Driver's Licensure and Driving Outcomes Among Youths With Mood Disorders

Importance

Mood disorders are prevalent among adolescents and young adults, and their onset often coincides with driving eligibility. The understanding of how mood disorders are associated with youth driving outcomes is limited.

Objective

To examine the association between the presence of a mood disorder and rates of licensing, crashes, violations, and suspensions among adolescents and young adults.

Design, Setting, and Participants

This cohort study was conducted among New Jersey residents who were born 1987 to 2000, age eligible to acquire a driver's license from 2004 to 2017, and patients of the Children's Hospital of Philadelphia network within 2 years of licensure eligibility at age 17 years. The presence of a current (ie, ≤2 years of driving eligibility) mood disorder was identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Rates of licensure and driving outcomes among youths who were licensed were compared among 1879 youths with and 84 294 youths without a current mood disorder from 2004 to 2017. Data were analyzed from June 2022 to July 2023.

Main Outcomes and Measures

Acquisition of a driver's license and first involvement as a driver in a police-reported crash and rates of other adverse driving outcomes were assessed. Survival analysis was used to estimate adjusted hazard ratios (aHRs) for licensing and driving outcomes. Adjusted rate ratios (aRRs) were estimated for driving outcomes 12 and 48 months after licensure.

Results

Among 86 173 youths (median [IQR] age at the end of the study, 22.8 [19.7-26.5] years; 42 894 female [49.8%]), there were 1879 youths with and 84 294 youths without a mood disorder. A greater proportion of youths with mood disorders were female (1226 female [65.2%]) compared with those without mood disorders (41 668 female [49.4%]). At 48 months after licensure eligibility, 75.5% (95% CI, 73.3%-77.7%) and 83.8% (95% CI, 83.5%-84.1%) of youths with and without mood disorders, respectively, had acquired a license. Youths with mood disorders were 30% less likely to acquire a license than those without a mood disorder (aHR, 0.70 [95% CI, 0.66-0.74]). Licensed youths with mood disorders had higher overall crash rates than those without mood disorders over the first 48 months of driving (137.8 vs 104.8 crashes per 10 000 driver-months; aRR, 1.19 [95% CI, 1.08-1.31]); licensed youths with mood disorders also had higher rates of moving violations (aRR, 1.25 [95% CI, 1.13-1.38]) and license suspensions (aRR, 1.95 [95% CI, 1.53-2.49]).

Conclusions and Relevance

This study found that youths with mood disorders were less likely to be licensed and had higher rates of adverse driving outcomes than youths without mood disorders. These findings suggest that opportunities may exist to enhance driving mobility in this population and elucidate the mechanisms by which mood disorders are associated with crash risk.

Changes in the burden of medications that may impair driving among older adults before and after a motor vehicle crash

BACKGROUND

Medications are one of the most easily modifiable risk factors for motor vehicle crashes (MVCs) among older adults, yet limited information exists on how the use of potentially driver-impairing (PDI) medications changes following an MVC. Therefore, we examined the number and types of PDI medication classes dispensed before and after an MVC.

METHODS

This observational study included Medicare fee-for-service beneficiaries aged ≥67 years who were involved in a police-reported MVC in New Jersey as a driver between 2008 and 2017. Analyses were conducted at the "person-crash" level because participants could be involved in more than one MVC. We examined the use of 36 PDI medication classes in the 120 days before and 120 days after MVC. We described the number and prevalence of PDI medication classes in the pre-MVC and post-MVC periods as well as the most common PDI medication classes started and stopped following the MVC.

RESULTS

Among 124,954 person-crashes, the mean (SD) age was 76.0 (6.5) years, 51.3% were female, and 83.9% were non-Hispanic White. The median (Q1 , Q3 ) number of PDI medication classes was 2 (1, 4) in both the pre-MVC and post-MVC periods. Overall, 20.3% had a net increase, 15.9% had a net decrease, and 63.8% had no net change in the number of PDI medication classes after MVC. Opioids, antihistamines, and thiazide diuretics were the top PDI medication classes stopped following MVC, at incidences of 6.2%, 2.1%, and 1.7%, respectively. The top medication classes started were opioids (8.3%), skeletal muscle relaxants (2.2%), and benzodiazepines (2.1%).

CONCLUSIONS

A majority of crash-involved older adults were exposed to multiple PDI medications before and after MVC. A greater proportion of person-crashes were associated with an increased rather than decreased number of PDI medications. The reasons why clinicians refrain from stopping PDI medications following an MVC remain to be elucidated.

The Variability of Recovery From Pediatric Concussion Using Multimodal Clinical Definitions

BACKGROUND

While concussions are common pediatric injuries, a lack of agreement on a standard definition of recovery creates multiple challenges for clinicians and researchers alike.

HYPOTHESIS

The percentage of concussed youth deemed recovered as part of a prospective cohort study will differ depending on the recovery definition.

STUDY DESIGN

Descriptive epidemiologic study of a prospectively enrolled observational cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

Participants aged 11 to 18 years were enrolled from the concussion program of a tertiary care academic center. Data were collected from initial and follow-up clinical visits ≤12 weeks from injury. A total of 10 recovery definitions were assessed: (1) cleared to full return to sports; (2) return to full school; (3) self-reported return to normal; (4) self-reported full return to school; (5) self-reported full return to exercise; (6) symptom return to preinjury state; (7) complete symptom resolution; (8) symptoms below standardized threshold; (9) no abnormal visio-vestibular examination (VVE) elements; and (10) ≤1 abnormal VVE assessments.

RESULTS

In total, 174 participants were enrolled. By week 4, 63.8% met at least 1 recovery definition versus 78.2% by week 8 versus 88.5% by week 12. For individual measures of recovery at week 4, percent recovered ranged from 5% by self-reported full return to exercise to 45% for ≤1 VVE abnormality (similar trends at 8 and 12 weeks).

CONCLUSION

There is wide variability in the proportion of youth considered recovered at various points following concussion depending on the definition of recovery, with higher proportions using physiologic examination-based measures and lower proportions using patient-reported measures.

CLINICAL RELEVANCE

These results further emphasize the need for a multimodal assessment of recovery by clinicians as a single and standardized definition of recovery that captures the broad impact of concussion on a given patient continues to be elusive.

Variation in drivers' seat belt use by indicators of community-level vulnerability

INTRODUCTION

Examining crash reports with linked community-level indicators may optimize efforts aimed at improving traffic safety behaviors, like seat belt use. To examine this, quasi-induced exposure (QIE) methods and linked data were used to (a) estimate trip-level seat belt non-use of New Jersey (NJ) drivers and (b) determine the degree to which seat belt non-use is associated with community-level indicators of vulnerability.

METHOD

Driver-specific characteristics were identified from crash reports (age, sex, number of passengers, vehicle type) and licensing data (license status at the time of the crash). Geocoded residential addresses were leveraged within the NJ Safety and Health Outcomes warehouse to create quintiles of community-level vulnerability. QIE methods were applied to estimate trip-level prevalence of seat belt non-use in non-responsible, crash-involved drivers between 2010-2017 (n = 986,837). Generalized linear mixed models were then conducted to calculate adjusted prevalence ratios and 95 % confidence intervals for being unbelted for driver-specific variables and community-level indicators of vulnerability.

