Reporting Patterns for “Lapses of Consciousness” by California Emergency Physicians

Syncope and Traffic Crash: A Population-Based Case-Crossover Analysis

BACKGROUND

Among individuals with recent syncope, recurrence of syncope while driving might incapacitate a driver and cause a motor vehicle crash. Current driving restrictions assume that some forms of syncope transiently increase crash risk. We evaluated whether syncope is associated with a transient increase in crash risk.

METHODS

We performed a case-crossover analysis of linked administrative health and driving data from British Columbia, Canada (2010 to 2015). We included licensed drivers who visited an emergency department with "syncope and collapse" and who were involved as a driver in an eligible motor vehicle crash, both within the study interval. Using conditional logistic regression, we compared the rate of emergency visits for syncope in the 28 days before crash (the "pre-crash interval") with the rate of emergency visits for syncope in 3 self-matched 28-day control intervals (ending 6, 12, and 18 months before the crash).

RESULTS

Among eligible crash-involved drivers, 47 of 3026 pre-crash intervals and 112 of 9078 control intervals had emergency visits for syncope, indicating syncope was not significantly associated with subsequent crash (1.6% vs 1.2%; adjusted odds ratio [OR], 1.27; 95% confidence interval [CI], 0.90-1.79; P = 0.18). There was no significant association between syncope and crash in subgroups at higher risk for adverse outcomes after syncope (eg, age > 65 years, cardiovascular disease, cardiac syncope).

CONCLUSIONS

In the context of prevailing modifications of driving behaviour after syncope, an emergency department visit for syncope did not transiently increase the risk of subsequent traffic collision. Overall crash risks after syncope appear to be adequately addressed by current driving restrictions.

Syncope While Driving and the Risk of a Subsequent Motor Vehicle Crash

STUDY OBJECTIVE

Syncope that occurs while driving can result in a motor vehicle crash. Whether individuals with a prior syncope-related crash exhibit an exceptional risk of subsequent crash remains uncertain.

METHODS

We performed a population-based retrospective observational study of patients diagnosed with 'syncope and collapse' at any of 6 emergency departments in British Columbia, Canada (2010 to 2015). Data were obtained from chart abstraction, administrative health records, insurance claims and police crash reports. We compared crash-free survival among individuals with crash-associated syncope (a crash and an emergency visit for syncope on the same date) to that among controls with syncope alone (no crash on date of emergency visit for syncope).

RESULTS

In the year following their index emergency visit, 13 of 63 drivers with crash-associated syncope and 852 of 9,160 controls with syncope alone experienced a subsequent crash as a driver (crash risk 21% versus 9%). After accounting for censoring and potential confounders, crash-associated syncope was not associated with a significant increase in the risk of subsequent crash (adjusted hazard ratio [aHR] 1.38, 95% confidence interval [CI] 0.78 to 2.47). Individuals with crash-associated syncope were 31-fold more likely to have physician driving advice documented during their index visit (prevalence ratio 31.0, 95% CI, 21.3 to 45.1). In the subgroup without documented driving advice, crash-associated syncope was associated with a significant increase in subsequent crash risk (aHR 1.88, 95% CI 1.06 to 3.36).

CONCLUSIONS

Crash risk after crash-associated syncope appears similar to crash risk after syncope alone.

Reporting Policy Regarding Drivers with Dementia

PURPOSE OF THE STUDY

States have various policies regarding physician reporting of drivers with dementia to the Department of Motor Vehicles (DMV) for testing. Some states have mandatory reporting policies, others have optional reporting policies, and some have no policy regarding this issue. Arkansas has no reporting policy. Physicians in Arkansas face the risk of liability if they report a patient against their will to the DMV.

DESIGN AND METHODS

Three research questions were developed to identify how the problem of drivers with dementia is defined among neurologists and geriatricians in Arkansas: (i) What knowledge do these specialists have of state policy regarding reporting of drivers with dementia to the DMV; (ii) What are their opinions regarding various policy options for reporting such drivers; and (iii) What are their reporting practices for drivers with dementia? A survey was distributed to Arkansas neurologists and geriatricians.

RESULTS

There was considerable uncertainty among respondents, regarding the process of assessing and reporting at-risk drivers with dementia. Support for optional reporting policy was strong. Mandatory reporting policy was less favored. Conversations with patients and caregivers regarding cessation of driving were described as being contentious and ongoing.

IMPLICATIONS

These findings lead to the recommendation that the Arkansas legislature adopt an optional reporting policy. There is also a need for physician education regarding state reporting policy, as well as training for assessment of fitness to drive for patients with dementia.

