Medical referral and license disposition for drivers in Iowa

Introduction: Driver retirement and determination of fitness-to-drive are important aspects of reducing the risk of motor-vehicle collision for an older driver. A lack of information about the review process may lead to poor evaluation of drivers or an increased testing burden to referred drivers. Methods: This paper evaluates the license review process for the state of Iowa. We evaluated data from January 2014 to January 2018 and described the source of referral, testing process, and ultimate license disposition. Cox proportional hazards for competing risk were used to determine the risk of having a change in restrictions on the license and the risk of license denial. Results: 20,742 individuals were followed through the medical referral process. The most common source of referrals was licensing officials (39.7%). Drivers referred by licensing officials were less likely to be denied their license when compared to drivers from other sources (HR = 0.92 95%CI: 0.87–0.98); however, licensing official referrals were more likely to result in license restrictions compared to other sources (HR = 1.91, 95%CI: 1.82–2.00). Drivers referred by either law enforcement or a physician were more likely to ultimately have their license denied. Conclusions: Physician and law enforcement referred the drivers most likely to have their license denied. A smaller proportion of drivers were referred by physicians and law enforcement compared to licensing officials. Practical Applications: Licensing agencies should work with physicians and law enforcement to identify drivers who may need a review of their license. Comprehensive tracking of all medical referrals for a driver’s license review is important for individual states to understand the burden of their driver referral process and for identifying referral sources with a high proportion of referrals with no licensing change for targeted outreach and education.     

Continued trends in older driver crash involvement rates in the United States: Data through 2017–2018

Introduction: With the growing older adult population due to the aging baby-boom cohort, there was concern that increases in fatal motor-vehicle crashes would follow. Yet, previous analyses showed this to be untrue. The purpose of this study was to examine current trends to determine if previous declines have persisted or risen with the recent increase in fatalities nationwide. Methods: Trends among drivers ages 70 and older were compared with drivers 35–54 for U.S. passenger vehicle fatal crash involvements per 100,000 licensed drivers from 1997 to 2018, fatal and all police-reported crash involvements per vehicle miles traveled using the 1995, 2001, 2009, and 2017 National Household Travel Surveys, and driver deaths per 1,000 crashes. Results: Since the mid-1990s, fatal crashes per licensed driver trended downward, with greater declines for drivers ages 70 and older than for middle-aged drivers (43% vs. 21%). Fatal crash rates per 100,000 licensed drivers and police-reported crash rates per mile traveled for drivers ages 70–79 are now less than those for drivers ages 35–54, but their fatal crash rates per mile traveled and risk of dying in a crash remain higher as they drive fewer miles. As the economy improved over the past decade, fatal crash rates increased substantially for middle-aged drivers but decreased or remained stable among older driver age groups. Conclusions: Fatal crash involvements for adults ages 70 and older has recently increased, but they remain down from their 1997 peak, even as the number of licensed older drivers and the miles they drive have increased. Health improvements likely contributed to long-term reductions in fatal crash rates. As older drivers adopt vehicles with improved crashworthiness and safety features, crash survivability will improve. Practical Application: Older adults should feel confident that their independent mobility needs pose less risk than previously expected.     

The overall program effects of California's 3-Tier Assessment System pilot on crashes and mobility among senior drivers

IntroductionIn 2007, the California Department of Motor Vehicles (DMV) undertook a pilot study of the 3-Tier Assessment System, the purpose of which was to examine, in a large-scale real-time public agency setting, the effectiveness of this method for both reducing the crash risk of individual drivers and for extending the safe driving years of Californian drivers of all ages.MethodThe 3-Tier Assessment System consisted of tiered series of screening tools incorporated into the in-office driver's license renewal process. These screening tools identified drivers with various kinds of functional limitations (physical, visual, and cognitive/perceptual), that might impact safe driving. Paired with the screening tools were educational materials designed to improve drivers' knowledge of their own limitations, including compensating techniques. The present study is a population-based evaluation of the effects of the pilot on subsequent crash risk and mobility outcomes (including delicensure) of participating drivers age 70 and older. Pilot participants were compared with two control groups processed according to standard California DMV license renewal procedures. Because the 3-Tier Assessment System was designed to identify limitations normally associated with aging, the present analyses focus on drivers age 70 and older. However, it should be emphasized that during the 3-Tier pilot the screening tools were applied to drivers of all ages.ResultsThere were two main findings. First, there were no consistent, statistically significant differences between the pilot and control groups in crash risk in the two years following screening. Second, pilot participants experienced statistically significant effects on mobility. These effects included delays in time to complete their license renewal, an increase in the number of assigned license restrictions, and an increase in the number of customers failing to renew their driving privilege.ConclusionsBased on these findings, suggestions for further research are made.Impact on industryNone.     

