BACKGROUND:Three sources used for poisoning surveillance-child fatality reviews (CFRs), poison centre (PC) calls and death certificates-employ disparate data methodologies. Our study objectives were to (1) characterise the number of fatalities captured by CFRs and PC data compared with death certificates by age and (2) compare demographic and substance characteristics of fatalities captured by the three sources. METHODS:We acquired CFR data from the National Fatality Review-Case Reporting System (NFR-CRS), PC calls from the National Poison Data System (NPDS) and death certificate data from Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (WONDER) on poisoning fatalities among children 0-17 years old between 2005 and 2020. RESULTS:A total of 6376 poisoning fatalities among children 0-17 years were reported to WONDER, 3460 to NFR-CRS and 1622 to NPDS. Using WONDER as the reference standard, NFR-CRS captured 71.1% of fatalities among infants, and 68.0% among children 1-4 years. NPDS captured 30.9% of fatalities among infants and 59.3% among children 1-4 years. Children≤4 years represented a greater proportion of fatalities in NFR-CRS (25.5%) and NPDS (37.0%) than WONDER (19.9%). NFR-CRS had a slightly higher proportion of fatalities involving Black or African American race (16.8%) compared with WONDER (14.4%). Opioids were the most common fatal substances associated with NFR-CRS and WONDER. CONCLUSIONS:Fatality counts, as well as demographic and substance characteristics of those fatalities, differ between poisoning databases used by investigators and health agencies. Reliable death classification can improve data quality. Optimising poisoning fatality capture is critical for informing effective prevention strategies.

Motor vehicle crashes (MVCs) are a leading cause of injury among adults aged 65 years and older (“older adults”). As the number of older drivers grows, it is increasingly important to understand clinical factors associated with an increased risk of MVC. A major barrier, however, is the lack of data. To address this, we linked two large-scale administrative databases, the New Jersey Safety and Health Outcomes (NJ-SHO) Data Warehouse, which contains information on all police-reported crashes in New Jersey from 2004 to 2019, and Medicare Fee-for-Service (FFS) insurance claims, which contains health care encounters and prescription drug dispensings among older adults in the United States over the same period. This paper explains the linkage process, describes selected work leveraging these data to study MVCs in older drivers, and highlights features and strengths of this linkage for future research. The NJ-SHO–Medicare linkage was performed using categories of name (first and last), sex, age (birth and death date), and residence (state and ZIP code). Matches were ranked by quality and overall confidence. After comparing different match strategies, we accepted a match when (1) the name match quality was High or Medium and the age match was High or (2) the name, sex, and residence match categories were all High. Of the 2,722,773 individuals successfully linked, we accepted 2,661,782 matches (97.76

Purpose:Thousands of motor vehicle crash (MVC) related deaths and injuries occur among older adults every year in the United States. Injuries from MVC may cause acute or chronic pain resulting in functional decline and disability. Opioid treatment poses risk of adverse drug events (ADEs) including dependency, overdose, respiratory problems, and other complications. Our objective was to evaluate the comparative risks of ADEs associated with three opioid prescribing strategies: 1) greater versus lesser days' supply (≥6 days versus ≤5 days), 2) higher versus lower doses (≥30 MME versus <30 MME), and 3) tramadol versus other opioids over 45 days of follow-up. Methods:The study utilized Medicare claims linked to New Jersey drivers' licensing and police-reported crashes to emulate three target trials for each pairwise treatment comparison from May 1, 2007-November 16, 2017. The study included Medicare beneficiaries aged >67 years who initiated opioids within 10 days after MVC. Results:Among 510 beneficiaries, the mean (standard deviation) age was 76.1 (6.6) years, with 59.8% females and 90.4% White race. For the intention-to-treat estimand, risk ratios (RRs) [95% confidence limits (CLs)] were 1.64 (0.64, 4.57), 0.83 (0.45, 1.76), and 0.54 (0.21, 4.01) for days' supply, dose, and tramadol treatment strategies, respectively. There were no significant differences in ADE risk for any of the pairwise treatment comparisons in the intention-to-treat or per-protocol analyses. However, there was a considerable amount of uncertainty surrounding our effect measures. Conclusion:Physicians must continue to exercise caution while considering prescribing opioids for pain management in older adults.

