Notation 8428: The National Transportation Safety Board (NTSB) has reviewed the National Highway Traffic Safety Administration's (NHTSA) "Amendments to Highway Safety Program Guidelines," published at 77 Federal Register 37093 (June 20, 2012). NHTSA proposes to amend five existing highway safety guidelines and add a new "Older Driver Safety" guideline. The NTSB is pleased that NHTSA is providing the states with guidance on older driver safety. However, the NTSB is concerned that attention by interested parties to the new guideline may be overlooked because the "action" requested at the beginning of the proposed guideline solicits comments on the more general "highway safety program guidelines."
Our comments address only the newly proposed Highway Safety Program Guideline No. 13-Older Driver Safety. This guideline recommends the key components of a state older driver safety program that aims to reduce crashes, fatalities and injuries among this growing segment of the population. The NTSB supports NHTSA's efforts to promote older driver safety and agrees it is important that states include in their highway safety programs considerations for (1) driver licensing and medical review of at-risk drivers, (2) education for the medical and law enforcement community, and (3) roadway design for older driver safety.
The NTSB has investigated a number of accidents involving older drivers, but in no case has cited age as a probable cause of the accident. One such accident occurred in 2003, when an 86-year-old driver struck the left rear of a vehicle stopped at an intersection light and then continued through portable, temporary barricades that blocked a street being used for a farmers market. The accident vehicle moved through the farmers market for approximately 2.5 blocks, striking pedestrians and display booths, and ultimately killing 10 people and injuring 63. The NTSB concluded that the cause of this accident was unintended acceleration following the initial collision at the intersection. In a 1999 investigation, a 79-year-old school bus driver drove past flashing red lights and a stop sign and into the path of a dump truck towing a utility trailer, seriously injuring five students and two adults. The NTSB found that the driver had various medical conditions that could have impaired his driving.
In November 2002, the NTSB investigated an accident involving a driver with a history of epilepsy and subsequently identified five other accidents in which medical incapacitation was the probable cause. During these investigations, NTSB investigators found that licensing issues were not restricted to drivers with a history of seizures, prompting the NTSB to broaden its interest to encompass medical oversight of all noncommercial drivers and providing the impetus for the NTSB's March 2003 hearing on this issue.
Healthcare experts from academia, advocacy organizations, and Federal and state governments participated in this hearing, which focused on the following major areas: (1) current knowledge regarding potentially impairing medical conditions, (2) identification and reporting of medically high-risk drivers, (3) procedures for assessing the driving fitness of medically high-risk drivers, (4) state licensure and oversight of noncommercial drivers with high-risk medical conditions, (5) programs to increase public awareness of state oversight laws and procedures, and (6) rehabilitation and transportation options for medically high-risk drivers.
Following the hearing, the NTSB adopted a special investigation report on the medical oversight of noncommercial drivers, which incorporated the findings of the hearing and the six accident investigations.4 As a result of its special investigation, the NTSB issued 12 recommendations (H-04-37 through -48) to improve the reporting and rehabilitation of at-risk drivers and develop alternative transportation options for medically unqualified drivers. Although the hearing and special investigation did not focus on older drivers, the correlation between advancing age and driver disease and impairment was an essential part of the discussion.
In November 2010, the NTSB hosted a forum on Safety, Mobility, and Aging Drivers that examined our scientific understanding of the issues associated with aging drivers.5 Forum panelists discussed topics including the (1) safety risks associated with aging drivers, (2) occupant protection issues, (3) needed highway and vehicle design improvements, and (4) licensing practices and methods to assess aging driver capability, both in terms of mental and physical abilities. The forum's final panel examined state programs and practices, including a discussion of (1) the components of an effective program to identify at-risk aging drivers, (2) the role of medical advisory boards in determining medical fitness to drive, (3) the work of state departments of transportation (DOT) in determining whether statutory changes to the licensing of aging drivers have had a safety impact, and (4) nonstatutory programs to ensure that aging drivers are safe drivers, particularly in the area of medical assessment. The 2-day forum provided a broad overview and scientific understanding of the issues associated with aging drivers, and the discussion was consistent with NHTSA's work in the development of an aging driver highway safety program.
