Impacts of graduated driver licensing regulations.

We evaluate the impact of the Graduated Driver Licensing (GDL) system introduced in Victoria, Australia as they influence both injury and fatality rates. Since 1990, the Victorian GDL scheme has undergone several modifications including the introduction of new requirements and the stricter enforcement of existing regulations. Our evaluation of the GDL is based on monthly mortality and morbidity data for drivers 18-25 for the period January 2000 to June 2017. We estimate the immediate and long-term impacts of each policy change to the GDL system. Our results indicate that several initiatives in the GDL system have had impacts on both fatalities and injuries requiring hospitalisation when differentiated by gender. In a number of cases we observe that reactions to these measures are common to both genders. These include: the signalling of the proposed GDL changes in the media, the introduction of an extra probationary year for those under 21, the total alcohol ban for the entire probationary period, and limits on peer passengers for the first year. Stricter mobile phone restrictions appear to have had no impact on injuries for either males or females although they were associated with lower fatality rates for both. In addition, we found an indication that in the period prior to the introduction of the mandatory requirement of 120 h supervised driving, there was a rise in male driver injuries possibly caused by a rush of more inexperienced learners to obtain their probationary licence.

Interregional inequality and road accident rates in Spain.

The aim of this study was to determine whether interregional inequality in Spain had the same impact on the risks of fatality and injury across the different provinces of Spain, in the period from 1999 to 2015. This allows us to map fatality and injury rates in Spanish provinces depending on their level of economic development. Provinces were divided in two large groups according to the mean weight of their per capita GDP on the national GDP from 2000 to 2015. Using fixed effects data panel models, estimations were obtained for each group of the impact of the relationships between per capita GDP, unemployment rate and other control variables on their risks of fatality and injury. The models reveal that economic conditions and education are explanatory factors with greater significance and impact on the risks of fatality and injury in provinces with higher levels of economic development. In this group, the penalty-points driving licence was found have a greater impact, although its effectiveness is now being questioned. In contrast, to reduce the risks of fatality and injury in less developed provinces, it is imperative to invest in road infrastructure, increasing the proportion of high capacity roads and investing more in road replacement and maintenance. The geographical distribution generated in this study allows us to better identify the areas with a higher risk of fatality or injury. This, in turn, confirms the need to improve the configuration of road safety policy, taking into account the different fatality or injury rates across provinces, the origins of which lie in the specific provincial conditions.

Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update.

PURPOSE: Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier. METHODS: Using the DEA list of providers with a waiver to prescribe buprenorphine to treat OUD and the Area Health Resources File, we assigned waivered providers to counties in 1 of 4 geographic categories. We calculated the number of counties in each category that did not have a waivered provider and county provider to population ratios and then compared our results to the waivered workforce in 2012. FINDINGS: The availability of a physician with a DEA waiver to provide office-based MAT has increased across all geographic categories since 2012. More than half of all rural counties (56.3%) still lack a provider, down from 67.1% in 2012. Almost one-third (29.8%) of rural Americans compared to 2.2% of urban Americans live in a county without a buprenorphine provider. NPs and PAs add otherwise lacking treatment availability in 56 counties (43 rural). CONCLUSIONS: Overall, MAT access has improved, but rural communities still experience treatment disparities.

Unlicensed and off-label uses of medicines: definitions and clarification of terminology.

The terms 'licensed', 'unlicensed', and 'off-label', often used in relation to marketing and prescribing medicinal products, may confuse UK prescribers. To market a medicinal product in the UK requires a Marketing Authorization ('product licence') for specified indications under specified conditions, regulated by the Medicines and Healthcare products Regulatory Agency (MHRA). The Marketing Authorization includes the product's agreed terms of use (the 'label'), described in the Summary of Product Characteristics (SmPC). Prescribing a licensed product outside those terms is called 'off-label' prescribing. Products for which no-one holds a UK Marketing Authorization are unlicensed. Prescribers can prescribe authorized products according to the conditions described in the SmPC ('on-label') or outside those conditions ('off-label'). They can also prescribe unauthorized products, even if they are unlicensed in the UK, if they are licensed elsewhere or if they have been manufactured in the UK by a licensed manufacturer as a 'special'. The complexities of this system can be understood by considering the status of the manufacturer of the product, the company that markets it (which may or may not be the same), the product itself, and its modes of use, and by emphasizing the word 'authorized'. If a Marketing Authorization is granted to the supplier of a product, it will specify the authorized modes of use; the product will be prescribable as authorized (i.e. 'on-label') or in other modes of use, which will all be off-label. Unlicensed products with no authorized modes of use can be regarded as 'unauthorized products'. All 'specials' can be regarded as authorized products lacking authorized modes of use.