BACKGROUND:Rearview cameras have been federally required in new passenger vehicles since 2018, yet disparities in vehicle ownership patterns are reflected in which drivers are operating vehicles equipped with this technology. This study examines disparities by race/ethnicity and income in the prevalence of rearview camera-equipped vehicles and their association with backing crash involvement. METHODS:The quasi-induced exposure method was used to estimate 1) differences in the rearview camera prevalence and 2) associations between rearview camera presence and the odds of involvement in a backing crash across race/ethnicity and income groups, using the New Jersey Safety and Health Outcomes (NJ-SHO) data warehouse and publicly available vehicle data. Logistic regression models assessed the associations between rearview cameras and backing crash odds, including interaction terms for race/ethnicity and income. RESULTS:Overall, 36.8% of passenger vehicles had rearview cameras. Rearview camera presence was associated with a 41% reduction in backing crash odds. Drivers in lower-income areas and Non-Hispanic Black or African American drivers were significantly less likely to operate rearview camera-equipped vehicles compared to those in the highest income areas and Non-Hispanic White drivers, respectively. Among drivers involved in backing crashes, Hispanic and Non-Hispanic Asian drivers with rearview cameras experienced a stronger protective association than Non-Hispanic White drivers without the technology. CONCLUSIONS:Rearview cameras are associated with reduced odds of backing crashes; however, disparities in who operate vehicles with the technology may limit equitable benefits across racial/ethnic and income groups. Strategies are needed to broaden distribution of crash-avoidance technologies.

Introduction: Transportation safety priorities emphasize the importance of incorporating equity into efforts to reduce deaths and injuries. Using integrated data, we investigated relationships between individual- and residence-based measures of equity and rates of crash involvement in New Jersey, 2016-2019. Methods: We used statewide integrated data that includes linked crash reports, hospital discharge data, and residence-based equity measures. We calculated crash rates among drivers involved in and injured in a crash by residential census tract. Using generalized Poisson regression, we estimated rate ratios and 95% confidence intervals (aRR, 95% CI) in separate models for race and ethnicity categories and for six previously developed, multi-dimensional equity measures, controlling for driver sex and age. Results: We identified 1,629,219 drivers involved in crashes of whom 8.3% were injured. Hispanic and non-Hispanic Black drivers had higher rates of crash involvement than non-Hispanic White drivers (aRR, 1.67 [95% CI, 1.65-1.68] and aRR, 1.78 [95% CI, 1.77-1.80], respectively). For community equity measures, drivers who resided in census tracts with poorest equity scores had higher crash rates than those living in census tracts with most favorable equity scores (e.g., Index of Concentration at the Extremes: aRR, 2.10 [95% CI, 2.07-2.12]). We observed similar results for injury crash rates. Model fit improved for both all crashes and injury crashes models after adding each equity measure to baseline. Conclusions: Rates of all crashes and injury crashes were consistently higher among drivers of minoritized race and ethnicity groups and among those who lived in less equitable communities. Associations among crash rates and different equity measures provided similar evidence that disparities in traffic safety outcomes are related to inequity. Practical Applications: The usefulness of individual and residence-based equity measures lies in the opportunity to identify communities with higher crash risks for tailored intervention to improve traffic safety and to reduce disparities.

