Employer-mandated sleep apnea screening and diagnosis in commercial drivers

Evaluation of advanced emergency braking systems in drowsy driving-related real-world truck collisions

STUDY OBJECTIVES

The effectiveness of advanced emergency braking systems (AEBS) in preventing drowsy driving-related truck collisions remains unclear. We aimed to evaluate the damage-mitigation effect of AEBS on drowsy driving-related collisions involving large trucks using collision rate and damage amount.

METHODS

Data collected by a Japanese transportation company from 1,699 collisions involving 31,107 large trucks over 7 years were analyzed post-hoc. The collision rate (number of trucks with collisions/total number of trucks) and damage amount (total amount of property damage and personal injury) were compared based on whether the collisions were caused by drowsy or non-drowsy driving and whether the trucks were equipped with AEBS or not.

RESULTS

For all and non-drowsy driving-related collisions, the collision rate for the 12,887 trucks with AEBS (1.62 and 1.20 collisions/truck/7 years, respectively) was significantly lower than that for the 18,220 trucks without AEBS (1.94 and 1.56 collisions/truck/7 years, respectively) (p=0.04 and p=0.008, respectively). However, for drowsy driving-related collisions, the collision rate did not significantly differ between trucks with and without AEBS. The damage amount in neither type of collision (drowsy vs. non-drowsy) significantly differed between trucks with and without AEBS.

CONCLUSIONS

Regarding the collision rate of large trucks, AEBS was effective in non-drowsy driving-related collisions, but not in collisions involving drowsy driving. The damage amount was not mitigated for trucks with and without AEBS regardless of the collision type. The limited effect of AEBS for damage-mitigation suggests the need for combined use with other safety-support systems that intervene in driving operations.

Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression

PURPOSE

This study aimed to identify the prevalence of obstructive sleep apnea (OSA) and associated risk factors globally.

METHODS

Six databases and registrations and three grey databases were explored for observational field research. Independently and impartially paired reviewers selected research, gathered data, and evaluated the methodological quality. Heterogeneity was investigated using subgroup analysis and meta-regression following the moderating variable in a meta-analysis of proportions with a random-effects model. The critical appraisal instrument developed by the Joanna Briggs Institute was used to evaluate the listed studies' methodology. The certainty of the evidence was evaluated using the GRADE tool.

RESULTS

A total of 8236 articles were collected during the database search, resulting in 99 articles included for qualitative synthesis, and 98 articles were included for the meta-analysis. The estimated combined prevalence of OSA was 54% [CI 95% = 46-62%; I2 = 100%]. Mean age, percentage of moderate-severe cases, and the sample's body mass index (BMI) did not affect the heterogeneity that was already present when meta-regressed (p > 0.05). Ninety-one studies were deemed to have a low risk of bias, while eight were deemed to have a moderate risk. For OSA prevalence outcomes, the GRADE criteria were considered very low.

CONCLUSION

Approximately half of the people worldwide have OSA. High BMI, increasing age, and male gender are described as risk factors in the literature, but these covariates do not affect pre-existing heterogeneity.

Yield of overnight pulse oximetry in screening commercial drivers for obstructive sleep apnea

PURPOSE

To assess the efficacy of overnight pulse oximetry in screening male commercial drivers (CDs) for obstructive sleep apnea (OSA).

METHODS

Consecutive male CDs undergoing their annual scheduled occupational health visit were enrolled from ten transportation facilities. All subjects underwent a home sleep apnea test (HSAT) to determine the Respiratory Event Index (REI). Oxygen desaturation indices (ODIs) below the 3% and 4% thresholds were computed using the built-in HSAT pulse oximeter. We then assessed the association between ODI values and the presence of OSA (defined as an REI ≥ 5 events/hour) as well as moderate to severe OSA (REI ≥ 15 events/hour).

RESULTS

Of 331 CDs recruited, 278 (84%) completed the study protocol and 53 subjects were excluded due to inadequate HSAT quality. The included and excluded subjects were comparable in demographics and clinical characteristics. The included CDs had a median age of 49 years (interquartile range (IQR) = 15 years) and a median body mass index of 27 kg/m2 (IQR = 5 kg/m2). One hundred ninety-nine (72%) CDs had OSA, of which 48 (17%) were with moderate OSA and 45 (16%) with severe OSA. The ODI3 and ODI4 receiving operating characteristic curve value were 0.95 for predicting OSA and 0.98-0.96 for predicting moderate to severe OSA.

CONCLUSION

Overnight oxygen oximetry may be an effective means to screen CDs for OSA.

Stop-bang questionnaire for screening obstructive sleep apnea syndrome among hypertensive patients in Kenya

INTRODUCTION

Obstructive sleep apnea (OSA) is a type of breathing problem during sleep caused by the blockage of the upper airway, which can cause cessation of airflow. There is limited research on the prevalence of OSA in hypertensive patients in sub-Saharan Africa (SSA). The study aimed to describe the prevalence and clinical characteristics of OSA among hypertensive patients at a tertiary hospital in Nairobi, Kenya.

METHODS

This cross-sectional study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Two hundred and fifty-one hypertensive patients were screened for OSA risk using the STOP-Bang questionnaire (SBQ). Patients with a SBQ score of ≥ 4 were categorized as high risk for OSA. Descriptive statistics were employed to describe both categorical and continuous variables and binary logistic regression to assess factors associated with the high risk of OSA.

RESULTS

The study reported that 78.5% of the participants had high-risk OSA. The median age and body mass index (BMI) were 57.0 years (IQR: 50.0-64.0) and 28.3 kg/m2, respectively. Age, neck circumference, gender, and BMI were significantly higher in the high-risk OSA group as compared to the low-risk group.

CONCLUSION

The study highlights the importance of screening hypertensive patients for OSA using the SBQ in clinical settings, particularly in low-and middle-income countries (LMICs). Healthcare providers can use patient characteristics such as age, gender, neck circumference, and BMI to identify those at greater risk of developing OSA. Further research could focus on developing effective OSA prevention and treatment interventions in hypertensive patients.

Work-Related Sleep Disorders: Causes and Impacts

Insufficient sleep syndrome, shift work disorder, and obstructive sleep apnea (OSA) not only significantly impact the health of affected individuals, but also pose a threat to public safety. This article describes the clinical manifestations and impact of these sleep disorders, particularly as they pertain to workers' health and those with safety-sensitive positions. Sleep deprivation, circadian rhythm disruptions, and excessive daytime sleepiness-hallmarks of insufficient sleep, shift work disorder, and OSA, respectively-all lead to a series of cognitive deficits and impaired concentration that affect workers in a wide variety of fields. We describe the health consequences of these disorders along with treatment strategies, with a focus on current regulatory standards and the under-recognition of OSA in commercial drivers. Given its large scale, there is a need for improved guidelines and regulations for the screening, diagnosis, treatment, and long-term follow-up of OSA in commercial motor vehicle drivers. Increased recognition of the ways in which these sleep disorders impact workers will pave the way for significant improvements in occupational health and safety.