NHTSA Highway Safety Program Guideline No. 13 (Older Driver Safety) The new guideline is consistent with NHTSA's 2005 Older Driver Traffic Safety Plan and its Older Driver Program Five-Year Strategic Plan (2012-2017).6 The guideline directs each state, in cooperation with its political subdivisions and other stakeholders, to include a comprehensive approach to older driver safety through highway safety programs that aim to reduce older driver crashes, fatalities, and injuries. The guideline is divided into major areas of emphasis; our following comments address those areas, either individually or in combination.
The proposed guideline calls on the states to include older driver safety in their highway safety plans. It also encourages states to consider the issue as an emphasis area in their State Strategic Highway Safety Plan (SHSP), if data analysis identifies older driver safety as an area of concern. The NTSB commends NHTSA for directing the states to address this issue in their highway safety plans and for encouraging its inclusion in the SHSPs.
The Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU) established the Highway Safety Improvement Program as a core Federal program of the Federal Highway Administration (FHWA). SHSPs are a coordinated framework, developed by state DOTs, that use a data-driven process to establish statewide goals and objectives to reduce fatalities and injuries. SHSPs seek to integrate engineering, education, enforcement, and emergency medical service (referred to as "the 4Es") in order to identify safety needs.
The NTSB believes that demographic trends and crash data will lead states to include older driver safety in their SHSPs and, given the national statistics, likely recognize older driver safety as an SHSP emphasis area.8 In 20 I 0, 32,885 highway traffic fatalities occurred. Although people 65 or older made up 13 percent of the population that year, they accounted for 17 percent of deaths (n=5,484). Further, individuals over 65 accounted for 16 percent of all occupant fatalities and 19 percent of pedestrian deaths.9 Older drivers also experience a higher rate of fatal crashes; but, by some estimates, 20-60 percent of that rate can be attributed to fragility, highlighting the need to consider older driver occupant protection. While 20 10 fatalities were down 3 percent overall, fatalities in crashes involving older drivers increased 2 percent. This increase is likely because of the increased number of older drivers.
Roadway Design for Older Driver Safety
The FHWA's Highway Design Handbook for Older Drivers and Pedestrians, first published in 1998 and updated in 2001, addresses practical recommendations that link older road user characteristics to highway design and operational and traffic engineering solutions.
Highway safety improvements targeted toward older drivers, such as improved signage, road markings, and intersection design, increase safety for all drivers. The proposed rule states that the FHW A guidelines should be implemented on state and local roadways; the NTSB agrees.
According to the Governors Highway Safety Association, 33 states have special provisions for licensing older drivers including accelerated renewal frequency, in-person renewals, vision tests, or road tests. 12 State licensing requirements for older drivers vary considerably. Maryland requires a vision test for drivers over 40; Georgia, for drivers over 64; and Virginia, for drivers over 80. Texas drivers over 85 must renew their licenses every 2 years; Missouri drivers over 70, every 3 years; and Montana drivers over 75, every 4 years. In-person renewals are required for California drivers over 70, Alaska drivers over 69, and Florida drivers over 80 (unless they can provide a physician's letter).
Older drivers are a highly heterogeneous group and, for that reason, it is difficult to determine a specific age for increased license scrutiny. Perceptual capabilities, motor skills, and cognitive abilities deteriorate with age, but these performance decrements are not tied to a particular age. However, increasing age is associated with an increase in chronic medical conditions and use of medications. Of particular concern are diseases that affect vision and cognition. Safety concerns center around identifying medically at-risk drivers, particularly those with cognitive decrements who may not realize that their driving abilities have degraded.
