Physicians' warnings for unfit drivers and the risk of trauma from road crashes

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.

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

COVID Vaccine Hesitancy and Long-Term Traffic Risks

BACKGROUND

COVID vaccine hesitancy identifies a discrepancy between personal decisions and public guidelines. We tested whether COVID vaccine hesitancy was associated with the long-term risks of a traffic crash.

METHODS

We conducted a population-based longitudinal cohort analysis of adults by determining COVID vaccination status through linkages to electronic medical records. Traffic crashes requiring emergency medical care were defined by multicenter outcome ascertainment of all hospitals throughout the region over the subsequent year.

RESULTS

We identified 11,598,549 total individuals, of whom 1,210,754 had not received a COVID vaccine. A total of 54,558 were subsequently injured in traffic crashes during the 1-year follow-up interval, equal to a risk of 4704 per million. Those who had not received a COVID vaccine had a 58% higher risk than those who had received a COVID vaccine (6983 vs 4438 per million, P < .001). The increased traffic risks among unvaccinated individuals included diverse subgroups, were accentuated for single-vehicle crashes, extended to fatal outcomes, exceeded the risks associated with sleep apnea, and persisted after adjustment for baseline characteristics. The increased risks were validated in analyses using Artificial Intelligence techniques and generally larger than the risks of other adverse events frequently ascribed to COVID vaccination.

CONCLUSIONS

COVID vaccine hesitancy is associated with significant increased long-term risks of a traffic crash. A greater awareness of traffic risks might encourage patients to take protective actions for personal safety.

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 Requirements, Confidentiality, and Legal Immunity for Physicians Who Report Medically Impaired Drivers

Importance

Physicians play an important role in assessing patients' ability to drive. There is a dearth of peer-reviewed information on policies regarding physician reporting of medically impaired drivers.

Objective

To investigate state reporting requirements and the availability of confidentiality and legal immunity for physicians who report medically impaired drivers.

Design, Setting, and Participants

This cross-sectional study was conducted from November 1 to 30, 2022, in 3 rounds. First, all 50 US states' Department of Motor Vehicle (DMV) websites were systematically reviewed. Second, DMV staff from each state were surveyed via telephone. Third, each state's legal codes for driver licensing were reviewed.

Main Outcomes and Measures

Outcome measures included the percentage of states with mandatory and voluntary reporting policies, reporting instructions on DMV websites, anonymous reporting options, and legal immunity for reporting physicians, in addition to characteristics of states' mandatory reporting policies (ie, types of medical conditions that require reporting) and policies surrounding the confidentiality of reports. The data were analyzed using descriptive statistics.

Results

One-third of state DMV websites (17 [34%]) lacked instructions regarding physician reporting. Six states had mandatory reporting requirements; 4 of these states only required reporting of conditions characterized by lapses of consciousness. Only 3 states (6%) accepted anonymous reports, and 7 states (14%) deemed physician reports of medically impaired drivers confidential without exception. Nearly one-third of states (15 [30%]) deemed reports by physicians confidential, with the exception that reported drivers could find out who reported them if they asked for a copy of the reporting form. Most states (37 [74%]) had statutes that protected physicians from liability related to reporting medically impaired drivers.

Conclusions and Relevance

This cross-sectional study of state reporting requirements regarding medically impaired drivers found many differences in state policies regarding mandatory reporting and the conditions that require reporting. There was also limited availability of online reporting instructions, anonymous reporting options, and legal protections for reporting physicians.

Adaptation of a European categorization system for driving-impairing medicines in Iran

OBJECTIVE

Road traffic crashes due to impaired driving are a leading cause of preventable injuries and deaths. The purpose of this study was adaptation of a European categorization system for driving-impairing medicines in Iran.

METHODS

DRUID categorization system was used as a leading model to classify medicines. Medicines that were compatible with DRUID categorization system were identified and classified accordingly. Medicines that were not compatible with DRUID categorization system were assessed in an expert panel in terms of possiblity of classification. Instructions for health care providers and advice for patients were prepared based on the medicine's influence on fitness to drive.

RESULTS

Of the 1255 medicines in Iranian pharmacopeia, 488 medicines were classified in four categories. Among classified medicines 43.85% and 25.41% belonged to Category 0 and Category 1. About 13.94%, 10.04%, and 6.76% pertained to Category 2, Category 3, and Multiple categories respectively. Majority of the medicines with moderate and severe adverse influences on driving fitness belonged to the nervous system medicines (72.65%). Most of the medicines with non-existing or minor adverse influences on driving fitness pertained to cardiovascular medicines (16.56%). Majority of uncategorized medicines belonged to Iranian herbal medicines.

CONCLUSION

The current study disclosed that DRUID categorization system was implementable for most of the commonly prescribed medicines. Experimental studies are needed to determine the influence of uncategorized medicines of Iranian pharmacopeia. Other countries with similar settings can adapt DRUID categorization system until they develop their own model using original studies.

COVID Vaccine Hesitancy and Risk of a Traffic Crash

BACKGROUND

Coronavirus disease (COVID) vaccine hesitancy is a reflection of psychology that might also contribute to traffic safety. We tested whether COVID vaccination was associated with the risks of a traffic crash.

METHODS

We conducted a population-based longitudinal cohort analysis of adults and determined COVID vaccination status through linkages to individual electronic medical records. Traffic crashes requiring emergency medical care were subsequently identified by multicenter outcome ascertainment of all hospitals in the region over a 1-month follow-up interval (178 separate centers).

RESULTS

A total of 11,270,763 individuals were included, of whom 16% had not received a COVID vaccine and 84% had received a COVID vaccine. The cohort accounted for 6682 traffic crashes during follow-up. Unvaccinated individuals accounted for 1682 traffic crashes (25%), equal to a 72% increased relative risk compared with those vaccinated (95% confidence interval, 63-82; P < 0.001). The increased traffic risks among unvaccinated individuals extended to diverse subgroups, was similar to the relative risk associated with sleep apnea, and was equal to a 48% increase after adjustment for age, sex, home location, socioeconomic status, and medical diagnoses (95% confidence interval, 40-57; P < 0.001). The increased risks extended across the spectrum of crash severity, appeared similar for Pfizer, Moderna, or other vaccines, and were validated in supplementary analyses of crossover cases, propensity scores, and additional controls.

CONCLUSIONS

These data suggest that COVID vaccine hesitancy is associated with significant increased risks of a traffic crash. An awareness of these risks might help to encourage more COVID vaccination.

