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The impact of the 2007 graduated driver licensing law in Massachusetts on the rate of citations and licensing in teenage drivers
Journal of Safety Research 61 (2017) 199–204
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The impact of the 2007 graduated driver licensing law in Massachusetts on the rate of citations and licensing in teenage drivers Christopher DePesa, a,b Toby Raybould, a,b Shelley Hurwitz, e Jarone Lee, a,b,d,e Alice Gervasini, a,b,e George C. Velmahos, a,b,e Peter T. Masiakos, a,c,e Haytham M.A. Kaafarani a,b,e,⁎ a
The Trauma Injury Prevention and Outreach Program, Massachusetts General Hospital, 165 Cambridge St., Suite 810, Boston, MA 02114 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital Department of Pediatric Surgery, Massachusetts General Hospital d Department of Emergency Medicine, Massachusetts General Hospital e Harvard Medical School, 25 Shattuck St, Boston, MA 02115 b c
a r t i c l e
i n f o
Article history: Received 27 September 2016 Received in revised form 31 October 2016 Accepted 22 February 2017 Available online 06 March 2017
a b s t r a c t Objective: We recently demonstrated that the 2007 Massachusetts Graduated Driving Licensing (GDL) law decreased the rate of motor vehicle crashes in teenage drivers. To better understand this decrease, we sought to examine the law's impact on the issuance of driving licenses and traffic citations to teenage drivers. Methods: Citation and license data were obtained from the Massachusetts Department of Transportation. Census data were obtained from the Census Data Center. Two study periods were defined: pre-GDL (2002–2006) and post-GDL (2007–2012). Two populations were defined: the study population (aged 16–17) and the control population (aged 25–29). The rates of licenses per population were compared pre- vs. post-GDL for the study group. The numbers of total, state, and local citations per population were compared pre- vs. post-GDL for both populations. A sensitivity analysis was performed for the rates of citations using licenses issued as a denominator. Results: While licenses per population obtained by the study group decreased over the entire period, there was no change in the rate of decrease per year pre- vs. post-GDL (2.0% vs. 1.4%; p = 0.6392). In the study population, total, state, and local citations decreased post-GDL (17.8% vs. 8.1%, p b 0.0001; 3.7% vs. 2.2%, p b 0.0001; 14.1% vs. 5.8%, p b 0.0001, respectively). In the control group, total and state citations did not change (26.7% vs. 23.9%, p = 0.3606; 9.2% vs. 10.2%, p = 0.3404, respectively), and local citations decreased (17.5% vs. 13.7%, p = 0.0389). The rates of decrease per year for total, state, and local citations were significantly greater in the study population compared with control (p b 0.0001, p = 0.0002, p b 0.0001, respectively). Conclusions: The 2007 GDL law in Massachusetts was associated with fewer traffic citations without a change in the rate of licenses issued to teenagers. These findings suggest that 2007 GDL may be improving driving habits as opposed to motivating teenagers to delay the issuing of licenses. © 2017 Published by Elsevier Ltd.
1. Introduction Motor vehicle collisions (MVCs) are the second most common mechanism of injury for all trauma admissions in the United States and the most common mechanism of injury for patients aged 15–54 (Committee on Trauma, American College of Surgeons, 2014). For drivers 15 to19 years in age, MVCs represent 44% of all trauma-related admissions (Committee on Trauma, American College of Surgeons, 2014; Curry, Pfeiffer, Durbin, & Elliott, 2015; MMWR Morb Mortal Wkly Rep, 2010). Many states, and countries, have enacted graduated ⁎ Corresponding author at: Massachusetts General Hospital, Division of Trauma, Emergency Surgery, and Surgical Critical Care, 165 Cambridge St., Suite 810, Boston, MA 02114. E-mail address: [email protected] (H.M.A. Kaafarani).
http://dx.doi.org/10.1016/j.jsr.2017.02.012 0022-4375/© 2017 Published by Elsevier Ltd.
driver licensing (GDL) laws that phase in driving privileges for novice, young drivers. The aim is to decrease the disproportionately higher rate of MVCs and MVC-related fatality in drivers under the age of 18 years, as well as the MVC-related financial cost to society (Bates et al., 2014; Begg, Langley, Brookland, Ameratunga, & Gulliver, 2014; Brookland & Begg, 2011; Chapman, Masten, & Browning, 2014; Chen, Baker, & Li, 2006; Cheng et al., 2012; Curry, Elliott, Pfeiffer, Kim, & Durbin, 2015; Curry, Pfeiffer, Durbin, Elliott, & Kim, 2015; Dee, Grabowski, & Morrisey, 2005; Ehsani, Bingham, & Shope, 2013; Fell, Jones, & Romano, 2011; Fell, Todd, & Voas, 2011; Foss & Evenson, 1999; Hinchcliff, Ivers, Poulos, & Senserrick, 2010; Kaafarani et al., 2015; Lyon, Pan, & Li, 2012; Masten, Foss, & Marshall, 2013; O'Brien, Foss, Goodwin, & Masten, 2013; Rouse et al., 2013; Russell, Vandermeer, & Hartling, 2011; Steadman, Bush, Thygerson, & Barnes, 2014; Steenbergen et al., 2001; Shope & Molnar, 2003; Williams, Tefft,
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Table 1 Description of the 2007 modifications to the 1998 GDL in Massachusetts.
Learner's Permit Stage Minimum Entry Age Mandatory Holding Period Minimum amount of supervised driving (in addition to driver education) Driver Education 2-h driver education course for parents Ban on driving unless with a licensed adult 21+ years of age, who has been driving for at least a year and is sitting in the passenger seat Junior Operator's License Stage Minimum entry age: 16.5 years and a clean driving record Ban on Night Driving (without a parent or legal guardian present) Passenger restrictions
Penalties for Drivers Under 18-Years Old BAC N 0.02 or refusal to submit to a chemical test
Conviction for Violation of Passenger Restrictions (license phase only)
1998 Law
2007 Law
16 6 months 12 h 30 h classroom instruction, 6 h in-car behind the wheel training and 6 h observation No Yes
Same Same 40 h (30 h if driver completed a driver skills development program) 30 h classroom instruction, 12 h in-car behind the wheel training and 6 h observation Yes Same
Yes
Same
Ban 12:00 am to 5:00 am Secondary enforcement for 12:00 am - 1 am and 4:00 am-5:00 am During the first 6 months, no passengers b18 years old (except family) unless supervised by a 21+ year old licensed driver (who has at least 1 year of driving experience and holds a valid U.S. driver license, seated beside the driver).
