Fitness to Drive: It is Time for Evidence-Based Consensus and Italian Guidelines for Medical Driving Assessment.

European Union (EU) and non-EU countries have adopted different medical procedures for the issuance and renewal of a driver's license showing relevant matters of concern. In Europe, EU directives have been only partially supplemented with national laws, and there is a paucity of evidence-based criteria and methods for fitness-to-drive assessment. For instance, there is no agreement on standards for establishing which is the competent authority charged with the medical examination. Furthermore, license conditions, restrictions, or vehicle modifications, which appear as "limited use" codes on the driver's license are not regulated. This may generate confusion and deformity when it comes to the medico-legal evaluation, with potential ethical implications due to lack of transparency and equity and legal disputes between citizens and competent authorities. In this article, Italian experts on fitness-to-drive medical assessment highlight some major issues concerning the medical driving assessment activity in the EU. The Italian experience is shown as a case study, which is representative of other EU member states, for launching a call for evidence-based consensus documents and scientific guidelines on this topic, which may be helpful to international regulators and medico-legal stakeholders.

[Assessment of ability to drive in patients with MCI and dementia]. / Beurteilung der Fahrtauglichkeit bei Patienten mit MCI und demenziellen Syndromen.

People with mild cognitive impairment and dementia are a frequent and continuously increasing patient group in practically all fields of medicine. The associated challenges involve nearly all areas of life in addition to the direct medical treatment. Assessment of the ability to drive in patients with cognitive deficits is becoming increasingly more important. What are the options available to physicians in order to make a valid assessment? Which legal aspects must be taken into consideration? Which rights and obligations arise from the framework conditions? These questions nowadays give rise to great uncertainty for many medical personnel; however, the increasing importance of these problems necessitates a clear procedure, which allows difficult decisions to be made with utmost sovereignty and legal certainty and to be able to give patients and relatives a plausible explanation. Because age is a substantial risk factor for the development of cognitive disorders, the question of the ability to drive is affected not only by neuropsychiatric diseases, such as mild cognitive disorders or dementia but also the frequently occurring somatic comorbidities. Estimation of the ability to drive is therefore a complex approach, which should be standardized in order to appreciate all relevant aspects. It would be desirable to have a practice-oriented algorithm, the formulation of which is the aim of this article. Additionally, we would like to make a contribution to road safety and make medical personnel fully aware of this topic.

The importance of context in logic model construction for a multi-site community-based Aboriginal driver licensing program.

UNLABELLED: Evidence indicates that Aboriginal people are underrepresented among driver licence holders in New South Wales, which has been attributed to licensing barriers for Aboriginal people. The Driving Change program was developed to provide culturally responsive licensing services that engage Aboriginal communities and build local capacity. AIM: This paper outlines the formative evaluation of the program, including logic model construction and exploration of contextual factors. METHODS: Purposive sampling was used to identify key informants (n=12) from a consultative committee of key stakeholders and program staff. Semi-structured interviews were transcribed and thematically analysed. Data from interviews informed development of the logic model. RESULTS: Participants demonstrated high level of support for the program and reported that it filled an important gap. The program context revealed systemic barriers to licensing that were correspondingly targeted by specific program outputs in the logic model. Addressing underlying assumptions of the program involved managing local capacity and support to strengthen implementation. DISCUSSION: This formative evaluation highlights the importance of exploring program context as a crucial first step in logic model construction. The consultation process assisted in clarifying program goals and ensuring that the program was responding to underlying systemic factors that contribute to inequitable licensing access for Aboriginal people.

[Role of the medical officer for the assessment of driving ability. Practical aspects, liability and confidentiality]. / Rôle du médecin agréé pour l'évaluation de l'aptitude à la conduite. Aspects pratiques, responsabilité et secret médical.