The elevated risk for drivers older than 75 is confounded by fragility and Injury propensity; in general, older drivers are more of a risk to themselves than to other road users.13 This risk, however, must be balanced against other adverse outcomes of driver cessation: increased depression and social isolation, decreased employment opportunity, reduced access to health care, and increased placement in long-term care. State legislatures and licensing authorities have responded by enacting special provisions for older drivers. The older driver safety guideline proposed by NHTSA involves evaluation of the safety effectiveness of the states's different approaches to this issue. In addition, NHTSA has made several specific recommendations to the states on driver licensing (in-person renewals, medical review policies, reporting immunity, and MABs). The NTSB believes that implementation and evaluation of these programmatic recommendations should advance sound older driver policy.
At the heart of the issue of driver licensing is screening versus evaluation. Many states are using age as a marker for initial screening, in order to identify drivers who exhibit characteristics that warrant medical evaluation. Two-thirds of the states have established Medical Advisory Boards (MABs) to oversee the evaluation of medically at-risk drivers identified through screening at the Department of Motor Vehicles (DMV) or by physicians, law enforcement, or the public. The proposed guideline recommends that all states develop MABs; the NTSB agrees, and encourages recognition of an expanded role for MABs that includes the education and training of other practitioners and the public. The NTSB commends NHTSA for developing Driver Fitness Medical Guidelines in conjunction with the American Association of Motor Vehicle Administrators to help guide medical evaluations. The education of medical providers on patient driving safety was identified in the NTSB's forum on the medical oversight of noncommercial drivers, and the NTSB believes that NHTSA is seeking to address this issue in the proposed guidance. In particular, the NTSB supports the specific inclusion of Continuing Medical Education credits to disseminate educational materials to medical professionals. The NTSB urges NHTSA to specifically include emergency medical technicians (EMT) and emergency room physicians in education and training initiatives. Such professionals are uniquely qualified to observe drivers after an accident and identify impairing medical conditions; further, EMTs have a close working relationship with law enforcement officers and are familiar with the accident scene.
Education and Communication
The guideline recommends that DMV staff, medical providers, and law enforcement personnel be trained to identify at-risk drivers. The NTSB agrees that law enforcement personnel are key players; comments during the NTSB's forum on the medical oversight of noncommercial drivers indicated that, in some states, law enforcement personnel account for anywhere from 35-90 percent of driver referrals. The NTSB supports efforts to educate and train officers in the identification and referral of at-risk drivers.
Although the proposed guideline addresses immunity for medical professionals, no mention is made of the people who have the most direct contact with at-risk drivers-their friends and family. This group is in the best position to assess the impact of aging and aging-related medical conditions on the physical and mental abilities of an at-risk driver and has greater contact with such drivers than a doctor, a police officer, or the DMV. NHTSA recognized the importance of this group in a 2005 report on MABs, noting "Family members can serve as a front-line source of referrals, prompting driver reevaluation before an adverse driving event occurs. The same report concluded that family referrals were just as valid as referrals from law enforcement officers. The NTSB urges NHTSA to revise the proposed guideline to include mechanisms for family members to report drivers to the DMV, including immunity and confidentiality. The NTSB also believes that family members should be specifically included in education and awareness efforts performed under the guideline.
The NTSB strongly supports the provision for civil immunity for medical providers of all kinds [emphasis added] who, in good faith, refer a driver to the licensing authority. The absence of such laws was recognized as a hindrance to state oversight systems in the NTSB's special investigation on driver medical oversight. 15 The NTSB hopes, however, that NHTSA will make it clear in the guideline that medical providers specifically include emergency room physicians and EMTs. As noted in the NTSB's special investigation, emergency room doctors and EMTs are uniquely positioned to observe a potential causal relationship between accidents and age-related factors, including medical conditions. However, the NTSB remains concerned that the immunity provision specifies only civil immunity. The NTSB urges NHTSA to revise the proposed guideline to more closely reflect the model law developed by the National Committee on Uniform Traffic Laws and Ordinances to protect reporting medical professionals from civil, administrative, and criminal liability.