RESULTS

Drivers were unbelted during 1.2 % of trips. Males, those with suspended licenses, and those without passengers had higher rates of being unbelted than their counterparts. An increase was observed in traveling unbelted with increasing quintiles of vulnerability, such that drivers in the most vulnerable communities were 121 % more likely to be unbelted than those in the least vulnerable communities.

CONCLUSIONS

Prevalence of driver seat belt non-use may be lower than previously estimated. Additionally, communities with the highest amount of the population living with three or more indicators of vulnerability have higher rates of seat belt non-use; this may be a particularly useful metric to inform future translational efforts improving seat belt use.

PRACTICAL APPLICATIONS

As evidenced by the findings that risk of being unbelted increased as drivers' community vulnerability increased, novel communication efforts tailored to drivers from vulnerable neighborhoods may optimize efforts.

Sociodemographic disparities in child restraint selection and variation in child passenger safety information sources

PURPOSE

Marginalized and otherwise vulnerable groups remain at higher risk than their counterparts for not having all of their children appropriately restrained during vehicle trips. Little is known about potential sources of these disparities, however a commonly theorized factor has been where caregivers find or obtain information (i.e., their information sources). The objective of this study was to: (1) characterize caregivers' actual and preferred sources of information related to child passenger safety information, overall and within sociodemographic groups; and (2) determine if, and if so how, sources impact appropriate child restraint use (i.e., child/seat fit).

METHODS

We conducted an online, cross-sectional survey of US caregivers. Caregivers answered questions about themselves, their child(ren), their child(ren)'s restraint use during trips, and their information sources to learn which seat their child should be using. We used Fisher's exact and Pearson chi-square tests to compare used and preferred sources of information across caregiver demographics (age, education, race/ethnicity), as well as to determine whether information sources were associated with caregivers' appropriate child restraint use.

RESULTS

A total of 1,302 caregivers from 36 states with 2,092 children completed the survey. The majority (91%) of children were appropriately restrained. More caregivers from marginalized and otherwise vulnerable groups had children inappropriately restrained when compared with their counterparts. We identified multiple differences in both used and preferred information sources by caregivers' age, race/ethnicity, and education level. In addition, we found a trend that caregivers from populations with higher rates of inappropriate use seemingly used fewer information sources. Ultimately, information sources were not associated with appropriate restraint use; however, within vulnerable populations, almost all caregivers had all of their children appropriately restrained if they had used a Child Passenger Safety Technician (CPST)/Inspection Station or their Pediatrician.

CONCLUSION

Our findings reiterate calls for more tailored interventions and efforts to combat widening disparities in child restraint use and crash outcomes and suggest one promising method may be providing more access to child passenger safety experts. Future studies must untangle the likely complex relationship between information sources and appropriate/accurate child restraint use.

Distance From Home to Motor Vehicle Crash Location: Implications for License Restrictions Among Medically-At-Risk Older Drivers

In 30 states, licensing agencies can restrict the distance from home that "medically-at-risk" drivers are permitted to drive. However, where older drivers crash relative to their home or how distance to crash varies by medical condition is unknown. Using geocoded crash locations and residential addresses linked to Medicare claims, we describe how the relationship between distance from home to crash varies by driver characteristics. We find that a majority of crashes occur within a few miles from home with little variation across driver demographics or medical conditions. Thus, distance restrictions may not reduce crash rates among older adults, and the tradeoff between safety and mobility warrants consideration.

Restraint use characteristics among crash-involved child passengers: identifying opportunities to enhance optimal restraint use

OBJECTIVE

Our objective was to describe child passenger restraint use in police reported crashes by key child and driver characteristics.

METHODS

We used data from 2017-2019 police reported crashes in New Jersey to identify child passengers who: (1) were less than 13 years of age, (2) were in an identified seating location in the first, second, or third vehicle row, and (3) had a known restraint status at the time of the crash. We described prevalence of child restraint use by key child and driver characteristics (child: age, sex, seating position, and crash-reported injury status; driver: age, sex, restraint use, evidenced alcohol use, and crash fault). We included 108,780 crash-involved child passengers in our analytic sample.

RESULTS

A small proportion of child passengers were unrestrained at the time of the crash. Most child passengers <2 years were restrained in a rear-facing restraint (59.7%). However, a sizeable proportion were either forward-facing (26.7%) or belted (11.3%). Use of booster seats among passengers age 5 to 8 years was limited. We observed few fatalities, with most children noted to have no apparent injury (89.8%). Among children with serious, minor, and possible injuries, the greatest proportion of injured children were restrained by the vehicle belt. Regarding driver characteristics, slightly more than half of child passengers riding in vehicles driven by drivers aged 21-34 years were restrained in either rear- or forward-facing restraints (53.0%), whereas the majority of children riding with younger (<21 years) or older (>34 years) drivers were restrained with the vehicle belt. Among unrestrained drivers, drivers with evidence of alcohol use, and drivers at fault for the crash, a larger proportion of children were unrestrained compared to drivers who were restrained, had no evidence of alcohol use, and were not at fault.

CONCLUSIONS

While most child passengers were restrained at the time a crash, optimal age-based restraint use was inconsistent, particularly for the youngest child passengers. A sizeable proportion of drivers in this study failed to adhere to best practice recommendations for child restraint use and New Jersey child passenger restraint laws. This was particularly true for drivers who engaged in unsafe driving behaviors, for whom a larger proportion child passengers were unrestrained at the time of the crash. Across all injury categories, the greatest proportion of injured children were restrained by the vehicle belt rather than a child restraint system, suggesting a continued need to understand specific patterns of injuries to inform possible mitigation efforts. Future work to identify intervention opportunities for optimal child restraint practices for drivers is essential to enhancing child passenger safety.

Improving identification of crash injuries: Statewide integration of hospital discharge and crash report data

OBJECTIVE

The availability of complete and accurate crash injury data is critical to prevention and intervention efforts. Relying solely on hospital discharge data or police crash reports may result in a biased undercount of injuries. Linking hospital data with crash reports may allow for a more robust identification of injuries and an understanding of which populations may be missed in an analysis of one source. We used the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse to examine the share of the entire crash-injured population identified in each of the two data sources, overall and by age, race/ethnicity, sex, injury severity, and road user type.

METHODS

We utilized 2016-2017 data from the NJ-SHO warehouse. We identified crash-involved individuals in hospital discharge data by applying the ICD-10-CM external cause of injury matrix. Among crash-involved individuals, we identified those with injury- or pain-related diagnosis codes as being injured. We also identified crash-involved individuals via crash report data and identified injuries using the KABCO scale. We jointly examined the two sources; injuries in the hospital discharge data were documented as being related to the same crash as injuries found in the crash report data if the date of the crash report preceded the date of hospital admission by no more than two days.

RESULTS

In total, there were 262,338 crash-involved individuals with a documented injury in the hospital discharge data or on the crash report during the study period; 168,874 had an injury according to hospital discharge data, and 164,158 had an injury in crash report data. Only 70,694 (26.9%) had an injury in both sources. We observed differences by age, race/ethnicity, injury severity, and road user type: hospital discharge data captured a larger share of those ages 65+, those who were Black or Hispanic, those with higher severity injuries, and those who were bicyclists or motorcyclists.

CONCLUSIONS

Each data source in isolation captures approximately two-thirds of the entire crash-injured population; one source alone misses approximately one-third of injured individuals. Each source undercounts people in certain groups, so relying on one source alone may not allow for tailored prevention and intervention efforts.