Metabolic syndrome among commercial truck drivers: The relationship between condition prevalence and crashes

BACKGROUND

Metabolic syndrome (MetS) is especially prevalent among US truck drivers. However, there has been limited research exploring associations between MetS conditions with roadway crashes among truck drivers. The objective of this paper is to assess relationships between specific combinations of individual MetS components and crashes and near-misses.

METHODS

Survey, biometric, and anthropometric data were collected from 817 truck drivers across 6 diverse US states. Survey data focused on demographics and roadway safety outcomes, and anthropometric/biometric data corresponded to five MetS conditions (waist circumference blood pressure, hemoglobin A1c, triglycerides, and high-density lipoprotein [HDL] cholesterol). Logistic regression was used to calculate odds ratios of lifetime crashes and near-miss 1-month period prevalence associated with: 1) specific MetS conditions regardless of presence or absence of other MetS conditions, and 2) specific MetS conditions and counts of other accompanying MetS conditions.

RESULTS

Hypertension was the MetS characteristic most strongly associated with lifetime crash and 1-month near-miss outcomes, while high triglycerides, low HDL cholesterol, and large waist circumference were most commonly present among groups of conditions associated with crashes and near-misses. Overall, an increasing number of specific co-occurring MetS conditions were associated with higher reporting of roadway crashes.

CONCLUSIONS

Specific combinations and higher prevalence of MetS conditions were associated with increased frequency of reported crashes. Moreover, when the co-occurrence of MetS conditions is aggregated, a dose-response relationship with crashes appears. These results suggest that policy changes and interventions addressing MetS may increase driver health and reduce crash risk.

Fatigue in transportation operations: A contextual factors survey among Iranian suburban drivers

BACKGROUND

Fatigue, as a persistent and serious occupational hazard, plays an important role in traffic accidents by reducing the driver's ability to maneuver with the vehicle and increasing the likelihood of falling asleep at the wheel.

OBJECTIVE

The purpose of this study was to identify the individual contextual factors, sleep condition, lifestyle, job characteristics, environmental, and economic conditions that affect the fatigue and alertness of Iranian suburban bus drivers.

METHODS

A questionnaire-based cross-sectional survey was used for this study. Non-probability sampling was used to study 401 suburban bus drivers from Tehran province, Iran, ranging in age from 24 to 67 years. The SPSS22 statistical software V27 was used for the analysis.

RESULTS

Approximately half of the participants (50.5%) had experienced fatigue while driving in the previous six months. According to a logistic regression analysis, the contextual factors were all independently related to falling asleep and fatigue while driving.

CONCLUSION

This study provides a thorough understanding of the contextual factors related to drowsy driving and emphasizes the importance of taking these things into consideration when developing interventions aimed at improving the driver's wellbeing and health and lowering the risk of errors and accidents.

Unravelling the Complexity of Irregular Shiftwork, Fatigue and Sleep Health for Commercial Drivers and the Associated Implications for Roadway Safety

Fatigue can be a significant problem for commercial motor vehicle (CMV) drivers. The lifestyle of a long-haul CMV driver may include long and irregular work hours, inconsistent sleep schedules, poor eating and exercise habits, and mental and physical stress, all contributors to fatigue. Shiftwork is associated with lacking, restricted, and poor-quality sleep and variations in circadian rhythms, all shown to negatively affect driving performance through impaired in judgment and coordination, longer reaction times, and cognitive impairment. Overweight and obesity may be as high as 90% in CMV drivers, and are associated with prevalent comorbidities, including obstructive sleep apnea, hypertension, and cardiovascular and metabolic disorders. As cognitive and motor processing declines with fatigue, driver performance decreases, and the risk of errors, near crashes, and crashes increases. Tools and assessments to determine and quantify the nature, severity, and impact of fatigue and sleep disorders across a variety of environments and populations have been developed and should be critically examined before being employed with CMV drivers. Strategies to mitigate fatigue in CMV operations include addressing the numerous personal, health, and work factors contributing to fatigue and sleepiness. Further research is needed across these areas to better understand implications for roadway safety.

Research gaps and needs for preventing worker fatigue in the transportation and utilities industries

BACKGROUND

The transportation and utilities industries include establishments engaged in the movement of passengers and freight, or the provision of public power, water, and other services. Along with the warehousing industry, they make up the US National Occupational Research Agenda's Transportation, Warehousing and Utilities (TWU) industry sector. In 2018 the sector composed 5% of the US workforce, with approximately 8 million workers. TWU workers experienced 19% of all fatalities among U.S. workers in 2018 and 7% of total occupational injuries and illnesses.

METHODS

Around-the-clock operations, heavy workloads, long and irregular shifts, complicated schedules, and time pressures characterize work across the US TWU sector. However, there are considerable differences in worker priorities and concerns between TWU industries. Major areas of concern within the sector include disparities in work schedules; required training for employee fatigue awareness and prevention; physical and mental job demands; and safety culture.

RESULTS

Strategies for fatigue mitigation are critical to reduce the prevalence of injuries, safety-critical events, and crashes in TWU workers. Further research on the incidence and characterization of fatigue among TWU workers will guide the development of effective mitigation strategies. The influence of work scheduling on missed sleep opportunities and disrupted circadian rhythms should be determined. Evaluation of fatigue mitigation strategies can lead to the adoption of the most effective ones for each TWU industry.

CONCLUSION

Implementation of effective strategies is critical for the health, safety, wellbeing, and productivity of workers in the TWU sector.

Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry

Obstructive sleep apnea (OSA) is a common, identifiable, and treatable disorder with serious health, safety, and financial implications-including sleepiness- related crashes and incidents-in workers who perform safety-sensitive functions in the transportation industry. Up to one-third of crashes of large trucks are attributable to sleepiness, and large truck crashes result in more than 4,000 deaths annually. For each occupant of a truck who is killed, 6 to 7 occupants of other vehicles are killed. Treatment of OSA is cost-effective, lowers crash rates, and improves health and well-being. A large body of scientific evidence and expert consensus supports the identification and treatment of OSA in transportation operators. An Advanced Notice of Proposed Rulemaking regarding the diagnosis and treatment of OSA in commercial truck and rail operators was issued by the Federal Motor Carrier Safety Administration and Federal Railroad Administration, but it was later withdrawn. This reversal of the agencies' position has caused confusion among some, who have questioned whether efforts to identify and treat the disorder are warranted. In response, we urge key stakeholders, including employers, operators, legislators, payers, clinicians, and patients, to engage in a collaborative, patient-centered approach to address the disorder. At a minimum, stakeholders should follow the guidelines issued by a medical review board commissioned by the Federal Motor Carrier Safety Administration in 2016 alone, or in combination with the 2006 criteria, "Sleep Apnea and Commercial Motor Vehicle Operators," a Statement from the Joint Task Force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation developed by a joint task force. As research in this area continues to evolve, waiting is no longer an option, and the current standard of care demands action to mitigate the burden of serious health and safety risks due to this common, treatable disorder.

CITATION

Das AM, Chang JL, Berneking M, Hartenbaum NP, Rosekind M, Gurubhagavatula I. Obstructive sleep apnea screening, diagnosis, and treatment in the transportation industry. J Clin Sleep Med. 2022;18(10):2471-2479.

