Wake-Up Call

Employers should pay heed to mounting evidence that sleep apnea is to blame for employee accidents and rising healthcare costs.

Wednesday, August 1, 2012
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Don Osterberg, senior vice president for safety, security and driver training at Schneider National Inc., was puzzled. Nine years ago, he discovered that driver fatigue was the No. 1 factor in high-severity crashes at his trucking company. But what was causing the fatigue?

Osterberg's leadership team collaborated with the company's registered nurse who worked in HR's occupational-health division. Among her key responsibilities was to implement strategies that cut healthcare costs for the self-insured company, based in Green Bay, Wis. She suspected that a percentage of the drivers were afflicted with obstructed sleep apnea, a severe form of sleep apnea, says Osterberg.

"While I had heard those words before, I didn't know exactly what that meant," says Osterberg, referring to sleep apnea. Neither did he realize the profound impact the condition was having on his employees and company's bottom line.

Sleep apnea is a potentially serious sleep disorder that causes a person's breathing to repeatedly stop and start throughout the night. After waking up, the person feels tired, even after a full night's sleep.

Was sleep apnea the real culprit behind these accidents? Did it contribute to Schneider's high healthcare costs? Not fully convinced, Osterberg started researching the topic and was shocked by the findings of one researcher, Allan Pack, professor of medicine and director of the Center for Sleep and Respiratory Neurobiology at the University of Pennsylvania Medical Center in Philadelphia. According to Pack's studies, up to 28 percent of commercial drivers had some type of sleep disorder such as sleep apnea. Pack believes that number is still accurate today.

Many other sleep-apnea studies have since been conducted, all reaching similar conclusions. The disorder has been cited as "an independent risk factor for high blood pressure and cardiovascular disease, and is strongly associated with insulin resistance, diabetes, obesity and mood disorders, such as depression," according to the Washington-based American Sleep Apnea Association.

Not surprisingly, OSA patients are also heavy users of healthcare resources. They incur medication and hospital costs that are two to three times higher than non-OSA patients and total healthcare costs that are more than twice as high, according to studies referenced in the ASAA's booklet, Sleep Apnea: What Employers Should Know.

Because of the disorder's prevalence in the U.S. workforce, the ASAA is sponsoring a solutions conference in October for employers and health plans (, says Ed Grandi, executive director of the ASAA.

Many human resource executives are not aware of the condition's invisible impact on employee productivity, workplace accidents or healthcare costs. While an estimated 5 percent of adults are diagnosed with sleep apnea, another 5 percent may be unaware they have it and up to 15 percent may have mild sleep-disordered breathing, says Anne Wheaton, epidemiologist with the Atlanta-based Centers for Disease Control and Prevention's division of public health. Considering that another risk factor for sleep apnea is obesity and that more than one-third of U.S. adults (36 percent) are obese -- according to CDC figures -- those percentages, she says, may actually be higher.

These numbers reveal a disturbing picture. At least 31 million Americans suffer from sleep apnea. But who are they? They could be the store cashier, the accountant who controls his employer's billion-dollar budget, or the technician who monitors a global network. Sleep apnea crosses all occupational boundaries. Yet, HR and safety professionals within the transportation industry may be the only ones who are doing anything about it.

Although screening for the condition is costly, sometimes as high as seven figures, some employers believe it's an investment that will yield a high return, especially when adding up the collective cost of absenteeism, low productivity and serious workplace errors, accidents or injuries that may be caused by sleep apnea. Based on thousands of accident investigations over the last decade, the National Transportation Safety Board has made 180 employer recommendations for minimizing worker fatigue, some involving sleep apnea.

In many cases, it is up to HR to get the ball rolling. Either independently or in collaboration with the safety department, HR professionals at some transportation companies work with health experts to develop sleep-apnea programs. Such programs typically involve designing employee questionnaires that screen for the condition, coordinating appointments at sleep clinics to diagnose those at-risk, distributing medical devices that help employees manage their condition and monitoring their use of those devices.

Once the program is up and running, HR bows out, turning program management over to safety. (At most transportation companies, HR and safety are completely separate departments.) So far, employers have reported amazing results. The number of accidents has dropped. Healthcare costs have plummeted. And employees never felt better.