Association between mandatory cognitive testing for license renewal and motor vehicle collisions and road injuries

BACKGROUND

We examined whether the policy amendment from March 2017 for a cognitive screening test for older drivers at driver's license renewal was associated with the decreased risk of motor vehicle collisions for drivers and the increased risk of injuries for pedestrians and cyclists among older people.

METHODS

This was a controlled interrupted time-series study. We used police-reported data on the number of collisions as drivers and injuries as pedestrians and cyclists among people aged 70 years or older in Japan from July 2012 to December 2019. As the outcome measures, we used the ratio of the monthly number of collisions per population among drivers of three groups aged 75 years or older (75-79, 80-84, and ≥85 years), who were targeted or exposed by the policy, to that among drivers aged 70 to 74 years, who were unaffected or unexposed by the policy and would serve as controls. The ratio of pedestrian and cyclist injuries was also calculated, as previous studies have shown a concomitant increase in these injuries after the introduction of cognitive screening for driver's licenses.

RESULTS

During the study period, there were 602,885 collisions as drivers and 196,889 injuries as pedestrians and cyclists among people aged 70 years or older. After the policy amendment in March 2017, collisions decreased among male drivers, and injuries increased among some age subgroups in both sexes. Cumulative estimated changes in the numbers of collisions and injuries from March 2017 to December 2019 were -3670 (95% confidence interval: -5125, -2104) and 959 (95% confidence interval: 24, 1834), respectively.

CONCLUSIONS

Following the policy amendment, there was a decrease in motor vehicle collisions as drivers and an increase in road injuries as pedestrians and cyclists among older people.

Syncope and subsequent traffic crash: A responsibility analysis

BACKGROUND

Physicians are often asked to counsel patients about driving safety after syncope, yet little empirical data guides such advice.

METHODS

We identified a population-based retrospective cohort of 9,507 individuals with a driver license who were discharged from any of six urban emergency departments (EDs) with a diagnosis of 'syncope and collapse'. We examined all police-reported crashes that involved a cohort member as a driver and occurred between 1 January 2010 and 31 December 2016. We categorized crash-involved drivers as 'responsible' or 'non-responsible' for their crash using detailed police-reported crash data and a validated responsibility scoring tool. We then used logistic regression to test the hypothesis that recent syncope was associated with driver responsibility for crash.

RESULTS

Over the 7-year study interval, cohort members were involved in 475 police-reported crashes: 210 drivers were deemed responsible and 133 drivers were deemed non-responsible for their crash; the 132 drivers deemed to have indeterminate responsibility were excluded from further analysis. An ED visit for syncope occurred in the three months leading up to crash in 11 crash-responsible drivers and in 5 crash-non-responsible drivers, suggesting that recent syncope was not associated with driver responsibility for crash (adjusted odds ratio, 1.31; 95%CI, 0.40-4.74; p = 0.67). However, all drivers with cardiac syncope were deemed responsible, precluding calculation of an odds ratio for this important subgroup.

CONCLUSIONS

Recent syncope was not significantly associated with driver responsibility for traffic crash. Clinicians and policymakers should consider these results when making fitness-to-drive recommendations after syncope.

Categorization and labeling systems concerning driving-impairing medicines: A scoping review

OBJECTIVE

Classification systems concerning driving-impairing medicines can help healthcare providers identify medicinal drugs with no or the least impairing effects and inform patients of the potential risks of certain medicines to safe driving. This study aimed to comprehensively assess the characteristics of classifications and labeling systems regarding driving-impairing medicines.

METHODS

Google Scholar and several databases, including PubMed, Scopus, Web of Science, EMBASE, safetylit.org, and TRID were searched to identify the relevant published material. The retrieved material was assessed for eligibility. Data extraction was done to compare the categorization/labeling systems concerning driving-impairing medicines in terms of characteristics such as the number of categories, description of each category, and description of pictograms.

RESULTS

After screening 5,852 records, 20 studies were selected for inclusion in the review. This review identified 22 categorization/labeling systems regarding medicines and driving. Classification systems had different characteristics, but most of them were designed based on the graded categorization system described by Wolschrijn. Initially, categorization systems had seven levels, but later the medicine impacts were summarized into 3 or 4 levels.

CONCLUSIONS

Although different categorization/labeling systems regarding driving-impairing medicines are available, the most effective systems in changing driver's behavior are the simple and understandable ones. Besides, health care providers should consider patient's socio-demographic features when informing them about driving under the influence.

Syncope and the Risk of Subsequent Motor Vehicle Crash: A Population-Based Retrospective Cohort Study

IMPORTANCE

Medical driving restrictions are burdensome, yet syncope recurrence while driving can cause a motor vehicle crash (MVC). Few empirical data inform current driving restrictions after syncope.

OBJECTIVE

To examine MVC risk among patients visiting the emergency department (ED) after first-episode syncope.

DESIGN, SETTING, AND PARTICIPANTS

A population-based, retrospective observational cohort study of MVC risk after first-episode syncope was performed in British Columbia, Canada. Patients visiting any of 6 urban EDs for syncope and collapse were age- and sex-matched to 4 control patients visiting the same ED in the same month for a condition other than syncope. Patients' ED medical records were linked to administrative health records, driving history, and detailed crash reports. Crash-free survival among individuals with syncope was then compared with that among matched control patients. Data analyses were performed from May 2020 to March 2022.

EXPOSURES

Initial ED visit for syncope.

MAIN OUTCOMES AND MEASURES

Involvement as a driver in an MVC in the year following the index ED visit. Crashes were identified using insurance claim data and police crash reports.

RESULTS

The study cohort included 43 589 patients (9223 patients with syncope and 34 366 controls; median [IQR] age, 54 [35-72] years; 22 360 [51.3%] women; 5033 [11.5%] rural residents). At baseline, crude MVC incidence rates among both the syncope and control groups were higher than among the general population (12.2, 13.2, and 8.2 crashes per 100 driver-years, respectively). In the year following index ED visit, 846 first crashes occurred in the syncope group and 3457 first crashes occurred in the control group, indicating no significant difference in subsequent MVC risk (9.2% vs 10.1%; adjusted hazard ratio [aHR], 0.93; 95% CI, 0.87-1.01; P = .07). Subsequent crash risk among patients with syncope was not significantly increased in the first 30 days after index ED visit (aHR, 1.07; 95% CI, 0.84-1.36; P = .56) or among subgroups at higher risk of adverse events after syncope (eg, age >65 years; cardiogenic syncope; Canadian Syncope Risk Score ≥1).

