The American Medical Association Older Driver Curriculum for health professionals: changes in trainee confidence, attitudes, and practice behavior.

Few gerontology and geriatrics professionals receive training in driver fitness evaluation, state reporting of unfit drivers, or transportation mobility planning yet are often asked to address these concerns in the provision of care to older adults. The American Medical Association (AMA) developed an evidence-based, multi-media Curriculum to promote basic competences. This study evaluated reported changes in practice behaviors 3 months posttraining in 693 professionals trained via the AMA approach. Eight Teaching Teams, designated and trained by AMA staff, offered 22 training sessions across the United States in 2006 to 2007. Trainees (67% female; mean age 46) completed a pretest questionnaire and a posttest administered by mail. Physicians were the largest professional group (32%). Although many trainees acknowledged having conversations with patients about driving at pretest, few endorsed utilizing specific techniques recommended by the AMA prior to this training. The posttest response rate was 34% (n = 235). Significant improvements in reported attitudes, confidence, and practices were found across measured items. In particular, posttest data indicated new adoption of in-office screening techniques, chart documentation of driver safety concerns, and transportation alternative planning strategies. Findings suggest that a well-designed, one-time continuing education intervention can enhance health professional confidence and clinical practice concerning driver fitness evaluation and mobility planning. Targeted dissemination of this Curriculum (in-person and online) will allow more to benefit in the future.

[Comparison of pelvic floor muscle strength in competition-level athletes and untrained women].

INTRODUCTION: Exercise can stress the pelvic floor muscles. Numerous women experience urinary incontinence while exercising or competing in sports. This study investigated pelvic floor muscle strength, urinary incontinence, and knowledge in contracting pelvic floor muscles among female athletes and untrained women. MATERIALS AND METHODS: This was a prospective case-control study measuring pelvic floor muscle strength using vaginal pressure meas-urement. Participants answered questions regarding general health, urinary incontinence, and knowledge on pelvic floor muscles. Partici-pants were healthy nulliparous women aged 18-30 years, athletes and untrained women. The athletes had competed in their sport for at least three years; including handball, soccer, gymnastics, badminton, BootCamp and CrossFit. RESULTS: The women were comparable in age and height. The athletes (n=18) had a body mass index (BMI) of 22.8 kg/m² vs. 25 kg/m² for the untrained (n=16); p<0.05. The athletes trained on average 11.4 hours/week while the untrained women participated in some activity on average for 1.3 hours/week; p< 0.05. Mean pelvic floor strength was 45±2 hPa in the athletes vs. 43±4 hPa in the untrained; p=0.36 for whether the athletes were stronger. Of the athletes, 61.1% experienced urinary incontinence (n=11) compared with 12.5% of the untrained women (n=2); p<0.05. Incontinence usually occurred during high intensity exercise. The athletes were more knowledgeable about the pelvic floor muscles; p<0.05. CONCLUSION: There was not a significant difference in the strength of pelvic floor muscles of athletes and untrained women. This suggests that pelvic floor muscles are not strengthened during general training but require specific exercises. This holds especially for football, handball and sports with high physical intensity. Coaches need to pay special attention to training and strengthening women's pelvic floor muscles to reduce the occurrence of urinary incontinence.

Bicyclist injury severities in bicycle-motor vehicle accidents.

This research explores the factors contributing to the injury severity of bicyclists in bicycle-motor vehicle accidents using a multinomial logit model. The model predicts the probability of four injury severity outcomes: fatal, incapacitating, non-incapacitating, and possible or no injury. The analysis is based on police-reported accident data between 1997 and 2002 from North Carolina, USA. The results show several factors which more than double the probability of a bicyclist suffering a fatal injury in an accident, all other things being kept constant. Notably, inclement weather, darkness with no streetlights, a.m. peak (06:00 a.m. to 09:59 a.m.), head-on collision, speeding-involved, vehicle speeds above 48.3 km/h (30 mph), truck involved, intoxicated driver, bicyclist age 55 or over, and intoxicated bicyclist. The largest effect is caused when estimated vehicle speed prior to impact is greater than 80.5 km/h (50 mph), where the probability of fatal injury increases more than 16-fold. Speed also shows a threshold effect at 32.2 km/h (20 mph), which supports the commonly used 30km/h speed limit in residential neighborhoods. The results also imply that bicyclist fault is more closely correlated with greater bicyclist injury severity than driver fault.