Characteristics of Diagnosed Concussions in Children Aged 0 to 4 Years Presenting to a Large Pediatric Healthcare Network

OBJECTIVE

The aim of the study was to comprehensively describe the natural history of concussion in early childhood between 0 and 4 years.

METHODS

Retrospective cohort study of 329 patients aged 0 to 4 years, with an International Classification of Diseases, Ninth Revision, concussion diagnosis in the Children's Hospital of Philadelphia healthcare network from October 1, 2013, to September 30, 2015. Clinical data were abstracted from the Children's Hospital of Philadelphia electronic health record, which captured all clinical care visits and injury characteristics.

RESULTS

Nearly 9 (86.6%) of 10 patients sought care in the emergency department or urgent care setting, most commonly on the day of injury (56.2%) and as a result of a fall (64.4%). More than two-thirds (64.4%) of patients or their parent/caregiver reported somatic symptoms (ie, vomiting or headache), whereas close to half (49.2%) reported sleep issues. One of 5 patients identified emotional symptoms (21.9%) or visio-vestibular dysfunction (20.4%). Many patients also experienced symptoms not included in standard assessment tools including personality changes (34.0%) and change in appetite (12.8%).

CONCLUSIONS

These results provide insight into the clinical characteristics of concussion in early childhood up to 4 years of age. Because assessment in this group relies heavily on parent/caregiver symptom reporting, rather than patient self-report, these results will aid clinicians with the challenge of diagnosing concussions in this population. These findings highlight the need to develop additional tools to adequately and systematically assess common signs and symptoms of concussion in early childhood that may not be included in standard assessment scales routinely used in older adolescents and adults.

Facilitating research on racial and ethnic disparities and inequities in transportation: Application and evaluation of the Bayesian Improved Surname Geocoding (BISG) algorithm

OBJECTIVE

Racial and ethnic disparities and/or inequities have been documented in traffic safety research. However, race/ethnicity data are often not captured in population-level traffic safety databases, limiting the field's ability to comprehensively study racial/ethnic differences in transportation outcomes, as well as our ability to mitigate them. To overcome this limitation, we explored the utility of estimating race and ethnicity for drivers in the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse using the Bayesian Improved Surname Geocoding (BISG) algorithm. In addition, we summarize important recommendations established to guide researchers developing and implementing racial and ethnic disparity research.

METHODS

We applied BISG to estimate population-level race/ethnicity for New Jersey drivers in 2017 and evaluated the concordance between reported values available in integrated administrative sources (e.g., hospital records) and BISG probability distributions using an area under the receiver operator curve (AUC) within each race/ethnicity category. Overall AUC was calculated by weighting each AUC value by the population count in each reported category. In an exemplar analysis using 2017 crash data, we conducted an analysis of average monthly police-reported crash rates in 2017 by race/ethnicity using the NJ-SHO and BISG sets of race/ethnicity values to compare their outputs.

RESULTS

We found excellent or outstanding concordance (AUC ≥0.86) between reported race/ethnicity and BISG probabilities for White, Hispanic, Black, and Asian/Pacific Islander drivers. We found poor concordance for American Indian/Alaskan Native drivers (AUC= 0.65), and concordance was no better than random assignment for Multiracial drivers (AUC = 0.52). Among White, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan native drivers, monthly crash rates calculated using both NJ-SHO reported race/ethnicity values and BISG probabilities were similar. Monthly crash rates differed by 11% for Black drivers, and by more than 200% for Multiracial drivers.

CONCLUSION

Findings of excellent or outstanding concordance between and mostly similar crash rates derived from reported race/ethnicity and BISG probabilities for White, Hispanic, Black, and Asian/Pacific Islander drivers (98.9% of all drivers in this sample) demonstrate the potential utility of BISG in enabling research on transportation disparities and inequities. Concordance between race/ethnicity values were not acceptable for American Indian/Alaskan Native and Multiracial drivers, which is similar to previous applications and evaluations of BISG. Future work is needed to determine the extent to which BISG may be applied to traffic safety contexts.

Development of the integrated New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse: catalysing advancements in injury prevention research

OBJECTIVE

Our objective was to describe the development of the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse-a unique and comprehensive data source that integrates state-wide administrative databases in NJ to enable the field of injury prevention to address critical, high-priority research questions.

METHODS

We undertook an iterative process to link data from six state-wide administrative databases from NJ for the period of 2004 through 2018: (1) driver licensing histories, (2) traffic-related citations and suspensions, (3) police-reported crashes, (4) birth certificates, (5) death certificates and (6) hospital discharges (emergency department, inpatient and outpatient). We also linked to electronic health records of all NJ patients of the Children's Hospital of Philadelphia network, census tract-level indicators (using geocoded residential addresses) and state-wide Medicaid/Medicare data. We used several metrics to evaluate the quality of the linkage process.

RESULTS

After the linkage process was complete, the NJ-SHO data warehouse included linked records for 22.3 million distinct individuals. Our evaluation of this linkage suggests that the linkage was of high quality: (1) the median match probability-or likelihood of a match being true-among all accepted pairs was 0.9999 (IQR: 0.9999-1.0000); and (2) the false match rate-or proportion of accepted pairs that were false matches-was 0.0063.

CONCLUSIONS

The resulting NJ-SHO warehouse is one of the most comprehensive and rich longitudinal sources of injury data to date. The warehouse has already been used to support numerous studies and is primed to support a host of rigorous studies in the field of injury prevention.

Individual and Geographic Variation in Driver's License Suspensions: Evidence of Disparities by Race, Ethnicity and Income

INTRODUCTION

Although access to a motor vehicle is essential for pursuing social and economic opportunity and ensuring health and well-being, states have increasingly used driver's license suspensions as a means of compelling compliance with a variety of laws and regulations unrelated to driving, including failure to pay a fine or appear in court. Little known about the population of suspended drivers and what geographic resources may be available to them to help mitigate the impact of a suspension.

METHODS

Using data from the New Jersey Safety Health Outcomes (NJ-SHO) data warehouse 2004-2018, we compared characteristics of suspended drivers, their residential census tract, as well as access to public transportation and jobs, by reason for the suspension (driving or non-driving related). In addition, we examined trends in the incidence and prevalence of driving- and non-driving-related suspensions by sub-type over time.

RESULTS

We found that the vast majority (91%) of license suspensions were for non-driving-related events, with the most common reason for a suspension being failure to pay a fine. Compared to drivers with a driving-related suspension or no suspension, non-driving-related suspended drivers lived in census tracts with a lower household median income, higher proportion of black and Hispanic residents and higher unemployment rates, but also better walkability scores and better access to public transportation and jobs.

CONCLUSIONS

Our study contributes to a growing literature that shows, despite public perception that they are meant to address traffic safety, the majority of suspensions are for non-driving-related events. Further, these non-driving-related suspensions are most common in low-income communities and communities with a high-proportion of black and Hispanic residents. Although non-driving-related suspensions are also concentrated in communities with better access to public transportation and nearby jobs, additional work is needed to determine what effect this has for the social and economic well-being of suspended drivers.

Clinical and Device-based Metrics of Gait and Balance in Diagnosing Youth Concussion

PURPOSE

Evaluate the discriminatory ability of two clinical measures and one device-based measure of gait and balance for concussed youth.

