DOI: 10.1111/ajag.12045
Research General practitioners' opinions and attitudes towards medical assessment of fitness to drive of older adults in Ireland Sami Omer
Introduction
Sligo/Leitrim Mental Health Services, Sligo, Ireland, and Department of Psychiatry, College of Medicine, University of Dammam, Dammam, Saudi Arabia
Over the next four or five decades, there will be a substantial increase in both the number and proportion of older people in most industrialised countries [1]. While this increase is often discussed in the context of demand for general health and social care services, another key consequence is the resultant increase in driver licensing rates in this older people population [2]. The ability to drive safely requires the individual driver to possess sufficient physical and cognitive capacity to respond to unexpected situations that may occur on the road, in addition to the everyday ‘automatic’ tasks of driving.
Catherine Dolan St. John of God Hospital, Dublin, Ireland
Borislav D Dimitrov HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland, and Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
Camilla Langan Mayo Mental Health Services, Co., Mayo, Ireland
Geraldine McCarthy Sligo/Leitrim Mental Health Services, Sligo, and Sligo Medical Academy, National University of Ireland, Galway, Ireland
Objective: The study sought to assess opinions and attitudes of general practitioners (GPs) in Ireland towards fitness to drive (FTD) assessment in people older than 65 years old as well as to gather information on current assessment practices. Method: A postal-based cross-sectional survey was carried out with 603 GP practices randomly selected using the Irish College of General Practitioners database. Results: Response rate was 42.6%. The prevalence of GPs not confident in assessing FTD was less than 15% with 81% reporting the need for more education on assessing FTD, and 82% identifying that mandatory reporting of unsafe drivers posed a conflict of interest. Only 37% of GPs always/often used the Irish Road Safety Authority handbook when assessing FTD with 14% not aware of its existence. Of responders, 89% were of the opinion that a clinical assessment tool would be of benefit in assessing FTD. Conclusion: Our study highlights the need for education and training for Irish GPs on FTD assessment in the older people patient population. Key words: assessment, cross-sectional survey, fitness to drive, general practice, opinions and attitudes.
Correspondence to: Dr Sami Omer, Department of Psychiatry, College of Medicine, University of Dammam. Email: [email protected] This paper was partially presented as a poster at the 11th annual research conference, Sligo General Hospital, Ireland, 26 November 2010. Australasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
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Specific medical conditions such as epilepsy may lead to restricted driver licensing, on account of the increased risk of a collision during a seizure [3]. Similarly, drivers with diabetes or cardiovascular disease may also be at increased risk of collision due to acute hypoglycaemia [4] or sudden cardiac events at the wheel [5]. Older persons are more likely to develop serious medical conditions or be maintained on medication that may affect their driving ability [6]. This is evidenced by findings from Naughton and colleagues, who reported that more than 85% of Irish persons older than 70 years take at least one medication regularly to treat a chronic medical condition and that almost one in five persons were diagnosed with three or more chronic medical conditions [7]. Drivers aged 70 years or older have been reported to present an increased crash rate per mile driven compared with other adult groups [8,9]. It is very likely that many older drivers tend to limit their own driving as an adaptive response to functional limitations associated with aging, which culminate in the deterioration of driving skills. However, a particular concern still remains in relation to age-related cognitive limitations, given that cognitive function is recognised to decline with age, and cognitive impairment is associated with increased collision rates in older drivers [10]. There are widespread international differences in legislation governing the medical assessment of fitness to drive (FTD) in older people and resulting licensing procedures. From a European perspective, driving licence renewal procedures vary from ‘lifelong’ licences without any accompanying medical assessment to the issuing of a licence up to the age of 70 with between 3 and 5-year subsequent renewals based on medical self-assessment or medical examination [11]. In most countries, the general practitioner (GP) is the key health professional in helping to identify older drivers at increased risk of collision while driving. Currently, an Irish driving licence automatically expires when a person E33