CONCLUSIONS AND RELEVANCE

The findings of this population-based retrospective cohort study suggest that patients visiting the ED with first-episode syncope exhibit a subsequent crash risk no different than the average ED patient. More stringent driving restrictions after syncope may not be warranted.

Association of obstructive sleep apnea and opioids use on adverse health outcomes: A population study of health administrative data

Rationale

Despite the high prevalence of obstructive sleep apnea (OSA) and concurrent use of opioid therapy, no large-scale population studies have investigated whether opioid use and pre-existing OSA may interact synergistically to increase the risk of adverse health consequences. To address this knowledge gap, we conducted a retrospective cohort study using provincial health administrative data to evaluate whether the combined presence of opioid use and OSA increases the risk of adverse health consequences, such as mortality, hospitalizations, and emergency department (ED) visits; and if it does, whether this co-occurrence has synergistic clinical relevance.

Methods

We included all adults who underwent a diagnostic sleep study in Ontario, Canada, between 2013 and 2016. Individuals were considered exposed to opioids if they filled a prescription that overlapped with the date of their sleep study (Opioid+). Individuals with at least a 50% probability of having a diagnosis of moderate to severe OSA (OSA+) were identified using a previously externally validated case-ascertainment model. The primary outcome was all-cause mortality; secondary outcomes were all-cause or ischemic heart disease hospitalizations, all-cause ED visits, and motor vehicle collisions (MVC) requiring hospital or ED visit. We used multivariable Cox regression models to compare hazards between four mutually exclusive groups: (1) Opioid+ OSA+; (2) Opioid+ OSA-; (3) Opioid- OSA+, and (4) OSA- Opioid- (reference for comparison). Relative excess risks due to interaction (RERI) were calculated to test for additive interaction.

Results

Of 300,663 adults who underwent a sleep study, 15,713 (5.2%) were considered as Opioid+ and 128,351 (42.7%) as OSA+. Over a median of two years, 6,223 (2.1%) died from any cause. Regardless of OSA status, opioid use at the date of the sleep study was associated with an increased hazard for all-cause mortality with the greatest hazard associated with Opioid+ OSA- (adjusted hazard ratio [aHR]: 1.75, 95% CI 1.57–1.94), but not Opioid+ OSA+ (aHR: 1.14, 95% CI 1.02–1.27) as hypothesized. Regardless of OSA status, opioid use at the date of the sleep study was associated with an increased hazard for all secondary outcomes. Opioid+ OSA+ was associated with the greatest hazards of all-cause hospitalizations (aHR 1.55, 95% CI 1.49–1.61) and MVC (aHR of 1.39; 95% CI 1.09–1.77); however, no statistically significant synergistic effects were observed.

Conclusions

Adults referred for sleep disorder assessment who used opioids had a significantly increased hazard of adverse health outcomes than those who did not, regardless of whether they had a high probability of moderate to severe OSA. The use of opioids and OSA was associated with the greatest hazard of all-cause hospitalizations and MVC requiring hospital or ED visit. The interaction of opioids and OSA did not confer a synergistic risk for poor outcomes.

Physicians' views on the usefulness of practical tools for assessing the driving ability of older drivers: a cross-sectional study

OBJECTIVE

We aimed to explore Swiss physicians' views on the usefulness of a self-administered questionnaire completed by older drivers before the consultation and a reference guide summarising current Swiss guidelines on the fitness-to-drive assessment of older drivers. We also aimed to assess the frequency with which physicians used the information sources provided by the Swiss traffic medicine website.

DESIGN

Questionnaire-based cross-sectional study.

SETTING

The study was conducted in four cantons of Western Switzerland (Geneva, Vaud, Neuchâtel and Jura).

PARTICIPANTS

All physicians certified to carry out fitness-to-drive assessments in the canton of Geneva (medical assessors; n=69) and a random sample of 500 general practitioners practising in the cantons of Vaud, Neuchâtel and Jura were invited to participate. They were asked to report their estimated average number of fitness-to-drive assessments per week and to rate on a 5-point Likert scale the perceived usefulness of the preconsultation patient questionnaire and reference guide, and the frequency of use of the information sources provided by the traffic medicine website. We computed the proportion of physicians who found the assessment tools very/somewhat useful and the proportion of physicians who always/often used the traffic medicine website. We compared the responses according to medical specialty (medical assessors vs general practitioners) using design-based F tests and weighted logistic regressions.

RESULTS

268 physicians (47%) agreed to participate in the study. Their median number of assessments was 2 per week (IQR 2). Overall, the majority of physicians found the questionnaire (75%) and reference guide (89%) very/somewhat useful. Only 17% of the sample always/often used the traffic medicine website. There were no statistically significant associations in multivariable analysis between the medical specialty and the perceived usefulness of the questionnaire and reference guide and the frequency of use of the traffic medicine website.

CONCLUSION

Many physicians find the preconsultation patient questionnaire and reference guide useful to guide them for assessing the driving ability of older drivers, but only a minority regularly use the information sources provided by the traffic medicine website. Future studies should explore the reasons why many physicians do not use these available sources of information.

Risks of Serious Injury with Testosterone Treatment

BACKGROUND

Injury causes significant morbidity and mortality that is sometimes attributed to testosterone and violence. We hypothesized that prescribed testosterone might be associated with the subsequent risk of serious injury.

METHODS

We conducted a self-matched individual-patient exposure-crossover analysis comparing injury risks before and after initiation of testosterone. We selected adults treated with testosterone in Ontario, Canada, from October 1, 2012, to October 1, 2017 (enrollment) and continued until October 1, 2018 (follow-up). The primary outcome was defined as an acute traumatic event that required emergency medical care.

RESULTS

A total of 64,386 patients were treated with testosterone of whom 89% were men with a median age of 52 years. We identified 34,439 serious injuries during the baseline interval before starting testosterone (584 per month) and 7349 serious injuries during the subsequent interval after starting testosterone (565 per month). Rates of injuries were substantially above the population norm in both intervals with no significant increased risk after starting testosterone (relative risk = 1.00; 95% confidence interval: 0.96-1.04, P = 0.850). The unchanged risk extended to diverse patients, was observed for different formulations and applied to all injury mechanisms. In contrast, testosterone treatment was associated with a 48% increased risk of a thromboembolic event (relative risk = 1.48; 95% confidence interval: 1.25-1.74, P < 0.001).

