Special Article
The Effect of Epilepsy or Diabetes Mellitus on the Risk of Automobile Accidents
N Engl J Med 1991; 324:22-26January 3, 1991
- Abstract
- Abstract
Background.
Previous studies of possible associations between chronic medical conditions and traffic safety have been inconsistent and subject to bias because of the incomplete identification of affected persons. Recent advances in the diagnosis and management of epilepsy and diabetes mellitus have improved the control of these disorders and suggest a need to reexamine the risk of traffic mishaps among patients with these conditions.
Methods.
We conducted a population-based retrospective cohort study of 30,420 subjects 16 to 90 years of age, with and without epilepsy or diabetes mellitus. Subjects included all the licensed drivers in seven contiguous ZIP Code areas in which the Marshfield Clinic and St. Joseph's Hospital, Marshfield, Wisconsin, are the primary sources of medical care. Standardized rates of moving violations and accidents over a four-year period (1985 through 1988) were compared in affected and unaffected cohorts.
Results.
Standardized mishap ratios for subjects with diabetes were 1.14 for all moving violations (P = 0.23) and 1.32 for accidents (P = 0.01); for subjects with epilepsy the ratios were 1.13 for moving violations (P = 0.26) and 1.33 for accidents (P = 0.04).
Conclusions.
We conclude that drivers with epilepsy or diabetes mellitus have slightly increased risks of traffic accidents as compared with unaffected persons. The increases in risk observed in our study were generally smaller than those in previous studies, and we believe they are not great enough to warrant further restrictions on driving privileges. (N Engl J Med 1991; 324:22–6.)
Media in This Article
Table 1
Characteristics of the Study Cohorts and of All Licensed Drivers in the Area Studied, from 1985 through 1988.Table 2
Characteristics of the Diabetes Cohort.Article Activity
- Article
EVER since automobiles were introduced to the public in the late 1800s, some medical conditions have been recognized as posing risks of driving accidents. Conditions such as epilepsy and diabetes mellitus that can impair consciousness or cause loss of body control have been of special interest to those concerned with traffic safety. By 1940, medical advances such as the discoveries of electroencephalography and of new antiepileptic drugs such as phenytoin had demonstrated that epilepsy could often be controlled. In the case of diabetes, insulin and other medications used to control the disease may actually increase the risk of traffic accidents, because the frequency and severity of hypoglycemia are increased among patients with insulin-dependent diabetes treated intensively.1 Laws governing the issuance of driver's licenses to patients with an epileptic-seizure disorder or diabetes mellitus differ from state to state. Driving is important to Americans for social, educational, economic, recreational, and other reasons, but motor vehicle accidents are an important cause of injury, death, and disability. Physicians are frequently asked whether impaired persons should continue to have full driving privileges, and they weigh the loss of the patient's mobility against the risk of a traffic accident to the patient and the community. These decisions have been based on studies that were sometimes poorly controlled and that often gave conflicting results.
A previous study has suggested that drivers with chronic medical conditions, especially alcoholism, have higher accident rates than the rest of the driving public.2 In contrast, Swedish investigators have con-
eluded that persons with conditions such as diabetes mellitus, heart disease, renal disease, deafness, and reduced vision are no more likely than drivers without these conditions to have collisions and traffic violations.3 Three earlier studies 4 5 6 suggested that the accident rate among drivers with epilepsy was 1.3 to 2 times the rate among age-matched controls without epilepsy. In a recent article on the risk of automobile accidents caused by seizures,7 the authors report that "though only 55 percent of seizures at the wheel were in fact responsible for accidents, up to 38 percent of other seizures could well have resulted in damage, injury or death." These studies form the basis of regulations in many states that prohibit people with epilepsy from driving.
Although there are fewer regulations governing driving by patients with diabetes, their rates of accidents and violations have also been shown to be higher than expected.5 , 6 A recent study showed higher accident rates among persons with diabetes than among their nondiabetic siblings, but the increases were not statistically significant after multivariate analysis.8
The inconsistency of these findings accounts in part for the variability in the driving regulations of different states. Earlier studies cannot be relied on in assessing the risk of traffic accidents associated with these conditions because technology and pharmacopeia for controlling illness have changed so rapidly. Improved medications, monitoring by diabetic patients of their own blood glucose levels, and improved understanding of the causes and effects of epilepsy and diabetes have undoubtedly altered the risk of losing consciousness or bodily control. To our knowledge, there have been no recent studies that have systematically compared the rates of accidents and traffic violations among normal subjects with those among subjects with these two medical conditions.
