Sleep Apnea and Driver Wellness
This webcast will cover ...
• Regulatory and Legal Overview,
• Walmart’s Sleep Apnea Program,
• Screening, Diagnosis and Treatment of
Sleep Apnea, and
• Question & Answer
Moderator
Dr. Gary Petty, President & CEO, National Private
Truck Council
Panelists
Bob Rose, Editor – Transportation Management,
J. J. Keller & Associates, Inc.
Tom Moore, Vice President of Education, National
Private Truck Council
Rick Foster, Senior Director-Fleet Safety,
Walmart Transportation LLC
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Dr. Gary Petty
President & CEO
National Private Truck Council
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Introduction
• Regulatory and Legal Overview – Bob Rose
• Screening, Diagnosis and Treatment of Sleep Apnea –
Tom Moore
• Walmart’s Sleep Apnea Program – Rick Foster
• Housekeeping issues:
Gary Petty
National Private
Truck Council
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Disclaimers
• The content in this webcast is intended for
Gary Petty
information purposes only and should not be
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construed as providing legal or medical advice.
Truck Council
• This is an introductory course and is intended
to highlight critical safety and compliance topics. Time
constraints limit our ability to go in depth.
• We invite you to ask questions. We will answer them
throughout today’s webcast.
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Bob Rose
Editor, Transportation Management
J. J. Keller & Associates, Inc.
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What is Obstructive Sleep
Apnea (OSA)
• “Apnea” is an episode of not breathing
• Causes
 Blocked or narrowed airways in your nose, mouth, or throat
 Large tonsils or adenoids or a large uvula
 Overweight, use of certain medicines or alcohol
before bed, or sleeping on back
• AHI can be used to classify the severity of
disease:
 Mild: 5-15 events per hour of sleep
 Moderate: 15-30 events per hour of sleep
 Severe: greater than 30 events per hour of sleep
• OSA afflicts at least 15 million in the US—over
90% remain undiagnosed; FMCSA study indicated 26% of
drivers have OSA
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Bob Rose
J. J. Keller
FMCSRs Driver Qualifications
• 391.41(b) A person is physically qualified to drive a
commercial motor vehicle if that person—
 (5) Has no established medical history
or clinical diagnosis of a respiratory
dysfunction likely to interfere with
his/her ability to control and drive a
commercial motor vehicle safely
• FMCSA Medical Examination Report
for Commercial Driver Fitness
Determination contains a question:
“Sleep disorders, pauses in breathing
while asleep, daytime sleepiness,
loud snoring”
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Bob Rose
J. J. Keller
FMCSA FAQs -- Medical
• “Drivers should be disqualified until the diagnosis of
sleep apnea has been ruled out or has been treated
Bob Rose
J. J. Keller
successfully. As a condition of continuing
qualification, it is recommended that a CMV driver agree to
continue uninterrupted therapy (e.g., C-PAP), monitoring and
undergo objective testing as required.”
• “A driver with a diagnosis of (probable) sleep apnea or a driver
who has Excessive Daytime Somnolence (EDS) should be
temporarily disqualified until the condition is either ruled out by
objective testing or successfully treated.”
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FMCSA OSA Activity
• 1988, 1991, and 2008 – FMCSA convened Medical
Expert Panels (MEP) to provide recommendations on
Bob Rose
J. J. Keller
revising the Medical Examiner’s Guidelines for OSA
• 2009 – FMCSA’s Medical Review Board essentially adopted the
recommendations of the 2008 MEP and included screening at a
BMI of 30
• June 30 - Medical Review Board held public meeting updating
industry on sleep apnea
• August 29 – FMCSA scheduled to meet with Medical Review
Board and the Motor Carrier Safety Advisory Committee to
discuss options for regulating OSA
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2008 Medical Expert Panel
Recommendations
• OSA at certain levels should be a disqualifying
condition
Bob Rose
J. J. Keller
• Screen at 33 BMI (a BMI of 30 was discussed but that
would cover ~42% of commercial drivers), high risk result on
Berlin Questionnaire, or high risk based on clinical evaluation
• 1-month, 3-month and 1-year conditional medical certifications
depending on severity of OSA and contingent on compliance
with treatment program
• Symptoms: chronic loud snoring, witnessed apneas, daytime
sleepiness
• Risk factors: advancing age, BMI ≥ 28, small jaw, large neck
(≥ 17/15.5), small airway, family history
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2008 Medical Expert Panel
Recommendations (cont.)
