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Rogers CR, May FP, Petersen E, Brooks E, Lopez JA, Kennedy CD, Thiese MS. Factors Associated with Colorectal Cancer Prevalence Among Long-Haul Truck Drivers in the United States. Am J Health Promot 2022; 36:1142-1151. [PMID: 35410488 DOI: 10.1177/08901171221090500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To determine the age-adjusted association between colorectal cancer (CRC) risk factors and CRC prevalence among long-haul truck drivers (aged 21-85), after adjustment for age. DESIGN Pooled cross-sectional analysis using Commercial Driver Medical Exam (CDME) data. Setting. National survey data from January 1, 2005, to October 31, 2012. PARTICIPANTS 47,786 commercial motor vehicle drivers in 48 states. MEASURES CRC prevalence was the primary outcome; independent variables included demographics, body mass index (BMI), and concomitant medical conditions. ANALYSIS Kruskal-Wallis tests to analyze continuous variables; Fischer's exact tests to analyze categorical variables; univariate and multivariable logistic regression for rare events (Firth method) to quantify the association between the independent variables of interest and CRC prevalence. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for age, gender, years with current employer, year of exam, and BMI in a multivariate logistic regression. RESULTS Many factors were statistically significant. Obesity (OR = 3.14; 95% CI = 1.03-9.61) and increasing age (OR = 1.10 per year; 95% CI = 1.07-1.13) were significantly associated with CRC prevalence. Truckers with 4 or more concomitant medical conditions were significantly more likely to have CRC (OR = 7.03; 95% CI = 1.83-27.03). CONCLUSIONS Our findings highlight mutable risk factors and represent an opportunity for intervention that may decrease CRC morbidity and mortality among truck drivers, a unique population in the United States estimated to live up to 16 years less than the general population.
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Affiliation(s)
- Charles R Rogers
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Folasade P May
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ethan Petersen
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ellen Brooks
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jasmine A Lopez
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Carson D Kennedy
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Matthew S Thiese
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Sinclair DC, Hegmann KT, Holland JP. Acceptable Risk of Sudden Incapacitation Among Safety Critical Transportation Workers: A Comprehensive Synthesis. J Occup Environ Med 2021; 63:329-342. [PMID: 33769399 DOI: 10.1097/jom.0000000000002140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Identify a risk threshold for sudden incapacitation for safety critical positions in transportation industries supporting medical fitness for duty standards. METHODS Systematic literature searches were performed examining acceptable risk criteria for medically related incapacitation using PubMed Central and Google Scholar databases. Websites for professional societies and national and international governmental agencies were also accessed. Article abstracts were reviewed and exhaustive searches were performed. RESULTS International regulatory bodies have adopted definitions of acceptable risk typically with a threshold of 1% to 2% absolute risk of sudden incapacitation per annum. Several "risk-of-harm" models have been proposed that incorporate factors modulating an absolute risk constant derived from epidemiological studies. CONCLUSION A 1% absolute annual risk of sudden incapacitation should be adopted as the threshold for determining medical fitness for duty among employees in safety critical positions in transportation industries.
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Affiliation(s)
- Donald C Sinclair
- Steptoe & Johnson PLLC, 1233 Main St., Ste. 3000, Wheeling, West Virginia (Mr Sinclair); Director Rocky Mountain Center for Occupational and Environmental Health, University of Utah, Salt Lake City, Utah (Dr Hegmann); Puyallup, Washington (Dr Holland)
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Thiese MS, Moffitt G, Hanowski RJ, Kales SN, Porter RJ, Hartenbaum N, Hegmann KT. What Medical Conditions Limit or Medically Disqualify Truck Drivers: A Large Cross Sectional Study. J Occup Environ Med 2021; 63:139-146. [PMID: 33523617 DOI: 10.1097/jom.0000000000002101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Commercial Motor Vehicle drivers must be medically certified to obtain/maintain a commercial driver license. 88,246 exams from 2005 to 2012 were analyzed for relationships between health and certification length. Relationships were quantified using adjusted odds ratios (ORs). Most conditions and/or examination findings had statically significantly limited medical certification. Obesity > 35 kg/m2, hypertension and diabetes mellitus requiring medication were most common. Significant and meaningful relationships were found for opioid or benzodiazepine use (OR = 7.30), heart disease (OR = 5.19), musculoskeletal conditions (OR = 5.13), seizures (10.18), stroke (OR = 6.73), neurological (OR = 18.51) and vascular (OR = 11.83). Drivers with 2 or more of 13 medical conditions were statistically significantly more likely to have limited medical certification (OR = 122.35) or disqualification (OR = 4.91). Drivers with any condition are more likely to have limited medical certification. There is variability in medical certification lengths related to medical conditions and differences between examiners.
