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Volume 12 No. 03
Earn CME
Accepted Papers





Scientific Investigations

Self-Reporting by Unsafe Drivers Is, with Education, More Effective than Mandatory Reporting by Doctors

Nathan J. Elgar, BSc (Hons)1; Adrian J. Esterman, PhD2; Nick A. Antic, PhD3; Brian J. Smith, PhD1,4
1Respiratory Medicine Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia; 2School of Nursing and Midwifery, University of South Australia, Adelaide, South Australia, Australia; 3Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, South Australia, Australia; 4Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia

ABSTRACT

Study Objectives:

Health professionals are frequently required to report to relevant authorities all drivers who are potentially unsafe due to medical conditions. We aimed to assess both the effect of mandatory reporting (MR) on patient self-predicted behavior and what factors might encourage unsafe drivers to self-report to these authorities.

Methods:

We included 5 questions in the South Australian Health Omnibus Survey, an annual, community based, face-to-face survey. We asked (1) how subjects would behave towards their doctor in light of MR if they believed their licences were at risk due to a medical condition; and (2) which factor(s) would cause them to self-report to the same authorities.

Results:

Responses to 3,007 surveys (response rate 68.5%, age 15–98) showed that 9.0% would avoid diagnosis, lie to their doctor, or doctor shop in order to keep their licence; 30.8% were unaware of the legislated requirement to self-report; and 37.9% were unaware of potentially jeopardizing insurance support if they failed to comply. If educated in these 2 areas, warned about the dangers of driving against medical advice and instructed to do so by their doctor, then 95.8% of people would self-report to the authorities, a number significantly higher than could be reported by their doctors (91.0%).

Conclusions:

MR causes 9.0% of people to predict to behave towards their doctor in a manner that reduces road safety. With education and encouragement to do so, more people will self-report to the authorities than could be reported by their doctors via the MR pathway.

Commentary:

A commentary on this article appears in this issue on page 287.

Citation:

Elgar NJ, Esterman AJ, Antic NA, Smith BJ. Self-reporting by unsafe drivers is, with education, more effective than mandatory reporting by doctors. J Clin Sleep Med 2016;12(3):293–299.


INTRODUCTION

The physical and mental ability of a driver to operate a vehicle safely is one key factor in road safety. Governments therefore actively control the issuing and renewal of driving licences based on medical fitness to drive. This is assessed by health professionals who must balance their responsibilities towards their patients and the general public.1 Doctor-patient confidentiality is vital to establishing a patient's trust. Without trust, the acquisition of clinical information necessary for correct diagnosis and treatment of health issues becomes much more difficult.2,3 Many legal precedents have been set for the breaching of confidentiality by health professionals when public safety is threatened.4,5 Consequently in some jurisdictions legislators have introduced various forms of mandatory reporting (MR) legislation.68 A Canadian study indicated MR led to reduced emergency department admissions from road crashes.3 This outcome, however, was also associated with less desirable consequences, including compromised doctor-patient relationships. Unfortunately the possibility of MR causing other at-risk drivers to deliberately avoid diagnosis was not evaluated.

BRIEF SUMMARY

Current Knowledge/Study Rationale: Mandatory reporting of patients who are potentially unfit to drive due to a medical condition has been shown to adversely affect the doctor-patient relationship, but little is known about how it affects the general population's behaviour toward their doctor should they suspect they have a medical condition that might affect their ability to drive. Little is known about which factors would encourage an individual to self-report to the road traffic authorities.

Study Impact: Our study suggests that due to mandatory reporting 9% of individuals would behave toward their doctor in a manner that reduces road safety. With education and instruction, more potentially unsafe drivers are likely to self-report to the road traffic authorities than could be reported by their doctors via a mandatory reporting pathway.

