Non-benzodiazepine Hypnotics and Police-Reported Motor Vehicle Crash Risk among Older Adults: A Sequential Target Trial Emulation.

Non-benzodiazepine hypnotics ( "Z-drugs") are prescribed for insomnia, but might increase risk of motor vehicle crash (MVC) among older adults through prolonged drowsiness and delayed reaction times. We estimated the effect of initiating Z-drug treatment on the 12-week risk of MVC in a sequential target trial emulation. After linking New Jersey driver licensing and police-reported MVC data to Medicare claims, we emulated a new target trial each week (July 1, 2007 - October 7, 2017) in which Medicare fee-for-service beneficiaries were classified as Z-drug-treated or untreated at baseline and followed for an MVC. We used inverse probability of treatment and censoring weighted pooled logistic regression models to estimate risk ratios (RR) and risk differences with 95% bootstrap confidence limits (CLs). There were 257,554 person-trials, of which 103,371 were Z-drug-treated and 154,183 untreated, giving rise to 976 and 1,249 MVCs, respectively. The intention-to-treat RR was 1.06 (95%CLs 0.95, 1.16). For the per-protocol estimand, there were 800 MVCs and 1,241 MVCs among treated and untreated person-trials, respectively, suggesting a reduced MVC risk (RR 0.83 [95%CLs 0.74, 0.92]) with sustained Z-drug treatment. Z-drugs should be prescribed to older patients judiciously but not withheld entirely over concerns about MVC risk.

Motor Vehicle Crash Risk among Adults Undergoing General Surgery: A Retrospective Case-crossover Study.

BACKGROUND: Surgery causes transient impairment in cognition and function, which may impact driving safety. The authors hypothesized that the risk of a motor vehicle crash would increase after compared to before surgery. METHODS: The authors performed a nested case-crossover study within population-based observational data from the New Jersey Safety Health Outcomes Data Warehouse. The study included adults 18 yr or older with a valid driver's license who underwent general surgery in an acute care hospital in New Jersey between January 1, 2016, and November 30, 2017, and were discharged home. Individuals served as their own controls within a presurgery interval (56 days to 28 days before surgery) and postsurgery interval (discharge through 28 days after surgery). General surgery was defined by Common Procedural Terminology Codes. The primary outcome was a police-reported motor vehicle crash. RESULTS: In a cohort of 70,722 drivers, the number of crashes after surgery was 263 (0.37%) compared to 279 (0.39%) before surgery. Surgery was not associated with a change in crash incidence greater than 28 days using a case-crossover design (adjusted incidence rate ratio, 0.92; 95% CI, 0.78 to 1.09; P = 0.340). Statistical interaction was present for sex and hospital length of stay. Younger versus older adults (adjusted risk ratio, 1.87; 95% CI, 1.10 to 3.18; P = 0.021) and non-Hispanic Black individuals (adjusted risk ratio, 1.96; 95% CI, 1.33 to 2.88; P = 0.001) and Hispanic individuals (adjusted risk ratio, 1.38; 95% CI, 1.00 to 1.91; P = 0.047) versus non-Hispanic White individuals had a greater risk of a crash after surgery. CONCLUSIONS: Using population-based crash and hospital discharge data, the incidence of motor vehicle crashes over a 28-day period did not change on average before compared to after surgery. The authors provide data on crash risk after surgery and highlight specific populations at risk.

Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion.

OBJECTIVE: To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents. DESIGN: Cross-sectional. SETTING: Suburban high school and academic pediatric tertiary care center. PARTICIPANTS: Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion. ASSESSMENT OF INDEPENDENT VARIABLES: Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions. MAIN OUTCOME MEASURES: Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment. RESULTS: Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%). CONCLUSIONS: A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions. CLINICAL RELEVANCE: The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.

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.

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.

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.

Characteristics of Concussion in Elementary School-Aged Children: Implications for Clinical Management.

