Identify Driving Risk Factors in T1DM and their Reduction via Behav Intervention

描述（由申请人提供）：与车辆碰撞相关的发病率和死亡率是一个主要的公共卫生问题，伴随着巨大的财政和情感成本。虽然1型糖尿病（T1DM）司机的驾驶事故是非糖尿病司机的两倍多，但这是由一个亚组来解释的。我们需要的是一种方法来识别那些处于高风险的糖尿病司机，以及可以降低这种风险的干预措施。我们证明了这一高风险亚组与大多数T1DM驾驶员在三个风险级别上不同。1)一般：他们更有可能在驾驶时冒险，有碰撞和传票的历史，消耗更多的酒精，一般认知功能较差，独居。2)生理上：他们需要更多的葡萄糖来维持血糖，轻度低血糖时肾上腺素释放较少，驾驶障碍更大。3)糖尿病管理：他们更有可能采用严格的胰岛素治疗方案，从事高风险的糖尿病管理实践，在较低的血糖水平下驾驶，有频繁的严重低血糖史，对高血糖有更多的恐惧。基于这些发现，我们开发了糖尿病驾驶安全培训（DDST）来逆转或中和危险因素。试点测试表明，DDST显著降低了风险因素和驾驶事故。这增加了一种令人兴奋的可能性，即高风险的T1DM驾驶员可以使他们的风险正常化，减少未来的撞车事故及其负面后遗症。我们提出了一个分三个阶段的项目：1)再分析阶段将利用我们广泛而独特的T1DM驾驶员数据集，其中包括来自我们国际横断面调查的bb1700名驾驶员，bb1600名驾驶员被评估并跟踪调查驾驶事故的发生情况，bb280名驾驶员在实验室诱导的血糖正常和进行性低血糖期间驾驶。这些数据以前被用来确定有/没有事故的司机之间的组差异。再分析阶段将使用项目反应理论和这些数据来开发风险概况，以量化个人未来驾驶事故的风险。2)评估阶段将前瞻性地评估该风险概况在预测未来驾驶事故方面的敏感性/特异性，并以全国范围内的大量T1DM驾驶员为样本。3)治疗阶段是一个随机临床试验，被确定为未来驾驶事故高风险的司机将接受三种“剂量”治疗中的一种：1)静态信息，2)互动，个性化的糖尿病驾驶安全培训，或3)安全培训加上动机访谈，评估干预前后的风险概况，并对驾驶事故进行12个月的随访。为了使未来传播的可能性最大化，治疗将通过互联网提供。该项目的结果旨在为临床医生提供一个实用而准确的工具来识别高风险患者，为这些高风险驾驶员提供有效的治疗，以减少未来的驾驶事故及其相关费用，并有助于减少通常推断为所有T1DM驾驶员的偏见态度。

DESCRIPTION (provided by applicant): Morbidity and mortality associated with vehicular crashes are a major public health concern, accompanied by great fiscal and emotional costs. While Type 1 Diabetes Mellitus (T1DM) drivers have over twice as many driving mishaps as non-diabetic drivers, this is accounted for by a subgroup. What is needed is a way to identify those diabetic drivers who are at high-risk, and interventions that can reduce this risk. We demonstrated that this high-risk subgroup differs from the majority of T1DM drivers at three levels of risk. 1) General: they are more likely to take risks while driving, have a history of collisions and citations, consume more alcohol, have poorer general cognitive functioning, and live alone. 2) Physical: they require more glucose to maintain euglycemia, and release less epinephrine and experience greater driving impairment during mild hypoglycemia. 3) Diabetes management: they are more likely to be on a rigid insulin regimen, engage in risky diabetes management practices, drive at lower blood glucose levels, have a history of frequent severe hypoglycemia, and have more fear of hyperglycemia. Based on these findings, we developed Diabetes Driving Safety Training (DDST) to reverse or neutralize risk factors. Pilot testing demonstrated that DDST significantly reduced both risk factors and driving mishaps. This raises the exciting possibility that high risk T1DM drivers can normalize their risk, reducing future crashes and their negative sequelae. We propose a three phase project: 1) Reanalysis Phase will take advantage of our extensive and unique data set of T1DM drivers including >1,700 drivers from our international cross sectional survey, >600 who were assessed then followed for occurrence of driving mishaps, and >80 who drove during laboratory- induced euglycemia and progressive hypoglycemia. These data were previously used to determine group differences among drivers with/without mishaps. The Reanalysis Phase will use Item Response Theory with this data to develop Risk Profiles to quantify an individual's risk for future driving mishaps. 2) Assessment Phase will prospectively evaluate the sensitivity/specificity of this Risk Profile in predicting future driving mishaps with a large national sample of T1DM drivers. 3) Treatment phase is a randomized clinical trial where drivers identified as High Risk for future driving mishaps would receive one of three "doses" of treatment: 1) Static Information, 2) interactive, personalized Diabetes Driving Safety Training, or 3) this safety training plus motivational interviewing, with assessment of Risk Profiles pre and post intervention, and prospective follow-up for 12 months for driving mishaps. To maximize the possibility of future dissemination, treatment would be delivered over the Internet. The results of this project are intended to provide clinicians with a practical and accurate tool to identify high risk patients, provide these high risk drivers with effective treatment to reduce future driving mishaps and their associated costs, and help to decrease a prejudicial attitude often extrapolated to all T1DM drivers. PUBLIC HEALTH RELEVANCE: Morbidity, mortality and fiscal consequences due to vehicular collisions are a huge public health problem in the United States, accounting for 119 deaths each and every day, estimated to have cost the U.S. economy in 2000 approximately $230.6 billion. A subgroup of drivers with Type 1 Diabetes Mellitus (T1DM) has been estimated to have 8 times more driving mishaps than the majority of safer T1DM drivers. This study is intended to assist in identifying these high risk T1DM drivers and then to successfully rehabilitate them so that their risk of future driving mishaps is no greater than that of the general public.