A Corporate Driven Sleep Apnea Detection and Treatment Program
Page 1 of 5: Results and Challenges
Mark B. Berger, MD FCCP, Wendy Sullivan, RN, Ross Owen, MPA, and Charlotte Wu, MS Precision Pulmonary Diagnostics, Inc., Schneider National, Inc., and Definity Health Corp. Houston, Texas USA
Summary/Abstract: Sleep disordered breathing (SDB), including sleep apnea, is very prevalent in commercial drivers and contributes significantly to higher healthcare and liability costs. Without a mandated screening program, driver and physician recognition of this condition remains low. Our corporate supported recognition and treatment program for SDB utilizes an objective screening tool that yields a positive predictive value of 91%. Of those continuous positive airway pressure (CPAP) treated drivers successfully contacted, one month or longer treatment compliance is 91% with high subjective rating scores. In 348 SDB drivers, CPAP intervention resulted in a 47.8% (p<.0001) reduction in per member per month (PMPM) health care spending. There was a 73% reduction in preventable driving accidents in a subgroup of 225 full-time CPAP-treated drivers. The driver retention rate in CPAP treated individuals was 2.29 times greater than the 2004 global corporate driver retention rate. On-going corporate measures that facilitate testing and treatment of drivers with SDB are described. These activities are proving both clinically and financially beneficial for a major commercial carrier.
Sleep disordered breathing (SDB) is associated with excessive daytime fatigue and diminished vigilance. Kryger et al (2005) estimates that sleep disordered breathing (SDB) affects around 4% of U.S. adults between the ages of 40 and 65. Pack, Dinges, and Maislin (2002) found the prevalence of this condition much higher in commercial drivers, approaching 28%. With the FMCSA's calculation of between 6 and 7 million truck and bus drivers in the U.S. (Gunnels, 2005), a conservative estimate of commercial drivers with SDB exceeds 600,000 individuals. The higher prevalence of sleep disordered breathing in truck drivers is likely related to the higher predominance of males to females ( 9:1) as well as the high frequency of obesity in that group, as cited in Hartenbaum (2003). Studies have shown that drivers with SDB have from 2 to 15 times more frequent motor vehicle accidents compared to unaffected drivers (Aldrich, 1989; Stoohs, et al, 1994; Horstmann, et al, 2000; Howard, et al, 2004). Large truck crashes are expensive, according to a FMCSA study (1999). Beyond the immeasurable cost of loss of life and permanent injury, the average cost per large truck crash involving a fatality in 1999 was $3.54 million, and involving an injury was $217,005. Additionally, it is becoming increasingly evident from multiple studies reviewed by Young, Peppard, and Gottlieb (2002) that untreated SDB is associated with higher risks for cardiovascular and cerebrovascular events. Mortality rates in untreated SDB have been shown to be higher in a paper recently published by Campos-Rodriquez, et al (2005), and this excess mortality was mainly from cardiovascular disease. Since cardiovascular disease, hypertension, and diabetes represent three of the most costly health expenditures in the commercial trucker population, efforts to mitigate these diseases should provide significant health care cost savings. Treatment of SDB, usually with CPAP, will result in fewer motor vehicle injuries. Vorona and Ware (2002) summarized several studies showing a marked reduction in the frequency of crashes in patients receiving CPAP therapy for their SDB.
There is a clear and pressing need to identify commercial drivers with SDB because effective treatment of this disorder results in reduced accident rates comparable to drivers without this condition, as previously cited in Vorona and Ware (2002). Health costs might also be positively affected by such a strategy. Although sleep apnea has not yet been specifically listed in the Federal Motor Carrier Safety Regulations, Section 391.41(b)(5)(8) considers a commercial driver physically qualified if he/she " Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a commercial motor vehicle safely?." Indeed, the recently revised FMCSA Medical Examination Report for Commercial Driver Fitness Determination now includes a specific question regarding "Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring." Unfortunately, many affected individuals are unaware of their condition or they may consciously conceal or deny symptoms attributable to this disorder. According to Gunnels (2005), "There are medical gaps that FMCSA does not address, such as guidance for commercial motor vehicle operators with sleep disorders?." Surprisingly, Young, et al (1997) estimates that only 10% of adults with SDB have been diagnosed and Reuveni, et al (2004) states that only 10% of physicians inquire about sleep apnea related symptoms. Quoting Gunnels (2005), "The FMCSA?encourage[s] motor carriers and physicians to have higher medical standards." DOT-certified physicians and trucking companies are in need of reliable tools facilitating the identification of drivers with SDB.
A purpose of our study is to examine if a reduction in preventable accidents can be achieved in the commercial trucker population with appropriate treatment of SDB. An additional goal of this study is to examine how employer health costs are affected by a concerted effort to identify and treat SDB in their drivers. This paper describes the utility of a simple screening tool used to identify commercial drivers who may have SDB. Of those commercial drivers identified with and receiving treatment for SDB, this paper also reports their intermediate term CPAP treatment compliance and corporate retention rates.