• Condition associations: Hypertension, Type 2 Diabetes,
Hypothyroidism
• Preferred diagnosis: Overnight Polysomnography
• Preferred treatment: Positive Airway Pressure (PAP)
 Certify after: 1 week of use, 4 hours per night, 70% of nights
-- MINIMUM STANDARD
• Alternative treatment: Surgery
 Certify after: post-op confirmation of success
• Alternative treatment: Dental Appliance
 Not acceptable due to lack of compliance verification
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Bob Rose
J. J. Keller
Tom Moore, CTP
Vice President of Education
National Private Truck Council
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Health Risks of OSA
• Risks of untreated, sleep apnea:






Tom Moore
High blood pressure (2-3x incidence of Non-OSA)
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Heart failure (30% higher risk versus Non-OSA)
Truck Council
Stroke
Obesity and Diabetes (negatively impacts leptin and grehlin levels)
Mental Health
Other
• Versus people without OSA, those with untreated OSA have
health care costs 2x or $1,336 more and their risk of death is 3x
greater
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Crash Risks of OSA
• Fatigue-induced motor vehicle crashes
occur at a rate of 2 to 7x that of those
without OSA
• Drivers with severe sleep apnea
were 4.6x more likely to be involved
in a severe crash
• 800,000+ drivers were involved in
OSA-related car crashes in 2000,
costing more than $15.9 billion in
damage and claiming 1,400 lives
• CPAP treatment can reduce
collision cost by $11.1 billion per
year
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Tom Moore
National Private
Truck Council
Sleep Apnea-Related Crash
Litigation
• Plaintiffs’ lawyers:
 Know the “disqualifying” nature of sleep apnea and the gray area
of the regulations
 Will tell a jury that a driver with OSA is disqualified and should not
have been driving a CMV and the carrier was negligent in allowing
them to drive
 Will make it sound like the driver was asleep at the wheel
Tom Moore
National Private
Truck Council
• Cases
 DOT Physicals can be a shield
 No - Achey v. Crete Carrier Corp
 Yes - U.S. Xpress, Inc. v. Am. Field Serv. Corp
 “Sudden-medical-emergency” defense can be used if sleep apnea isn’t
diagnosed before accident
 No - Dunlap v. W.L. Logan Trucking Company
 Yes - Slone v. Ibert
 People v. Wilson – untreated OSA risks finding of criminal reckless
homicide
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Financial Impact of Untreated
OSA
• $2,727 reduction in health insurance claims per
Tom Moore
treated driver in first year after treatment
National Private
• $3,086 reduction per driver in second year
Truck Council
• $528 reduction per treated driver in 2 years of short-term
disability claims after treatment
• 6.9 day reduction in lost work days per treated driver over 2 year
period post treatment
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Findings of Key Study on OSA
in Trucking
• Findings
 36% of accidents were fatigue-related (gross under-reporting of
fatigue on police reports)
 28% of drivers have OSA but only 15% diagnosed
 18% of drivers with OSA have a BMI under 30 (screen all drivers)
 82% accuracy in online pre-screen questionnaire
Tom Moore
National Private
Truck Council
• Program
 Pre-screen with online questionnaire, screen all drivers, cover all costs, monitor
treatment compliance real-time for first 30 days and every 90 days thereafter
• Outcomes




12% reduction in preventable accidents
63% reduction in the median cost of crashes
$539 monthly savings per driver in the 12 months after being diagnosed
60% improvement in driver retention
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So What Do You Do?
• FMCSA has not indicated that it will issue a specific
Tom Moore
regulation on sleep apnea, although it is under
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consideration by the agency
Truck Council
• “Standard of Care” means models of managing the
issue have been developed by the industry
• Best approach is to have a company policy that addresses the
screening, diagnosis, treatment and management of sleep apnea
in drivers
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Rick Foster
Senior Director-Fleet Safety
Walmart Transportation LLC
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Walmart Fleet Operations
• Fleet stats:
 6,399 Power Units
 55,000 Trailers
 7,515 CDL Drivers
• Walmart serves customers and
members more than 208 million
times per week at more than
8,600 retail units under 59
different banners in 15
countries. With fiscal year 2010
sales of $405 billion, Walmart
employs more than 2 million
associates worldwide.
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Rick Foster
Walmart
Why is Walmart Establishing an
OSA Policy
• It is the right thing to do for our drivers.
