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INTRODUCTION: Military Service Members, Veterans, and other patient populations who experience traumatic brain injury (TBI) may have increased risk of early neurodegenerative diseases relative to those without TBI history. Some evidence suggests that exposure to psychotropic medications may play a role in this association. The Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) prospective longitudinal study provides an ideal setting to examine the effects of psychotropic medication exposure on long-term neurological health of those with and without mild TBI history. In this study, we sought to develop and pilot test a self-report electronic survey instrument to measure participants' psychotropic medication histories for use across LIMBIC-CENC study sites. MATERIALS AND METHODS: We developed a new survey instrument measuring psychotropic medication history and fielded it among Service Members and Veterans enrolled in a single site of the LIMBIC-CENC study to evaluate response rates and patterns, and to compare survey responses to prescription data extracted from participants' Veterans Affair (VA) records. Descriptive statistics estimated survey respondents' lifetime psychotropic medication exposures by their TBI history and other demographic and clinical characteristics of interest. We also compared survey responses to participants' VA outpatient prescription records to estimate sensitivity and negative predictive values (NPVs) for participants' self-reported medication exposures relative to this single prescription data source. RESULTS: Among 310 Veterans enrolled at the study site, 249 completed the survey (response rate = 80%), of whom 248 also had VA health records and were included in the analysis. Most (69%) had a history of mild TBI. Over three-fourths of survey respondents (78%) reported ever having used prescription opioids, 26% reported benzodiazepines, 50% reported muscle relaxants, 42% reported antidepressants, 13% reported non-benzodiazepine sedative-hypnotics, 15% reported stimulants, 7% reported mood stabilizers, and 6% reported antipsychotics. Veterans with, versus without, a history of mild TBI were more likely to self-report psychotropic medication history as well as have confirmed receipt of VA prescriptions for each medication class. Using VA records as a criterion standard, the sensitivity of the survey for detecting VA prescriptions ranged from 19% to 84%, while the NPVs ranged from 64% to 97%. Sensitivity and NPVs were similar for participants with, versus without, mild TBI history. CONCLUSIONS: Service Members and Veterans may receive psychotropic medications from multiple sources over their lifetimes. Valid methods to examine and quantify these exposures among those with a history of TBI are important, particularly as we evaluate causes of neurodegenerative disorders in this population over time. The measurement of Veterans' lifetime psychotropic medication exposures using a self-report survey, in combination with health care records, holds promise as a valid approach, but further testing and refinement are needed.

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OBJECTIVE: Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI. SETTING: Nationwide VA-purchased care from 2016 through 2019. PARTICIPANTS: Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144). DESIGN: This was a retrospective, observational study. MAIN MEASURES: Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019. RESULTS: Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use. CONCLUSIONS: Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

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OBJECTIVE: To describe associations between a history of traumatic brain injury (TBI) and the severity of tinnitus-related functional impairment among a national, stratified random sample of veterans diagnosed with tinnitus by the Department of Veterans Affairs (VA) healthcare system. SETTING: A multimodal (mailed and internet) survey administered in 2018. Participants: VA healthcare-using veterans diagnosed with tinnitus; veterans with comorbid TBI diagnosis were oversampled. DESIGN: A population-based survey. MAIN MEASURES: TBI history was assessed using International Classification of Diseases (ICD) diagnosis codes in veterans' VA electronic health records. The severity of participants' overall tinnitus-related functional impairment was measured using the Tinnitus Functional Index. Population prevalence and 95% confidence intervals (CIs) were estimated using inverse probability weights accounting for sample stratification and survey nonresponse. Veterans' relative risk ratios of very severe or moderate/severe tinnitus-related functional impairment, versus none/mild impairment, were estimated by TBI history using bivariable and multivariable multinomial logistic regression. RESULTS: The population prevalence of TBI was 5.6% (95% CI: 4.8-6.4) among veterans diagnosed with tinnitus. Veterans with a TBI diagnosis, compared with those without a TBI diagnosis, had 3.6 times greater likelihood of rating their tinnitus-related impairment as very severe (95% CI: 2.1-6.3), and 1.5 times greater likelihood of rating their impairment as moderate/severe (95% CI: 1.0-2.4), versus none/mild. CONCLUSIONS: These findings suggest an important role of TBI in the severity of tinnitus-related functional impairment among veterans. This knowledge can help inform the integration of tinnitus management services into the care received by veterans with TBI.