Every candidate for a driving license or any driver who meets a health problem must, on its own initiative, to submit to a medical examination. The list of approved doctors is available in the prefectures. There is a list of medical conditions that are incompatible with the licensing or involve restrictions on the use of the license. The treating physician is not authorized to carry out the assessment of medical fitness to drive for his own patients. This is the prefect who decides after consulting a licensed physician or medical committee composed of licensed doctors. If it deems medically necessary, the medical consultant outside medical commission may request the person to be summoned before the primary medical committee whose jurisdiction is then substituted for his. Possible advice is: fitness, temporary fitness, fitness subject to the license restrictions on use, or the inability of the candidate or driver to drive vehicles of the requested class. We emphasize the absence of shared secret between the attending physician and the medical officer or the Medical Committee.

[Assessment of driving in patients with vertigo and dizziness]. / Fahreignungsbeurteilung bei Schwindel aus neurologischer Sicht.

The driving performance of patients with dizziness and vertigo has gained only minor attention so far. Patients with permanent vestibular loss or with episodic vestibular symptoms can experience difficulties in driving a motor vehicle. The presence of a chronic or episodic syndrome presenting with dizziness and/or vertigo does not automatically exclude the ability to drive. Assessment of driving performance should consider the degree of the deficits and compensation in chronic dysfunction and the severity and frequency of attacks, prodromes and triggers of symptoms in episodic disorders.

[Assessment of mesopic and contrast vision for driving licences: which cut-off values, which methods are appropriate?]. / Untersuchung des Dämmerungs- und Kontrastsehens nach Fahrerlaubnisverordnung: Welche Grenzwerte, welche Verfahren sind geeignet?

BACKGROUND: Hitherto recommendations and thresholds for contrast tests are available for mesopic but not for photopic methods. While mesopic tests are widespread in ophthalmology, in occupational medicine photopic contrast tests are often used. With regard to the attachment 6 of the German Fahrerlaubnisverordnung (FeV) which is relevant since July 2011 we tested the specificity and sensitivity as well as the test-retest reliability of available test devices and defined cut-off values. METHODS: We examined patients with medium opacities, healthy volunteers and a sample of employees. Optovist EU, Binoptometer 4P and Pelli-Robson charts with standardised illumination were applied for contrast sensitivity testing. All these methods were compared to the Mesotest II as gold standard. We followed the recommendations of the German Qualitätssicherungs-Kommission der Deutschen Ophthalmologischen Gesellschaft (DOG) for contrast vision testing and definition of cut-off values. RESULTS: 64 patients with cataract (age 42-70 years, median 62 years), 50 pilots (age 40-69 years, median 53.5 years) and 109 employees of a transportation company (age 40-59 years, median 50 years) were included in the trial. All contrast sensitivity tests showed a good sensitivity and specificity (AUC 0.86 to 0.99). For Optovist EU and Binoptometer 4P a threshold of 15 % Weber contrast is recommended for examinations according to FeV. The test-retest reliability was high in all methods with highly significant Pearson correlation coefficients of 0.77 to 0.94 and a repeatability coefficient between 0.08 und 0.4. The standard distance of 1 m common for the Pelli-Robson chart cannot be recommended for FeV examinations, while the results at 3 m distance are comparable to those of the other contrast vision tests. The preliminary cut-off for the Pelli-Robson chart at 3 m distance is 1.65. CONCLUSIONS: Cut-off values for the lawful assessment of applicants are now available. Both Binoptometer 4P and Optovist EU proved to be appropriate and - as expected due to comparable technical properties - the same cut-off can be recommended. At 1 m distance the Pelli-Robson chart is not sensitive enough. Because the new distance of 3 m for the Pelli-Robson chart was investigated in 55 cataract patients and 10 pilots in this trial, a confirmatory trial for this distance is planned.

Variation in teen driver education by state requirements and sociodemographics.

