title: In Patients With Cirrhosis, Driving Simulator Performance Is Associated With Real-life Driving.
abstract: OBJECTIVE
  Minimal hepatic encephalopathy (MHE) has been linked to higher real-life rates of automobile crashes and poor performance in driving simulation studies, but the link between driving simulator performance and real-life automobile crashes has not been clearly established. Furthermore, not all patients with MHE are unsafe drivers, but it is unclear how to distinguish them from unsafe drivers. We investigated the link between performance on driving simulators and real-life automobile accidents and traffic violations. We also aimed to identify features of unsafe drivers with cirrhosis and evaluated changes in simulated driving skills and MHE status after 1 year.
  
  
  METHODS
  We performed a study of outpatients with cirrhosis (n = 205; median 55 years old; median model for end-stage liver disease score, 9.5; none with overt hepatic encephalopathy or alcohol or illicit drug use within previous 6 months) seen at the Virginia Commonwealth University and McGuire Veterans Administration Medical Center, from November 2008 through April 2014. All participants were given paper-pencil tests to diagnose MHE (98 had MHE; 48%), and 163 patients completed a standardized driving simulation. Data were collected on traffic violations and automobile accidents from the Virginia Department of Motor Vehicles and from participants' self-assessments when they entered the study, and from 73 participants 1 year later. Participants also completed a questionnaire about alcohol use and cessation patterns. The driving simulator measured crashes, run-time, road center and edge excursions, and illegal turns during navigation; before and after each driving simulation session, patients were asked to rate their overall driving skills. Drivers were classified as safe or unsafe based on crashes and violations reported on official driving records; simulation results were compared with real-life driving records. Multivariable regression analyses of real-life crashes and violations was performed using data on demographics, cirrhosis details, MHE status, and alcohol cessation patterns, at baseline and at 1 year.
  
  
  RESULTS
  Drivers categorized as unsafe had more crashes and made more illegal turns on the driving simulator than drivers categorized as safe; a higher proportion of subjects with MHE were categorized as unsafe drivers at baseline (16%) than subjects without MHE (7%; P = .02), and at 1-year follow-up (18% vs 0%; P = .02). Alcohol cessation within <1 year and illegal turns during simulator navigation tasks were associated with real-life automobile crashes and MHE in regression analysis; road edge excursions in the simulator were associated with real-life traffic violations. Personal assessment of driving skills improved after each simulation episode.
  
  
  CONCLUSIONS
  In a study of 205 patients with cirrhosis, we associated results from driving simulation tests with real-life driving records and MHE. Traffic safety counseling should focus on patients with cirrhosis who recently quit consuming alcohol and perform poorly on driving simulation.
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Mette M
authors.initials: MM
authors.lastname: Lauridsen
authors.affiliation: Division of Biostatistics, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Leroy R
authors.initials: LR
authors.lastname: Thacker
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Melanie B
authors.initials: MB
authors.lastname: White
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Ariel
authors.initials: A
authors.lastname: Unser
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Richard K
authors.initials: RK
authors.lastname: Sterling
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Richard T
authors.initials: RT
authors.lastname: Stravitz
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Scott
authors.initials: S
authors.lastname: Matherly
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Puneet
authors.initials: P
authors.lastname: Puri
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Arun J
authors.initials: AJ
authors.lastname: Sanyal
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Edith A
authors.initials: EA
authors.lastname: Gavis
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Velimir
authors.initials: V
authors.lastname: Luketic
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Muhammad S
authors.initials: MS
authors.lastname: Siddiqui
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Douglas M
authors.initials: DM
authors.lastname: Heuman
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia.
authors.forename: Michael
authors.initials: M
authors.lastname: Fuchs
authors.affiliation: Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Administration Medical Center, Richmond, Virginia. Electronic address: jsbajaj@vcu.edu.
authors.forename: Jasmohan S
authors.initials: JS
authors.lastname: Bajaj
mesh_terms: D000063:Accidents, Traffic; D000293:Adolescent; D000328:Adult; D000368:Aged; D001334:Automobile Driving; D003198:Computer Simulation; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014768:Virginia; D055815:Young Adult
keywords: Car Crash; Hepatic Encephalopathy; Public Policy; Traffic Violation