METHODS

We enrolled 81 cases and 90 controls age 14-18 yr old from August 2017 to June 2018. Controls were recruited from a suburban high school, and cases were recruited from the concussion program of an academic pediatric tertiary care center. Tests included two clinical measures: 1) complex tandem gait, scored as sway/errors walking forward and backward eyes open and closed; 2) Modified Balance Error Scoring System (mBESS), scored as total number of errors on three standing tasks; and one device-based measure; 3) Modified Clinical Test of Sensory Interaction and Balance (mCTSIB) using the Biodex Biosway Balance System, scored as a sway index. Sensitivity, specificity, ideal cutpoint, and area under the receiver operating characteristic curve (AUC) were calculated for all test components.

RESULTS

Ideal cutpoint for total number of sway/errors for tandem gait = 5, sensitivity 41%, specificity 90%. Ideal cutpoint for total mBESS errors = 4, sensitivity 55%, specificity 75%. Ideal cutpoint for mCTSIB = 1.37, sensitivity 37%, specificity 88%. Among each test, some individual components outperformed overall composites, in particular tandem gait (specificity forward eyes open = 99%, sensitivity backward eyes closed = 81%). Among the 40 cases and 65 controls with all three assessments, AUC (95% CI) for tandem gait = 0.63 (0.52,0.75), mBESS = 0.70 (0.60,0.81), and mCTSIB = 0.54 (0.42,0.66).

CONCLUSIONS

A device-based measure of balance did not produce better discriminatory ability than two clinical assessments. Complex tandem gait has the additional benefit of being an easy-to-perform and graded test with highly sensitive and specific individual components.

Telephone Triage in Pediatric Head Injury: Follow-up Patterns and Subsequent Diagnosis of Concussion

Head injuries in childhood can result in concussion. Families of a child with a head injury often seek medical advice through telephone triage call systems. It is important to understand if patients follow telephone triage recommendations and what proportion of triage calls result in subsequent concussion diagnosis. We used a one-year retrospective cohort of triage calls screened with the Barton Schmitt Pediatric Head Injury Telephone Triage Protocol. The objectives were to estimate the proportion who followed up with urgent recommendations to see a provider and determine prevalence of diagnoses of concussion. Out of 2,454 calls with recommendations to be seen urgently, the estimated proportion of being seen in the medical home network or an outside health care facility was 84.1%. Estimated overall diagnoses of concussion among those who were seen was 39.5%. These data can be used to improve patient education and follow-up, as well as the utility of the telephone triage system.

Driver licensing, motor-vehicle crashes, and moving violations among older adults

INTRODUCTION

Driving is important for well-being among older adults, but age-related conditions are associated with driving reduction or cessation and increased crash risk for older drivers. Our objectives were to describe population-based rates of older drivers' licensing and per-driver rates of crashes and moving violations.

METHODS

We examined individual-level statewide driver licensing, crash, and traffic citation data among all New Jersey drivers aged ≥ 65 and a 35- to 54-year-old comparison group during 2010-2014. Rate ratios (RR) of crashes and moving violations were estimated using Poisson regression.

RESULTS

Overall, 86% of males and 71% of females aged ≥ 65 held a valid driver's license. Older drivers had 27% lower per-driver crash rates than middle-aged drivers (RR: 0.73, 95% CI: 0.73, 0.74)-with appreciable differences by sex-but 40% higher fatal crash rates (RR: 1.40 [1.24, 1.58]). Moving violation rates among older drivers were 72% lower than middle-aged drivers (RR: 0.28 [0.28, 0.28]).

CONCLUSION

The majority of older adults are licensed, with substantial variation by age and sex. Older drivers have higher rates of fatal crashes but lower rates of moving violations compared with middle-aged drivers. Practical applications: Future research is needed to understand the extent to which older adults drive and to identify opportunities to further reduce risk of crashes and resultant injuries among older adults.

Catalyzing traffic safety advancements via data linkage: Development of the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse

Objective: Our objective is to describe the development of the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse, a unique and comprehensive data source that integrates various state-level administrative databases in New Jersey to enable the field of traffic safety to address critical, high-priority research questions.Methods: We have obtained full identifiable data from the following statewide administrative databases for the state of New Jersey: (1) driver licensing database; (2) Administration Office of the Courts data on traffic-related citations; (3) police-reported crash database; (4) birth certificate data; (5) death certificate data; and (6) hospital discharge data as well as (7) childhood electronic records from New Jersey residents who were patients of the Children's Hospital of Philadelphia pediatric health care network and (8) census tract-level indicators. We undertook an iterative process to develop a linkage algorithm in LinkSolv 9.0 software using records for individuals born in select birth years (1987 and 1988) and subsequently execute the linkage for the entire study period (2004-2017). Several metrics were used to evaluate the quality of the linkage process.Results: We identified a total of 62,685,619 records and 19,247,363 distinct individuals; 10,352,998 of these individuals had more than one record brought together during the linkage process. Our evaluation of this linkage suggests that the linkage was of high quality.Conclusions: The resulting NJ-SHO data warehouse will be one of the most comprehensive and rich traffic safety data warehouses to date. The warehouse has already been utilized for numerous studies and will be fully primed to support a host of rigorous studies, both in and beyond the field of traffic safety.

Young Driver Compliance With Graduated Driver Licensing Restrictions Before and After Implementation of a Decal Provision

PURPOSE

In May 2010, New Jersey implemented the first-in-the-nation decal provision to increase intermediate drivers' compliance with Graduated Driver Licensing restrictions and ultimately reduce young driver crashes. We previously found that the provision was associated with a 9.5% decline in crash rates. This study evaluates whether the decal provision was associated with an increase in compliance with passenger and nighttime restrictions.

METHODS

We analyzed New Jersey driver licensing and crash data from 2008 through 2012. We used the quasi-induced exposure method to estimate prevalence of noncompliance among 20,593 nonresponsible 17- to 20-year-old intermediate drivers involved in crashes. Multivariate log-binomial regression models compared the monthly prevalence of noncompliance with restrictions pre and post implementation, adjusted for age, sex, season, and area income and population density. Analyses were conducted in 2016-2017.

RESULTS

Overall estimated noncompliance with the nighttime restriction was 1.75% before and 1.71% after the decal provision (p = .83). Noncompliance with the passenger restriction was 8.68% before and 8.31% after (p = .35). Introduction of the decal provision was not associated with a change in noncompliance rates.

CONCLUSIONS

Compliance rates among New Jersey intermediate drivers were high both before and after the decal provision. Findings do not suggest that the decline in crash rates following implementation was because of increased compliance with nighttime or passenger driving restrictions. Additional research is needed to understand mechanisms by which decal provisions may reduce young driver crashes.

Can Adolescent Drivers' Motor Vehicle Crash Risk Be Reduced by Pre-Licensure Intervention?

PURPOSE

Although motor vehicle crashes are the leading cause of death for adolescents, there is a scarcity of research addressing adolescents' lack of pre-licensure practical driving experience, which is theorized to increase their post-licensure crash risk.

METHODS

Utilizing police-reported crashes and survey data from a randomized and quasi-randomized trial (n = 458 adolescents, 16 or 17 years of age at enrollment), the impact of a parent-directed supervised practice driving intervention and a comprehensive on-road driving assessment (ODA) with feedback was evaluated on adolescent drivers' motor vehicle crashes involvement.

