Use of Clinical Practice Guidelines and Quality Metrics to Assess Primary Care Management of Osteoporosis.

Background: Clinical practice guidelines and quality measures provide recommendations for physicians addressing osteoporosis management. This study explored the alignment of osteoporosis clinical practice in a primary care geriatric clinic with recommended guidelines. Methods: This retrospective chart review included 388 patients 65 or older from a primary care geriatric clinic diagnosed with osteopenia or osteoporosis, with or without a fragility fracture. Data included history of falls and use of DXA scans, FRAX® fracture risk assessment tool, osteoporosis medication, and fall risk mitigation plans. Results: For age-related primary fracture prevention, 68% of women and 87% of men had documented DXA scans, and 45% of patients diagnosed with osteoporosis and 42% determined at high risk were prescribed osteoporosis medication. For secondary fracture prevention, 72% of women aged 67 to 85 had DXA scans and 21% were prescribed osteoporosis medication. Only 10% of patients with a history of falls had documented fall risk management plans. Conclusion: Although showing higher rates of primary and secondary prevention outcomes than did research results from general primary care, gaps were identified for high fracture risk patients and fall risk management documentation. Medical record review may not provide sufficient data to capture factors influencing decision-making for fracture prevention.

Quality improvement for age-friendly care: An experiential model for instructing medical students in system-based practice.

Early learning experiences in quality improvement (QI) can prepare medical students for practice in complex health systems and can improve processes of care for various groups, including older adult patients with multiple chronic conditions. We applied the Institute for Healthcare Improvement (IHI) Age-Friendly Health Systems 4Ms framework to a twelve-week geriatrics-focused QI project for third-year medical students training in rural medicine. Students (N = 40) conducted their projects at primary care practice sites and focused on the identified needs of older adult patients within the 4Ms framework areas of Mobility, Mentation, Medication, and What Matters. Students completed evaluation surveys to rate the usefulness of training and to self-assess knowledge and skills using five-point Likert-type items. Students (n = 23) reported increased knowledge and skills in conducting QI activities and improved understanding of the importance of improving processes and patient care. Such projects for QI training can support competency development in systems-based practice while also implementing practice frameworks for improving processes and patient care, such as the use of Age-Friendly practices and resources within a health care setting.

A Collaborative Implementation Strategy to Increase Falls Prevention Training Using the Age-Friendly Health Systems Approach.

Falls in the home and in community environments are the leading cause of injuries and long-term disabilities for the aging population. The purpose of this study was to examine outcomes of a partnership among an academic institution, government agency, community organizations, and emergency management services to implement a falls prevention training program using an Age-Friendly Health Systems approach. In this prospective study, partners identified gaps in services and targeted and non-targeted delivery areas for implementation of an evidence-based falls prevention intervention addressing the 4Ms of Age-Friendly Health Systems-Mobility, Medications, Mentation, and What Matters. Descriptive statistics were calculated for program implementation and participant demographic variables, and paired t-test analysis compared scores for self-assessed general health and falls efficacy prior to and after program participation. Twenty-seven falls prevention classes were implemented, with over half (52%) in targeted areas. A total of 354 adults aged 50 and older participated, with N = 188 participants (53%) completing the program by attending at least five of eight sessions. Of completers, 35% resided in targeted areas. The results showed a statistically significant improvement in falls efficacy by program completers in targeted and non-targeted areas. However, there was no statistically significant difference in self-rated health. Overall, the findings of this study indicate that collaboration to deliver falls prevention training can be effective in reaching at-risk older adults. By mobilizing collaborative partnerships, limited resources can be allocated towards identifying at-risk older adults and improving community-based falls prevention education.

Effects of Routine Checkups and Chronic Conditions on Middle-Aged Patients with Diabetes.

