Diabetes: Driving and the Workplace

Transcription

1 Diabetes: Driving and the Workplace John E. Anderson, M.D. The Frist Clinic Nashville, TN Past President, Medicine and Science American Diabetes Association Presenter Disclosure Information In compliance with the accrediting board policies, the American Diabetes Association requires the following disclosure to the participants: Speaker s Bureaus: Consultant: Advisory Boards: Bristol Myers Squibb Novo Nordisk Eli Lilly and Company Boehringer Ingelheim Sanofi Sanofi Eli Lilly and Company Janssen Pharmaceuticals Abbott Pharmaceuticals 1. There are multiple diabetes variables that can affect driving safety 2. Moderate hypoglycemia impairs driving safety 3. There are individual differences in terms of risk of driving mishaps for drivers with T1DM 4. Ethical issues/legal liabilities 5. Treatment recommendations 6. Future directions 1

2 Private Driving Licenses Regulated by State DMV U.S. Department of Transportation Federal Motor Carrier Safety Administration Commercial Driving Licenses Regulated by State departments of motor vehicle (DMVs) State DMVs collaborate in the American Association of Motor Vehicle Administrators (AAMVA) Guidance by the National Highway Transportation Safety Administration (NHTSA) Varies State by State New License Questionnaire Do you have any medical condition that may interfere with safe operation of a motor vehicle? Above plus specific list including diabetes Evaluation after a MVA Referral to DMV after a severe hypoglycemic or hyperglycemic event (+MVA ) Physician reporting Mandatory or Optional (varies by state PA Mandatory severe hypo) Blanket ban on insulin treated diabetes except: Federal Exemption Program: Be operating in interstate commerce On insulin for > 1 2 months No severe hypoglycemia in prior 12 months No more than 2 episodes of severe hypoglycemia in preceding 5 years No unstable retinopathy or other disqualifying conditions have undergone diabetes education and demonstrate willingness to manage the condition maintain driving and BG log Check BG q 2 4 hours Only drive if BG is between mg/dl ( mm) Submit quarterly and annual reports to DOT Report all MVA or adverse driving events Diabetes and Commercial Motor Vehicle Safety ECRI Systematic Review PREPARED FOR FMCSA al_may_27_2011 p.pdf 2

3 Are individuals with diabetes mellitus at increased risk for a motor vehicle crash when compared with comparable individuals who do not have diabetes? Is hypoglycemia an important risk factor for a motor vehicle crash among individuals with diabetes mellitus? Are individuals with diabetes mellitus at increased risk for a motor vehicle crash when compared with comparable individuals who do not have diabetes? Fifteen studies examined the risk of motor vehicle crashes in diabetics vs. nondiabetics. The summary relative risk was 1.12 ( ). These were low quality studies (potentially biased) There was no evidence for a higher risk of crash among people on insulin. Is hypoglycemia an important risk factor for a motor vehicle crash among individuals with diabetes mellitus? There were no data on the relationship between hypoglycemia and crash risk. Hypoglycemia has a significant deleterious effect on the driving ability of some individuals with type 1 DM when measured using a driving simulator (Strength of Evidence: Moderate). 3

4 Is hypoglycemia an important risk factor for a motor vehicle crash among individuals with diabetes mellitus? Three studies with a small number of patients suggested a possible deleterious relationship between hypoglycemia and simulated driving tasks There was no consistency in the pattern of simulated driving task impairment or in the sensitivity of these task impairments to specific levels of hypoglycemia Is hypoglycemia an important risk factor for a motor vehicle crash among individuals with diabetes mellitus? Ten studies examined impairments of cognitive function with hypoglycemia in Type 1 diabetes. Not surprisingly, there was a deleterious relationship in some but not all individuals at blood glucose levels of mg/dl Motor Vehicle Accidents and Severe Hypoglycemia in ACCORD Intensive N (%) Standard N (%) CHF 152 (3.0) 124 (2.4) 0.10 P MVA* 9 (0.2) 14 (0.3) 0.31 Non-hypo SAE 113 (2.2) 82 (1.6) 0.03 Fluid Retention 3541 (70.1) 3378 (66.8) <0.001 ALT > 3 X Normal 51 (1.0) 77 (1.5) 0.02 *Motor Vehicle Accident Diabetes X controls Type 1 DM with Hx of severe hypo in prior 2 years X controls Hypo unawareness probably increased A1C, Pump, Complications: NS 16 y.o. males 42 X y.o. females Rural highways 9.2 X urban highways 1 A.M. Sunday 142 X 11 AM Sunday 4