RESULTS

Compared with the control condition, a nonsignificant 20% relative reduction in risk was observed for the parent-directed intervention: adjusted hazard ratio  = .80 (95% confidence interval [CI] .44, 1.43); the unadjusted absolute risk reduction was 1.1% (95% CI -4.4, 7.1). Exposure to the ODA resulted in an 53% relative reduction of risk: adjusted hazard ratio  = .47 (95% CI .24, .91); the unadjusted absolute risk reduction was 5.4% (95% CI -.3, 10.7).

CONCLUSIONS

Comprehensive ODA might be protective for adolescents; however, additional research is needed.

Motor Vehicle Crash Risk Among Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder

IMPORTANCE

Attention-deficit/hyperactivity disorder (ADHD) often persists into adolescence, when motor vehicle crash risk peaks. We know little about when adolescents with ADHD get licensed and, once they do, the extent to which they have increased crash risk compared with adolescents without ADHD.

OBJECTIVES

To examine the association between ADHD and both driver licensing and crash involvement and whether it varies by sex, licensing age, and/or being prescribed ADHD medication at licensure.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study was conducted at 6 primary care practices of the Children's Hospital of Philadelphia, a large pediatric health care network in southeastern Pennsylvania and southern New Jersey. Using electronic health records, we defined a cohort of 2479 adolescents and young adults with ADHD and 15 865 without ADHD who were (1) born from 1987 to 1997; (2) residents of New Jersey and patients at 1 of 6 New Jersey primary care practices at age 12 years or older; and (3) age-eligible to obtain a driver's license from 2004 through 2014. Electronic health records data were then linked with New Jersey's statewide driver licensing and crash databases for 2004 through 2014.

MAIN OUTCOMES AND MEASURES

Acquisition of a driver's license and first involvement as a driver in a police-reported crash. Survival analysis was used to estimate adjusted hazard ratios for licensing and crash outcomes through age 25 years.

RESULTS

The median age of individuals at the end of the study was 22.2 years (interquartile range, 19.7-24.8). Compared with individuals without ADHD, the licensing probability of individuals with ADHD 6 months after eligibility was 35% lower (for males: adjusted hazard ratio, 0.65; 95% CI, 0.61-0.70; females: adjusted hazard ratio, 0.64; 95% CI, 0.58-0.70). Among individuals with a driver's license, 764 of 1785 with ADHD (42.8%) and 4715 of 13 221 without ADHD (35.7%) crashed during the study period. The adjusted risk for first crash among licensed drivers with ADHD was 1.36 times higher than for those without ADHD (95% CI, 1.25-1.48) and did not vary by sex, licensing age, or over time. Only 129 individuals with ADHD (12.1%) were prescribed medication in the 30 days before licensure.

CONCLUSIONS AND RELEVANCE

Adolescents with ADHD get licensed less often and at an older age. Once licensed, this cohort has a greater risk of crashing. Additional research is needed to understand the specific mechanisms by which ADHD influences crash risk.

Compliance With and Enforcement of Graduated Driver Licensing Restrictions

INTRODUCTION

Graduated Driver Licensing (GDL) is the most effective strategy to reduce the burden of young driver crashes, but the extent to which young intermediate (newly licensed) drivers comply with, and police enforce, important GDL passenger and night-time restrictions is largely unknown. Population-level rates of intermediate drivers' compliance were estimated as well as police enforcement among crash-involved drivers who were noncompliant.

METHODS

New Jersey's statewide driver licensing and crash databases were individually linked. The quasi-induced exposure method's fundamental assumption-that nonresponsible young intermediate drivers in clean (i.e., only one responsible driver) multivehicle crashes are reasonably representative of young intermediate drivers on the road-was borrowed. Incidence was then estimated among the 9,250 nonresponsible intermediate drivers who were involved in clean multivehicle crashes from July 2010 through June 2012. The proportion of crash-involved noncompliant intermediate drivers who were issued a GDL citation, by crash responsibility, was calculated. Data were collected in 2013 and analyzed in 2015.

RESULTS

Overall, 8.3% (95% CI=7.8%, 8.9%) of intermediate drivers' trips were noncompliant with New Jersey's passenger restriction and 3.1% (95% CI=2.8%, 3.5%) with its night-time restriction; compliance was significantly lower among those residing in low-income and urban areas, among male drivers, on weekends, and in summer months. The proportion of crash-involved noncompliant intermediate drivers who were issued a GDL citation was low (nonresponsible drivers, 10.3%; responsible drivers, 19.0%).

CONCLUSIONS

The vast majority of intermediate driver trips are in compliance with GDL restrictions. Outreach activities should consider focusing on higher-risk situations and groups with higher noncompliance rates.

Parental influence on driver licensure in adolescence: A randomized controlled trial

OBJECTIVE

Newly licensed adolescent drivers have skill deficits that increase risk for motor vehicle crashes. Development of programs targeted to prelicensed adolescents has been hindered by concerns about encouraging overconfidence and early licensure. The study had 2 primary objectives: (a) determine whether an Internet-based intervention designed to improve parent-supervised practice (TeenDrivingPlan [TDP]) influenced adolescents' time to licensure and parents' perceptions of adolescents' driving skill, expertise, and safety and (b) evaluate the association of these perceptions and practice diversity (number of different environments where practiced occurred) with time to licensure.

METHOD

A randomized controlled trial was used to compare TDP with a control condition. Participants (N = 295 parent-adolescent dyads) completed periodic surveys over 24 weeks and were subsequently followed for up to a year to determine adolescents' licensure status.

RESULTS

TDP did not influence time to licensure and did not affect parents' perceptions of skill, expertise, and safety. Practice diversity was associated with faster licensure. A more favorable perception of adolescents' skill in comparison to peers was associated with faster licensure.

CONCLUSIONS

Targeting parents' beliefs about adolescents' safety in relation to other road users may not be conducive to altering licensing trajectories, whereas sensitizing parents to their adolescents' emerging skills might be more effective in promoting safe entry into licensure. (PsycINFO Database Record

Point of Health Care Entry for Youth With Concussion Within a Large Pediatric Care Network

IMPORTANCE

Previous epidemiologic research on concussions has primarily been limited to patient populations presenting to sport concussion clinics or to emergency departments (EDs) and to those high school age or older. By examining concussion visits across an entire pediatric health care network, a better estimate of the scope of the problem can be obtained.

OBJECTIVE

To comprehensively describe point of entry for children with concussion, overall and by relevant factors including age, sex, race/ethnicity, and payor, to quantify where children initially seek care for this injury.

DESIGN, SETTING, AND PARTICIPANTS

In this descriptive epidemiologic study, data were collected from primary care, specialty care, ED, urgent care, and inpatient settings. The initial concussion-related visit was selected and variation in the initial health care location (primary care, specialty care, ED, or hospital) was examined in relation to relevant variables. All patients aged 0 to 17 years who received their primary care from The Children's Hospital of Philadelphia's (CHOP) network and had 1 or more in-person clinical visits for concussion in the CHOP unified electronic health record (EHR) system (July 1, 2010, to June 30, 2014) were selected.

MAIN OUTCOMES AND MEASURES

Frequency of initial concussion visits at each type of health care location. Concussion visits in the EHR were defined based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes indicative of concussion.