Purpose. Middle-aged males and females with diabetes are more likely to have poor physical (PH) and mental health (MH); however, there is limited research determining the relationship between MH and PH and routine check-up in diabetic middle-aged adults, especially by gender. The purpose of this study was to determine whether PH and MH status differ by routine check-up in middle-aged (age 45-64) adults with diabetes in the general population. Methods. This cross-sectional analysis used data from the 2017 BRFSS conducted by the CDC for adults aged 45-64 who reported having diabetes in Florida (N = 1183), Kentucky (N = 617), Maryland (N = 731), New York (N = 593), and Ohio (N = 754). Multiple logistic regression by state and gender was used to determine the relationship between MH and PH status and routine check-up while controlling for health-related, socioeconomic, and demographic factors. Results. Across states, up to one-half reported good PH (32-50%), over one-half reported good MH (46-67%), and most reported having a routine check-up (87-93%). Adjusted analysis indicated that MH and PH were not significantly related to routine check-up, but both were inversely related to having diabetes plus two other health conditions. Conclusions. Overall, routine check-up was not related to good PH and MH in this target population; however, a number of health conditions were inversely related to good PH and MH status. In a primary care setting for this target population, there may be a low to moderate prevalence of good PH and MH and a high prevalence of having a routine check-up and having multiple health conditions. It is recommended to automatically screen this target population for PH, MH, other chronic conditions, and physical activity and treat concurrently.

Do physical activity levels differ by number of children at home in women aged 25-44 in the general population?

OBJECTIVES: While physical activity is important for health, many women do not meet recommended levels, particularly mothers. The purpose of this study was to assess whether physical activity levels differ by number of children at home in women aged 25-44 in the general US population. METHODS: This cross-sectional analysis used 2017 Behavioral Risk Factor Surveillance System data for females aged 25-44 (N = 6266) from California, Colorado, New York, Texas, and Utah. Ordered logistic regression analysis assessed the relationship between physical activity levels and number of children at home while controlling for state and demographic, socioeconomic, and health-related factors. RESULTS: About half of participants reported "inactive" or "insufficiently active" physical activity levels and about two-thirds reported having one or more children at home. The results of adjusted analysis indicated that physical activity level was significantly related to having one child (adjusted odds ratio = 0.75, 95% confidence interval = 0.63, 0.89), two children (adjusted odds ratio = 0.79; 95% confidence interval = 0.67, 0.93), and three or more children (adjusted odds ratio = 0.80, 95% confidence interval = 0.67, 0.94) at home. CONCLUSION: Overall, physical activity levels were significantly related to presence of children at home for women aged 25-44, but increasing number of children at home did not impact effect size. For women aged 25-44 in a primary care setting, a moderate prevalence of inactive or insufficiently active physical activity may be expected. Providers should address physical activity with all patients in this target population during well-visits, but particularly for women with children at home; educate patients about the health benefits of regular physical activity; and provide resources that will help them integrate physical activity into their daily lifestyles.

Daily fruit and vegetable consumption and diabetes status in middle-aged females in the general US population.

OBJECTIVES: Fruit and vegetable consumption may impact development of diabetes, but limited research has addressed whether daily consumption of fruits and vegetables differs by those with and without diabetes, especially within high-risk groups. Thus, the purpose of this study was to determine whether daily fruit and vegetable consumption differs by diabetes status in middle-aged females in the general US population. METHODS: This cross-sectional analysis used 2017 Behavioral Risk Factor Surveillance System data for females ages 45-64 years old in Arizona (n = 2609), Florida (n = 3768), Georgia (n = 1018), and Texas (n = 2092). Multiple logistic regression analysis by state assessed the relationship between the daily consumption of fruit (fruit, 100% fruit juice) and vegetables (green leafy or lettuce salad, potatoes, other vegetables) and diabetes status, while controlling for health status, health behaviors, demographic factors, and socioeconomic status. RESULTS: Across states, relatively similar proportions of participants with and without diabetes reported daily fruit consumption (with: 58%-63%; without: 61%-68%) and daily vegetable consumption (with: 58%-63%; without: 61%-68%). The results of adjusted analyses indicated that daily fruit and vegetable consumption did not differ by diabetes status across states. CONCLUSION: Across states, daily fruit and vegetable consumption did not differ by diabetes status in middle-aged females. In the primary care setting, providers should educate all females ages 45-64 on the importance of eating fresh fruits and vegetables and may consider sharing information about flavonoid-rich fruit and vegetable consumption for diabetes.

Does Current General Mental Health Status Relate to Current Smoking Status in Pregnant Women?