Ban 12:30 am to 5:00 am Secondary enforcement for 12:30 am-1a and 4:00 am – 5:00 am Same
In addition to any penalty assessed by a court of law, junior operators will also receive and additional one year suspension 1st offense: 30 day suspension 2nd offense: 60 day suspension 3rd offense: 90 day suspension
Same
$50 reinstatement fee
Conviction for driving during banned night driving hours
Conviction for driving without a licensed driver (permit phase only)
Conviction for driving recklessly or negligently (license phase only)
Conviction for speeding
Conviction for drag racing
Conviction for use of mobile electronic device (text or phone)
1st offense: 60 day suspension 2nd offense: 180 day suspension and driver retraining course 3rd offense: 1 year suspension, driver retraining course and driver must reapply for permit
$100 reinstatement fee for each offense 1st offense: 60 day suspension 2nd offense: 180 day suspension and driver retraining $50 reinstatement fee course 3rd offense: 1 year suspension, driver retraining course (during license phase) and driver must reapply for permit If violations occur during permit phase, driver must reapply for permit $100 reinstatement fee for each offense No specific penalty. 1st offense: 60 day suspension and driver must reapply for permit Likely to be arrested for a violation of driving without a 2nd offense: 180 day suspension, driver retraining license, a criminal violation. $100 - $200 penalty. course and driver must reapply for permit 3rd offense: 1 year suspension and driver must reapply for permit $100 reinstatement fee Fine of $20 - $200 or by imprisonment for two weeks to 1st offense: 180 day suspension two years or both 2nd or subsequent offense: 1 year suspension and driver must reapply for permit $500 reinstatement fee for each offense 1st offense: Minimum of a $50 fine. 1st offense: 90 day suspension, driver retraining course Fine of additional $10 per mile for each mile over 10 mph (during license phase), and driver must reapply for over the limit. permit 2nd offense: 180 day suspension 2nd or subsequent offense: 1 year suspension, driver 3rd offense: 1 year suspension retraining course (during license phase), and driver must reapply for permit $100 reinstatement fee for permit holder $500 reinstatement fee for junior operator license holders 1st offense: $100 - $500 fine. At least 30 day suspension of 1st offense: 1 year suspension, driver retraining course, license. and driver must reapply for permit 2nd or subsequent offense: 3 year suspension, driver Subsequent offenses: $200 - $1000 fine and at least a 60 day retraining course, and driver must reapply for permit suspension of license. $500 reinstatement fee for 1st offense $1000 reinstatement fee for 2nd and subsequent offenses None 1st offense: 60 day suspension, driver retraining course, $100 fine and driver must reapply for permit 2nd offense: 180 day suspension and $250 fine Fine between $100–$200
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Table 1 (continued) 1998 Law
Conviction for negligent operation and injury from mobile phone use
2007 Law 3rd offense: 1 year suspension and $500 fine $100 reinstatement fee for each offense 1st offense: 180 day suspension 2nd or subsequent offense: 1 year suspension and driver must reapply for permit $500 reinstatement fee for each offense
None
& Grabowski, 2012; Zhu, Cummings, Chu, Coben, & Li, 2013). Two graduated driver licensing (GDL) laws have been enacted in Massachusetts, the first in 1998 and the second in 2007. The 2007 GDL included new supervision and training requirements for teen drivers and parents, as well as increased penalties for moving and night-time restriction violations [Table 1]. These latter changes presented new enforcement responsibilities for state and local police departments (Goodwin & Foss, 2004; Goodwin, Wells, Foss, & Williams, 2006). The impact of the 2007 GDL has been previously evaluated and has demonstrated a strong association between the law enactment and a decrease in the rate of MVCs and the fatalities resulting from MVCs in the teenage driver population (Kaafarani et al., 2015). In a subsequent study, it was estimated that the 2007 GDL has saved more than $7 million dollars to the Commonwealth of Massachusetts and its residents in the first 5 years of its enactment (Sangji et al., 2015). However, it remained unclear whether a broader impact of the law on driving behavior can be attributed to a simple decrease in the rate of licenses obtained by underage drivers or to a change in the driving behavior of these drivers due to the enforcement of the new laws. In this study, we sought to investigate the impact of the 2007 GDL law on: (1) the rate of licenses obtained by underage (less than 18 years) drivers, and (2) the rate of state and local police citations in the teenage driver population.
Massachusetts State Police Department. Otherwise, they were defined as “local police citations”.
2. Methods
3.1. Licenses obtained by the study group
2.1. Study period
Among the study group, there was a significant decreasing trend in the licensing rate over the entire study period (p b 0.0001). However, there was not a significant change in that decreasing trend pre-GDL to post-GDL (2.0% per year to 1.4% per year, p = 0.6392) [Table 2].
The study period included data from January 2002 to December 2012. The period of 2002–2006 was defined as “pre-GDL,” and the period of 2007–2012 was defined as “post-GDL.” 2.2. Study population Two population cohorts were defined and then compared: the study cohort included drivers aged 16–17 years, and the control cohort included those aged 25–29 years. The latter cohort was chosen as the control group because it was the closest in age and behavior to the study cohort but was not affected by the 2007 GDL during the entirety of the study period. 2.3. Data sources The population census data were obtained from the United States National Census Data Center. State and local police citation data were obtained from the Massachusetts Department of Transportation. License data were also obtained from the Massachusetts Department of Transportation. 2.4. Citations A citation was defined as any moving violation that resulted in a penalty to the driver. Not all crashes result in a citation, and up to four violations can be put on one single citation. Citations defined as “state police citations” were those identified as originating from the
2.5. Statistical analysis The rates of total, state, and local police traffic citations were analyzed using negative binomial regression for count outcome data, mainly using population as the exposure and, secondarily, using licenses issued as the exposure in a sensitivity analysis. The main grouping factors were the cohort (study vs. control) and the time period (pre- vs. post-GDL) with year included in the model as a covariate. The interaction between cohort and time period was included to test whether the effect of the law was different in the study cohort compared with the control cohort. The effect of the law within each cohort was derived from the interaction between time period and cohort. Rate ratios (incidence density ratios) comparing study groups and time periods were reported with 95% confidence intervals. Adding year to the model enabled tests of trends across the study period overall, pre-GDL, and post-GDL, and to estimate rate ratios per year. SAS version 9.4 was used. The study was reviewed and consent was waived by our institutional review board (IRB: 2013P001298). 3. Results
3.2. Total citations In the study population, the rate of total citations post-GDL decreased by 54% of the pre-GDL level (17.8% to 8.1%, p b 0.0001). In the control group, the rate of total citations did not change significantly (26.7% to 23.9%, p = 0.3606) [Fig. 1]. While there was an overall yearto-year decreasing trend in total citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p b 0.0001). Table 2 The rate of decrease in licenses obtained by the study group pre- vs. post-GDL Year
Population
Licenses
Licenses by Population
Change in Licenses by Population
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
168,679 170,310 173,398 176,553 181,384 183,868 179,024 176,670 174,794 173,038 170,825
58,657 56,903 58,686 56,935 57,977 56,861 47,542 48,703 47,674 46,639 47,643
0.347743 0.334114 0.338447 0.322481 0.319637 0.309249 0.265562 0.275672 0.272744 0.26953 0.278899
(Pre-GDL) −2.02%† [Incidence density ratio per year: 0.98 95% CI (0.96, 1.00) p = 0.05] (Post-GDL) −1.41† [Incidence density ratio per year: 0.99 95% CI (0.97, 1.00) p = 0.07]
†
p = 0.6392.