OBJECTIVES: There is renewed attention on national standardization of formal driver education (DE) instruction and momentum toward realigning DE with its original goal of producing safer teen drivers. However, teen DE participation rates and how they differ among sociodemographic groups and in states with and without DE requirements remain largely unknown. Thus, our objective was to estimate national teen participation rates in formal classroom and behind-the-wheel DE instruction in relevant demographic subgroups and also estimate subgroup-specific participation rates by presence of a state DE requirement. METHODS: Data were collected via the National Young Driver Survey, administered to a nationally representative sample of 5665 public school 9th- through 11th-graders in Spring 2006. Analyses were restricted to 1770 students with driver licenses. Survey data were weighted to reflect national prevalence estimates. RESULTS: Overall, 78.8% of students reported participating in formal DE. However, in states without DE requirements, more than 1 in 3 students had no formal DE before licensure, and more than half had no behind-the-wheel training. Hispanics, blacks, males, and students with lower academic achievement participated in DE at markedly lower levels than counterparts in states with requirements. Notably, 71% of Hispanic students in states with no requirement received a license without receiving formal DE. CONCLUSIONS: Considerable racial/ethnic, socioeconomic, and gender disparities in DE participation may exist in states with no DE requirements. State DE requirements may be an effective strategy to reduce these disparities.

The social and policy predictors of driving mobility among older adults.

This research was designed to identify the impact of state driver's license renewal requirements on the driving mobility (i.e., the reduction or cessation of driving) of older (70 years or older) drivers in the United States. Nationally representative data from four waves (1993-2000) of the Asset and Health Dynamics of the Oldest Old study were linked to state policies on relicensing and used in a longitudinal logistic regression analysis. The author assessed the driving behaviors of a sample of 9,638 men and women. The findings demonstrate that the driving mobility of older people is influenced by state relicensing policies. The analysis indicates that five policies--accelerated renewal, mental testing, peripheral vision testing, renewal in person at age 70+ (as opposed to renewal by mail or online), and restricted licensing--have a significant effect on an older driver's decision to reduce or cease driving. The driving patterns of older adults are influenced not only by their health and socioeconomic backgrounds, but also by state relicensing policies. In terms of public policy, this result shows that there is a mechanism for extending the years of independent mobility for older people: restricted licensing.

Australian occupational therapy driver assessors' opinions on improving on-road driver assessment procedures.

OBJECTIVE: We collected practitioner opinions to improve the validity and reliability of the on-road driver assessment procedures used in Australia. METHOD: We used focus groups to document the views of experienced occupational therapy driver assessors using a purposive sampling method. RESULTS: Eight focus groups were conducted with 55 clinicians practicing in urban and rural regions. There was strong support for greater standardization of procedures for all tests. For drivers seeking unrestricted (open) licenses, use of standard routes with predetermined assessment points was important where practicable. Where use of a nonstandard route for this purpose was unavoidable, it was important to specify a minimum set of requirements related to route characteristics and assessment items. CONCLUSION: Australian occupational therapy driver assessors support greater standardization of test routes and procedures to improve reliability and validity. However, the extent to which standardization can be achieved is limited by variable road traffic environments where assessments are conducted.

An evaluation of graduated driver licensing programs in North America using a meta-analytic approach.