RESULTS

A total of 8083 patients were included (median age, 13 years; interquartile range, 10-15 years). Overall, 81.9% (95% CI, 81.1%-82.8%; n = 6624) had their first visit at CHOP within primary care, 5.2% (95% CI, 4.7%-5.7%; n = 418) within specialty care, and 11.7% (95% CI, 11.0%-12.4%; n = 947) within the ED. Health care entry varied by age: 52% (191/368) of children aged 0 to 4 years entered CHOP via the ED, whereas more than three-quarters of those aged 5 to 17 years entered via primary care (5-11 years: 1995/2492; 12-14 years: 2415/2820; and 15-17 years: 2056/2403). Insurance status also influenced the pattern of health care use, with more Medicaid patients using the ED for concussion care (478/1290 Medicaid patients [37%] used the ED vs 435/6652 private patients [7%] and 34/141 self-pay patients [24%]).

CONCLUSIONS AND RELEVANCE

The findings suggest estimates of concussion incidence based solely on ED visits underestimate the burden of injury, highlight the importance of the primary care setting in concussion care management, and demonstrate the potential for EHR systems to advance research in this area.

Validation of quasi-induced exposure representativeness assumption among young drivers

OBJECTIVE

Young driver studies have applied quasi-induced exposure (QIE) methods to assess relationships between demographic and behavioral factors and at-fault crash involvement, but QIE's primary assumption of representativeness has not yet been validated among young drivers. Determining whether nonresponsible young drivers in clean (i.e., only one driver is responsible) 2-vehicle crashes are reasonably representative of the general young driving population is an important step toward ensuring valid QIE use in young driver studies. We applied previously established validation methods to conduct the first study, to our knowledge, focused on validating the QIE representativeness assumption in a young driver population.

METHODS

We utilized New Jersey's state crash and licensing databases (2008-2012) to examine the representativeness assumption among 17- to 20-year-old nonresponsible drivers involved in clean multivehicle crashes. It has been hypothesized that if not-at-fault drivers in clean 2-vehicle crashes are a true representation of the driving population, it would be expected that nonresponsible drivers in clean 3-or-more-vehicle crashes also represent this same driving population (Jiang and Lyles 2010 ). Thus, we compared distributions of age, gender, and vehicle type among (1) nonresponsible young drivers in clean 2-vehicle crashes and (2) the first nonresponsible young driver in clean crashes involving 3 or more vehicles to (3) all other nonresponsible young drivers in clean crashes involving 3 or more vehicles. Distributions were compared using chi-square tests and conditional logistic regression; analyses were conducted for all young drivers and stratified by license status (intermediate vs. fully licensed drivers), crash location, and time of day of the crash.

RESULTS

There were 41,323 nonresponsible drivers in clean 2-vehicle crashes and 6,464 nonresponsible drivers in clean 3-or-more-vehicle crashes. Overall, we found that the distributions of age, gender, and vehicle type were not statistically significantly different between the 3 groups; in each group, approximately one fourth of drivers were represented in each age from age 17 through 20, half were males, and approximately 80% were driving a car/station wagon/minivan. In general, conclusions held when we evaluated the assumption within intermediate and fully licensed young drivers separately and by crash location and time.

CONCLUSIONS

It appears that the representativeness assumption holds among the population of young NJ drivers. We encourage young driver studies utilizing QIE methods to conduct internal validation studies to ensure appropriate application of these methods and we propose utilization of QIE methods to address broader foundational and applied questions in young driver safety.

Young driver crash rates by licensing age, driving experience, and license phase

BACKGROUND

Few studies have concurrently assessed the influence of age and experience on young driver crashes, in particular in the post-Graduated Driver Licensing (GDL) era. Further, little attention is given to the transition from intermediate to full licensure. We examined the independent and joint contributions of licensing age, driving experience, and GDL license phase on crash rates among the population of young New Jersey (NJ) drivers.

METHODS

From a unique linked database containing licensing and crash data, we selected all drivers who obtained their NJ intermediate license at 17-20 years old from 2006-2009 (n=410,230). We determined the exact age at which each driver obtained an intermediate and full license and created distinct, fixed cohorts of drivers based on their age at intermediate licensure. For each cohort, we calculated and graphed observed monthly crash rates over the first 24 months of licensure. Further, we examined crash rates by age at licensure, driving experience (i.e., time since licensure), and license phase.

RESULTS

First-month crash rates were higher among the youngest drivers (licensed at 17y0m). Drivers who were licensed later experienced a reduced "steepness" in the slope of their crash rates in the critical initial months of driving, but there did not appear to be any incremental benefit of later licensure once drivers had six months of driving experience. Further, at each age, those with more driving experience had lower crash rates; however, the benefit of increased experience was greatest for the substantial proportion of teens licensed immediately after becoming eligible (at 17y0m). Finally, independent of age and experience, teen drivers' crash risk increased substantially at the point of transition to a full license, while drivers of a similar age who remained in the intermediate phase continued to experience a decline in crash rates.

CONCLUSION

Age and driving experience interact to influence crash rates. Further, independent of these two factors, there is an abrupt increase in crash risk at the point of transition from intermediate to full licensure. Future studies should investigate whether this increase is accounted for by a change in driving exposure, driving behaviors, and/or other factors.

Young driver licensing: examination of population-level rates using New Jersey's state licensing database

Recent surveys have provided insight on the primary reasons why US teens delay licensure but are limited in their ability to estimate licensing rates and trends. State administrative licensing data are the ideal source to provide this information but have not yet been analyzed for this purpose. Our objective was to analyze New Jersey's (NJ) licensing database to: (1) describe population-based rates of licensure among 17- to 20-year-olds, overall and by gender and zip code level indicators of household income, population density, and race/ethnicity; and (2) examine recent trends in licensure. We obtained records on all licensed NJ drivers through June 2012 from the NJ Motor Vehicle Commission's licensing database and determined each young driver's age at the time of intermediate and full licensure. Data from the US Census and American Community Survey were used to estimate a fixed cohort of NJ residents who turned 17 years old in 2006-2007 (n=255,833). Licensing data were used to estimate the number of these drivers who obtained an intermediate license by each month of age (numerators) and, among those who obtained an intermediate license, time to graduation to full licensure. Overall, 40% of NJ residents-and half of those who ultimately obtained a license by age 21-were licensed within a month of NJ's minimum licensing age of 17, 64% by their 18th birthday, and 81% by their 21st birthday. Starkly different patterns of licensure were observed by socioeconomic indicators; for example, 65% of 17-year-olds residing in the highest-income zip codes were licensed in the first month of eligibility compared with 13% of residents living in the lowest-income zip codes. The younger an individual obtained their intermediate license, the earlier they graduated to a full license. Finally, the rate and timing of licensure in NJ has been relatively stable from 2006 to 2012, with at most a 1-3% point decline in rates. These findings support the growing body of literature suggesting that teens delay licensure primarily for economic reasons and that a substantial proportion of potentially high-risk teens may be obtaining licenses outside the auspices of a graduated driver licensing system. Finally, our finding of a relatively stable trend in licensure in recent years is in contrast to national-level reports of a substantial decline in licensure rates.

Long-term changes in crash rates after introduction of a Graduated Driver Licensing decal provision

BACKGROUND

New Jersey (NJ) implemented the first Graduated Driver Licensing (GDL) decal provision in the U.S. in May 2010. An initial study reported a 1-year post-decal decrease in the crash rate among NJ intermediate drivers aged <21 years. Longer-term analysis is critical for policymakers in other states considering whether to implement a decal provision.

PURPOSE

To evaluate the longer-term (2-year) effect of NJ's decal provision on overall and age-specific crash rates of young drivers with intermediate licenses.

