1. September 11, 2012 Mike Hummel Watermark Medical Obstructive Sleep Apnea (OSA) Impacting Workplace Safety and Cost

2. “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.

3. 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

4. 4 Obstructive Sleep Apnea Pathophysiology AwakeAsleep

5. 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

6. Obesity Trend No Data<10%10%-14%15%-19%≥30%25%-29%20%-24% 199020002010

7. Obstructive Sleep Apnea is: Common Dangerous Diagnosable Treatable Over the past 35 years we have learned

8. Prevalence of Sleep-Disordered Breathing Among Working-Age Adults SBDMenWomen Habitual Snorers44%28% AHI > 524%9% AHI > 1015%5% AHI > 159%4% Young, et. al. NEJM 1993; 328: 1230-5 Government Employees in Wisconsin

9. Prevalence of Sleep-Disordered Breathing Among Working-Age Adults “ approximately 10% of all habitual snorers will have an AHI of 20 or more” Young, et. al. NEJM 1993; 328: 1230-5 Young, et. al. Am J Respir Crit Care Med 2002; 165: 1217-39 “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”

10. Obstructive Sleep Apnea Consequences for the Worker

11. 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 )

12. 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

13. 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

14. 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.

15. Car Accidents and Sleep Disorders  Powell NB et al. Otolaryngol Head Neck Surg. 2002; 126:217-227

16. Avoid this guy on the road!

17. Obstructive Sleep Apnea FMCSA / DOT Recommendations

18.  Screening  The driver has a Body Mass Index (BMI) of greater than or equal to 35 kg/m 2  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. General Recommendations Regarding OSA MCSAC-MRB Joint Recommendations

19. 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!

20. Diagnosis of OSA In-lab Polysomnography and Home Sleep Testing

21. OSA Clinic Evaluation  History and Physical  Screening Questionnaires  Epworth Sleepiness Scale  Berlin Questionnaire  ARES Questionnaire  STOP Bang  Assess risk  Move on to testing

22. 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

23. Cost Analysis: Lab PSG versus Focused Home SDB Testing* 2008 allowed/memberPSG 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.

24. Obstructive Sleep Apnea ARES Home Sleep Study with the Chain of Custody

25. OSA Treatment

26. 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

27. 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!)

28. What Now?

29. 29 ensuring a successful outcome and a positive experience ScreenTreatDiagnoseTest Sleep Coach