U.S. Preventive Services Task Force

Counseling About Proper Use of Motor Vehicle Occupant Restraints and Avoidance of Alcohol Use While Driving: Recommendation Statement



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This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on counseling about the proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving. It also summarizes the supporting scientific evidence, and updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, 2nd ed.1  See Table 1 for a description of the USPSTF grades and Table 2 for a description of USPSTF classification of levels of certainty regarding net benefit. The complete information on which this statement is based, including evidence tables and references, is included in the brief evidence synthesis2 on this topic, available on the USPSTF Web site at http://www.uspreventiveservicestaskforce.org. The recommendation is also posted on the Web site of the National Guideline Clearinghouse at http://www.guideline.gov.

Table 1

What the USPSTF Grades Mean and Suggestions for Practice

Grade Grade definition Suggestions for practice

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer/provide this service.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer/provide this service.

C

The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small.

Offer/provide this service only if there are other considerations in support of offering/ providing the service in anindividual patient.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I

The USPSTF concludes that the current evidence is Insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined.

Read “Clinical Considerations” section of USPSTF Recommendation Statement. If offered, patients should understand the uncertainty about the balance of benefits and harms.


USPSTF = U.S. Preventive Services Task Force.

Table 1   What the USPSTF Grades Mean and Suggestions for Practice

View Table

Table 1

What the USPSTF Grades Mean and Suggestions for Practice

Grade Grade definition Suggestions for practice

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer/provide this service.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer/provide this service.

C

The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small.

Offer/provide this service only if there are other considerations in support of offering/ providing the service in anindividual patient.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I

The USPSTF concludes that the current evidence is Insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality or conflicting, and the balance of benefits and harms cannot be determined.

Read “Clinical Considerations” section of USPSTF Recommendation Statement. If offered, patients should understand the uncertainty about the balance of benefits and harms.


USPSTF = U.S. Preventive Services Task Force.

Table 2

USPSTF Levels of Certainty Regarding Net Benefit

Level of Certainty Description

High

The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Moderate

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:

  • the number, size, or quality of individual studies

  • inconsistency of findings across individual studies

  • limited generalizability of findings to routine primary care practice

  • lack of coherence in the chain of evidence

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low

The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:

  • the limited number or size of studies

  • important flaws in study design or methods

  • inconsistency of findings across individual studies

  • gaps in the chain of evidence

  • findings not generalizable to routine primary care practice

  • a lack of information on important health outcomes

More information may allow an estimation of effects on health outcomes.


note: The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

USPSTF = U.S. Preventive Services Task Force.

Table 2   USPSTF Levels of Certainty Regarding Net Benefit

View Table

Table 2

USPSTF Levels of Certainty Regarding Net Benefit

Level of Certainty Description

High

The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Moderate

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by factors such as:

  • the number, size, or quality of individual studies

  • inconsistency of findings across individual studies

  • limited generalizability of findings to routine primary care practice

  • lack of coherence in the chain of evidence

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low

The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of:

  • the limited number or size of studies

  • important flaws in study design or methods

  • inconsistency of findings across individual studies

  • gaps in the chain of evidence

  • findings not generalizable to routine primary care practice

  • a lack of information on important health outcomes

More information may allow an estimation of effects on health outcomes.


note: The USPSTF defines certainty as “likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.” The net benefit is defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level based on the nature of the overall evidence available to assess the net benefit of a preventive service.

USPSTF = U.S. Preventive Services Task Force.

The USPSTF makes recommendations about preventive care services for patients without recognized signs or symptoms of the target condition. It bases its recommendations on a systematic review of the evidence of the benefits and harms and an assessment of the net benefit of the service.

The USPSTF recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. Physicians and policy makers should understand the evidence, but individualize decision making to the specific patient or situation.