Spatial regression analysis of traffic crashes in Seoul.

Traffic crashes can be spatially correlated events and the analysis of the distribution of traffic crash frequency requires evaluation of parameters that reflect spatial properties and correlation. Typically this spatial aspect of crash data is not used in everyday practice by planning agencies and this contributes to a gap between research and practice. A database of traffic crashes in Seoul, Korea, in 2010 was developed at the traffic analysis zone (TAZ) level with a number of GIS developed spatial variables. Practical spatial models using available software were estimated. The spatial error model was determined to be better than the spatial lag model and an ordinary least squares baseline regression. A geographically weighted regression model provided useful insights about localization of effects. The results found that an increased length of roads with speed limit below 30 km/h and a higher ratio of residents below age of 15 were correlated with lower traffic crash frequency, while a higher ratio of residents who moved to the TAZ, more vehicle-kilometers traveled, and a greater number of access points with speed limit difference between side roads and mainline above 30 km/h all increased the number of traffic crashes. This suggests, for example, that better control or design for merging lower speed roads with higher speed roads is important. A key result is that the length of bus-only center lanes had the largest effect on increasing traffic crashes. This is important as bus-only center lanes with bus stop islands have been increasingly used to improve transit times. Hence the potential negative safety impacts of such systems need to be studied further and mitigated through improved design of pedestrian access to center bus stop islands.

The crash severity impacts of fixed roadside objects.

INTRODUCTION: This study analyzes the in-service performance of roadside hardware on the entire urban State Route system in Washington State by developing multivariate statistical models of injury severity in fixed-object crashes using discrete outcome theory. The objective is to provide deeper insight into significant factors that affect crash severities involving fixed roadside objects, through improved statistical efficiency along with disaggregate and multivariate analysis. METHOD: The developed models are multivariate nested logit models of injury severity and they are estimated with statistical efficiency using the method of full information maximum likelihood. RESULTS: The results show that leading ends of guardrails and bridge rails, along with large wooden poles (e.g. trees and utility poles) increase the probability of fatal injury. The face of guardrails is associated with a reduction in the probability of evident injury, and concrete barriers are shown to be associated with a higher probability of lower severities. Other variables included driver characteristics, which showed expected results, validating the model. For example, driving over the speed limit and driving under the influence of alcohol increase the probability of fatal accidents. Drivers that do not use seatbelts are associated with an increase in the probability of more severe injuries, even when an airbag is activated. IMPACT ON INDUSTRY: The presented models show the contribution of guardrail leading ends toward fatal injuries. It is therefore important to use well-designed leading ends and to upgrade badly performing leading ends on guardrails and bridges. The models also indicate the importance of protecting vehicles from crashes with rigid poles and tree stumps, as these are linked with greater severities and fatalities.

Family reports of medically impaired drivers in Missouri: cognitive concerns and licensing outcomes.

This study investigated reasons why older adults (n=689) were reported to the Driver License Bureau, Missouri Department of Revenue, by family members as potentially unfit to drive with an emphasis on cognitive concerns and associated licensing outcomes. A total of 448 drivers were reported to have some cognitive issue; common symptoms included confusion, memory loss, and becoming lost while driving. Diagnostic labels (Alzheimer's disease (AD), cognitive impairment/dementia, brain injury/insult) were listed for 365 cases. A physician evaluation is required for license review. Of those with a diagnostic label, half (51%, n=187) failed to submit this evaluation and almost all were de-licensed immediately. Of those evaluated by a physician, diagnostic agreement between family members and physicians was high for specific conditions (100% for AD, 97% for acute brain injury), and less so for cognitive impairment/dementia (75%). This latter finding suggests that physicians and family members may understand cognitive symptoms differently. Whether cognitively impaired or not, few family reported drivers in this sample (∼2%) retained a valid license. Family members may be in the best position to recognize when medical-functional deficits impact on driving safety, and physicians and driver licensing authorities would do well to take their observations into account with respect to older driver fitness.

Differences in male and female injury severities in sport-utility vehicle, minivan, pickup and passenger car accidents.