What Predicts Performance? A Multicenter Study Examining the Association Between Resident Performance, Rank List Position, and United States Medical Licensing Examination Step 1 Scores.

BACKGROUND: Each application cycle, emergency medicine (EM) residency programs attempt to predict which applicants will be most successful in residency and rank them accordingly on their program's Rank Order List (ROL). OBJECTIVE: Determine if ROL position, participation in a medical student rotation at their respective program, or United States Medical Licensing Examination (USMLE) Step 1 rank within a class is predictive of residency performance. METHODS: All full-time EM faculty at Los Angeles County + University of Southern California (LAC + USC), Harbor-UCLA (Harbor), Alameda Health System-Highland (Highland), and the University of California-Irvine (UCI) ranked each resident in the classes of 2013 and 2014 at time of graduation. From these anonymous surveys, a graduation ROL was created, and using Spearman's rho, was compared with the program's adjusted ROL, USMLE Step 1 rank, and whether the resident participated in a medical student rotation. RESULTS: A total of 93 residents were evaluated. Graduation ROL position did not correlate with adjusted ROL position (Rho = 0.14, p = 0.19) or USMLE Step 1 rank (Rho = 0.15, p = 0.14). Interestingly, among the subgroup of residents who rotated as medical students, adjusted ROL position demonstrated significant correlation with final ranking on graduation ROL (Rho = 0.31, p = 0.03). CONCLUSIONS: USMLE Step 1 score rank and adjusted ROL position did not predict resident performance at time of graduation. However, adjusted ROL position was predictive of future residency success in the subgroup of residents who had completed a sub-internship at their respective programs. These findings should guide the future selection of EM residents.

Public health workforce taxonomy.

Thoroughly characterizing and continuously monitoring the public health workforce is necessary for ensuring capacity to deliver public health services. A prerequisite for this is to develop a standardized methodology for classifying public health workers, permitting valid comparisons across agencies and over time, which does not exist for the public health workforce. An expert working group, all of whom are authors on this paper, was convened during 2012-2014 to develop a public health workforce taxonomy. The purpose of the taxonomy is to facilitate the systematic characterization of all public health workers while delineating a set of minimum data elements to be used in workforce surveys. The taxonomy will improve the comparability across surveys, assist with estimating duplicate counting of workers, provide a framework for describing the size and composition of the workforce, and address other challenges to workforce enumeration. The taxonomy consists of 12 axes, with each axis describing a key characteristic of public health workers. Within each axis are multiple categories, and sometimes subcategories, that further define that worker characteristic. The workforce taxonomy axes are occupation, workplace setting, employer, education, licensure, certification, job tasks, program area, public health specialization area, funding source, condition of employment, and demographics. The taxonomy is not intended to serve as a replacement for occupational classifications but rather is a tool for systematically categorizing worker characteristics. The taxonomy will continue to evolve as organizations implement it and recommend ways to improve this tool for more accurate workforce data collection.

Views of New Jersey teenagers about their state's policies for beginning drivers.

BACKGROUND: Three New Jersey licensing policies are unique in the United States: (a) minimum licensing age of 17; (b) applying full graduated driver licensing (GDL) rules to beginners younger than 21; and (c) requiring license status decals on vehicle plates of drivers in GDL. METHODS: New Jersey 17-19 year-olds were surveyed by telephone and online. RESULTS: Eighty-four percent approved licensing at 17; 77% approved applying GDL to older novices; 23% approved the decal policy. Probationary licensees ages 18-19 were more likely than 17 year-olds to have multiple nighttime restriction violations in the past month. There were no age group differences in passenger restriction violations. DISCUSSION: All three policies have been considered in other states. Views of teenagers directly affected by the policies can be taken into account in considering their implementation. PRACTICAL APPLICATIONS: Views of licensing policies by affected teenagers indicate potential support or obstacles to their adoption in other states.

Using cognitive status to predict crash risk: blazing new trails?