METHODS

Monthly per-driver police-reported crash rates during January 2006-June 2012 were estimated. Specific crash types included injury, midnight-4:59am, single-vehicle, multiple-vehicle, and peer passenger crashes. Negative binomial modeling compared pre- versus post-decal crash rates, adjusting for age, gender, calendar month, gas price, and 21- to 24-year-old licensed driver crash rates; piecewise negative binomial regression models accounted for pre-decal crash trends among intermediate drivers. Analyses were conducted in 2013.

RESULTS

The adjusted crash rate for intermediate drivers was 9.5% lower in the 2-year post-decal period than the 4-year pre-decal period (95% CI=0.88, 0.93). Crash rates decreased 1.8% per year before the provision and 7.9% per year in the post-decal period (p<0.001 for difference in slopes). For several crash types, effects appeared to be particularly strong for 18- and 19-year-olds. An estimated 3,197 intermediate drivers had crashes prevented.

CONCLUSIONS

NJ's decal provision was associated with a sustained decline in intermediate driver crashes. Future research should aim to better understand the causal mechanism by which NJ's decal provision may have exerted an effect.

Inaccuracy of Federal Highway Administration's licensed driver data: implications on young driver trends

PURPOSE

The Federal Highway Administration (FHWA) collects and publishes annual state-based counts of licensed drivers, which have been used to estimate per-driver crash rates and document a decline in young licensed drivers. The accuracy of these data has been questioned.

METHODS

We compared the number of young licensed drivers as reported by the FHWA (2006-2012) with that generated directly from New Jersey (NJ) administrative licensing data. Census data were used to estimate the proportion of NJ adolescents who were licensed.

RESULTS

FHWA data showed a decline in the proportion of licensed 17- to 20-year olds over the 7-year period (77%-63%), whereas analysis of NJ licensing data revealed a more stable trend (75%-74%).

CONCLUSIONS

We advise against use of FHWA licensing data for research purposes and encourage FHWA to work with state licensing agencies to review and enhance data collection and quality control procedures with the goal of ensuring the accuracy of licensing data.

Engagement with the TeenDrivingPlan and diversity of teens' supervised practice driving: lessons for internet-based learner driver interventions

OBJECTIVE

Inexperienced, less-skilled driving characterises many newly licensed drivers and contributes to high crash rates. A randomised trial of TeenDrivingPlan (TDP), a new learner driver phase internet-based intervention, demonstrated effectiveness in improving safety relevant, on-road driving behaviour, primarily through greater driving practice diversity. To inform future learner driver interventions, this analysis examined TDP use and its association with practice diversity.

DESIGN

Posthoc analysis of data from teen/parent dyads (n=107), enrolled early in learner phase and assigned to treatment arm in randomised trial.

METHODS

Inserted software beacons captured TDP use data. Electronic surveys completed by parents and teens assessed diversity of practice driving and TDP usability ratings at 24 weeks (end of study period).

RESULTS

Most families (84%) used TDP early in the learner period; however, the number of TDP sessions in the first week was three times higher among dyads who achieved greater practice diversity than those with less. By week five many families still engaged with TDP, but differences in TDP use could not be detected between families with high versus low practice diversity. Usability was not a major issue for this sample based on largely positive user ratings.

CONCLUSIONS

An engaging internet-based intervention, such as TDP, can support families in achieving high practice diversity. Future learner driver interventions should provide important information early in the learner period when engagement is greatest, encourage continued learning as part of logging practice drives, and incorporate monitoring software for further personalisation to meet family needs.

TRIAL REGISTRATION

NCT01498575.

Statistical implications of using moving violations to determine crash responsibility in young driver crashes

Traditional methods for determining crash responsibility - most commonly moving violation citations - may not accurately characterize at-fault status among crash-involved drivers given that: (1) issuance may vary by factors that are independent of fault (e.g., driver age, gender), and (2) these methods do not capture driver behaviors that are not illegal but still indicative of fault. We examined the statistical implications of using moving violations to determine crash responsibility in young driver crashes by comparing it with a method based on crash-contributing driver actions. We selected all drivers in police-reported passenger-vehicle crashes (2010-2011) that involved a New Jersey driver <21 years old (79,485 drivers<age 21, 61,355 drivers ≥age 21). For each driver, crash responsibility was determined from the crash report using two alternative methods: (1) issuance of a moving violation citation; and (2) presence of a driver action (e.g., failure to yield, inattention). Overall, 18% of crash-involved drivers were issued a moving violation while 50% had a driver action. Only 32.2% of drivers with a driver action were cited for a moving violation. Further, the likelihood of being cited given the presence of a driver action was higher among certain driver subgroups-younger drivers, male drivers, and drivers in single-vehicle and more severe crashes. Specifically among young drivers, those driving at night, carrying peer passengers, and having a suspended or no license were more often cited. Conversely, fatally-injured drivers were almost never cited. We also demonstrated that using citation data may lead to statistical bias in the characterization of at-fault drivers and of quasi-induced exposure measures. Studies seeking to accurately determine crash responsibility should thoughtfully consider the potential sources of bias that may result from using legal culpability methods. For many studies, determining driver responsibility via the identification of driver actions may yield more accurate characterizations of at-fault drivers.

Graduated driver licensing decal law: effect on young probationary drivers

BACKGROUND

Decal laws have been implemented internationally to facilitate police enforcement of graduated driver licensing (GDL) restrictions (e.g., passenger limit, nighttime curfew) but have not been evaluated. New Jersey implemented the first decal law in the U.S. on May 1, 2010.

PURPOSE

The aim of this study was to evaluate the effect of New Jersey's law on the rate of citations issued for violation of GDL restrictions and police-reported crashes among probationary drivers aged <21 years and to estimate the number of probationary drivers whose crashes were prevented by the law.

METHODS

New Jersey's licensing and crash databases were linked from January 1, 2008 to May 31, 2011, and each driver's license status, age, and outcome status were ascertained for each month. Monthly rates were calculated as the proportion of probationary drivers who experienced the outcome in that month. The pre-law period was defined as January 2008-January 2010 and the post-law period as May 2010-May 2011. Negative binomial regression models with robust SEs were used to determine the law's effect on crash and citation rates (adjusted for gender, seasonal trends, and overall trends) and estimate prevented crashes. Analyses were conducted in 2012.

RESULTS

In the first year post-law, there was a 14% increase in the GDL citation rate (adjusted rate ratio 1.14 [95% CI=1.05, 1.24]); a 9% reduction in the police-reported crash rate (adjusted rate ratio 0.91 [95% CI=0.86, 0.97]), and an estimated 1624 young probationary drivers for whom a crash was prevented.

CONCLUSIONS

Findings suggest that the law is positively affecting probationary drivers' safety. Results contribute to building the evidence base for the effectiveness of decal laws and provide valuable information to U.S. and international policymakers who are considering adding decal laws to enhance existing GDL laws.

Excess mortality among injection drug users with AIDS, New York City (1999-2004)

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, 2006 , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Comparing the National Death Index and the Social Security Administration's Death Master File to ascertain death in HIV surveillance

OBJECTIVES

New York City (NYC) maintains a population-based registry of people with human immunodeficiency virus (HIV) infection to monitor the epidemic and inform resource allocation. We evaluated record linkages with the National Death Index (NDI) and the Social Security Administration's Death Master File (SSDMF) to find deaths occurring from 2000 through 2004.