BACKGROUND:Antidepressants are prescribed for depression among older adults but might increase the risk of motor vehicle crash (MVC) through adverse effects (AEs) like sedation, dizziness, and blurred vision. Antidepressant subclasses may have different MVC risks since AE risks vary across subclasses. Our objective was to estimate the comparative one-year risks of MVC upon initiating atypical (AA) or tricyclic (TCA) versus selective serotonin reuptake inhibitor (SSRI) antidepressants. METHODS:We emulated 470 sequential target trials each week from January 6, 2008, through January 1, 2017, using Medicare fee-for-service claims linked to New Jersey police-reported MVCs and driver's licensing data. Our sequential target trial emulation included older adults aged ≥ 66 years with a recent diagnosis of depression who initiated AAs, SSRIs, or TCAs. The unit of analysis was the "person-trial" a unique instance of a person in a sequential trial. Using inverse probability of treatment and censoring weighted Kaplan-Meier estimators to account for potential confounding and selection bias, we estimated the intention-to-treat cumulative incidence and risk ratios (RRs) of MVC over 1 year of follow-up. RESULTS:We identified 13,034 person-trials from 11,604 persons (median [first quartile, third quartile] age: 76.0 [71.0, 82.0] years, 69.8% female, 89.4% non-Hispanic White race). There were 31 (37.6 [95% confidence limits {CLs} 20.3, 59.5] per 1000), 65 (37.6 [95% CLs 25.7, 47.7] per 1000), and 380 (38.0 [95% CLs 24.1, 39.7] per 1000) MVCs among 644 TCA-treated, 2130 AA-treated, and 10,260 SSRI-treated person-trials, respectively. The adjusted RRs were 0.99 (95% CLs 0.72, 1.56) comparing AAs versus SSRIs and 0.99 (95% CLs 0.56, 1.86) comparing TCAs versus SSRIs. CONCLUSION:We observed no differences in the one-year risk of MVC between antidepressant subclasses. When selecting among antidepressant subclasses to manage depression in older adults, MVC risk should not guide prescribing decisions, and other considerations should take precedence.

Despite the well-documented benefits of driving for life satisfaction and mental health, there remains a gap in understanding the unique needs of the autistic community. Our objective was to address this gap by learning about autistic adolescents’ and their caregivers’ perspectives on factors that promote independent driving. Semi-structured interviews were conducted with autistic adolescents and their caregivers. Adolescents with an autism diagnosis, aged 16–24, and their caregivers each completed interviews lasting approximately 45 min. Topics included travel behaviors, attitudes toward licensing, family decision-making, and sources of information and support. Four central themes emerged: (1) Motivation and Readiness to Drive; (2) Cognitive and Sensory Factors; (3) Support Systems and Training; and (4) Facilitators and Success Strategies. Caregivers who viewed driving as a pathway to independence were motivated to support their adolescent’s learning, often balancing personal anxieties with the desire to foster autonomy. Adolescents built readiness through varied travel experiences and developed confidence through repeated practice and tailored instruction. Cognitive and sensory challenges—such as anxiety, multitasking, and sensory sensitivities—shaped learning trajectories and required adaptive strategies. Support systems involving caregivers, professionals, and peers were essential in navigating these complexities and promoting skill development. These findings underscore the importance of a relational, family-centered approach and the need for early, individualized conversations about driving. Ensuring autistic adolescents and their families can access timely, appropriate resources is critical. Future research should expand mobility pathways and address autism-specific barriers to driving to refine instructional supports and enhance independence.

Nonbenzodiazepine hypnotics ("Z-drugs") are prescribed for insomnia but might increase the 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, to 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 (RRs) 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 1249 MVCs, respectively. The intention-to-treat RR was 1.06 (95% CL, 0.95-1.16). For the per-protocol estimand, there were 800 MVCs and 1241 MVCs among treated and untreated person-trials, respectively, suggesting a reduced MVC risk (RR, 0.83; 95% CL, 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. This article is part of a Special Collection on Pharmacoepidemiology.