CONCLUSIONS

Testosterone treatment was associated with a substantial baseline risk of serious injury that did not increase further after starting therapy. Physicians prescribing testosterone could consider basic safety reminders to mitigate injury risks.

Impact of medical fitness to drive policies in preventing property damage, injury, and death from motor vehicle collisions in Ontario, Canada

INTRODUCTION

Drivers with medical conditions and functional impairments are at increased collision risk. A challenge lies in identifying the point at which such risk becomes unacceptable to society and requires mitigating measures. This study models the road safety impact of medical fitness-to-drive policy in Ontario.

METHOD

Using data from 2005 to 2014, we estimated the losses to road safety incurred during the time medically-at-risk drivers were under review, as well as the savings to road safety accrued as a result of licensing decisions made after the review process.

RESULTS

While under review, drivers with medical conditions had an age- and sex-standardized collision rate no different from the general driver population, suggesting no road safety losses occurred (RR = 1.02; 95% CI: 0.93-1.12). Licensing decisions were estimated to have subsequently prevented 1,211 (95% CI: 780-1,730) collisions, indicating net road safety savings resulting from medical fitness to drive policies. However, more collisions occurred than were prevented for drivers with musculoskeletal disorders, sleep apnea, and diabetes. We theorize on these findings and discuss its multiple implications.

CONCLUSIONS

Minimizing the impact of medical conditions on collision occurrence requires robust policies that balance fairness and safety. It is dependent on efforts by academic researchers (who study fitness to drive); policymakers (who set driver medical standards); licensing authorities (who make licensing decisions under such standards); and clinicians (who counsel patients on their driving risk and liaise with licensing authorities). Practical Applications: Further efforts are needed to improve understanding of the effects of medical conditions on collision risk, especially for the identified conditions and combinations of conditions. Results reinforce the value of optimizing the processes by which information is solicited from physicians in order to better assess the functional impact of drivers' medical conditions on driving and to take suitable licensing action.

The Predictors of Driving Cessation among Older Drivers in Korea

Background: As the elderly population and the number of older drivers grow, public safety concerns about traffic accidents involving older drivers are increasing. Approaches to reduce traffic accidents involving older drivers without limiting their mobility are needed. This study aimed to investigate the driving cessation (DC) rate among older Korean adults and predictors of DC based on the comprehensive mobility framework. Method: In this cross-sectional study, data from 2970 to 10,062 older adults over 65 years old from the 2017 National Survey of Elderly People were analyzed in April 2020. Multivariate logistic regression analyses were conducted to identify the predictors of DC. Results: Residential area, an environmental factor, was a strong predictor of DC (Odds Ratio (OR) 2.21, 95% Confidential Interval (CI) 1.86–2.62). Older drivers living in an area with a metro system were 2.21 more likely to stop driving than those living in an area without a metro system. Other demographic, financial, psychosocial, physical, and cognitive variables also predicted DC. Conclusion: Environmental factors were strong predictors of older adults’ DC. Therefore, political and environmental support, such as the provision of accessible public transportation, is essential to increase the DC rate among older adults to increase public safety without decreasing their mobility.

Assessment of Sleepiness in Drivers: Current Methodology and Future Possibilities

Many patients with obstructive sleep apnea syndrome (OSAS) drive a vehicle both for pleasure and as part of their employment. Some, but not all, patients with OSAS are at increased risk of being involved in road traffic accidents. Clinicians are often asked to make recommendations about an individual's fitness to drive, and these are likely to be inconsistent in the absence of objective criteria. This article discusses the current practice of the assessment of individuals' sleepiness with respect to driving, the limitations of available techniques, and future possibilities.

Are cardiac patients in Saudi Arabia provided adequate instructions when they should not drive?

Objective:

Driving capability can be significantly affected by different heath disorders; cardiovascular diseases (CVDs) should be considered when assessing patients for medical fitness to drive (MFTD). The aim of this study was to evaluate the awareness of Saudi patients about driving recommendations and to assess the incidence of motor vehicle accidents (MVAs) among cardiac patients.

Materials and Methods:

We conducted a cross-sectional survey-based study. Male patients diagnosed with CVDs and who were visiting outpatient departments were invited to complete a questionnaire regarding their awareness of driving recommendations. Patients’ demographics, clinical diagnosis, echocardiography parameters, and time-to-CVD diagnosis were all obtained from the patients’ medical records. Women were excluded because it was illegal for women to drive in Saudi Arabia during the study period.

Results:

In total, 800 men were included, with a mean age of 54 ± 12 years. Driving counseling had been provided to 241 participants (30%). Of these, 207 (25%) were advised not to drive for a period of between one week and six months. Five percent of the patients had a history of MVAs during the follow-up period of 6.2 ± 4 years. We found that the presence of a dyspnea ≥2, according to the New York Heart Association (NYHA), and a history of loss of consciousness (syncope/pre-syncope) were significantly associated with accidents (46% vs. 20%, P < 0.0001 and 41% vs. 10%, P < 0.0001, respectively).

Conclusion:

Patient–physician discussion about MFTD was only performed with 30% of the patients with CVDs in Saudi Arabia. Dyspnea NYHA class ≥2 or a prior history of syncope were significantly associated with the incidence of MVAs.

Dementia

Alzheimer disease (AD) and other dementia syndromes are becoming more common; an estimated 5.5 million adults aged 65 years or older are living with AD in the United States. It is important for primary care physicians to gain knowledge in this field because most community-dwelling older adults receive their care from them. This article discusses the latest findings in approaches to prevent cognitive decline as well as dementia screening, diagnosis, and treatment. Approaches to address quality of life for persons with dementia and their caregivers are also discussed.

Dizziness, driving, and the Driver and Vehicle Licensing Agency: audit of advice given to patients, and design of a patient information leaflet

BACKGROUND

Evidence from the literature shows that clinicians' knowledge of rules and legislation surrounding driving can often be poor. A closed-loop audit was conducted to gauge the level of driving advice given to patients with dizziness.

METHODS

The clinical notes of 100 patients referred to the vertigo clinic at a tertiary referral centre were retrospectively searched for evidence of driving advice. Education sessions were undertaken and a patient information leaflet was developed before a second cycle of the audit.

