May I see your license, please? Exclusive license rankles genome researchers.
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Automation↗
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Local licensing, facility licensing, and practitioners from other states.
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Animals↗
The evolution and effectiveness of graduated licensing.
This paper traces the history of graduated licensing, starting about the point in time when Pat Waller's paper on the genesis of the concept ends, and examines the extent to which graduated licensing has produced reductions in collisions. It concludes with some general observations about future research needs, anticipating several of the papers that follow. The evolution of graduated licensing is chronicled, beginning with the early and largely unsuccessful efforts to introduce it in the United States in the late 1970s, through the pioneering efforts in New Zealand, which resulted in the first truly graduated system in 1987, to Canada where the program was introduced 7 years later, to the United States where it has flourished in more recent years. This 25-year history lesson hopefully creates an appreciation for the somewhat torturous journey that graduated licensing has experienced in achieving acceptance among the public and policy-makers-a journey that is not yet over, as subsequent papers in the symposium will show. The proliferation of graduated licensing in recent years is a mixed blessing-the wider adoption of graduated licensing has been a very positive development, but the programs that have evolved are anything but homogeneous in structure or content. Although this is often necessary for various reasons, it is worrisome that some programs are graduated licensing in name only. This suggests that future efforts to promote graduated licensing must emphasize adherence to the fundamental risk reduction and multistage principles on which the concept is based. The paper also considers the extent to which graduated licensing achieves its objective of reducing collisions among those covered by the program. Understandably, most jurisdictions would not introduce graduated licensing until it was shown to be effective and this, to some extent, slowed the process of implementation. The obvious irony is that it could not be shown to be effective until it was introduced. Fortunately, as history demonstrates, some jurisdictions were prepared to try the system based on its very sound empirical rationale. And, their confidence has been rewarded. A growing body of research, which shows that graduated licensing has been associated with significant and substantial reductions in collisions, is briefly described. The paper concludes with some general observations designed to anticipate the papers that follow. First, it outlines questions that still remain unanswered about graduated licensing-why or how it works, with whom it works, and what features are most effective. Precise and unambiguous answers to these questions are essential for the design of a system that maximizes the potential for reducing collisions, injuries, and deaths. Second, it signals a note of caution on the limits of graduated licensing-it is important to recognize just how effective and beneficial this program is; it is equally important to recognize that it is not the sole panacea for the problem of collisions involving new drivers.
Accidents, Traffic↗
Medical licensing requirements.
While there are differences among the licensing jurisdictions in regard to the details of licensing, in general boards require applicants to have graduated from an acceptable school, to have completed a period of residency training in the United States or Canada, and to pass an acceptable licensing examination. Applicants for licensure should seek information about the detailed requirements for licensure from the licensing board where they want to be licensed. Medical graduates who are being licensed through FLEX should keep in mind that later applications for licensure by endorsement will depend on fulfilling acceptable licensing requirements in connection with initial licensure. Thus, graduates should be informed in general of licensing requirements at the time of initial licensure. The annual AMA licensing publication, cited previously, is a good source of information of this kind. Boards are increasing the length of graduate medical education required for licensure at present; they are also adding to the requirements for endorsement of licenses, for instance, setting limits to the number of years a licensing examination will be accepted for licensure endorsement. The AMA will continue its efforts to provide information about licensing requirements and to adopt policy positions in regard to licensing that will serve the interests of the medical profession while protecting the health and welfare of the American public.
American Medical Association↗
Licensed nurse staffing and adverse events in hospitals.