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Affiliation(s)
- Matthew S Thiese
- Rocky Mountain Center for Occupational & Environment Health, Department of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City, Utah (Dr Thiese, Dr Hegmann); Arkansas Occupational Health Clinic, Springdale, Arkansas (Dr Moffitt); Center for Truck and Bus Safety, Virginia Tech Transportation Institute, Blacksburg, Virginia (Dr Hanowski); Department of Environmental Health, Harvard Chan School of Public Health, Boston, Massachusetts (Dr Kales); Occupational Medicine, Cambridge Health Alliance, Cambridge, Massachusetts (Dr Kales, Dr Porter); VHB - Vanasse Hangen Brustlin, Raleigh, North Carolina (Dr Kales, Dr Porter); Occumedix, Inc., Dresher, Pennsylvania (Dr Hartenbaum)
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The Pre-Registry Commercial Driver Medical Examination: Screening Sensitivity and Certification Lengths for Two Safety-Related Medical Conditions. J Occup Environ Med 2020; 62:237-245. [PMID: 31977920 DOI: 10.1097/jom.0000000000001816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Use independent diagnostic data to analyze the screening effectiveness of the pre-Registry commercial driver medical examination (CDME) for obstructive sleep apnea (OSA), and its sensitivity for hypertension; analyze certification lengths where relevant. METHODS CDME screening results for 1668 drivers were compared to polysomnogram diagnostic test results, and CDME screening results were evaluated for 1155 drivers with at least one insurance claim with a hypertension diagnostic code. Any CDME documentation of the medical condition was considered as detection by screening. RESULTS CDME sensitivity was 20.7% for moderate OSA (AHI ≥ 15). While sensitivity was 77.5% for hypertension, 93.3% of drivers with Stage 3 hypertension were certified, contrary to Federal Motor Carrier Safety Administration standards. CONCLUSIONS The pre-Registry CDME was ineffective in screening commercial drivers for OSA. Screening was better for hypertension; incorrect certifications were given to many hypertensive drivers.
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Sleep and Mental Health in Truck Drivers: Descriptive Review of the Current Evidence and Proposal of Strategies for Primary Prevention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091852. [PMID: 30150599 PMCID: PMC6164547 DOI: 10.3390/ijerph15091852] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 11/21/2022]
Abstract
Background: Professional truck drivers (TDs) are exposed to stressful working (and living) conditions and are vulnerable. They report physical and mental health problems and psychological distress more frequently than the general population and their problems can affect safety on the roads. Actions to improve TDs’ health and reduce the risks of (co-)morbidity or unsafe driving are imperative. Methods: The published studies dealing with the TDs’ sleep habits and mental health were reviewed to define the scenario and organize the preventive strategies proposed thus far. Results: Awareness among TDs of the high risk for health and safety due to (often co-existing) untreated sleep and mental health problems is critical. Alcohol and prescribed or illicit drugs are often misused to compensate for depression, anxiety, job strain, fatigue, and social isolation. Polypharmacy and dependence increase the chance of unsafe behaviors on the road. The TDs’ access to healthcare services is scant, and participation in industry-sponsored wellness programs is limited. Conclusions: Primary prevention is a first unavoidable step to deal with sleep and mental health problems. Educational programs, online support and tele-health assessment/monitoring would help improve the well-being, safety and health of professional TDs and increase safety on the road.