RESULTS AND CONCLUSION

The proportion of patients having documented evidence of receiving driving advice increased from 6.3 per cent to 10.4 per cent. It is therefore clear that, despite this improvement, a significant proportion of patients' notes did not contain documentation about driving. This is likely because of many reasons, including individual interpretation by clinicians. This paper provides a reminder of the rules, and discusses their interpretation and implementation in an increasingly medicolegal environment.

A decision tree to determine fitness to drive in epilepsy: Results of a pilot in two Australian states

OBJECTIVE

Certification by treating physicians of fitness to drive in people with epilepsy creates a conflict of interest that may result in unsafe decisions, damage the doctor-patient relationship, expose the physician to legal liability and prevent optimal treatment. Ideally, the treating physician should provide objective clinical information to the driver licensing authority (DLA), which then determines fitness or otherwise. However, DLAs in Australia do not employ medical staff and the national standards are complex. Fitness is determined by the treating physician, according to published national standards. The purpose of this study was to determine the feasibility of using a decision tree to determine fitness, according to the Australian standards.

METHODS

A decision tree was constructed to use clinical data to determine whether a patient met the national standard to drive a private motorcar, failed to meet it or required further assessment. A form was designed to collect the necessary clinical data from the treating physician. A computerized version of the decision tree was then used in a pilot in two Australian states in parallel with the existing certification system. Four hundred thirty-nine drivers with declared epilepsy and their treating physicians were invited to participate when their annual driver licence review was due.

RESULTS

Two hundred fifty-three (58%) forms were returned. All patients were considered fit to drive by their physician. Seventy-six percent had not had a seizure for over two years. In 88.1%, there was agreement between the decision tree and treating physician, with 3.6% identified by the decision tree as requiring review. Although considered fit by their physician, 6.3% did not meet the national standard to drive.

SIGNIFICANCE

The decision tree model is a practical alternative to fitness certification by treating physicians. This Australian pilot can serve as a model for applying objective standards to driving assessments in other jurisdictions, using local driving standards. It has the potential to improve road safety by avoiding the negative effects of certification by treating physicians and can cope with complex standards. It is now in use in two states of Australia.

A virtual second opinion: Acceptability of a computer-based decision tool to assess older drivers with dementia

Clinicians face challenges in deciding which older patients with dementia to report to transportation administrators. This study used a qualitative thematic analysis to understand the utility and limitations of implementing a computer-based Driving in Dementia Decision Tool in clinical practice. Thirteen physicians and eight nurse practitioners participated in an interview to discuss their experience using the tool. While many participants felt the tool provided a useful 'virtual second opinion', specialist physicians felt that the tool did not add value to their clinical practice. Barriers to using the Driving in Dementia Decision Tool included lack of integration with electronic medical records and inability to capture certain contextual nuances. Opinions varied about the impact of the tool on the relationship of clinicians with patients and their families. The Driving in Dementia Decision Tool was judged most useful by nurse practitioners and least useful by specialist physicians. This work highlights the importance of tailoring knowledge translation interventions to particular practices.

Traumatic brain injury as an independent risk factor for problem gambling: a matched case-control study

PURPOSE

To assess whether traumatic brain injury (TBI) increases the risks of subsequent problem gambling.

METHODS

We conducted a matched case-control analysis of adults in Ontario, Canada. The study included those who self-reported their gambling activities in the Canadian Community Health Survey 2007-2008. Using Problem Gambling Severity Index, we defined cases as those who were problem gamblers and controls who were recreational gamblers. Cases were matched to controls 1:2 using propensity scores based on demographics, prior mental health, and self-reported behaviours. The main predictor was prior TBI defined as requiring emergency care and identified using ICD-10 codes from administrative health databases. We estimated the likelihood of prior TBI in problem gamblers compared to controls using conditional logistic regression.

RESULTS

Of 30,652 survey participants, 16,002 (53%) reported gambling activity of whom 14,910 (49%) were recreational gamblers and 4% (n = 1092) were problem gamblers. A total of 1469 respondents (5%) had a prior TBI. Propensity score matching yielded 2038 matched pairs with 1019 cases matched to 2037 controls. Case-control analysis showed a significant association between prior TBI and subsequent problem gambling (odds ratio 1.27, 95% confidence interval 1.07-1.51, P = 0.007). The increased risk was mostly apparent in men aged 35 to 64 years who reported alcohol use or smoking. The relative risk of problem gambling in those with two or more TBIs equated to an odds ratio of 2.04 (95% confidence interval 1.05-3.99).

CONCLUSIONS

We found that a prior TBI was associated with an increased subsequent risk of problem gambling. Our findings support more awareness, screening, and treating problem gambling risks among TBI patients.

Effect of a cognitive test at license renewal for older drivers on their crash risk in Japan

OBJECTIVE

To evaluate the effect of adding a cognitive test to a license renewal procedure for drivers aged 75 years or older in reducing their motor vehicle collisions (MVCs). The test has been obligatory since June 2009.

METHODS

Using monthly police-reported national data on MVCs from January 2005 through December 2016, we calculated the rates of MVCs per licensed driver-year by sex and age group (70-74, 75-79, 80-84 and 85 years or older) for each month together with the ratios of MVC rates of drivers in the three oldest age groups (which are subject to the test) to those of the 70-74 years group (not subject to the test) to control for extraneous factors affecting MVCs over the study period. Then, we conducted an interrupted time-series analysis by regressing the rate ratio stratified by sex and age group on the number of months from January 2005, June 2009 (when the cognitive test was introduced to a license renewal procedure) and June 2012 (when all drivers subject to the test have taken it at least once).

RESULTS

The rates showed a longitudinal decrease in male and female drivers over the study period without any apparent effects of the introduction of the cognitive test while no significant decrease was observed in the rate ratios after the introduction of the cognitive test.

CONCLUSIONS

There were no clear safety benefits of the cognitive test for drivers aged 75 years or older to reduce their MVCs.