O m e r
S ,
reaches 70 years of age. It cannot be renewed until a GP has carried out a medical examination to confirm FTD [12,13]. Irish medical practitioners may then issue a certificate of FTD for either 1 or 3 years. While mandatory reporting of driving concerns is not required in Ireland, the Road Safety Authority provides guidance to medical practitioners to assist them in FTD assessment [12]. While such guidance documents present a broad template to assist medical practitioners in assessing FTD, they are unable to take into account a range of additional factors that hinder the medical practitioner’s ability to perform a comprehensive and dispassionate assessment of FTD. Such factors include an inadequate level of knowledge of medical practitioners regarding the specific methods to assess FTD [14]. Additionally, a recommendation that a patient is not fit to drive may compromise the doctor–patient and doctor–family relationships, thus placing considerable pressure on a medical practitioner who is called upon to make such a judgement [15–17]. Loss of a driving licence may be detrimental to an older person by reducing their independence and increasing social isolation, particularly for rural dwellers with limited or no access to public transport. Consequently, older persons may have limited access to vital services, such as health care, resulting in a significantly impaired quality of life. Older persons who lose their driving licence are often required to walk instead, which is not without its own risks, as the literature reports that people older than 65 years are at greater risk of death as a pedestrian than as a car driver [11]. Taken together, concerns about safety must be balanced against the effects of depriving patients of what may be their only means of transport [18]. Therefore, such decisions are critical, and require the development of validated and accessible assessments to assist medical practitioners in reaching a decision regarding an individual’s FTD. Not all drivers age in the same way, however, and there remains considerable difficulty in separating the subgroup of ‘medically-at-risk’ older drivers from the total population [19,20]. Little is known about the opinions and attitudes of medical practitioners towards the FTD assessment process. There are no current reports in the literature of attitudes and practices of GPs regarding the assessment of FTD in an Irish setting. In light of this, a nationwide survey was undertaken to explore this issue further in the Republic of Ireland.
Method Written approval for this study was obtained from the Research Ethics Committee at the Royal College of Surgeons in Ireland. Participants A postal-based cross-sectional survey was carried out in April–June 2010. The planned population under study were 530 GPs, practising in the Republic of Ireland, in active E34
D o l a n
C ,
D i m i t r o v
B D
e t
a l .
practices including patients 65 years and older. An explicit database of members on the Irish College of General Practitioners (ICGP) website was used to identify all GP practices sorted by 26 geographical divisions known as counties, within the Republic of Ireland (n = 1267). A simple, stratified sampling strategy was used, with 29 strata corresponding to 25 Irish counties plus the County Dublin, which is divided into four areas according to the ICGP list. A list of 603 randomly selected GP practices was generated proportional to the percentage distribution of the total GP population. A random number sequence was generated for each of these GP practices. In GP practices with more than one GP practising, the first named GP within the practice according to the official ICGP website list was included in the study. As the initial sample selection was based on active GP practices, some GPs were selected twice owing to the fact that some GPs work in more than one practice. In this case, the original list was revisited and the next practice in the same area was selected instead. Contact details for practices were mostly obtained from the same website with some additional information obtained via telephone directory services.