Introduction

Over the past decade, legislation and enforcement have contributed substantially to the increasing trends in the use of child safety seats and safety belts. This high prevalence of their use in the United States is considered a public health success. The 1996 USPSTF recommendation addressed primary care interventions to increase the use of these restraints. This current recommendation focuses on the independent role of primary care interventions to increase the proper use of child safety seats, booster seats, and lap-and-shoulder belts (i.e., safety belts that include straps across both the lap and shoulder) to prevent motor vehicle occupant injuries. This recommendation also addresses the effectiveness of primary care counseling to prevent alcohol-related motor vehicle occupant injuries in adolescents and adults.

Summary of Recommendations and Evidence

Recommendation 1: Counseling About Proper Use of Motor Vehicle Occupant Restraints to Prevent Motor Vehicle Occupant Injuries

The USPSTF concludes that the current evidence is insufficient to assess the incremental benefit, beyond the effectiveness of legislation and community-based interventions, of counseling in the primary care setting in improving rates of proper use of motor vehicle occupant restraints (i.e., child safety seats, booster seats, and lap-and-shoulder belts). (See the Clinical Considerations section for definitions of proper use.) I statement.

Rationale

Importance. Motor vehicle occupant injury is the single leading cause of death in U.S. children, adolescents, and young adults three to 33 years of age, and of unintentional injury-related deaths for persons of all ages. Proper use of motor vehicle occupant restraints (i.e., child safety seats, booster seats, and lap-and-shoulder belts) is associated with a 45 to 70 percent reduction of fatality risk. Improper use reduces the efficacy of restraints substantially.

Recognition of Behavior. Approximately 80 percent of adults use seat belts. General use of child safety seats is 90 percent, and booster seat use is rapidly increasing. However, proper use of child safety seats and booster seats in infants and children is low

Effectiveness of Counseling to Change Behavior. Legislation and community-based interventions along with counseling in primary care settings have dramatically increased the use of motor vehicle occupant restraints and have reduced the incidence of motor vehicle occupant injuries in all populations. However, the incremental benefit of primary care counseling for general restraint use in the context of legislation and community interventions is unknown. There is insufficient evidence addressing the effectiveness of counseling in the primary care setting to increase the proper use of motor vehicle occupant restraints in the current high-use environment. This constitutes a critical gap in the evidence for counseling.

Harms of Counseling. There is no evidence addressing the harms of counseling. However, these potential harms are estimated to be none or minimal in magnitude.

USPSTF Assessment. The USPSTF concludes that current evidence is insufficient to assess the net benefit of counseling interventions in primary care settings to increase the proper use of motor vehicle occupant restraints to reduce motor vehicle occupant injuries in children, adolescents, and adults.

Recommendation 2: Counseling to Prevent Alcohol-Related Motor Vehicle Occupant Injuries in Adolescents and Adults

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine counseling of all patients in the primary care setting to reduce driving under the influence of alcohol or riding with drivers who are alcohol impaired. I statement.

Rationale

Importance. Alcohol use is involved in nearly 40 percent of all traffic-related fatalities.

Effectiveness of Counseling to Change Behavior. There is evidence that screening for misuse of alcohol and targeted counseling of persons who screen positive reduces alcohol consumption and alcohol-related motor vehicle injuries. However, there is a critical gap in the evidence of the effectiveness of behavioral counseling interventions directed to all patients in the primary care setting to reduce driving under the influence of alcohol or riding with drivers who are alcohol impaired.

Harms of Counseling. There is no evidence addressing the harms of counseling to prevent alcohol-related motor vehicle occupant injuries. However, these potential harms are estimated to be none or minimal in magnitude.

USPSTF Assessment. The USPSTF concludes that the evidence is insufficient to assess the net benefit of universal counseling in the primary care setting (in the absence of screening and targeted counseling) to reduce the incidence of alcohol-related motor vehicle occupant injuries.

Clinical Considerations

  • Patient Population. This recommendation refers to behavioral counseling interventions performed in the primary care setting addressing parents of all infants and children; and children, adolescents, and adults.