Increased Risk of Traffic Injury After a Cerebrovascular Event

Background and Purpose- We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events. Methods- We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) between 2003 and 2013 in Ontario, Canada. Hemispheric laterality was determined using radiological and clinical findings. We identified subsequent serious injuries involving the patient as a driver using linked administrative data. Secondary outcomes included serious injuries involving the patient as a pedestrian, as a passenger, or other traumatic events (fall, fracture, ankle sprain). We used proportional hazard models accounting for death as a competing risk to test the association of hemispheric laterality and outcomes with and without adjustment for age, sex, discharge modified Rankin Scale score, home location, and prior driving record. Patients were followed through to 2017. Results- Among 26 144 patients with hemispheric cerebrovascular events, 377 subsequent serious traffic injuries as a driver (2.2 per 1000 person-year) were identified over a median follow-up of 6.4 person-years. The rate did not differ by laterality (adjusted hazard ratio, 1.00; 95% CI, 0.82-1.23). The risk of a serious traffic injury as a pedestrian was significantly higher after a right-sided than left-sided event (adjusted hazard ratio, 1.27; 95% CI, 1.02-1.58). Subsequent risks for other traumatic injuries did not differ by laterality of cerebrovascular event. Conclusions- The risk of a serious traffic injury as a pedestrian is substantially higher after a right-hemispheric cerebrovascular event compared with a left-sided event. Walking should be promoted for exercise in survivors of a stroke or transient ischemic attack, but these vulnerable road users may benefit from additional poststroke rehabilitation to optimize safety.

Gambling and Subsequent Road Traffic Injuries: A Longitudinal Cohort Analysis

BACKGROUND

To compare the risks of a road traffic injury (RTI) crash among adults who were involved in high-risk gambling and those who did not gamble.

METHODS

We conducted a linked longitudinal cohort analysis of adult persons in large population survey conducted during 2007 and 2008 in Ontario, Canada. We used responses to Problem Gambling Severity Index to distinguish persons as nongamblers, no-risk, low-risk, or high-risk gamblers. All persons were subsequently monitored for a subsequent RTI crash as a driver, pedestrian, or bicyclist up to March 31, 2014, through health insurance databases. We estimated relative risks as rate ratios (RRs) with 95% confidence intervals (95% CIs).

RESULTS

In all, 30,652 adults were included, of whom 52% self-identified as gamblers, including 49% as no-risk gamblers, 2% as low-risk gamblers, and 1% as high-risk gamblers. During a median follow-up period of 6.8 years, 708 participants (2%) were involved in 821 RTI crashes. The absolute risks of an RTI were 6.4 per 1000 person-years (95% CI 3.7-10.4) in high-risk gamblers and 3.6 per 1000 person-years (95% CI 3.2-4.0) in nongamblers. The relative risks for RTI crashes were significantly higher in high-risk gamblers than in nongamblers (adjusted RR 1.68, 95% CI 1.03-2.76). The risks for RTI crashes as a driver were augmented in high-risk gamblers than in nongamblers (RR 1.97, 95% CI 1.13-3.43).

CONCLUSIONS

We found an increased risk of an RTI crash among drivers who self-identified as high-risk gamblers. Further research exploring the underlying mechanisms of these associations might interest health professionals to monitor RTI risks in adults involved in high-risk gambling.

The Teen Driver

For many teenagers, obtaining a driver's license is a rite of passage, conferring the ability to independently travel to school, work, or social events. However, immaturity, inexperience, and risky behavior put newly licensed teen drivers at risk. Motor vehicle crashes are the most common cause of mortality and injury for adolescents and young adults in developed countries. Teen drivers (15-19 years of age) have the highest rate of motor vehicle crashes among all age groups in the United States and contribute disproportionately to traffic fatalities. In addition to the deaths of teen drivers, more than half of 8- to 17-year-old children who die in car crashes are killed as passengers of drivers younger than 20 years of age. This policy statement, in which we update the previous 2006 iteration of this policy statement, is used to reflect new research on the risks faced by teen drivers and offer advice for pediatricians counseling teen drivers and their families.

Association of Cataract Surgery With Traffic Crashes

Importance

Cataracts are the most common cause of impaired vision worldwide and may increase a driver's risk of a serious traffic crash. The potential benefits of cataract surgery for reducing a patient's subsequent risk of traffic crash are uncertain.

Objective

To conduct a comprehensive longitudinal analysis testing whether cataract surgery is associated with a reduction in serious traffic crashes where the patient was the driver.

Design, Setting, and Participants

Population-based individual-patient self-matching exposure-crossover design in Ontario, Canada, between April 1, 2006, and March 31, 2016. Consecutive patients 65 years and older undergoing cataract surgery (n = 559 546).

Interventions

First eye cataract extraction surgery (most patients received second eye soon after).

Main Outcomes and Measures

Emergency department visit for a traffic crash as a driver.

Results

Of the 559 546 patients, mean (SD) age was 76 (6) years, 58% were women (n = 326 065), and 86% lived in a city (n = 481 847). A total of 4680 traffic crashes (2.36 per 1000 patient-years) accrued during the 3.5-year baseline interval and 1200 traffic crashes (2.14 per 1000 patient-years) during the 1-year subsequent interval, representing 0.22 fewer crashes per 1000 patient-years following cataract surgery (odds ratio [OR], 0.91; 95% CI, 0.84-0.97; P = .004). The relative reduction included patients with diverse characteristics. No significant reduction was observed in other outcomes, such as traffic crashes where the patient was a passenger (OR, 1.03; 95% CI, 0.96-1.12) or pedestrian (OR, 1.02; 95% CI, 0.88-1.17), nor in other unrelated serious medical emergencies. Patients with younger age (OR, 1.27; 95% CI, 1.13-1.14), male sex (OR, 1.64; 95% CI, 1.46-1.85), a history of crash (baseline OR, 2.79; 95% CI, 1.94-4.02; induction OR, 4.26; 95% CI, 2.01-9.03), more emergency visits (OR, 1.34; 95% CI, 1.19-1.52), and frequent outpatient physician visits (OR, 1.17; 95% CI, 1.01-1.36) had higher risk of subsequent traffic crashes (multivariable model).

Conclusions and Relevance

This study suggests that cataract surgery is associated with a modest decrease in a patient's subsequent risk of a serious traffic crash as a driver, which has potential implications for mortality, morbidity, and costs to society.

Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records.

METHODS

Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC.

RESULTS

From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control.

CONCLUSION

Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.

Does Chronic Kidney Disease-Induced Cognitive Impairment Affect Driving Safety?

PURPOSE OF REVIEW

One of the principal mechanisms by which illness can affect driving safety is by impairing cognition. Nevertheless, despite the substantial evidence demonstrating cognitive impairment in chronic kidney disease (CKD), little is known about the effects of CKD on driving safety.

OBJECTIVE

Investigate the current national medical guidelines and research literature with respect to CKD and driving safety.