Effectiveness of mandatory license testing for older drivers in reducing crash risk among urban older Australian drivers

Most licensing jurisdictions in Australia maintain mandatory assessment programs targeting older drivers, whereby a driver reaching a specified age is required to prove his or her fitness to drive through medical assessment and/or on-road testing. Previous studies both in Australia and elsewhere have consistently failed to demonstrate that age-based mandatory assessment results in reduced crash involvement for older drivers. However studies that have based their results upon either per-population or per-driver crash rates fail to take into account possible differences in driving activity. Because some older people maintain their driving licenses but rarely if ever drive, the proportion of inactive license-holders might be higher in jurisdictions without mandatory assessment relative to jurisdictions with periodic license assessment, where inactive drivers may more readily either surrender or lose their licenses. The failure to control for possible differences in driving activity across jurisdictions may be disguising possible safety benefits associated with mandatory assessment. The current study compared the crash rates of drivers in Melbourne, Australia, where there is no mandatory assessment and Sydney, Australia, where there is regular mandatory assessment from 80 years of age onward. The crash rate comparisons were based on four exposure measures: per population, per licensed driver, per distance driven, and per time spent driving. Poisson regression analysis incorporating an offset to control for inter-jurisdictional road safety differences indicated that there was no difference in crash risk for older drivers based on population. However drivers aged 80 years and older in the Sydney region had statistically higher rates of casualty crash involvement than their Melbourne counterparts on a per license issued basis (RR: 1.15, 1.02-1.29, p=0.02) and time spent driving basis (RR: 1.19, 1.06-1.34, p=0.03). A similar trend was apparent based on distance travelled but was of borderline statistical significance (RR: 1.11, 0.99-1.25, p=0.07). Collectively, it can be inferred from these findings that mandatory license re-testing schemes of the type evaluated have no demonstrable road safety benefits overall. Further research to resolve this on-going policy debate is discussed and recommended.     

Poverty as a determinant of young drivers' fatal crash risks

Problem

U.S. teenaged and young-adult drivers' elevated rates of fatal traffic crash involvement typically are attributed to biological and developmental risk-taking associated with young age. However, young drivers differ from older ones along several sociodemographic dimensions, including higher poverty rates and greater concentration in poorer areas, which may contribute to their risks.

Method

Using Fatality Analysis Reporting System, Census, and Federal Highway Administration data for 1994-2007, bivariate and multivariate regression analyses were conducted of fatal motor-vehicle crash involvements per 100 million miles driven by driver age (16 through 74) and state along with 14 driver-, vehicle-, and state-level variables.

Results

Driver age was not a significant predictor of fatal crash risk once several factors associated with high poverty status (more occupants per vehicle, smaller vehicle size, older vehicle age, lower state per-capita income, lower state population density, more motor-vehicle driving, and lower education levels) were controlled. These risk factors were significantly associated with each other and with higher crash involvement among adult drivers as well.

Summary and Discussion

The strong association between fatal crash risk and environments of poverty as operationalized by substandard vehicle and driving conditions suggests a major overlooked traffic safety factor particularly affecting young drivers.     

Michigan's graduated driver licensing program: evaluation of the first four years

INTRODUCTION: To evaluate the four-year outcome of Michigan's graduated driver licensing (GDL) program, motor-vehicle crash data for 16-year-old drivers in 1996 (pre-GDL), and 1998-2001 (post-GDL) were analyzed. METHOD: Relative risks and 95% confidence intervals for several crash types were computed, and pre-post-GDL population-based crash rates were compared. Reductions in crash risks among 16-year-olds previously found in 1998 and 1999 were generally maintained in 2000 and 2001. RESULTS: Reductions in crash risk among 16-year-olds from 1996 to 2001 were 29% for all, 44% for fatal, 38% each for nonfatal-injury and fatal-plus-nonfatal-injury, 32% for day, 31% for evening, 59% for night, 32% for single-vehicle, and 28% for multi-vehicle crashes. Even after adjusting for more general population-wide changes among drivers 25 years and older that might have contributed to changes in 16-year-old crash risk, reductions remained impressive (19% for all crashes in 2001). IMPACT ON INDUSTRY: As one approach to reducing teenage motor-vehicle morbidity and mortality, GDL remains promising.     