Challenges in Conducting Empirical Epidemiological Research with Truck and Bus Drivers in Diverse Settings in North America

Over 6.5 million commercial vehicle drivers were operating a large truck or bus in the United States in 2020. This career often has high stress and long working hours, with few opportunities for physical activity. Previous research has linked these factors to adverse health conditions. Adverse health conditions affect not only the professional drivers' wellbeing but potentially also commercial motor vehicle (CMV) operators' safe driving ability and public safety for others sharing the roadway. The prevalence of health conditions with high impact on roadway safety in North American CMV drivers necessitates empirical epidemiological research to better understand and improve driver health. The paper presents four challenges in conducting epidemiological research with truck and bus drivers in North America and potential resolutions identified in past and current research. These challenges include (1) the correlation between driving performance, driving experience, and driver demographic factors; (2) the impact of medical treatment status on the relationship between health conditions and driver risk; (3) capturing accurate data in self-report data collection methods; and (4) reaching the CMV population for research. These challenges are common and influential in epidemiological research of this population, as drivers face severe health issues, health-related federal regulations, and the impact of vehicle operation on the safety of themselves and others using the roadways.

Fatigue in NTSB-investigations 2013-2019: evidence of accidents and injuries

ABSTRACTThis study updates the prevalence of operator fatigue as a causative factor in accidents investigated by the National Transportation Safety Board (NTSB) and the associated injury severity in fatigue-related accidents. 394 investigations were analyzed and 12% of them were identified fatigue. The prevalence of fatigue varied among the transportation modes, ranging from 28% of aviation to 7% of marine. Most fatigue-related accidents (48%) occurred during late night or morning. Compared to non-fatigued operators, fatigued operators were more involved in severe or fatal injuries (odds ratio (OR)  =  2.30; 95% confidence interval (CI) [1.66, 2.95]) and to injure non-operators (OR = 3.32; 95% CI [2.70, 3.95]). Obstructive sleep apnea (OSA) was identified as a probable cause, contributing cause, or finding in 15% of fatigued-related accidents, and 85.7% of these accidents, the operator met OSA screening criteria. Thus, opportunities remain for preventing fatigue-related accidents, including through more systematic operator screening for OSA.

Obstructive Sleep Apnea Among Army Aircrew

INTRODUCTION: Obstructive sleep apnea (OSA) is a condition characterized by disrupted sleep and excessive daytime fatigue. Associated cognitive and psychomotor decrements pose a threat to aviators' performance and flight safety. Additionally, the longer term health effects associated with the disease can jeopardize an aviator's career and negatively impact operational outputs. This study reviews OSA prevalence, related comorbid conditions in Army aviators, and analyzes the aeromedical dispositions of affected individuals.METHODS: The U.S. Army Aeromedical Electronic Resource Office (AERO) database was interrogated for all cases of OSA from June 2005 through June 2015 using ICD-9 code 327.23. Prevalence rates for OSA and other comorbid conditions were then calculated using the total number of aviators in the AERO database.RESULTS: A total of 663 unique instances of OSA were found among the aviator population (N = 24,568), giving a point prevalence of 2.69%. Four cases affected women. Mean age of initial presentation was 42.62 yr and mean Body Mass Index was 28.69. The top five most prevalent comorbid conditions were hypertension, lumbago, degeneration of a lumbar or lumbosacral intervertebral disc, PTSD, and testicular hypofunction.DISCUSSION: Prevalence of OSA among aviators is lower than the general population but is not uncommon. A positive diagnosis requires a waiver or can result in suspension if not managed effectively, potentially leading to a reduction in aviator numbers. Aggressive health promotion and robust medical surveillance and aeromedical disposition management by the aeromedical community is essential to reduce OSA numbers, maintain aviator health, and maximize flight safety.Goldie C, Stork B, Bernhardt K, Gaydos SJ, Kelley AM. Obstructive sleep apnea among army aircrew. Aerosp Med Hum Perform. 2022; 93(5):415-420.

Results of a 1-Year Follow-Up Sleep Apnea Screening and Referral Initiative During Routine Yearly Examination of Environmental Inspection Workers

BACKGROUND

There are strong links between obstructive sleep apnea (OSA), chronic disease, mental health, job performance, and motor vehicle accidents. Corporate wellness clinics and health monitoring programs present ideal settings to educate and screen employees for OSA.

METHODS

In January 2020, the Stop-Bang Sleep Apnea Questionnaire was added to the yearly health monitoring program of 571 State of Texas air, water, and hazardous waste workers as part of routine care. Medium- and high-risk (HR) scoring employees were counseled to seek follow-up care from a primary-care provider (PCP). The January 2021 exams provided an opportunity to determine the success of counseling efforts.

FINDINGS

Of the 479 returning employees in 2021, 24 (49%) of HR and 17 (21.8%) of intermediate risk (IR) had discussed OSA with a PCP. Seven (14.3%) HR and 1 (<1%) IR employee underwent a sleep study and 4 (8.2%) were prescribed continuous positive airway pressure (CPAP).

CONCLUSIONS/APPLICATION TO PRACTICE

Screening for OSA at the workplace was inexpensive and, when diagnosed and treated, can mitigate associated chronic disease, improve worker productivity, and reduce associated accidents and injuries. The described OSA screening delivered value to the employer and employees. The screening was performed at a very low cost, involved little time on the part of the nurse practitioner and employees, brought signs and symptoms of OSA to the consciousness level of 571 employees, encouraged at-risk participants to discuss OSA with a PCP and led to 4 (8.2%) being prescribed CPAP.

Validation of the STOP questionnaire as a screening tool for OSA among different populations: a systematic review and meta-regression analysis

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a sleep breathing disorder associated with adverse health outcomes, but it remains largely underdiagnosed. The STOP questionnaire is a simple tool for screening OSA and is widely used in various populations. The objective of this study was to determine the predictive parameters of the STOP questionnaire to detect OSA in sleep clinics, medical population, surgical population, commercial drivers, and the general population.

METHODS

Electronic databases were searched from January 2008 to April 2021. Pooled predictive parameters were recalculated using 2 × 2 contingency tables and random-effects meta-analyses were performed. The combined test characteristics at different OSA severities [any OSA (AHI≥5), moderate-to-severe OSA (AHI≥15), severe OSA (AHI≥30)] were used to compare the accuracy of the STOP questionnaire with polysomnography. The quality of the studies was evaluated using Cochrane Methods criteria.

RESULTS

Twenty-four studies met the inclusion criteria: 16 were in the sleep clinic population (n=8,132), four in medical population (n=1,023), two in the surgical population (n=258), and one study each on commercial drivers (n=85) and general population (n=4,770). A STOP score ≥2 showed excellent sensitivity to the different OSA severities for the sleep clinic population (>89%) and to severe OSA for the medical population (85.6%). In both populations, the STOP questionnaire also had excellent discriminative power to exclude severe OSA [negative predictive values (NPV) >84%]. The pooled sensitivity and NPV for the surgical population with moderate-to-severe OSA was 81% and 75%.