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Multiple Conditions Increase Preventable Crash Risks Among Truck Drivers in a Cohort Study. J Occup Environ Med 2018; 59:205-211. [PMID: 28079676 DOI: 10.1097/jom.0000000000000937] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aims to quantify the crash risk for truck drivers with multiple comorbid medical conditions, after adjusting for confounders. METHODS This retrospective cohort of 38,184 drivers evaluated concomitant medical conditions and subsequent crash data between January 1, 2005, and October 31, 2012. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated for any cause and preventable crashes of varying severity. RESULTS Drivers with three or more medical conditions had a significantly increased risk of preventable Department of Transportation (DOT) reportable crashes (HR = 2.53, 95% CI = 1.65 to 3.88) and preventable crashes with injuries (HR = 2.23, 95% CI = 1.09 to 5.31) after adjustment for covariates. Similarly, adjusted HRs were 2.55 (95% CI = 1.37 to 4.73) for any cause DOT-reportable crashes and 3.21 (95% CI = 1.18 to 8.75) for any cause crashes with injuries. CONCLUSIONS Having three concomitant medical conditions may be a statistically significant risk factor for preventable and any cause DOT-reportable crashes and crashes with injuries.
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Thiese MS, Hanowski RJ, Moffitt G, Kales SN, Porter RJ, Ronna B, Hartenbaum N, Hegmann KT. A retrospective analysis of cardiometabolic health in a large cohort of truck drivers compared to the American working population. Am J Ind Med 2018; 61:103-110. [PMID: 29114913 DOI: 10.1002/ajim.22795] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Truck drivers face many health challenges, including lifestyle, diet, inactivity, stressors, and social support. METHODS A repeated cross-sectional analysis compared 88,246 truck drivers with data from (n = 11 918) the National Health and Nutrition Examination Survey (NHANES). Trends over time for body mass index (BMI), high blood pressure, diabetes mellitus, heart disease, and sleep disorders were analyzed, adjusting for potential confounders. RESULTS Truck drivers had significantly worsening health metrics between 2005 and 2012 compared to NHANES participants. Truck drivers were significantly more likely to be obese and morbidly obese with prevalence odds ratios (POR) and 95% confidence intervals (95%CI) of 1.99 (1.87, 2.13) and 2.34 (2.16, 2.54), respectively. Measured blood pressure, self-reported high blood pressure, diabetes mellitus, and heart disease all significantly increased. Also, sleep disorders increased among truck drivers from 2005 to 2012 (POR = 6.55, 95%CI 5.68, 7.55). CONCLUSION These data suggest disproportionate increases in poor health among truck drivers from 2005 to 2012.