With regard to the voluntary or MR of potentially unsafe drivers by health professionals, jurisdictions worldwide are divided. Luxembourg, Italy, and Sweden, for instance, all favor MR, while in the UK, France, and Belgium, legislators prefer voluntary reporting—the latter two countries requiring the patient's consent before any report can be lodged.9 Reporting in the US and Canada, however, is determined by state and territory boundaries, with 8 of 50 states and 10 of 13 territories, respectively, favoring MR.1012 Within Australia, while 5 of 6 states have opted for voluntary reporting, South Australia (SA) has legislated in Section 148 of its Motor Vehicles Act 1959 that all health professionals report any patient to the Department of Planning, Transport and Infrastructure (DPTI) if they believed they “would be likely to endanger the public” should they drive a motor vehicle.7 While such legislation covers all disciplines of medicine it is clear that some specialists such as neurologists (epilepsy, dementia) and sleep physicians (narcolepsy, obstructive sleep apnea syndrome [OSAS]) may have a higher proportion of patients who are eligible to be reported.13 Severe OSAS, for instance, increases accident risk by as much as 1.2–4.9 times.14,15

Section 148 may lead some SA drivers to avoid medical assessments in an attempt to protect their licence, thereby resulting in an actual decrease in public road safety. To investigate this possibility and to explore another avenue by which the DPTI could reliably be informed of potentially dangerous drivers, we developed five questions for release in the 2009 South Australian Health Omnibus Survey (SAHOS). These tested two main areas: firstly the general population's attitude to and practice surrounding Section 148, and specifically whether gender, or the need for a licence to maintain their occupation affected a driver's self-predicted behavior towards their doctor; and secondly whether with education in safety, legislative requirement to self-report, and the effect on insurance of not doing so, self-reporting to the DPTI by drivers would achieve a similar reporting rate to MR by their doctors.

METHODS

SAHOS is a random, state-wide, cross-sectional, non-replacement sample, face-to-face survey (age ≥ 15 years) of an attempted 5,200 households, which has reported a wide range of public health related findings.1618 Ten standard demographic and numerous researcher-designed questions form each annual survey. Of 172 questions in the 2009 survey, 5 related to our study (see supplemental material). SAHOS's rigorous methodology has been previously reported.17,19,20 Ten percent of respondents were re-interviewed on selected questions to measure test-retest reliability. All data were double entered and weighted by age, gender, and geographic region to the 2009 census data for SA to ensure the analysis would be representative of the State. The questionnaire and methodology were approved by the Human Research Ethics Committee for the SA Department of Health, and all participants gave informed consent prior to taking part in the survey.

Our first question assessed both the state and essentiality of responders' driver's licences with respect to “employment” and “other reasons.” Only responses from those aged ≥ 17 years (the age at which a probationary licence can first be held in SA) were included for the analysis of this question. Question 2 assessed responders' awareness of both: the legal requirement for all drivers to self-report to the DPTI any permanent/long-term injury or illness potentially affecting their ability to drive safely; and the potential of being uninsured in the event of a crash caused by that injury or illness should they have failed to self-report. Question 3 asked responders to indicate which factor(s) would make them “likely to report (themselves) to the DPTI” if they believed they had such an injury or illness. Question 4 imagined a scenario in which responders suspected they had a medical condition such as OSAS that affected their safety while driving but for which treatment was available. They were then informed about the MR requirement and asked how they would relate to their doctor. Responses were grouped into 2 categories—self-predicted behavior that would “improve” or “reduce” road safety. Question 5 asked whether they agreed with Section 148 as it stood, or believed doctors should either have discretion in their reporting or never report anyone. Due to the length of each question and the possibility of responder fatigue in such a large survey, all 5 questions had prompt cards containing both the questions and their possible responses enabling responders to read as well as listen to our questions before making a response.

