System facilitators and barriers to discussing older driver safety in primary care settings

Abstract

Background Primary care physicians play a leading role in counseling older drivers, but discussions often do not occur until safety concerns arise. Prior work suggests that routine questioning about driving might facilitate these difficult conversations. Objective To explore system-level factors affecting driving discussions in primary care settings, in order to inform the design and implementation of a program supporting routine conversations. Methods This qualitative descriptive study used iterative interviews with providers (physicians, nurses, medical assistants, social workers, and administrative staff) working at two clinics (one geriatric, one general internal medicine) at a tertiary-care teaching hospital. General inductive techniques in transcript analysis were used to identify stakeholder-perceived system-level barriers and facilitators to routine conversations with older drivers. Results From fifteen interviews, four themes emerged: (1) complexity of defined provider roles within primary care setting (which can both support team work and hamper efficiency); (2) inadequate resources to support providers (including clinical prompts, local guides, and access to social workers and driving specialists); (3) gaps in education of providers and patients about discussing driving; and (4) suggested models to enhance provider conversations with older drivers (including following successful examples and using defined pathways integrated into the electronic medical record). A fifth theme was that participants characterized their experiences in terms of current and ideal states. Conclusions Physicians have been tasked with assessing older driver safety and guiding older patients through the process of “driving retirement.” Attention to system-level factors such as provider roles, resources, and training can support them in this process.

“Are you still driving?” Metasynthesis of patient preferences for communication with health care providers

“…Our findings could inform efforts to support respectful and effective conversations about driving between older drivers and their providers; these efforts could include provider education, embedding of appropriate questions within the electronic medical record (Betz et al 2015), and other system changes. While conversations about driving can be emotionally charged for all parties involved, healthcare providers are uniquely positioned to establish trusting, tactful conversations with their older adult patients regarding the risks and benefits of driving and future transitions to other forms of transportation.…”

“…There is evidence that both older drivers and healthcare providers would support such routine questioning (Betz et al 2014). However, barriers to implementation exist (Betz et al 2015; Friedland et al 2006), including inadequate education of providers and the public and inadequate communication between providers and patients (Classen et al 2007). …”

Discussions About Driving Between Older Adults and Primary Care Providers

“…Most older adults face a decision at some point about driving “retirement,” a complicated and emotional transition. Recommendations from older adults and providers call for earlier and routine questioning about driving as a way to “normalize” the topic . Discussing driving before safety concerns arise confers multiple benefits: identification of treatable conditions, referral for specialist evaluation and retraining to support prolonged mobility, and a longer time to adjust and plan.…”

“…Patients and families often welcome this physician involvement, albeit with inclusion of family members. Physicians appear to recognize and accept their role in older driver safety while acknowledging the barriers to making the discussion comfortable or routine . These barriers include inadequate training, concern over harming the physician–patient relationship, time pressures in clinical practice, and inadequate resources for further evaluation or alternative transportation …”

“…The current study therefore sought to estimate, based on medical record documentation, how many older adults have one or more discussions with a primary care provider about driving within a calendar year. Another goal was to describe the most common triggers of these discussions, including whether they occurred in the setting of Medicare Wellness Exams, which have been suggested as a time to include questions about driving …”