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Total Citation Rates
Local Police Citation Rates 0.2
Incidence density ratio: 0.90 95% CI (0.72, 1.13) p = 0.3606
0.3
0.18
0.2
0.15 0.267 0.239 0.1
preGDL postGDL
0.178
0.05
Incidence density ratio: 0.78 95% CI (0.62, 0.99) p = 0.0389
0.16
Incidence density ratio: 0.45 95% CI (0.36, 0.56) p < 0.0001
0.0808
Citations per Population
Citations per Population
0.25
Incidence density ratio: 0.41 95% CI (0.33, 0.51) p < 0.0001
0.14 0.12 0.1 0.175
0.08 0.141
0.137
0.06
preGDL postGDL
0.04
0 Study
0.0584
Control
0.02
Fig. 1. Total citation rates for the study and control cohorts pre- vs. post-GDL.
0 Study
Control
3.3. State police citations Fig. 3. Local Police citation rates for the study and control cohorts pre- vs. post-GDL.
In the study population, state police citations post-GDL decreased by 41% of the pre-GDL level (3.7% to 2.2%, p b 0.0001). In the control group, the rate of State Police citations did not change significantly (9.2% to 10.2%, p = 0.3404) [Fig. 2]. While there was an overall year-to-year decreasing trend in state citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p = 0.0002). 3.4. Local police citations In the study population, local police citations post-GDL decreased by 59% of the pre-GDL level (14.1% to 5.8%, p b 0.0001). In the control group, citations post-GDL also decreased by 22% of the pre-GDL level (17.5% to 13.7%, p = 0.0389) [Fig. 3]. While there was an overall yearto-year decreasing trend in local citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p b 0.0001). 3.5. Pre/post citation rate differences Further analysis showed that the effect of the 2007 GDL was significantly greater in the study population than in the control population for total, state and local citations (all p b 0.001) [Fig. 4].
State Police Citation Rates 0.12 Incidence density ratio: 1.12 95% CI (0.89, 1.41) p = 0.34
Citations per Popluation
0.1
0.08
0.06
Incidence density ratio: 0.60 95% CI (0.48, 0.76 ) p < 0.0001
0.102 0.0918
0.04
0.02
preGDL postGDL
0.0368 0.0223
0 Study
Control
Fig. 2. State Police citation rates for the study and control cohorts pre- vs. post-GDL.
3.6. Sensitivity analyses As a reference, we repeated the analyses using licenses issued as the exposure for the count data, instead of population. The results were similar. Focusing on the interactions in the regressions, the effect of the 2007 GDL was significantly greater for the study group as compared with the control group for overall police citations (p = 0.0001), for state citations (p = 0.0016), and for local citations (p = 0.0004).
4. Discussion In summary, this study suggests that the previously found decreased rate of MVCs and fatal MVCs observed following the enactment of the 2007 GDL law was accompanied by a concomitant decrease in the rates of total, state, and local police citations, but not with any additional decrease in the rate of licenses obtained by the teenage driver population. This study suggests that teenagers (and their parents) did not respond to the increased restrictions and added training responsibilities of the 2007 GDL law by delaying obtaining their licenses and avoiding these added requirements. In addition, while it is likely that all of the components of the law contributed to its overall effect, the fact that it was accompanied by a decreased rather than an increased number of citations point to a potential change in driving habits of teenage drivers as a result of training and supervision. This potential behavior modification may explain the sustainability of the impact of the 2007 GDL in decreasing MVCs, as was found in earlier investigations. Many studies have demonstrated that modifying risky behavior through legislative efforts is possible (Blais & Gagné, 2010; Davis et al., 2006; Fell et al., 2014; Keats, Emery, & Finch, 2012; Lewis-Evans, 2010; Montag, 2014; Nazif-Munoz, Quesnel-Vallée, & van den Berg, 2015; Passmore, Nguyen, Nguyen, & Olivé, 2010; Setien et al., 2014; Solomon & Chamberlain, 2014; Sze, Wong, Pei, Choi, & Lo, 2011). Davis et al. (2006) demonstrated that when a city receives additional resources to more strictly enforce traffic laws, the rate of MVC admissions to the nearby trauma center and the severity of injury observed both decrease. Blais and Gagné (2010) observed that, in Quebec City, the negotiation of a police union contract that led to a 61% decrease in issued traffic citations also resulted in a significant increase in MVC-related injuries (about eight more collisions per month). Their findings suggest that, if a traffic law does not result in real behavioral change, a decrease in enforcement will result in a rebound of risky behavior and MVCs. It is therefore strongly encouraged that injury prevention experts should continue to work with state agencies, including law enforcement, to advance legislation capable of changing at-risk-for-trauma populations'
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Change in Citation Rates postGDL 0.02 0.0105
Citations per Population
0
-0.0145 -0.02
-0.0278
p = 0.0002
-0.0383
-0.04 -0.06
Study Control
-0.08 -0.0973 -0.1 -0.12
-0.0829 p < 0.0001
p < 0.0001
Total
State
Local
Fig. 4. Citation rate differences (post- minus pre-GDL) for all jurisdictions, and for State and Local jurisdictions.