CONCLUSIONS

This meta-analysis suggests that the STOP questionnaire is a valid and effective screening tool for OSA among these population.

Improving Machine Learning Technology in the Field of Sleep

The authors discuss the challenges of machine- and deep learning-based automatic analysis of obstructive sleep apnea with respect to known issues with the signal interpretation, patient physiology, and the apnea-hypopnea index. Their goal is to provide guidance for sleep and machine learning professionals working in this area of sleep medicine. They suggest that machine learning approaches may well be better targeted at examining and attempting to improve the diagnostic criteria, in order to build a more nuanced understanding of the detailed circumstances surrounding OSA, rather than merely attempting to reproduce human scoring.

Poor performance of screening questionnaires for obstructive sleep apnea in male commercial drivers

PURPOSE

Screening commercial drivers (CDs) for obstructive sleep apnea (OSA) reduces the risk of motor vehicle accidents. We evaluated the accuracy of standard OSA questionnaires in a cohort of CDs.

STUDY DESIGN AND METHODS

We enrolled consecutive male CDs at 10 discrete transportation companies during their yearly scheduled occupational health visit. The CDs had their anthropometric measures taken; completed the Berlin, STOP, STOP-BANG, OSAS-TTI, SACS, EUROSAS, and ARES questionnaires; and underwent a home sleep apnea test (HSAT) for the determination of their respiratory events index (REI). We assessed the questionnaires' ability to predict OSA (REI ≥ 5 events/h) and moderate-to-severe OSA (REI ≥ 15 events/h).

RESULTS

Among 315 CDs recruited, 243 (77%) completed the study protocol, while 72 subjects were excluded for inadequate HSAT quality. The demographics and clinical data were comparable in both the included and excluded subjects. The included CDs had a median age of 50 years (interquartile range (IQR) 25-70) and a mean body mass index of 27 ± 4 kg/m². One hundred and seventy-one subjects (71%) had OSA, and 68 (28%) had moderate-to-severe OSA. A receiver operating characteristic curve of the questionnaires were 0.51-0.71 for predicting OSA and 0.51-0.66 for moderate-to-severe OSA. The STOP-BANG questionnaire had an unsatisfactory positive predictive value, while all of the other questionnaires had an inadequate negative predictive value.

CONCLUSIONS

Standard OSA questionnaires are not suited for screening among CDs. The use of the HSAT could provide an objective evaluation of for OSA in this special population.

Employer-mandated obstructive sleep apnea treatment and healthcare cost savings among truckers

OBJECTIVE

To evaluate the effect of an employer-mandated obstructive sleep apnea (OSA) diagnosis and treatment program on non-OSA-program trucker medical insurance claim costs.

METHODS

Retrospective cohort analysis; cohorts constructed by matching (randomly, with replacement) Screen-positive Controls (drivers with insurance screened as likely to have OSA, but not yet diagnosed) with Diagnosed drivers (n = 1,516; cases = 1,224, OSA Negatives = 292), on two factors affecting exposure to medical claims: experience level at hire and weeks of job tenure at the Diagnosed driver's polysomnogram (PSG) date (the "matching date"). All cases received auto-adjusting positive airway pressure (APAP) treatment and were grouped by objective treatment adherence data: any "Positive Adherence" (n = 932) versus "No Adherence" (n = 292). Bootstrap resampling produced a difference-in-differences estimate of aggregate non-OSA-program medical insurance claim cost savings for 100 Diagnosed drivers as compared to 100 Screen-positive Controls before and after the PSG/matching date, over an 18-month period. A two-part multivariate statistical model was used to set exposures and demographics/anthropometrics equal across sub-groups, and to generate a difference-in-differences comparison across periods that identified the effect of OSA treatment on per-member per-month (PMPM) costs of an individual driver, separately from cost differences associated with adherence choice.

RESULTS

Eighteen-month non-OSA-program medical claim costs savings from diagnosing (and treating as required) 100 Screen-positive Controls: $153,042 (95% CI: -$5,352, $330,525). Model-estimated effect of treatment on those adhering to APAP: -$441 PMPM (95% CI: -$861, -$21).

CONCLUSIONS

Results suggest a carrier-based mandatory OSA program generates substantial savings in non-OSA-program medical insurance claim costs.

Validation of the STOP-Bang questionnaire for screening of obstructive sleep apnea in the general population and commercial drivers: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is a critical occupational health concern, but is often undiagnosed in the general population and commercial drivers. The STOP-Bang questionnaire is a simple, reliable tool to screen for OSA, which could improve public health in a cost-effective manner. The objective of this systematic review and meta-analysis is to assess the validity of the STOP-Bang questionnaire to detect OSA in these key populations.

Methods

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, Journals @ Ovid, Web of Science, Scopus, and CINAHL for relevant articles from 2008 to March 2020. The quality of studies was appraised using Cochrane Methods criteria. To calculate pooled predictive parameters, we created 2 × 2 contingency tables and performed random-effects meta-analyses.

Results

Of 3871 citations, five studies that evaluated STOP-Bang in the general population (n = 8585) and two in commercial drivers (n = 185) were included. In the general population, prevalence of all OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥ 15), and severe OSA (AHI ≥ 30) was 57.6%, 21.3%, and 7.8% respectively. In commercial drivers, the prevalence of moderate-to-severe OSA was 37.3%. The trends of high sensitivity and negative predictive value of a STOP-Bang score ≥ 3 illustrates that the questionnaire helps detect and rule out clinically significant OSA in the general population and commercial drivers.

Conclusion

This meta-analysis demonstrates that the STOP-Bang questionnaire is a valid and effective screening tool for OSA in the general population and commercial drivers.

Trial registration

PROSPERO No. CRD42020200379; 08/22/2020

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02299-y.

Clinical use of STOP-BANG and ESS questionnaires in the evaluation of obstructive sleep apnoea-related risk factors for motor vehicle accidents among public transport drivers in Delhi, India

PURPOSE

To assess the clinical use of Epworth Sleepiness Score (ESS) and STOP-BANG questionnaires in the evaluation of sleep apnoea-related risk factors for motor vehicle accident (MVA) among public transport drivers in Delhi, India.

METHODS

The present cross-sectional study is based on data collected between April 2018 and March 2019 from public transport drivers in Delhi. All drivers coming for gas filling to 43 compressed natural gas (CNG) stations in Delhi were included in the study. The evaluation of sleep apnoea-related risk factors for motor vehicle accident was done using ESS and STOP-BANG Score.

RESULTS

A total of 4094 drivers participated in this study, and 299 drivers (7%) gave a history of motor vehicle accidents during the preceding 3 years. Drivers with STOP-BANG score ≥ 3 had a higher risk for MVA (OR 1.59; 95% CI 1.26-2.02; p value < 0.0001). Score of ESS ≥ 10 carried a very high risk for MVA (OR 26.95; 95% CI 16.18-44.87; p value < 0.0001). The other risk factor of significance was alcoholism (OR 1.37; 95% CI 1.04-1.80; p value < 0.0248).

