Journal of the National Medical Association

Abstract Background Suicide prevention strategies are targeted at three levels: the general population (Universal), persons at risk (Selected), and persons who have attempted suicide or have suicidal ideation (Indicated). This study describes the implementation of an innovative indicated suicide prevention service that prioritizes peer and psychosocial support at one of Australia’s largest mental health services. The purpose of this paper is threefold. (1) To describe the process of designing and implementing an innovative indicated suicide prevention service in Melbourne (2) To compare the implementation framework developed around it with other relevant frameworks and (3) To describe its stages of care. Results Based on the activities undertaken by the ‘project champion’ in designing and implementing Clayton HOPE, a pragmatic framework of implementation (PFI) was developed. The PFI included six steps. 1: Determine client needs; 2: Plan the model of care; 3: Determine the workforce and other resource requirements to achieve client needs; 4: Establish the workforce and finalize the team; 5: Facilitate stakeholder buy-in and 6: Regular monitoring and evaluation. The steps of the PFI, fit within the Quality Implementation Framework, albeit in a different sequence, owing to variations in settings, organizational circumstances, and readiness for change. The PFI also enhances the Levels of Change model by including additional requirements. A five-stage model of care was developed and implemented. They are 1: Early engagement and empathetic support (within 24 h of referral); 2: Assessment of psychosocial needs and suicidal risk (within 72 h of referral) 3: Construction of a personal safety plan (within 7 days of referral) 4: Implementation of the personal safety plan and risk management (week 2 - week12) and 5: Discharge and handover to ongoing supports (12 weeks from enrollment). Conclusions The main implications of this work are twofold: (1) The implementation of innovative models of care can be achieved by a ‘project champion’ with the relevant experience, authority and determination when funding is available and (2) Indicated suicide prevention models of care can strike a balance between clinical and non-clinical interventions that are tailored to client needs.

Abstract Background Extreme Risk Protection Orders (ERPOs) are a legislative tool that temporarily restrict firearm access and purchasing ability in patients at risk for harm. Data from four states with ERPO legislation, including Connecticut, estimates 17 to 23 filed ERPOs can prevent 1 suicide. Connecticut medical providers are permitted to independently file an ERPO directly to the courthouse. This survey assesses provider knowledge and attitudes towards use of ERPOs. Methods This study electronically surveyed providers from six hospitals regarding their current knowledge of the Connecticut ERPO law, perceived barriers to the use of the law and procedures that might make use more likely. Results 114 providers completed the survey in 2022. 66 (57.8%) providers encountered at least 1 patient per year at risk for suicide with firearm access. Only 2 (1.7%) providers had ever initiated an ERPO, but both found it extremely helpful. Only 1 provider was extremely familiar with ERPO while 91 (78.9%) were not familiar. Barriers to using ERPO include negatively impacting the patient relationship, and not enough time to call and follow up. ERPO specific training, and trained on-site coordinators to help file and follow through were ways to encourage to ERPO utilization. Conclusion The majority of providers encounter at least one patient annually who may benefit from ERPO utilization. However, providers are largely unfamiliar with ERPO and the filing process. Time cost is the greatest barrier to its utilization. Provider training and trained coordinators to process ERPO were the two most requested supports to encourage providers to initiate ERPOs.

Abstract Background Firearm violence is a major public health problem and the leading cause of death among children and youth aged one to nineteen in the United States (US). School shootings, though a relatively rare form of firearm violence in the US, have been occurring with increasing frequency, exposing more than 380,000 students to such events since 1999. This study engaged school shooting survivors to identify key research areas regarding their mental health, aiming to enhance the relevance and impact of future research for this community. Methods Participants for individual and group interviews were recruited from survivor support groups and through snowball sampling between May and August 2024. The interview guide, based on a recent scoping review highlighting gaps in research on the mental health impacts of school shootings, facilitated discussions on participants’ experiences, needs, and research priorities. Interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. Thirteen individuals participated (median age: 40 years; range: 18–47), including 11 former student survivors, one parent of a survivor, and one sibling of a victim. These participants represented ten school shootings from 1997 to 2022 across eight US states including Colorado, Florida, Kentucky, Maryland, Michigan, Oregon, Tennessee, and Washington. Eight participants experienced a mass school shooting (four or more fatalities excluding the perpetrator). Results The study identified three key research priorities: (1) understanding the long-term mental health impacts of school shootings across the life course, (2) expanding research to include broader outcomes beyond traditional mental health metrics, and (3) diversifying research approaches, study designs, and study populations to better capture the varied experiences of survivors. Conclusion There is a need for researchers to explore a wider range of outcomes, communities, and timeframes when studying the mental health impacts of school shootings. Such investigations are essential for understanding the complex and unique aspects of recovery and resilience among survivors. Centering survivor perspectives enhances our understanding of ongoing challenges facing survivors of school shootings, which should be prioritized in designing and evaluating interventions and policies.