Survey instrument A questionnaire that had been previously used in a similar study in Canada was adapted to the Irish setting, with the written permission of the principal author of the Canadian study [15]. The questionnaire contained sections on (i) driving assessment attitudes and practices and the reporting practices in those considered medically unsafe to drive, (ii) components of older people’s fitness to drive assessment, (iii) national reporting policy awareness and procedures and (iv) demographic information about the respondent (age, sex, years in practice), their type of medical practice, that is, lone GP or group practice, and their FTD assessment experience and reporting of patients to the licensing authorities. The same, original 5-point ordinal scale was also used for GP responses (i.e. from ‘strongly agree’ to ‘strongly disagree’ or ‘always’ to ‘never’). Several methods were used to maximise the response rate including personalisation via a cover letter using the GP’s name as well as self-addressed and pre-stamped return envelopes. The questionnaire was returned anonymously to ensure confidentiality, with no identifiers on the questionnaire or return envelope. GPs were requested to return an enclosed postcard with their identification information separately from their completed questionnaire, allowing the identification of respondents. A telephone call was made to those who had not responded after 1 month, as a reminder. A second mailing distribution was sent out to the nonresponders 2 months after the first mailing distribution, and contained identical components to those enclosed in the initial distribution. All responses and GP practices were coded and anonymised according to the previously planned procedures. Australasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
A s s e s s m e n t
o f
fi t n e s s
Sample size, data elaboration and statistical analyses Since the aim of this study was to assess the knowledge, opinions and attitudes of GPs in Ireland regarding FTD medical assessment in older adults, the main outcome was the prevalence of the GPs’ lack of confidence in assessing FTD. Secondary outcomes included describing and identifying possible relationships with their knowledge and opinions. The minimum sample size required to identify a 45% prevalence of the main outcome was 212 GPs (minimum 10% difference at P = 0.05, power ⱖ90%). The figure of 45% prevalence of GPs identifying lack of confidence in assessing FTD was chosen based on previous Canadian and Australian studies [15,21], both of which reported approximately 45% prevalence of GPs lacking confidence in this area. Gathered data were coded and entered into PASW Statistics 18 software. Quantitative variables were reported as means and standard deviations, with categorical variables reported using frequency (percentage). Proportions were compared using c2 test. The statistical significance was assumed at P < 0.05 unless stated otherwise.
Results A total of 257 completed questionnaires were returned (response rate of 42.6%). The majority of participants in the study were men (73%) with half the study sample practising in an urban setting. The characteristics of the respondents and frequency of patients assessed for FTD are presented in Table 1. Table 2 presents the responses of the GPs to selected questions regarding their main attitudes towards FTD assessments. The prevalence of GPs’ lack of confidence in assessing FTD was 14%. Notably, 62% of the GPs stated that they are confident in their ability to assess the driving fitness of their patients; approximately 82% of all GPs consider assessing FTD to be an important issue in their practice. Despite over 55% of the study sample reporting that GPs were the most qualified professionals to identify unsafe drivers, only 26.5% of GPs report receiving adequate training to assess FTD. Furthermore, 81% of GPs agree they would benefit from further education in assessing FTD, and 89% agree that a clinical screening instrument which helps identify drivers at increased collision risk would be of help in their practice. More than eighty percent (82%) of GPs identify that mandatory reporting of unsafe drivers poses a conflict of interest and 76% identify mandatory reporting negatively impacts on the doctor–patient relationship; 42% agree that GPs should be legally required to report unsafe drivers to the authorities. Responses to questions about frequency of practices/ activities pertaining to driving assessments and reporting are shown in Table 3. Only 37% of GPs always/often use the Irish Road Safety Authority handbook Medical Aspects of Driver Licensing: A Guide for Registered Medical PractitionAustralasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
t o
d r i v e
i n
o l d e r
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Table 1: Characteristics of GPs and FTD assessment patterns Characteristic Sex Male Female Age (years) 31–40 41–50 51–60 >60 Practice location Urban Rural Mixed Community size 10 Number of patients declared unfit the previous year 0 1–2 3–5 6–9 >10 Time spent assessing FTD 30 minutes
Frequency (%) 73.0 27.0 8.2 24.6 44.1 23.0 50.8 38.6 10.6 47.8 38.9 13.4 38.3 61.7 6.5 56.0 34.6 2.9 0.4 0.4 2.0 4.7 10.6 82.4 33.3 58.3 7.1 0.4 0.8 27.0 63.9 7.1 0.8
ers when assessing FTD, and a further 14% are not aware of this handbook. Seventy percent of the GPs rarely/never refer patients for a road assessment. Of those, male GPs were more likely to state they rarely/never refer patients for road assessment than female GPs (P < 0.001). Moreover, GPs practising in a large community size (50 001–100 000) are less likely to state they rarely/never refer patients for road assessment compared to GPs who practise in smaller communities (
Research General practitioners' opinions and attitudes towards medical assessment of fitness to drive of older adults in Ireland Sami Omer
Introduction
Sligo/Leitrim Mental Health Services, Sligo, Ireland, and Department of Psychiatry, College of Medicine, University of Dammam, Dammam, Saudi Arabia
Over the next four or five decades, there will be a substantial increase in both the number and proportion of older people in most industrialised countries [1]. While this increase is often discussed in the context of demand for general health and social care services, another key consequence is the resultant increase in driver licensing rates in this older people population [2]. The ability to drive safely requires the individual driver to possess sufficient physical and cognitive capacity to respond to unexpected situations that may occur on the road, in addition to the everyday ‘automatic’ tasks of driving.