OBJECTIVE: To examine the changes in licensed nursing staff in Pennsylvania hospitals from 1991 to 1997, and to assess the relationship of licensed nursing staff with patient adverse events in hospitals. DATA SOURCE: A convenience sample of all Pennsylvania, acute-care, hospitals, 1991 to 1997. STUDY DESIGN: The study first describes the percentage change of licensed nursing staff categories in Pennsylvania hospitals from 1991 to 1997. Second, random effects Poisson regressions are used to assess the association of the numbers and proportions of licensed nurses with yearly iatrogenic lung collapse, pressure sores, falls, pneumonia, posttreatment infections, and urinary tract infections. Controls are the yearly number of patients, hospital acuity, and other hospital characteristics. DATA COLLECTION: Secondary data containing patient- and hospital-level measures from three sources were recoded to establish the incidence of adverse events, aggregated to the hospital level, and merged to form one data set. PRINCIPAL FUNDING: Licensed nurses' acuity-adjusted patient load increased from 1991 to 1997. Licensed nurse/total nursing staff declined from 1994 to 1997. Greater incidence of nearly all adverse events occurred in hospitals with fewer licensed nurses. Greater incidence of decubitus ulcers and pneumonia occurred in hospitals with a lower proportion of licensed nurses. CONCLUSIONS: This study suggests that licensed nurses' patient load began increasing in the 1990s. Adequate licensed nurse staffing is important in minimizing the incidence of adverse events in hospitals. Ensuring adequate licensed nurse staffing should be an area of major concern to hospital management. Improved measures of nurse staffing and patient outcomes, and further studies are suggested.
Accidental Falls↗
Driver licenses as a measure of older drivers' exposure: a methodological note.
The limitations of the number of driver licenses as an estimate of driving exposure were demonstrated by comparing Finnish and Swedish driver licensing practices, licensing rates and accident rates of older drivers. In Sweden, there is no screening for older license holders, and most of them keep their licenses for life. In Finland, there is a heavy and costly medico-legal control system for older license holders, leading to both screening and self-screening. Consequently, in the two countries, the numbers of driver licenses do not reflect the numbers of active older drivers in the same manner. This difference affects the comparative accident statistics: with respect to population, Finland and Sweden have similar age trends in accidents risk, but with respect to the number of driver licenses, the Finnish older drivers seem to have a higher risk of accident than the Swedish ones. It is concluded that if group comparisons of accident risk are presented using the number of driver licenses as an estimate of exposure, the licensing legislation and practice should affect all the groups in an identical manner for the comparison to be valid.
Accidents, Traffic↗
Graduated driver licensing in Utah: is it effective?
STUDY OBJECTIVE: We seek to examine the effectiveness of the graduated driver licensing system in Utah by determining whether crash rates of 16-year-old drivers decreased after graduated driver licensing implementation. METHODS: We studied 16-year-old-driver crashes using statewide motor vehicle crash data probabilistically linked to emergency department (ED), hospital inpatient, and driver licensure data for 1996 to 2001. Outcomes examined included overall crash rates, nighttime crashes, crash severity indicators (eg, noninjury crash, injury crash, ED crash, inpatient crash, fatal crash), seat belt usage, licensure status, and citations. Rate ratios (RR), chi 2 tests, and interventional time series analyses were used to assess changes before and after graduated driver licensing implementation. RESULTS: There were 27,304 16-year-old-driver crashes during the study period. The overall crash rate per 1,000 licensed 16-year-old drivers decreased by 5% (RR 0.95; 95% confidence interval [CI] 0.92 to 0.97), and a time-series analysis showed a reduction of 0.8 (SD 0.39) crashes per month per 1,000 licensed drivers after graduated driver licensing implementation (1996 to 1999 versus 1999 to 2001). The nighttime crash rate did not change (RR 0.91; 95% CI 0.78 to 1.04), and there was no association between crash severity and graduated driver licensing implementation ( P =.096). Reported seat belt usage increased by 6.3%, and few graduated driver licensing citations were issued by law enforcement. CONCLUSION: The results suggest that graduated driver licensing may have contributed to a reduction in young driver crashes, but the effects were minimal compared with those shown in many other graduated driver licensing evaluations.
Accidents, Traffic↗
Obtaining a driver's license and seizure relapse in patients with childhood-onset epilepsy.