This research explores differences in injury severity between male and female drivers in single and two-vehicle accidents involving passenger cars, pickups, sport-utility vehicles (SUVs), and minivans. Separate multivariate multinomial logit models of injury severity are estimated for male and female drivers. The models predict the probability of four injury severity outcomes: no injury (property damage only), possible injury, evident injury, and fatal/disabling injury. The models are conditioned on driver gender and the number and type of vehicles involved in the accident. The conditional structure avoids bias caused by men and women's different reporting rates, choices of vehicle type, and their different rates of participation as drivers, which would affect a joint model of all crashes. We found variables that have opposite effects for the genders, such as striking a barrier or a guardrail, and crashing while starting a vehicle. The results suggest there are important behavioral and physiological differences between male and female drivers that must be explored further and addressed in vehicle and roadway design.

Random parameter models of interstate crash frequencies by severity, number of vehicles involved, collision and location type.

A nine-year (1999-2007) continuous panel of crash histories on interstates in Washington State, USA, was used to estimate random parameter negative binomial (RPNB) models for various aggregations of crashes. A total of 21 different models were assessed in terms of four ways to aggregate crashes, by: (a) severity, (b) number of vehicles involved, (c) crash type, and by (d) location characteristics. The models within these aggregations include specifications for all severities (property damage only, possible injury, evident injury, disabling injury, and fatality), number of vehicles involved (one-vehicle to five-or-more-vehicle), crash type (sideswipe, same direction, overturn, head-on, fixed object, rear-end, and other), and location types (urban interchange, rural interchange, urban non-interchange, rural non-interchange). A total of 1153 directional road segments comprising of the seven Washington State interstates were analyzed, yielding statistical models of crash frequency based on 10,377 observations. These results suggest that in general there was a significant improvement in log-likelihood when using RPNB compared to a fixed parameter negative binomial baseline model. Heterogeneity effects are most noticeable for lighting type, road curvature, and traffic volume (ADT). Median lighting or right-side lighting are linked to increased crash frequencies in many models for more than half of the road segments compared to both-sides lighting. Both-sides lighting thereby appears to generally lead to a safety improvement. Traffic volume has a random parameter but the effect is always toward increasing crash frequencies as expected. However that the effect is random shows that the effect of traffic volume on crash frequency is complex and varies by road segment. The number of lanes has a random parameter effect only in the interchange type models. The results show that road segment-specific insights into crash frequency occurrence can lead to improved design policy and project prioritization.

Driver-injury severity in single-vehicle crashes in California: A mixed logit analysis of heterogeneity due to age and gender.

This research develops a mixed logit model of driver-injury severity in single-vehicle crashes in California. The research especially considers the heterogeneous effects of age and gender. Older drivers (65+ years old) were found to have a random parameter with about half the population having a higher probability of a fatal injury given a crash than the comparison group of 25-64 year olds with all other factors than age kept constant. The other half of the 65+ population had a lower probability of fatal injury. Heterogeneity was also noted in vehicle age, but related to the gender of the driver, with males linked to, on average, a higher probability of fatal injury in a newer vehicle compared with females, all other factors kept constant. These effects lend support to the use of mixed logit models in injury severity research and show age and gender based population heterogeneity. Several other factors were found to significantly increase the probability of fatal injury for drivers in single-vehicle crashes, most notably: male driver, drunk driving, unsafe speed, older driver (65+) driving an older vehicle, and darkness without streetlights.

Analyzing fault in pedestrian-motor vehicle crashes in North Carolina.

Crashes between pedestrians and motor vehicles are an important traffic safety concern. This paper explores the assignment of fault in such crashes, where observed factors are associated with pedestrian at fault, driver at fault, or both at fault. The analysis is based on police reported crash data for 1997 through 2000 in North Carolina, U.S.A. The results show that pedestrians are found at fault in 59% of the crashes, drivers in 32%, and both are found at fault in 9%. The results indicate drivers need to take greater notice of pedestrians when drivers are turning, merging, and backing up as these are some of the prime factors associated with the driver being found at fault in a crash. Pedestrians must apply greater caution when crossing streets, waiting to cross, and when walking along roads, as these are correlated with pedestrians being found at fault. The results suggest a need for campaigns focused on positively affecting pedestrian street-crossing behavior in combination with added jaywalking enforcement. The results also indicate that campaigns to increase the use of pedestrian visibility improvements at night can have a significant positive impact on traffic safety. Intoxication is a concern and the results show that it is not only driver intoxication that is affecting safety, but also pedestrian intoxication. The findings show in combination with other research in the field, that results from traffic safety studies are not necessarily transferable between distant geographic locations, and that location-specific safety research needs to take place. It is also important to further study the specific effects of the design of the pedestrian environment on safety, e.g. crosswalk spacing, signal timings, etc., which together may affect pedestrian safety and pedestrian behavior.

