STATE REPORTING PRACTICES
To understand the legal and practical context in which family and friends intervene with older problem drivers, a study was undertaken of state laws and regulations for reporting highrisk drivers to state authorities and how these requirements are actually implemented. Research on reporting of problem drivers has been limited. Most states lack agebased policies for handling unsafe drivers and according to Anapolle (1992) apply their impaired populations policies to screen and process older drivers. In some states (including California) provisions specifically prohibit special tests from being administered based on the driver's age alone.
A 1992 study of driver licensing programs in 7 states (Petrucelli & Malinowski, 1992) found that reports by physicians are considered confidential in 34 states; and in 27 states, laws provide immunity to physicians for reporting. Hawley and Tannenhill's 1989 summary of driver licensing programs, identified other sources that assist in the detection of problem drivers, including law enforcement, courts, insurance companies, and family members, but suggest that their reports are largely spontaneous and typically do not result from a systematic and structured reporting process.
A state driver safety advisory committee was appointed by the Governor of Illinois in 1992. The committee studied state reporting regulations to help assess the merits of implementing a state law allowing family reporting of unsafe drivers.
Twentyeight states automatically keep the reporter's identity confidential; an additional 2 states (Wisconsin and Alaska) do so only if requested by the reporter; and one state (Ohio) maintains confidentiality only for reports submitted by law enforcement. However, in most states, the reporter's identity is released if required by court order.
Three states provided statistics on reporting frequencies by source. Family members account for 5% (Iowa) to 10% (Michigan) of requests submitted for reexamination in these states. Law enforcement officials are by far the most common reporting source, reporting 70% (Wisconsin) to 91% (Iowa). Over 80% of referrals in Florida are submitted by driver licensing personnel; less than 10% originate from medical providers. In Oregon, 4% of referrals come from the licensing administration and medical specialists account for 37% of referrals and are the primary reporting source.
Physicians represent a significant reporting source in Pennsylvania, which requires that physicians report to the transportation department all patients over age 15 diagnosed as having any condition that could impair driving ability. Before 1990, the department received about 10,000 medical reports annually. About half of the reports submitted are for patients over age 45. Seizure disorders and other neurological disorders account for 67% of the license recalls. About 9% of physician reports result in driving restrictions, generally for vehicle modifications.
McKnight and Urquijo (1993) analyzed reporting by law enforcement officials in five states (California, Maryland, Massachusetts, Michigan and Oregon). Triggers differed by age of driver with sensory deficiencies increasing and medical conditions decreasing as a basis for referral among drivers in the advanced ages.
A 33item questionnaire was developed to evaluate reporting regulations and procedures, provisions for confidentiality and immunity, reporting frequencies by source, medical and functional conditions triggering reports, background characteristics of reported drivers, and followup activities including licensing outcomes and relicensing procedures.
The questionnaire was mailed to nine state driver license agencies and one provincial driver license agency: California, Connecticut, Florida, Massachusetts, Michigan, Ohio, Oregon, Texas, Wisconsin and Ontario, Canada. States selected for participation were considered to have licensing departments that would cooperate with the study, model driver safety programs and/or data relevant to this project.
Summary of State Reporting Requirements and Practices
Health Care Provider Reporting Laws and Regulations
Seven states and one Canadian province returned questionnaires on their reporting regulations and practices: California, Connecticut, Florida, Michigan, Oregon, Texas, Wisconsin, and Ontario, Canada.
Of the states and province that responded, threeCalifornia, Oregon and Ontariohave laws mandating physicians to report potentially unsafe drivers. The remaining 5 states have laws permitting reporting by health professions, including physicians, psychologists, occupational and physical therapists, chiropractors and nurses.
Since 1939, California law has required physicians and surgeons to report patients aged 14 and above with disorders characterized by loss or lapse of consciousness that may recur. In 1988, the law was amended to specifically include Alzheimer's Disease and related dementia among conditions that physicians are required to report (California is the only state in the U.S. that requires referrals for Alzheimer's and related disorders).
In states with laws that permit reporting, referrals are accepted for all conditions that may adversely impact driving. Seven of the responding states require health providers to submit reports directly to the licensing department. In Ontario, reports are submitted to the ministry of transportation, medical review section/registrar of motor vehicles.
In Ontario, health providers who report potentially unsafe drivers are immune from both civil and criminal lawsuits. In Oregon, health care providers who report have no immunity from civil and criminal lawsuits. Of 5 states with reporting laws, 2 (Florida and Texas) provide health providers who report with immunity from civil and criminal lawsuits; one state (Wisconsin) provides immunity from a civil lawsuit; and one (Connecticut) provides no immunity.
Two jurisdictions require reports from sources other than health providers. In Ontario, reports are required from law enforcement; in Texas, law enforcement, court officials and DMV staff are required to report. Opportunities arise for law enforcement to identify problem drivers during normal traffic surveillance and during collision investigations. Results of license screenings can also alert DMV staff to possible medical or functional problems. Other potential reporting sources include family and friends, insurance companies, and drivers themselves.
