Obstructive Sleep Apnea (OSA)
Impacting Workplace Safety and Cost
September 11, 2012
Mike Hummel
Watermark Medical
“Adequate sleep,
like adequate nutrition and
adequate exercise, is required
for good health”
So if you fall asleep while I am
talking, you may be better off than
if you listened.
Obstructive Sleep Apnea (OSA): What is
it and why is it important?
OSA – inadequate breathing during sleep due
to sleep-induced collapse of the upper airway
Prevalence is High and Growing
20-40 million in U.S.
> 90% undiagnosed
Most of those with OSA are in the workforce
Obstructive Sleep Apnea
Pathophysiology
Awake
Asleep
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OSA: Consequences in the Workplace
Work performance:
 Impaired alertness & memory, inability to
concentrate
 Impaired judgment & poor decision making
 Decreased motivation & productivity
 Increased absenteeism
 Increased risk of accidents
 Difficult interactions with co-workers
Obesity Trend
1990
No Data
2000
<10%
10%-14%
15%-19%
2010
20%-24%
25%-29%
≥30%
Over the past 35 years we have learned
Obstructive Sleep Apnea is:
•
•
•
•
Common
Dangerous
Diagnosable
Treatable
Prevalence of Sleep-Disordered Breathing
Among Working-Age Adults
Government Employees in Wisconsin
SBD
Men
Women
Habitual Snorers
AHI > 5
AHI > 10
AHI > 15
44%
24%
15%
9%
28%
9%
5%
4%
•Young, et. al. NEJM 1993; 328: 1230-5
Prevalence of Sleep-Disordered Breathing
Among Working-Age Adults
“approximately 10% of all habitual snorers will
have an AHI of 20 or more”
“we estimate that roughly 1 of every
5 adults has as least mild OSA and
that 1 of every 15 has at least
moderate OSA”
•Young, et. al. NEJM 1993; 328: 1230-5
•Young, et. al. Am J Respir Crit Care Med 2002; 165: 1217-39
Obstructive Sleep Apnea
Consequences for the
Worker
OSA: Consequences for the worker
 Drowsiness and memory loss
 3-5 times increased risk for
accidents
 Greatly reduced productivity
 Increased risk of fatal disease
(Myocardial infarction, CHF, CVA)
OSA: Health Consequences for the worker
 1.3 to 2.5 times more hypertension
 2.2 times increased risk of nocturnal
cardiac arrhythmia
 3.9 times more likely to have congestive
heart failure
 1.6 times increased chance of stroke
 1.4 to 2.3 times greater risk of myocardial
infarction
 40% increased risk of depression
 Increased risk of diabetes
OSA: Costs for all
 More than two times the number of physician
claims
 1.9 times more cardiac medication
 2.7 times more hypertension medication
 50% more hospital stays
 2.63 times the amount of absenteeism
 20% reduction in performance
 Estimated additional healthcare costs for
untreated OSA patients is $2000 per patient per
year
Sleep Disorders in Commercial Drivers
 Stanford U. & U. of Penn.studies- 5-10% of commercial
drivers have untreated severe OSA*
 Driving performance in sleep-deprived people & OSA
patients is similar to a blood alcohol content of .06 - .08
 9 out of 10 police officers have stopped a driver who
they believed was drunk, but was drowsy
Stoohs, R.A., et al., Chest, 1995. 107(5).; Pack, A.I., et al., 2002, FMCSA: Washington D.C.
% Reporting sleep disorder
Car Accidents and Sleep Disorders
30.00%
25.00%
20.00%
Sleep apnea
Insomnia
15.00%
10.00%
5.00%
0.00%
0 (n=8337)
Sleep apnea
Insomnia
7.10%
16.70%
1 or 2
(n=2297)
> 3 (n=130)
6.70%
19.20%
18%
26.10%
Number of accidents
Powell NB et al. Otolaryngol Head Neck Surg. 2002; 126:217-227
Avoid this guy on the road!
Obstructive Sleep Apnea
FMCSA / DOT
Recommendations
General Recommendations Regarding OSA
MCSAC-MRB Joint Recommendations
 Screening
 The driver has a Body Mass Index (BMI) of greater than
or equal to 35 kg/m2
 Diagnosis
 Methods of diagnosis include in-laboratory
polysomnography, at-home polysomnography, or an
FDA-approved limited channel ambulatory testing device
which ensures chain of custody.
 Treatment
 PAP is the preferred OSA therapy New OSA screening
technologies will likely emerge.
OSA Consequences
Remember…
•Almost all workers drive
•Accidents involve innocents
•It is a disease that can kill you even if
you don’t have it!
Diagnosis of OSA
In-lab Polysomnography and
Home Sleep Testing
OSA Clinic Evaluation
 History and Physical
 Screening Questionnaires
 Epworth Sleepiness Scale
 Berlin Questionnaire
 ARES Questionnaire
 STOP Bang
 Assess risk
 Move on to testing
Current Diagnostic Procedures
“PSG is utilized as a reference standard in
many clinical trials; however, we do not
believe it is a true gold standard”
CMS, March 2008
Cost Analysis: Lab PSG versus Focused
Home SDB Testing*
2008 allowed/member
PSG
CPAP Titration
Slit-Night
2 night home test
Assume 6% require attended
in-lab CPAP titration
Diagnostic Test Cost
$1033.16
$303.30
+$42.66 ($711.16 for CPAP
titration x .06)
Total Cost
$1033.16
$345.96
*Cost estimates from a VERY large insurance company.
They will routinely authorize only home testing because its cost is
only 1/3 of the cost of a laboratory PSG.
Obstructive Sleep Apnea
ARES Home Sleep Study
with the Chain of Custody
OSA Treatment
What are the Therapeutic Goals?
 Resolution of the clinical signs and
symptoms of OSA
 Prevention of the cardiovascular and
neurological consequences of OSA
Ensuring Fitness for Work
OSA Treatment Options
Multiple Proven Treatments:
 Continuous Positive Airway Pressure
(CPAP)
 Oral appliances (fitted by dentist)
 Provent (Nasal adhesive device)
 Positional therapy
 Surgery (many different procedures)
 Weight Loss (good luck!)
What Now?
ensuring a successful outcome and a positive experience
Screen
Test
Diagnose
Treat
Sleep Coach
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