Methods
Study Design
We designed a retrospective cohort study to assess the effect of diabetes mellitus and epilepsy on traffic safety. The study subjects were all licensed drivers between 16 and 90 years of age from seven contiguous ZIP Code areas surrounding and including the city of Marshfield, Wisconsin. The Marshfield Clinic, a 312-physician multispecialty clinic, and St. Joseph's Hospital in Marshfield, a 525-bed facility, are the main sources of primary, secondary, and tertiary care for the inhabitants of this area, which contains no other hospitals or physicians. Ninety percent of the residents of the study area were estimated to have been seen at least once at the Marshfield Clinic in 1986 and 1987, according to an in-house count. This rate of use is slightly higher than that indicated by national figures compiled in 1983.9 Because of the distance to alternative sources of medical care, the high rate of membership in the Marshfield Clinic's health-maintenance-organization plan, and the presence of specialists in endocrinology and neurology at the clinic, nearly all subjects with the medical conditions under study should have received care at some point in their illness at either the Marshfield Clinic or St. Joseph's Hospital, and thus nearly complete case ascertainment was expected. The hospital and clinic also use a combined medical record that facilitates the abstraction of data. In addition, the clinic maintains computerized diagnostic codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)10 for all visits dating back to 1960. For purposes of this study, the search of diagnostic records went back to 1979.
Study Subjects
The institutional review board of the Marshfield Medical Center reviewed and approved the study protocol after being assured that the confidentiality of the subjects' medical and driving records would be protected. Potential study subjects were identified with use of the computerized ICD-9-CM diagnostic codes for diabetes (250 to 250.9) and epilepsy (345 to 345.9). The computer initially identified 1819 potential subjects with diabetes and 556 potential subjects with epilepsy from the study area. We decided to study all subjects with epilepsy and to sample randomly as many subjects with diabetes as the study budget and time frame would permit. Ultimately, 895 records of subjects with diabetes were reviewed.
Demographic and medical data on disease severity, treatment, and complications were abstracted from the charts of the patients. On review of the records, a number of patients were eliminated from the study because of an incorrect diagnostic code. The underlying condition was confirmed in 714 patients with diabetes (79.8 percent of the charts reviewed) and 434 patients with epilepsy (78.1 percent). All abstraction of data and confirmation of diagnoses were done by a trained abstracter who was a registered nurse. Samples of cases from each cohort were reabstracted by one of us for purposes of quality assurance. Of 27 subjects with diabetes and 64 subjects with seizures whose medical condition had been reported independently to the Wisconsin Department of Transportation, the clinic computer correctly identified all but 5, who turned out on review of the records not to have the disease in question.
The study's time frame for recording traffic accidents and violations covered the four years from 1985 through 1988. In order to include subjects whose condition had recently been diagnosed, diagnoses made through 1988 were accepted. The small number of subjects whose disease was diagnosed from 1985 through 1988 were counted in the appropriate affected cohort beginning with the date of diagnosis, with mishaps and the period at risk that occurred before the diagnosis ignored.
Data on Traffic Violations and Accidents
A computer tape of the licensing, accident, and violation records for all persons who held a regular (noncommercial) driver's license during the study period and lived in the study area was provided by the Wisconsin Department of Transportation. Persons with epilepsy or diabetes were matched with their driving histories. All persons from the area who were not included in the epilepsy cohort served as the comparison group for that cohort. A different approach was used for the diabetes cohort, which was a sample of the patients with diabetes in the area. To ensure that as few diabetics as possible were included in the comparison group, that group comprised all subjects who did not have a computerized diagnostic code suggesting diabetes. Many affected persons did not have driver's licenses or had inactive licenses because of suspensions or revocations, reducing the size of the final cohorts to 484 for diabetes and 241 for epilepsy. The periods of license revocation, suspension, and voluntary surrender were subtracted from the period each subject was considered to be at risk. In the analysis of data, each accident or violation was assigned to one of five groups, according to the type of mishap, and the data were further grouped for the summary tabulation into the categories of all moving violations and all accidents. The driving records of 30,420 active drivers were included in the study.
Statistical Analysis
Mishap rates per 1000 person-years of licensed driving and rate ratios were used to characterize the driving experience of each cohort and its comparison group, according to age. Marked differences in rates of mishaps according to age and in the age distribution of the affected and unaffected drivers necessitated standardization for age. The indirect method of standardization was chosen in order to adjust the rate for the affected drivers to the age distribution of the unaffected drivers.11 A summary measure, the standardized mishap ratio, was calculated for each affected cohort and type of mishap. The standardized mishap ratio is an estimate of the risk of a mishap in the affected group relative to the risk in the comparison group. The 95 percent confidence interval for the standardized mishap ratio was constructed by approximate methods as described by Rothman and Boice.12 The significance (P value) of the difference between the standardized mishap ratio and 1 was based on the probability in the two tails of the Poisson distribution that the deviation from the expected number of mishaps was as large as or larger than that observed, in either direction. A chi-square test with one degree of freedom (with correction for continuity) was used when the expected number of mishaps exceeded 50. Summary values for the standardized mishap ratio were confirmed with use of Poisson regression13 to adjust for age as a continuous variable and for sex.
Results
Table 1Table 1
Characteristics of the Study Cohorts and of All Licensed Drivers in the Area Studied, from 1985 through 1988. shows descriptive information for each of the study cohorts. Most of the affected subjects were being treated at the Marshfield Clinic, and nearly all had been seen at the clinic at least once during the study period. Of the subjects with diabetes, only one had a medical record indicating that a physician had recommended that the subject not drive. Such recommendations were more frequent among the subjects with epilepsy (11.8 percent).More detailed information on the diabetes cohort is shown in Table 2Table 2
Characteristics of the Diabetes Cohort.. Although most subjects were considered to have Type II diabetes, more than one third of the members of the cohort took insulin. Of these, 36.3 percent used more than one daily injection. Most subjects monitored their blood glucose levels at least occasionally. Only a small number had severe hypoglycemic reactions that were recorded during the study period.Table 3Table 3
Characteristics of the Epilepsy Cohort. shows additional information about the cohort with epilepsy. Almost one fourth of the study subjects had had only a single seizure. More than half had no documented seizure during the study period, although 18.6 percent had three or more seizures during this period. The subjects with epilepsy had numerous other medical conditions, including strokes, dementia, clinical depression, and other psychiatric disorders.Tables 4Table 4
Accident Rates in the Diabetic and Nondiabetic Cohorts According to Age.* and 5Table 5
Accident Rates in the Epileptic and Nonepileptic Cohorts According to Age.* show age-specific accident rates and rate ratios for the two affected cohorts and the corresponding unaffected cohorts. The estimated standardized mishap ratios were 1.32 for diabetes (P = 0.01) and 1.33 for epilepsy (P = 0.04). For all moving violations (Table 6Table 6
Standardized Mishap Ratios (SMRs) for Specific Types of Mishaps, According to Study Cohort.*), the estimated standardized mishap ratio for diabetes was 1.14 (95 percent confidence interval, 0.92 to 1.39; P = 0.23), and for epilepsy it was 1.13 (95 percent confidence interval, 0.90 to 1.41; P = 0.26). These estimates were confirmed with use of sex and age (as a continuous variable) in a Poisson regression, and in no case did the estimated standardized mishap ratios differ by more than 0.03 for the two methods.Table 6 also shows estimated standardized mishap ratios and confidence intervals for specific types of mishaps. There is no evidence that rates of speeding violations were higher among the subjects with either epilepsy or diabetes. Careless driving was more frequent in both affected cohorts than in the comparison cohorts, but the increase was significant only for the subjects with epilepsy. The rate of violations involving alcohol or drugs was greatly increased among these subjects. In both affected cohorts the risk of accidents causing injury was markedly higher than in the comparison cohorts, with a smaller but not statistically significant increase in the risk of accidents causing property damage.