The data were used for descriptive purposes and to test 6 hypotheses: (1) Self-reporting to the DPTI by drivers who have been (i) encouraged to do so by their doctor and (ii) educated regarding safety, the requirement to self-report and its effect upon insurance, would achieve a higher reporting rate than MR via the doctor pathway; (2) Drivers unaware of the legal requirement to self-report are more likely to predict to behave toward their doctor in a manner that reduces road safety than drivers who are aware; (3) Drivers unaware of the potential adverse effect of not self-reporting on their 3rd party insurance in the event of a culpable crash are more likely to predict to behave toward their doctor in a manner that reduces road safety than drivers who are aware; (4) Drivers who consider their licence essential for work are more likely to predict to behave in a manner that reduces road safety than drivers who do not; (5) Males are less likely than females to predict to self-report to the DPTI; and (6) Males are more likely than females to predict to behave toward their doctor in a manner that reduces road safety

Statistical Analysis

Descriptive analyses were undertaken with counts and percentages for categorical variables, and the mean (range) provided for age. Responses to each question were tested for differences between genders using χ2 tests. The response to question 4 was dichotomized to reflect an attitude towards reduced road safety (Avoid doctor + Doctor shop + Lie) and improved road safety (Comply strictly with treatment + Accept any/all consequences). This was then used as the dependent variable in a log binomial generalized linear model with predictors gender, essentialness of driving licence (Essential/Not essential), awareness of legal requirements to self-report (Aware/Not aware) and awareness of the potential effect that not self-reporting has on 3rd party insurance (Aware/Not aware). An interaction term with each of the latter 3 variables and gender was also included in the original model. Backwards elimination was then used, retaining only variables in the model that were statistically significant (p ≤ 0.05). Analyses were undertaken in Statcalc (EpiInfo version 6) and Stata 13. Analyses were undertaken on weighted data (rounded to the nearest whole number). All statistical tests used definite responses to questions with the following responses being discarded: “no response”; “refused”; and “I don't know.”

RESULTS

A total of 3,007 interviews (see Table 1 for participant characteristics) were completed, giving a response rate of 68.5% once vacant lots and non-contacts were accounted for (see Figure 1).

Characteristics of 3,007 participants for 2009 SAHOS.

 

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Table 1

Characteristics of 3,007 participants for 2009 SAHOS.

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Flow chart.

Flow chart showing final response rate and reasons for survey non-completion.

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Figure 1

Flow chart.

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Descriptive Analyses (includes testing of hypotheses #5 and #6)

Full descriptive analyses results are contained in Table 2, including differentiation by gender. Only significant differences between the genders have been highlighted below.

Responses to questions (including by gender).

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Table 2

Responses to questions (including by gender).

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View of Licence (Q1)

Males were significantly more likely than females to have a driver's licence (92.7% vs. 85.7%, p < 0.001) and if so to consider it essential: for all reasons (95.5% males vs. 92.6% females, p = 0.002); and specifically for work (71.2% vs. 57.8%, p < 0.001).

Factors Influencing Self-Reporting to the DPTI (Q3)

Males indicated that they were significantly more likely than females to never self-report (4.9% vs. 2.0%, p < 0.001) as their licence was too important.

Beyond urging patients to self-report, a doctor could also: (1) educate patients regarding both their legal responsibility to self-report and their potential insurance liability in the event of an accident if they did not; (2) highlight the safety concerns of driving against medical advice. Given this possibility, the 4 responses were combined into one value to indicate how many individuals might potentially be encouraged to self-report by their doctor. Males were significantly less likely than females to be so encouraged (94.1% vs. 97.5%, p < 0.001), proving our fifth hypothesis to be correct.

Patient Self-Predicted Behavior towards their Doctor (Q4)

Supporting our final hypothesis, males proved significantly more likely than females to predict to behave towards their doctor in a manner that reduced road safety (11.4% vs. 6.7%, p < 0.001) if they suspected they had an adverse medical condition.

Testing of Hypotheses

1) Self-reporting to the DPTI by drivers who have been i) encouraged to do so by their doctor and ii) educated regarding safety, the requirement to self-report and its effect upon insurance would achieve a higher reporting rate than MR via the doctor pathway.

Responses to Q3 and Q4 were compared (Figure 2) to determine which pathway (patient self-reporting or doctor MR) would lead to the greatest number of potentially unsafe drivers being reported. If educated and instructed to do so by their doctor, significantly more individuals would self-report to the DPTI than would be possible for their doctors to report via the MR pathway (95.8% vs. 91.0%, p < 0.001). This was true for both males (94.1% vs. 88.6%, p < 0.001) and females (97.5% vs. 93.3%, p < 0.001).