OBJECTIVE: To examine factors influencing obtaining a driver's license and subsequent prognosis among people with epilepsy vs control subjects. METHODS: Eighty-one patients from a population-based cohort with childhood-onset epilepsy, followed prospectively for 45 years, and 96 general population control subjects were compared with regard to driving licensing, seizure relapses, and accidents. RESULTS: By the end of the follow-up period, all 81 subjects had achieved at least one 2-year seizure-free interval in adulthood and were eligible for a driver's license. Of these, 64 vs 90% of control subjects had obtained a license (p < 0.0001). On multivariable analysis, factors associated with not obtaining a driver's license among subjects were female gender (relative risk [RR] 2.4, 95% CI 1.0 to 5.5, p = 0.02), nonidiopathic etiology (RR 2.0, 95% CI 1.1 to 3.8, p = 0.02), and presence of learning disabilities (RR 2.0, 95% CI 1.2 to 3.2, p = 0.02). Having a driver's license was associated with a higher rate of employment (RR 1.9, 95% CI 1.2 to 3.0, p = 0.0002). Relapses of seizures had occurred in 37% of the 81 patients theoretically eligible for a license but only in 25% of the 52 subjects who actually obtained one (p = 0.003). Shortening the eligibility period from 2 to 1 year would not significantly alter the relapse rate in this population. The accident rate was not increased among patients vs control subjects. CONCLUSIONS: During a long-term follow-up, differences in driving licensing between patients with uncomplicated epilepsy and healthy control subjects persist despite legal eligibility. The lower actual relapse rates among those with epilepsy who obtain a license than in those who are eligible suggest that those at higher risk of relapse are less likely to obtain a license.
Accidents↗
Unbalanced expression of licensing DNA replication factors occurs in a subset of mantle cell lymphomas with genomic instability.
DNA licensing is a crucial process for chromosome replication control. Deregulation of the licensing factors Cdt1, Cdc6 and the licensing inhibitor geminin has been associated with DNA replication defects and chromosomal instability. We examined the expression of these factors, in mantle cell lymphoma (MCL) and non-neoplastic lymphoid samples, and analysed the potential role of their deregulation in genomic instability. Geminin, Cdt1 and Cdc6 were coordinately expressed in non-neoplastic tissues and most MCL in relationship to the proliferative activity of the cells. However, 6 (18%) tumours showed an unbalanced "licensing signature" characterized by a higher expression of Cdt1 and Cdc6 than the negative regulator geminin. Tumours with this unbalanced signature and p53/p14(ARF) alterations had significantly higher number of chromosome abnormalities than lymphomas with p53/p14(ARF) alterations but with a normal licensing signature. No aberrations of Cdct1, Cdc6, and geminin genes were detected in cases with unbalanced licensing. However, tumours with p53/ARF inactivation and unbalanced licensing signature had significantly higher cyclin D1 levels than tumours with normal licensing signature. These results suggest that an unbalanced mRNA expression of licensing regulatory genes may play a role in the pathogenesis of the chromosomal instability of a subset of MCL with inactivation of the p53/p14(ARF) pathway.
Cell Cycle Proteins↗
Licensing criteria for nuclear medicine.
The use of radioactive materials in medicine is one of the most highly regulated areas the physician has to deal with. There are three basic types of licenses for use of radioactive material defined in the Code of Federal Regulations (CFR), chapter 10, part 35. These are the general license, which is mainly applicable to small volume in vitro work; the specific license, which is used in most medical facilities; and the broad license, which is suited for larger research-oriented practices. Licensing requires proof of competence of the user and of adequate provision for protection of public health. Materials used in medicine are grouped for convenience into three diagnostic categories and two therapeutic categories. A sixth group, for sealed implants, is not generally applicable in nuclear medicine. Training and experience of users may be documented in a number of ways, including board certification in nuclear medicine. Therapeutic applications require additional proof of direct personal experience. The radiation safety officer is a pivotal individual in the licensing procedure, being directly responsible for carrying out the highly detailed requirements for protection of personnel and patients. A radiation safety program based on the "as low as reasonably achievable" (ALARA) concept requires personal monitoring, inventory control, detection and control of contamination, and strict adherence to licensing rules. Training of personnel and proper maintenance of equipment and facilities are also vital parts of the licensing process. The requirements of licensing and for renewal are clearly spelled out by the various regulatory agencies and require meticulous record keeping with documentation that all prescribed procedures have been followed and duly recorded.
