A Corporate Driven Sleep Apnea Detection and Treatment Program

Page 4 of 5: Discussion

This is the first published report of a large commercial long-haul carrier employing a systematic program of screening, diagnosing, and treating its drivers for SDB. Indeed SNI, with its dedicated departments of Occupational Health and Loss Prevention, is employing its unique position to explore the utility of such programs. Successful implementation of these initiatives requires a commitment from management to expend the "hard dollar" costs of screening, testing, and educating its drivers regarding SDB. It has also proven necessary to educate and demand a higher standard than that which is currently mandated from the DOT physicians responsible for certifying commercial drivers as fit for duty. The hypothesized, and now proven, results of such initiatives are the larger "soft dollar" savings in health care expenditures, diminished liability risks from fewer accidents, and an improved retention rate of drivers who are generally pleased with the results of CPAP treatment of their condition.

Difficulties encountered in our initiative include a mobile work force, an industry-wide high driver turn-over rate, a continued need to educate the DOT examiner regarding SNI's expectations from the DOT Physical Exam (SNI contracts with numerous DOT clinics across the country and turnover of office and physician staff becomes a factor as well), and the maintenance of the infrastructure and education within the SNI organization as it grows. While balancing the desire to have as many safe drivers on the road at all times, driver shortages and business needs exact pressures when drivers are pulled out of service for testing.

In developing our screening tool for SDB, it was important to provide an instrument sensitive enough to identify affected individuals utilizing easy to obtain objective criteria. Discovering commercial drivers afflicted with SDB presents a rather unique situation in medicine where subjective complaints suggesting this condition are often willfully denied and objective criteria for diagnosis require a relatively expensive sleep study. Several investigations looking at various screening strategies have relied heavily on subjective responses to help identify patients with SDB (Maislin, et al 1995; Chesson, et al 1997; Gurubhagavatula, et al 2004). Other reports have shown predictive associations between biochemical markers and the presence of SDB. Shamsuzzaman, et al (2002) found the level of C-reactive protein in the blood to correlate proportionally to the severity of obstructive sleep apnea. Dixon, Schachter, and O'Brien (2003) have found that fasting blood insulin levels and the level of glycosylated hemoglobin A1C were predictive of the apnea/hypopnea index. Although these studies are promising in contributing to a potential objective screening tool for SDB, their utility, validity, and costs remain to be defined. Additionally, most reports of various screening tools, including ours, reflect models "developed from a population of patients referred to a sleep center for evaluation," according to Rowley, Aboussouan, and Badr (2000). These tools' utilities will be proven only after their broad application to large, randomly selected groups (coupled with polysomnography as the gold standard for diagnosis and exclusion) regardless of any a priori bias.

Our screening tool incorporates easy to obtain objective and subjective criteria which have been consistently shown in the literature to be predictive of SDB. These criteria incorporate BMI, presence of hypertension (Flemons, et al; 1994), and heavy snoring. It is our belief that most SDB individuals will admit to a history of heavy snoring even while consciously concealing symptoms of daytime hypersomnolence. The utility of our tool also relies on corporate-promoted education of nurses, physical therapists, and contracted physicians to inquire and recognize subjective cues a driver might offer suggesting an underlying sleep disorder. Additionally, medical reviews of an obese driver's co-morbidities, such as diabetes or heart disease, may trigger a referral for a sleep study. This latter fact may account for the low negative predictive value of our tool. The recent article by Gurubhagavatula, et al (2004) suggests that coupling nocturnal oximetry to certain screened subgroups will improve specificity. Nevertheless, in a population where SDB is so prevalent, the positive predictive value of our tool at 91% represents an important and inexpensive aid in identifying affected drivers.