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Affiliation(s)
- Matthew S. Thiese
- Department of Family and Preventive Medicine, Rocky Mountain Center for Occupational and Environment Health, School of Medicine; University of Utah; Salt Lake City Utah
| | - Richard J. Hanowski
- Center for Truck and Bus Safety; Virginia Tech Transportation Institute; Blacksburg Virginia
| | - Gary Moffitt
- Arkansas Occupational Health Clinic; Springdale Arkansas
| | - Stefanos N. Kales
- Department of Environmental Health; School of Public Health; Harvard University; Cambridge Massachusetts
| | - Richard. J. Porter
- Department of Civil and Environmental Engineering, Utah Traffic Lab; University of Utah; Salt Lake City Utah
| | - Brenden Ronna
- Department of Family and Preventive Medicine, Rocky Mountain Center for Occupational and Environment Health, School of Medicine; University of Utah; Salt Lake City Utah
| | | | - Kurt T. Hegmann
- Department of Family and Preventive Medicine, Rocky Mountain Center for Occupational and Environment Health, School of Medicine; University of Utah; Salt Lake City Utah
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Abstract
Narcolepsy is a chronic sleep disorder that has a typical onset in adolescence and is characterized by excessive daytime sleepiness, which can have severe consequences for the patient. Problems faced by patients with narcolepsy include social stigma associated with this disease, difficulties in obtaining an education and keeping a job, a reduced quality of life and socioeconomic consequences. Two subtypes of narcolepsy have been described (narcolepsy type 1 and narcolepsy type 2), both of which have similar clinical profiles, except for the presence of cataplexy, which occurs only in patients with narcolepsy type 1. The pathogenesis of narcolepsy type 1 is hypothesized to be the autoimmune destruction of the hypocretin-producing neurons in the hypothalamus; this hypothesis is supported by immune-related genetic and environmental factors associated with the disease. However, direct evidence in support of the autoimmune hypothesis is currently unavailable. Diagnosis of narcolepsy encompasses clinical, electrophysiological and biological evaluations, but simpler and faster procedures are needed. Several medications are available for the symptomatic treatment of narcolepsy, all of which have quite good efficacy and safety profiles. However, to date, no treatment hinders or slows disease development. Improved diagnostic tools and increased understanding of the pathogenesis of narcolepsy type 1 are needed and might lead to therapeutic or even preventative interventions.
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Affiliation(s)
- Birgitte R Kornum
- Molecular Sleep Laboratory, Department of Clinical Biochemistry, Rigshospitalet, Forskerparken, Nordre Ringvej 69, 2600 Glostrup, Denmark.,Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Stine Knudsen
- Norwegian Centre of Expertise for Neurodevelopmental Disorders and Hypersomnias, Oslo University Hospital, Oslo, Norway
| | - Hanna M Ollila
- Department of Psychiatry and Behavioral Sciences, Center for Sleep Sciences, Stanford University, Stanford, California, USA
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | - Poul J Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Yves Dauvilliers
- Sleep Unit, Narcolepsy Reference Center, Department of Neurology, Gui de Chauliac Hospital, INSERM 1061, Montpellier, France
| | - Sebastiaan Overeem
- Sleep Medicine Center Kempenhaeghe, Heeze, The Netherlands.,Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
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Bhatti JA, Nathens AB, Redelmeier DA. Driver's obesity and road crash risks in the United States. TRAFFIC INJURY PREVENTION 2016; 17:604-609. [PMID: 26890412 DOI: 10.1080/15389588.2015.1134793] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/17/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE We assessed obesity trends in U.S. drivers involved in fatal crashes since 1999 and distinguished whether crash risk factors were different between obese and nonobese drivers. METHODS We included only drivers of passenger cars involved in fatal traffic crashes between January 1, 1999, and December 31, 2012. Obesity was classified according to the World Health Organization guidelines and profiled between 1999 and 2012 using the adjusted prevalence ratio (aPR) from log-binomial regression models. Differences in crash risks (e.g., driver's fatality, drunk driving, seat belt nonuse) between obese and nonobese drivers were estimated as adjusted odds ratios (aORs) using logistic regression models. RESULTS A total of 753,024 U.S. drivers were involved in fatal crashes, for which obesity information was available for 534,887. About 56% (n = 299,078) were driving passenger cars. The prevalence of class I obesity increased from 10% in 1999 to 14% in 2012 (aPR = 1.50, 95% confidence interval [CI], 1.42-1.58), class II obesity from 3 to 5% (aPR = 2.22, 95% CI, 2.05-3.01), and class III obesity from 1 to 2% (aPR = 2.65; 95% CI, 2.27-3.10). Compared to nonobese controls, obese drivers had significantly higher risks for fatality (1.10 ≤ aOR ≤ 1.47), seat belt nonuse (1.00 ≤ aOR ≤ 1.21), need for extrication (1.01 ≤ aOR ≤ 1.23), and ambulance transport time ≥30 min (1.01 ≤ aOR ≤ 1.28). Compared to nonobese controls, obese drivers were less likely to drink drive (0.41 ≤ aOR ≤ 0.72) or speed >65 mph (0.78 ≤ aOR ≤ 0.93). CONCLUSION The rising national prevalence of obesity extends to U.S. drivers involved in fatal crashes and indicates the need to improve seat belt use, vehicle design, and postcrash care for this vulnerable population.