PURPOSE: Research shows that smoking during pregnancy is related to mental health diagnoses. The purpose of this study was to assess whether current general mental health status is related to current smoking status in pregnant women after controlling for other factors related to both mental health and tobacco use during pregnancy. METHODS: This cross-sectional analysis used 2017 Behavioral Risk Factor Surveillance Survey (BRFSS) data for 621 pregnant women aged 18-38 from Florida (N=136), Kansas (N=116), Minnesota (N=105), Nebraska (N=90), New York (N=78), and Utah (N=96). Multiple logistic regression analysis was used to assess the relationship between current mental health status and current tobacco use, while controlling for state, depression diagnosis, routine checkup, healthcare plan, age, marital status, ethnicity/race, education level, income level, and employment status. RESULTS: Overall, very few participants reported current smoking (6%) and about one-third reported low or moderate mental health status in the past 30 days. Adjusted results indicated that those who reported high mental health status were about 3 times less likely (OR=0.29, 95% CI=0.09, 0.88) to report current smoking status compared to those who reported low mental health status. CONCLUSIONS: Overall, current mental health status was highly related to current smoking status in pregnant women. Clinicians in obstetrics may expect a very low proportion of pregnant women to report smoking and up to one-third to report low or moderate current general mental health status. Given that current mental health issues and current tobacco use may harm both mother and child, be highly related in pregnant women, and change throughout the pregnancy, pregnant women should be screened automatically for both at each visit.

Does Mental Health Differ by Alcohol Use in Elderly Male Veterans?

Introduction: With limited research for mental health and alcohol use among veterans in the general population and none for elderly male veterans only, the purpose is to assess whether mental health differs by alcohol use in elderly male veterans in the general population. Method: This cross-sectional analysis uses 2017 Behavioral Risk Factor Surveillance System data for male veterans aged 65 and older in general population samples from Florida (n = 1,700), Maryland (n = 1,060), New York (n = 552), and Washington (n = 1,031). Multiple logistic regression by state assessed the relationship between mental health and alcohol use, after controlling for health-related, demographic, and socioeconomic factors. Results: Across states, most participants reported good mental health (80%-84%) and more than half reported drinking (53%-63%). Adjusted results indicated that mental health did not differ by alcohol use in any state; however, it was related to physical health and activity limitations across states. Conclusion: Overall, alcohol use was not related to mental health in elderly male veterans in the general population; however, physical health status and activity limitations were. Practitioners should always screen for alcohol use and should automatically screen for mental health, physical health, and activity limitations when symptoms present for any and assess concurrent treatment and management strategies.

Temperature as a Causative Factor in Diabetic Foot Ulcers: A Call to Revisit Ulceration Pathomechanics.

BACKGROUND: Diabetic foot ulcers (DFUs) are a major burden to patients and to the health-care systems of many countries. To prevent or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development. METHODS: Thirty-seven individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 nonneuropathic control participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperatures were determined in four anatomical regions-hallux and medial, central, and lateral forefoot-and separate linear models with specified contrasts among the DFU, DN, and DC groups were set to reveal mean differences for each foot region while controlling for group characteristics. RESULTS: The mean temperature reading in each foot region was higher than 30.0°C in the DFU and DN groups and lower than 30.0°C in the DC group. Mean differences were greatest between the DFU and DC groups, ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux. CONCLUSIONS: Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in patients with previous ulcers, may easily reach hazard thresholds indicated by previous pressure ulcer studies. The results necessitate further exploration of temperature in the diabetic foot and how it may contribute to ulceration.

Hearing Loss Contributes to Balance Difficulties in both Younger and Older Adults.

OBJECTIVE: The number of steps required to regain balance is an easily obtainable clinical outcome measure. This study assessed whether number of steps during loss of balance could identify older adults with hearing loss who have balance deficits. We aimed to answer two questions: 1) Does hearing loss negatively affect the ability to regain balance, as reflected by an increased number of steps needed to respond to a perturbation while simultaneously attending to speech-in-noise; and 2) Do hearing aids improve balance control, reflected by a decrease in number of steps needed to regain balance? METHODS: 20 young adults and 20 older adults with normal hearing, and 19 older adults with hearing loss performed an auditory-balance dual-task. Participants were asked to listen and repeat back sentences from a standardized audiology test, while simultaneously responding to backward surface translations. Outcome measures were performed on the auditory test and number of steps needed to regain balance. Repeated measures ANCOVA models were run in using group, time, hearing levels, and perturbation levels as predictors. RESULTS: Auditory scores confirmed difficulty hearing speech-in-noise in older adults with hearing loss and no hearing aids, and in young and older adults with normal hearing and simulated hearing loss. Results showed that group, auditory and balance conditions are significantly related to both outcomes measures and time is not significant for steps. Older adults with hearing loss had a significant increase in number of steps needed to regain balance compared to young adults and older adults with normal hearing. CONCLUSION: Number of steps may be an appropriate clinical assessment tool for identifying fall risk in older adults with hearing loss. Further research needs to be performed to identify proper assessments and treatment interventions for older adults with hearing loss who have balance deficits.