One of the most dramatic and significant results of our study is the documented reduction in global health care costs derived from the treatment of SDB drivers. After CPAP intervention, affected SDB patients experienced roughly one fourth as many hospital admissions and spent about one half the health care dollars compared with the period prior to intervention. These per member per month (PMPM) savings are large, ranging from $433.59 to $666.53 per month. When coupled with the fact that at least 10%, and perhaps closer to 28% of a commercial carrier's drivers have SDB, annual savings in health care costs alone become staggering. For example, using the most conservative figures of a 10% prevalence for SDB and a $433.59 per month per SDB-treated driver, a company employing 1000 drivers can expect annual health cost savings of over $500,000. Larger companies, such as SNI, can expect annual savings in the millions of dollars implementing programs designed to identify and treat their SDB drivers.

Our results demonstrating these huge savings are consistent with the few previous studies published in this regard. From Canada, a study published by Kryger, et al (1996) showed that severe sleep apnea patients generated twice as much expenditures from physician claims than a comparable matched group of controls without sleep apnea. In that report, hospital stays were nearly three times greater in the sleep apnea patients compared to matched controls. Bahammam, et al (1999) extended these findings showing a 57% reduction in hospital stays in pre-versus-post sleep apnea treated patients. Interestingly, our findings of a 73% reduction in hospital admissions and an approximate 50% reduction in global health care spending closely match these Canadian studies.

Significant reductions in health care utilization and costs gained from CPAP treatment of SDB highlights the increasingly recognized interplay between this condition and the major health risk concerns encountered in commercial drivers. First and foremost is cardiovascular disease which remains the number one killer in America. It is estimated by the American Heart Association (2004) that 70 million Americans have some form of cardiovascular disease. Hypertension is a major risk factor for heart disease and afflicts 65 million Americans. Both of these conditions, as well as diabetes and obesity, represent major health expenditures for the commercial carrier. Appropriate treatment of SDB has been shown to ameliorate these conditions. Kryger et al (2005) cites data showing an increased insulin level in sleep apnea independent of weight and central obesity. They further state that CPAP improves insulin sensitivity in type 2 diabetes mellitus. Campos-Rodriguez, et al (2005) has found that the trend in excess mortality in SDB patients was attributable to poor compliance with CPAP therapy and the presence of hypertension. Anecdotally, many physicians who treat SDB patients with co-existing hypertension have witnessed significant reductions in their patients' blood pressure with CPAP therapy. These associations between SDB and other medical conditions are continually refined and expanded, offering numerous reasons why CPAP therapy of SDB results in significant health cost savings.

Our study suggests that most drivers treated for SDB with CPAP are compliant and they generally rate their quality of life as improved with therapy. Future studies should explore productivity measures in drivers before and after therapy. Our finding of a 73% reduction in preventable accidents highlights the societal, as well as the financial value of identifying and treating commercial drivers with SDB. According to the 1999 FMCSA study, the average cost per large truck crash involving a fatality in 1999 was $3.54 million, and involving an injury was $217,005. Preventing just a single major accident can avoid millions of dollars in claims and enhances our society's welfare. As Friedman (2005) states in his popular novel, The World is Flat, "The bottom line is that a growing number of companies have come to believe that moral values?can help drive shareholder values?.In sum, we are now in a huge transition as companies are coming to understand not only their power in [the] world but also their responsibilities." Indeed, SDB-treated drivers at SNI are demonstrating high retention rates, perhaps reflecting a heightened level of satisfaction with their employer.

Commercial carriers who embrace the widespread identification and treatment of drivers afflicted with SDB should be commended by society and government for their efforts in reducing the risk for large truck accidents. Programs already underway to identify and treat sleep apnea will save lives and millions of dollars in liability costs. These forward thinking companies are pursuing their programs without a specific federal mandate to do so. In time, these same companies will enjoy reduced employee health care costs. Their drivers will have been screened for possible SDB and treated when indicated. Their drivers will be more alert and healthier. Those same commercial carriers will be rewarded financially through lower health care costs, lower liability premiums, and drivers anxious to work for a company considerate of their well-being.