CONCLUSION

Among public transport drivers in Delhi, daytime sleepiness is the major contributing factor to motor vehicle accidents. ESS and STOP-BANG questionnaires may be good screening tools for the clinical evaluation of OSA. Community-based screening of OSA is required for identification of public transport drivers at high risk of MVA.

Employee Sleep Enhancement and Fatigue Reduction Programs: Analysis of the 2017 CDC Workplace Health in America Poll

BACKGROUND

Poor sleep health, including sleep deficiency and sleep disturbance, is common among employed adults in the U.S. and is associated with undesirable workplace outcomes. Adoption of workplace health promotion programs (WHPPs) is increasing, yet few programs aim to reduce fatigue or improve sleep among employees.

OBJECTIVE

We analyzed data from the nationally representative 2017 Centers for Disease Control Workplace Health in America poll to identify the prevalence of sleep enhancement or fatigue reduction WHPPs and the characteristics of employers that offer these programs.

METHOD

A stratified random sample of nationally-representative worksites with ≥10 employees was generated. It comprised 2,843 worksites. Worksite representatives reported workplace characteristics, health promotion activities, and the likelihood of offering WHPPs relating to sleep enhancement or fatigue reduction. Logistic regression analyses were utilized to identify characteristics associated with offering a sleep enhancement or fatigue reduction WHPP, controlling for WHPP budget and size of the company, and contingent on worksites having a comprehensive workplace health plan.

RESULTS

Less than 1 in 10 worksites (10%) reported offering a sleep enhancement or fatigue reduction WHPP. Worksites most likely to offer a sleep-focused WHPP were those in retail, wholesale, or technology industries (OR = 2.71, 95%CI: 1.08-6.8) vs. those in the finance, information, technology industries; those with a large WHPP budget (>$500,000, OR = 6.85, 95%CI: 2.1-22.35) vs. those with no budget; and those that had visible support of WHPP initiatives from senior leadership (OR = 4.74, 95%CI: 1.91-11.75) vs. those without such support.

CONCLUSIONS

Our results highlight how few worksites reported offering sleep-focused programs for their employees. Those worksites that did feature such programs, were commonly well-resourced and had senior leadership support for WHPP initiatives in general. Future research should consider working directly with leaders to expand the implementation of employee sleep enhancement and fatigue reduction WHPPs.

Sleep Apnea Screening for Commercial Drivers: A Retrospective Comparison of the 2016 FMCSA MRB Recommendations and the 2006 Joint Task Force Consensus Guidelines

OBJECTIVE

Compare the 2016 Federal Motor Carrier Safety Administration (FMCSA) and 2006 Joint Task Force (JTF) Guidelines for commercial drivers' obstructive sleep apnea (OSA) screening.

METHODS

Retrospective review of all commercial driver medical examinations performed in 2017 at an academic occupational medicine clinic. Screening criteria from both the JTF and FMCSA were applied, separately, and jointly. Statistical tests were applied as appropriate.

RESULTS

Applying the FMCSA or JTF criteria separately to 706 commercial drivers, the positive OSA screening yields were 15.7% and 16.9%, respectively. Using both criteria produced an overall positive OSA screen yield of 20.1%. Positive predictive values for applying both guidelines ranged from 72.7% to 95.5%.

CONCLUSIONS

The combined use of the 2016 FMCSA and 2006 JTF OSA screening criteria in series has a higher screening yield than using either guideline individually.

OSA in Professional Transport Operations: Safety, Regulatory, and Economic Impact

OSA is common among commercial vehicle operators (CVOs) in all modes of transportation, including truck, bus, air, rail, and maritime operations. OSA is highly prevalent and increases the risk of drowsiness-related crashes in CVOs. Internationally, specific regulations regarding its identification and management vary widely or do not exist; medical examiners and sleep medicine specialists are urged to use available guidance documents in their absence. Education, screening, prompt identification and treatment, and ongoing surveillance to ensure effective therapy can lower the risk of fatigue-related crashes.

Excessive daytime sleepiness and alcohol consumption among commercial drivers

BACKGROUND

Commercial drivers suffering from excessive daytime sleepiness (EDS) have been identified as a major cause of road traffic accidents. Alcohol usage directly affects sleep, adversely affecting next-day alertness and performance.

AIMS

To examine the relationship between alcohol consumption and EDS among commercial truck drivers in Japan and the implications of this on public health.

METHODS

All participants in this cross-sectional study were commercial motor vehicle drivers from Tokyo and Niigata Prefecture. Participants completed a self-administered questionnaire with details of their age, body mass index, alcohol consumption, Epworth Sleepiness Scale (ESS) score and tobacco usage. Participants' oxygen desaturation index was determined by a pulse oximetry device that participants took home.

RESULTS

A total of 1422 males registered with the Japan Trucking Association and aged 20-69 years participated. The multivariate-adjusted odds ratio (OR) of EDS among participants aged <43 years was 0.81 (95% confidence interval (CI) 0.47-1.40) for light drinkers, 0.93 (95% CI 0.51-1.70) for moderate drinkers and 0.61 (95% CI 0.21-1.79) for heavy drinkers, compared to non-drinkers. The multivariate-adjusted OR among participants aged ≥43 years was 1.42 (95% CI 0.59-3.45) for light drinkers, 1.53 (95% CI 0.63-3.75) for moderate drinkers and 3.37 (95% CI 1.14-9.96) for heavy drinkers (P for interaction = 0.05).

CONCLUSION

We found that the association between ESS and alcohol intake was more evident among those aged ≥43 years, who reported higher levels of EDS with increased alcohol consumption.

Screening for obstructive sleep apnoea in professional drivers

Professional drivers show a higher prevalence of obstructive sleep apnoea (OSA) compared with the general population. Furthermore, there is concern about the association between OSA and car crash risk given that drivers with OSA show an increased risk for car accidents. Despite this risk, OSA is often underdiagnosed and undertreated in this population, mainly due to lack of appropriate screening and sleep study referrals. Polysomnography (PSG), the gold standard test, is inappropriate for systematic screening because of its high expense, complexity and relative inaccessibility in this population. Therefore, there is a strong demand for good screening tools, including both subjective and objective data that may assist in early identification of possible OSA among professional drivers and, thus, aid in PSG examination referral and OSA management in an accredited sleep centre. However, there is considerable disagreement over screening methods and criteria for triggering a sleep study referral in different countries. There is also a strong need for further research in the area of OSA screening of commercial drivers in order to improve the diagnostic accuracy of screening tools and ensure that patients with OSA are accurately identified.

KEY POINTS

Obstructive sleep apnoea (OSA) is often undiagnosed and undertreated in professional drivers.Professional drivers often under-report and are reluctant to report OSA symptoms.Barriers to OSA diagnosis include appropriate screening and sleep study referrals.Screening tools including both subjective and objective data may assist in early identification of possible OSA among professional drivers.

EDUCATIONAL AIMS

To evaluate screening instruments currently used to identify OSA risk in professional drivers.To provide guidance for developing an assessment strategy for OSA by professional driver medical examiners.