SOURCES OF INFORMATION

Medline, CINAHL, PEDro, Scopus as of August 2017. The most up to date national driving guidelines and available information provided by the provincial and territorial ministries of transportation across Canada.

FINDINGS

Fives studies of driving fitness in patients with CKD have been published with minimal data available for patients at early stages of the disease. Amongst these studies, only two come from an era when modern end stage renal disease therapies were routinely provided. The first study demonstrated that 40% of 186 surveyed patients on hemodialysis felt uncomfortable driving and that 1/3 of patients were involved in motor vehicle collisions (MVC) since starting dialysis. Of the patients who felt comfortable driving, more than 75% were found to be at increased driving risk. The second study reported that 15% of patients on hemodialysis were involved in MVCs over a three year span and that the "Am I A Safe Driver" assessment tool by the American Medical Association may not capture all patients at high driving risk. Despite these alarming numbers, national guidelines place few driving restrictions on this patient population and only 3 of 11 available provincial or territorial driving forms include kidney disease as a category that physicians should consider when assessing medical fitness to drive.

LIMITATIONS

Our review is limited by the lack of randomized control studies evaluating the effects of CKD on driving safety.

IMPLICATIONS

Our review demonstrates that driving safety in this patient population remains poorly understood. The limited evidence that does exist, however, suggests that these patients are at substantial risk for unsafe driving. Future research is necessary to determine the impact of CKD-associated cognitive impairment on driving risk, and to parse out the contributions of CKD and its various treatments to driving impairment.

Computer-Based Driving in Dementia Decision Tool With Mail Support: Cluster Randomized Controlled Trial

Background

Physicians often find significant challenges in assessing automobile driving in persons with mild cognitive impairment and mild dementia and deciding when to report to transportation administrators. Care must be taken to balance the safety of patients and other road users with potential negative effects of issuing such reports.

Objective

The aim of this study was to assess whether a computer-based Driving in Dementia Decision Tool (DD-DT) increased appropriate reporting of patients with mild dementia or mild cognitive impairment to transportation administrators.

Methods

The study used a parallel-group cluster nonblinded randomized controlled trial design to test a multifaceted knowledge translation intervention. The intervention included a computer-based decision support system activated by the physician-user, which provides a recommendation about whether to report patients with mild dementia or mild cognitive impairment to transportation administrators, based on an algorithm derived from earlier work. The intervention also included a mailed educational package and Web-based specialized reporting forms. Specialists and family physicians with expertise in dementia or care of the elderly were stratified by sex and randomized to either use the DD-DT or a control version of the tool that required identical data input as the intervention group, but instead generated a generic reminder about the reporting legislation in Ontario, Canada. The trial ran from September 9, 2014 to January 29, 2016, and the primary outcome was the number of reports made to the transportation administrators concordant with the algorithm.

Results

A total of 69 participating physicians were randomized, and 36 of these used the DD-DT; 20 of the 35 randomized to the intervention group used DD-DT with 114 patients, and 16 of the 34 randomized to the control group used it with 103 patients. The proportion of all assessed patients reported to the transportation administrators concordant with recommendation did not differ between the intervention and the control groups (50% vs 49%; Z=−0.19, P=.85). Two variables predicted algorithm-based reporting—caregiver concern (odds ratio [OR]=5.8, 95% CI 2.5-13.6, P<.001) and abnormal clock drawing (OR 6.1, 95% CI 3.1-11.8, P<.001).

Conclusions

On the basis of this quantitative analysis, in-office abnormal clock drawing and expressions of concern about driving from caregivers substantially influenced physicians to report patients with mild dementia or mild cognitive impairment to transportation administrators, but the DD-DT tool itself did not increase such reports among these expert physicians.

Trial Registration

ClinicalTrials.gov NCT02036099; https://clinicaltrials.gov/ct2/show/NCT02036099 (Archived by WebCite at http://www.webcitation.org/6zGMF1ky8)

Mandatory Physician Reporting of At-Risk Drivers: The Older Driver Example

Purpose of the Study

In a number of states, physicians are mandated by state law to report at-risk drivers to licensing authorities. Often these patients are older adult drivers who may exhibit unsafe driving behaviors, have functional/cognitive impairments, or are diagnosed with conditions such as Alzheimer's disease and/or seizure disorders. The hypothesis that mandatory physician reporting laws reduce the rate of crash-related hospitalizations among older adult drivers was tested.

Design and Methods

Using retrospective data (2004-2009), this study identified 176,066 older driver crash-related hospitalizations, from the State Inpatient Databases. Three age-specific negative binomial generalized estimating equation models were used to estimate the effect of physician reporting laws on state's incidence rate of crash-related hospitalizations among older drivers.

Results

No evidence was found for an independent association between mandatory physician reporting laws and a lower crash hospitalization rate among any of the age groups examined. The main predictor of interest, mandatory physician reporting, failed to explain any significant variation in crash hospitalization rates, when adjusting for other state-specific laws and characteristics. Vision testing at in-person license renewal was a significant predictor of lower crash hospitalization rate, ranging from incidence rate ratio of 0.77 (95% confidence interval 0.62-0.94) among 60- to 64-year olds to 0.83 (95% confidence interval 0.67-0.97) among 80- to 84-year olds.

Implications

Physician reporting laws and age-based licensing requirements are often at odds with older driver's need to maintain independence. This study examines this balance and finds no evidence of the benefits of mandatory physician reporting requirements on driver crash hospitalizations, suggesting that physician mandates do not yet yield significant older driver safety benefits, possibly to the detriment of older driver's well-being and independence.

An International Approach to Enhancing a National Guideline on Driving and Dementia

PURPOSE OF REVIEW

The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement.

METHODS

An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus.

RECENT FINDINGS

The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Dementia and motor vehicle crash hospitalizations: Role of physician reporting laws

OBJECTIVE

To determine the effect of physician reporting laws and state licensing requirements on crash hospitalizations among drivers with dementia.

METHODS

A study of drivers hospitalized because of vehicle crashes, identified from the State Inpatient Databases of the Agency for Healthcare Research and Quality. Multivariable logistic regression was used to examine the effect of mandatory physician reporting of at-risk drivers and state licensing requirement on the prevalence of dementia among hospitalized drivers.