Abstract Background Following the Supreme Court’s decision in New York State Rifle & Pistol Association, Inc. v. Bruen, which ruled a New York concealed-carry permitting requirement unconstitutional, laws restricting the public carrying of firearms in “sensitive places,” like college campuses, have received increasing attention. However, there is little evidence for whether permissive campus carry policies increase firearm violence or, via deterrence, reduce general crime on campus. We estimated the effect of implementing state laws allowing the carry of firearms on public college and university campuses on rates of violent crime and burglary. Methods Arkansas, Georgia, and Texas, containing 106 public institutions, implemented permissive campus carry laws in 2017, 2017, and 2016, respectively. Control institutions were all those in states that did not allow the carry of firearms on college campuses for the entire study period (2006–2019) (n = 324 institutions, 21 states). The rates of major violence and burglary per 1,000 enrolled students was obtained from the Office of Postsecondary Education Campus Safety and Security Statistics website. We use two-way fixed effects difference-in-differences models to estimate state-specific effects and a modified difference-in-differences approach that accounts for variation in treatment timing to generate an overall estimate. Results Differences in rates of major violence and burglary were not statistically distinguishable from zero in our main models and sensitivity analyses. The overall estimated difference in the rate of major violence following policy implementation was − 0.01 (− 0.113, 0.093). For burglary, we estimated a difference of − 0.02 (− 0.147, 0.106). Violence rates trended upward in treated states in the last exposure period, but differences were not consistently distinguished from the null. Conclusions This study does not find significant changes in crime rates following state implementation of permissive campus carrying laws. Decision-makers might therefore consider other factors such as the opinions of students, faculty, and staff regarding campus carry policies and feelings of safety, potential impacts on instructional quality and student engagement, and potential impacts on accidental or self-directed harm.

Abstract Background Around 40% of US households with children have a firearm kept in the home. This study sought to describe firearm storage practices and locking device preferences among caregivers of children presenting to a pediatric emergency department (ED). Methods We conducted a cross-sectional survey of caregivers of children presenting to a pediatric ED who endorsed having a firearm in the home from August 2023 to May 2024. A self-administered electronic survey inquired about current firearm storage practices and locking device preferences. Caregivers who endorsed any unsafe firearm storage practice (i.e., firearm stored unlocked, loaded, and/or with ammunition) were offered, based on their preference, a free cable gun lock, lock box, or gun safe along with safe firearm storage education materials. Caregivers given a device were surveyed 30 days later to reevaluate firearm storage behavior. McNemar’s test was used to evaluate differences in reported baseline locking device use. Wilcoxon signed rank test was used to evaluate changes in storage behaviors (locked, unloaded, and stored separate from ammunition) from baseline to 30-day follow-up. Results Of 139 caregivers with a firearm in the home, 91% (n = 126) reported having a handgun and 41% (n = 57) reported storing firearms with triple safe storage. Safes/vaults were more frequently used (40%, n = 56) than cable gun locks (20%, n = 28) (p = 0.003). Factors involved in caregiver preference for firearm locking devices were: speed of access to firearms (47%, n = 66), strength of the device (45%, n = 63), and cost of device (42%, n = 58). Seventeen caregivers were provided a free device based on preference: 15 gun safes, 2 lock boxes, and 0 cable gun locks. At 30-day follow up, 70.6% (n = 12) of eligible caregivers responded, and the proportion of respondents who reported storing all firearms locked increased significantly from baseline (from 67 to 100%, p = 0.036). Conclusions Caregivers in a pediatric ED reported using safes most frequently and, when offered a device, preferred safes over other locking devices. After being provided a free device of their preference, all caregivers who completed follow-up surveys reported all firearms were locked. Healthcare and community organizations should align resources with caregiver preferences.