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Tinnitus is highly prevalent among military Veterans. Severe tinnitus can be associated with negative impacts on daily life. Veterans with severe tinnitus may also have greater difficulties in functional roles, including work. However, few studies have explicitly explored this relationship. Traumatic brain injury (TBI), also prevalent among Veterans, is associated with tinnitus and can additionally impair work functioning. This quantitative investigation used a population-based survey to assess the relationship between tinnitus severity, measured using the Tinnitus Functional Index (TFI), and the impact of tinnitus on work, measured using a composite score from the Tinnitus History Questionnaire, among a stratified random sample of VA healthcare-using Veterans diagnosed with tinnitus, with and without comorbid TBI. Analyses were weighted to account for sampling design and Veteran non-response; multiple imputation was used to account for missing data. Results indicated that for every 1-point increase in TFI score, there was an average 8% increase in the odds of reporting a high level of impact on work functioning (OR: 1.08; 95% CI: 1.06, 1.11). Veterans with a comorbid TBI diagnosis, compared with those without, were more likely to have high tinnitus-related impact on work functioning (OR: 2.69, 95% CI: 1.85, 3.91), but the relationship between tinnitus severity and the impact of tinnitus on work functioning did not differ by TBI status. These data can help researchers and clinicians understand complex symptoms experienced by Veterans with tinnitus, with and without TBI, supporting the improved provision of clinical services to these patients.

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BACKGROUND: Suicide is a leading cause of death in the United States, particularly among Veterans. Nonfatal firearm injuries may indicate subsequent risk of suicide and, thus, provide important opportunities for prevention in emergency departments and other health care settings. We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used U.S. Department of Veterans Affairs (VA) health care, nationally, between 2010 and 2019. METHODS: We linked VA health care and mortality data to identify VA users, nonfatal firearm injuries, and deaths. International Classification of Diseases (ICD)-10th Revision cause-of-death codes were used to identify suicides. Veterans' firearm injuries and their intent were categorized using cause-of-injury codes from the ICD Clinical Modification-9th and 10th Revisions systems. Using bivariable and multivariable regression, we estimated risk of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries. Among Veterans with nonfatal firearm injuries, we examined characteristics associated with subsequent suicide; electronic health record (chart) reviews explored documentation about firearm access among those who died. RESULTS: Among 9,817,020 VA-using Veterans, 11,503 experienced nonfatal firearm injuries (64.9% unintentional, 12.3% intentional self-harm, 18.5% assault). Of these, 69 (0.6%) subsequently died by suicide (42 involving firearms). The odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were 2.4 (95% confidence interval 1.9-3.0); odds were only slightly attenuated in multivariable modeling. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without. Chart reviews identified small proportions of suicide decedents who were assessed for (21.7%), and/or counseled about (15.9%), firearm access. CONCLUSIONS: Findings suggest that Veterans' nonfatal firearm injuries, regardless of injury intent, may be important but underutilized opportunities for suicide prevention. Future work should explore mechanisms to reduce risk among these patients.

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BACKGROUND: The National Violent Death Reporting System (NVDRS) collects data on the circumstances of violent deaths, and all firearm-related deaths, across states and territories in the USA. This surveillance system is critical to understanding patterns and risk factors for these fatalities, thereby informing targets for prevention. NVDRS variables include behavioral health conditions among decedents, but the validity of the reported behavioral health data is unknown. Using Department of Veterans Affairs (VA) healthcare records as a criterion standard, we examined the accuracy of NVDRS-reported behavioral health variables for veteran decedents in a sample state (Oregon) between 2003 and 2017. METHODS: We linked Oregon NVDRS data to VA healthcare data to identify veteran decedents who used VA services within two years of death. Veterans' VA diagnoses within this time frame, including depression, post-traumatic stress disorder (PTSD), anxiety, and substance use disorders, were compared to behavioral health variables identified in the Oregon NVDRS. Concordance, sensitivity, and correlates of sensitivity were examined over time and by decedent characteristics. RESULTS: We identified 791 VA-using veterans with violent and/or firearm-related fatal injuries documented in the Oregon NVDRS between 2003 and 2017. In this cohort, the Oregon NVDRS accurately identified only 49% of decedents who were diagnosed with depression, 45% of those diagnosed with PTSD, and 17% of those diagnosed with anxiety by the VA. Among 211 veterans diagnosed by the VA with a substance use disorder, the Oregon NVDRS coded only 56% as having a substance use problem. In general, the sensitivity of behavioral health variables in the Oregon NVDRS remained the same or decreased over the study period; however, the sensitivity of PTSD diagnoses increased from 21% in 2003-2005 to 54% in 2015-2017. Sensitivity varied by some decedent characteristics, but not consistently across behavioral health variables. CONCLUSIONS: NVDRS data from one state missed more than half of behavioral health diagnoses among VA-using veterans who died from violence or from firearm injuries. This suggests that reports of behavioral health conditions among decedents nationally may be severely undercounted. Efforts to improve validity of these variables in state NVDRS data are needed.