INTRODUCTION: A computer-based version of an established neuropsychological paper-and-pencil assessment tool, the Trail-Making Test, was applied with approximately 700 drivers aged 70 years and older in offices of the Maryland Motor Vehicle Administration. METHOD: This was a volunteer sample that received a small compensation for study participation, with an assurance that their license status would not be affected by the results. Analyses revealed that the study sample was representative of Maryland older drivers with respect to age and indices of prior driving safety. The relationship between drivers' scores on the Trail-Making Test and prospective crash experience was analyzed using a new outcome measure that explicitly takes into account error responses as well as correct responses, the error-compensated completion time. RESULTS: For the only reliable predictor of crash risk, Trail-Making Test Part B, this measure demonstrated a modest gain in specificity and was a more significant predictor of future safety risk than the simple time-to-completion measure. IMPACT ON INDUSTRY: Improved specificity and the potential for autonomous test administration are particular advantages of this measure for use with large populations, in settings such as health care or driver licensing.

Learner driver experiences and crash risk as an unsupervised driver.

OBJECTIVE: The purpose of this study was to describe the driving experiences of learner licensed drivers and examine the association between these driving experiences, associated factors, and on-road car crash involvement during the unsupervised restricted license stage. METHODS: Data were drawn from a cohort investigation of newly licensed drivers. Information on demographic characteristics, personality, and risk behaviors was collected at the baseline interview. At the first follow-up interview (restricted license stage) study members were asked details about their experiences as a learner licensed driver: professional driving lessons, supervised driving, unsupervised driving, and driving courses in which they participated. During the second follow-up interview (full license stage), data were collected on crash involvement and driving exposure during the restricted license stage. Regression analysis was used to determine independent relationships between learner license driving experience variables and crash involvement. RESULTS: After adjusting for demographic, personality factors, and driving exposure at the restricted license stage, increased time spent on the learner license was associated with a reduced risk of crash involvement during the unsupervised restricted license stage. CONCLUSION: Results presented in this paper suggest that learner drivers in New Zealand should be encouraged to spend more time on their learner license to enable them to gain skills and experience to help reduce their crash risk when they are allowed to drive unsupervised. IMPACT ON INDUSTRY: Compared with novice drivers who are on their learner license for the least amount of time, those who spend the most amount of time on their learner license have reduced risk of on-road crash involvement as an unsupervised driver. Learner drivers and their supervisors need to be aware of the length of time required for practice in order to reduce the risks of crash involvement when they are able to drive unsupervised (O'Brien et al., 2012). The recently introduced increase in the minimum driver licensing age in NZ, tougher restricted license stage driving test (aimed at encouraging 120 hours of supervised driving), and the Safe Teen driver campaign (NZ Transport Agency, 2012) are all strategies targeted at improving the safety of learner drivers. These strategies need to be evaluated to ensure they are achieving their goals.

Reducing young driver crash casualties in Great Britain - use of routine police crash data to estimate the potential benefits of graduated driver licensing.

Crashes involving young drivers (YD) cause significant morbidity and mortality in Great Britain (GB). Graduated Driver Licensing (GDL) is used in some countries to address this. This study assessed potential casualty and cost savings of possible GDL programmes in GB. Police road crash data were analysed to identify YD crashes at night or while carrying passengers. These data were then used to estimate the potential effects of GDL. 314,561 casualties and 3469 fatalities occurred in YD crashes. 25.1% of YD crashes occurred between 9 pm and 6 am and 24.4% occurred with a 15- to 24-year old passenger in the car. A 'strict' form of GDL in GB (night time restriction 9 pm-6 am, no 15-24 year old passengers) with 50% compliance would prevent 114 deaths and 872 serious casualties each year. The estimated value of prevention is £424M pa. A 'less strict' form of GDL (night time restriction 10 pm-5 am, maximum of one 15-19 year old passenger) with 50% compliance would prevent 81 deaths and 538 serious injuries. The estimated value of prevention is £273M pa. Implementing GDL in GB could save significant numbers of lives. Public health organisations have a duty to advocate for such legislation.

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.

Graduated driver licensing research, 2010-present.

This is the latest in a series of reviews of research on graduated driver licensing (GDL) published in the Journal of Safety Research, covering the period January 1, 2010-June 1, 2012 and works in progress. The intent is to keep researchers and policy makers current regarding the existing state of knowledge about GDL, and to identify information gaps and areas where clarification of research findings are needed. The recent research indicates that we continue to learn about ways to extend GDL benefits, but there remain important questions in need of further inquiry. In terms of impact on industry, the review provides guidance for the future GDL research agenda.

National evaluation of the effect of graduated driver licensing laws on teenager fatality and injury crashes.