Most jurisdictions in North America have some version of graduated driver licensing (GDL). A sound body of evidence documenting the effectiveness of GDL programs in reducing collisions, fatalities and injuries among novice drivers is available. However, information about the relative importance of individual components of GDL is lacking. The objectives of this study are to calculate a summary statistic of GDL effectiveness and to identify the most effective components of GDL programs using a meta-analytic approach. Data from 46 American States, the District of Columbia and 11 Canadian jurisdictions are used and were obtained from the Fatality Analysis Reporting System (FARS) for the U.S. and from Transport Canada's Traffic Accident Information Database (TRAID) for Canada. The timeframe of this evaluation is 1992 through 2006, inclusive. Relative fatality risks and their 95% confidence intervals were calculated using fatality counts and population data for target and comparison groups, both in a pre-implementation and post-implementation period in each jurisdiction. The target groups were 16-, 17-, 18- and 19-year-old drivers. The comparison group was 25-54-year-old drivers. The relative fatality risks of all jurisdictions were summarized using the random effects DerSimonian and Laird model. Meta-regression using Restricted Maximum Likelihood (REML) and Markov Chain Monte Carlo (MCMC) Gibbs sampling was also conducted. Strong evidence in support of GDL was found. GDL had a positive and significant impact on the relative fatality risk of 16-year-old drivers (reduction of 19.1%). Significant effects were found for meta-regression models with 16-, 18- and 19-year-old drivers. These effects include length of night restriction in the learner stage, country, driver education in the learner stage and in the intermediate stage, whether night restrictions are lifted in the intermediate stage for work purposes, passenger restriction in the intermediate stage, whether passenger restrictions in the intermediate stage are lifted if passengers are family members, and whether there is an exit test in the intermediate stage. In conclusion, several GDL program components have an important effect on the relative fatality risk of novice drivers. These results help understand how such effects are achieved.

Motor vehicle injury, mortality, and hospital charges by strength of graduated driver licensing laws in 36 States.

BACKGROUND: To assess the relation between strength of graduated driver licensing (GDL) laws and motor vehicle (MV) injury burden, this study examined injury mortality, hospitalizations and related charges for 15 year to 17 year olds in 36 states by strength of GDL legislation. METHODS: Data sources include the CDC's Web-Based Injury Statistics Query and Reporting System (WISQARS) and the 2003 Healthcare Cost and Utilization Kids' Inpatient database (KID). Hospital admissions for injuries in 15 year to 17 year olds (n = 49,520) are unweighted. Injury severity was assessed using ICDMAP-90 and International Classification of Injury Severity Scores. The Insurance Institute for Highway Safety rating system was used to categorize legislative strength: good, fair, marginal/poor, and none. Logistic regression was used to assess independent predictors of MV injury. RESULTS: MV injury accounted for 14.6% of all-cause injury-related hospital admissions with 47.7% classified as drivers. Total MV occupant mortality was 14.6% lower after enactment of GDL with greater improvement observed in the good law category (26.0%). In multivariate models for hospitalized injury, all GDL law categories were protective for MV driver injury in 16 year olds. Compared with whites, black and Hispanic teens were more frequently injured as passengers than drivers. The contribution of MV occupant to all-cause injury-related hospital charges was 16.0% lower in good versus no-GDL categories and 39.5% lower for MV drivers. CONCLUSIONS: These findings suggest that the presence of any GDL legislation is associated with a lower burden of MV-related injury and expenditures with the largest differences observed for 16-year-old drivers.

The opinions of newly licensed drivers in New Zealand on the minimum car driver licensing age and reasons for getting a licence.

AIM: To investigate the opinions of newly licensed drivers towards the minimum age of car driver licensing, and reasons for getting a licence. METHOD: The New Zealand Drivers Study (NZDS) is a prospective cohort study of 3992 newly licensed car drivers in New Zealand, recruited between 1 February 2006 and 31 January 2008 from driver licensing agencies and licensing courses throughout New Zealand. The cohort comprises 51% females and 49% males, 49% were aged 15 years and 28% 16-17 years, 55% self-identified as New Zealand European, 21% Maori, 13% Pacific, 11% Asian, and 15% as "other". After passing the learner licence theory test all participants completed a questionnaire that included a range of questions on driver licensing topics, including minimum driver licence age and reasons for getting a car driver's licence. RESULTS: Overall, 51% of newly licensed drivers supported 15 years as the minimum age to start licensing but this varied significantly by the age, gender, and residential location of the learner driver. The most frequently reported reason for getting a licence related to independence and freedom. This applied equally to males and females, rural and urban drivers, and across all ages, although for learner drivers aged 18+ years, to drive to work was also a very important reason for having a licence. CONCLUSION: Contrary to what many may believe to be the case, the evidence presented here showed that there was not universal opposition by young people to raising the driver licensing age. Also those in rural and urban areas had much in common with respect to the reasons for obtaining a licence. With respect to the latter it is worth noting that travel for work was of most relevance to the learner drivers aged 18 years or older. Overall, these findings suggest that increasing the minimum age for licensing would have relatively little impact on essential travel among young people in New Zealand.