OBJECTIVE: To comprehensively characterize the clinical presentation and course of care for concussion among 5- to 11-year-old children, identifying preinjury and injury factors potentially influencing clinical outcomes. STUDY DESIGN: A single-institution retrospective cohort study using electronic health record data from children ages 5- to 11 years with a concussion from July 1, 2014, through June 30, 2015. Electronic health record data were abstracted for a 20% random sample of 292 patients. RESULTS: Three-fourths of patients (74.3%) presenting for concussion care had a standardized visiovestibular assessment performed. Almost all of those who eventually sought specialty care (92.9%) also had such an assessment, and only 42.9% patients initially seen in the emergency department or urgent care were examined in this manner. Of those assessed, 62.7% (n = 136) demonstrated deficits, with children ages 9-11 years more frequently exhibiting deficits than their younger counterparts (67.9% vs 53.2%; P = .03). Almost all patients (95.9%) reported at least 1 somatic symptom (eg, headache, dizziness), and one-half to two-thirds reported problems with sleep (54.1%) and visiovestibular symptoms (66.1%). Only 11.6% of children were referred for rehabilitation therapies and less than one-half of concussed patients (43.8%) were provided with a letter recommending school accommodations. CONCLUSIONS: Somatic symptoms, sleep problems, and visiovestibular deficits are common in elementary school-aged children with concussion, but specific visiovestibular clinical assessments are often not performed, particularly in the emergency department setting. Recommendations for school accommodations are often not provided at the time of concussion diagnosis. Incorporating a standardized visiovestibular assessment into practice could facilitate early targeted school accommodations and thereby improve return to learning for elementary school-aged children with concussion.

Variations in Mechanisms of Injury for Children with Concussion.

OBJECTIVES: To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system. STUDY DESIGN: All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities. RESULTS: Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%). CONCLUSIONS: Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.

Association between New Jersey's Graduated Driver Licensing decal provision and crash rates of young drivers with learners' permits.

New Jersey (NJ) implemented the first-in-the-US Graduated Driver Licensing (GDL) decal provision in May 2010 for young drivers with learner's permits or intermediate licenses. Previous analyses found an association between the provision and crash reduction among intermediate drivers. The aim of this study is to examine the association between NJ's provision and GDL citation and crash rates among drivers aged <21 years with learner's permits. We estimated monthly per-driver rates from January 2006 through June 2012. Negative binomial modeling compared pre and post decal crash rates adjusted for gender, age, calendar month, and gas price. The monthly GDL citation rate was two per 10,000 drivers in the predecal and postdecal periods. Crashes were rare and rates declined similarly pre and post decal (adjusted rate ratio of postdecal vs predecal slope: 1.04 (0.97 to 1.12)). NJ's GDL decal provision was not associated with a change in citation or crash rates among young NJ drivers with learner's permits.

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.

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.

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.

Implications of using administrative healthcare data to identify risk of motor vehicle crash-related injury: the importance of distinguishing crash from crash-related injury.

BACKGROUND: Administrative healthcare databases, such as Medicare, are increasingly used to identify groups at risk of a crash. However, they only contain information on crash-related injuries, not all crashes. If the driver characteristics associated with crash and crash-related injury differ, conflating the two may result in ineffective or imprecise policy interventions. METHODS: We linked 10 years (2008-2017) of Medicare claims to New Jersey police crash reports to compare the demographics, clinical diagnoses, and prescription drug dispensings for crash-involved drivers ≥ 68 years with a police-reported crash to those with a claim for a crash-related injury. We calculated standardized mean differences to compare characteristics between groups. RESULTS: Crash-involved drivers with a Medicare claim for an injury were more likely than those with a police-reported crash to be female (62.4% vs. 51.8%, standardized mean difference [SMD] = 0.30), had more clinical diagnoses including Alzheimer's disease and related dementias (13.0% vs. 9.2%, SMD = 0.20) and rheumatoid arthritis/osteoarthritis (69.5% vs 61.4%, SMD = 0.20), and a higher rate of dispensing for opioids (33.8% vs 27.6%, SMD = 0.18) and antiepileptics (12.9% vs 9.6%, SMD = 0.14) prior to the crash. Despite documented inconsistencies in coding practices, findings were robust when restricted to claims indicating the injured party was the driver or was left unspecified. CONCLUSIONS: To identify effective mechanisms for reducing morbidity and mortality from crashes, researchers should consider augmenting administrative datasets with information from police crash reports, and vice versa. When those data are not available, we caution researchers and policymakers against the tendency to conflate crash and crash-related injury when interpreting their findings.