Catherine Dolan St. John of God Hospital, Dublin, Ireland
Borislav D Dimitrov HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland, and Academic Unit of Primary Care and Population Sciences, University of Southampton, Southampton, UK
Camilla Langan Mayo Mental Health Services, Co., Mayo, Ireland
Geraldine McCarthy Sligo/Leitrim Mental Health Services, Sligo, and Sligo Medical Academy, National University of Ireland, Galway, Ireland
Objective: The study sought to assess opinions and attitudes of general practitioners (GPs) in Ireland towards fitness to drive (FTD) assessment in people older than 65 years old as well as to gather information on current assessment practices. Method: A postal-based cross-sectional survey was carried out with 603 GP practices randomly selected using the Irish College of General Practitioners database. Results: Response rate was 42.6%. The prevalence of GPs not confident in assessing FTD was less than 15% with 81% reporting the need for more education on assessing FTD, and 82% identifying that mandatory reporting of unsafe drivers posed a conflict of interest. Only 37% of GPs always/often used the Irish Road Safety Authority handbook when assessing FTD with 14% not aware of its existence. Of responders, 89% were of the opinion that a clinical assessment tool would be of benefit in assessing FTD. Conclusion: Our study highlights the need for education and training for Irish GPs on FTD assessment in the older people patient population. Key words: assessment, cross-sectional survey, fitness to drive, general practice, opinions and attitudes.
Correspondence to: Dr Sami Omer, Department of Psychiatry, College of Medicine, University of Dammam. Email: [email protected] This paper was partially presented as a poster at the 11th annual research conference, Sligo General Hospital, Ireland, 26 November 2010. Australasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
bs_bs_banner
Specific medical conditions such as epilepsy may lead to restricted driver licensing, on account of the increased risk of a collision during a seizure [3]. Similarly, drivers with diabetes or cardiovascular disease may also be at increased risk of collision due to acute hypoglycaemia [4] or sudden cardiac events at the wheel [5]. Older persons are more likely to develop serious medical conditions or be maintained on medication that may affect their driving ability [6]. This is evidenced by findings from Naughton and colleagues, who reported that more than 85% of Irish persons older than 70 years take at least one medication regularly to treat a chronic medical condition and that almost one in five persons were diagnosed with three or more chronic medical conditions [7]. Drivers aged 70 years or older have been reported to present an increased crash rate per mile driven compared with other adult groups [8,9]. It is very likely that many older drivers tend to limit their own driving as an adaptive response to functional limitations associated with aging, which culminate in the deterioration of driving skills. However, a particular concern still remains in relation to age-related cognitive limitations, given that cognitive function is recognised to decline with age, and cognitive impairment is associated with increased collision rates in older drivers [10]. There are widespread international differences in legislation governing the medical assessment of fitness to drive (FTD) in older people and resulting licensing procedures. From a European perspective, driving licence renewal procedures vary from ‘lifelong’ licences without any accompanying medical assessment to the issuing of a licence up to the age of 70 with between 3 and 5-year subsequent renewals based on medical self-assessment or medical examination [11]. In most countries, the general practitioner (GP) is the key health professional in helping to identify older drivers at increased risk of collision while driving. Currently, an Irish driving licence automatically expires when a person E33
O m e r
S ,
