and Product-Based Risk and Their Applicability to Diet-Related Chronic Disease

We aimed to identify and categorize the types of policies that have been adopted to protect Americans from harmful exposures that could also be relevant for addressing diet-related chronic diseases. This article examines and categorizes the rationales behind government regulation. Our interest in the historical analysis is to inform judgments about how best to address newly emergent risks involving diet-related chronic disease within existing regulatory and information-based frameworks. We assessed exemplars of regulation with respect to harmful exposures from air, water, and food, as well as regulations that are intended to modify voluntary behaviors. Following the comparative analysis, we explored how exposures that lead to diet-related chronic diseases among the general population fit within models of regulation adopted for other comparable risks. We identified five rationales and five approaches that protect people from harmful exposures. Reasons for regulation include: protection from involuntary exposure to risk, high risk of death or chronic illness, ubiquity of risk, counteraction to limit compulsive behaviors, and promotion of population health. Regulatory approaches include: mandatory limits on use, mandatory limits on exposure, mandatory controls on quality, mandatory labeling, and voluntary guidance. In contrast to the use of mandates, the prevention of diet-related chronic diseases thus far has largely relied on information-only approaches and voluntary adoption of guidelines. There is ample precedent for mandatory regulatory approaches that could address harms related to exposure to unhealthy diets, but several barriers to action would need to be overcome.

Public Opinion in Puerto Rico on Alcohol Control Policies

This article discusses the first study to assess public opinion of alcohol policies in Puerto Rico. In 2001, a telephone survey of 514 adults on the island assessed levels of support for 20 alcohol control policies covering five domains: (a) raising alcohol taxes, (b) restricting alcohol consumption in public places, (c) punishing adult providers of alcohol, (d) restricting youth access to alcohol, and (e) restricting marketing of alcohol. Results show high-level support for all alcohol policies, especially for restrictions on alcohol consumption in public places (93% to 95% support) and increases in alcohol taxes earmarked for alcohol treatment, prevention, and education (92% support). Multiple regression analyses reveal older respondents, compared to younger respondents, and respondents reporting lower levels of alcohol consumption were more supportive of alcohol control policies. Results demonstrate a willingness in Puerto Rico to consider public policy solutions to social and health problems associated with drinking.

Effects of acute alcohol intoxication on visuospatial attention

The aim of the present study was to examine the effects of acute alcohol intoxication on the spatial distribution of visual attention measured with simple reaction times (RTs) to targets presented over an extended region of the visual field. Control (n =10) and alcohol groups (n =14) were tested with the same protocol. Participants were tested in two different conditions; in Experiment I, participants were instructed to direct their visual attention to the centre, while in Experiment II they were asked to orient their attention covertly to both right and left, but not to the centre. Throughout participants were required to fixate a small cross in the centre of the computer screen. In the alcohol group, participants received an alcohol dose of 0.4 g/kg so as to produce a blood alcohol concentration (BAC) in the range of 0.08% during the experiments. The spatial distribution of RTs was analysed graphically with geostatistical methods and statistically through analysis of variance of particular regions of the visual field. Results showed that controls were able to direct their attention tightly towards the centre (Expt I) and also to divide attention (Expt II) to the right and left. Participants in the alcohol group fixed their attention more diffusely in the centre (Expt I) and were unable to disengage attention from the centre in Experiment II. We conclude that acute alcohol intoxication impairs the ability to dissociate attention from gaze. Human & Experimental Toxicology (2007) 26, 311-319

The alcohol policy environment, enforcement and consumption in the United States

INTRODUCTION AND AIMS

Many studies of alcohol policies examine the presence or absence of a single policy without considering policy strength or enforcement. We developed measures for the strength of 18 policies (from Alcohol Policy Information System) and levels of enforcement of those policies for the 50 US states, and examined their associations with alcohol consumption.

DESIGN AND METHODS

We grouped policies into four domains (underage alcohol use, provision of alcohol to underage, alcohol serving, general availability) and used latent class analysis to assign states to one of four classes based on the configuration of policies-weak except serving policies (6 states), average (29 states), strong for underage use (11 states) and strong policies overall (4 states). We surveyed 1082 local enforcement agencies regarding alcohol enforcement across five domains. We used multilevel latent class analysis to assign states to classes in each domain and assigned each state to an overall low (15 states), moderate (19 states) or high (16 states) enforcement group. Consumption outcomes (past month, binge and heavy) came from the Behavioral Risk Factor Surveillance System.