behavior, particularly young and inexperienced drivers (Buckley, Chapman, & Sheehan, 2014; Buckley & Sheehan, 2010; Híjar et al., 2013; Scott-Parker, Watson, King, & Hyde, 2011; Simons-Morton & Winston, 2006). This study demonstrates a different effect of the GDL than observed in other states, most notably California (Males, 2007; Peck, 2011), where the data suggested that teenage drivers were delaying licensure in order to avoid the effects of the state's GDL. The inherent differences between states, like Massachusetts and California, or the fact that the 2007 GDL in Massachusetts added restrictions to a pre-existing GDL may explain these differences. The effectiveness of the Massachusetts law is likely due to the specific circumstances in the time and place of its enactment, and these may be important factors for the legislative bodies of other states in designing or amending their own GDL. This study has some limitations. First, as a population study, the findings indicate only association and do not confirm causation. As such, discussing citation data as a proxy to behavioral change is an extrapolation at best, and a real change in attitude and driving habits cannot be proved with this data. Other factors, such as nighttime driving and passenger restrictions, likely contributed to the decrease in traffic citations by decreasing driving hours. Second, a law banning texting and driving in all age groups was enacted in 2010 in Massachusetts and could have confounded the results. However, this should have, theoretically, affected both the study and the control group in a similar fashion. Third, both the study and control group were observed to be obtaining fewer licenses over the study period. This could potentially be due to the concomitant economic crisis that overlapped with the study period and thus may have partially confounded the results by having more teens use public transportation instead of driving. 5. Conclusion The 2007 GDL in Massachusetts, previously shown to be associated with a decrease in the rate of MVCs and fatal MVCs, was associated with a concomitant decrease in the rate of traffic citations without a change in the rate of licenses issued to junior operators. Such findings may suggest a cultural or behavioral improvement in driving habits for this cohort rather than a simple delay in licensing. References Bates, L. J., Allen, S., Armstrong, K., Watson, B., King, M. J., & Davey, J. (2014, Nov). Graduated driver licensing: an international review. Sultan Qaboos University Medical Journal, 14(4), e432–e441. Begg, D. J., Langley, J. D., Brookland, R. L., Ameratunga, S., & Gulliver, P. (2014, Jan). Prelicensed driving experience and car crash involvement during the learner and restricted, licence stages of graduated driver licensing: findings from the New Zealand drivers study. Accident; Analysis and Prevention, 62, 153–160. Blais, E., & Gagné, M. P. (2010, Dec). The effect on collisions with injuries of a reduction in traffic citations issued by police officers. Injury Prevention, 16(6), 393–397.
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Christopher DePesa, RN, MS, TCRN is the Trauma Nurse Coordinator at Massachusetts General Hospital. In addition to working with the Trauma Injury Prevention and Outreach Program (TIPOP), he also designs and executes projects that monitor and enhance the quality of care for trauma and emergency surgery patients. He received his education at Boston College, and prior to his current role, he worked in the emergency department as a staff nurse. Toby Raybould, MS is the Trauma Prevention and Outreach Program Manager in the Division of Trauma at Massachusetts General Hospital. In this role, she manages an internal team of clinicians to conduct child and adult injury prevention research in order to identify and disseminate best practices. She works closely with state agencies and other non-profit organizations. Toby received her B.A. from The George Washington University and her M.S. from the Harvard School of Public Health. Shelley Hurwitz, PhD is Director of Biostatistics in the Center for Clinical Investigation at Brigham and Women’s Hospital in Boston, MA. She is also a faculty member in the Department of Medicine at Harvard Medical School, a fellow of the American Statistical Association, and an elected member of the International Statistical Institute. Jarone Lee, MD, MPH is an emergency medicine and critical care physician at Massachusetts General Hospital, and also an Assistant Professor at Harvard Medical School. Alice A. Gervasini, PhD, RN, NE-C is the Nurse Director for the Division of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital, Boston, Ma. She has 30 years experience in the management of trauma and acute care surgical patients, trauma systems design, and injury prevention. In conjunction with the Medical Director, she is responsible for the overall program dynamics for both the adult and pediatric trauma programs. She received her BS in nursing from American University, a Masters Degree from University of Maryland Baltimore with a focus on trauma nursing, and a PhD in Nursing from Boston College. Research interests include clinical practice, trauma epidemiology, and injury prevention. She has published numerous articles and spoken nationally and internationally on many trauma related topics. She contributes to the ACNP curriculum and serves on the advisory board for the PhD program at Northeastern University, and is an Instructor in Surgery at Harvard Medical School. George C. Velmahos, MD, PhD, MSEd is the John F. Burke Professor of Surgery at Harvard Medical School and Chief of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital. He is the Trauma Program Leader for the Center for Integration of Medicine with Innovative Technology (CIMIT), and is the Founder of the Center for Early Trauma Research at Massachusetts General Hospital. Peter T. Masiakos, MD is a Pediatric General and Thoracic Surgeon at MGH and Associate Professor at Harvard Medical School. He was trained at the Boston City Hospital and Hospital for Sick Children (Toronto), where he developed a clinical interest in pediatric trauma care and injury prevention. He is the director of the pediatric trauma surgery service at MGH and has become a vocal injury prevention advocate. He has also been involved in successfully educating the Massachusetts legislature and the US Congress on the inherent risks that certain products pose to children and has testified both at the Massachusetts state house and at the consumer product safety commission on the need for new legislation which would prohibit the use of ATVs within specific age groups. He has aided in the development and passage of several forward thinking injury prevention laws and continues to work alongside Massachusetts State Legislators and the Congress on several other comprehensive injury prevention laws including junior operator laws, safe driving laws and child restraint laws. Haytham Kaafarani, MD, MPH is a surgeon-scientist and the Director of Patient Safety & Quality at the division of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital (MGH), an Assistant Professor of Surgery at Harvard University, and Associate Faculty at the Codman’s Center for Clinical Effectiveness. He did his General Surgery internship at the Brigham and Women’s Hospital, his residency at Tufts Medical Center and completed the fellowship in Trauma, Emergency Surgery and Surgical Critical Care at MGH. During his residency, he pursued a Masters in Health Policy and Management at Harvard University and a Health Services Research Fellowship at the VA Boston Healthcare System and the Center for Health Quality, Outcomes and Economic Research (CHQOER). His research focuses on improving surgical outcomes, injury prevention, patient safety, and quality benchmarking of surgical care using advanced health services methodologies.