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Affiliation(s)
- Junaid A Bhatti
- a Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute , Toronto , Ontario , Canada
- b University of Toronto , Department of Surgery , Toronto , Ontario , Canada
- c Institute for Clinical Evaluative Sciences , Toronto , Ontario , Canada
| | - Avery B Nathens
- a Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute , Toronto , Ontario , Canada
- b University of Toronto , Department of Surgery , Toronto , Ontario , Canada
- c Institute for Clinical Evaluative Sciences , Toronto , Ontario , Canada
- d Department of Surgery , Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Donald A Redelmeier
- a Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute , Toronto , Ontario , Canada
- b University of Toronto , Department of Surgery , Toronto , Ontario , Canada
- c Institute for Clinical Evaluative Sciences , Toronto , Ontario , Canada
- e Department of Medicine , Sunnybrook Health Sciences Centre , Toronto , Ontario , Canada
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Abstract
OBJECTIVE To assess relationships and trends over time in individual conditions and multiple conditions among a large sample of independent, nonoverlapping truck drivers using a repeated cross-sectional study design. METHODS Commercial driver medical examinations were conducted on 95,567 commercial drivers between January 1, 2005, and October 31, 2012. Specific medical conditions that have been identified by the Federal Motor Carrier Safety Administration's Medical Review Board as possibly increasing crash risk were examined. Prevalence and trends over time were analyzed. RESULTS A total of 8 of the 13 conditions significantly increased from 2005 to 2012. Prevalence of multiple concomitant conditions also increased, with prevalence odds ratios as high as 7.39 (95% confidence interval, 3.92 to 13.98) for four or more conditions in 2012 as compared with 2005. CONCLUSIONS Individual and multiple conditions thought to be associated with increased crash risk significantly increased between 2005 and 2012.
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Thiese MS, Moffitt G, Hanowski RJ, Kales SN, Porter RJ, Hegmann KT. Commercial Driver Medical Examinations: Prevalence of Obesity, Comorbidities, and Certification Outcomes. J Occup Environ Med 2016; 57:659-65. [PMID: 25710607 PMCID: PMC4448672 DOI: 10.1097/jom.0000000000000422] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Supplemental Digital Content is Available in the Text. Objective: The objective of this study was to assess relationships between body mass index (BMI) and comorbid conditions within a large sample of truck drivers. Methods: Commercial driver medical examination data from 88,246 commercial drivers between 2005 and 2012 were analyzed for associations between BMI, medical disorders, and driver certification. Results: Most drivers were obese (53.3%, BMI >30.0 kg/m2) and morbidly obese (26.6%, BMI >35.0 kg/m2), higher than prior reports. Obese drivers were less likely to be certified for 2 years and more likely to report heart disease, hypertension, diabetes mellitus, nervous disorders, sleep disorders, and chronic low back pain (all P < 0.0001). There are relationships between multiple potentially disqualifying conditions and increasing obesity (P < 0.0001). Morbid obesity prevalence increased 8.9% and prevalence of three or more multiple conditions increased fourfold between 2005 and 2012. Conclusions: Obesity is related to multiple medical factors as well as increasing numbers of conditions that limit driving certification.