Abstract Background This study assesses the impact of heatwaves on road safety in five Québec cities (Montréal, Québec City, Laval, Longueuil, and Sherbrooke) from June to September 2015–2022. Using Urban Heat Island (UHI), 90th and 95th percentile thresholds for heatwaves, we analyze their effects on collisions, traffic injuries, and killed and seriously injured (KSI) cases. Methods Traffic data were analyzed across two heatwave definitions, utilizing a time-stratified case-crossover design. UHI was approximated using the annual maximum of mean warm-season land surface temperatures (LST) derived from Landsat 8 (30 m resolution) over three consecutive years, identifying areas that stay hotter during the day and radiate excess heat at night. Heatwaves were defined as periods of at least two consecutive days with mean temperatures exceeding the historical 90th or 95th percentile of mean temperatures. Negative Binomial regression models were used to examine associations between UHI, heatwave events and traffic incidents. Models controlled for time varying variables such as rainfall, seasonality, and COVID-19 impacts. Results Heatwaves, particularly at the 95th percentile threshold, significantly increased traffic incidents in Montréal and Longueuil. In Sherbrooke, the 90th percentile threshold showed significant effects on collisions and injuries, while Québec City and Laval exhibit no significant associations. UHIs show a modest overall increase in collisions (IRR: 1.07) but limited effects on traffic injuries and KSI. Differences across cities highlight Montréal's higher IRR for collisions under heatwaves and lower IRR for KSI compared to Québec and Longueuil respectively. Discussion and conclusion The results indicate that cities like Montréal and Longueuil, with slightly stronger UHI and higher susceptibility to heatwaves, face increased road safety risks. However, UHI levels in Montréal were not significantly different from those in other cities, and heatwaves at the 95th percentile showed variability across regions. These findings highlight the need for targeted climate-adaptive strategies, such as green spaces and heat-reflective materials, to mitigate risks. Integrating climate resilience into urban planning remains critical as extreme weather events grow more frequent.

Abstract Background Nearly 7,000 snakebite injuries are reported yearly in the United States, with almost one quarter of those in the pediatric population. Due to increased exposure to snakes, rural children may experience different clinical outcomes for snakebite injuries. The goal of this study was to examine differences in resource utilization of rural and urban pediatric patients with snakebite injuries. Methods This is a retrospective cross-sectional study of patients aged 21 years and under presenting with venomous snakebites in the United States from January 1, 2016, through March 31, 2023, using the Pediatric Hospital Information System database and ICD-10 codes indicating snakebites. Comparisons were conducted to evaluate demographic and clinical characteristics in association with resource utilization and complications between patients living in rural areas and patients living in urban areas. Results The study included 2,633 patients from 23 states. The median age was 9 years; 61% of patients were male. Most patients were in the South and over 70% resided in urban areas. 82% of the population was admitted to a hospital, with median length of stay 1.59 days. Compared to urban patients, rural patients were more likely to be admitted and receive antivenom but were less likely to have an intensive care unit admission and have abnormal coagulation studies. Conclusions Rural pediatric patients with snakebites had different resource utilization and clinical complications than urban patients.

Abstract Background Young couples transitioning into parenthood are at elevated risk of experiencing intimate partner violence (IPV), in part, due to the social and economic stressors associated with this critical time. Interpersonal racial discrimination is a known risk factor for male-to-female IPV perpetration, however few studies have examined this relationship among men transitioning to fatherhood. Similarly, structural racism acknowledges how inequitable systems reinforce racial discrimination; yet, few studies have investigated whether structural racism relates to the discrimination-IPV perpetration association. This study examined relationships among structural racism, racial discrimination, stress, and IPV perpetration among racially diverse men transitioning into fatherhood. Methods Using data from the 2007–2011 American Community Survey, a structural racism was assessed using a latent variable with four indicators: racial residential segregation, education inequity, income inequity, and employment inequity. Individual-level prospective data were collected during 2007–2011 from 296 men in expectant couples recruited from obstetrics, and ultrasound clinics in Connecticut. Structural equation models were conducted to investigate longitudinal associations among structural racism, discrimination, stress, optimism and emotional IPV perpetration. Results Compared to white men, Black men were more likely to experience structural racism (B = 0.95, p <.001). Structural racism was associated with more racial discrimination (B = 0.45, p <.05), more stress (B = 0.40, p <.05), and less optimism (B=-0.50, p <.001). Racial discrimination was associated with more stress (B = 0.23, p <.05) and marginally associated with a greater likelihood to perpetrate emotional violence against a female partner (B = 0.23, p =.06). Stress was associated with a greater likelihood to perpetrate emotional violence against a female partner (B = 0.31, p =.05). The indirect path from structural racism to IPV perpetration via racial discrimination and stress was marginally significant (B = 0.05, p =.07). Conclusions This study provides evidence of the ways in which structural racism in housing, education, income, and employment can contribute to men’s use of aggression and violence against a female partner. Future intervention efforts to reduce emotional IPV perpetration could benefit from addressing structural racism.