PROBLEM: Automobile crashes remain a prominent cause of death and injury for teenagers in the United States. While it is generally agreed that graduated drivers licensing (GDL) influences crash rates, it is unclear which components have the strongest effect on any specific types of crashes. METHOD: We analyze the relative effect of different stages of GDL on teenage fatal and injury crash risk via a negative binomial generalized linear model with random state effects. Overall, nighttime, and crashes with multiple teenage passengers are considered. RESULTS: The strongest effects are seen by 16-year-olds, for which a strict permit stage is associated with a 58% reduction in fatal crash risk over a lenient permit stage. Similar reductions are seen for injury crashes. The intermediate stage, involving nighttime and passenger restrictions, is associated with a 44% reduction in fatalities but has relatively little effect on injury crashes. The strongest effects are generally seen for passenger crashes, followed by nighttime, and then overall crashes. IMPACT ON INDUSTRY: This study identifies stronger relationships between GDL and crash risk than has previously been discovered and captures the relative effects of permit and intermediate licensing restrictions, two high-level components of GDL which differ in intent and implementation.

An evaluation of graduated driver licensing effects on fatal crash involvements of young drivers in the United States.

OBJECTIVE: Graduated driver licensing (GDL) systems are designed to reduce the high crash risk of young novice drivers. Almost all states in the United States have some form of a 3-phase GDL system with various restrictions in the intermediate phase. Studies of the effects of GDL in various states show significant reductions in fatal crash involvements of 16- and 17-year-old drivers; however, only a few national studies of GDL effects have been published. The objective of this national panel study was to evaluate the effect of GDL laws on the fatal crash involvements of novice drivers while controlling for possible confounding factors not accounted for in prior studies. METHODS: The Fatality Analysis Reporting System (FARS) was used to examine 16- and 17-year-old driver involvement in fatal crashes (where GDL laws are applied) relative to 2 young driver age groups (19-20, 21-25) where GDL would not be expected to have an effect. Dates when various GDL laws were adopted in the states between 1990 and 2007 were coded from a variety of sources. Covariates in the longitudinal panel regression analyses conducted included 4 laws that could have an effect on 16- and 17-year-old drivers: primary enforcement seat belt laws, zero-tolerance (ZT) alcohol laws for drivers younger than age 21, lowering the blood alcohol concentration limit for driving to 0.08, and so-called use and lose laws where drivers aged 20 and younger lose their licenses for underage drinking violations. RESULTS: The adoption of a GDL law of average strength was associated with a significant decrease in fatal crash involvements of 16- and 17-year-old drivers relative to fatal crash involvements of one of the 2 comparison groups. GDL laws rated as "good" showed stronger relationships to fatal crash reductions, and laws rated as "less than good" showed no reductions in crash involvements relative to the older driver comparison groups. CONCLUSIONS: States that adopt a basic GDL law can expect a decrease of 8 to 14 percent in the proportion of 16- and 17-year-old drivers involved in fatal crashes (relative to 21- to 25-year-old drivers), depending upon their other existing laws that affect novice drivers, such as those used in these analyses. This finding is consistent with recent national studies that used different outcome measures and covariates. The results of this study provide additional support for states to adopt, maintain, and upgrade GDL systems to reduce youthful traffic crash fatalities.

Identifying driver characteristics influencing overtaking crashes.

OBJECTIVE: To identify the most important driver characteristics influencing crash-causing overtaking maneuvers on 2-lane, 2-way rural roads of Iran. METHODS: Based on the crash data for rural roads of Iran over 3 years from 2006 to 2008, the classification and regression tree (CART) method combined with the quasi-induced exposure concept was applied for 4 independent variables and one target variable of "driver status" with 2 classes of at fault and not at fault. The independent variables were vehicle type, driver's age, driving license, and driving experience of the driver-the latter 2 driver characteristics are relatively new in traffic safety studies. RESULTS: According to the data set, 16,809 drivers were involved in 2-lane, 2-way rural roads overtaking crashes. The analysis revealed that drivers who are younger than 28 years old, whose driving license is type 2--a common driving license that is for driving with passenger car and light vehicles--and whose driving experience is less than 2 years are most probably responsible for overtaking crashes. CONCLUSION: It was indicated that vehicle type is the most important factor associated with drivers being responsible for the crashes. The results also revealed that younger drivers (18-28 years) are most likely to be at fault in overtaking crashes. Therefore, enforcement and education should be more concentrated on this age group. Due to the incompliant nature of this group, changing the type and amount of traffic fines is essential for more preventing objectives. The research also found 2 relatively new factors of driving license and driving experience to have considerable effects on drivers being at fault, such that type 2 licensed drivers are more responsible compared to type 1 (a driving license for driving with all motor vehicles, which has some age and experience requirements) licensed drivers or drivers with a special license (a driving license with special vehicle types). Moreover, drivers with less than 2 years' driving experience are more responsible for these kind of crashes; thus prohibiting new drivers from driving on rural roads for new drivers seems substantial.