Most states have special forms for reporting problem drivers. Oregon, Wisconsin, and Ontario presented the most comprehensive profiles. Data for Oregon for the year 1993 suggest that close to 5,300 reports are submitted annually. About 60% of the reports refer to drivers aged 56 and above; about 55% are drivers aged 65 and above; an estimated 35% are over 75 years; and about 5% are 87 years plus.
Approximately 36% of reports submitted in Oregon are selfreferrals (largely from accident reports); among older drivers, selfreports drop to 29%. Health providers also represent an important source of referrals, accounting for 37% of all reports and 31% of reports of drivers aged 56 and over.
While the proportion of selfreports and reports by health providers drops among older drivers, law enforcement staff are a more significant reporting source, accounting for 17% of all reports as compared to 24% of reports for older drivers. DMV staff also are important, representing 3% of all reports and 4% of reports of older drivers. Family and friends account for 6% of all reports and 10% of reports for older drivers. Close to 90% of reports submitted by law enforcement, DMV staff, and even family and friends are for older drivers.
In 1995, Wisconsin received about 2,400 referrals. About twothirds (68%) of these reports were submitted by law enforcement. While Wisconsin does not mandate physician reporting, about 22% of its reports originate from this source. About 3% are submitted by DMV staff. Michigan receives about 5,000 referrals annually. Physicians and law enforcement are the two primary reporting sources, followed by family members.
What are the medical conditions that prompt reports to state authorities? In Oregon, reported drivers investigated by the licensing department are most likely to be referred for either a seizure disorder (19%) or stroke (15%) (Data are not separately available for medical conditions of older reported drivers). Data on medical conditions of reported drivers are also available for Ontario. In 1995, there were 25,990 reported drivers with medical conditions and impairments. The three top ranking conditions were epilepsy (24%); neurological disorders, including stroke, Alzheimer's disease and other dementia (19%); and cardiovascular conditions (15%). Age breakdowns of reported drivers are also available for Ontario, and show that close to 7% of the reported drivers are aged 65 or older.
A typical scenario is that when the report is received, the DMV checks the license status and driving record of the referred driver. The reexamination differs depending upon the person's medical or functional condition. A drive test may also be required. Three of the seven states participating in the survey (California, Connecticut, and Wisconsin) have special road tests they may administer. These tests are longer in length (4560 minutes versus 15 minutes for the standard test) to help evaluate the driver's endurance, and use routes designed especially for the driver's condition. If the driver has dementia, the examiner tests the driver's ability to follow multiple instructions, concentrate, recall information, and perform divided attention tasks. Some states also rely on other testing procedures. In Oregon, California, and Connecticut, a personal interview may also be conducted with the driver. In more serious cases, a license revocation or suspension may occur which prohibits driving. License suspensions are temporary and are typically issued if the medical condition is expected to improve.Licensing Actions
Limited data are available on licensing actions that result for reported drivers following their reexamination. In Florida and Oregon it is equally likely for drivers to require a license suspension as to receive no license action at all. In Florida, 11.7% of reported drivers had licenses suspended, and 11.9% had no change in licensure status. License restrictions rarely occur in Oregon (4 in 1994 and 5 in 1995). Data for Ontario, by contrast, indicate that most reported drivers (92%) experience no change in license status; about 7% of reported drivers have their license suspended.
Data on licensing actions are not available by driver age. However, California reports that when license restrictions occur for older drivers, they commonly involve the use of corrective lenses, followed by daylight driving only; geographic restrictions rarely occur.AgeBased License Procedures
In California, license renewals are prohibited by mail after age 69. Beyond that age, drivers must pass vision and knowledge tests every four years. A road test may be required if the driver demonstrates confusion, tremors, or other symptoms that may seriously jeopardize driving.
In Oregon, drivers aged 50 and above must pass a vision screening every eight years. Respondents were sometimes uncertain about their state laws and regulations. Although limited, the data from the questionnaire corroborate other research findings (e.g., Illinois study, 1991) which suggest family and friends rarely report potentially unsafe drivers to state authorities. In Oregon, about 300 reports were submitted by family and friends (in 1993), accounting for about 6% of all referrals and 10% of referrals of older drivers. In Oregon, where physicians are mandated to report, health providers accounted for 37% of all referrals (and 31% of referrals of older drivers). The large share of these referrals are actually submitted by nurse practitioners and physician assistants; physicians account for up to 10% of referrals. In Oregon, about 8.5 of every 10,000 licensed drivers are reported by health providers to state authorities; in Wisconsin the rate of reporting by health providers is 1.6 per 10,000 licensed drivers. Considering health provider reporting of older drivers, the rate climbs to 16 of every 10,000 licensed drivers aged 56 and above in Oregon. (Corresponding data are unavailable for other states.)
In Oregon, about 23.1 of every 10,000 licensed drivers (and as many as 51 of 10,000 licensed drivers aged 56 plus) were reported (in 1993). The corresponding rate for all drivers in Wisconsin is 6.6 (in 1995). Currently, states mandating reporting by health care providers only include physicians under this requirement. Other health care professionals are also wellpositioned to detect and intervene with problem drivers.
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