Program Evaluation and Data
The NTSB's forum on the medical oversight of noncommercial drivers recognized the need to collect detailed safety data to identify the role that age-related medical conditions play in accidents. The NTSB is pleased to see that NHTSA also recognizes this problem and is attempting to address it though the proposed guideline. However, the NTSB notes that the "driver condition" field on a state's accident reporting form is interpreted differently by each state and is too general to collect useful information on a driver's specific medical conditions. The NTSB suggests that NHTSA, as part of the proposed guideline, encourage the inclusion of a specific field for impairing medical conditions in the Model Minimum Uniform Crash Criteria (MMUCC) to facilitate collection of the data.
In summary, the NTSB suggests the following inclusions in the proposed guideline on older driver safety:
• Emphasize the ability of the MAB to assist with other areas of the proposed guidance, such as public education and the training of DMV personnel and law enforcement officers;
• Specifically include emergency room medical practitioners and emergency medical technicians in the immunity of medical practitioners, and expand the proposed civil immunity to include administrative and criminal immunity;
• Specifically include family members and friends in communication and education efforts;
• Encourage the reporting of at-risk drivers by family members and friends by allowing for immunity and confidentiality for such persons; and • Recommend, as part of the guideline, that the MMUCC be modified to include a specific field for impairing medical conditions to enhance data collection.
Vehicle Design Considerations
The NTSB notes that the proposed guideline does not address how vehicle design and technology can allow older drivers to continue to safely operate their vehicles. Although vehicle design would be inappropriate in a guideline to the states, the NTSB is interested in learning more about NHTSA's plans to address the older driver issue from vehicle design standpoint.
Older drivers have special occupant protection needs because, among other things, of skeletal changes experienced by the aging body's increased fragility. The NTSB's forum on aging drivers discussed developing injury criteria that could inform occupant protection systems targeted toward older drivers, but no concluding recommendations were agreed upon by the expert panel. The NTSB encourages NHTSA to continue researching occupant protection for older drivers. With regard to vehicle design, NHTSA released the first of three proposed guidelines for Vehicle Interface Design in February 2012. Given the increasing number of older drivers anticipated in the future, the NTSB urges NHTSA to specifically address older driver usability.
The NTSB's special investigation on the medical oversight of noncommercial drivers 17 contained several recommendations that are associated with Highway Safety Program Guideline No. 13-O1der Driver Safety including the following two to NHTSA, in cooperation with the American Association of Motor Vehicle Administrators:
Determine the most effective licensing countermeasures to reduce the risks posed by medically impaired drivers. (Open-Acceptable Response)
Once the most effective reporting methods and licensing countermeasures have been determined, develop a model comprehensive medical oversight program for States to use to oversee medically impaired drivers. Such a program should include, as a minimum:
a. Methods to provide information to the public on resource availability and on the medical oversight laws and procedures to assist medically high-risk drivers.
b. Plans and strategies to simplify and maximize reporting of potential driver medical impairment to medical evaluation units of State driver licensing organizations by law enforcement officers, health care providers, emergency services providers, and the public.
c. Methods to capture all cases of motor vehicle incidents or accidents potentially related to driver medical impairment.
d. Standardized methods of driver evaluation for potentially medically impaired drivers incorporating medical records review, systematic testing, and on-road appraisals, as needed.
e. Methods for timely and appropriate restriction of driving privileges for drivers found to have medical conditions or treatments that impair their ability to safely operate a motor vehicle. (Open-Acceptable Response)
As the proposed guideline progresses toward final publication, and as states act on the recommendations contained in the guideline, the NTSB will evaluate NHTSA actions in light of countermeasures to reduce risks posed by medically impaired drivers.
The NTSB is pleased that NHTSA is moving forward to provide the states with guidance on older driver safety. The promulgation of this guideline furthers the action begun by the Older Driver Program Five-Year Strategic Plan by creating a mechanism for its implementation. Thank you for the opportunity to comment on the proposed guideline.