reaches 70 years of age. It cannot be renewed until a GP has carried out a medical examination to confirm FTD [12,13]. Irish medical practitioners may then issue a certificate of FTD for either 1 or 3 years. While mandatory reporting of driving concerns is not required in Ireland, the Road Safety Authority provides guidance to medical practitioners to assist them in FTD assessment [12]. While such guidance documents present a broad template to assist medical practitioners in assessing FTD, they are unable to take into account a range of additional factors that hinder the medical practitioner’s ability to perform a comprehensive and dispassionate assessment of FTD. Such factors include an inadequate level of knowledge of medical practitioners regarding the specific methods to assess FTD [14]. Additionally, a recommendation that a patient is not fit to drive may compromise the doctor–patient and doctor–family relationships, thus placing considerable pressure on a medical practitioner who is called upon to make such a judgement [15–17]. Loss of a driving licence may be detrimental to an older person by reducing their independence and increasing social isolation, particularly for rural dwellers with limited or no access to public transport. Consequently, older persons may have limited access to vital services, such as health care, resulting in a significantly impaired quality of life. Older persons who lose their driving licence are often required to walk instead, which is not without its own risks, as the literature reports that people older than 65 years are at greater risk of death as a pedestrian than as a car driver [11]. Taken together, concerns about safety must be balanced against the effects of depriving patients of what may be their only means of transport [18]. Therefore, such decisions are critical, and require the development of validated and accessible assessments to assist medical practitioners in reaching a decision regarding an individual’s FTD. Not all drivers age in the same way, however, and there remains considerable difficulty in separating the subgroup of ‘medically-at-risk’ older drivers from the total population [19,20]. Little is known about the opinions and attitudes of medical practitioners towards the FTD assessment process. There are no current reports in the literature of attitudes and practices of GPs regarding the assessment of FTD in an Irish setting. In light of this, a nationwide survey was undertaken to explore this issue further in the Republic of Ireland.
Method Written approval for this study was obtained from the Research Ethics Committee at the Royal College of Surgeons in Ireland. Participants A postal-based cross-sectional survey was carried out in April–June 2010. The planned population under study were 530 GPs, practising in the Republic of Ireland, in active E34
D o l a n
C ,
D i m i t r o v
B D
e t
a l .
practices including patients 65 years and older. An explicit database of members on the Irish College of General Practitioners (ICGP) website was used to identify all GP practices sorted by 26 geographical divisions known as counties, within the Republic of Ireland (n = 1267). A simple, stratified sampling strategy was used, with 29 strata corresponding to 25 Irish counties plus the County Dublin, which is divided into four areas according to the ICGP list. A list of 603 randomly selected GP practices was generated proportional to the percentage distribution of the total GP population. A random number sequence was generated for each of these GP practices. In GP practices with more than one GP practising, the first named GP within the practice according to the official ICGP website list was included in the study. As the initial sample selection was based on active GP practices, some GPs were selected twice owing to the fact that some GPs work in more than one practice. In this case, the original list was revisited and the next practice in the same area was selected instead. Contact details for practices were mostly obtained from the same website with some additional information obtained via telephone directory services.