 Improve overall health of drivers
 Improve alertness while driving / improve safety
Rick Foster
Walmart
• Compliance
 Our belief is that we will get more regulation around sleep apnea and
we want to be ahead of the game.
 We have always tried to be in the forefront of compliance issues (i.e.
Hours of Service).
• Better selection of suppliers
 Once the rulemaking begins, companies will scramble to contract
with a supplier and may struggle to get the services they need.
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Policy/Program Considerations
• Who pays? Company? Driver? Shared?
Rick Foster
• Driver wellness program enhancements
Walmart
• Communication and education of policy, expectations,
etc. to drivers and applicants
• What type of monitoring program will we have?
• Do we use a national health care provider to ensure consistency
in our program?
• Does our truck equipment spec have the means to support
needed medical equipment?
• Will program require more frequent physicals…with added
costs?
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Funding Considerations
• Current program
 Driver covers screening, diagnosis and treatment through
company medical plan which includes deductible and co-pay.
Rick Foster
Walmart
• Future plan
 Our benefits group is considering a program outside our company
funded benefits plan that will pay 100% of cost of the program for
DOT drivers.
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Driver Communication Plan
• Roll Out / Communication Plan
Rick Foster
 Select pilot location
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 Communicate the program to drivers through depart group
meetings, recorded messages delivered over the OBC to each driver,
and written communication to each driver
 Invite sleep center personnel to driver meetings to answer technical
questions and explain the process
 Make the process as convenient as possible for the driver
 Remove fear of the process
 Explain the benefit coverage
 Reduce downtime
 Reassure driver of continued certification
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Screening for OSA
• Currently relying on DOT examiner to evaluate and
recommend screening
• Future program will utilize the following:
 Utilize questionnaire (Berlin or equivalent) to determine
immediate testing needs
 Provide ambulatory testing that can be done at driver’s
home or in cab
 Follow up with full PSG, if indicated, to determine
appropriate treatment protocol
 Central apneas
 Borderline cases
• Goal is to get driver back in the truck as soon as
possible
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Rick Foster
Walmart
Diagnosing OSA
• Screening will identify drivers that should have further
testing.
• Utilize ambulatory test equipment that allows the
driver to be tested at home or in cab
• Perform full Polysomnogram if indicated by initial
testing
• Remove time constraints
 Screen and perform ambulatory test same or next day
 Send test results to sleep specialist and receive diagnosis
and treatment protocol the same day the results are
downloaded
 Provide treatment equipment and training that day
 Return driver to work with electronic monitoring
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Rick Foster
Walmart
Diagnosing OSA
• Polysomnogram (aka sleep study)




Brain activity
Eye movement and other muscle activity
Breathing, heart rate, and blood pressure
How much air moves in and out of your
lungs while you're sleeping
 The amount of oxygen in your blood
• Two methods:
 Sleep Centers
 In-home equipment
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Rick Foster
Walmart
Treating OSA
• Select a provider
 Select a provider who is willing to customize a program
that meets your operational needs and offers sufficient
coverage to serve all your driver domicile locations
Rick Foster
Walmart
• Treatment Program
 Full service - provider supplies screening, testing, equipment and
monitoring of compliance
 Local provider network - sometimes an option based on insurance
requirements
• Equipment: CPAP, APAP or Bi-PAP
 Utilize auto-set device with 12 volt operating system
 Adjusts to patient’s needs automatically
 Easy implementation in sleeper berth operations
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Walmart OSA Results
• Number of drivers currently treated
 Approximately 10-11% of our driver group based on a
physical survey early last year
 We have had our DOT medical examiners evaluating
drivers at recertification for 3 years.
• Expected number when program has been fully
implemented
 We expect to be between 30 and 40% when fully
implemented due to our job requirements. We are mostly
drop and hook and drivers normally do not load or unload
freight.
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Rick Foster
Walmart
Question & Answer
Gary Petty
National Private
Truck Council
Bob Rose
J. J. Keller
Tom Moore
National Private
Truck Council
Please submit questions to “Q&A”
using the Q&A tool
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Rick Foster
Walmart
Closing Remarks
• Checkout the archive of past topics at:
http://www.jjkeller.com/nptcinfo
 PowerPoint slides up in 1-2 days
 Recording up in 1 week
• Topics for 2011:
 October 12 – Driver Discipline and Coaching
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Gary Petty
National Private
Truck Council