RESULTS

Regression models show inverse associations between alcohol consumption and policy class, with past month alcohol consumption at 54% in the weakest policy class and 34% in the strongest. In adjusted models, the strong underage use policy class was consistently associated with lower consumption. Enforcement group did not affect the policy class and consumption associations.

DISCUSSION AND CONCLUSIONS

Results suggest strong alcohol policies, particularly underage use policies, may help to reduce alcohol consumption and related consequences. [Erickson DJ, Lenk KM, Toomey TL, Nelson TF, Jones-Webb R. The alcohol policy environment, enforcement, and consumption in the United States. Drug Alcohol Rev 2015;●●:●●-●●].

Store Impulse Marketing Strategies and Body Mass Index

OBJECTIVES

We quantified the use of placement and price reduction marketing strategies in different food retail outlets to identify associations between these strategies and the risk of overweight and obesity among customers.

METHODS

In 2011 we collected dietary and health information from 1372 residents in "food deserts" in Pittsburgh, PA. We audited neighborhood restaurants and food stores (n = 40) including 16 distant food venues at which residents reported shopping. We assessed end-aisle displays, special floor displays, cash register displays, and price reductions for sugar-sweetened beverages (SSBs); foods high in saturated oils, fats, and added sugars; and nutritious foods such as fruits, vegetables, and products with at least 51% whole grains.

RESULTS

Supermarkets and superstores had the largest numbers of displays and price reductions for low-nutrient foods. Exposure to displays of SSBs and foods high in saturated oils, fats, and added sugars and price reduction of SSBs was associated with increased body mass index.

CONCLUSIONS

In-store marketing strategies of low-nutrient foods appear to be risk factors for a higher body mass index among regular shoppers. Future research is needed to confirm the causal role of marketing strategies in obesity.

Measuring the Strength of State-Level Alcohol Control Policies

PURPOSE

We describe a multi-step method of coding the strength of 18 alcohol policies included in the Alcohol Policy Information System for each of the 50 states.

METHOD

After thoroughly reviewing each policy area, we chose components that were most important in categorizing the strength or restrictiveness of the policy using the following criteria: overall reach, enforceability, and implementation. We determined a unique coding scheme for each policy area.

RESULTS

The total number of categories per policy area ranged from two to six, with categories numbered in an ordered sequence from least to most restrictive. We provide three examples of our coding schemes: Keg Registration, Underage Possession, and Sunday Sales. We also rank the states on their alcohol policy sum score.

DISCUSSION

This study demonstrates how alcohol policies can be measured quantitatively, an important step for assessing the effects of alcohol policies on various outcomes.

A new scale of the U.S. alcohol policy environment and its relationship to binge drinking

BACKGROUND

Of outcomes related to excessive drinking, binge drinking accounts for approximately half of alcohol-attributable deaths, two thirds of years of potential life lost, and three fourths of economic costs. The extent to which the alcohol policy environment accounts for differences in binge drinking in U.S. states is unknown.

PURPOSE

The goal of the study was to describe the development of an Alcohol Policy Scale (APS) designed to measure the aggregate state-level alcohol policy environment in the U.S. and assess the relationship of APS scores to state-level adult binge drinking prevalence in U.S. states.

METHODS

Policy efficacy and implementation ratings were developed with assistance from a panel of policy experts. Data on 29 policies in 50 states and Washington DC from 2000-2010 were collected from multiple sources and analyzed between January 2012 and January 2013. Five methods of aggregating policy data to calculate APS scores were explored; all but one was weighted for relative policy efficacy and/or implementation. Adult (aged ≥18 years) binge drinking prevalence data from 2001-2010 was obtained from the Behavioral Risk Factor Surveillance System surveys. APS scores from a particular state-year were used to predict binge drinking prevalence during the following year.

RESULTS

All methods of calculating APS scores were significantly correlated (r >0.50), and all APS scores were significantly inversely associated with adult binge drinking prevalence. Introducing efficacy and implementation ratings optimized goodness of fit in statistical models (e.g., unadjusted beta=-3.90, p<0.0001, R(2)=0.31).

CONCLUSIONS

The composite measure(s) of the alcohol policy environment have internal and construct validity. Higher APS scores (representing stronger policy environments) were associated with less adult binge drinking and accounted for a substantial proportion of the state-level variation in binge drinking among U.S. states.