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OBJECTIVE: Many post-9/11 Veterans have received Department of Veterans Affairs (VA) healthcare for traumatic brain injury (TBI). Pain conditions are prevalent among these patients and are often managed with opioid analgesics. Opioids may impose unique risks to Veterans with a history of TBI, especially when combined with other psychotropic medications. We examined receipt of opioid and sedative-hypnotic prescriptions among post-9/11 Veterans with TBI who received VA care nationally between 2012 and 2020. SETTING: Nationwide VA outpatient care. PARTICIPANTS: Veterans with, versus without, clinician-confirmed TBI based on the VA's Comprehensive TBI Evaluation (CTBIE) were followed up for subsequent years in which they received VA care. DESIGN: A historical cohort study. MAIN MEASURES: Proportions of Veterans who received opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were compared by CTBIE outcome (TBI yes/no) and by year; overlaps between medication classes, long-term opioid therapy, and high-dose opioid therapy were also examined. Among those with confirmed TBI, logistic regression was used to examine associations between veteran characteristics and likelihood of these potentially high-risk opioid use outcomes. RESULTS: Among 69 752 Veterans with clinician-confirmed TBI, 26.9% subsequently received opioids. The prevalence receiving opioids each year increased from 2012 (16.7%) to 2014 (17.7%), and then decreased each of the following years through 2020 (5.8%). Among Veterans with TBI who received opioids, large proportions also received benzodiazepine (30.1%) and nonbenzodiazepine (36.0%) sedative-hypnotic prescriptions; these proportions also decreased in recent years. In both bivariable and multivariable regression models, Veterans' demographic, TBI, and clinical characteristics were associated with likelihood of potentially high-risk opioid use. CONCLUSIONS: VA opioid prescribing to Veterans with TBI has decreased in recent years but remains an important source of risk, particularly when considering coprescriptions of sedative-hypnotic medication. Understanding patterns of psychotropic prescription use among Veterans with TBI can highlight important healthcare and rehabilitation needs in this large patient cohort.

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OBJECTIVE: Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. SETTING: Oregon VA and non-VA outpatient care. PARTICIPANTS: Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. DESIGN: Historical cohort study. MAIN MEASURES: Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. RESULTS: Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. CONCLUSION: Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.

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BACKGROUND: The American Academy of Pediatrics recommends pre-discharge Car Seat Tolerance Screening (CSTS) for all neonates born <37 weeks estimated gestational age (EGA), or otherwise at risk for cardiorespiratory compromise. Screening is burdensome and there remains tremendous variation in testing criteria and methodology. DESIGN/METHODS: We conducted a retrospective chart review of 1,072 infants who underwent CSTS between 11/2013 and 7/2016 at a single academic health center. CSTS outcomes (failure and, separately, significant cardiorespiratory instability (CRI)), including those not meeting failure thresholds) were analyzed for all infants screened, and for preterm infants by screening location (Neonatal Intensive Care Unit (NICU) and Mother/Baby Unit (MBU)). Logistic regression was used to estimate associations between infant characteristics and CSTS outcomes. RESULTS: Overall incidence of CSTS failure was 9.2%. Among all infants, hemodynamically significant congenital heart disease, apnea, chronic lung disease, and being small for EGA were associated with failure. Additionally, those born ≤28 weeks EGA had 2.4 times greater likelihood of failure than those 34-36 weeks EGA. Among preterm infants in the NICU and MBU, those of earlier EGA were also more likely to fail. Almost half (47.5%) of all preterm infants demonstrated CRI during CSTS. CONCLUSION: We found high CSTS failure rates, and identified key infant characteristics that were associated with increased likelihood of failure. Significant CRI events were remarkably common. Larger, prospective studies are needed to elucidate risk factors for instability and failure and define practical criteria for CSTS recommendations.

