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.

Excessive daytime sleepiness in obstructive sleep apnea: implications for driving licenses.

PURPOSE: Excessive daytime sleepiness (EDS) while driving is a major international public health issue resulting in a more than doubled risk of motor vehicle accidents (MVAs). Obstructive sleep apnea (OSA) is the most frequent medical cause of EDS. Therefore, the European Union Directive 2014/85/EU determined that "untreated moderate to severe OSA coincident with EDS constitutes a medical disorder leading to unfitness to drive." The paper aims are to provide a brief review of sleepiness and its implications for driving safety, as well as to describe the subjective and objective methods to accurately evaluate EDS in order to assess fitness to drive in patients with OSA. METHODS: We examined databases including PubMed, Medline, and EMBASE using the search terms "sleepiness at the wheel, excessive daytime sleepiness, sleepiness measure, sleep-wake cycle, obstructive sleep apnea, driving license, fitness to drive." RESULTS: Significant interindividual variability in EDS exists in patients with comparable severity of OSA. Objective methods of measuring EDS are too expensive and time consuming to be suitable for the certification of driving licenses. The reliability of subjective methods depends upon the clinical setting and subjective tools assess only limited aspects of EDS. Objective measures, such as biochemical biomarkers, must, therefore, support subjective methods. CONCLUSIONS: Extensive data have supported different subjective and objective methods for the appraisal of EDS in patients with OSA depending upon the clinical and experimental setting. Challenges remain to determine an appropriate tool for the evaluation of fitness to drive.

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.

The impact of changes to the NSW graduated driver licensing system on subsequent crash and offense experience.

INTRODUCTION: In mid-2007 the State of New South Wales (NSW) in Australia introduced modifications to the existing graduated driver licensing system, lengthening the mandatory number of supervised hours for learner drivers aged under 25 years from 50 to 120 and extending the minimum learner period from 6 to 12 months. Additional driving restrictions were also introduced for young drivers in the two provisional licensed periods, P1, P2. This paper aims to evaluate this change by comparing the crash and offense experiences of young learner drivers before and after it occurred. METHOD: From driver licensing files supplied by the NSW transport authority two cohorts of persons obtaining their initial learner's permits in the year prior to the changes and in the subsequent year were constructed with demographic data, dates of transition to the driving phases, dates of crashes, and dates and types of traffic offenses. Both cohorts comprised around 100,000 individuals. Crash rates per 100 years of person-time under observation post P1 with their standard errors were calculated. Using a survival-analytic approach the proportion of crashes of all types were graphed in three month periods post P1. Sexes were treated separately as were initial learner ages of 16, 17, 18-21, and 22-24 years. The distribution of traffic offense types during P1 and P2 phases were also compared. With such large numbers formal statistical testing was avoided. RESULTS: No meaningful differences in the crash or offense experiences of the two cohorts in either sex or at any age were observed. Delaying progress to unsupervised driving has road safety benefits. CONCLUSIONS: At least in conditions similar to those in NSW, requiring more than 50 h of supervised driving seems to have few road safety benefits. Practical applications: Licensing authorities should be cautious in extending the mandated number of supervised driving hours beyond 50.

Teen driver licensure provisions, licensing, and vehicular fatalities.

Between 1996 and 2015, vehicular fatalities per capita involving 16- to 17-year-old drivers declined by 68.7%. During this same period, states enacted teen driver licensure provisions in an á la carte fashion, now collectively referred to as graduated driver licensing (GDL) programs, that restricted teen driving. While the literature demonstrates that 'good' GDL programs reduce vehicular fatalities, how these reductions occur remains open. In this study, separate GDL provisions and no pass, no drive laws are studied to understand reduction mechanisms. The evaluation is based on a state-by-year panel and uses difference-in-difference and triple-difference specifications to identify causal impacts on rates of licensing, vehicular fatalities, and fatalities per licensee. The empirical results find that the minimum intermediate licensing age of 16.5 or older provision reduces licensing of 16- to 17-year-old teens by 20.1%, and no other licensure provision consistently impacts licensing. In addition, vehicular fatalities decrease from the minimum intermediate licensing age of 16.5 or older provision by 22.7%, the driver's education reduces supervised hours provision by 5.9%, and no pass, no drive laws by 7.3%, while vehicular fatalities increase from the supervised driving hours required provision by 6.3%. Furthermore, only teen driver cellphone or texting bans have impacts on vehicular fatalities per 16- to 17-year-old licensed female and few long-term impacts are identified on those ages 18-20 who 'graduated' from licensing programs. This research suggests that GDL programs affect vehicular fatalities mostly through incapacitation, rather than programmatically.

