AAOS Now

Published 4/1/2009
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Jennie McKee

What’s your “return-to-driving” policy?

Researchers recommend developing a consistent procedure

“Deciding when a patient can return to driving is a complex decision that should not be made lightly, given the patient and public safety implications, as well as potential legal issues,” said Edward K. Rodriguez, MD, PhD. He covered many of those issues in his podium presentation at the 2009 Annual Meeting, “Return to driving after orthopaedic injury or surgery: Patient concerns.”

Based on a patient survey that Dr. Rodriguez and his colleagues conducted, their orthopaedic trauma service developed a consistent policy for advising patients about driving after a musculoskeletal injury or surgery.

Dr. Rodriguez noted that although the National Highway Traffic Safety Association, in cooperation with the American Medical Association, has developed guidelines for evaluating return to driving ability in elderly patients, those guidelines do not always apply to younger patients or to specific orthopaedic issues.

“Because practitioners’ recommendations vary significantly, and because patients often feel pressed to drive when they may not be ready to do so, formulating a return-to-driving policy may be useful, even if only meant for application within a single practice group,” he said.

The survey was conducted as patients returned for follow-up care. The anonymous questionnaire asked about their experiences, concerns, and practices regarding their return to driving. Of the 438 patients asked to complete the questionnaire, 187 did so. After eliminating 66 questionnaires as unusable, researchers analyzed the remaining 121 questionnaires.

Driving restrictions were problematic
Many participating patients had multiple injuries; approximately 85 percent (104 respondents) had undergone a surgical procedure. The patients also provided the following information:

  • Not driving presented a major difficulty for 40 percent of patients; 33 percent noted that it was a minor difficulty, and 27 percent reported that it posed no difficulty.
  • Seventy-five percent of patients relied on family and 42 percent of patients relied on friends for rides; only 14 percent relied on public transportation.
  • The inability to drive presented a major financial hardship beyond the hardships caused by their injury for 30 percent of patients.

Patients were also asked about their return to driving and reported the following:

  • Two out of three (67 percent) did not consult with their physician before returning to driving.
  • One in four (26 percent) said that their physician initially opposed their return to driving.
  • 5 percent reported convincing their physician they were able to drive before the physician would have preferred.
  • 10 percent returned to driving before family or friends felt they were ready to do so.

“One in four patients (25 per­cent) began driving while still taking narcotic medications, and 18 percent reported feeling unsafe behind the wheel,” said Dr. Rodriguez. “Although 88 per­cent of the patients not yet driving at the time of the survey reported that they would consult with their doctor before driving again, only 57 percent of those who were already driving actually had consulted with their physician before beginning to drive again.”

Developing a policy
Researchers offered patients several options to help the practice determine what type of return-to-driving policy would be acceptable. Two out of three (66 percent) of the patients surveyed favored a strict policy that would recommend a state-administered driving test following a “serious” injury; however, only 12 percent stated they would approve of a new driving test after “any” type of musculoskeletal injury.

“We used the results to develop a return-to-driving policy that meets our patients’ needs, addresses their safety, and also takes into account our physicians’ medico-legal concerns,” said Dr. Rodriguez.

As part of the policy, Dr. Rodriguez and the other orthopaedic surgeons in the group explain to patients that they can no longer “clear” them for driving, no matter how long it has been since the injury or surgery. Instead, the surgeons offer advice regarding when patients may be ready to retest with the state department of motor vehicles and recommend that they do so. The conversation is noted in the patient’s medical record.

In addition, the recommendation to retest is printed in a patient brochure given to trauma patients early in their care. Patients have responded positively in most instances.

“Although we may be able to tell when a limb can support the mechanical stress of driving, driving is a multisystem activity that requires a comprehensive assessment of abilities that orthopaedic surgeons cannot perform in the office,” explained Dr. Rodriguez. “As an alternative to our recommendation to recertify with state authorities, we can also provide our patients with a referral to a return-to-driving program managed by independent occupational therapy services.”

Dr. Rodriguez pointed out that the policy may not be applicable to all practice settings, but is one example of how orthopaedists can address return-to-driving issues at the level of a single practice when no accepted or standard recommendations exist.

“Guidelines from orthopaedic specialty societies or the AAOS regarding return to driving would be welcome,” he said. Dr. Rodriguez initially published his results in The Journal of Bone and Joint Surgery (American Volume) in December 2008.

Dr. Rodriguez reported ties to Regenesys Orthopaedics and MX Orthopaedics. His co-authors include Aron Chacko, BS; Vincent Chen, BS; Nicole Desrosiers, and Paul Appleton, MD.

Jennie McKee is a staff writer with AAOS Now. She can be reached at mckee@aaos.org