Service-Learning Enhances Physical Therapy Students' Ability to Examine Fall Risk in Older Adults.

Service-learning (SL) is one educational methodology that provides students opportunities to practice and refine affective, cognitive and psychomotor skills in a community-based setting. PURPOSE: The aims of this study were: 1) to investigate the impact of SL on physical therapy (PT) students' attitudes and perceived clinical competence when working with older adults, and 2) to evaluate the difference between perceptions of students who developed and implemented the SL activity vs those who implemented only. METHODS: Eighty PT students, (from two consecutive cohorts) enrolled in a first-year geriatrics course, participated in this study. The first cohort designed and implemented the SL activities, while the second cohort only implemented these activities. Student self-perceived anxiety, confidence, knowledge and skills were assessed by pre- and post-SL surveys using a 5- point Likert-like scale. RESULTS: Both cohorts reported similar anxiety and confidence levels pre-SL. For both cohorts, with the exception of one item, all responses to anxiety items significantly decreased from pre- to post-SL. All students' confidence levels for assessing and mitigating fall risk in older adults increased post-SL (p<0.01). Moreover, students in cohort 1, who designed and delivered SL activities, expressed self-perceived improvement in their ability to interpret results of evaluations, to determine type and severity of balance impairments, and to serve a geriatric population (p<0.05) compared to students in cohort 2 who only implemented the activities. CONCLUSION: Embedding SL into a geriatrics course decreased self-perceived anxiety and improved student confidence regarding working with older adults. Also, empowering students to be actively involved in the design and implementation of SL increased self-perceived ability in interpreting results from assessments.

Relationships Among Chewing Tobacco, Cigarette Smoking, and Chronic Health Conditions in Males 18-44 Years of Age.

As more public places are designated "non-smoking," chewing tobacco could be an alternative choice for tobacco use; however, controversy exists over the long-term health effects associated with it. This study assessed the relationship between chewing tobacco, cigarette smoking, and chronic health conditions in a representative sample of males 18-44 years of age, while controlling for other variables known to be related to tobacco use. This cross sectional analysis used 2013 data from the Behavioral Risk Factor Surveillance System (BRFSS). The results indicated that about 41% of males reported one or more chronic health conditions, and that about 15% used chewing tobacco only, 21% smoked cigarettes only, and 6% did both. From adjusted analyses, those who chewed tobacco only were 49% more likely to report one or more health conditions; those who smoked cigarettes only were 34% more likely to report one or more health conditions; and those who did both were 95% more likely to report at least one health condition. Overall, any combination of tobacco use was significantly and similarly related to the increased prevalence of chronic health conditions in males aged 18-44 years. Although chewing tobacco use may not be as prevalent in the general population as cigarette smoking, clinicians should be aware of the similar health risks associated with all tobacco use at ages younger than may be expected, and encourage cessation of any tobacco use.

Sleep and Mental Health in the General Population of Elderly Women.