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Affiliation(s)
- Matthew S Thiese
- From the Rocky Mountain Center for Occupational & Environment Health (Drs Thiese and Hegmann), Department of Family and Preventive Medicine, School of Medicine, University of Utah, Salt Lake City; Arkansas Occupational Health Clinic (Dr Moffitt), Springdale; Center for Truck and Bus Safety (Dr Hanowski), Virginia Tech Transportation Institute, Blacksburg; Department of Environmental Health (Dr Kales), School of Public Health, Harvard, Cambridge, Mass; and Utah Traffic Lab (Dr Porter), Department of Civil & Environmental Engineering, University of Utah, Salt Lake City
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Colvin LJ, Collop NA. Commercial Motor Vehicle Driver Obstructive Sleep Apnea Screening and Treatment in the United States: An Update and Recommendation Overview. J Clin Sleep Med 2016; 12:113-25. [PMID: 26094916 PMCID: PMC4702187 DOI: 10.5664/jcsm.5408] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/21/2015] [Indexed: 11/13/2022]
Abstract
ABSTRACT No regulatory mandate exists in the United States (U.S.) for comprehensive obstructive sleep apnea (OSA) risk assessment and stratification for commercial motor vehicle (CMV) drivers. Current Federal Motor Carrier Safety Administration (FMCSA) requirements are outdated and depend largely on subjective report, a less reliable strategy in an occupational setting. Without FMCSA standards, sleep specialists, occupational medical examiners and employers rely on a collection of medical consensus recommendations to establish standards of care. These recommendations advise OSA risk assessment through a combination of focused medical history, physical examination, questionnaires, and accident history, which increase OSA detection compared to current FMCSA standards. For those diagnosed with OSA, consensus-based risk stratification helps identify CMV drivers who may benefit from OSA treatment and establish minimum standards for assessing treatment efficacy and adherence. Unfortunately no consolidated recommendation exists; rather, publications span medical and governmental literature in a patchwork fashion that no longer fully reflect current practice due to subsequent advances in OSA diagnosis, treatment, and technology. Based on searches of medical literature, internet materials, and reference lists from existing publications, an overview and discussion of key published recommendations regarding OSA assessment and treatment in CMV operators is provided. Suggestions for incorporating these recommendations into clinical sleep medicine practice in the U.S. are presented. The challenge for sleep specialists is maintaining the delicate balance between recommendations impacting standard of care and associated medico-legal impact with stakeholder interests from medical, regulatory, industry and public perspectives while providing high quality and efficient care.
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Sharples L, Glover M, Clutterbuck-James A, Bennett M, Jordan J, Chadwick R, Pittman M, East C, Cameron M, Davies M, Oscroft N, Smith I, Morrell M, Fox-Rushby J, Quinnell T. Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure. Health Technol Assess 2015; 18:1-296. [PMID: 25359435 DOI: 10.3310/hta18670] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease. OBJECTIVES (1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH. TOMADO A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY. META-ANALYSIS A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)]. LONG-TERM COST-EFFECTIVENESS An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2. CONCLUSIONS Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates. TRIAL REGISTRATION This trial is registered as ISRCTN02309506. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Linda Sharples
- University of Leeds Clinical Trials Research Unit, Leeds, UK
| | - Matthew Glover
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | | | - Maxine Bennett
- Medical Research Council Biostatistics Unit, Cambridge, UK
| | - Jake Jordan
- Health Economics Research Unit, Brunel University, Uxbridge, UK
| | - Rebecca Chadwick
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Marcus Pittman
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Clare East
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Malcolm Cameron
- Maxillofacial Unit, Addenbrooke's NHS Foundation Trust, Cambridge, UK
| | - Mike Davies
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Nick Oscroft
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Ian Smith
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
| | - Mary Morrell
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Timothy Quinnell
- Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK
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Krahn LE, Hershner S, Loeding LD, Maski KP, Rifkin DI, Selim B, Watson NF. Quality measures for the care of patients with narcolepsy. J Clin Sleep Med 2015; 11:335. [PMID: 25700880 DOI: 10.5664/jcsm.4554] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/22/2015] [Indexed: 01/12/2023]
Abstract
ABSTRACT The American Academy of Sleep Medicine (AASM) commissioned a Workgroup to develop quality measures for the care of patients with narcolepsy. Following a comprehensive literature search, 306 publications were found addressing quality care or measures. Strength of association was graded between proposed process measures and desired outcomes. Following the AASM process for quality measure development, we identified three outcomes (including one outcome measure) and seven process measures. The first desired outcome was to reduce excessive daytime sleepiness by employing two process measures: quantifying sleepiness and initiating treatment. The second outcome was to improve the accuracy of diagnosis by employing the two process measures: completing both a comprehensive sleep history and an objective sleep assessment. The third outcome was to reduce adverse events through three steps: ensuring treatment follow-up, documenting medical comorbidities, and documenting safety measures counseling. All narcolepsy measures described in this report were developed by the Narcolepsy Quality Measures Work-group and approved by the AASM Quality Measures Task Force and the AASM Board of Directors. The AASM recommends the use of these measures as part of quality improvement programs that will enhance the ability to improve care for patients with narcolepsy.