Facility Regulation and Control↗
Evaluating the crash and citation rates of Utah drivers licensed with medical conditions, 1992-1996.
BACKGROUND: Medical problems may affect the ability to drive motor vehicles, and programs that control the issuing of driver licenses to individuals with medical conditions exist in most states. The main activity of these programs is the imposition of restrictions upon the driving privileges of individuals with medical conditions that are deemed to pose some risk to public safety. However, little is known about the effectiveness of these licensing programs. OBJECTIVE: The objective of this study was to compare the rates of adverse driving events (crash, at-fault crash and citations) experienced by drivers licensed with medical conditions to those of age-, sex- and location-matched controls. Separate comparisons were made for drivers reporting medical conditions licensed with full driving privileges, and those with restricted driving privileges (e.g. speed, area and time of day). DESIGN: Retrospective case-control. METHODS: The study population was all drivers licensed in the state of Utah who reported a medical condition on their driver license application, over the 5-year period 1992-1996. Drivers enter the program by self-reporting their medical problems. Control drivers were chosen from the entire population of drivers licensed in Utah for the same period. Information on driver license status, participation in the medical conditions program, citations, involvement in crashes, and death certificate data was obtained from the relevant state agencies. Probabilistic linkage methodology was used to link the records in these disparate databases for eventual analysis. Rates of citation, crashes and at-fault crashes, expressed as events per 10000 license days, were calculated separately for program drivers and their corresponding control groups for each medical condition category and restriction status. These data were used to determine an estimate of relative risk (RR) and 95% confidence intervals. RESULTS: As a group, medical conditions drivers had modestly elevated rates of adverse driving events compared with control drivers (RR 1.09-1.74). Rates in the largest medical category, 'cardiovascular conditions', were not higher than controls. Rates were higher than control for some conditions, such as 'alcohol' and 'learning and memory', for some adverse events (RR 2.2 -5.75). Drivers with more than one medical condition appeared comparable to the general group of medical conditions program drivers. CONCLUSIONS: Drivers in Utah medical conditions program had modestly elevated rates of adverse driving events compared to matched controls. Possible underreporting of medical conditions and accurate assessment of exposure rates are potential weaknesses in the program.
Accidents, Traffic↗
Use 'em or lose 'em: the licensed practical nurse.
This article examines the process our gastroenterology unit has undergone in redesigning and enhancing the role of the licensed practical nurse. Within the department, there had existed some dissatisfaction among the licensed practical nurses regarding their role. The unit norm was to use these nurses as healthcare technicians or associates in the procedure and reprocessing rooms. The licensed practical nurses struggled with the restriction of their role and the unit reexamined the appropriate usage of licensed practical nurses. In this article, a literature review has been provided along with a description of the process of developing orientation tools and training of the licensed practical nurses to new roles. Barriers to staff acceptance has also been highlighted. Enhancement of the licensed practical nurse role has had a positive impact on our unit. This practice change has improved the job satisfaction of the licensed practical nurse as well as provided greater unit flexibility and improved teamwork within the department. Alice, a licensed practical nurse (LPN) with 30 years of experience, joined the gastrointestinal (GI) department 7 years ago. She recently corrected my introduction of her as "the tech" by explaining to our patient that: "I am a licensed nurse who will assist the doctor." This simple statement made me realize that Alice was actually a nurse! This initiated the exciting and somewhat painful process of reevaluating our use of staff, individual staff skills and competencies, and staffing patterns within our GI unit.