Abstract Background TikTok is one of the fastest-growing social media platforms. With 50 million active daily users in the United States, videos on TikTok have the opportunity to reach an exceptionally large audience. It is of concern that some of these videos may be harmful, especially if they encourage dangerous or risky behavior that can increase injury risk. This is common for social media challenges, where people are encouraged to participate in and record a task and then post it on social media. The “Orbeez Challenge” was a challenge that went viral in 2022 and encouraged viewers to shoot water beads with Gel Blaster guns at others. The purpose of this study was to describe content for the “Orbeez Challenge” on TikTok, informed by pathways of the Elaboration Likelihood Model (ELM). Methods This study conducted a content analysis of TikTok videos related to the Orbeez challenge identified between October 5–11, 2022. A codebook was created by using abductive code generation, driven by an inductive iterative review of a sample of videos not included in the final study sample, and deductive code development to collect elements of the ELM. Results There were 125 videos in the final sample. Collectively, these videos had over 255 million views. Most (70.0%) of the creators were laypersons. Text (n = 97; 77.6%) and music (n = 83; 66.4%) were frequently present in the videos. Individuals were primarily shooting (47.2%) or loading (25.6%) the Gel Blaster. Nearly half (46.3%) of the content creators had between 10,000 and 500,000 followers. Most videos (n = 109; 87.2%) did not depict any injury prevention precautions, but of the 15 videos (12.0%) that did show injury prevention precautions, 14 (93.3%) were for eye protection. Conclusions This study characterized the content of the TikTok videos associated with the viral “Orbeez Challenge” and showed that TikTok videos could be characterized with guidance from a health communication theory. Despite their increased injury risk, the videos had high engagement and were most frequently posted by laypersons. This research presents an opportunity for countering injury challenges on social media and can guide injury professionals in designing and improving virtual health education campaigns.

Abstract Background Veterans show increased vulnerability to trauma exposure. Yet, there is limited research examining Veterans’ prevalence of experiencing different trauma exposure types by race, gender, and ethnicity and across unique phases of life (i.e., pre-military service, during service, and post-service). This study compares trauma exposure prevalence across women and men Veterans of differing ethnoracial identities (i.e., white, Black, Hispanic) within three life phases (i.e., pre-military service, during military service, post-military service). Methods This study examined survey data from 3,544 Veterans (1,781 women; 1,686 men) across six discrete data collection points (between August 2018 to March 2022). Surveys were mailed nationally and oversampled for women (51.6%) and Veterans living in high crime areas (67.6%). Veterans reported on their exposure to various trauma types (e.g., sexual assault, physical assault, community violence, captivity, serious accident, witnessing violent death) at each wave of data collection using items from a modified Life Events Checklist. Veterans also reported on demographic information (e.g., gender, race, ethnicity). Chi-square analyses were conducted to compare prevalence of reported exposure to each trauma type within each life phase across gender and ethnoracial groups. Results There were significant differences in trauma exposure prevalence across: (1) men vs. women Veterans; (2) white vs. Black vs. Hispanic Veterans; (3) Black vs. Hispanic vs. white women Veterans; and (4) Black vs. Hispanic, vs. white men Veterans. For example, in this study, Black men Veterans reported higher prevalence of intimate partner physical assault exposure pre-service (14.8%) and post-service (27.1%) than White men Veterans (9.0% and 13.8%; prevalence ratios = 1.64, 95% CI = 1.17, 2.32 and 1.96, 95% CI = 1.53, 2.51). White women Veterans were less likely to witness a violent death pre-service (11.5%) than Black (21.1%; prevalence ratio = 1.83, 95% CI = 1.42, 2.37) or Hispanic (18.1%) women Veterans. Conclusions Findings help uncover disparities within Veteran subgroups. They inform mental health treatment and prevention services to better meet the needs of all Veterans across differing life phases.