The Pre-Registry Commercial Driver Medical Examination: Screening Sensitivity and Certification Lengths for Two Safety-Related Medical Conditions

OBJECTIVE

Use independent diagnostic data to analyze the screening effectiveness of the pre-Registry commercial driver medical examination (CDME) for obstructive sleep apnea (OSA), and its sensitivity for hypertension; analyze certification lengths where relevant.

METHODS

CDME screening results for 1668 drivers were compared to polysomnogram diagnostic test results, and CDME screening results were evaluated for 1155 drivers with at least one insurance claim with a hypertension diagnostic code. Any CDME documentation of the medical condition was considered as detection by screening.

RESULTS

CDME sensitivity was 20.7% for moderate OSA (AHI ≥ 15). While sensitivity was 77.5% for hypertension, 93.3% of drivers with Stage 3 hypertension were certified, contrary to Federal Motor Carrier Safety Administration standards.

CONCLUSIONS

The pre-Registry CDME was ineffective in screening commercial drivers for OSA. Screening was better for hypertension; incorrect certifications were given to many hypertensive drivers.

Screening for Sleepiness and Sleep Disorders in Commercial Drivers

Sleep disorders in commercial drivers are common and treatable. Left unidentified, they lead to a host of adverse consequences, including daytime sleepiness, adverse health effects, economic costs, and public safety risks owing to sleepiness-related crashes. The best studied of these is obstructive sleep apnea, which is common and identifiable among commercial drivers. This article provides an overview of screening, and specific approaches to screen for and manage obstructive sleep apnea in commercial drivers with the goal of reducing the risk of vehicular crashes.

Sleep and Transportation Safety: Role of the Employer

Human fatigue is an important factor in transportation safety and a major causal factor of accidents. Employers play a vital role in minimizing fatigue-related risk, and are legally liable for damages arising from failure to address the risk. By taking an active role as stakeholders in transportation safety, employers not only reduce their risk of adverse safety events and limit their legal liability but may also benefit from improvements in productivity, morale, and health care expenditures. Employers should focus on reducing fatigue-related risk, with ongoing support from sleep safety research.

Psychophysical stress and strain of maritime pilots in Germany. A cross-sectional study

Introduction

Maritime pilots work in an irregular deployment system (rotation system) with unpredictable work assignments under high levels of physical and mental stress. Fatigue or chronic diseases, e.g. coronary heart disease, peptic ulcers or gastritis can occur as a consequence. This can lead to long-term limitations of pilots’ work ability. The aim of this study is to analyse current stress and strain in maritime pilots.

Methods

Initially, all German pilots were interviewed with an online questionnaire about their living and working situation (response rate 43%). Subsequently, a medical and psychological examination of a random sample was carried out with pilots working in a 4-month rotation system compared with those working in a 1-week system. Most of the measurements took place at the beginning and the end of continuous work assignments each lasting several weeks (pre vs post-rotation). The questionnaires RESTQ-work 27, Resilience Scale RS-13 and Berlin Questionnaire were used as well as a sleeping diary. Furthermore, cardiovascular parameters (during rest and under ergometric stress), activity and blood parameters, urine stress hormones, and the pupillary unrest index were surveyed.

Results

60 pilots were recorded with an average age of 48.7 years (SD 8.3 years). Among the parameters collected, there were no significant differences between pre and post-rotation examinations. Pilots with a 4-month rotation system experienced a much higher subjective strain level in RESTQ work-27 (OR 10.12 (95% CI 1.21–84.59)). According to the sleep diaries of the pilots working in a 4-month rotation system, reduced levels were found concerning the pre and post-rotation subjective performance level (p = 0.042 and 0.029), subjective sleep duration (p = 0.032) and current subjective feeling post-rotation (p = 0.036). Objectively measured arterial hypertension was significantly more frequent among pilots working 4 months at a time (OR 21.41 (95% CI 1.26–364.05)). In addition, elevated levels of total cholesterol, triglycerides and uric acid were more common among this group of pilots (p = 0.038, p = 0.033 and p = 0.038). In particular, the risk of hypertriglyceridemia was increased (OR 4.41 (95% CI 1.15–16.91)).

Discussion

Maritime pilotage represents a very straining profession that has been studied very little up to this point. The present results indicate that 4-month rotation systems lead to higher levels of subjective and objective strain than 1-week rotation systems. Interventions are therefore recommended; especially a change in the rotation system should be considered.

Screening for Obstructive Sleep Apnea in Commercial Drivers Using EKG-Derived Respiratory Power Index

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is common in commercial motor vehicle operators (CMVOs); however, polysomnography (PSG), the gold-standard diagnostic test, is expensive and inconvenient for screening. OSA is associated with changes in heart rate and voltage on electrocardiography (EKG). We evaluated the utility of EKG parameters in identifying CMVOs at greater risk for sleepiness-related crashes (apnea-hypopnea index [AHI] ≥ 30 events/h).

METHODS

In this prospective study of CMVOs, we performed EKGs with concurrent PSG, and calculated the respiratory power index (RPI) on EKG, a surrogate for AHI calculated from PSG. We evaluated the utility of two-stage predictive models using simple clinical measures (age, body mass index [BMI], neck circumference, Epworth Sleepiness Scale score, and the Multi-Variable Apnea Prediction [MVAP] score) in the first stage, followed by RPI in a subset as the second-stage. We assessed area under the receiver operating characteristic curve (AUC), sensitivity, and negative posttest probability (NPTP) for this two-stage approach and for RPI alone.

RESULTS

The best-performing model used the MVAP, which combines BMI, age, and sex with three OSA symptoms, in the first stage, followed by RPI in the second. The model yielded an estimated (95% confidence interval) AUC of 0.883 (0.767-0.924), sensitivity of 0.917 (0.706-0.962), and NPTP of 0.034 (0.015-0.133). Predictive characteristics were similar using a model with only BMI as the first-stage screen.

CONCLUSIONS

A two-stage model that combines BMI or the MVAP score in the first stage, with EKG in the second, had robust discriminatory power to identify severe OSA in CMVOs.

Occupational health disparities among U.S. long-haul truck drivers: the influence of work organization and sleep on cardiovascular and metabolic disease risk

OBJECTIVE

The organization of work has undergone vast transformations over the past four decades in the United States and has had profound impacts on worker health and wellbeing. The profession of commercial truck driving is one of the best examples. Particularly for long-haul truck drivers, changes in work organization have led to disproportionately poor physiological, psychological, and sleep health outcomes.

METHODS

The present study examined disparities in cardiometabolic disease risk among long-haul truck drivers and the general population, and the influence of work organization and sleep in generating these outcomes. Researchers collected survey data from 260 drivers, and blood assay samples from 115 of those drivers, at a large highway truck stop in North Carolina. Comparisons were made for cardiovascular and metabolic risk against the 2011-2012 National Health and Nutrition Examination Survey (NHANES). In addition, logistic regression was used to explore predictive relationships between work organization and sleep and risk for cardiovascular and metabolic disease.