[Evaluation of cardiovascular diseases in connection with the issuing or renewal of driving licenses following the European Union law harmonization]. / Cardiovascularis betegségek megítélése a gépjármuvezetoi engedélyek kiadásának vagy meghosszabbításának szempontjából az európai uniós jogharmonizációt követoen.

The European Union (EU) law harmonization expects from each EU country to apply the same principles and same standards of the medical evaluation of driving licenses. All EU member states have to apply common evaluations of the driving licenses - based on the EU Regulation 2016/1006 - at the latest from January of this year. Hungary launched this new regulation on the 12th of January 2018. The most important source document of the current national regulation is the expert consensus document "New Standards for Driving and Cardiovascular Diseases" published in 2013. This is the professional evaulation of the cardiovascular diseases which can influence driving, and its importance is highlighted because even the Hungarian law listed this document as a resource. In this summary, in accordance with the current law, we provide a practical guide for the day-to-day work of assessing the permission of driving licence in connection with the different kinds of cardiovascular diseases. Orv Hetil. 2019; 160(10): 370-377.

Renewal of driving license in India and glaucoma: A study of prevalent practice and its lacunae.

PURPOSE: Glaucoma affects different aspects of vision including visual field. This prospective observational study aims to collect details of driving license (DL) renewal procedure (in an urban metro in India) among patients with diagnosed glaucoma and the method of reporting of vision-related requirements during renewal. METHODS: One-hundred patients with diagnosed glaucoma above 40 years, having valid DL (with at least one renewal cycle), were included. Patients with other ocular comorbidities were excluded. Driving Habits Questionnaire and a questionnaire about license renewal were administered. Driving eligibility was compared to international guidelines. RESULTS: Study population included patients with 69% early, 29% moderate, and 2% advanced glaucoma. Sixteen percent of patients had stopped driving. Legal license renewal procedure was bypassed by 45%. Form-1 was not submitted by 43% and 49% did not submit Form-1A at the time of renewal. Only 7.01% mentioned about glaucoma in the self-declaration form. None were asked about their visual field during renewal. Among 61 patients who submitted a medical certificate, the undersigning doctor was an ophthalmologist in only six patients. Thirty percent patients with valid Indian DL would not have satisfied International College of Ophthalmologists guidelines. Driving difficulties were experienced by 44%, more so in advanced glaucoma (F (1, 82) = 22.12, P < 0.001). CONCLUSION: Vision-related testing at the time of renewal of DL is inadequate in India. Chronic eye diseases such as glaucoma are commonly not self-declared or detected at pre-renewal testing. Clear-cut guidelines about visual requirements and implementation are required to prevent road traffic events because of vision-related errors.

Strain out a gnat and swallow a camel? - vision and driving in the Nordic countries.

PURPOSE: This study describes the present legislation for visual requirements for driving in the Nordic countries in relation to the European Driving License Directive. METHODS: Information about the formal legislation was gathered from each countries legal text. Further information about the implementation and common practices were achieved from national authorities in vision and driving. RESULTS: Even though the Nordic countries use the same framework of legislation, the implementation varies widely. Sweden and Norway have more specified visual field requirements than the others. On the other hand, no periodic testing of visual acuity (VA) is performed in Sweden as in all other Nordic countries. Physicians on Iceland are not obliged to report a person no longer fulfilling the visual requirements, as in other Nordic countries. In Denmark, Finland and Norway a person may apply for dispensation from the requirements by performing a practical driving test. In Sweden, a person applying for dispensation can undergo a traffic simulator test. CONCLUSION: Because of the national legislation in the Nordic countries, a person with a visual impairment may be given different permissions depending on which country they live in. As the inhabitants in the Nordic countries frequently cross the regional borders, a harmonization of the legislation would be of value. More research in this field could provide future standards, combining the greatest autonomy with the highest possible safety.

Comparison of Unsafe Driving Across Medical Conditions.