  • Elements of Effective Counseling Interventions. The injury prevention benefits of child safety seat and booster seat use require proper use (i.e., the seats should be age- and weight-appropriate and should be installed and placed into the vehicle correctly). Infants younger than one year who weigh less than 20 lb (9.0 kg) should be placed in rear-facing, infant-only car safety seats or convertible seats positioned in the back seat. Infants younger than one year who weigh between 20 and 35 lb (16.0 kg) should be placed in rear-facing convertible seats positioned in the back seat. Rear-facing child safety seats must not be placed in the front passenger seat of any vehicle equipped with an airbag on the front passenger side. Death or serious injury can result from the impact of the airbag against the child safety seat. Toddlers one to four years of age who weigh 20 to 40 lb (18.0 kg) should be restrained in a forward-facing convertible seat or forward-facing-only seat positioned in the back seat. Young children four to eight years of age and up to 4 ft 9 in (57 in; 1.45 m) should be placed in a booster seat in the back seat. After this age (or height), lap-and-shoulder belt use is appropriate. Children younger than 13 years should sit in the back seat with lap-and-shoulder belts.

Behavioral counseling interventions that include an educational component as well as a demonstration of use or a distribution component are more effective than those that include education alone.

  • Other Approaches to Prevention. Clinical counseling in conjunction with community-based interventions has been effective in increasing proper use of child safety seats. Over the past decade, legislation and enforcement have contributed substantially to the increasing trends in child safety seat and seat belt use. A comprehensive strategy that includes community-based interventions, counseling in the primary care setting, legislation, and enforcement is critical to the improvement of proper safety restraint usage and decrease in the incidence of motor vehicle occupant injuries.

  • Other Relevant USPSTF Recommendations. The USPSTF currently recommends screening for alcohol misuse and counseling targeted to those patients identified as risky or harmful drinkers.3

Other Considerations

Implementation. There is good evidence that community and public health interventions, including legislation, law enforcement campaigns, car seat distribution campaigns, news media campaigns, and other community-based interventions, are effective in improving the proper use of car seats, booster seats, and seat belts.

Links between primary care and community interventions are critical for improving proper car seat, booster seat, and seat belt use.

Research Needs. On the basis of the effectiveness of legislation and community-based interventions in increasing car safety seat and seat belt use, increasing booster seat use probably will require similar interventions. Randomized controlled trials of counseling interventions are needed to clarify the effectiveness of counseling parents and children in the primary care setting to improve proper use of child safety and booster seats.

The U.S. Preventive Services Task Force recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

The Discussion and Recommendations of Others sections are available in the full recommendation statement on the USPSTF Web site at http://www.ahrq.gov/clinic/uspstf07/mvoi/mvoirs.htm.

This recommendation statement was first published in Ann Intern Med. 2007;147(3):187–193.

 

REFERENCES

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Washington, DC: U.S. Dept. of Health and Human Services, Office of Public Health and Science, Office of Disease Prevention and Health Promotion, 1996.

2. Williams S, Whitlock E, Smith P, Edgerton B, Beil T. Primary Care Interventions to Prevent Motor Vehicle Occupant Injuries. Evidence synthesis no. 51. Rockville, Md.: Agency for Healthcare Research and Quality. http://www.ahrq.gov/clinic/uspstf07/mvoi/mvoisyn.pdf. Accessed June 2, 2008.

3. U. S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140(7):554–556.

This summary is one in a series excerpted from the Recommendation Statements released by the U.S. Preventive Services Task Force (USPSTF). These statements address preventive health services for use in primary care clinical settings, including screening tests, counseling, and preventive medications. The practice recommendations in this activity are available at http://www.ahrq.gov/clinic/uspstf07/mvoi/mvoirs.htm.

The series coordinator for AFP is Uma Jayaraman, MD, Georgetown University Department of Family Medicine, Washington, D.C.



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