Data-Driven Policy Changes
by Dr. Leo M. Hattrup, FAA Medical Officer
In the 1980s, many cardiac conditions effectively ended careers of professional pilots and grounded private pilots. Over time, the number of conditions eligible for special issuance has grown. For many, we have also been able to reduce the frequency of evaluations.
For perspective: in 2010, the cardiac panels (a group of cardiologists and aerospace medical specialists that convenes bimonthly at the Civil Aerospace Medical Institute (CAMI)) reviewed, in aggregate, 380 applications for special issuance of different cardiac conditions. Of these, 93 applications, or 24 percent, were denied, while cardiac panels in 2019 considered 466 applications and denied only 46, or 10 percent. We have been able to halve the denial rate over the past ten years.
This outcome reflects several FAA actions over the past decade. In January 2013, the Federal Air Surgeon (FAS) convened a roundtable of aerospace medicine experts plus cardiologists and a cardiothoracic surgeon, all with expertise in aviation medicine. They reviewed available literature and the FAA experience with various cardiac conditions. Using their recommendations, the FAS was able to ease restrictions for a number of conditions. For example, the initial observation period for coronary artery stenting went from six to three months, and the time between renewals of a special issuance for most pacemakers doubled from six to twelve months. Also, we now special issue most individuals with hypertrophic cardiomyopathy; previously, many were denied.
Our goal is to find the path to “yes,” but data does not always support “yes.” In fact, sometimes new data requires us to rethink allowable conditions. Such was the case for implantable cardioverter-defibrillators (ICDs). For a period prior to 2011, the FAA allowed ICDs because available literature showed an acceptable safety profile. Subsequent studies on ICDs showed that while survival improved with these devices, ICD patients still had a much higher risk of sudden cardiac death and, following a shock, incapacitation (loss of consciousness/confusion). This data forced us to conclude that the overall risk of death and incapacitation in ICD patients was not acceptable, and we had to designate ICDs as disqualifying for all classes of medical certificates.
On a brighter note, the FAA introduced CACIs (Conditions an AME Can Issue) in early 2013. This change came after CAMI physicians noticed that a number of special-issued medical conditions were relatively benign, common, and routinely approved. They identified eighteen conditions for further review. A search of FAA records revealed that over 19 percent of all medical applicants had at least one of these conditions. Ninety-two pilots with at least one of these conditions were in a fatal mishap. However, correlation with data from the National Transportation Safety Board (NTSB) revealed that a CACI condition was not causative in any mishap. We therefore determined that the AME could safely issue a medical if the airman met specific criteria (those we used for special issuance). CACI has been a huge success: after providing complete and acceptable information to the AME, in 96 percent of cases the airman can depart with medical certificate in hand.
Review of our certification policies is an ongoing and continuous effort; we are accelerating the pace of change. A number of conditions are now under review and additional CACI options are in development. Future advances in medicine should allow even greater flexibility in certification decisions.
Leo M. Hattrup, M.D., received a bachelor’s degree from Wichita State University, a master’s in public health from Harvard University, and a doctorate from Vanderbilt University. He is retired from the U.S. Air Force in which he spent the majority of his career in aerospace medicine. He is board certified in aerospace and occupational medicine. He is a certificated flight instructor and enjoys flying airplanes, helicopters, and gliders.