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Journal of Safety Research journal homepage: www.elsevier.com/locate/jsr
The impact of the 2007 graduated driver licensing law in Massachusetts on the rate of citations and licensing in teenage drivers Christopher DePesa, a,b Toby Raybould, a,b Shelley Hurwitz, e Jarone Lee, a,b,d,e Alice Gervasini, a,b,e George C. Velmahos, a,b,e Peter T. Masiakos, a,c,e Haytham M.A. Kaafarani a,b,e,⁎ a
The Trauma Injury Prevention and Outreach Program, Massachusetts General Hospital, 165 Cambridge St., Suite 810, Boston, MA 02114 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital Department of Pediatric Surgery, Massachusetts General Hospital d Department of Emergency Medicine, Massachusetts General Hospital e Harvard Medical School, 25 Shattuck St, Boston, MA 02115 b c
a r t i c l e
i n f o
Article history: Received 27 September 2016 Received in revised form 31 October 2016 Accepted 22 February 2017 Available online 06 March 2017
a b s t r a c t Objective: We recently demonstrated that the 2007 Massachusetts Graduated Driving Licensing (GDL) law decreased the rate of motor vehicle crashes in teenage drivers. To better understand this decrease, we sought to examine the law's impact on the issuance of driving licenses and traffic citations to teenage drivers. Methods: Citation and license data were obtained from the Massachusetts Department of Transportation. Census data were obtained from the Census Data Center. Two study periods were defined: pre-GDL (2002–2006) and post-GDL (2007–2012). Two populations were defined: the study population (aged 16–17) and the control population (aged 25–29). The rates of licenses per population were compared pre- vs. post-GDL for the study group. The numbers of total, state, and local citations per population were compared pre- vs. post-GDL for both populations. A sensitivity analysis was performed for the rates of citations using licenses issued as a denominator. Results: While licenses per population obtained by the study group decreased over the entire period, there was no change in the rate of decrease per year pre- vs. post-GDL (2.0% vs. 1.4%; p = 0.6392). In the study population, total, state, and local citations decreased post-GDL (17.8% vs. 8.1%, p b 0.0001; 3.7% vs. 2.2%, p b 0.0001; 14.1% vs. 5.8%, p b 0.0001, respectively). In the control group, total and state citations did not change (26.7% vs. 23.9%, p = 0.3606; 9.2% vs. 10.2%, p = 0.3404, respectively), and local citations decreased (17.5% vs. 13.7%, p = 0.0389). The rates of decrease per year for total, state, and local citations were significantly greater in the study population compared with control (p b 0.0001, p = 0.0002, p b 0.0001, respectively). Conclusions: The 2007 GDL law in Massachusetts was associated with fewer traffic citations without a change in the rate of licenses issued to teenagers. These findings suggest that 2007 GDL may be improving driving habits as opposed to motivating teenagers to delay the issuing of licenses. © 2017 Published by Elsevier Ltd.
1. Introduction Motor vehicle collisions (MVCs) are the second most common mechanism of injury for all trauma admissions in the United States and the most common mechanism of injury for patients aged 15–54 (Committee on Trauma, American College of Surgeons, 2014). For drivers 15 to19 years in age, MVCs represent 44% of all trauma-related admissions (Committee on Trauma, American College of Surgeons, 2014; Curry, Pfeiffer, Durbin, & Elliott, 2015; MMWR Morb Mortal Wkly Rep, 2010). Many states, and countries, have enacted graduated ⁎ Corresponding author at: Massachusetts General Hospital, Division of Trauma, Emergency Surgery, and Surgical Critical Care, 165 Cambridge St., Suite 810, Boston, MA 02114. E-mail address: [email protected] (H.M.A. Kaafarani).
http://dx.doi.org/10.1016/j.jsr.2017.02.012 0022-4375/© 2017 Published by Elsevier Ltd.
driver licensing (GDL) laws that phase in driving privileges for novice, young drivers. The aim is to decrease the disproportionately higher rate of MVCs and MVC-related fatality in drivers under the age of 18 years, as well as the MVC-related financial cost to society (Bates et al., 2014; Begg, Langley, Brookland, Ameratunga, & Gulliver, 2014; Brookland & Begg, 2011; Chapman, Masten, & Browning, 2014; Chen, Baker, & Li, 2006; Cheng et al., 2012; Curry, Elliott, Pfeiffer, Kim, & Durbin, 2015; Curry, Pfeiffer, Durbin, Elliott, & Kim, 2015; Dee, Grabowski, & Morrisey, 2005; Ehsani, Bingham, & Shope, 2013; Fell, Jones, & Romano, 2011; Fell, Todd, & Voas, 2011; Foss & Evenson, 1999; Hinchcliff, Ivers, Poulos, & Senserrick, 2010; Kaafarani et al., 2015; Lyon, Pan, & Li, 2012; Masten, Foss, & Marshall, 2013; O'Brien, Foss, Goodwin, & Masten, 2013; Rouse et al., 2013; Russell, Vandermeer, & Hartling, 2011; Steadman, Bush, Thygerson, & Barnes, 2014; Steenbergen et al., 2001; Shope & Molnar, 2003; Williams, Tefft,
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Table 1 Description of the 2007 modifications to the 1998 GDL in Massachusetts.
Learner's Permit Stage Minimum Entry Age Mandatory Holding Period Minimum amount of supervised driving (in addition to driver education) Driver Education 2-h driver education course for parents Ban on driving unless with a licensed adult 21+ years of age, who has been driving for at least a year and is sitting in the passenger seat Junior Operator's License Stage Minimum entry age: 16.5 years and a clean driving record Ban on Night Driving (without a parent or legal guardian present) Passenger restrictions
Penalties for Drivers Under 18-Years Old BAC N 0.02 or refusal to submit to a chemical test
Conviction for Violation of Passenger Restrictions (license phase only)
1998 Law
2007 Law
16 6 months 12 h 30 h classroom instruction, 6 h in-car behind the wheel training and 6 h observation No Yes
Same Same 40 h (30 h if driver completed a driver skills development program) 30 h classroom instruction, 12 h in-car behind the wheel training and 6 h observation Yes Same
Yes
Same
Ban 12:00 am to 5:00 am Secondary enforcement for 12:00 am - 1 am and 4:00 am-5:00 am During the first 6 months, no passengers b18 years old (except family) unless supervised by a 21+ year old licensed driver (who has at least 1 year of driving experience and holds a valid U.S. driver license, seated beside the driver).