RESULTS

There were statistically significant mean differences between the long-haul truck driver sample and the NHANES sample for both cardiovascular (3.71 vs. 3.10; p <0.001) and metabolic (4.31 vs. 3.09; p <0.001) disease risk. The truck driver sample was less physically active and had lower HDL cholesterol along with greater levels of smoking, BMI, and metabolic syndrome diagnosis. More years of driving experience and poor sleep quality were statistically significant predictors for both cardiovascular and metabolic disease risk.

CONCLUSIONS

Study findings implicate elements of the occupational milieu experienced by long-haul truck drivers that induce disproportionate cardiometabolic disease risk. Sleep quality, largely compromised by poor work conditions and workplace environments, plays a significant role in increased risks for cardiometabolic disease. There is an urgent need for longitudinal studies of this critical occupational sector as well as intervention research centered on policy and systems level change.

A Policy Analysis of Mandatory Obstructive Sleep Apnea Screening in the Trucking Industry

Obstructive sleep apnea (OSA) is a chronic condition characterized by occlusion of the upper airway during sleep resulting in daytime sleepiness. Drivers with OSA are at a two- to sevenfold increase in risk of motor vehicle crashes (MVCs). Approximately, 13% to 28% of commercial motor vehicle drivers (CMVDs) are thought to have OSA. Obstructive sleep apnea is a significant issue in the transportation industry. Currently, The Federal Motor Carrier Safety Association (FMCSA) does not mandate OSA screening. Federal regulations only specify that CMVDs be free of "respiratory dysfunction" that would impair driving. Untreated OSA is a public safety concern. The purpose of this article is to use Bardach's eightfold policy analysis approach to examine policy options related to OSA screening in the trucking industry.

Randomized, Prospective Study of the Impact of a Sleep Health Program on Firefighter Injury and Disability

Study Objectives

Firefighters' schedules include extended shifts and long work weeks which cause sleep deficiency and circadian rhythm disruption. Many firefighters also suffer from undiagnosed sleep disorders, exacerbating fatigue. We tested the hypothesis that a workplace-based Sleep Health Program (SHP) incorporating sleep health education and sleep disorders screening would improve firefighter health and safety compared to standard practice.

Design

Prospective station-level randomized, field-based intervention.

Setting

US fire department.

Participants

1189 firefighters.

Interventions

Sleep health education, questionnaire-based sleep disorders screening, and sleep clinic referrals for respondents who screened positive for a sleep disorder.

Measurements and Results

Firefighters were randomized by station. Using departmental records, in an intention-to-treat analysis, firefighters assigned to intervention stations which participated in education sessions and had the opportunity to complete sleep disorders screening reported 46% fewer disability days than those assigned to control stations (1.4 ± 5.9 vs. 2.6 ± 8.5 days/firefighter, respectively; p = .003). There were no significant differences in departmental injury or motor vehicle crash rates between the groups. In post hoc analysis accounting for intervention exposure, firefighters who attended education sessions were 24% less likely to file at least one injury report during the study than those who did not attend, regardless of randomization (OR [95% CI] 0.76 [0.60, 0.98]; χ2 = 4.56; p = .033). There were no significant changes pre- versus post-study in self-reported sleep or sleepiness in those who participated in the intervention.

Conclusions

A firefighter workplace-based SHP providing sleep health education and sleep disorders screening opportunity can reduce injuries and work loss due to disability in firefighters.

Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force

ABSTRACT

The American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.

Screening Commercial Vehicle Drivers for Obstructive Sleep Apnea: Tools, Barriers, and Recommendations

Obstructive sleep apnea (OSA) is a disorder characterized by a cessation of breathing during sleep, leading to poor sleep patterns and daytime somnolence. Daytime somnolence is of particular concern for commercial vehicle drivers, whose crash risk increases 50% with untreated OSA. The process of diagnosing and treating OSA in commercial drivers begins with effective and consistent screening. Therefore, the researchers screened drivers with both the STOP-Bang Questionnaire and the Obstructive Sleep Apnea Evaluation Worksheet (OSAEW) and compared the two tools. Drivers screening positive on the STOP-Bang Questionnaire, OSAEW, and both questionnaires were 28%, 23%, and 13%, respectively. Sleep study referrals were made for 50 drivers; 12 drivers were scheduled for sleep tests within 3 months. Health care provider referral rates for drivers screening at high risk (37%) and commercial driver monitoring rates (24%) were both low. Recommendations to improve OSA screening and testing practices include Federal Motor Carrier Safety Administration-mandated screening and referral guidelines, employee-facilitated sleep testing, and OSA awareness campaigns.

Multiple Conditions Increase Preventable Crash Risks Among Truck Drivers in a Cohort Study

OBJECTIVE

This study aims to quantify the crash risk for truck drivers with multiple comorbid medical conditions, after adjusting for confounders.

METHODS

This retrospective cohort of 38,184 drivers evaluated concomitant medical conditions and subsequent crash data between January 1, 2005, and October 31, 2012. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated for any cause and preventable crashes of varying severity.

RESULTS

Drivers with three or more medical conditions had a significantly increased risk of preventable Department of Transportation (DOT) reportable crashes (HR = 2.53, 95% CI = 1.65 to 3.88) and preventable crashes with injuries (HR = 2.23, 95% CI = 1.09 to 5.31) after adjustment for covariates. Similarly, adjusted HRs were 2.55 (95% CI = 1.37 to 4.73) for any cause DOT-reportable crashes and 3.21 (95% CI = 1.18 to 8.75) for any cause crashes with injuries.

CONCLUSIONS

Having three concomitant medical conditions may be a statistically significant risk factor for preventable and any cause DOT-reportable crashes and crashes with injuries.

Repeated Cross-Sectional Assessment of Commercial Truck Driver Health

OBJECTIVE

To assess relationships and trends over time in individual conditions and multiple conditions among a large sample of independent, nonoverlapping truck drivers using a repeated cross-sectional study design.

METHODS

Commercial driver medical examinations were conducted on 95,567 commercial drivers between January 1, 2005, and October 31, 2012. Specific medical conditions that have been identified by the Federal Motor Carrier Safety Administration's Medical Review Board as possibly increasing crash risk were examined. Prevalence and trends over time were analyzed.

RESULTS

A total of 8 of the 13 conditions significantly increased from 2005 to 2012. Prevalence of multiple concomitant conditions also increased, with prevalence odds ratios as high as 7.39 (95% confidence interval, 3.92 to 13.98) for four or more conditions in 2012 as compared with 2005.

CONCLUSIONS

Individual and multiple conditions thought to be associated with increased crash risk significantly increased between 2005 and 2012.

Risk of Occupational Accidents in Workers with Obstructive Sleep Apnea: Systematic Review and Meta-analysis

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is the single most important preventable medical cause of excessive daytime sleepiness (EDS) and driving accidents. OSA may also adversely affect work performance through a decrease in productivity, and an increase in the injury rate. Nevertheless, no systematic review and meta-analysis of the relationship between OSA and work accidents has been performed thus far.