Graduated driver licensing: the New Zealand experience

In New Zealand, on 1 August 1987, a three-stage graduated driver licensing (GDL) system that applied to all new drivers aged 15-24 years was introduced. The essential elements of GDL were a 6-month learner license (supervised driving) and an 18-month restricted license stage (with restrictions on night driving and carrying passengers). A blood alcohol limit of 0.03 mg% applied at both stages. EVALUATION STUDIES: Early studies indicated that young people were reasonably accepting of the restrictions, with the passenger restriction being the least acceptable. Problems of compliance with the restricted license driving restrictions were reported. Evaluations of the impact of the graduated driver licensing (GDL) on serious traffic-related injury showed that up until 1991-1992, an 8% reduction could be attributed to GDL. At this time, it was considered that reduced exposure was the main reason for this reduction. However, the number of fatalities and hospital admissions among young people continued to decline, as did the population rate and the rate per number of licensed drivers among the young driver age group. A further evaluation study showed that drivers with a restricted license had a smaller proportion of crashes at night, and with passengers, compared with drivers licensed before GDL. IMPACT OF GDL: These results suggested that GDL restrictions had contributed to the reduction in crashes among young people and that it was not simply a case of reduced exposure to risk. An update of the most recent crash statistics indicated that, compared with older age groups, the fatal and serious injury crash rate among young people has remained substantially below the pre-GDL level. This suggests that the impact of GDL has not diminished over time.     

Driver licensing,motor-vehicle crashes,and moving violations among older adults

IntroductionDriving is important for well-being among older adults, but age-related conditions are associated with driving reduction or cessation and increased crash risk for older drivers. Our objectives were to describe population-based rates of older drivers’ licensing and per-driver rates of crashes and moving violations.Methods: We examined individual-level statewide driver licensing, crash, and traffic citation data among all New Jersey drivers aged ≥ 65 and a 35- to 54-year-old comparison group during 2010–2014. Rate ratios (RR) of crashes and moving violations were estimated using Poisson regression.Results: Overall, 86% of males and 71% of females aged ≥ 65 held a valid driver’s license. Older drivers had 27% lower per-driver crash rates than middle-aged drivers (RR: 0.73, 95% CI: 0.73, 0.74)—with appreciable differences by sex—but 40% higher fatal crash rates (RR: 1.40 [1.24, 1.58]). Moving violation rates among older drivers were 72% lower than middle-aged drivers (RR: 0.28 [0.28, 0.28]).Conclusion: The majority of older adults are licensed, with substantial variation by age and sex. Older drivers have higher rates of fatal crashes but lower rates of moving violations compared with middle-aged drivers.Practical applications: Future research is needed to understand the extent to which older adults drive and to identify opportunities to further reduce risk of crashes and resultant injuries among older adults.     

The Effects of Learner's Permit Requirements in Tennessee

Sixteen and 17 year-olds were surveyed at motor-vehicle offices in Tennessee after qualifying for their first driver's license. When the survey was conducted during October and November 1995, neither a learner's permit nor completion of a driver education course was required to obtain a license at age 16 or 17. The survey was repeated during December and January 1996–97, approximately one year after a requirement to hold a learner's permit for 90 days or complete a driver education course was implemented. Results from the 1991 drivers (ages 16 and 17) surveyed indicated Tennessee's licensing law change was associated with approximately 100 additional miles and 8 additional hours of practice driving prior to licensure for the typical 16 or 17 year-old, most often while supervised by a parent or guardian. Results are discussed in relation to the prelicense practice driving requirements of graduated licensing systems.     

