Blog | Tuesday, October 2, 2012

QD: News Every Day--Ease into talks with potentially unfit drivers

Counseling potentially unfit drivers decreases trauma from road crashes but may risk mood disorders and the lead to patients not returning to their physicians, a study found.

Physicians in Ontario, Canada, have had to report medical conditions that make it unsafe to drive since 1968, but compliance was low. In 2006, Ontario offered $36.25 for physicians to provide warnings to patients who are potentially unfit to drive.

Researchers identified consecutive patients who received a medical warning from April 2006 and December 2009 from a physician who judged them to be potentially unfit to drive. These were compared them to emergency department visits for road crashes before the warning and after the warning.

Results appeared in the New England Journal of Medicine.

More than 100,000 patients received warning from nearly 6,100 physicians. During the 3-year baseline interval, there were 1,430 road crashes in which the patient was a driver and presented to the emergency department (4.76 events per 1,000 persons annually, which was about twice the rate in the general population. During the 1-year subsequent interval, there were 273 road crashes (2.73 events per 1,000 persons annually, which was still higher than the rate in the general population). This was a reduction of approximately 45% in the annual rate of crashes per 1,000 patients after the warning (P less than 0.001).

Researchers noted that medical warnings were associated with an increase in subsequent emergency department visits for depression and a decrease in return visits to the responsible physician.

"The reduction in risk was immediate, substantial, and sustained, and it was not attributable to population shifts, confounding by differences in patient characteristics, concurrent temporal trends, or a significant change in events in which the patients were involved as passengers or pedestrians," researchers wrote.

But they added that "[P]hysicians' warnings to unfit drivers are associated with a significant increase in depression, can compromise the doctor-patient relationship, and still do not reduce the patient's risk to the level of risk in the general population. Consequently, clinical judgment is needed in deciding which patients are most likely to benefit from a warning."

For strategies for easing seniors into the subject, the Annual Wellness Visit that is now covered by Medicare is a good opportunity to talk about driving with older patients, said one internist and ACP Fellow.

Hollis D. Day, MD, suggests routinely asking seniors about changes in their driving patterns in the past year and any recent accidents or violations. If a patient seems like a potential driving risk, he or she can be asked a list of 10 standard questions from the AMA Physician's Guide to Assessing and Counseling Older Drivers.

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