Hidden Danger

Since 2004, more than 40,000 truck drivers at Schneider have been screened for OSA in both the United States and Canada, says Osterberg, adding that the company has about 23,000 employees worldwide.

As a condition of employment, he says, each new truck driver completes a questionnaire that was co-developed by the company's occupational nurse and Houston-based Precision Pulmonary Diagnostics.

"Commercial drivers, to some degree, are incented to deceive," he says. "They're very protective of their medical qualifications. So we had to develop a prescreening instrument that had a deception indicator for drivers who were reluctant to acknowledge that they had symptoms associated with obstructive sleep apnea."

For example, when completing the questionnaire, employees may deny they snore or feel tired after a full night's sleep -- both symptoms of sleep apnea. However, they readily admit they have common health problems, such as high blood pressure, heartburn or frequent urination at night, which are also affiliated with sleep apnea. These secondary indicators help predict the likelihood that employees have the sleep disorder.

During the pilot phase, 339 truck drivers volunteered to be prescreened, then another 788 participated in 2006. Those at risk for the disorder were scheduled for a sleep study by HR, which also gathered the results. If diagnosed with OSA, drivers were issued a continuous-positive-airway-pressure (CPAP) device, which involves wearing either a full face or nasal mask while sleeping that injects a continuous stream of air into a person's air passage to prevent it from closing off due to sleep apnea. The company funded both the sleep studies and CPAP machines.

Although all of the initial 339 candidates tested positive for sleep apnea, Osterberg cautions that the prescreening instrument was roughly 90-percent accurate.

"We also looked at their safety performance 12 months prior to [CPAP] treatment and 12 months after treatment," he says, explaining that employers can download reports from CPAP machines to monitor employee compliance. "We saw a 30-percent reduction in crashes and a reduction of 48 percent in the median cost of the crashes that the drivers were involved with post treatment."

Not to mention the dramatic drop in healthcare costs: While 17 percent of the company's employees now receive treatment for OSA, their healthcare costs fell 50 percent, which translates into an estimated savings of $2 million each year, says Osterberg.

"We looked at this three different times," he says, adding that 95 percent of employees with OSA are compliant with their treatment. "We got comparable results each time between 2004 and 2006."

However, there was one benefit no one anticipated. While the company's employee-turnover rate was 60 percent, 60 percent of drivers being treated for OSA stayed on the job. Osterberg believes their loyalty stems from their appreciation of Schneider for caring about their well-being.

Considering all the research conducted on sleep apnea, Osterberg doesn't understand why more employers haven't recognized the problem and adopted a proactive approach.

"I am frankly perplexed that this hasn't gained more momentum than it has because the benefits are so clear," says Osterberg, explaining that the program's annual costs reach into the seven-figure range.

"Almost anything [HR] does will be better than turning a blind eye to it," he adds.

If a company's workforce is comprised of a large number of overweight, middle-aged individuals, especially those in sedentary jobs, HR should consider screening for sleep apnea, says Alison Smiley, president at Human Factors North Inc., a Toronto-based human-factors-engineering-consulting company.

Call-center operators, assembly-line workers, security guards and those operating heavy construction equipment, to name a few, could all be at-risk of suffering from the disorder.

Smiley, who supervised a four-year study from 2005 to 2009 on sleep apnea involving truck drivers in the United States and Canada (see section below), says shift work can exacerbate the condition.

"As soon as you have people with sleep apnea doing shift work, then you've increased the probability of [them] falling asleep while operating machinery or diagnosing patients, which might result in error," she says. "The most important thing to know about sleep apnea is that it's very treatable and that people experience an increase in quality of life -- if they get treated."

According to the National Sleep Foundation's 2012 Sleep in America poll, which surveyed 1,087 people, 10 percent of professionals holding jobs outside the transportation industry reported they had been diagnosed with a sleep disorder. Of those, at least seven in 10 had sleep apnea. Moreover, 12 percent stated they had made serious errors or experienced incidents at work because of sleepiness. Nineteen percent even admitted taking naps during work.