Abstract Background Cycling promotes health but carries significant injury risks, especially for older adults. In the U.S., cycling fatalities have increased since 1990, with adults over 50 now at the highest risk. As the population ages, the burden of cycling-related trauma is expected to grow, yet age-specific factors associated with mortality risk remain unclear. This study identifies age-specific mortality risk thresholds to inform targeted public health strategies. Methods We conducted a cross-sectional analysis of the National Trauma Data Bank (NTDB) data (2017–2023) on non-motorized cycling injuries. A total of 185,960 records were analyzed using logistic regression with splines to evaluate the relationship between age and mortality risk. The dataset was split into training (80%) and testing (20%) sets. Age thresholds where mortality risk changed were identified, and models were adjusted for injury severity, comorbidities, and helmet use. Results The median patient age was 43 years (IQR 20–58). Four key age thresholds (12, 17, 31, and 69) were identified, with the largest mortality increase after age 69. Our model achieved an AUC of 0.93, surpassing traditional age cutoff models, with 84.6% sensitivity and 88.0% specificity. Conclusions Age is a significant predictor of mortality in cycling trauma, with marked increases in risk during adolescence and for adults over 69. These findings underscore the need for age-targeted interventions, such as improved cycling infrastructure for teens and enhanced safety measures for older adults. Public health initiatives should prioritize these vulnerable age groups to reduce cycling-related mortality.

Abstract Background Veterans are at elevated risk for suicide compared to non-Veteran U.S. adults. Data sources and analyses to inform prevention efforts, especially for those who do not use Department of Veterans Affairs (VA) healthcare services, are needed. This study aimed to link VA and CDC’s National Violent Death Reporting System (NVDRS) data to create a novel data source to characterize the circumstances precipitating and preceding suicide among Veterans, including among those who did not use VA healthcare. Methods Multi-variable, multi-stage, deterministic linkage of VA-Department of Defense (DoD) Mortality Data Repository (MDR) and NVDRS-Restricted Access Database suicide and undetermined intent mortality records within 189 state-year strata (42 states, 2012–2018). Three linkage stages: (1) exact (matched on: age, sex, death date, underlying cause of death, day of month of birth, first initial of last name); (2) probable (all but one variable matched); (3) possible (all but 2 variables matched). Linkage success and accuracy of NVDRS-documented military history were assessed. Results Across all state-years, 22,019 matches (89.20% of 24,685 MDR Veteran records) were identified (65.47% exact). When high missingness (2 + matching variables in > 10% of records; n = 23) or incomplete reporting (n = 12) state-years were excluded, match rate increased to 94.29% (77.15% exact). NVDRS-documented military history (ever served) was accurate for 87.79% of matched records, with an overall sensitivity of 84.62%. Sensitivity was lower for female (61.01%) and younger (17–39 years; 77.51%) Veterans. Conclusions Accurate linkage of VA-DoD and NVDRS data is feasible and offers potential to improve understanding of circumstances surrounding suicide among Veterans.

Abstract Background Rates of suicide remain elevated among U.S. Veterans and have increased disproportionately among Asian American and Pacific Islander (AAPI) Veterans. Knowledge is limited regarding suicide prevention considerations for clinicians working with AAPI Veterans, yet culturally responsive strategies tend to be most effective. To address this gap, we sought to elucidate subject matter experts’ perspectives regarding suicide prevention considerations for AAPI Veterans. Methods Qualitative interviews were conducted with 14 key informants (e.g., clinicians, researchers) in 2023 to understand their experiences with, and recommendations for, preventing suicide among AAPI Veterans in the Continental U.S. Interview transcripts were analyzed through thematic analysis, with an inductive approach. Results Key informants discussed the heterogeneity of the AAPI population and emphasized the need to balance cultural sensitivity and cultural humility in suicide prevention with AAPI Veterans. Fear of bringing shame and dishonor upon one’s family was described as a factor which may prevent AAPI Veterans from disclosing mental health concerns and suicide risk and which may prevent them from accessing healthcare services for mental health and suicidality. Suicide risk among AAPI Veterans was viewed as being shaped by shame and the centrality of the family-collective, with family conferring both protection against and risk for suicide. Cultural norms and beliefs regarding suicide were considered pertinent to suicide among AAPI Veterans and included beliefs about perseverance in coping with distress to permittance of suicide in specific circumstances. Somatic idioms were described as a means by which AAPI Veterans may communicate distress and suicidality, with key informants discussing how this may impact treatment and outreach. Conclusion Key informant interviews provided crucial insights into cultural factors salient to conceptualizing and addressing AAPI Veterans’ risk for suicide. These findings can be utilized to inform tailored suicide prevention for this population, with emphasis on addressing mental health stigma, considering somatic idioms of distress, and considering the role of family in suicide risk and prevention.

