Date Published: December 8, 2009
Publisher: Public Library of Science
Author(s): Donald A. Redelmeier, Anne B. Kenshole, Joel G. Ray, Leif Groop
Abstract: Using a population-based case control analysis, Donald Redelmeier and colleagues found that tighter glycemic control, as measured by the HbA1c, is associated with an increased risk of a motor vehicle crash.
Partial Text: Diabetic patients account for substantial amounts of driving. At a population disease prevalence of 5% to 7% for this diagnosis, general mobility statistics would suggest that diabetic patients drive about 250 million miles during the average day in the United States ,. Such distances are extraordinary—greater than traveling from the earth to the sun and back . The exact figure could be either somewhat larger if diabetes correlates with a sedentary lifestyle that favors driving or somewhat smaller if diabetes is associated with incapacitating complications that leave the patient institutionalized . The substantial driving distances are likely to continue into the future given societal reliance on road travel for work, recreation, leisure, and health care .
During the 2-y study interval a total of 3,900 individuals were reported to licensing authorities, of whom 795 were diabetic patients who had HbA1c values documented. Their mean age was 52 y, 84% were men, and the average patient had about a 20-y history of diabetes (Table 1). Most patients had end organ damage including retinopathy, nephropathy, and neuropathy. About 81% were treated with insulin, 27% with oral glucose-lowering medications, and 15% with neither insulin nor an oral medication. Overall, one in six lacked hypoglycemic awareness and one-third had a history of hypoglycemia that required outside assistance. The spread of HbA1c values was remarkable, ranging from 4.4% to 14.7%.
We studied a selected sample of diabetic adults driving during a 2-y interval using a population-based approach. The main finding was that lower HbA1c levels were associated with an increased risk of a motor vehicle crash. The adverse association was observed across the range of HbA1c values, persisted after adjustment for independent confounders, yet was not as large as the relative risk associated with a history of severe hypoglycemia requiring outside assistance. The attributable risk was substantial, so that eliminating the association by extrapolating the risk observed at the highest HbA1c quartile to all drivers at all HbA1c quartiles would have eliminated about half of all observed crashes. These findings are difficult to explain with random chance, reverse-causality, or simple reporting bias.