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https://nap.nationalacademies.org/catalog/27432/critical-issues-in-transportation-for-2024-and-beyond

Estimated rate of failure to disclose psychiatric and cardiac conditions during FAA aeromedical certification examinations

Civilian aviators seeking first, second, or third class medical certificates are required to submit to periodic medical examinations. The exam includes physical examination, various tests, and review of the pilot’s medical history and medication use. Pilots face potential disqualification or being subjected to further medical review if they report medical conditions or medications. There is an obvious incentive to conceal medical conditions or medications which they fear may jeopardize their medical certificate application by simply failing to disclose medical conditions that do not have clear signs or symptoms that would be apparent on physical examination. The rate of failure to disclose medical information is not known, since there is no requirement to provide private medical records unless needed for review of a known or detected medical condition. Although the Federal Aviation Administration (FAA) does not require access to private medical records for all pilots, there are sources of medical information other than private medical records for a subset of pilots. Following a fatal aircraft accident, the FAA requests autopsy records and post-mortem samples for toxicology analysis. These post-mortem samples are analyzed at the FAA Civil Aerospace Medical Institute (CAMI) for ethanol and other volatiles, drugs of abuse, and a wide variety of both prescription and non-prescription medications and their metabolites as part of routine fatal mishap investigations. These records are stored at the FAA CAMI in the ToxFlo database, which is searchable by drug and metabolite name. Using post-mortem toxicology data, it is possible, within limits, to detect unreported psychiatric conditions at the time of the accident based on medications detected in post-mortem samples. In addition to toxicology results, the CAMI Medical ANalysis TRAcking registry (MANTRA) is a searchable database (2008 to present) used to store autopsy and civilian aviator aeromedical records data from fatal aircraft mishaps. MANTRA archives both conditions reported on certification exams as well as conditions reported at autopsy and the conditions are ICD coded. The ICD codes in MANTRA from 2008 to the present were recoded using ICD-10 (2017 version) and have been coded as such since then without code updates. DATA: Although the FAA does not require access to private medical records for all pilots, there are sources of medical information other than private medical records for a subset of pilots. Following a fatal aircraft accident, the FAA requests autopsy records and post-mortem samples for toxicology analysis. These post-mortem samples are analyzed at the FAA Civil Aerospace Medical Institute (CAMI) for ethanol and other volatiles, drugs of abuse, and a wide variety of both prescription and non-prescription medications and their metabolites as part of routine fatal mishap investigations. These records are stored at the FAA CAMI in the ToxFlo database, which is searchable by drug and metabolite name. Using post-mortem toxicology data, it is possible, within limits, to detect unreported psychiatric conditions at the time of the accident based on medications detected in post-mortem samples. In addition to toxicology results, the CAMI Medical ANalysis TRAcking registry (MANTRA) is a searchable database (2008 to present) used to store autopsy and civilian aviator aeromedical records data from fatal aircraft mishaps. MANTRA archives both conditions reported on certification exams as well as conditions reported at autopsy and the conditions are ICD coded. The ICD codes in MANTRA from 2008 to the present were recoded using ICD-10 (2017 version) and have been coded as such since then without code updates. METHOD: A compilation of targeted drugs used to treat anxiety, stress, depression, attention deficit disorder, and post-traumatic stress disorder is listed. The ToxFlo database will be searched by drug name (and metabolite if appropriate). Cases identified by toxicology will be followed by retrospective review of the pilot’s FAA medical certification records to determine if the corresponding conditions or medications were reported during the most recent or any prior medical certification exam. Only pilots with a current medical certificate at the time of the accident will be included in the dataset. MANTRA will be queried for targeted conditions by ICD-10 code as below. Pilots who reported on exam one of these conditions but allegedly discontinued use of the medication will be compared to toxicology results to see if they accurately reported their status. Once the toxicology results and medical record review results have been linked, all PII will be deleted from the record. Only the medications detected, the class of medical certificate (First, Second, Third) held by the pilot, and the results of the record review for each case will be retained. Data will be handled and stored according to the Data Management Plan. The cases will be sorted and grouped according to the type of medication (TCA, MAOI, etc). The metrics calculated will include the following: (1) total