A CMV driver questions the guidelines on apnea testing for long-distance truckers.

Are individuals with obstructive sleep apnea (OSA) at more risk of crash than are comparable individuals who do not have the disorder?

Studies on the general driving population are in agreement on this point. When you narrow the search to studies done on commercial motor vehicle (CMV) operators, you get a much different result. The Medical Expert Panel (MEP) convened by the Federal Motor Carrier Safety Administration (FMCSA) Medical Review Board (MRB) found only one of two studies showed CMV operators with a higher risk of crash.1 A major issue in the trucking community is that the FMCSA Sleep Apnea Crash Risk Study,2 which found “no statistical evidence in the data to suggest that drivers with sleep apnea are more likely than drivers without sleep apnea to have a commercial vehicle crash,” is not even listed or discussed in the MRB literature review.

Crashes reported to police are used as the metric to measure motor carrier safety performance in justifying the OSA testing guidelines, but transportation safety literature indicates that 65% to 80% of crashes between CMV and passenger vehicles were the fault of the passenger vehicle.

BMI Triggers Mandatory PSG

The OSA screening guidelines adopted by the FMCSA MRB mandate that all CMV operators with a body mass index (BMI) >30 undergo a PSG.

There was not consensus among the MRB on the 30 cut point for testing. The cut point was suggested by Barbara Phillips, MD, and adopted over the objections of one MRB member.3 The MEP recommendation was for a cut point of 33. The cut point of 30 is also not in agreement with the screening guidelines in the Joint Task Force (JTF) report.4 The winter 2009 issue of Wake Up Call 5 has a more in-depth discussion of this topic.

There are approximately 3.5 million CMV operators. The OSA screening program at Schneider National Carriers6 found 46% had a BMI >30, but the sleep screening program also found 15% of drivers screened for OSA, given PSG, and found positive for OSA had a BMI <30. Using BMI alone will miss large numbers of CMV operators who have OSA and should get treatment. Since the Wake Up Call article, a new study by Parks et al6 validates the accuracy and specificity of the JTF screening procedures.

The question is why a nonspecific and inaccurate screening guideline (BMI), which appears to lack a consensus on cut point, has been adopted when an apparent consensus report (JTF) is available with much different screening recommendations.

Rates of Driver Fatigue

The Large Vehicle Crash Causation Study (LVCCS)7 is often cited in OSA literature to justify CMV-OSA testing. Many transportation industry experts have discounted the study as highly flawed. The LVCCS found fatigue was an associated causal factor for the large vehicle operator in only 7.5% of the accidents—at the bottom of the top 10 factors. Why call for OSA testing for just CMV operators? The literature supports a causal link between OSA and crash involvement for the general driving public, and the general driving public is two times as likely to be driving fatigued. Mandatory OSA testing of passenger vehicle drivers—not CMV operators—is better supported by the literature.

Educate and Persuade Drivers

One of the interesting outcomes of the Parks study was a finding of virtually 0% CPAP compliance among CMV operators who were given no support in obtaining the required PSG or CPAP treatment. Compare this to a 91% CPAP compliance rate in the Schneider National program, which has pretesting education, driver manager involvement, a driver-to-driver peer counseling network, and all costs for OSA testing and treatment covered by health insurance. The Schneider program is self-funding through reductions in health care costs for the comorbidities associated with untreated OSA. Unfortunately, this type of program is not practical for the entire trucking industry, which is dominated by small motor carriers with 20 or fewer trucks.

Remove Barriers for Drivers

Commercial motor vehicle operators do not seek OSA testing as there is hiring discrimination against drivers with OSA. While this is a violation of the Americans with Disabilities Act (ADA), there is little enforcement. One method of discrimination is for trucking companies to require maintaining a 2-year DOT medical certification. Current MRB guidelines for OSA require issuing a 1-year certification with annual review of CPAP compliance and effectiveness of treatment. The Equal Opportunity Employment Commission investigates ADA complaints, and having the commission take a more public stance in vigorous enforcement is needed.

Truck drivers are part of the “working poor” who often cannot afford medical insurance. Forty percent of truck drivers work for firms with fewer than five trucks. Many of these are one-truck owner operators; 25% of these have no medical insurance coverage.8 Of the truck drivers who do have medical insurance, it is often “limited benefit” coverage.

Call for a Review of the MRB Guidelines

The process used by the MRB in developing the OSA guidelines did not allow for review of the proposal or the supporting literature, or allow for discussion of alternatives. FMCSA often uses what they call “listening sessions” to get stakeholders on an issue together to review a regulatory topic. OSA testing and treatment guidelines might be one topic to consider reviewing after holding such a listening session.

Bob Stanton is a truck driver who was diagnosed with OSA in 2002. He operates a CMV in interstate commerce, delivering freight throughout the contiguous United States.

The opinions in this article are the author’s and do not represent positions of any specific trucking industry group, his employer, or this publication.

References

  1. Ellen RLB, Marshall SC, Palayew M, et al. Systematic review of motor vehicle crash risk in persons with sleep apnea. J Clinl Sleep Med 2006;2:193-200.
  2. Ancoli-Israel S, Czeisler CA, George CFP, Guilleminault C, Pack AI. Obstructive Sleep Apnea and Commercial Motor Vehicle Driver Safety. Expert Panel Recommendations. Presented to Federal Motor Carrier Safety Administration January 14, 2008. Available at: www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdf. Accessed September 23, 2009.
  3. US Department of Transportation. Sleep Apnea Crash Risk Study. Publication No. FMCSA-RT-04-007. September 2004. Available at: www.fmcsa.dot.gov/facts-research/briefs/SleepApneaCrash-RiskStudy-TechBrief.htm. Accessed September 23, 2009.
  4. Meeting Minutes, FMCSA Medical Review Board Meeting. January 28, 2008. Available at: [removed]www.mrb.fmcsa.dot.gov/012808_meeting.htm[/removed].
  5. Hartenbaum N, Collop N, Rosen JM. Sleep apnea and commercial motor vehicle operators: statement from the joint Task Force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine, and the National Sleep Foundation, J Occupa Environ Med. 2006; 48(suppl 9): S4-37..
  6. Wake Up Call. Winter 2009. Available at: [removed]www.sleepapnea.org/support/newsletter.html[/removed]. Accessed September 23, 2009.
  7. Parks P, Durand G, Tsismenakis AJ, Vela-Bueano A, Kales S. Screening for obstructive sleep apnea during commercial driver medical cxaminations. J Occupa Environmen Med. 2009;51:275-82.
  8. Report to Congress on the Large Truck Crash Causation Study MC-R/MC-RRA March 2006, Available at: www.fmcsa.dot.gov/facts-research/research-technology/report/ltccs-2006.htm. Accessed September 23, 2009.
  9. Executive Summary. 2007 Independent Driver Survey.Owner Operator Independent Driver’s Association. Available at: [removed]www.ooida.com/OOIDA Foundation/Recent_Research/recent_research.html[/removed]. Accessed September 23, 2009