Abstracts

Rationale: Driving is of major importance to people with epilepsy and seizures. In the United States (U.S.) driving restrictions for applicants with epilepsy and seizures vary widely by state based on seizure-free periods, Medical Advisory Board (MAB) or treating physician opinion. U.S. consensus guidelines developed by the American Epilepsy Society, American Academy of Neurology, and the Epilepsy Foundation propose general standards for states, and endorse a 3 month minimum seizure-free requirement with proposed favorable and unfavorable modifiers.  Here we analyze the implementation, outcomes and effectiveness of the U.S. consensus guidelines adopted by Maryland in 2003. Methods: MAB reviews and licensing records for Maryland driver applicants with seizures between 2004 and 2005 were reviewed, during which 254 first-time applicants were processed. We assessed initial licensing decisions and the subsequent seizure recurrence and crash rates over the following 7 years. Results: The MAB approved driving for 74.8% of initial applicants; most had been seizure-free for over 6 months. Approved drivers had a longer median seizure-free period (563 days) compared to those denied (104.5 days, p < 0.01). Of applicants initially denied (n = 50), 89.3% were eventually licensed.One fourth (40/160, 25%) of the applicants who completed an MAB review at 1 year reported seizures during their first year of monitoring. Seizure recurrence was higher in those denied licensure (15/50, 30%) compared to all approved applicants 14.7% (25/170), which includes the 60 individuals who were exempt from further monitoring during the first year (none of whom reported seizure recurrences). Clinical factors not associated with an increased risk of seizure recurrence included AED treatment, changes in AED regimen, a history of substance abuse, and the presence of medical comorbidities such as diabetes.  No crashes were reported in the first 3 years of MAB monitoring.  Over the subsequent 4 years, only two seizure related crashes with no deaths were reported. Although evaluation by treating physicians is an integral part of the Maryland review system, their recommendations often deviated from the MAB: 87.3% of applicants the MAB denied licensure were reported as fit to drive by their treating physicians. Treating physicians did not report a poor prognosis in any patient. Seizures were often minimized as single “breakthroughs” due to illness or other factors.  Conclusions: Maryland’s individualized system based on U.S. consensus guidelines for assessing driving applicants with seizures resulted in a dynamic process of approvals and denials based on favorable and unfavorable risk factors and lengths of seizure freedom. Seizure recurrences, as well as crashes and deaths were comparable to internationally accepted rates. Over the course of monitoring, most applicants were eventually licensed. Further assessment is needed of the risk factors deemed favorable and unfavorable by the U.S. consensus guidelines. Treating physicians recommended that nearly all of their patient applicants be permitted to drive, which raises safety concerns for the 10 states that rely solely on physician recommendations.  Funding: The Rosen Founation of the University of Maryland School of Medicine