METHODS

We linked records from 32,837 people reported with HIV and not previously known to be dead with deaths reported in the NDI and the SSDMF. We calculated the kappa statistic to assess agreement between data sources. We performed subgroup analyses to assess differences within demographic and transmission risk subpopulations. We quantified the benefit of linkages with each data source beyond prior death ascertainment from local vital statistics data.

RESULTS

We discovered 1,926 (5.87%) deaths, which reduced the HIV prevalence estimate in NYC by 2.03%, from 1.19% to 1.16%. Of these, 458 (23.78%) were identified only from NDI, and 305 (15.84%) only from SSDMF. Agreement in ascertainment between sources was substantial (kappa = [K] 0.74, 95% confidence interval [CI] 0.72, 0.76); agreement was lower among Hispanic people (K = 0.65, 95% CI 0.62, 0.69) and people born outside the U.S. (K = 0.60, 95% CI 0.52, 0.68). We identified an additional 13.62% of deaths to people reported with HIV in NYC; white people and men who have sex with men were disproportionately likely to be underascertained without these linkages (p < 0.0001).

CONCLUSION

Record linkages with national databases are essential for accurate prevalence estimates from disease registries, and the SSDMF is an inexpensive means to supplement linkages with the NDI to maximize death ascertainment.

Incident sexually transmitted infections among persons living with diagnosed HIV/AIDS in New York City, 2001-2002: a population-based assessment

OBJECTIVE/GOAL

To describe the incidence of 3 bacterial sexually transmitted infections (STIs) among persons living with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) (PLWHA) in New York City (NYC) and to identify predictors for STI acquisition.

STUDY DESIGN

The surveillance registry of PLWHA diagnosed with HIV through December 31, 2000, and reported to the NYC Department of Health and Mental Hygiene was matched with the surveillance registry of persons diagnosed with other STIs during 2001-2002. Incident STIs were defined as cases of gonorrhea, chlamydia, or early syphilis acquired after HIV diagnosis.

RESULTS

Among 62,264 NYC PLWHA, 1466 (2.4%) had an incident STI diagnosed during 2001-2002. Two-year cumulative STI incidence was highest among PLWHA who were men (2.6%), non-Hispanic white (3.2%), aged 13-24 years (8.4%), men who have sex with men (4.5%), and persons living with HIV (non-AIDS) (4.1%). Predictors of STI acquisition among PLWHA varied substantially by STI type.

CONCLUSIONS

This population-based surveillance registry cross-match reveals that high-risk sexual practices occur among specific segments of the NYC PLWHA population. To decrease associated morbidity and prevent the secondary spread of HIV and STIs, prevention efforts should focus on PLWHA who continue to engage in high-risk sexual activity.

Concurrent HIV/AIDS diagnosis increases the risk of short-term HIV-related death among persons newly diagnosed with AIDS, 2002-2005

Despite the overall effectiveness and availability of highly active antiretroviral therapy (HAART), 1500 HIV-related deaths still occur annually in New York City. In considering ways to further reduce deaths, we assessed the contribution of concurrent HIV/AIDS diagnosis to HIV-related mortality in New York City among persons newly diagnosed with AIDS. We used Cox regression to conduct a retrospective cohort analysis of HIV-related mortality among 15,211 residents age 13+ reported with AIDS to the population-based HIV/AIDS registry between January 2002 and June 2005. Concurrent HIV/AIDS diagnosis was defined as a diagnosis of AIDS occurring within 1 month of initial diagnosis of HIV. HIV-related mortality was 20.2% among persons diagnosed concurrently and 12.2% among those diagnosed nonconcurrently (p < 0.0001). Concurrent HIV/AIDS was associated with more than twice the risk of HIV-related death within the 4 months after diagnosis (hazard ratio [HR] 2.27, 95% confidence interval [CI] 1.94-2.65) but no increased risk thereafter (HR 1.12, 95% CI 0.77-1.61). Other significant predictors of death included injection drug use and birth in the Caribbean or Latin America. After 4 years 11.9% of all HIV-related deaths were attributable to a concurrent HIV/AIDS diagnosis. Public health initiatives that facilitate early diagnosis of HIV may reduce HIV-related mortality by giving people the opportunity to initiate care and begin treatment with HAART before immunosuppression places them at risk for opportunistic illness and death.

Estimation of HIV prevalence, risk factors, and testing frequency among sexually active men who have sex with men, aged 18-64 years--New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5-9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8-17.6), aged 35-44 (12.6%, 95% CI = 10.4-15.9), or 45-54 years (13.1%, 95% CI = 10.2-18.3), and residents of Manhattan (17.7%, 95% CI = 14.5-22.8). Overall, 37% (95% CI = 32-43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28-39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0-13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners.

Causes of death among persons with AIDS in the era of highly active antiretroviral therapy: New York City

BACKGROUND

Monitoring the full spectrum of causes of death among persons with AIDS is increasingly important as survival improves because of highly active antiretroviral therapy.

OBJECTIVE

To describe recent trends in deaths due to HIV-related and non-HIV-related causes among persons with AIDS, identify factors associated with these deaths, and identify leading causes of non-HIV-related deaths.

DESIGN

Population-based cohort analysis.

SETTING

New York City.

PATIENTS

All adults (age > or =13 years) living with AIDS between 1999 and 2004 who were reported to the New York City HIV/AIDS Reporting System and Vital Statistics Registry through 2004 (n = 68,669).

MEASUREMENTS

Underlying cause of death on the death certificate.

RESULTS

Between 1999 and 2004, the percentage of deaths due to non-HIV-related causes increased by 32.8% (from 19.8% to 26.3%; P = 0.015). The age-adjusted mortality rate decreased by 49.6 deaths per 10,000 persons with AIDS (P < 0.001) annually for HIV-related causes but only by 7.5 deaths per 10 000 persons with AIDS (P = 0.004) annually for non-HIV-related causes. Of deaths due to non-HIV-related causes, 76% could be attributed to substance abuse, cardiovascular disease, or a non-AIDS-defining type of cancer. Compared with men who have sex with men, injection drug users had a statistically significantly increased risk for death due to HIV-related causes (hazard ratio, 1.59 [95% CI, 1.49 to 1.70]) and non-HIV-related causes (hazard ratio, 2.54 [CI, 2.24 to 2.87]).

LIMITATIONS

Compared with autopsy and chart review, death certificates may lack specificity in the underlying cause of death or detailed clinical and treatment-related information.

CONCLUSIONS

Non-HIV-related causes of death account for one fourth of all deaths of persons with AIDS. Cardiovascular disease, non-AIDS-defining cancer, and substance abuse account for most non-HIV-related deaths. Reducing deaths from these causes requires a shift in the health care model for persons with AIDS from a primary focus on managing HIV infection to providing care that addresses all aspects of physical and mental health.

Tuberculosis prevention for non-US-born pregnant women

OBJECTIVE

The purpose of this study was to evaluate whether non-US-born pregnant women receiving prenatal care are targeted for treatment of latent tuberculosis (TB) infection (LTBI) with isoniazid (INH) to prevent active TB.

STUDY DESIGN

This was a retrospective chart review study of 730 non-US-born pregnant women receiving care at 5 New York City prenatal clinics from 1999 to 2000.

RESULTS

Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%).

CONCLUSION

The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion.