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Abstract
Background There is a dearth of information and guidance for healthcare providers on how to manage a patient’s return to driving following a mild traumatic brain injury (mTBI).
Methods Using the 2020 DocStyles survey, 958 healthcare providers were surveyed about their diagnosis and management practices related to driving after an mTBI.
Results Approximately half (52.0%) of respondents reported routinely (more than 75% of the time) talking with patients with mTBI about how to safely return to driving after their injury. When asked about how many days they recommend their patients with mTBI wait before returning to driving after their injury: 1.0% recommended 1 day or less; 11.7% recommended 2–3 days; 24.5% recommended 4–7 days and 45.9% recommended more than 7 days. Many respondents did not consistently screen patients with mTBI for risk factors that may affect their driving ability or provide them with written instructions on how to safely return to driving (59.7% and 62.6%, respectively). Approximately 16.8% of respondents reported they do not usually make a recommendation regarding how long patients should wait after their injury to return to driving.
Conclusions Many healthcare providers in this study reported that they do not consistently screen nor educate patients with mTBI about driving after their injury. In order to develop interventions, future studies are needed to assess factors that influence healthcare providers behaviours on this topic.
- concussion
- traumatic brain injury
- injury diagnosis
- motor vehicle - non traffic
- motor vehicle � occupant
Data availability statement
Data may be obtained from a third party and are not publicly available.
Statistics from Altmetric.com
Introduction
Approximately, 75% of people in the USA who sustain a traumatic brain injury (TBI) are classified as having had a mild TBI (mTBI).1 Caused by a bump, blow or jolt to the head or a hit to the body that causes the head and brain to move rapidly back-and-forth or twist in the skull, an mTBI is associated with transient neurological or neuropsychological abnormalities. mTBIs affect each person differently. Individuals with mTBI may experience one or more cognitive, physical, emotional and sleep-related symptoms.1 Symptoms of mTBI are generally most severe within the first few days after the injury and often evolve over the course of recovery.2 3 For example, patients initially may experience one or more symptoms that affect reaction time or processing speed,4 5 cognition, vision and attention,4–6 sensitivity to light and noise,7 and memory.8 For some patients, later in recovery behavioural and emotional symptoms, as well as sleep related problems, may become more prevalent.3 9 10 While most people will have a good recovery with the majority asymptomatic 1-year postinjury, approximately half of individuals with an mTBI demonstrate cognitive impairment 3 months postinjury.11
Symptoms of an mTBI may appear or get worse as a person with an mTBI returns to school and/or work. Patient and family education about mTBI, symptom monitoring, and graded return to activity are associated with improved health outcomes for patients with mTBI.12–15 As such, current guidelines recommend that individuals with mTBI are screened for risk factors for prolonged recovery and to rest at home for the first few days after the injury.12 16 17 Within 2–3 days, most individuals are guided to resume school and work gradually; limiting activities at school and work to those that do not exacerbate symptoms.12 16 17 Additionally, guidelines outline detailed stepwise processes for returning to sports and physical activities.16 18
As driving a motor vehicle requires the ability to use a complex set of skills simultaneously, some studies suggest that the deficits that may result from an mTBI may temporarily inhibit an individual’s ability to drive safely.19 20 For example, mTBI or concussion symptoms that may interfere with work and school, such as problems with vision,21 cognitive deficits22 23 and sleep impairment,24 are also associated with an increased risk of being in a motor vehicle crash. Moreover, Baker et al found that within 24 hours of their injury, patients with mTBI performed worse than their orthopaedic control counterparts on driving tests that assess executive functioning, planning, decision-making and attention skills.19 A study using video-based driving simulators also demonstrated that patients with mTBI, within 24 hours postinjury, may be at increased risk for a motor vehicle crash due to a decreased ability to identify potentially dangerous traffic situations (ie, situations where the driver may have to brake or change course to avoid other road users).20
Despite the potential for increased motor vehicle crash risk after an mTBI,19 20 many mTBI guidelines do not include recommendations related to screening for risk factors and advising patients regarding safely returning to driving. The American Medical Society for Sports Medicine position statement was the first to address the importance of discussing return to driving with patients with mTBI.25 However, this recommendation focuses solely on managing the care of athletes. Thus, using data from the 2020 DocStyles survey, our study assessed current practices related to how healthcare providers may screen for and educate patients with mTBI, from any cause, about return to driving. The goal of this paper is to describe current discharge practices among healthcare providers for patients with mTBI.
Methods
From 23 March to 16 April 2020, Porter Novelli Public Services commissioned DocStyles, a web-based survey with a main sample of primary care physicians and additional samples of other specialties. Quotas were set to reach 1000 primary care physicians, 250 obstetrician/gynaecologists (OB/GYNs), 250 paediatricians and 250 nurse practitioners/physician assistants (NPs/PAs). As patients do not generally seek care for mTBI during an OB/GYN visit, they were not included in our study. Respondents were paid an honorarium of US$40–US$60 for completing the survey based on the number of questions they were asked to complete. The survey was conducted by SERMO. SERMO’s Global Medical panellists are verified using a double opt-in sign up process with telephone confirmation at place of work. SERMO sampled its currently active panel members based on their activity level so that high responders (answer >75% of surveys they are sent) are invited first, followed by Medium (answer 25%–75%) and Low (answer <25%) responders. Panellists who did not participate in the previous year’s DocStyles survey were prioritised above previous respondents. All invitations included a link to the web-based survey. Respondents were screened to include only those who practice in the USA, actively see patients, work in an individual, group, or hospital practice, and who have been practising for at least 3 years. Respondents were not required to participate and could exit the survey at any time. To protect respondent confidentiality, no individual identifiers were included in the database. Centers for Disease Control and Prevention licensed the results of the survey from Porter Novelli after data were collected.
Instrument
The DocStyles 2020 survey instrument was developed by Porter Novelli with technical guidance provided by federal public health agencies and other non-profit and for-profit clients. DocStyles contained 115 questions, some with multiple subparts, which were designed to provide insight into healthcare providers’ attitudes and counselling behaviours regarding a variety of health issues and to assess their use and trust of available health information sources.
In addition to providing demographic (sex, age, race, region) and practice-related information (specialty, work setting, years in medical practice), respondents were asked seven questions related to mTBI or concussion in the 2020 DocStyles survey. First, respondents were asked: ‘In the last 12 months, have you cared for a patient age 16 and older with an mTBI or concussion?’ If the respondent answered affirmatively to this first question (n=958), they were directed to answer six additional questions regarding driving after an mTBI or concussion. These questions included: (1) ‘How often do you talk with patients about how to safely return to driving a car or other motor vehicle after getting an mTBI or concussion?’, (2) ‘How many days do you recommend that patients with an mTBI or concussion wait before they drive a car or other motor vehicle?’, (3) ‘How often do you screen patients with a suspected mTBI or concussion to assess whether their symptoms (such as slowed reaction time and blurry vision) may affect their driving ability?’, (4) ‘How often do you provide patients with mTBI or concussion with written information that includes content on how and when to return to driving following this injury?’, (5) ‘How confident are you in your ability to educate patients about return to driving after an mTBI?’ and (6) ‘Have you ever referred a patient with mTBI for assistance with return to driving?” Response options for question 2 included: ‘1 hour or less,’ ‘2–3 days,’ ‘4–7 days,’ ‘more than 7 days’ and ‘I usually don’t make a recommendation.’ Response options for questions 1, 3 and 4 included: ‘more than 75% of the time,’ ‘between 75% and 25% of the time,’ ‘less than 25% of the time’ and ‘never’. Response options for question 5 included: ‘very or somewhat confident’ and ‘not confident’. Response options for question 6 included: ‘yes’ and ‘no’.
Analysis
All data were analysed using SAS V.9.4 (SAS Institute) and IBM SPSS Statistics Subscription. Frequency distributions were calculated for each question. In order to determine whether practice specialty or setting was associated with return to driving guidance, χ2 tests were conducted. For the χ2 analyses, response options for the independent variables were condense to binary levels (ie, more than 75% of the time vs 75% of the time or less, I usually don’t make a recommendation vs I make a recommendation, etc). Bonferroni post hoc proportions tests were also performed to decrease type I error if the Pearson χ2 results were significant, p<0.05, to determine where the differences lie for each individual group.
Results
Of the 1500 providers, 63.5% (958) indicated that they cared for a patient age 16 and older with mTBI or concussion within the past year. Nearly two-thirds (61.2%) of the respondents were male and over three-fourths were under the age of 55 years (77.7%) (table 1). The respondents were primarily white (69.3%) and were spread out across the four regions of the USA. Most respondents reported working in an urban practice setting (93.0%). About one-third (34.3%) identified as family practitioners, 29.5% as internists, 21.3% as paediatricians, and the remaining (14.8%) as NPs/PAs. Most healthcare providers (71.2%) worked in a group outpatient practice and had practised in their profession for 18 years or less (63.3%).
Characteristics of respondents who completed questions regarding driving after an mTBI or concussion in the 2020 DocStyles Survey*
Table 2 displays the results of healthcare providers’ responses to the mTBI-related driving questions. Half (52.0%) of respondents routinely (more than 75% of the time) talk with patients with mTBI about how to safely return to driving after their injury. When asked about how many days they recommend their patients with mTBI wait before returning to driving after their injury, 1.0% recommended 1 day or less, 11.7% recommended 2–days, 24.5% recommended 4–7 days and 45.9% recommended more than 7 days. Approximately 16.8% of respondents reported they do not usually make a recommendation regarding how long patients should wait after their injury to return to driving. Many respondents do not consistently (more than 75% of the time) screen patients for risk factors that may affect their driving ability or provide patients with mTBI with written instructions on how to safely return to driving (59.7% and 62.6%, respectively). Only 36.7% of respondents have referred a patient with mTBI for assistance with return to driving. Still, most respondents (80.6%) reported that they are confident in their ability to educate patients about return to driving after an mTBI.
Frequency and percentage of respondents* who completed questions regarding driving after an mTBI or concussion contained in the 2020 DocStyles survey
After correcting for multiple comparisons, post hoc tests demonstrated a significantly higher proportion of family practitioners (59.3%) that talked with their patients more than 75% of the time about how to safely return to driving after sustaining an mTBI or concussion compared with paediatricians (42.6%), p=0.0024 (table 3). Family practitioners (86.9%) had a higher percentage of being very or somewhat confident in their ability to educate patients about return to driving after an mTBI than internists (77.7%) and NPs/PAs (74.6%), p=0.0033. Family practitioners (39.2%), internists (44.2%) and NPs/PAs (38.0%) also had a higher proportion of referring a patient with an mTBI for assistance with return to driving compared with paediatricians (21.6%), p<0.0001.
Frequency and percentage of respondents* who completed questions regarding driving after an mTBI or concussion contained in the 2020 DocStyles survey by specialty
After correcting for multiple comparisons, post hoc tests demonstrated that healthcare providers practising in an individual outpatient setting had a significantly higher proportion of talking with their patients more than 75% of the time about how to safely return to driving after sustaining an mTBI or concussion (60.0%) and screening their patients to assess whether their symptoms may affect their driving ability (50.4%) compared with healthcare providers practising in an inpatient setting (44.4% and 33.1%, respectively), p<0.04 (table 4). Healthcare providers practising in an individual outpatient or group outpatient setting had a higher percentage of being very or somewhat confident in their ability to educate patients about return to driving after an mTBI (86.4% and 81.5%) and more often refer patients with an mTBI for assistance with return to driving (43.2% and 37.7%) compared with healthcare providers practising in an inpatient setting (71.5% and 27.2%, respectively), p<0.02.