A note on modeling pedestrian-injury severity in motor-vehicle crashes with the mixed logit model.

Pedestrian-injury severity has been traditionally modeled with approaches that have assumed that the effect of each variable is fixed across injury observations. This assumption ignores possible unobserved heterogeneity which is likely to be particularly important in pedestrian injuries because unobserved physical health, strength, and behavior may significantly affect the pedestrians' ability to absorb collision forces. To address such unobserved heterogeneity, this research applies a mixed logit model to analyze pedestrian-injury severity in pedestrian-vehicle crashes. Using police-reported collision data from 1997 through 2000 from North Carolina, several factors were found to more than double the average probability of fatal injury for pedestrians in motor-vehicle crashes including: darkness without streetlights (400% increase in fatality probability), vehicle is a truck (370% increase), freeway (330% increase), speeding involved (360% increase), and collisions involving a motorist who had been drinking (250% increase). It was also found that the effect of pedestrian age was normally distributed across observations, and that as pedestrians became older the probability of fatal injury increased substantially. Heterogeneity in the mean of the random parameters for the freeway and pedestrian-solely-at-fault collision indicators was related to pedestrian gender, and heterogeneity in the mean of the random parameters for the traffic-sign and motorist-back-up indicators was related to pedestrian age.

Motor-vehicle crash history and licensing outcomes for older drivers reported as medically impaired in Missouri.

The identification and evaluation of medically impaired drivers is an important safety issue. Medical fitness to drive is applicable to all ages but is particularly salient for older adults. Voluntary procedures, whereby various professionals and family members may report medical fitness concerns to State driver license bureaus, are common in the United States. This paper examines traffic crashes of drivers reported during 2001-2005 under the State of Missouri's voluntary reporting law (House Bill HB-1536) and the resulting licensing outcomes. Missouri's law is non-specific as to age, but the mean age of reported drivers was 80. Reports were submitted by police officers (30%), license office staff (27%), physicians (20%), family members (16%), and others (7%). The most common medical condition was dementia/cognitive (45%). Crash history for reported drivers was higher than that of controls, dating back to 1993, reaching a peak in 2001 when the crash involvement of reported drivers was 9.3% vs. 2.2% for controls--a fourfold difference. The crash involvement of reported drivers decreased rapidly after, indicating the impact of HB-1536 reporting with subsequent license revocation and to a lesser degree, mortality. Of the 4,100 reported individuals, 144 (3.5%) retained a driver's license after the process.

Age and pedestrian injury severity in motor-vehicle crashes: a heteroskedastic logit analysis.

This research explores the injury severity of pedestrians in motor-vehicle crashes. It is hypothesized that the variance of unobserved pedestrian characteristics increases with age. In response, a heteroskedastic generalized extreme value model is used. The analysis links explanatory factors with four injury outcomes: fatal, incapacitating, non-incapacitating, and possible or no injury. Police-reported crash data between 1997 and 2000 from North Carolina, USA, are used. The results show that pedestrian age induces heteroskedasticity which affects the probability of fatal injury. The effect grows more pronounced with increasing age past 65. The heteroskedastic model provides a better fit than the multinomial logit model. Notable factors increasing the probability of fatal pedestrian injury: increasing pedestrian age, male driver, intoxicated driver (2.7 times greater probability of fatality), traffic sign, commercial area, darkness with or without streetlights (2-4 times greater probability of fatality), sport-utility vehicle, truck, freeway, two-way divided roadway, speeding-involved, off roadway, motorist turning or backing, both driver and pedestrian at fault, and pedestrian only at fault. Conversely, the probability of a fatal injury decreased: with increasing driver age, during the PM traffic peak, with traffic signal control, in inclement weather, on a curved roadway, at a crosswalk, and when walking along roadway.