METHODS

PubMed, PsycInfo, Scopus, Web of Science, and Cochrane Library were searched. Out of an initial list of 1,099 papers, 10 studies (12,553 participants) were eligible for our review, and 7 of them were included in the meta-analysis. The overall effects were measured by odds ratios (OR) and 95% confidence intervals (CI). An assessment was made of the methodological quality of the studies. Moderator analysis and funnel plot analysis were used to explore the sources of between-study heterogeneity.

RESULTS

Compared to controls, the odds of work accident was found to be nearly double in workers with OSA (OR = 2.18; 95% CI = 1.53-3.10). Occupational driving was associated with a higher effect size.

CONCLUSIONS

OSA is an underdiagnosed nonoccupational disease that has a strong adverse effect on work accidents. The nearly twofold increased odds of work accidents in subjects with OSA calls for workplace screening in selected safety-sensitive occupations.

COMMENTARY

A commentary on this article appears in this issue on page 1171.

Commercial Driver Medical Examinations: Prevalence of Obesity, Comorbidities, and Certification Outcomes

Supplemental Digital Content is Available in the Text.

Objective:

The objective of this study was to assess relationships between body mass index (BMI) and comorbid conditions within a large sample of truck drivers.

Methods:

Commercial driver medical examination data from 88,246 commercial drivers between 2005 and 2012 were analyzed for associations between BMI, medical disorders, and driver certification.

Results:

Most drivers were obese (53.3%, BMI >30.0 kg/m²) and morbidly obese (26.6%, BMI >35.0 kg/m²), higher than prior reports. Obese drivers were less likely to be certified for 2 years and more likely to report heart disease, hypertension, diabetes mellitus, nervous disorders, sleep disorders, and chronic low back pain (all P < 0.0001). There are relationships between multiple potentially disqualifying conditions and increasing obesity (P < 0.0001). Morbid obesity prevalence increased 8.9% and prevalence of three or more multiple conditions increased fourfold between 2005 and 2012.

Conclusions:

Obesity is related to multiple medical factors as well as increasing numbers of conditions that limit driving certification.

Nonadherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes

STUDY OBJECTIVES

To evaluate the effect of an employer-mandated obstructive sleep apnea (OSA) program on the risk of serious preventable truck crashes.

METHODS

Data are from the first large-scale, employer-mandated program to screen, diagnose, and monitor OSA treatment adherence in the US trucking industry. A retrospective analysis of cohorts was constructed: polysomnogram-diagnosed drivers (OSA positive n = 1,613, OSA negative n = 403) were matched to control drivers unlikely to have OSA (n = 2,016) on two factors affecting crash risk, experience-at-hire and length of job tenure; tenure was matched on the date of each diagnosed driver's polysomnogram. Auto-adjusting positive airway pressure (APAP) treatment was provided to all cases (i.e. OSA positive drivers); treatment adherence was objectively monitored. Cases were grouped by treatment adherence: "Full Adherence" (n = 682), "Partial Adherence" (n = 571), or "No Adherence" (n = 360). Preventable Department-of-Transportation-reportable crashes/100,000 miles were compared across study subgroups. Robustness was assessed.

RESULTS

After the matching date, "No Adherence" cases had a preventable Department of Transportation-reportable crash rate that was fivefold greater (incidence rate ratio = 4.97, 95% confidence interval: 2.09, 10.63) than that of matched controls (0.070 versus 0.014 per 100,000 miles). The crash rate of "Full Adherence" cases was statistically similar to controls (incidence rate ratio = 1.02, 95% confidence interval: 0.48, 2.04; 0.014 per 100,000 miles).

CONCLUSIONS

Nontreatment-adherent OSA-positive drivers had a fivefold greater risk of serious preventable crashes, but were discharged or quit rapidly, being retained only one-third as long as other subjects. Thus, the mandated program removed risky nontreatment-adherent drivers and retained adherent drivers at the study firm. Current regulations allow nonadherent OSA cases to drive at another firm by keeping their diagnosis private.

COMMENTARY

A commentary on this article appears in this issue on page 961.

Commercial Motor Vehicle Driver Positive Airway Pressure Therapy Adherence in a Sleep Center

STUDY OBJECTIVES

To assess positive airway pressure (PAP) therapy adherence in commercial motor vehicle (CMV) drivers presenting to a sleep center.

METHODS

A retrospective chart review of 120 drivers evaluated for obstructive sleep apnea OSA and 53 initiated on PAP therapy in a single sleep center over a one-year period (2012); PAP therapy data were collected up to 1 year.

RESULTS

Early PAP usage best predicted adherence up to 1 year (p < 0.0001) compared to patient factors, OSA disease characteristics, and treatment elements analyzed. The proportion of participants adherent to therapy was 68.0% at 1 week, decreasing to 39.6% at 1 year, with 31.1% lost to follow-up by 1 year. In the group categorized based on adherence at week 1, 80.6% were adherent at 1 month, decreasing to 52.8% at 1 year. For the group non-adherent at 1 week, 29.4% were adherent at 1 month, decreasing to 11.7% at 1 year. Participants were predominantly male (75.8%), middle-aged (median 50.5 years), and African American (71.7%). Of those referred to the sleep center, 86.7% had OSA (median apnea-hypopnea index [AHI] or respiratory event index [REI] 20.1), with 51.0% of the OSA group having an AHI or REI > 20 and initiating PAP therapy.

CONCLUSIONS

Early PAP utilization patterns predicted one year adherence for our CMV driver population within a sleep clinic setting. OSA testing of these CMV drivers after occupational health referral identifies high proportions of undiagnosed OSA, with approximately half requiring PAP therapy based on current published treatment recommendations.

Commercial Motor Vehicle Driver Obstructive Sleep Apnea Screening and Treatment in the United States: An Update and Recommendation Overview

ABSTRACT

No regulatory mandate exists in the United States (U.S.) for comprehensive obstructive sleep apnea (OSA) risk assessment and stratification for commercial motor vehicle (CMV) drivers. Current Federal Motor Carrier Safety Administration (FMCSA) requirements are outdated and depend largely on subjective report, a less reliable strategy in an occupational setting. Without FMCSA standards, sleep specialists, occupational medical examiners and employers rely on a collection of medical consensus recommendations to establish standards of care. These recommendations advise OSA risk assessment through a combination of focused medical history, physical examination, questionnaires, and accident history, which increase OSA detection compared to current FMCSA standards. For those diagnosed with OSA, consensus-based risk stratification helps identify CMV drivers who may benefit from OSA treatment and establish minimum standards for assessing treatment efficacy and adherence. Unfortunately no consolidated recommendation exists; rather, publications span medical and governmental literature in a patchwork fashion that no longer fully reflect current practice due to subsequent advances in OSA diagnosis, treatment, and technology. Based on searches of medical literature, internet materials, and reference lists from existing publications, an overview and discussion of key published recommendations regarding OSA assessment and treatment in CMV operators is provided. Suggestions for incorporating these recommendations into clinical sleep medicine practice in the U.S. are presented. The challenge for sleep specialists is maintaining the delicate balance between recommendations impacting standard of care and associated medico-legal impact with stakeholder interests from medical, regulatory, industry and public perspectives while providing high quality and efficient care.