The effect of internal possession laws on underage drinking among high school students: a 12-state analysis

OBJECTIVES

We assessed the effect of internal possession (IP) laws, which allow law enforcement to charge underage drinkers with alcohol possession if they have ingested alcohol, on underage drinking behaviors.

METHODS

We examined Youth Risk Behavior Survey (YRBS) data from 12 states with IP laws and with YRBS data before and after each law's implementation. We used logistic regression models with fixed effects for state to assess the effects of IP laws on drinking and binge drinking among high school students.

RESULTS

Implementation of IP laws is associated with reductions in the odds of past-month drinking. This reduction was bigger among male than among female adolescents (27% vs 15%) and only significant among younger students aged 14 and 15 years (15% and 11%, respectively). Male adolescents also reported a significant reduction (24%) in the odds of past-month binge drinking under IP laws.

CONCLUSIONS

These findings suggest that IP laws are effective in reducing underage drinking, particularly among younger adolescents.

Addressing the proximal causes of obesity: the relevance of alcohol control policies

Many policy measures to control the obesity epidemic assume that people consciously and rationally choose what and how much they eat and therefore focus on providing information and more access to healthier foods. In contrast, many regulations that do not assume people make rational choices have been successfully applied to control alcohol, a substance — like food — of which immoderate consumption leads to serious health problems. Alcohol-use control policies restrict where, when, and by whom alcohol can be purchased and used. Access, salience, and impulsive drinking behaviors are addressed with regulations including alcohol outlet density limits, constraints on retail displays of alcoholic beverages, and restrictions on drink “specials.” We discuss 5 regulations that are effective in reducing drinking and why they may be promising if applied to the obesity epidemic.

Adopting local alcohol policies: a case study of community efforts to regulate malt liquor sales

PURPOSE

To learn how the local context may affect a city's ability to regulate alcohol products such as high-alcohol-content malt liquor, a beverage associated with heavy drinking and a spectrum of nuisance crimes in urban areas.

APPROACH

An exploratory, qualitative case study comparing cities that adopted policies to restrict malt liquor sales with cities that considered, but did not adopt policies.

SETTING

Nine large U.S. cities in seven states.

PARTICIPANTS

City legislators and staff, alcohol enforcement personnel, police, neighborhood groups, business associations, alcohol retailers, and industry representatives.

METHOD

Qualitative data were obtained from key informant interviews (n = 56) and media articles (n = 360). The data were coded and categorized. Similarities and differences in major themes among and across Adopted and Considered cities were identified.

RESULTS

Cities faced multiple barriers in addressing malt liquor-related problems, including a lack of enforcement tools, alcohol industry opposition, and a lack of public and political will for alcohol control. Compared to cities that did not adopt malt liquor sales restrictions, cities that adopted restrictions appeared to have a stronger public mandate for a policy and were less influenced by alcohol industry opposition and lack of legislative authority for alcohol control. Strategies common to successful policymaking efforts are discussed.

CONCLUSION

Understanding the local context may be a critical step in winning support for local alcohol control policies.

A regionalised strategy for improving motor vehicle-related highway driver deaths using a weighted averages method

OBJECTIVE

The state of Florida has some of the most dangerous highways in the USA. In 2006, Florida averaged 1.65 fatalities per 100 million vehicle miles travelled (VMT) compared with the national average of 1.42. A study was undertaken to find a method of identifying counties that contributed to the most driver fatalities after a motor vehicle collision (MVC). By regionalising interventions unique to this subset of counties, the use of resources would have the greatest potential of improving statewide driver death.

METHODS

The Florida Highway Safety Motor Vehicle database 2000-2006 was used to calculate driver VMT-weighted deaths by county. A total of 3,468,326 motor vehicle crashes were evaluated. Counties that had driver death rates higher than the state average were sorted by a weighted averages method. Multivariate regression was used to calculate the likelihood of death for various risk factors.

RESULTS

VMT-weighted death rates identified 12 out of 67 counties that contributed up to 50% of overall driver fatalities. These counties were primarily clustered in central and south Florida. The strongest independent risk factors for driver death attributable to MVC in these high-risk counties were alcohol/drug use, rural roads, speed limit ≥45 mph, adverse weather conditions, divided highways, vehicle type, vehicle defects and roadway location.

CONCLUSIONS

Using the weighted averages method, a small subset of counties contributing to the majority of statewide driver fatalities was identified. Regionalised interventions on specific risk factors in these counties may have the greatest impact on reducing driver-related MVC fatalities.