Ban 12:30 am to 5:00 am Secondary enforcement for 12:30 am-1a and 4:00 am – 5:00 am Same
In addition to any penalty assessed by a court of law, junior operators will also receive and additional one year suspension 1st offense: 30 day suspension 2nd offense: 60 day suspension 3rd offense: 90 day suspension
Same
$50 reinstatement fee
Conviction for driving during banned night driving hours
Conviction for driving without a licensed driver (permit phase only)
Conviction for driving recklessly or negligently (license phase only)
Conviction for speeding
Conviction for drag racing
Conviction for use of mobile electronic device (text or phone)
1st offense: 60 day suspension 2nd offense: 180 day suspension and driver retraining course 3rd offense: 1 year suspension, driver retraining course and driver must reapply for permit
$100 reinstatement fee for each offense 1st offense: 60 day suspension 2nd offense: 180 day suspension and driver retraining $50 reinstatement fee course 3rd offense: 1 year suspension, driver retraining course (during license phase) and driver must reapply for permit If violations occur during permit phase, driver must reapply for permit $100 reinstatement fee for each offense No specific penalty. 1st offense: 60 day suspension and driver must reapply for permit Likely to be arrested for a violation of driving without a 2nd offense: 180 day suspension, driver retraining license, a criminal violation. $100 - $200 penalty. course and driver must reapply for permit 3rd offense: 1 year suspension and driver must reapply for permit $100 reinstatement fee Fine of $20 - $200 or by imprisonment for two weeks to 1st offense: 180 day suspension two years or both 2nd or subsequent offense: 1 year suspension and driver must reapply for permit $500 reinstatement fee for each offense 1st offense: Minimum of a $50 fine. 1st offense: 90 day suspension, driver retraining course Fine of additional $10 per mile for each mile over 10 mph (during license phase), and driver must reapply for over the limit. permit 2nd offense: 180 day suspension 2nd or subsequent offense: 1 year suspension, driver 3rd offense: 1 year suspension retraining course (during license phase), and driver must reapply for permit $100 reinstatement fee for permit holder $500 reinstatement fee for junior operator license holders 1st offense: $100 - $500 fine. At least 30 day suspension of 1st offense: 1 year suspension, driver retraining course, license. and driver must reapply for permit 2nd or subsequent offense: 3 year suspension, driver Subsequent offenses: $200 - $1000 fine and at least a 60 day retraining course, and driver must reapply for permit suspension of license. $500 reinstatement fee for 1st offense $1000 reinstatement fee for 2nd and subsequent offenses None 1st offense: 60 day suspension, driver retraining course, $100 fine and driver must reapply for permit 2nd offense: 180 day suspension and $250 fine Fine between $100–$200
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Table 1 (continued) 1998 Law
Conviction for negligent operation and injury from mobile phone use
2007 Law 3rd offense: 1 year suspension and $500 fine $100 reinstatement fee for each offense 1st offense: 180 day suspension 2nd or subsequent offense: 1 year suspension and driver must reapply for permit $500 reinstatement fee for each offense
None
& Grabowski, 2012; Zhu, Cummings, Chu, Coben, & Li, 2013). Two graduated driver licensing (GDL) laws have been enacted in Massachusetts, the first in 1998 and the second in 2007. The 2007 GDL included new supervision and training requirements for teen drivers and parents, as well as increased penalties for moving and night-time restriction violations [Table 1]. These latter changes presented new enforcement responsibilities for state and local police departments (Goodwin & Foss, 2004; Goodwin, Wells, Foss, & Williams, 2006). The impact of the 2007 GDL has been previously evaluated and has demonstrated a strong association between the law enactment and a decrease in the rate of MVCs and the fatalities resulting from MVCs in the teenage driver population (Kaafarani et al., 2015). In a subsequent study, it was estimated that the 2007 GDL has saved more than $7 million dollars to the Commonwealth of Massachusetts and its residents in the first 5 years of its enactment (Sangji et al., 2015). However, it remained unclear whether a broader impact of the law on driving behavior can be attributed to a simple decrease in the rate of licenses obtained by underage drivers or to a change in the driving behavior of these drivers due to the enforcement of the new laws. In this study, we sought to investigate the impact of the 2007 GDL law on: (1) the rate of licenses obtained by underage (less than 18 years) drivers, and (2) the rate of state and local police citations in the teenage driver population.
Massachusetts State Police Department. Otherwise, they were defined as “local police citations”.
2. Methods
3.1. Licenses obtained by the study group
2.1. Study period
Among the study group, there was a significant decreasing trend in the licensing rate over the entire study period (p b 0.0001). However, there was not a significant change in that decreasing trend pre-GDL to post-GDL (2.0% per year to 1.4% per year, p = 0.6392) [Table 2].
The study period included data from January 2002 to December 2012. The period of 2002–2006 was defined as “pre-GDL,” and the period of 2007–2012 was defined as “post-GDL.” 2.2. Study population Two population cohorts were defined and then compared: the study cohort included drivers aged 16–17 years, and the control cohort included those aged 25–29 years. The latter cohort was chosen as the control group because it was the closest in age and behavior to the study cohort but was not affected by the 2007 GDL during the entirety of the study period. 2.3. Data sources The population census data were obtained from the United States National Census Data Center. State and local police citation data were obtained from the Massachusetts Department of Transportation. License data were also obtained from the Massachusetts Department of Transportation. 2.4. Citations A citation was defined as any moving violation that resulted in a penalty to the driver. Not all crashes result in a citation, and up to four violations can be put on one single citation. Citations defined as “state police citations” were those identified as originating from the
2.5. Statistical analysis The rates of total, state, and local police traffic citations were analyzed using negative binomial regression for count outcome data, mainly using population as the exposure and, secondarily, using licenses issued as the exposure in a sensitivity analysis. The main grouping factors were the cohort (study vs. control) and the time period (pre- vs. post-GDL) with year included in the model as a covariate. The interaction between cohort and time period was included to test whether the effect of the law was different in the study cohort compared with the control cohort. The effect of the law within each cohort was derived from the interaction between time period and cohort. Rate ratios (incidence density ratios) comparing study groups and time periods were reported with 95% confidence intervals. Adding year to the model enabled tests of trends across the study period overall, pre-GDL, and post-GDL, and to estimate rate ratios per year. SAS version 9.4 was used. The study was reviewed and consent was waived by our institutional review board (IRB: 2013P001298). 3. Results
3.2. Total citations In the study population, the rate of total citations post-GDL decreased by 54% of the pre-GDL level (17.8% to 8.1%, p b 0.0001). In the control group, the rate of total citations did not change significantly (26.7% to 23.9%, p = 0.3606) [Fig. 1]. While there was an overall yearto-year decreasing trend in total citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p b 0.0001). Table 2 The rate of decrease in licenses obtained by the study group pre- vs. post-GDL Year
Population
Licenses
Licenses by Population
Change in Licenses by Population
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
168,679 170,310 173,398 176,553 181,384 183,868 179,024 176,670 174,794 173,038 170,825
58,657 56,903 58,686 56,935 57,977 56,861 47,542 48,703 47,674 46,639 47,643
0.347743 0.334114 0.338447 0.322481 0.319637 0.309249 0.265562 0.275672 0.272744 0.26953 0.278899
(Pre-GDL) −2.02%† [Incidence density ratio per year: 0.98 95% CI (0.96, 1.00) p = 0.05] (Post-GDL) −1.41† [Incidence density ratio per year: 0.99 95% CI (0.97, 1.00) p = 0.07]
†
p = 0.6392.