Discussion
This study has attempted to identify all persons with diabetes or epilepsy in a defined geographic area and to compare their rates of traffic accidents and moving violations with those of healthy persons. Previous studies in 19655 and 19686 provided strong evidence of increased rates of accidents and violations among drivers known by state motor vehicle divisions to have certain chronic medical conditions. Uncertainty about the completeness of medical reporting, conflicting results from other studies, and suspicion that subjects identified to the state represented the most severe end of the disease spectrum have made application of the results of these studies controversial. In restricting our study to an area in which nearly complete case ascertainment could be assured, we intended that comparisons between affected and unaffected cohorts would be fairly representative of differences within the population at large. By studying a recent period (1985 through 1988), we also hoped to obtain information reflecting the current diagnosis and treatment of these persons.
Our study showed increased age-adjusted rates of accidents among drivers with epilepsy or diabetes mellitus, supporting the earlier studies of Waller5 and Crancer and McMurray.6 The estimated rate ratios were generally smaller than those observed in the earlier studies, however.
In our study the most common moving violation was speeding. For both medical cohorts, the standardized mishap ratios for speeding were either very close to 1 or less than 1. Speeding might be characterized as a willful violation, as opposed to careless driving, which may be more likely to be attributed to lapses of concentration, consciousness, or bodily control. For careless driving the standardized mishap ratios were in excess of 1 for both cohorts, although the increase was significant only for drivers with epilepsy. The relative risk of alcohol and drug violations among the subjects with epilepsy was 2.75 (P<0.001). Chronic alcohol and drug abuse may play a part in the causation and control of epilepsy by reducing the threshold for seizures and affecting compliance.
In both affected cohorts, the larger increases in the risk of accidents causing injury than in that of accidents causing property damage may reflect a tendency not to report accidents causing property damage for fear of losing driving privileges. It is also possible that diabetes and epilepsy result in impairments of driving skills that are more likely to result in injury, such as the skills required to drive for longer distances at highway speeds. The factors contributing to increased risk in these two populations are yet to be clearly defined.
One limitation of our study is the lack of information on the number of miles driven by the study subjects annually. Waller's study5 suggested that affected drivers drive less than unaffected drivers, on the average, but these data are now 25 years old, and driving patterns have changed markedly since that time. One would expect that with proper adjustment for miles driven, the estimated standardized mishap ratios in our study might increase somewhat. Our data provide an estimate of the effect on accident and violation rates of granting driving privileges to drivers with epilepsy or diabetes, according to current Wisconsin law.
On the basis of this study, we do not think it wise to restrict further the driving privileges of persons with diabetes or epilepsy. Estimates of relative risk must be interpreted with reference to the size of the population at risk. Our data suggest that the excess risk associated with epilepsy accounted for approximately 13 of the 5665 accidents occurring in this area over the four-year period. In contrast, drivers under the age of 25 had 1058 more accidents than would have been expected if the accident rate for all older drivers combined had applied to them. Also, the estimated standardized mishap ratio for accidents involving male as compared with female drivers suggests that 1586 accidents would have been avoided if men had the same risk as women. Waller's data from California5 showed increased risks of both accidents and violations among alcoholics. Knowing these and other highly prevalent risk factors for traffic mishaps may provide more opportunities for prevention than would increased attention to the less prevalent medical conditions considered here.
Supported by a grant from the Federal Highway Administration to the Wisconsin Department of Transportation.
We are indebted to Barbara Wyman, R.N., for invaluable assistance with medical-record abstraction and data entry; to Peter Layde, M.D., M.Sc., Humberto Vidaillet, M.D., and Julian Waller, M.D., M.P.H., for assistance during the study-design phase; to Lisa Lynn for assistance in the preparation of the manuscript; and to the members of the Driver Licensing Longitudinal Study Advisory Committee: Henry Anderson, M.D., Edward Ehrlich, M.D., Lawrence Hanrahan, M.S., Assa Mayersdorf, M.D., Felix Tristani, M.D., David Cipra, Ph.D., Madelyn Glaeden, Peter Rahko, M.D., and Anna Biermeier.
Source Information
From the Department of Neurology, Marshfield Clinic (P.H.), and the Department of Epidemiology and Biostatistics, Marshfield Medical Research Foundation (S.K.B.), both in Marshfield, Wis. Address reprint requests to Dr. Hansotia at the Department of Neurology, Marshfield Clinic, 1000 N. Oak Ave., Marshfield, WI 54449.
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