RESULTS

Physician reporting laws, mandated or legally protected, were not associated with a lower likelihood of dementia among crash hospitalized drivers. Hospitalized drivers aged 60 to 69 years in states with in-person renewal laws were 37% to 38% less likely to have dementia than drivers in other states and 23% to 28% less likely in states with vision testing at in-person renewal. Road testing was associated with lower dementia prevalence among hospitalized drivers aged 80 years and older.

CONCLUSION

Vision testing at in-person renewal and in-person renewal requirements were significantly related with a lower prevalence of dementia in hospitalized older adults among drivers aged 60 to 69 years. Road testing was significantly associated with a lower proportion of dementia among hospitalized drivers aged 80 years and older. Mandatory physician driver reporting laws lacked any independent association with prevalence of dementia among hospitalized drivers.

Risk-Exposure Density and Mileage Bias in Crash Risk for Older Drivers

Crash rates per mile indicate a high risk of vehicle crash in older drivers. A reliance on mileage alone may underestimate the risk exposure of older drivers because they tend to avoid highways and travel more on nonfreeways (e.g., urban roads), which present greater hazards. We introduce risk-exposure density as an index of exposure that incorporates mileage, frequency of travel, and travel duration. Population-wide driver fatalities in the United States during 2002-2012 were assessed according to driver age range (in years: 16-20, 21-29, 30-39, 40-49, 50-59, 60-69, ≥70) and sex. Mileage, frequency, and duration of travel per person were used to assess risk exposure. Mileage-based fatal crash risk increased greatly among male (relative risk (RR) = 1.73; 95% CI: 1.62, 1.83) and female (RR = 2.08; 95% CI: 1.97, 2.19) drivers from ages 60-69 years to ages ≥70 years. Adjusting for their density of risk exposure, fatal crash risk increased only slightly from ages 60-69 years to ages ≥70 years among male (RR = 1.09; 95% CI: 1.03, 1.15) and female (RR = 1.22; 95% CI: 1.16, 1.29) drivers. While ubiquitous in epidemiologic research, mileage-based assessments can produce misleading accounts of driver risk. Risk-exposure density incorporates multiple components of travel and reduces bias caused by any single indicator of risk exposure.

Driving restrictions for patients with reflex syncope

Reflex syncope is the most common form of syncope that occurs while driving. The 2014 revision of Japanese Road Traffic Laws placed stricter driving restrictions, along with some associated legal penalties, on individuals with recurrent syncope. "Recurrent syncope" is defined as the occurrence of more than two episodes of syncope over a period of 5 years. No restrictions are recommended for private drivers unless they experience syncope without a reliable prodrome while driving or sitting. For commercial drivers, a driving restriction is recommended unless the efficacy of treatment can be confirmed. The "risk of harm" (RH) to other road users appears to be particularly high when commercial driving is involved. The RH formula is calculated using the time of driving, the type of vehicle driven, the risk of sudden cardiac incapacitation, and the probability of a fatal or injury-producing accident. Reducing the driving time or driving a lighter vehicle can reduce the RH. Physicians should talk to their patients about driving and advise their high-risk patients to refrain from driving.

Alzheimer's disease and driving: review of the literature and consensus guideline from Belgian dementia experts and the Belgian road safety institute endorsed by the Belgian Medical Association

Alzheimer's disease (AD) is a highly prevalent condition and its prevalence is expected to further increase due to the aging of the general population. It is obvious that the diagnosis of AD has implications for driving. Finally, driving discussions are also emotionally charged because driving is associated with independence and personal identity. However, it is not clear how to implement this in clinical practice and the Belgian law on driving is rather vague in its referral to neurodegenerative brain diseases in general nor does it provide clear-cut instructions for dementia or AD compared to for example driving for patients with epilepsy and as such does not prove to be very helpful. The present article reviews what is known from both literature and existing guidelines and proposes a consensus recommendation tailored to the Belgian situation agreed by both AD experts and the Belgian Road Safety Institute endorsed by the Belgian Medical Association. It is concluded that the decision about driving fitness should be considered as a dynamic process where the driving fitness is assessed and discussed early after diagnosis and closely monitored by the treating physician. The diagnosis of AD on itself definitely does not imply the immediate and full revocation of a driving license nor does it implicate a necessary referral for a formal on-road driving assessment. There is no evidence to recommend a reduced exposure or a mandatory co-pilot. A MMSE-based framework to trichotomise AD patients as safe, indeterminate or unsafe is presented. The final decision on driving fitness can only be made after careful history taking and clinical examination, neuropsychological, functional and behavioral evaluation and, only for selected cases, a formal assessment of driving performance.

Update on the Risk of Motor Vehicle Collision or Driving Impairment with Dementia: A Collaborative International Systematic Review and Meta-Analysis

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ² = 1.50, p = 0.68, I² = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road.

Impact of Prognostic Discussions on the Patient-Physician Relationship: Prospective Cohort Study

Purpose Some research has suggested that discussion of prognosis can disrupt the patient-physician relationship. This study assessed whether physician discussion of prognosis is associated with detrimental changes in measures of the strength of the patient-physician relationship. Methods This was a longitudinal cohort study of 265 adult patients with advanced cancer who visited 38 oncologists within community- and hospital-based cancer clinics in Western New York and Northern California. Prognostic discussion was assessed by coding transcribed audio-recorded visits using the Prognostic and Treatment Choices (PTCC) scale and by patient survey at 3 months after the clinic visit. Changes in the strength of the patient-physician relationship were computed as differences in patient responses to The Human Connection and the Perceived Efficacy in Patient-Physician Interactions scales from baseline to 2 to 7 days and 3 months after the clinic visit. Results Prognostic discussion was not associated with a temporal decline in either measure. Indeed, a one-unit increase in PTCC during the audio-recorded visit was associated with improvement in The Human Connection scale at 2 to 7 days after the visit (parameter estimate, 0.10; 95% CI, -0.02 to 0.23) and 3 months after the visit (parameter estimate, 0.18; 95% CI, 0.02 to 0.35) relative to baseline. Standardized effect sizes (SES) associated with an increase of two standard deviations in the PTCC at each time point were consistent with small beneficial effects (SES, 0.14 [95% CI, -0.02 to 0.29] at 2 to 7 days; SES, 0.24 [95% CI, 0.02 to 0.45] at 3 months), and lower bounds of CIs indicated that substantial detrimental effects of prognostic discussion were unlikely. Conclusion Prognostic discussion is not intrinsically harmful to the patient-physician relationship and may even strengthen the therapeutic alliance between patients and oncologists.