Clinical Competence↗
Graduated licensing for teens: why everybody's doing it.
While the United States traditionally has allowed quick and easy paths to full-privilege licensure of drivers at an early age, graduated licensing is becoming increasingly popular. The graduated licensing system phases in unrestricted driving by allowing beginners to get their initial behind-the-wheel experiences under conditions that reduce the risk of collision. As of June 2002, 35 states and the District of Columbia had enacted some sort of graduated licensing law. Recent evaluations of graduated licensing systems in four states have found reductions in crashes among 16-year-old drivers ranging from 11 to 33 percent. Yet, not all states have such laws, and many of the graduated licensing systems in use lack important provisions, such as nighttime driving and passenger restrictions. This article reviews the rules, restrictions, and provisions of the graduated licensing model; discusses evaluations of graduated licensing systems; identifies and analyzes variations in graduated licensing approaches across states; assesses the successes and failures of early graduated licensing laws, using New Mexico as an example; and discusses the potential of these systems to prevent injuries.
Accidents, Traffic↗
Predictive validity of osteopathic medical licensing examinations for osteopathic medical knowledge measured by graduate written examinations.
The purpose of this study was to evaluate the predictive validity of osteopathic medical licensing examinations for osteopathic medical knowledge measured by graduate written medical examinations. Performances on the three osteopathic initial licensing examinations, the three osteopathic internal medicine in-service examinations, and the osteopathic internal medicine board certification examinations were analyzed for a cohort of the most recent osteopathic internal medicine board certification examination candidates (N = 82). Multiple regressions were performed for the predictive value of licensing examination scores for the late examination scores. Logistic regressions were used for the prediction of pass/fail status on the licensing examinations for that on the board certification. A longitudinal performance profile was constructed to assess the rank changes in decile on the examinations at different times. All correlation coefficients between the licensing examinations and other examinations were significant and higher than .70. The licensing examinations together predicted at least 60% of the variance of any of the other examination scores. The pass/fail status on the licensing examinations predicted 89% of the pass/fail status on the certification examination. Decile ranks since the first licensing examination were consistent and stable over at least 5 years. The osteopathic licensing examinations had high predictive validity for the late written osteopathic internal medicine examinations. Generalization of the findings to other disciplines needs a caution, as a specialty bias may exist for these types of studies.
Educational Measurement↗
Graduated driver licensing: the New Zealand experience.
In New Zealand, on 1 August 1987, a three-stage graduated driver licensing (GDL) system that applied to all new drivers aged 15-24 years was introduced. The essential elements of GDL were a 6-month learner license (supervised driving) and an 18-month restricted license stage (with restrictions on night driving and carrying passengers). A blood alcohol limit of 0.03 mg% applied at both stages. EVALUATION STUDIES: Early studies indicated that young people were reasonably accepting of the restrictions, with the passenger restriction being the least acceptable. Problems of compliance with the restricted license driving restrictions were reported. Evaluations of the impact of the graduated driver licensing (GDL) on serious traffic-related injury showed that up until 1991-1992, an 8% reduction could be attributed to GDL. At this time, it was considered that reduced exposure was the main reason for this reduction. However, the number of fatalities and hospital admissions among young people continued to decline, as did the population rate and the rate per number of licensed drivers among the young driver age group. A further evaluation study showed that drivers with a restricted license had a smaller proportion of crashes at night, and with passengers, compared with drivers licensed before GDL. IMPACT OF GDL: These results suggested that GDL restrictions had contributed to the reduction in crashes among young people and that it was not simply a case of reduced exposure to risk. An update of the most recent crash statistics indicated that, compared with older age groups, the fatal and serious injury crash rate among young people has remained substantially below the pre-GDL level. This suggests that the impact of GDL has not diminished over time.