Practicing for and performance on drivers license tests in relation to gender differences in crash involvement among novice drivers

PROBLEM: Young male novice drivers are overrepresented in injury motor-vehicle crashes compared to females in the same category. This difference in crash involvement is often assumed to include factors such as overestimation, risk acceptance, and sensation seeking, but it can also be related to acquisition of knowledge, skills, insight, and driving experience. Therefore, this study explored possible gender differences among 18-24-year-olds in Sweden regarding practicing as learners, outcome of the driver's tests, and crash involvement during the first year after licensure. METHOD: Data for 2005 from different sources (e.g., questionnaires, license test, and crash statistics) were examined. It was not possible to follow individual subjects through all stages or in all analyses. Nevertheless, the study design did enable scrutinization and discussion of gender differences between younger inexperienced drivers with respect to education and training, license test results, and initial period of licensure. RESULTS: Males and females assimilated tuition in different ways. Females studied more theory, pursued training in a more structured manner, practiced more elements of driving in several different environments, and participated more extensively in driving school instruction. National statistics showed that females did better on the written test but not on the driving test. Males were involved in 1.9 more injury crashes per 1,000 drivers than females during their first year of licensed driving. The proportional distribution of crash types was the same for both sexes during the first period as novice drivers, but the circumstances surrounding the accidents varied (e.g., males were involved in more night crashes). IMPACT ON TRAFFIC SAFETY: More structured training while learning appears to be one of the reasons why females initially do better than males as novice drivers. Therefore, in the future, driver education should focus not only on matters such as the amount of time spent on training and preconditioning, but also on the importance of the organization and content of the learning process.     

Older driver retraining: An updated systematic review of evidence of effectiveness

Problem and Objective

The number of older drivers who might benefit from driver retraining is growing. A previous review on the effectiveness of older driver retraining included intervention studies up to 2004. The objective was to perform an updated systematic review of the effectiveness of older driver retraining for improving driving-related skills and reducing crash rates.

Method

Articles published from 2004-2008 were grouped according to the intervention provided and outcome studied. Randomized clinical trials (RCTs) were appraised using the Physiotherapy Evidence Database (PEDro) Scale and scored for quality according to their internal validity. Each intervention's effectiveness was then rated and assigned a level of evidence by combining pre- and post- 2004 findings.

Results

Three RCTs and one matched-pairs cohort design met the inclusion criteria. There is strong evidence (Level 1a) that education combined with on-road training improves driving performance and moderate evidence (Level 1b) that it improves knowledge. There is moderate evidence (Level 1b) that physical retraining improves driving performance. There is moderate evidence (Level 1b) that an educational intervention curriculum alone is not effective in reducing crashes.

Summary

The updated evidence on the effectiveness of retraining aimed at older drivers is sufficiently encouraging to merit assertive health promotion actions regarding intervention and program planning.

Impact on Industry

These positive findings warrant a comprehensive plan that has both behavioral and monetary incentives encouraging older driver participation in programs aimed at driver safety.     

Characteristics and risks of drivers with low annual distance driven

OBJECTIVES: It has been noted by several authors that risk (defined only in terms of total expected numbers of crash involvements per total distance driven) paints a misleading picture of crash liability, particularly for the young and the old, as their high risk is associated with risky driving patterns typical of people who drive low annual kms. This article sets out to analyze these driving patterns of low-km drivers and to evaluate the risk of these patterns. As licensing programs tend to focus on young and old drivers, who tend to drive lower annual distances, income and employment data are also analyzed for low-km drivers. This is to provide a better picture for policy makers of the sort of people and the sorts of transportation requirements that their policies may affect. METHODS: Crash data and travel data were disaggregated by driver characteristics and by driving conditions (road type, day and night, weekend and weekday) and combined to form estimates of risk for typical driving patterns of driver groups. Characteristics of driving patterns and of the drivers themselves were derived for groups defined by age and by the amount of annual driving undertaken. RESULTS: Older drivers who drive less tend to have higher risk per km mainly due to their predominantly urban trips. Nevertheless, because older drivers on average manage to reduce their risk per distance driven by choosing driving patterns that are safer than the driving patterns of other age groups, the risk of older drivers as a group is not overestimated. CONCLUSION: Despite being quite different from one another, the low- and high-km driving patterns of younger drivers were found to impose identical risks.     