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INTRODUCTION: Tinnitus is prevalent among Service members and Veterans and is often comorbid with mental health disorders. Associations between the severity of individuals' tinnitus and mental health symptoms are not well described. MATERIALS AND METHODS: We conducted a population-based survey of a stratified random sample of 1,800 Veterans diagnosed with tinnitus. We used the Tinnitus Functional Index to measure tinnitus severity and the Primary Care-Posttraumatic Stress Disorder (PTSD) screen and the Hospital Anxiety and Depression Scale to assess PTSD, depression, and anxiety. Descriptive statistics and bivariable and multivariable regression models were used to estimate associations between Veterans' tinnitus severity and mental health symptoms. Inverse probability weights were used to account for sample stratification and survey non-response. Multivariable odds ratios (ORs) and 95% confidence intervals (CIs) controlled for Veterans' demographics, military history, and health diagnoses. RESULTS: A total of 891 Veterans completed surveys (adjusted response rate = 53%). Large proportions rated their tinnitus as severe (29.4%; 95% CI: 27.2-31.6) or very severe (18.7%; 95% CI: 16.8-20.5). In multivariable regression models, and compared with Veterans with none/mild tinnitus, the likelihood of screening positive for PTSD was increased for those who reported moderate (OR = 4.0; 95% CI: 1.6-10.3), severe (OR = 7.5; 95% CI: 3.1-18.5), or very severe (OR = 17.5; 95% CI: 4.4-70.0) tinnitus. Similarly, Veterans' likelihood of positive depression screens were elevated for those with moderate (OR = 2.6; 95% CI: 1.1-5.9), severe (OR = 3.0; 95% CI: 1.4-6.5), or very severe (OR = 15.5; 95% CI: 4.3-55.5) tinnitus, as was the likelihood of positive anxiety screens for those with severe (OR = 2.6; 95% CI: 1.1-6.3) or very severe (OR = 13.4; 95% CI: 4.0-44.3) tinnitus. CONCLUSIONS: Mental health symptoms are strongly associated with Veterans' tinnitus severity. A better understanding of the interplay between these conditions may help improve the provision of interdisciplinary (Audiology and Mental Health) care for Service members and Veterans.

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OBJECTIVE: State prescription drug monitoring programs (PDMPs) identify controlled medications dispensed across providers and systems. Department of Veterans Affairs (VA) policy requires electronic health record documentation of PDMP queries at least annually for VA patients receiving controlled medications; however, queries are not uniformly conducted. We examined factors associated with PDMP queries for veterans receiving long-term opioid therapy. METHODS: Veterans with a VA provider who received long-term opioid therapy between August 2015 and August 2016 within a four-state region were identified; 9,879 were due for a PDMP query between August 2016 and February 2017. Likelihood of veterans' PDMP queries during this follow-up period was modeled as a function of patient, provider, and facility characteristics of interest in mixed-effects modified Poisson models estimating relative risk and 95% confidence intervals. Multivariable models controlled for potential confounders identified through the use of directed acyclic graphs. RESULTS: PDMP queries were documented for 62.1% of veterans that were due for a PDMP query. Veterans were more likely to be queried if they were Hispanic or if they received methadone, had average daily milligram morphine equivalents >20, or received urine drug screening during the studied period. Veterans were less likely to be queried if they had a rural address, mail order medication, or cancer diagnosis. Likelihood of PDMP queries was also lower for veterans whose opioid-prescribing provider was an oncologist or working in a low-complexity facility. CONCLUSIONS: Adherence to PDMP query policy within the VA varied by patient, clinician, and facility factors. Mechanisms to standardize the conduct of PDMP queries may be needed.

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Purpose Tinnitus is prevalent among military Veterans and may frequently co-occur with mental health disorders. This study examined health care utilization and mental health diagnoses among Veterans with and without tinnitus who receive Department of Veterans Affairs (VA) health care. Method We randomly sampled 10% of VA health care users for a 5-year period between 2011 and 2016. Tinnitus and other diagnoses were identified using International Classification of Diseases diagnosis codes; Veterans assigned 1 or more inpatient codes or 2 or more outpatient codes were considered to have the respective diagnosis. We examined demographics, military service, clinical characteristics, and health care utilization of Veterans with and without tinnitus diagnoses. Bivariable and multivariable logistic regression was used to estimate associations between tinnitus and mental health diagnoses of interest. Results Among 617,534 eligible Veterans, 3.8% met criteria for tinnitus diagnosis. Prevalence of tinnitus was associated with sex, age, race, marital status, and VA service connection status; additionally, hearing loss and traumatic brain injury were frequently codiagnosed with tinnitus. Veterans with tinnitus had higher annual health care utilization than those without. While controlling for potential confounders, tinnitus diagnoses were associated with mental health diagnoses, including anxiety, depression, and substance use disorders. Conclusion Findings suggest that Veterans who are diagnosed with tinnitus have more health care utilization and are more frequently diagnosed with mental health disorders than Veterans who are not diagnosed with tinnitus. This suggests a need for coordinated tinnitus and mental health care services for Veterans in the VA system of care.