Behavioral impact of graduated driver licensing on teenage driving risk and exposure.

Graduated driver licensing (GDL) is a critical policy tool for potentially improving teenage driving while reducing teen accident exposure. While previous studies demonstrated that GDL reduces teenage involvement in fatal crashes, much remains unanswered. We explore the mechanisms through which GDL influences accident rates as well as its long term effectiveness on teen driving. In particular, we investigate: (1) whether GDL policies improve teenage driving behavior, or simply reduce teenage prevalence on the roads; (2) whether GDL exposed teens become better drivers in later years. We employ a unique data source, the State Data System, which contains all police reported accidents (fatal and non-fatal) during 1990-2005 for 12 states. We estimate a structural model that separately identifies GDL's effect on relative teenage prevalence and relative teenage riskiness. Identification of the model is driven by the relative numbers of crashes between two teenagers, two adults, or a teenager and an adult. We find that the GDL policies reduce the number of 15-17-year-old accidents by limiting the amount of teenage driving rather than by improving teenage driving. This prevalence reduction primarily occurs at night and stricter GDL policies, especially those with night-time driving restrictions, are the most effective. Finally, we find that teen driving quality does not improve ex post GDL exposure.

Graduated driver licensing and teen traffic fatalities.

Over the last 8 years, nearly every state has introduced graduated driver licensing (GDL) for teens. These new licensing procedures require teen drivers to advance through distinct stages where they are subject to a variety of restrictions (e.g., adult supervision, daytime driving, passenger limits). In this study, we present evidence on whether these restrictions have been effective in reducing traffic fatalities among teens. These evaluations are based on state-by-year panel data from 1992 to 2002. We assess the reliability of our basic inferences in several ways including an examination of contemporaneous data for older cohorts who were not directly affected by these policies. Our results indicate that GDL regulations reduced traffic fatalities among 15-17-year-olds by at least 5.6%. We also find that the life-saving benefits of these regulations were plausibly related to their restrictiveness. And we find no evidence that these benefits were attenuated by an increase in fatality risks during the full-licensure period available to older teens.

Graduated driver licensing research in 2003 and beyond.

This paper updates the comprehensive summary of graduated driver licensing (GDL) published in the January 2003 special issue of the Journal of Safety Research. It summarizes recent research not included in the special issue as well as research in progress or planned research. The most active research areas are risk factors for beginning teen drivers and evaluations of GDL programs. Results in each area strengthen the case for GDL. Additional research is producing valuable information about specific GDL implementation issues and the roles of parents and driver education in helping teenagers learn to drive safely.

The genesis of GDL.

This paper discusses the early research that lead to graduated driver licensing, some of the educational principals on which it is based, obstacles to its acceptance, and some of the early efforts in the U.S. and elsewhere. EARLY RESEARCH: The research underlying the concept of graduated driver licensing was a 1971 North Carolina study that identified the overrepresentation of young drivers in crashes at night and when another young person was the right front passenger. EDUCATIONAL PRINCIPALS: Efforts to reduce the risk to young novice drivers applied what was known about learning. The concepts included distributed learning (i.e., over time) and progressing from simple to complex skills. A PROPOSAL: The proposed graduated licensing system based on learning principals included (a) initial experience under low risk conditions, (b) extended supervised practice, (c) gradual move to more complex conditions, and (d) harsher penalties for deliberate risk-taking. OBSTACLES: There were several most common objections raised against graduated licensing. Raising the licensing age decreased mobility. Some young drivers were "good" drivers. Enforcement is difficult. Fear of parental objections. Parents are not driver educators and some young people do not have an available parent. Administrative costs are too high. ACCEPTANCE: Driver educators were the first to see the benefits of a graduated system in the 1970s and 1980s. Toronto nearly adopted a graduated system in 1976. New Zealand was the first to adopt a graduated licensing system in 1984. Michigan in 1997 was the first state to require parental certification of extended supervised driving practice.