'Low mileage bias' and related policy implications--a cautionary note.

This research examined a relationship asserted in recent literature in the field of traffic safety and injury prevention--that a significant indicator for elevated crash risk among older drivers, and potential trigger for individualized assessment at license renewal, is a low (<3000 km) annual driving distance. Sampling problems in earlier reports, in particular a reliance on self-report measures of both exposure and crash involvement, are highlighted. A pattern of misestimation for those who self-report an extremely low or extremely high number of miles driven is documented, that casts serious doubt upon the effect reported earlier. The present findings underscore the need for objective exposure measures for future analyses of this nature, and impact discussions about the feasibility of this suggested strategy to aid detection of at-risk older drivers by licensing officials.

[Fitness-to-drive assessment in drivers with neurological and neuromuscular disorders at the driving test centres]. / Evaluación en los centros de reconocimiento de conductores de los pacientes con patología neurológica y neuromuscular.

INTRODUCTION: Drivers with a neurological pathology have a greater risk of involvement in traffic accidents than healthy drivers. AIM: To evaluate the fitness to drive of drivers with a neurological or neuromuscular pathology. SUBJECTS AND METHODS: 5,234 drivers attending two Medical Driver Test Centres with the aim of carrying out a medical-psychological examination to obtain or renew their driving license were included in the study. Information was obtained concerning sociodemographic aspects, driving habits, the referred pathology and consumption of medicaments and alcohol. RESULTS: 1.4% of the drivers presented a neuromuscular or neurological pathology. The most frequent were muscular disorders of a neurological origin (32.5%), a history of cerebrovascular accidents (27%) and epilepsy (24.3%). 21.6% of the drivers were considered 'fit', 77.1% were 'fit with restrictions', and only 1.3% were considered 'unfit' to drive. CONCLUSIONS: The great majority of drivers (98.7%) with a neurological pathology are considered 'fit' or 'fit with restrictions' to drive. Even though only a small percentage of divers with neurological pathologies are considered 'unfit' to drive, given their increased risk of involvement in traffic accidents, an early, individual evaluation of these patients' fitness to drive, taking into account the associated pathology, prescribed medication, consumption of alcohol and age, would seem necessary.

Trends in young driver risk and countermeasures in European countries.

This paper reviews European trends regarding young drivers' accident risk and the effects of countermeasures. Young driver risk differs between countries, and has improved in the last decade, probably as a result of general improvements in road safety levels. Young male drivers' relative risk is rising, indicating that current policies are less effective for males than for females. Further research is needed to understand the causes of this development. In Europe, most countries are moving toward multiphase licensing systems, including elements like accompanied driving, protective measures, and probation periods. European evaluation studies show mixed results regarding these elements, pointing to a need for more research into the effective components.

A population-based study of crashes involving 16- and 17-year-old drivers: the potential benefit of graduated driver licensing restrictions.

OBJECTIVE: To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs). METHODS: Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16-17 years old) relative to adult drivers (18-59 years old). RESULTS: TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone. CONCLUSIONS: TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.

The effect of state regulations on motor vehicle fatalities for younger and older drivers: a review and analysis.

Policymakers have had a long-standing interest in improving the motor vehicle safety of both younger and older drivers. Although younger and older drivers share the distinction of having more crashes and fatalities per mile driven than other age groups, the problems posed by these two groups stem from different origins and manifest in different ways. A number of state-level policies and regulations may affect the number of motor vehicle crashes and fatalities in these two high-risk groups. A critical review of the existing literature in regard to the risk factors and the effects of various policy measures on motor vehicle crashes in these two high-risk populations provides direction for policymakers and high-priority areas of interest for the research community.