Introduction:Obtaining a driver's license enhances independence and quality of life but can be challenging for adolescents with health conditions. Health conditions may impact driving behavior and not always require driving restrictions. Strategies that promote safe independent driving for adolescents with various health conditions are not well described. Methods and population:The goal of this integrative review was to summarize the body of literature about safe driving behaviors and strategies to promote positive driving experiences among adolescents (15-24 years old) with at least one of the following health conditions: attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), disruptive behavior/conduct disorder, type 1 diabetes (TID), congenital heart disease (CHD), epilepsy/seizure disorder, neurological/neurobehavioral conditions, obstructive sleep apnea (OSA), restless leg syndrome (RLS), narcolepsy, and mental health conditions. Results:Sixty-eight studies published between 2007 and 2024 were included in the review. Over 70% of the included studies focused on ADHD and/or ASD. Driving attitudes, driving behavior/performance, licensure processes, driving interventions and other driving-related factors emerged as key outcome themes. Older age at licensure was common among the included sample. Evidence consistently showed that adolescents with ADHD, ASD, traumatic brain injury, developmental coordination disorders, and mood disorders experienced more unsafe driving compared to their age-matched peers. Blood glucose management was a common concern in studies examining driving behaviors among adolescents with T1D. Studies among adolescents with ADHD and ASD using well-developed interventions may serve as a model for future research examining the impact of other health conditions on driving behaviors. Conclusion:Our findings substantiate the body of research devoted to understanding safe independent driving among adolescents with ADHD and ASD and reveal opportunities for more research among adolescents with disruptive behavior/conduct disorder, T1D, CHD, epilepsy/seizure disorder, neurological/neurobehavioral conditions, OSA, RLS, narcolepsy and mental health conditions to inform health policies and clinical practice.

Objective: Several factors increase crash risk for teen drivers, including vulnerability to distraction and increased propensity to engage in risky driving behaviors such as smart phone use while driving (SPUWD). The current study evaluated the efficacy of an augmented LifeSaver smartphone app in reducing SPUWD among teen drivers and their parents. Method: Objectively collected app data and survey data were used to evaluate the app's effectiveness in reducing SPUWD and its usability and acceptability among teen drivers and their parents. Results: Data collected by the LifeSaver app revealed no significant decrease in overall SPUWD, however parents spent significantly less time using social media apps while certain features of the app were enabled. Conclusions: Parents expressed reluctance to change their own distracted driving behavior but preferred that their teens not engage in that same behavior. This important finding suggests that anti-distracted driving interventions must target not only teens but families as a whole.

Objective Although child safety seats are highly effective in preventing injuries, they are frequently misused. Experts have identified two leading “critical misuses”: (1) loose harness straps and (2) loose vehicle attachment at the base. We designed an innovative child safety seat system that educates, instructs, and alarms participants of safety seat errors. The system includes both the Cellular Car Seat (CCS) smartphone app and a network of car seat sensors. Our objective was to determine if CCS system users had fewer child safety seat misuses than users with a child safety seat manual alone. Methods During the study visit, 92 participants completed three safety seat scenarios using a mock vehicle setup, test doll, and a convertible child safety seat: A) fully install a convertible safety seat, B) recognizing/correcting loose harness straps in a seat with intentionally loose straps, and C) recognizing/correcting loose attachment to the vehicle seat at the base in a seat with intentionally loose attachment. Intervention participants (n = 46) were asked to use the CCS app during each scenario and control participants (n = 46) were given only the paper child safety seat manual. For each scenario, researchers determined errors/misuses present at the end of the scenario, time to complete scenario, and tension achieved on the harness straps (collected via load cell). Results Compared with controls, intervention participants had significantly fewer errors and higher average harness tensions for all three scenarios; furthermore, a greater portion achieved a harness tension of 4 newtons. During Scenario A, the rate of loose harness strap errors was more than three times higher for controls and loose base attachment errors almost six times higher. We observed similar trends in Scenario B, with harness strap errors more than double for controls. In Scenario C, the rates of both critical misuse errors were four times higher for controls compared to the intervention group. Conclusions The innovative CCS system was highly effective at reducing child safety seat use errors, especially critical misuses. Reducing critical misuses will decrease injuries and fatalities among crash-involved children. The CCS system can alert families to everyday harnessing and installation errors and provide families and caregivers with ongoing, accessible support.