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Total Citation Rates
Local Police Citation Rates 0.2
Incidence density ratio: 0.90 95% CI (0.72, 1.13) p = 0.3606
0.3
0.18
0.2
0.15 0.267 0.239 0.1
preGDL postGDL
0.178
0.05
Incidence density ratio: 0.78 95% CI (0.62, 0.99) p = 0.0389
0.16
Incidence density ratio: 0.45 95% CI (0.36, 0.56) p < 0.0001
0.0808
Citations per Population
Citations per Population
0.25
Incidence density ratio: 0.41 95% CI (0.33, 0.51) p < 0.0001
0.14 0.12 0.1 0.175
0.08 0.141
0.137
0.06
preGDL postGDL
0.04
0 Study
0.0584
Control
0.02
Fig. 1. Total citation rates for the study and control cohorts pre- vs. post-GDL.
0 Study
Control
3.3. State police citations Fig. 3. Local Police citation rates for the study and control cohorts pre- vs. post-GDL.
In the study population, state police citations post-GDL decreased by 41% of the pre-GDL level (3.7% to 2.2%, p b 0.0001). In the control group, the rate of State Police citations did not change significantly (9.2% to 10.2%, p = 0.3404) [Fig. 2]. While there was an overall year-to-year decreasing trend in state citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p = 0.0002). 3.4. Local police citations In the study population, local police citations post-GDL decreased by 59% of the pre-GDL level (14.1% to 5.8%, p b 0.0001). In the control group, citations post-GDL also decreased by 22% of the pre-GDL level (17.5% to 13.7%, p = 0.0389) [Fig. 3]. While there was an overall yearto-year decreasing trend in local citations through the study period, the decreasing trend was significantly steeper post-GDL for the study cohort than for the control cohort (p b 0.0001). 3.5. Pre/post citation rate differences Further analysis showed that the effect of the 2007 GDL was significantly greater in the study population than in the control population for total, state and local citations (all p b 0.001) [Fig. 4].
State Police Citation Rates 0.12 Incidence density ratio: 1.12 95% CI (0.89, 1.41) p = 0.34
Citations per Popluation
0.1
0.08
0.06
Incidence density ratio: 0.60 95% CI (0.48, 0.76 ) p < 0.0001
0.102 0.0918
0.04
0.02
preGDL postGDL
0.0368 0.0223
0 Study
Control
Fig. 2. State Police citation rates for the study and control cohorts pre- vs. post-GDL.
3.6. Sensitivity analyses As a reference, we repeated the analyses using licenses issued as the exposure for the count data, instead of population. The results were similar. Focusing on the interactions in the regressions, the effect of the 2007 GDL was significantly greater for the study group as compared with the control group for overall police citations (p = 0.0001), for state citations (p = 0.0016), and for local citations (p = 0.0004).
4. Discussion In summary, this study suggests that the previously found decreased rate of MVCs and fatal MVCs observed following the enactment of the 2007 GDL law was accompanied by a concomitant decrease in the rates of total, state, and local police citations, but not with any additional decrease in the rate of licenses obtained by the teenage driver population. This study suggests that teenagers (and their parents) did not respond to the increased restrictions and added training responsibilities of the 2007 GDL law by delaying obtaining their licenses and avoiding these added requirements. In addition, while it is likely that all of the components of the law contributed to its overall effect, the fact that it was accompanied by a decreased rather than an increased number of citations point to a potential change in driving habits of teenage drivers as a result of training and supervision. This potential behavior modification may explain the sustainability of the impact of the 2007 GDL in decreasing MVCs, as was found in earlier investigations. Many studies have demonstrated that modifying risky behavior through legislative efforts is possible (Blais & Gagné, 2010; Davis et al., 2006; Fell et al., 2014; Keats, Emery, & Finch, 2012; Lewis-Evans, 2010; Montag, 2014; Nazif-Munoz, Quesnel-Vallée, & van den Berg, 2015; Passmore, Nguyen, Nguyen, & Olivé, 2010; Setien et al., 2014; Solomon & Chamberlain, 2014; Sze, Wong, Pei, Choi, & Lo, 2011). Davis et al. (2006) demonstrated that when a city receives additional resources to more strictly enforce traffic laws, the rate of MVC admissions to the nearby trauma center and the severity of injury observed both decrease. Blais and Gagné (2010) observed that, in Quebec City, the negotiation of a police union contract that led to a 61% decrease in issued traffic citations also resulted in a significant increase in MVC-related injuries (about eight more collisions per month). Their findings suggest that, if a traffic law does not result in real behavioral change, a decrease in enforcement will result in a rebound of risky behavior and MVCs. It is therefore strongly encouraged that injury prevention experts should continue to work with state agencies, including law enforcement, to advance legislation capable of changing at-risk-for-trauma populations'
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Change in Citation Rates postGDL 0.02 0.0105
Citations per Population
0
-0.0145 -0.02
-0.0278
p = 0.0002
-0.0383
-0.04 -0.06
Study Control
-0.08 -0.0973 -0.1 -0.12
-0.0829 p < 0.0001
p < 0.0001
Total
State
Local
Fig. 4. Citation rate differences (post- minus pre-GDL) for all jurisdictions, and for State and Local jurisdictions.