Sleep and mental health complaints are prevalent in the elderly and share common risk factors. We assessed the relationship between sleep and mental health in three representative samples of elderly women while controlling for multiple risk factors common to both. We performed this cross sectional secondary data analysis in 2015 using 2013 data from the Behavioral Risk Factor Surveillance System (BRFSS) for females ages 65 years and older from California (N = 1912), Florida (N = 9120), and Pennsylvania (N = 2429). We conducted multiple logistic regression analysis to assess the relationship between sleep duration group (short, moderate/reference, or long) and mental health issues in the past 30 days (yes or no) in elderly females, while controlling for multiple covariates. About 25% of the elderly females reported mental health issues and 20% reported short or long sleep durations. In adjusted analysis, compared to the elderly females in the moderate sleep duration group (averaging 6-8 h of sleep per day), those in the short and long sleep duration groups had increased prevalence of mental health issues by 66% and 26%, respectively. Mental health was also related to physical health issues including general health status, activity limitations, and chronic health conditions. Overall, sleep was related to mental health in representative samples of elderly females even after controlling for risk factors common to both. Even though we could not determine the direction of influence, the findings indicate a need for clinicians to screen their elderly female patients for both sleep and mental health issues, especially in those with physical health comorbidities.

Parent attitudes toward integrating parent involvement into teenage driver education courses.

OBJECTIVE: The widespread adoption of graduated driver licensing (GDL) policies has effectively reduced crash risk for young drivers; however, parents must support, reinforce, and enforce GDL for it to be effective, and research indicates that parents need better information and instruction for adhering to GDL requirements, conducting supervised practice driving, and restricting independent teenage driving. Because teenagers in most states must take driver education to enter the licensing process prior to age 18, integrating parent involvement into driver education may be an effective way to inform and instruct parents on a large scale about teen driver safety. This study assessed parent attitudes (overall and by rural status, minority status, and income level) toward integrating parent involvement into teenage driver education classes. METHODS: In this study, 321 parents of teenagers enrolled in driver education classes across the state of Montana completed surveys about current involvement in driver education and attitudes toward required involvement. RESULTS: The results indicated that parents were not very involved currently in their teenagers' driver education classes, but 76% reported that parents should be required to be involved. If involvement were required, parents would prefer having written materials sent home, access to information over the Internet, or discussions in person with the instructor; far fewer would prefer to attend classes or behind-the-wheel driving instruction. There were few differences in parent attitudes by rural or minority status but many by income level. Compared to higher income parents, lower income parents were more likely to endorse required parent involvement in teenage driver education classes and to want parent information from driver education about many teen driving issues. CONCLUSIONS: That the majority of parents are open to required involvement in their teenagers' driver education classes is promising because doing so could better prepare parents to understand and adhere to GDL policies, supervise teenagers' practice driving, and manage teen independent driving, all of which could further increase teen driver safety.

Perceived risk and other predictors and correlates of teenagers' safety belt use during the first year of licensure.

OBJECTIVES: Teenagers have the lowest rate of safety belt use and the highest crash rate compared to other age groups. Past studies on teenagers' belt use have mostly been cross-sectional. The first goals of this study were to examine, at licensure, teenagers' and parents' perceptions of risk of crash/injury for newly licensed teenagers when driving unbelted and teenagers' perceived and parents' intended consequences for safety belt rule violations. In addition, the comparability of these variables to other risky driving behaviors was explored. The second goal was to evaluate the importance of these variables in the prediction of teenagers' belt use during the first year of licensure, relative to other factors related to belt use, including demographics and substance use. METHODS: More than 2,000 parent-teenager dyads were interviewed by telephone, parents at permit and licensure and teenagers at permit, licensure, and 3, 6, and 12 months after licensure. RESULTS: Approximately a third of the teenagers reported at least once at 3, 6, or 12 months post-licensure not always using their safety belt in the past week. At licensure, participants' perceived risk of safety belt non-use was high and ranked among the behaviors most related to crash/injury for newly licensed teenagers, behind driving under the influence of alcohol or drugs. Parent-imposed consequences for safety belt rule violations were not as highly rated as parent-imposed consequences for driving under the influence of alcohol or drugs. Sequential logistic regression modeled the relationship between safety belt use and perceived risk and consequences of non-use, as well as other prospective predictors assessed at permit and licensure, and driving correlates measured after licensure. Teenagers' extreme perceived risk and parents' intended sure consequences for non-use were significant prospective predictors of regular use during the first year of licensure. Other significant predictors and correlates were race (White), high school grade average of "A," not smoking cigarettes, driving a passenger vehicle, and never receiving a traffic citation or engaging in risky driving behaviors, including driving under the influence of alcohol or drugs and running a red light. CONCLUSIONS: While the effect size was small for perceived risk of non-use, it is a modifiable factor and focused intervention contrived to enhance perceived risk could increase teenagers' belt use. Perceived risk is discussed as a target for intervention in relation to the Protection Motivation Theory. This theory appears helpful in guiding future research into the modifiable factors studied here as well as other factors, including perceived rewards and costs associated with non-use.