Accidents, Traffic↗
Effectiveness of mandatory license testing for older drivers in reducing crash risk among urban older Australian drivers.
Most licensing jurisdictions in Australia maintain mandatory assessment programs targeting older drivers, whereby a driver reaching a specified age is required to prove his or her fitness to drive through medical assessment and/or on-road testing. Previous studies both in Australia and elsewhere have consistently failed to demonstrate that age-based mandatory assessment results in reduced crash involvement for older drivers. However studies that have based their results upon either per-population or per-driver crash rates fail to take into account possible differences in driving activity. Because some older people maintain their driving licenses but rarely if ever drive, the proportion of inactive license-holders might be higher in jurisdictions without mandatory assessment relative to jurisdictions with periodic license assessment, where inactive drivers may more readily either surrender or lose their licenses. The failure to control for possible differences in driving activity across jurisdictions may be disguising possible safety benefits associated with mandatory assessment. The current study compared the crash rates of drivers in Melbourne, Australia, where there is no mandatory assessment and Sydney, Australia, where there is regular mandatory assessment from 80 years of age onward. The crash rate comparisons were based on four exposure measures: per population, per licensed driver, per distance driven, and per time spent driving. Poisson regression analysis incorporating an offset to control for inter-jurisdictional road safety differences indicated that there was no difference in crash risk for older drivers based on population. However drivers aged 80 years and older in the Sydney region had statistically higher rates of casualty crash involvement than their Melbourne counterparts on a per license issued basis (RR: 1.15, 1.02-1.29, p=0.02) and time spent driving basis (RR: 1.19, 1.06-1.34, p=0.03). A similar trend was apparent based on distance travelled but was of borderline statistical significance (RR: 1.11, 0.99-1.25, p=0.07). Collectively, it can be inferred from these findings that mandatory license re-testing schemes of the type evaluated have no demonstrable road safety benefits overall. Further research to resolve this on-going policy debate is discussed and recommended.
Accidents, Traffic↗
Relationship between licensing, registration, and other gun sales laws and the source state of crime guns.
OBJECTIVE: To determine the association between licensing and registration of firearm sales and an indicator of gun availability to criminals. METHODS: Tracing data on all crime guns recovered in 25 cities in the United States were used to estimate the relationship between state gun law categories and the proportion of crime guns first sold by in-state gun dealers. RESULTS: In cities located in states with both mandatory registration and licensing systems (five cities), a mean of 33.7% of crime guns were first sold by in-state gun dealers, compared with 72.7% in cities that had either registration or licensing but not both (seven cities), and 84.2% in cities without registration or licensing (13 cites). Little of the difference between cities with both licensing and registration and cities with neither licensing nor registration was explained by potential confounders. The share of the population near a city that resides in a neighboring state without licensing or registration laws was negatively associated with the outcome. CONCLUSION: States with registration and licensing systems appear to do a better job than other states of keeping guns initially sold within the state from being recovered in crimes. Proximity to states without these laws, however, may limit their impact.
Analysis of Variance↗
[Stages in the licensing process for immigrant physicians in Israel].
The latest wave of immigration, mostly from the former Soviet Union, has brought with it a large number of physicians. They are required to go through various stages of a licensing process in order to practice medicine in Israel. This overview describes the process, from arrival in Israel to the issuing of the license to practice medicine. From September 1989 to December 1991 some 9,800 of arriving immigrants identified themselves as physicians to Ministry of Absorption officials. However, only about 7,000 submitted requests for a medical license to the Ministry of Health. Physicians with at least 20 years of experience need not take an examination, but are required to work under supervision for 6 months in order to receive a license. Of those requesting a license, 1/3 had 20 years or more of professional experience, while the others had to take licensing examinations. By the end of December 1991, some 2,900 physicians had received licenses to practice medicine. This indicates that many immigrant physicians have yet to complete the licensing process.
Emigration and Immigration↗