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Abstract
This is a “patient-centered” review about narcolepsy that aims to awaken the reader to the narcolepsy condition and to the trials and tribulations of patients with sleep problems in general. Narcolepsy is a neurological disorder with a classic tetrad of symptoms consisting of excessive daytime sleepiness, cataplexy, sleep onset hallucinations, and sleep paralysis. The diagnosis of narcolepsy and other sleep disorders are often overlooked and could be attributed to other medical or even psychiatric conditions with years of missed diagnosis. Implementation of “two sleep-related questions” to the review of systems in the primary care physicians’ office visit may help address the issue of missed diagnosis and allow patients to seek prompt medical attention. Definitive diagnosis can be made by overnight sleep study followed by a nap test, “multiple sleep latency test” (MSLT). There is currently no cure for narcolepsy with the treatments addressing symptoms of excessive daytime sleepiness, cataplexy, and nighttime sleep disruption with stimulants (modafinil, methylphenidate, and amphetamines), anti-cataplexy medications (Serotonin-specific reuptake inhibitors and tricyclic antidepressants) and sedative-hypnotics including sodium oxybate. Narcolepsy, like other sleep disorders, can lead to marked reductions of health-related quality of life and affect patients’ social and work lives deleteriously. While traditional healthcare approaches are focused more on hard biomedical outcomes, a patient-centered approach with novel methods for better sleep assessment of patients, that can bypass the “impossibly crammed” physician office visit, would allow healthcare providers to better detect, diagnose and treat narcolepsy and other such sleep problems.
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Abu Dabrh AM, Firwana B, Cowl CT, Steinkraus LW, Prokop LJ, Murad MH. Health assessment of commercial drivers: a meta-narrative systematic review. BMJ Open 2014; 4:e003434. [PMID: 24604478 PMCID: PMC3948638 DOI: 10.1136/bmjopen-2013-003434] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Motor vehicle accidents associated with commercial driving are an important cause of occupational death and impact public safety. OBJECTIVES We summarise the evidence regarding the type, prevalence and impact of medical conditions discovered during health assessment of commercial drivers. EVIDENCE REVIEW We conducted a systematic review of multiple electronic databases and made a manual search for relevant studies that enrolled commercial drivers in any country and reported the outcomes of health assessment carried out in the context of commercial driving through November 2012. Data were extracted by a pair of independent reviewers and synthesised using a metanarrative approach. RESULTS We identified 32 studies of moderate methodological quality enrolling 151 644 commercial drivers (98% men). The prevalence of multiple health conditions was high (sleep disorders 19%, diabetes 33%, hypertension 23% and obesity 45%). Some conditions, such as sleep disorders and obesity, were linked to increased risk of crashes. Evidence on several other highly relevant medical conditions was lacking. Cost-effectiveness data were sparse. CONCLUSIONS Several medical conditions are highly prevalent in commercial drivers and can be associated with increased risk of crashes, thus providing a rationale for health assessment of commercial drivers.
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Affiliation(s)
- Abd Moain Abu Dabrh
- Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Belal Firwana
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, University of Missouri, Columbia, Missouri, USA
| | - Clayton T Cowl
- Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence W Steinkraus
- Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad Hassan Murad
- Division of Preventive, Occupational and Aerospace Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
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