Frequency and percentage of respondents* who completed questions regarding driving after an mTBI or concussion contained in the 2020 DocStyles survey by practice setting
Discussion
Consistent with previous studies on concussion management, many healthcare providers in this study did not consistently communicate (‘more than 75% of the time’) with patients with mTBI about driving after their injury.26 27Driving is often an integral part of a patient’s return to regular activities, facilitating transportation to activities such as school and work. Previous studies using video-based simulators indicate that patients with mTBI are less able to identify driving hazards that place them at risk for a motor vehicle crash (within the first 24 hours of their injury) and declines in driving performance may persist even after symptom resolution.19 20 28 Still, research on driving safety among patients with mTBI following the 24 hour time frame is limited and inconclusive.29 Future research on driving risk following the first 24 hours, as well as identification of specific symptoms that could increase the risk for impaired driving after an mTBI, may be beneficial. Further, the development, testing, and evaluation of stepwise, symptom-specific return-to-driving instructions that mirror those of return-to-sports and physical activity protocols is warranted.
Interestingly, most healthcare providers in this study reported being confident in their ability to educate patients about returning to driving, but few reported talking with their patients. This disconnect between confidence and implementation may suggest that knowledge and awareness of the importance of communicating with patients about return to driving is insufficient. Another factor may be concerns among healthcare providers regarding possible detrimental effects that may result from restricting driving. Previous studies suggest that restricting driving is associated with decreased health-related quality of life,30 increased likelihood of depression and social isolation,31 32 and reduced mobility.33 Furthermore, a preliminary study found that individuals with mTBI may not report symptoms due to concerns about being prohibited from driving.34 Guidance on return to driving for healthcare providers that takes into account transportation needs and the potential negative effects of restricting driving while balancing patient concerns, risk and readiness, may help support healthcare provider and patient uptake.
Diagnosis of mTBI is inclusive of symptom-based screenings. Yet, less than half of respondents reported consistently screening patients with mTBI for symptoms (such as slowed reaction time and blurred vision) that may affect their driving ability. It stands to reason that healthcare providers may ask about these symptoms, but not relate the potential effects of these symptoms to driving safety. On the other hand, while symptoms such as slowed reaction time and processing speed are common neuropsychological changes among individuals recovering from an mTBI, screening for these symptoms in the absence of neuropsychology testing is challenging. Development of validated screening tools designed to specifically assess symptoms that affect driving safety after mTBI and can be used in a variety of healthcare settings may be beneficial. Moreover, as symptoms of mTBI may worsen with certain activities or have a later onset, healthcare providers may consider screening individuals for changes in symptom presentation that may affect driving during follow-up visits.
Prior studies indicate the individuals may not refrain from driving during their recovery.34 35 Research suggests that clear and concise guidance (both verbal and written instructions) from healthcare providers that includes active engagement (eg, teach-back strategies, opportunities for the patient to ask questions) may be most effective.36 Internists, NP/PAs and healthcare providers working in an inpatient setting were less confident about their ability to educate patients about driving safety after an mTBI. This differs from a previous study that found that paediatricians were more confident in managing paediatric patients’ return to activities after an mTBI as compared with family practitioners, internists, and NPs.37 No data were available for this study on how frequently healthcare providers diagnosed and managed paediatric patients. It is likely that how often a healthcare provider treats patients with mTBI may play a role in their confidence regarding patient education, inclusive of driving after an mTBI. Future studies may take this into account and assess potential factors that lead to variations among healthcare provider specialties.