The effectiveness of limiting alcohol outlet density as a means of reducing excessive alcohol consumption and alcohol-related harms

The density of alcohol outlets in communities may be regulated to reduce excessive alcohol consumption and related harms. Studies directly assessing the control of outlet density as a means of controlling excessive alcohol consumption and related harms do not exist, but assessments of related phenomena are indicative. To assess the effects of outlet density on alcohol-related harms, primary evidence was used from interrupted time-series studies of outlet density; studies of the privatization of alcohol sales, alcohol bans, and changes in license arrangements-all of which affected outlet density. Most of the studies included in this review found that greater outlet density is associated with increased alcohol consumption and related harms, including medical harms, injury, crime, and violence. Primary evidence was supported by secondary evidence from correlational studies. The regulation of alcohol outlet density may be a useful public health tool for the reduction of excessive alcohol consumption and related harms.

Readiness for HIV testing among young people in northern Nigeria: the roles of social norm and perceived stigma

This study examined the predictors of readiness for HIV testing among young people in northern Nigeria, paying special attention to the role of stigma. Stigma is measured at two levels: individual and community (social norm). There are commonalities and differences in the correlates of readiness among men and women. For men and women, knowledge about HIV prevention, knowledge about a source for VCT, discussion about condom use for HIV prevention and perceived risk are strong predictors. Knowledge that an apparently healthy person can be HIV-infected is only significant for women. Perceived stigma is a significant predictor for both men and women although the specific dimension of note differs between the sexes. Social norm is strongly and directly associated with readiness among men but has no apparent influence among women. For both sexes, social norm appears to have strong mediating influence on the relationship between personal perceived stigma and readiness. The results strongly suggest that to eliminate HIV-related stigma, it is not enough to target individual cognitive processes; strategic efforts should target social structures in order to change negative social norms.

Processes and outcomes of substance abuse treatment between two programs for clients insured under managed care

The purpose of this research (N = 160) was to describe and compare substance abuse treatment in two programs under managed care: one residential (RT) and one outpatient (OP). Clients in both settings improved significantly from before to after treatment in relation to substance use and quality of life. However, intensity of treatment (hours of care/week) was much greater in RT and days of sobriety were significantly higher after treatment in RT than in OP (p = .04). Intensity was negatively related to incidents of substance use during treatment (SUdT), which predicted substance use after treatment; SUdT averaged .2 for RT, and 1.6 for OP (p = .0001). Importantly, treatment was completed by 74 patients (over 90%) from RT, with 8 dropping out, and 53 (almost 70%) of those in OP completed treatment while 25 dropped out. Intensity, as seen in the RT program, rather than duration, was more effective in substance use reduction and treatment completion.

Relationship between traffic fatalities and drunk driving in Japan

OBJECTIVE

The present study was performed to clarify the relation between alcohol use and traffic fatalities in accidents involving motor vehicles in Japan.

METHODS

Data on traffic accidents were collected from Fukuoka Prefectural Police records of traffic accidents which occurred in that prefecture between 1987 and 1996. Multiple logistic regression models were used to assess the effect of alcohol use on the risk of traffic-accident death.

RESULTS

The data showed that 58,421 male drivers were involved in traffic accidents during the 10-year study period, and that 271 of these were killed as a result of the accident. Alcohol use was significantly associated with speed, seat belt use, time, and road form. Among male motorcar drivers, the odds ratio of alcohol use before driving, after adjusting for age, calendar year, time, and road form, was 4.08 (95% confidence interval, 3.08-5.40), which means that about 75% of fatalities (attributable risk percent among exposed) might have been prevented if drivers had not drunk before driving.

CONCLUSIONS

Alcohol use before driving resulted in a 4.08-fold increase in the risk of death in a traffic accident. It is suggested that alcohol use is considered an important risk factor for fatality in traffic accidents.

Tobacco outlet density and demographics at the tract level of analysis in Iowa: implications for environmentally based prevention initiatives

This study assessed the geographic association between tobacco outlet density and three demographic correlates-income, race, and ethnicity-at the tract level of analysis for one county in the Midwestern United States. Data for residential census tracts in a Midwestern U.S. county were derived from year 2003 licenses for 474 tobacco outlets. Demographic variables were based on 2000 census data. Census tracts with lower median household income, higher percent of African American residents, and higher percent of Latinos residents had greater density of tobacco selling retail outlets. Areas characterized by lower income and disproportionately more African Americans and Latinos have greater physical access to tobacco products. Physical access to tobacco is a critical public-health issue because, given that smokers have been shown to be price sensitive, lowering access costs (e.g., reduced travel time) is likely to increase consumption. Findings also suggest the need for structural or environmental interventions, i.e., tobacco outlet zoning laws, to mitigate the health consequences associated with tobacco use in certain populations and geographic regions.