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OBJECTIVE: To examine the prevalence of concurrent Veterans Health Administration (VA) and non-VA prescriptions for opioids and sedative-hypnotic medications among post-9/11 veterans in Oregon. DATA SOURCES: VA health care and prescription data were probabilistically linked with Oregon Prescription Drug Monitoring Program (PDMP) data. STUDY DESIGN: This retrospective cohort study examined concurrent prescriptions among n = 19,959 post-9/11 veterans, by year (2014-2016) and by patient demographic and clinical characteristics. Veterans were included in the cohort for years in which they received VA outpatient care; those receiving hospice or palliative care were excluded. Concurrent prescriptions were defined as ≥1 days of overlap between outpatient prescriptions for opioids and/or sedative-hypnotics (categorized as benzodiazepines vs. non-benzodiazepines). PRINCIPAL FINDINGS: Among 5,882 veterans who filled opioid or sedative-hypnotic prescriptions at VA pharmacies, 1,036 (17.6 percent) filled concurrent prescriptions from non-VA pharmacies. Within drug class, 15.1, 8.8, and 4.6 percent received concurrent VA and non-VA opioids, benzodiazepines, and non-benzodiazepines, respectively. Veteran demographics and clinical diagnoses were associated with the likelihood of concurrent prescriptions, as was enrollment in the Veterans Choice Program. CONCLUSIONS: A considerable proportion of post-9/11 veterans receiving VA care in Oregon filled concurrent prescriptions for opioids and sedative-hypnotics. Fragmentation of care may contribute to prescription drug overdose risk among veterans.

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OBJECTIVES: To quantify the need for, and interest in, supported employment (SE) among recent military veterans with traumatic brain injury (TBI); and to examine characteristics associated with veterans' interest in SE. DESIGN: Stratified random sample of Iraq and Afghanistan War veterans confirmed to have TBI through the Veterans Health Administration (VHA) screening and evaluation system. SETTING: Community-based via mailed survey. PARTICIPANTS: We recruited 1800 veterans with clinician-confirmed TBI (mild TBI: n=1080; moderate/severe TBI: n=720) through multiple mailings. Among 1451 surveys that were not returned undeliverable, N=616 (42%) responded. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Veterans rated their interest in SE after reading a script describing the program. Additional measures assessed mental health and pain-related comorbidities, employment, financial/housing difficulties, demographics, and military service characteristics. Estimates were weighted to represent the population of veterans with VHA clinician-confirmed TBI. RESULTS: Unemployment was reported by 45% (95% confidence interval [CI], 43-47) of veterans with TBI. Although 42% (95% CI, 40-44) reported they would be interested in using SE if it were offered to them, only 12% had heard of SE (95% CI, 11-14) and <1% had used it. TBI severity and comorbidities were not associated with veterans' interest in SE. However, those who were unemployed, looking for work, experiencing financial strain, or at risk for homelessness were more likely to be interested in SE. CONCLUSIONS: Our research highlights an important gap between veterans' vocational needs and interests and their use of SE. Systematically identifying and referring those with employment and financial/housing difficulties may help close this gap.

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OBJECTIVE: To examine the prevalence and potential determinants of rear-facing car safety seat use among children approximately 18 months of age born at a university hospital. STUDY DESIGN: We administered a telephone survey to caregivers of children 17-19 months of age who were born between November 2013 and May 2014. The survey was designed to assess the prevalence of rear-facing car safety seat use and estimate the likelihood of rear-facing car safety seat use, compared with forward-facing car seat use, in reference to hypothesized determinants. aORs and 95% CIs were calculated using multivariable logistic regression. RESULTS: In total, 56% of potentially eligible caregivers (491/877) completed the survey; 62% of these reported rear-facing car safety seat use. Race, education, rurality, and household income were associated with rear-facing car safety seat use after controlling for potential confounders. Additionally, caregivers who reported having discussed car seats with their child's provider (aOR 1.7; 95% CI 1.1-2.6); receiving their child's primary care in pediatrics compared with family practice clinics (aOR 2.4; 95% CI 1.1-2.6); and being aware of the American Academy of Pediatrics rear-facing recommendation (aOR 2.8; 95% CI 1.8-4.1) were significantly more likely to report rear-facing car safety seat use. Conversely, caregivers who previously used a car seat with another child were less likely to have their child rear facing at 18 months of age (aOR 0.6; 95% CI 0.4-0.9). CONCLUSIONS: A large proportion of children were forward facing at 18 months of age. Future efforts focused on encouraging providers to discuss car seats during patient visits, increasing awareness of the American Academy of Pediatrics' rear-facing recommendation, and targeting high-risk populations may improve the prevalence of children who remain rear facing until 2 years of age.

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