Percent of people likely to be reported to the DPTI.

Graph showing a comparison of the % of people likely to be reported to the DPTI through one of two pathways: 1) Self-reporting pathway and 2) MR pathway by their doctors. Self-reporting pathway includes individuals who have been a) directed to do so by their doctor; b) fully educated (regarding both their responsibility to self-report and the issues surrounding 3rd party insurance); and c) warned of the risks and safety concerns of driving against medical advice.

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Figure 2

Percent of people likely to be reported to the DPTI.

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2) Drivers unaware of the legal requirement to self-report to the DPTI are more likely to predict to behave towards their doctor in a manner that reduces road safety than drivers who are aware.

3) Drivers unaware of the potential adverse effect of not self-reporting on their 3rd party insurance in the event of a culpable crash are more likely to predict to behave towards their doctor in a manner that reduces road safety than drivers who are aware.

4) Drivers who consider their licence essential for work are more likely to predict to behave towards their doctor in a manner that reduces road safety than drivers who do not.

The results of the log binomial generalized linear model are presented in Table 3. None of the interaction terms with gender were statistically significant. The only statistically significant predictors of actions likely to reduce road safety were “gender” (males were 1.56 times more likely to take such actions than females) and “essentiality of the driver's licence” (those who felt that their licence was essential were 1.62 times more likely to take such actions than those not thinking their licence was essential). Notably, after taking these variables into account, awareness of the legal requirements to self-report and awareness of the potential effect that not self-reporting has on 3rd party insurance did not predict actions likely to reduce road safety.

Predictors of question 4, whether actions taken as a result of the scenario would reduce or improve road safety (n = 2,821).

 

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Table 3

Predictors of question 4, whether actions taken as a result of the scenario would reduce or improve road safety (n = 2,821).

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DISCUSSION

Descriptive Analysis

We found that while the majority (72.2%) of responders were in favor of some form of reporting by doctors, 9.0% predicted that they would behave toward their doctor in a manner that reduced road safety if they thought they had a medical condition that might jeopardize their licence. These were much more likely to be males, meaning that those most at risk of OSAS are likely to be highly represented in those avoiding a diagnosis and thus the potential for treatment. It is well documented that individuals, when presented with a hypothetical situation, tend to predict that they will behave more ethically than they actually end up doing.21,22 This tendency may be relevant in this survey, despite its anonymity.23

Given that legislation exists which requires drivers to report themselves to the DPTI should they become aware of a health issue that affects their ability to drive safely, we wished to test responders' knowledge of this fact. Roughly a third were unaware of the need to self-report, and even more were found to be unaware that any future insurance claims related to motor vehicle accidents may be at risk as a result of not having self-reported significant medical conditions such as OSAS to the DPTI. There was no significant difference between male and female responses to either question indicating that the observed differences in self-predicted behavior toward their doctors between the genders is more likely to be driven by differences in attitude than a difference in knowledge.

We investigated items that may improve self-reporting. Concern for their own and for other road users' safety in relation to the risks of untreated medical conditions on driving ability, knowledge of the legislated requirements to self-report, and awareness of jeopardizing insurance claims were the three most influential factors. These results may provide an indication of where to target educational interventions. An individual's doctor is well placed to provide education regarding the dangers of driving with certain medical conditions. However, legislation and insurance matters may be less well addressed in the traditional clinical practice environment, unless a standardized educational intervention is implemented.