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.

Congruency of Crash- and Hospital- Reported Injuries Among Child Passengers.

INTRODUCTION: Prior work has found incongruencies in injury information reported by crash and hospital records. However, no work has focused on child passengers. The objective of this study was to compare crash scene and hospital-reported injury information for crash-involved child passengers. This study also explored injury location and severity by child age and restraint type. METHODS: Utilizing linked New Jersey data from 2017 through 2019, the authors identified crash-involved child passengers <13 years old and their injuries in crash and hospital reports. Then, they characterized the congruency of injury frequency, severity, and location, as well as the frequency of injuries by child age and restraint type. Analyses were conducted from December 2023 through February 2024. RESULTS: Of 84,060 crash-involved child passengers, crash reports documented 7,858 (9%) children with at least "possible" injuries, while 2,577 (3%) had at least one injury in hospital events. Crash report and hospital data were incongruent for both body region of injury and injury severity. The proportion of children injured increased as children's ages increased and as restraint type progressed. CONCLUSIONS: Crash reports overestimated the number of injured child passengers and misrepresented injury severity and locations. Child restraint systems mitigated a child's injury risk. Importantly, injury information documented on crash reports currently informs the allocation of traffic safety resources. These results highlight the importance of improving these reports' accuracy and underscore calls to link administrative datasets for public health efforts.

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.

School-age outcomes of late preterm infants in New York City.

OBJECTIVE: This study compares school-age outcomes among preterm (PT) (32 0/7-<34 weeks), late PT (LP) (34 0/7-<37 weeks), and full-term (FT) infants to assess cognitive sequelae of LP births. STUDY DESIGN: We obtained linked birth and educational data for all nonanomalous singleton infants born 1994 through 1998 in New York City who had a third-grade standardized test score (n = 215,138). RESULTS: Children delivered LP and PT had 30% and 50% higher adjusted odds of needing special education than those delivered FT (adjusted odds ratio, 1.34; 95% confidence interval, 1.29-1.40; and adjusted odds ratio, 1.53; 95% confidence interval, 1.30-1.69). They also had lower adjusted math and English scores than those delivered FT (math: 7% and 10% of SD, respectively; English: 4% and 6% of SD). A linear association between gestational age and test scores was seen through 39 weeks' gestation. CONCLUSION: There is a significant risk of developmental differences in PT and LP infants compared with FT infants.

Rates of early intervention referral and significant developmental delay, by birthweight and gestational age.

Though correlated, birthweight (BW) and gestational age (GA) have independent effects on cognitive and neurological outcomes. Jurisdictions vary in their inclusion of these two characteristics in their list of established conditions for automatic eligibility for Early Intervention (EI) services, which may lead them to miss important high-risk groups. We evaluated the relationship between BW-GA combinations and both EI referral rates and risk of EI-diagnosed significant developmental delay in a population of New York City (NYC) births. We linked birth certificates of children born in NYC to resident mothers during 1999-2001 and surviving the first 28 days of life (n = 339,522) to EI administrative data. We calculated EI referral rates for various BW-GA categories, and used a logistic model to directly estimate the predicted risk of delay. EI referral rates of over 50% were observed in children born <1,250 g and those born <30 weeks and 1,250-1,499 g. Additionally, more than one in two children born either less than 1,250 g or <30 weeks and 1,250-1,499 g were predicted to be diagnosed with a developmental delay, compared with almost one-tenth among those born >2,500 g and 39+ weeks. A BW threshold of <1,250 g would identify children with the highest risk of delay; GA as an additional criterion would prevent overlooking high-risk children born <30 weeks but at higher birthweights. Physicians should monitor children with high-risk birth characteristics and refer them, if appropriate, for formal evaluation. EI programs may use these findings to guide determination of automatic eligibility criteria.