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"I don't want HR professionals to be scared of sleep apnea," adds Grandi of the ASAA. "There are solutions."

International Concern

Tom Kenny first learned about sleep apnea while attending a 2009 transportation safety conference in Alberta, Canada.

During one session, researchers discussed a study that monitored 77 drivers -- between the ages of 24 and 64 -- who were employed at one U.S. and two Canadian motor-carrier companies. Supervised by Human Factors North and commissioned by multiple organizations that included the U.S. Federal Motor Carrier Safety Administration and Transport Canada -- a department in the Canadian government that develops federal regulations, policies and transportation services -- the study revealed startling statistics: 71 percent of survey participants were diagnosed with sleep apnea and 39 percent had moderate-to-severe sleep apnea.

"I was actually in shock," says Kenny, CEO of RTL-Westcan Group of Companies, an Edmonton, Canada- based trucking, construction and transportation company. "I cornered the guys from the FMCSA and Transport Canada in the hallway and said, 'You've got a small, skewed sample and can't make comments like that.' "

Kenny then challenged the officials. If they really believed the survey results, he added, when were they going to introduce legislation that mandated employee screening? Both sides agreed it would never happen because the topic is "too politically charged," he says, adding that it would be a very contentious issue among labor groups.

Kenny set out to prove that the study results were simply wrong. Out of his 1,100 employees, he says, 1,042 who held safety-sensitive positions such as truck drivers, mechanics and construction workers, volunteered to participate in his company's own study, which lasted from August 2009 to March 2012. 

Initially, employees were asked to complete a questionnaire. Based on their responses, they were divided into three groups: red indicated high probability of sleep apnea, yellow meant fair probability and those in the green category had no sleep issues. Employees labeled red were flown to an overnight sleep clinic. Those classified yellow were issued a Watch-PAT to determine if they had sleep apnea. The device, which would be worn on their wrist while sleeping, attaches probes to two fingers that monitors changes in their autonomic nervous system caused by respiratory disturbances.

Kenny says his HR department developed and managed the entire program, which has since been turned over to safety. HR professionals collected the questionnaires, communicated with the sleep clinic, trained the company's technicians to conduct Watch-PAT tests and scheduled employees in different locations for sleep-clinic tests. Likewise, they also spent hours coaching, mentoring, encouraging and coercing existing employees to complete the questionnaire. The handful of drivers who refused to participate were not dispatched and, subsequently, quit.

Considering the results, Kenny tells this story to anybody who will listen. Now a condition of employment for all new hires, he says, the questionnaire revealed that 60 percent of all employees who participated in it were sent to a sleep clinic to be tested for sleep apnea or were asked to wear a watchPAT device. Of those 60 percent, eight drivers were placed on short-term disability because they required further medical action for conditions that included REM-sleep-behavior disorder, a collapsed lung, respiratory failure, heart arrhythmia, extreme hypertension and low baseline oxygen levels.

"Sleep apnea has never been in the forefront," says Kenny. "Now I'm the preacher. I stand in front of my peers at conferences and say, 'You boys better get your head out of the sand because this is an issue in our industry and you better do something about it.' "

Still, he refuses to screen his company's 44 pilots. He says legislation in both the United States and Canada mandates that, when pilots are diagnosed with sleep apnea, their licenses are automatically pulled. Kenny says he could not convince the chief medical examiner at Transport Canada to change course by allowing companies to evaluate, diagnose and treat pilots without suspending their license. His conversations with the U.S. Federal Aviation Administration produced similar results.

"We haven't been able to find any bureaucrat [who] will say, 'I'd rather know you have a problem, that you're doing something [about it] and treating it, which is the common-sense approach,' " Kenny says. "They'd rather ignore it. Wow."

Meanwhile, his company spends hundreds of thousands of dollars each year on sleep studies, CPAP machines and Watch-PAT devices. While he doesn't advocate that all employers go to this extreme, he says they must do something because the problem isn't going to disappear.

"It's morally, absolutely, the right thing to do," Kenny says. "Theoretically, you should have a more productive, happy workforce."

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