Survey instrument A questionnaire that had been previously used in a similar study in Canada was adapted to the Irish setting, with the written permission of the principal author of the Canadian study [15]. The questionnaire contained sections on (i) driving assessment attitudes and practices and the reporting practices in those considered medically unsafe to drive, (ii) components of older people’s fitness to drive assessment, (iii) national reporting policy awareness and procedures and (iv) demographic information about the respondent (age, sex, years in practice), their type of medical practice, that is, lone GP or group practice, and their FTD assessment experience and reporting of patients to the licensing authorities. The same, original 5-point ordinal scale was also used for GP responses (i.e. from ‘strongly agree’ to ‘strongly disagree’ or ‘always’ to ‘never’). Several methods were used to maximise the response rate including personalisation via a cover letter using the GP’s name as well as self-addressed and pre-stamped return envelopes. The questionnaire was returned anonymously to ensure confidentiality, with no identifiers on the questionnaire or return envelope. GPs were requested to return an enclosed postcard with their identification information separately from their completed questionnaire, allowing the identification of respondents. A telephone call was made to those who had not responded after 1 month, as a reminder. A second mailing distribution was sent out to the nonresponders 2 months after the first mailing distribution, and contained identical components to those enclosed in the initial distribution. All responses and GP practices were coded and anonymised according to the previously planned procedures. Australasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
A s s e s s m e n t
o f
fi t n e s s
Sample size, data elaboration and statistical analyses Since the aim of this study was to assess the knowledge, opinions and attitudes of GPs in Ireland regarding FTD medical assessment in older adults, the main outcome was the prevalence of the GPs’ lack of confidence in assessing FTD. Secondary outcomes included describing and identifying possible relationships with their knowledge and opinions. The minimum sample size required to identify a 45% prevalence of the main outcome was 212 GPs (minimum 10% difference at P = 0.05, power ⱖ90%). The figure of 45% prevalence of GPs identifying lack of confidence in assessing FTD was chosen based on previous Canadian and Australian studies [15,21], both of which reported approximately 45% prevalence of GPs lacking confidence in this area. Gathered data were coded and entered into PASW Statistics 18 software. Quantitative variables were reported as means and standard deviations, with categorical variables reported using frequency (percentage). Proportions were compared using c2 test. The statistical significance was assumed at P < 0.05 unless stated otherwise.
Results A total of 257 completed questionnaires were returned (response rate of 42.6%). The majority of participants in the study were men (73%) with half the study sample practising in an urban setting. The characteristics of the respondents and frequency of patients assessed for FTD are presented in Table 1. Table 2 presents the responses of the GPs to selected questions regarding their main attitudes towards FTD assessments. The prevalence of GPs’ lack of confidence in assessing FTD was 14%. Notably, 62% of the GPs stated that they are confident in their ability to assess the driving fitness of their patients; approximately 82% of all GPs consider assessing FTD to be an important issue in their practice. Despite over 55% of the study sample reporting that GPs were the most qualified professionals to identify unsafe drivers, only 26.5% of GPs report receiving adequate training to assess FTD. Furthermore, 81% of GPs agree they would benefit from further education in assessing FTD, and 89% agree that a clinical screening instrument which helps identify drivers at increased collision risk would be of help in their practice. More than eighty percent (82%) of GPs identify that mandatory reporting of unsafe drivers poses a conflict of interest and 76% identify mandatory reporting negatively impacts on the doctor–patient relationship; 42% agree that GPs should be legally required to report unsafe drivers to the authorities. Responses to questions about frequency of practices/ activities pertaining to driving assessments and reporting are shown in Table 3. Only 37% of GPs always/often use the Irish Road Safety Authority handbook Medical Aspects of Driver Licensing: A Guide for Registered Medical PractitionAustralasian Journal on Ageing, Vol 33 No 3 September 2014, E33–E38 © 2013 The Authors Australasian Journal on Ageing © 2013 ACOTA
t o
d r i v e
i n
o l d e r
a d u l t s
Table 1: Characteristics of GPs and FTD assessment patterns Characteristic Sex Male Female Age (years) 31–40 41–50 51–60 >60 Practice location Urban Rural Mixed Community size 10 Number of patients declared unfit the previous year 0 1–2 3–5 6–9 >10 Time spent assessing FTD 30 minutes
Frequency (%) 73.0 27.0 8.2 24.6 44.1 23.0 50.8 38.6 10.6 47.8 38.9 13.4 38.3 61.7 6.5 56.0 34.6 2.9 0.4 0.4 2.0 4.7 10.6 82.4 33.3 58.3 7.1 0.4 0.8 27.0 63.9 7.1 0.8
ers when assessing FTD, and a further 14% are not aware of this handbook. Seventy percent of the GPs rarely/never refer patients for a road assessment. Of those, male GPs were more likely to state they rarely/never refer patients for road assessment than female GPs (P < 0.001). Moreover, GPs practising in a large community size (50 001–100 000) are less likely to state they rarely/never refer patients for road assessment compared to GPs who practise in smaller communities (