Testing of Hypotheses

We have demonstrated that through education in these three key areas of safety, legal requirement to self-report, and insurance status, there is the potential of education to achieve a self-report adherence of 95.8%. Interestingly, this significantly exceeds the 91.0% who could be reported by their doctors, highlighting the greater potential of education over MR. This potential self-report estimate would be limited by the fact that individuals who would doctor shop, lie to, or avoid their doctor to protect their licence are unlikely to then self-report despite educational efforts. In keeping with this limitation, a Canadian study found that only 27.1% of epilepsy patients instructed to self-report to the authorities by their doctors actually did so.24 There is evidence, however, that doctors do not adhere to MR legislation in at least two national settings.25,26 Legislators in Ontario, a jurisdiction where MR is in place, have even introduced a financial incentive for doctors to report their unsafe patients in order to combat low reporting rates.3 Hence, with appropriate education and instruction, a greater proportion of patients may self-report than are currently being reported by their doctors.

Testing of our second and third hypotheses showed that in both instances, awareness had no effect on whether a driver was likely to predict to behave toward their doctor in a manner that decreased road safety. These results only relate to an individual's self-predicted behavior with respect to interactions with their doctor, rather than likelihood of self-reporting.

Our data showed males were both more likely to predict to behave toward their doctors in a manner that reduced road safety and less likely to self-report than females. While this survey did not attempt to investigate why this might be so, one possible reason is that significantly more males considered their licence essential for maintaining their employment than females (61.0% vs. 49.6%, p < 0.001). This link is clearly supported by the fact that both male and female drivers who considered their licence essential for work, were 1.62 times more likely to predict to behave in a manner that reduced road safety. When the fact that males also spend more time on the roads than females (11,200 km/year vs. 8,800 km/year) is also considered, male gender is clearly of particular concern as a risk factor for reduced road safety in relation to unreported medical conditions.27

Limitations

The imbalance of males to females in our study may indicate that a greater proportion of males were away from home, perhaps at work, at the time of the survey being conducted despite up to 6 attempts at different times of the day.17,19 To account for this imbalance, we weighted the data by age, gender, and regional location to match the 2009 overall state population census data.

Participant responses to hypothetical scenarios may not match behaviors in real life. In particular, a potential limitation of face-to-face interviews may occur where questions have differing levels of perceived morality attached to their answers, as was the case in Q4 regarding predicted behavior toward doctors. However, any associated bias is likely to underestimate the size of the problem related to MR, given that compliance with the legislation is likely to be perceived as the morally preferable response. Our road safety risk estimates are therefore likely to be conservative.

Recommendations

This research has highlighted the need to better inform individuals of both their own responsibility to report medical issues to driver licensing authorities and the potential implications for their insurance should they fail to do so. Our results indicate that such an intervention would improve their compliance with the legislation and reduce the controversial and ineffective reporting burden currently placed on health professionals.28 One such step has been taken in the United Kingdom where a statement of the need to self-report to the appropriate authority is included on every licence.29 Measures like this recognize that while health professionals may choose to reinforce such a message, the onus of public education in this matter surely lies with the licensing authority.

Previous recommendations to find alternative approaches to MR are supported by our results and an example of a possible avenue of approach occurred in Connecticut, USA, where legislation switched from mandatory to voluntary reporting in 1990.1,30,31 Other alternatives exist in Victoria, Australia, and in England, where licensing decisions are often referred by a doctor to an independent multidisciplinary review board, which can take into account accident history. Health professionals welcome initiatives which facilitate a more holistic assessment.26,29 Health professional compliance in jurisdictions with MR legislation requires further evaluation, as does the behaviour of career vehicle drivers.

DISCLOSURE STATEMENT

This was not an industry supported study. Dr. Antic's institution has received research grants and equipment donations for research projects conducted by Dr. Antic from a combination of Philips Respironics, ResMed, Fisher and Paykel, Compumedics and SomnoMed. Dr. Antic's institution has also received payment for educational presentations conducted by Dr. Antic from ResMed and GSK. The other authors have indicated no financial conflicts of interest. The location where the research took place was at the Respiratory Medicine Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia.

ABBREVIATIONS

DPTI

Department of Planning, Transport and Infrastructure

MR

mandatory reporting

OSAS

obstructive sleep apnea syndrome

SA

South Australia

SAHOS

South Australian Health Omnibus Survey

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