behavior, particularly young and inexperienced drivers (Buckley, Chapman, & Sheehan, 2014; Buckley & Sheehan, 2010; Híjar et al., 2013; Scott-Parker, Watson, King, & Hyde, 2011; Simons-Morton & Winston, 2006). This study demonstrates a different effect of the GDL than observed in other states, most notably California (Males, 2007; Peck, 2011), where the data suggested that teenage drivers were delaying licensure in order to avoid the effects of the state's GDL. The inherent differences between states, like Massachusetts and California, or the fact that the 2007 GDL in Massachusetts added restrictions to a pre-existing GDL may explain these differences. The effectiveness of the Massachusetts law is likely due to the specific circumstances in the time and place of its enactment, and these may be important factors for the legislative bodies of other states in designing or amending their own GDL. This study has some limitations. First, as a population study, the findings indicate only association and do not confirm causation. As such, discussing citation data as a proxy to behavioral change is an extrapolation at best, and a real change in attitude and driving habits cannot be proved with this data. Other factors, such as nighttime driving and passenger restrictions, likely contributed to the decrease in traffic citations by decreasing driving hours. Second, a law banning texting and driving in all age groups was enacted in 2010 in Massachusetts and could have confounded the results. However, this should have, theoretically, affected both the study and the control group in a similar fashion. Third, both the study and control group were observed to be obtaining fewer licenses over the study period. This could potentially be due to the concomitant economic crisis that overlapped with the study period and thus may have partially confounded the results by having more teens use public transportation instead of driving. 5. Conclusion The 2007 GDL in Massachusetts, previously shown to be associated with a decrease in the rate of MVCs and fatal MVCs, was associated with a concomitant decrease in the rate of traffic citations without a change in the rate of licenses issued to junior operators. Such findings may suggest a cultural or behavioral improvement in driving habits for this cohort rather than a simple delay in licensing. References Bates, L. J., Allen, S., Armstrong, K., Watson, B., King, M. J., & Davey, J. (2014, Nov). Graduated driver licensing: an international review. Sultan Qaboos University Medical Journal, 14(4), e432–e441. Begg, D. J., Langley, J. D., Brookland, R. L., Ameratunga, S., & Gulliver, P. (2014, Jan). Prelicensed driving experience and car crash involvement during the learner and restricted, licence stages of graduated driver licensing: findings from the New Zealand drivers study. Accident; Analysis and Prevention, 62, 153–160. Blais, E., & Gagné, M. P. (2010, Dec). The effect on collisions with injuries of a reduction in traffic citations issued by police officers. Injury Prevention, 16(6), 393–397.
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Christopher DePesa, RN, MS, TCRN is the Trauma Nurse Coordinator at Massachusetts General Hospital. In addition to working with the Trauma Injury Prevention and Outreach Program (TIPOP), he also designs and executes projects that monitor and enhance the quality of care for trauma and emergency surgery patients. He received his education at Boston College, and prior to his current role, he worked in the emergency department as a staff nurse. Toby Raybould, MS is the Trauma Prevention and Outreach Program Manager in the Division of Trauma at Massachusetts General Hospital. In this role, she manages an internal team of clinicians to conduct child and adult injury prevention research in order to identify and disseminate best practices. She works closely with state agencies and other non-profit organizations. Toby received her B.A. from The George Washington University and her M.S. from the Harvard School of Public Health. Shelley Hurwitz, PhD is Director of Biostatistics in the Center for Clinical Investigation at Brigham and Women’s Hospital in Boston, MA. She is also a faculty member in the Department of Medicine at Harvard Medical School, a fellow of the American Statistical Association, and an elected member of the International Statistical Institute. Jarone Lee, MD, MPH is an emergency medicine and critical care physician at Massachusetts General Hospital, and also an Assistant Professor at Harvard Medical School. Alice A. Gervasini, PhD, RN, NE-C is the Nurse Director for the Division of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital, Boston, Ma. She has 30 years experience in the management of trauma and acute care surgical patients, trauma systems design, and injury prevention. In conjunction with the Medical Director, she is responsible for the overall program dynamics for both the adult and pediatric trauma programs. She received her BS in nursing from American University, a Masters Degree from University of Maryland Baltimore with a focus on trauma nursing, and a PhD in Nursing from Boston College. Research interests include clinical practice, trauma epidemiology, and injury prevention. She has published numerous articles and spoken nationally and internationally on many trauma related topics. She contributes to the ACNP curriculum and serves on the advisory board for the PhD program at Northeastern University, and is an Instructor in Surgery at Harvard Medical School. George C. Velmahos, MD, PhD, MSEd is the John F. Burke Professor of Surgery at Harvard Medical School and Chief of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital. He is the Trauma Program Leader for the Center for Integration of Medicine with Innovative Technology (CIMIT), and is the Founder of the Center for Early Trauma Research at Massachusetts General Hospital. Peter T. Masiakos, MD is a Pediatric General and Thoracic Surgeon at MGH and Associate Professor at Harvard Medical School. He was trained at the Boston City Hospital and Hospital for Sick Children (Toronto), where he developed a clinical interest in pediatric trauma care and injury prevention. He is the director of the pediatric trauma surgery service at MGH and has become a vocal injury prevention advocate. He has also been involved in successfully educating the Massachusetts legislature and the US Congress on the inherent risks that certain products pose to children and has testified both at the Massachusetts state house and at the consumer product safety commission on the need for new legislation which would prohibit the use of ATVs within specific age groups. He has aided in the development and passage of several forward thinking injury prevention laws and continues to work alongside Massachusetts State Legislators and the Congress on several other comprehensive injury prevention laws including junior operator laws, safe driving laws and child restraint laws. Haytham Kaafarani, MD, MPH is a surgeon-scientist and the Director of Patient Safety & Quality at the division of Trauma, Emergency Surgery, and Surgical Critical Care at Massachusetts General Hospital (MGH), an Assistant Professor of Surgery at Harvard University, and Associate Faculty at the Codman’s Center for Clinical Effectiveness. He did his General Surgery internship at the Brigham and Women’s Hospital, his residency at Tufts Medical Center and completed the fellowship in Trauma, Emergency Surgery and Surgical Critical Care at MGH. During his residency, he pursued a Masters in Health Policy and Management at Harvard University and a Health Services Research Fellowship at the VA Boston Healthcare System and the Center for Health Quality, Outcomes and Economic Research (CHQOER). His research focuses on improving surgical outcomes, injury prevention, patient safety, and quality benchmarking of surgical care using advanced health services methodologies.