Do recommended driving limits affect teen-reported traffic violations and crashes during the first 12 months of independent driving?

OBJECTIVES: Motor vehicle crashes are highly elevated among newly licensed teenage drivers. Limits on high-risk driving conditions by driver licensing policies and parents can protect novice teens from negative driving outcomes, while they experience and driving proficiency. The purpose of this research was to evaluate the effects of strict parent-imposed driving limits on driving outcomes during the first year of licensure. METHODS: A sample of 3,743 Connecticut teens was recruited and randomized to the Checkpoints Program or comparison condition. Assessments conducted at baseline, licensure, 3-, 6-, and 12-months postlicensure included parent-imposed driving limits, traffic violations, and crashes. Bivariate and multivariate analyses were conducted to assess the effects of strict parent limits on traffic violations and crashes during the first year of licensure. RESULTS: Thirty percent of teens reported at least one traffic violation and 40% reported at least one crash. More strict parent-imposed limits at licensure, 3-, 6-, and 12-months postlicensure, were associated with fewer violations and crashes in multivariate analyses. Notably, adherence to recommended night curfew was consistently associated with fewer violations and crashes. CONCLUSIONS: The findings indicate that strict parent-imposed limits may protect novice teen drivers from negative driving outcomes.

Relation of parent-teen agreement on restrictions to teen risky driving over 9 months.

OBJECTIVES: To determine the relations among parent-teen discordance for restrictions on driving conditions, driving rules, and consequences for rule violations at licensure and subsequent risky teen driving. METHODS: Parents and teens completed telephone interviews at 1, 4, and 9 months after teens became licensed. RESULTS: At each time interval, the degree of disagreement with parent restrictions on driving conditions was positively associated with teen risky driving. CONCLUSIONS: These results demonstrate a positive association between parent-teen discordance for driving conditions and teen risky driving. Initial establishment of restrictions and agreement with them may have longer term protective effects against teen driving risk.

Parents' views of teen driving risks, the role of parents, and how they plan to manage the risks.

PROBLEM: There is limited information about how parents view teen driving risks and intend to handle these risks during the licensing process, and how they will respond to graduated licensing provisions. METHODS: Parents in Connecticut were interviewed when their teens got their learner's permit. The survey was undertaken when the state did not have a midnight restriction or a passenger restriction. RESULTS: Generally, parents were well aware of teen driving risks, thought parents should be thoroughly involved in the licensing process, and plan to be active participants themselves. DISCUSSION: Parents were concerned about the risk of driving after midnight and already restrict that behavior. However, parents do not seem to see or understand the risks of having even one teen passenger in the vehicle. IMPACT ON INDUSTRY: The views and existing practices of parents need to be taken into account in deciding on the provisions of graduated licensing legislation and how to best ensure acceptance and compliance.

The effect on teen driving outcomes of the Checkpoints Program in a state-wide trial.

Crash rates among teenagers are highly elevated during the first months of licensure. Parent-imposed driving restrictions on initial driving privileges can reduce exposure to high-risk driving conditions, thus reducing crash risk while teens' driving proficiency develops. This report describes the effect of the Checkpoints Program on driving limits and outcomes. Connecticut teens who obtained a learners permit over a 9-month period were recruited, providing a final sample of 3743 who obtained driver licenses. Families were randomized to the intervention or comparison condition. Intervention families received by mail a series of persuasive communications related to high-risk teen driving and a parent-teen driving agreement, while comparison families received on the same schedule general information on driving and vehicle maintenance. Relative to the comparison group, teens and parents in the Checkpoints Program reported significantly greater limits on high-risk teen driving conditions at licensure, 3-, and 6-months post-licensure; and intervention teens reported significantly less risky driving at each reporting period. By the 12-month follow up teens in the intervention group were significantly less likely than those in the comparison group to have had a traffic violation. However, no treatment group effect was found for crashes. This is the first study to report significant effects on teen driving behavior and performance of education designed to increase parental-imposed teen driving limits.