5 Benadryl 25 mg Tylenol PM Contains benadryl 25 mg Tylenol Allergy Contains chlorpheniramine (chlor trimeton) 2 mg NyQuil Contains doxylamine 6.25 mg (antihistamine) Alka Seltzer Plus Contains chlorpheniramine 2 mg Vehicular collisions are twice as likely among drivers with T1DM One international survey Peripheral neuropathy of the feet - One 12 month prospective study Retinopathy central and peripheral Extreme hyperglycemia - Self attribution by adults, parents and adolescents Moderate to severe hypoglycemia - Three laboratory studies Moderate hypoglycemia impairs driving performance Diabetes Care, 2000, BG level (mmol/l) in 2-day GCRC study v Counterbalanced driving or video video or Driving 1.0 mu/kg/min Constant Insulin Infusion; Continuous EEG monitoring Euglycemia Hypoglycemia Time (minutes) Moderate hypoglycemia impairs: Motor coordination Information processing speed Awareness Judgment Impaired Driving Score History + History P<.02 Euglycemia Hypoglycemia During moderate hypoglycemia, high risk drivers with a + Hx of driving mishaps demonstrated: Less epinephrine response Fewer discriminating hypoglycemic symptoms Slower information processing speed and worse working memory Greater driving impairment Therefore, better to prevent than to detect and treat hypoglycemia while driving 5

6 AMA ethical guidelines Patients should be informed if their medical condition or treatment impairs their abilities, and authorities should be notified if the patient refuses to heed these warning and puts themselves and the general public in harm s way. PennDOT rules amended effective October 10, 2011 require health care professionals to report to DOT patients with unstable diabetes leading to severe hypoglycemia or symptomatic hyperglycemia Scope of Reporting is Broad: Severe Hypoglycemia: requires outside intervention and/or assistance of others or produces confusion, loss of attention or a loss of consciousness High glucose levels in the blood that have caused a loss of consciousness or an altered state of perception, including but not limited to decreased reaction time, impaired vision and/or hearing, and confusion PA DOT rules amended effective October 10, 2011 require health care professionals to report to DOT patients with unstable diabetes leading to severe hypoglycemia or symptomatic hyperglycemia Scope of Reporting is Broad: Severe Hypoglycemia: requires outside intervention and/or assistance of others or produces confusion, loss of attention or a loss of consciousness High glucose levels in the blood that have caused a loss consciousness or an altered state of perception, including but not limited to decreased reaction time, impaired vision and/or hearing, and confusion License ineligibility for 6 months following severe hypo or symptomatic hyper Waiver allowed if during or concurrent with a nonrecurring transient illness, toxic ingestion or metabolic imbalance. If you feel your patient is safe to operate a motor vehicle, even though he/she may have experienced some confusion, loss of attention, or an altered state of perception, and the episode did not require outside intervention, you do not have to report that patient to PennDOT. PennDOT s medical regulations are designed to disqualify only those individuals who represent a safety risk on the roadways. Patients who have suffered a loss of consciousness should always be reported. There is no obligation in NY for physician's to report individuals who may have impairments on their driving abilities (i.e., there is a voluntary reporting process, but no requirement to report). As a result, HIPAA mandates that the physician cannot report unless the physician has the patient's authorization OR there is a serious and imminent harm to the public. Now, when the individual involved is driving a commercial vehicle, such a school bus, our analysis can be a little different and we find that providers are more willing to take on the risk of a lawsuit that could result from an unauthorized disclosure Typically, in these situations, the "imminent" prong cannot be met, because a generalized potential threat just doesn't rise to the level of "imminent". 6

7 New Legislation Wisconsin Failure to recognize a federal exemption for commercial driver with moving violations, or otherwise points against license Drivers with diabetes held to a higher standard than drivers without diabetes Mandate that physicians and other HCPs report to the state any patient diagnosed to be afflicted with a disorder causing a loss, interruption, or lapse of consciousness or motor function License automatically cancelled with right to appeal Failure to report within 7 days can result in $300 find or 90 days in jail New Legislation Wisconsin with diabetes/know yourrights/discrimination/drivers licenses/drivers license laws bystate.html 39 Most people with diabetes do not pose an increased risk of MVA Individuals whose diabetes poses a significantly elevated risk must be identified and evaluated prior to getting behind the wheel. At time of licensure, a brief questionnaire can be used to find those drivers.. It is important that the identification and evaluation processes be appropriate and individualized Evaluation must include an assessment by the treating physician or diabetes specialist Physicians should be asked to evaluate: Any severe hypoglycemia in the prior 2 years The events surrounding severe hypoglycemia Is the driver at risk for severe hypoglycemia Can the driver detect early hypoglycemia Does the driver perform adequate SMBG Does the driver have diabetes related complications that may interfere with safe driving Does the driver have a good understanding of diabetes and its management. 7

8 1. Measure BG before driving 2. Never begin driving with BG 90 70mg/dl without prophylactic carbohydrates 3. Never drive when BG is <70mg/dl 4. During long drives, treat prophylactically 5. If detect hypoglycemia while driving, immediately: A. Pull off the road B. Consume Fast acting carbohydrates/dextrose C. Do not resume driving until BG >90 mg/dl 1. Peripheral neuropathy, i.e. can t feel pedals 2. Drive more miles, i.e. great exposure 3. Fear of hyperglycemia, i.e. run low 4. Mismanage hypoglycemia, i. e.g. delay/employ inappropriate treatment 5. History of moderate and severe hypoglycemia, i.e. past predicts future 6. History of hypoglycemia driving mishaps, i.e. past predicts future Conclusion 1. Diabetes can contribute to higher risk of driving impairments 2. Moderate hypoglycemia impairs driving safety 3. Some individuals with T1DM are more vulnerable to having driving mishaps 4. Clinicians have legal and ethical responsibilities 5. Join the Legal Advocacy HCP Panels and help us fight for our patients Diabetes Costs 2012 $245 billion $176 billion in direct costs $69 billion in reduced productivity Average medical expenditures $13,700/year of which $7900 attributed to diabetes Indirect costs include: Increased absenteeism ($5 billion) Presenteeism: reduced productivity at work ($50.8 billion) for employed population Reduced productivity for those not in the labor force ($21.6 billion) Lost productivity capacity due to early mortality ($18.5 billion) * Economic costs of Diabetes in the U.S, 2012, Diabetes Care, March 6,

9 Employer Objectives Identify employees at highest risk, screening for diabetes DHHS Healthy people 2010 goals for diabetes Reducing risk factors Improving diabetes controls processes Identifying and treating people with DM Reducing complications Increasing counseling and education * Healthy People 2010 Dept. of Health and Human Services Legal Protections for People with Diabetes Americans with Disabilities Act (ADA) Enacted in 1990 and Amended in Intended to provide comprehensive protection against discrimination against qualified individuals with disabilities. Recognizes that source of discrimination is often not due to an individual s limitations, but fears, myths and stereotypes by others. Is Diabetes a Disability? ADA Amendments Act of 2008 made clear that people with diabetes are protected from discrimination. Under the new law, when determining disability, the effects of medication or other mitigating measures may not be considered (insulin, diet, exercise, etc.). Substantial Limitation of Major Life Activity of Endocrine System Function. Ending Discrimination: Three Key Issues under the ADA Reasonable Modifications and Accommodations Breaks, place to perform diabetes care, leave, chair or stool, etc. Visit diabetes.org/jobaccommodations. Qualifications Standards Capable of participating, e.g., right degree, years of experience. Blanket bans (based on arbitrary criteria and not on a fair, individualized assessment). Safety Assessments Objective safety risk, not based on stereotypes or remote fears. 51 Reasonable Accommodations If employee falls under the ADA, the employer must make reasonable accommodations. Can typically be provided at little or no cost. To obtain reasonable accommodation, employee must make a request (does not need to be in writing, though good idea). If need for an accommodation is not obvious, employer may ask for reasonable medical documentation. Entire medical or mental health history not required. Reasonable Accommodations Breaks to check blood glucose and treat by administering insulin or eating. Place (typically work station) for blood glucose checking/treatment. Ability to keep diabetes supplies and food nearby. A modified schedule or standard shift. Leave for treatment, recuperation, or training on diabetes management (may be entitled to this under the Family Medical Leave Act). Larger computer screen for individuals with diabetic retinopathy. Chair or stool for persons with diabetic neuropathy. 9

10 Reasonable Accommodations: Documentation If it was not written down, it was not said. If it was not written down, it did not happen. Patient should submit own written request. Health Care Provider should write letter that: Describes diabetes to establish coverage. Documents needed accommodations. Emphasizes patient can successfully perform job. Avoids danger words. Counters safety concerns with individualized assessment. Sample request available at: diabetes.org/jobaccommodations. Letter from HCP: Emphasize Employee s Ability to Perform Job Identify each needed modification. Explain: with accommodations, employee can fully and safely perform job functions. Explain why modifications are directly connected to employee s diabetes. If no cost involved, as is often the case, state this. Emphasize: employee s qualifications, with appropriate accommodations, are critical to prevent the letter from being used against him/her in the future. Safety Assessments To exclude someone on safety grounds requires proof of direct threat that worker poses a significant risk of substantial harm to self or others: Cannot be reduced through reasonable accommodation. Must be supported by reasonable medical judgment relying on most current medical knowledge and/or best available objective evidence. Non compliant Uncontrolled Poorly controlled Brittle diabetes Restricted Danger Words 10