Autistic adolescents and their families may experience barriers to transportation, including independent driving, which is critical to supporting quality of life and engagement in social, educational, and employment opportunities. Healthcare providers may feel unprepared to provide guidance to autistic adolescents, although they are among the professionals families turn to for guidance. This study describes providers’ experiences supporting autistic adolescents and families in the decision to pursue licensure and identifies barriers experienced in providing support. We conducted interviews with 15 healthcare providers focused on how they support autistic adolescents and their families in navigating topics related to independence, driving, and transportation. Key themes identified included: importance of understanding adolescents’ perspectives and motivations, approaches to readying caregivers for children to pursue driving, and role of providers in fostering agreement between adolescents and caregivers. Results reflect healthcare providers as intermediaries between autistic adolescents and caregivers making the decision to pursue licensure and bring families to consensus. Our findings emphasize the importance of healthcare providers, in collaboration with community-based providers, in supporting autistic adolescents and their families considering licensure. Improving conversations between providers and families provides opportunity to better support quality of life among autistic adolescents and their caregivers navigating the transition to independence.

Licensure is an option for some autistic adolescents and families that increases mobility by enabling independent travel to employment, school, and social activities. The objective of this study was to identify current strategies used by healthcare providers (HCPs) in their guidance to autistic adolescents and families on the transition to independent driving. Semi-structured interviews were conducted with 15 HCPs. The team’s previous research, literature review and expert feedback informed the development of the interview guide. A content analysis approach was used in the coding of transcripts, nine of which were double coded. Study team members reviewed coded transcripts, provided and discussed narrative summaries, and identified themes. Interviews were conducted with physicians, social workers, psychologists, therapist and a nurse practitioner. HCP identified their perceptions of autistic adolescents’ strengths and weaknesses to be addressed in their individualized approaches. They described using clinical interactions as time to address licensure and driving, but also referred to specialists as needed. HCPs described using existing resources, but also provided a wish list of future resources. HCPs use an individualized approach for guidance in the transition to independent driving, considering the unique needs of autistic adolescent patients and families. These HCPs identified a clear need for tailored resources and guidance they can use in support of independent driving when appropriate for their patients and families.

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.

ImportanceMood 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.ObjectiveTo 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 ParticipantsThis 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 MeasuresAcquisition 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.ResultsAmong 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 RelevanceThis 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.

Objective To provide data on characterizing returning to drive after concussion in adolescents. Design Prospective cohort study. Setting A large integrated pediatric health system. Participants Concussed adolescents ≤28 days of injury, ages 16.5–18 years with a driver's license. Interventions (or Assessment of Risk Factors) Adolescents completed a self-report survey of demographic information and pre-injury and current concussion symptoms (Post-concussion Symptom Inventory (PCSI, total score pre- and post-injury)). Adolescents also downloaded an application for daily self-report symptom monitoring (Recovering Concussion Update on Progression of Symptoms (ReCoUPS)). Outcome Measures Length of time to return to drive post-injury measured via self-report survey or ReCoUPS. Main Results Forty-three concussed adolescents (65% female, 76% White), age 17.2 [95% CI 17.02–17.38] years, licensure length of 10.3 [7.88–12.63] months, 13.95 [11.45–16.46] days post-injury and current PCSI score=28.68 [20.53–36.84] (pre-injury PCSI=12.4 [7.61–17.32]). At enrollment, 76.7% (n=33) had already gone back to driving, within 5.9 [3.95–7.86] days post-injury. Of this back to driving cohort, PCSI score=22.2 [13.07–31.33] (pre-injury PCSI=12.16 [6.45–17.87]. Of the 23.3% (n=10) that had not yet gone back to driving at enrollment, daily reports from ReCoUPS and bi-weekly check-ins indicated six participants returned to driving within 15.1 days [95% CI 3.66–26.67] post-injury. PCSI score on day of returning to drive was 26.6 [95% CI 7.43, 45.76] (pre-injury PCSI=8.20 [0, 18.19]). Conclusions Overall, most concussed adolescents returned to driving within a week after injury, even while still experiencing substantial symptoms. Results will help provide evidence for clinicians as they guide families in their returning to drive experiences.

Abstract 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.