Bias in counseling of seizure patients following a transient impairment of consciousness: differential adherence to driver fitness guidelines

PURPOSE

To determine primary care physicians' counseling as well as patients' driving behaviors following seizure and non-seizure events impairing consciousness in the community.

METHODS

Patients attending a rapid-referral first seizure clinic were entered into the study if they were deemed medically-unfit to drive according to national guidelines for driving licensure: had experienced a seizure or an unexplained episode of lost consciousness, and had a valid driver's license at the time of their index event. Risk of physician counseling in the community regarding driving cessation in the interval between initial primary care assessment and neurological consultation was examined as a primary outcome, and patient driving cessation was examined as a secondary outcome.

RESULTS

106 of 192 (55%) patients attending clinic met guideline criteria requiring driver fitness counseling in the primary care community, and 89 patients (46%) were deemed medically-unfit to drive following the initial specialist consultation appointment. Among medically unfit driver cases, 73% were ultimately deemed to have experienced a seizure and 27% had experienced a non-seizure event (e.g. syncope, PNES). Driver fitness counseling was more likely for seizure than non-seizure cases (unadjusted odds ratio: 4.14, p<0.05), as was patient driving cessation (5.10, p<0.05).

CONCLUSION

Physician compliance with clinical practice guidelines appears strongly biased when counseling about driving following an episode of transient impairment in consciousness. The failure of the primary care medical community to apply driver fitness counseling equitably to both seizure and non-seizure drivers may have ramifications upon public safety or conversely disease-related quality-of-life.

Counseling at a Seizure Clinic Does Not Ensure Disclosure to the Transportation Registry

Background:The effectiveness of current self-reporting driving laws for medically-unfit potential seizure patients is unknown in Canada. We designed a prospective cohort study of patients’ self-reporting practices to the local Transportation Registry (TR) and their driving behaviors following detailed counselling at a seizure clinic in a discretionary physician-reporting jurisdiction.Methods:Medically unfit drivers, referred to our seizure clinic, who had a valid driver’s permit at the time of their episode of impaired consciousness were included. Patients’ self-reporting and driving behaviours were assessed using a standardized interview prior to a neurologist’s counseling and later at a follow-up visit.Results:Sixty three patients were included; 77% were diagnosed as having had a seizure at the time of their referral. Prior to their seizure clinic visit, 3/63 (5%) had been counseled to self-report to the TR by a non-neurologist physician, and none had done so. Following a neurologist’s documented counseling 34/63 (54%) had self-reported themselves at the follow-up seizure clinic visit, and 53/63 (84%) were not driving.Conclusion:This prospective study design is the first in North America to examine self-reporting rates for unfit drivers with a seizure disorder. Our findings suggest that self-reporting laws do not ensure high rates of self-reporting behaviors even when patients seen at a seizure clinic are appropriately counseled of their legal obligations. The rate of driving cessation appears greater than the rate of self-reporting to the TR among counseled patients.

Legal ramifications for physicians of patients who drive with hepatic encephalopathy

BACKGROUND & AIMS

Hepatic encephalopathy, a spectrum of neuropsychiatric abnormalities that can occur in patients with liver dysfunction, negatively affects driving performance, but no study has examined legal ramifications. We studied state requirements for reporting hepatic encephalopathy and investigated whether lawsuits have been completed against physicians or patients for motor vehicle accidents that were related to hepatic encephalopathy.

METHODS

We contacted motor vehicle departments from all 50 states and examined motor vehicle codes and legal databases to search for hepatic encephalopathy-related lawsuits.

RESULTS

Definitions of a medically impaired driver varied considerably. No state specifically mentioned hepatic encephalopathy or patients with advanced liver disease. Only 6 (12%) of the states had mandatory reporting laws for drivers who have medical impairment, and 25 of the remaining 44 states (57%) provided legal immunity to physicians for reporting such patients. The legal databases did not contain any cases against physicians for failure to warn against driving or diagnose hepatic encephalopathy that resulted in an accident. There were no lawsuits identified against an encephalopathic patient for causing a motor vehicle accident.

CONCLUSIONS

Only 6 states require physicians to report drivers with medical impairments. Hepatic encephalopathy is not specifically addressed in any state vehicle code. There are no completed lawsuits against physicians or patients for motor vehicle accidents associated with driving impairment from hepatic encephalopathy. In the absence of definitive laws, the onus of responsibility for identifying potentially hazardous drivers might still lie with the physician; physicians should carefully evaluate patients for driving abilities.