Using a driving simulator to identify older drivers at inflated risk of motor vehicle crashes

PROBLEM: To develop appropriate assessment criteria to measure the performance of older drivers using an interactive PC-based driving simulator, and to determine which measures were associated with the occurrence of motor-vehicle crash. METHOD: One hundred and twenty-nine older drivers residing in a metropolitan city volunteered to participate in this retrospective cohort study. Using the driving simulator, appropriate driving tasks were devised to test the older drivers, whose performances were assessed by 10 reliable assessment criteria. Logistic regression analysis was then undertaken to determine those criteria that influence the self-reported crash outcome. RESULTS: As expected, driving skill of older drivers was found to decline with age. Over 60% of the sample participants reported having at least one motor-vehicle crash during the past year. Adjusting for age in a logistic regression analysis, the cognitive abilities associated with the crash occurrence were working memory, decision making under pressure of time, and confidence in driving at high speed. SUMMARY: The findings of this retrospective study indicated those individuals at inflated risk of vehicle crashes could be identified using the PC-based interactive driving simulator. Prospective studies need to be undertaken to determine whether the driving simulator can predict future crash events. IMPACT ON INDUSTRY: This study demonstrated an economical driving simulator approach to screen out problematic or unsafe older drivers before a more detailed but expensive road test is considered.     

An Australasian model license reassessment procedure for identifying potentially unsafe drivers

Most licensing jurisdictions in Australia currently employ age-based assessment programs as a means to manage older driver safety, yet available evidence suggests that these programs have no safety benefits. This paper describes a community referral-based model license re assessment procedure for identifying and assessing potentially unsafe drivers. While the model was primarily developed for assessing older driver fitness to drive, it could be applicable to other forms of driver impairment associated with increased crash risk. It includes a three-tier process of assessment, involving the use of validated and relevant assessment instruments. A case is argued that this process is a more systematic, transparent and effective process for managing older driver safety and thus more likely to be widely acceptable to the target community and licensing authorities than age-based practices.     

Responsibility of drivers, by age and gender, for motor-vehicle crash deaths

Problem: Motor-vehicle crash rate comparisons by age and gender usually are based on the extent to which drivers in a particular age/gender category are themselves injured or involved in crashes (e.g., the number of 20-year-old females in crashes). Basing comparisons instead on the extent to which drivers in various age/gender groups are responsible for deaths (including themselves) in their crashes is more revealing of their overall contribution to the problem. Methods: Data from the Fatality Analysis Reporting System (FARS, 1996–2000) were used in the analysis, which was based on crashes that involved one or two vehicles only. Drivers in fatal single-vehicle crashes were assumed to have responsibility for the crash. In fatal two-vehicle crashes, driver operator errors reported by police were used to assign crash responsibility. Results: When all crashes were considered, both the youngest and oldest drivers were most likely to be responsible for deaths in their crashes. In two-vehicle crashes, the oldest drivers were more likely than young drivers to be responsible. Young males were more likely than young females to be responsible for crash deaths, whereas females in their 50s and older were more likely than same-age males to be responsible. In terms of responsibility for deaths per licensed driver, young drivers, especially males, had the highest rates because of their high involvement rates and high responsibility rates. The majority of deaths for which young drivers were responsible occurred to people other than themselves, especially passengers in their vehicles, whereas the bulk of the deaths for which older drivers were responsible were their own. Discussion: The results highlight the contribution of young drivers to the motor-vehicle crash problem, the need for measures such as passenger restrictions in graduated licensing systems, and the need for vehicle modifications to better protect older occupants.     

The effect of extending graduated driver licensing to older novice drivers in Indiana

Introduction: Graduated driver licensing (GDL) systems have been shown to reduce rates of crashes, injuries, and deaths of young novice drivers. However, approximately one in three new drivers in the United States obtain their first driver’s license at age 18 or older, and thus are exempt from most or all provisions of GDL in most states. Method: In July 2015, the state of Indiana updated its GDL program, extending its restrictions on driving at night and on carrying passengers during the first 6 months of independent driving, previously only applicable to new drivers younger than 18, to all newly-licensed drivers younger than 21 years of age. The current study examined monthly rates of crashes per licensed driver under the affected conditions (driving at night and driving with passengers) among Indiana drivers first licensed at ages 18, 19, and 20 under the updated GDL system compared with drivers licensed at the same ages under the previous GDL system. We used Poisson regression to estimate the association between the GDL system and crash rates, while attempting to control for other factors that might have also influenced crash rates. We used linear regression to estimate the association between the GDL system and the proportion of all crashes that occurred under conditions restricted by the GDL program. Results: Results showed, contrary to expectations, that rates of crashes during restricted nighttime hours and with passengers were higher among drivers licensed under the updated GDL system. This mirrored a statewide increase in crash rates among drivers of all ages over the study period and likely reflected increased overall driving exposure. The proportions of all crashes that were at night or with passengers did not change. Practical Applications: More research is needed to understand how older novice drivers respond when GDL systems originally designed for younger novice drivers are applied to them.     