OBJECTIVE: To compare risks of unsafe driving in patients with medical conditions. METHODS: This large population-based study included all patients who were referred for a fitness-to-drive evaluation at an official driving evaluation center in 2013 and 2014. Risks of unsafe driving included physician's fitness-to-drive recommendation, comprehensive fitness-to-drive decision, motor vehicle crash history, and traffic violation history. RESULTS: A total of 6584 patients were included in the study. Risks of unsafe driving were significantly different across medical conditions (P<.001 for all outcome measures). Patients with neurological conditions comprised the majority of the database (4837; 74%), but were not at the highest risk for unsafe driving. Patients with psychiatric conditions or substance abuse did worse on most driving safety outcomes, despite their low representation in the total sample (359 [6%] and 46 [1%], respectively). CONCLUSION: The risk of unsafe driving varied greatly across medical conditions. Sensitization campaigns, education, and medical guidelines for physicians and driver licensing authorities are warranted to identify patients at risk, especially for those with psychiatric conditions and substance abuse problems.

[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.

Implementation of a teaching programme to improve doctors' awareness of DVLA guidelines: a multicentre study.

INTRODUCTION: Over half of the UK population holds a driver's licence. Driver and Vehicle Licensing Authority (DVLA) guidelines are available for conditions from most specialties. Despite this, no focused training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching programme to improve guideline awareness. METHODS: A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later, a single-session teaching programme was implemented. The questionnaire was redistributed. Preintervention and postintervention scores were compared using the Wilcoxon rank sum test. RESULTS: 139 preteaching and 144 post-teaching questionnaires were completed. Implementation of a single-session teaching programme significantly improved the knowledge of DVLA guidelines in all five areas explored. Median scores: neurology, preteaching 40%, post-teaching 100%, p<0.001; cardiology, 0%, 100%, p<0.001; drug and alcohol misuse, 0%, 100%, p<0.001; visual disorders, 40%, 100%, p<0.001; respiratory disorders, 20%, 100%, p<0.001; and overall, 28%, 92%, p<0.001. CONCLUSIONS: Knowledge of DVLA guidelines among our cohort was poor. Implementation of a single-session teaching programme can significantly improve guideline knowledge and awareness, serving as a cost-effective intervention.

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.

[Fitness to drive under traffic ophthalmological aspects in elderly drivers]. / Fahreignung unter verkehrsophthalmologischen Aspekten beim älteren Fahrzeuglenker.

The Federal Roads Office (FEDRO), Switzerlands federal authority carries responsibility for the action program "Via Sicura" in order to reduce drastically the number of road traffic fatalities and serious injuries on Swiss roads. The revision of the VZV (Verkehrszulassungsverordnung) included in this program will come in to force on 1.July 2016. On that account the legal medical requirements for driver will be renewed. In particular, the requirements for vision (visual acuity, visual field) will be adjusted to international standards. Due to demographic changes the number of elderly drivers with old age (85 ­ 90+) with eye associated diseases increases. Therefore, questions concerning traffic ophthalmological problems have to be increasingly considered within traffic medical assessments. The driver's vision in traffic's safety must enable him to perceive relevant information, process information quickly and perform an adequate reaction in time, even if visibility is limited (e. g. due to rain, night, darkness) or in the presence of physical or psychical constraints.

Meeting the UK driving vision standards with reduced contrast sensitivity.

PurposeThe visual standard to hold a UK driver's license since 2012 includes visual acuity (VA) measured indoors and the ability to read a car numberplate outdoors. Individuals with reduced contrast sensitivity may have greater visual difficulties outdoors. The agreement between the two tests in the presence of combined reduction in contrast sensitivity and VA was investigated.MethodsSimulation glasses ('sim-specs') were used to reduce both high-contrast VA and contrast sensitivity (CS). Following evaluation of the influence of sim-specs on VA and CS, levels 2 to 4 were chosen to give a range of VAs on either side of the driving standard of 6/12. Sixty-two participants wearing sim-specs then had VA tested with Snellen and ETDRS charts indoors, and ability to read a numberplate assessed outdoors as per DVLA regulations.ResultsSim-specs reduced VA and CS by ~0.10 logMAR VA per 0.10 logCS. The sensitivity of test chart VA <6/12 to correctly predict failure on the numberplate was 61% for Snellen and 56% for ETDRS.ConclusionFalse-negative and -positive rates were higher than in a previous study with uncorrected refractive error only. Reduced CS increased the lack of agreement between the two driving vision standards, which likely occurs as the VA test is performed indoors and the numberplate test outdoors. The increased likelihood of failing the numberplate test even though VA is 6/12 or better needs to be considered when advising patients on fitness to drive who have ocular disease such as cataract.