Preventing alcohol-related traffic injury: a health promotion approach

The conditions that give rise to drinking and driving are complex, with multiple and interrelated causes. Prevention efforts benefit from an approach that relies on the combination of multiple interventions. Health promotion provides a useful framework for conceptualizing and implementing actions to reduce drinking and driving since it involves a combination of educational, behavioral, environmental, and policy approaches. This review draws on data from a range of settings to characterize the effectiveness of various interventions embedded within the health promotion approach. Interventions considered part of the health promotion approach include: (1) economic interventions (2) organizational interventions, (3) policy interventions, and (4) health education interventions, including the use of media, school and community education, and public awareness programs. Effective health promotion strengthens the skills and capabilities of individuals to take action and the capacity of groups or communities to act collectively to exert control over the determinants of alcohol-impaired driving. There is strong evidence for the effectiveness of some components of health promotion, including economic and retailer interventions, alcohol taxation, reducing alcohol availability, legal and legislative strategies, and strategies addressing the servers of alcohol. There is also evidence for the effectiveness of sobriety checkpoints, lower BAC laws, minimum legal drinking age laws, and supportive media promotion programs. Other interventions with moderate evidence of effectiveness include restricting alcohol advertising and promotion, and actions involving counter advertising. Health education interventions alone that have insufficient evidence for effectiveness include passive server training programs, school drug and alcohol education programs, community mobilization efforts, and health warnings. Because each intervention builds on the strengths of every other one, ecological approaches to reducing alcohol-impaired driving using all four components of the health promotion model are likely to be the most effective. Settings such as schools, workplaces, cities, and communities offer practical opportunities to implement alcohol-impaired driving prevention programs within this framework.

Preventing impaired driving using alcohol policy

Considerable progress has been made in the reduction of impaired driving crashes during the last two decades. Much of this progress is attributable to strengthening laws against impaired driving along with vigorous enforcement efforts aimed at deterring impaired driving. In addition, many useful strategies can also be applied that focus on the control of alcohol availability, use, and promotion. Alcohol policies include controls on the price of alcohol, the location, density, and opening hours of sales outlets, controls on the social availability of alcohol, and on the promotion and advertising of alcohol. Enforcement of these policies is an important aspect of their effectiveness. These strategies have been shown to be effective or promising in reducing impaired driving as well as other consequences related to alcohol use and misuse.

College student binge drinking and the "prevention paradox": implications for prevention and harm reduction

Considerable attention has been paid to heavy episodic or "binge" drinking among college youth in the United States. Despite widespread use, the binge measure is perceived by some as a low intervention threshold. We use data from the Harvard School of Public Health College Alcohol Study (n = 49,163) to describe patterns of consumption and harms along a continuum including the binge measure to demonstrate the validity of the binge threshold and prevention paradox in college. While the heaviest drinkers are at greatest risk for harm, they are relatively few and generate proportionately small amounts of all drinking-harms. The risk of harms is not zero among lower level drinkers in college. Because they are numerous, they account for the majority of harms. This paradoxical pattern suggests we moderate consumption among the majority using environmental approaches, the efficacy of which are described using case study data from a national prevention demonstration. Implications for prevention policy, programming, and media advocacy are discussed.

Fighting the Silent Epidemic

This article describes a statewide model program that provides a range of services for individuals with traumatic brain injury in Florida. The article answers questions regarding the organization, delivery, and financing of a system that includes surveillance data, case management, health services, a network of contractors, and a Medicaid waiver. With an annual budget of more than 15 million US dollars, the primary source of financing is a trust fund established through state statute with revenues from fines levied for driving while intoxicated. Lessons from Florida that will be useful to states as they respond to Olmstead and develop Medicaid waivers include (a) how a data registry laid the foundation for a service delivery system, (b) how early and aggressive case management has the potential for Medicaid savings, and (c) how a statewide system, critical mass of patients, and standards for providers can improve the quality of services for persons with traumatic brain injury.