Are age-based licensing restrictions a meaningful way to enhance rural older driver safety? The need for exposure considerations in policy development

The stated and revealed travel behavior of a sample of 60 rural drivers aged 54-92 years provided a basis to explore the potential effectiveness of two common driver's license restrictions aimed at older drivers: time of day and road class. The potential utility and impact of these restrictions have not been explored with revealed data for jurisdictions with a large population of rural older drivers where automobile dependence is high. Data were drawn from a multiday Global Positioning System-based travel diary survey of rural older drivers in New Brunswick, Canada. Revealed travel data showed that over 50 percent of the rural drivers in the sample did not drive after dark, and 40 percent drove less than 1 percent of their total surveyed kilometers on major highways, higher rates than from participant-stated responses. The proportion of participants taking night trips and traveling on major highways decreased with age. The majority of trips taken after dark by all participants had a rural destination. The average daily kilometers driven on major highways by men and women aged 75 years and older was nearly identical (1.79 km/day). These exposure considerations suggest that restricting night travel and major highway travel for the oldest rural drivers (75 years and older) may have limited utility given that the majority of participants did not drive in these situations, and for those who did, most of their trips were in rural areas where enforcement could be expected to be limited. A better approach may be to encourage increased self-regulation through training, age-friendly upgrades to transportation infrastructure to help rural older drivers stay driving safely as long as possible, and the development of appropriate rural alternatives to help a driver transition to nondriver.     

Teenage driver crash incidence and factors influencing crash injury by rurality

BackgroundPrevious research has identified teenage drivers as having an increased risk for motor-vehicle crash injury compared with older drivers, and rural roads as having increased crash severity compared with urban roads. Few studies have examined incidence and characteristics of teen driver-involved crashes on rural and urban roads.MethodsAll crashes involving a driver aged 10 through 18 were identified from the Iowa Department of Transportation crash data from 2002 through 2008. Rates of overall crashes and fatal or severe injury crashes were calculated for urban, suburban, rural, and remote rural areas. The distribution of driver and crash characteristics were compared between rural and urban crashes. Logistic regression was used to identify driver and crash characteristics associated with increased odds of fatal or severe injury among urban and rural crashes.ResultsFor younger teen drivers (age 10 through 15), overall crash rates were higher for more rural areas, although for older teen drivers (age 16 through 18) the overall crash rates were lower for rural areas. Rural teen crashes were nearly five times more likely to lead to a fatal or severe injury crash than urban teen crashes. Rural crashes were more likely to involve single vehicles, be late at night, involve a failure to yield the right-of-way and crossing the center divider.ConclusionsIntervention programs to increase safe teen driving in rural areas need to address specific risk factors associated with rural roadways.Impact on IndustryTeen crashes cause lost work time for teen workers as well as their parents. Industries such as safety, health care, and insurance have a vested interest in enhanced vehicle safety, and these efforts should address risks and injury differentials in urban and rural roadways.     

COMPARING THE IMPAIRMENT PROFILES OF OLDER DRIVERS AND NON-DRIVERS: TOWARD THE DEVELOPMENT OF A FITNESS-TO-DRIVE MODEL

The purpose of this research effort was to compare older driver and non-driver functional impairment profiles across some 60 assessment metrics in an initial effort to contribute to the development of fitness-to-drive assessment models. Of the metrics evaluated, 21 showed statistically significant differences, almost all favoring the drivers. Also, it was shown that a logistic regression model comprised of five of the assessment scores could completely and accurately separate the two groups. The results of this study imply that older drivers are far less functionally impaired than non-drivers of similar ages, and that a parsimonious model can accurately assign individuals to either group. With such models, any driver classified or diagnosed as a non-driver would be a strong candidate for further investigation and intervention.