Abstract Background In 2022, a nationally representative longitudinal survey in the USA found concerningly high prevalences of support for and personal willingness to engage in political violence, but those prevalences decreased in 2023. This study examines changes in those prevalences from 2023 to 2024, an election year in the USA. Methods Participants were members of Ipsos KnowledgePanel. Wave 3 of the survey was conducted May 23-June 14, 2024; invitations to participate were sent to all respondents to prior waves who remained in KnowledgePanel. Outcome measures concern justification for the use of violence to advance any of 17 specified political objectives, personal willingness to engage in political violence at 4 levels of severity and against 9 target populations, and expectation of firearm use in political violence. Outcomes are expressed as weighted proportions. Year-to-year change is based on the means of aggregated individual change scores, which have a potential range from 0 (no change) to ± 2. Results The 2024 completion rates were 88.4% (8896 respondents/10,064 invitees) overall, 91.6% (8185 respondents/8932 invitees) for invitees in 2024 who had responded in 2023, and 62.8% (711 respondents/1132 invitees) for invitees in 2024 who had responded in 2022 but not in 2023. After weighting, 50.9% (95% confidence interval (CI) 49.5%, 52.3%) were female; weighted mean (SD) age was 48.5 (24.9) years. From 2023 to 2024, the prevalence of the view that violence was usually or always justified to advance at least 1 political objective did not change (2024: 26.2%, 95% CI 25.0%, 27.5%; 2023: 25.3%, 95% CI 24.1%, 26.5%). There were no changes from 2023 to 2024 in willingness to damage property, threaten a person, injure a person, or kill a person in an act of political violence, and no changes in expectations of firearm use in situations where respondents considered political violence justifiable. Changes on other measures were infrequent (17 of 58 comparisons in the main analysis) and small where they occurred (with 2 exceptions, change < 0.05). Conclusions Contrary to expectation, support for and willingness to participate in political violence in this cohort showed little to no change from 2023 to 2024, an election year in the USA. These findings can help guide prevention efforts.

Abstract Background Motor vehicle crashes are the second leading cause of injury death among adults aged 65 and older in the U.S., second only to falls. A common state-level approach to mitigating older adult crash risk is the implementation of driver license renewal policies which vary largely between states and data on their effectiveness in preventing crashes and injuries are limited. To fill this gap, the aim of this study is to examine the association between state driver license renewal policies and older driver crash and injury rates. Methods Historical crash data, license renewal policy data, and other relevant policy and demographic data were gathered from 13 U.S. states (CO, IL, IA, KS, MN, MO, NE, ND, OH, SD, UT, WI, WY) for years 2000 through 2019, inclusive. Main exposures included six license renewal policies: renewal period, in-person renewal frequency, vision testing, knowledge testing, on-road drive testing, and mandatory physician reporting. The primary outcomes were crash and injury rates per 100,000 population. Results The study population included 19,010,179 crash-involved drivers aged 40 and older. State policies became less restrictive in many states over the study period, even for drivers aged 75 and older, resulting in longer times between renewals and fewer in-person renewal requirements. Loosening of in-person renewal from every time to less than every time was associated with increased crash rates, among drivers aged 65 to 74 (RRcrash = 1.08, 95% CI: 1.01–1.16). A longer duration between in-person renewals was associated with increased injury rates among drivers 75 and older (RRinjury = 1.18, 95% CI: 1.00–1.39). Conclusions Generally, state policies became less restrictive and resulted in longer required intervals between license renewal. Loosening of driver license renewal policies was associated with increased crash and injury rates. However, safety benefits of restrictive older driver licensing policies should be carefully weighed against costs to older adult well-being and quality of life following licensure loss. Additional methods to assess fitness to drive are necessary to identify the mechanisms behind the increased rates.