number of cases identified for each medication type / total number of fatally injured medically certified pilots = % of fatally injured pilots with a target condition severe enough to require medication; (2) number of cases of a diagnosis or medication accurately reported on the most recent exam / total number of cases identified by toxicology for each medication type = % accurately reported on current exam; (3) number of cases of each diagnosis or medication accurately reported on any exam / total number of cases identified for each medication type = % ever reported on any exam; and (4) number of pilots who reported on exam taking, and discontinuing, one of the target medications but still had positive toxicology / total number of pilots who reported on exam taking, and discontinuing, one of the test medications = % of fatally injured pilots who falsely claimed to have stopped taking medication for a target condition. These metrics will be calculated for each of the medication classes for the aggregate of all fatally injured pilots with a current and valid medical certificate, and will also be calculated separately for First, Second, and Third Class medical certificates. Pilots with multiple medications will be addressed in a separate category. The results will measure the frequency of targeted medications, and by implication the targeted conditions, among fatally injured pilots as well as how accurately these pilots reported on exam their history of psychiatric conditions severe enough to require use of medication. The results also will measure the accuracy of pilot reports claiming that they have stopped taking a potentially disqualifying medication. A similar method will be used to estimate the rate of undisclosed select cardiac diagnoses. Data: Although the FAA does not require access to private medical records for all pilots, there are sources of medical information other than private medical records for a subset of pilots. Following a fatal aircraft accident, the FAA requests autopsy records as part of the medical review process for the Medical Accident Review and Hazard Analysis Program (MARHAP). Summaries of the aeromedical certification exams and post-accident autopsy reports are summarized in the CAMI Medical ANalysis TRAcking registry (MANTRA). MANTRA is a searchable database (2008 to present) used to store autopsy and civilian aviator aeromedical records data from fatal aircraft mishaps. The conditions reported on certification exams as well as conditions reported at autopsy are CPT coded for medical procedure or ICD coded for diagnosis. The ICD codes in MANTRA from 2008 to the present were recoded using ICD-10 (2017 version) and have been coded as such since then without code updates. PART 1 Method: MANTRA aeromedical exam summaries of fatal aircraft accidents will be queried from 2008 to the present by ICD and CPT codes for the following: 1) ICD (I25.2) old myocardial infarction 2) CPT (33157) coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft 3) CPT (92933) percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch. Cases identified as having reported one of these codes on exam will be compared to their autopsy reports to test the accuracy of the medical history as reported on certification exam. The sensitivity of autopsy for detecting these conditions and procedures will also be assessed. Only rated pilots and pilot-rated passengers with current medical certificates at the time of death will be reviewed. The metrics calculated will include the following: 1) total number of cases identified for each diagnosis or procedure total number of fatally injured medically certificated pilots = % of all medically certificated fatally injured pilots with a pre-mortem reported history of myocardial infarction, coronary stent, or coronary bypass. 2) number of cases accurately reported on exam total number of cases reported on exam = % accurately reported on exam 3) number of cases reported on exam and confirmed on autopsy total number of cases reported on exam = % accuracy of autopsy findings PART 2 METHOD: MANTRA autopsy summaries will be queried from 2008 to the present for the same codes. Cases identified will be compared to aeromedical certification exams for those pilots. The metrics calculated will include the following: 1) number of cases identified on autopsy for each diagnosis or procedure total number of fatally injured medically certificated pilots = % of all medically certificated fatally injured pilots with a post-mortem identified history of myocardial infarction, coronary stent, or coronary bypass. 2) (total number of cases identified on autopsy for each diagnosis or procedure – the cases reported on pre-mortem exam) total number of fatally injured medically certified pilots = % of medically certificated fatally injured pilots who failed to accurately report a history of myocardial infarction, coronary stent, or coronary bypass on certification exam. Results: These results will measure: 1) the frequency of select cardiac conditions among medically certificated fatally injured pilots as well as how accurately these pilots reported their medical histories on their aeromedical certification exams, and 2) the sensitivity of autopsy for detecting these conditions as a measure of the efficacy of using autopsy data for hazard analysis as related to cardiac history.