While stepwise return-to-driving protocols are not yet available, it is apparent that driving performance is affected within at least the first 24 hours of the injury. Receiving education and discharge instructions from healthcare providers may promote more positive patient behaviours.13 As such, providing discharge instructions on driving safety to patients with mTBI may promote understanding of potential risks immediately after the injury and which symptoms (eg, sleep impairment, problems with attention) may put them at risk for a motor vehicle crash. In addition, healthcare provider–patient discharge discussions may facilitate better planning for transportation needs, without the ability to drive, to mitigate risk. However, poor use of discharge instructions for patients with mTBI is not just limited to instructions on driving.38–40 Currently, use of overall discharge instructions with patients with mTBI in the United States and in other countries is suboptimal—with adult patients and patients with non-sports-related injuries less likely to receive information to support their recovery.41 Brown et al reported that one-fifth of patients had no discharge information, including referrals or follow-up, recorded when leaving the hospital.39 Other studies indicate that less than half of patients with mTBI may receive educational materials on discharge.38 41 Interventions inclusive of electronic health record prompts on return to driving have demonstrated previous success in improving healthcare providers’ discharge behaviours around mTBI13 42 and may help increase screening and communication about return to driving.
Limitations
This study is subject to at least five limitations. First, the DocStyles sample is weighted to match the American Medical Association Masterfile proportions for age, sex and region, but healthcare providers are not randomly selected and thus results may not be generalisable. Future studies using a large, randomised sample of healthcare providers may be beneficial to substantiate findings in this study. Second, healthcare providers self-reported behaviours. The survey did not verify self-reports to confirm they reflect actual care practices. Thus, the findings are unable to report the reliability or validity of healthcare providers’ actual practices. Future studies are needed to explore this. Third, healthcare providers may have felt the need to answer questions in a way they thought would be acceptable to the survey administrators. Social desirability may have biased the level of self-efficacy and may also help explain the disconnect observed between self-efficacy and reported management practices. Fourth, as it was unlikely that healthcare providers could indicate an exact percentage to represent their behaviours, the survey responses provided a range of compliance (ie, less than 25% of the time; between 25% and 75% of the time; more than 75% of the time). Thus, it is not clear what percentage of healthcare providers reported doing an examined activity 100% of the time as compared with those never did an activity. Further, while the ranges were designed to primarily capture the low and high implementers, they did not allow for finer analysis of the data. This information could affect the observed differences between specialties and among the examined activities. Future studies with high and low implementers regarding their reported behaviours to elicit explanations for reported behaviours may be beneficial. Finally, as no data was available, the findings do not account for the volume of mTBI patients each healthcare provider diagnosed and/or managed. This may affect results regarding referral to a driving specialist, as well as overall responses from paediatricians and geriatricians who may see less patients who are driving.
Conclusion
Many healthcare providers reported they do not talk to their patients with mTBI about driving more than 75% of the time nor do they screen patients with mTBI for risk factors that may affect their driving more than 75% of the time. Lack of guideline recommendations and stepwise protocols, as well as concerns about the potential detrimental effects of returning to driving, may be barriers to healthcare provider-patient communication on this topic. However, as the findings in this study cannot be used to determine why some healthcare providers may or may not discuss and screen patients with mTBI for drive safety, future studies are needed to assess these factors as well as others barriers that may affect healthcare provider behaviour on this topic.
What is already known on the subject
As driving a motor vehicle requires the ability to use a complex set of skills simultaneously, some studies suggest that the deficits that may result from a mild traumatic brain injury (mTBI) may temporarily inhibit an individual’s ability to drive safely.
Many mTBI guidelines for healthcare providers do not include recommendations related to screening for risk factors and advising patients regarding safely returning to driving.
What this study adds
Patients with mTBI may not be consistently screened regarding their ability to drive safely and may not regularly receive education on how and when to return to driving.
In order to develop interventions, future studies are needed to assess factors that influence healthcare providers behaviours on this topic.
Data availability statement
Data may be obtained from a third party and are not publicly available.
Ethics statements
Patient consent for publication
Ethics approval
Centers for Disease Control and Prevention’s analyses were exempt from institutional review board approval because personal identifiers were not included in the data file.
References
Footnotes
Contributors All authors contributed to this work and agree with the publication of this manuscript in Injury Prevention.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.