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Health On The Highway

Trucker health is in a sorry state.

July 2008, TruckingInfo.com - Feature

by Bette Garber

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Trucker health is in a sorry state. The veteran driver population is aging, averaging between 45 and 60, and already feeling the onset of age-related ailments. This shrinking core demographic within the nation's estimated 10 to12 million commercial driver's license holders represents half the drivers of tractor-trailers and is expected to fall by more than 3 million by 2014. 

Truckers don't live as long as non-trucking men, one study relates, suggesting a life on the road can prune 15 years from a driver's life. And just last month, a study at Sweden's Umea University found that exposure to diesel exhaust causes a rapid deterioration of the function of blood vessels, which can cause heart attacks and stroke. Just what truck drivers needed: one more risk that keeps this profession on the list of America's 10 most dangerous occupations.

To add insult to injuries, truckers rarely see a doctor, do not have access to regular health care, and have trouble following medicine regimens because they have difficulty refilling prescriptions. They often go without health insurance, and are beset by a host of illnesses connected to, or triggered by, their job conditions.

This was the bleak picture painted by a health survey conducted by Professional Drivers Medical Depots, a chain of medical clinics opening in Petro and TAs and other travel centers across the country. 

The data revealed a driver population that for years has suffered the neglect of a health care system ill-suited to serving their special needs and mobile lifestyle. Over 2,700 truckers were interviewed, more than 50 percent of them fleet drivers. The balance were owner-operators. The majority of respondents spent 20 to 30 nights per month or more away from home, making it difficult to schedule any kind of medical care. 

Drivers' top health concerns were heart problems, diabetes and obesity/weight control issues. Sixty-six percent were found at risk for sleep disorders. The average weight of the sample group was 240 pounds, well within accepted guidelines for obesity. 

Roadside Medical, a chain of clinics now opening in Pilot Truck Centers, reports 62 percent of drivers failed to seek out needed health care when on the road working. Many choose to "push through to the house" rather than stop and seek medical attention.

Tim Begle, a driver for Automated Transportation, suffered nine years of unexplained excruciating pain in his chest that turned out to be his gall bladder. It got so bad he would vomit, even while driving. He self medicated himself with water and milk. 

Why did it take so long to get treated? "I just didn't want to be in a hospital hundreds of miles from home," he says. He had visited one doctor who could not diagnose the pain even while admitting Begle had a problem. That's when the driver decided to tough it out, and he did, for a few years. Eventually, however, "I just wanted them to relieve the pain or kill me!" 

Now recovered, he thinks the new travel center-based medical clinics are a great idea. "I'd like to try them," he says.

Recipe for Disaster

The truckers' health-challenged and sedentary lifestyle is a ticking time bomb, top heavy on stress, job pressure, high blood pressure, too much fast food, too much weight around the middle, too much time spent behind a steering wheel, and not enough exercise. Oh yes, and too little sleep. 

Drivers who think they are getting a good night's sleep frequently are not, because more than 28 percent are at high risk for a sleeping disorder called obstructive sleep apnea (OSA) which interrupts a driver's breathing during sleep and prevents the sleeper from reaching the deep restorative levels of sleep. The trucker awakes fatigued, drowsy and sleep-deprived and stays that way throughout the day. 

OSA has been a hidden enemy of truck drivers for years. That potent "cuppa joe," a standard in trucker stories and song for as long as there have been diesel jockeys, has kept sleepy drivers awake for decades. 

Drivers often do not recognize they have signs and symptoms of sleep apnea. That's because it's daytime and they are not experiencing the nighttime breathing symptoms that only happen when they are relaxed and lying down. The resulting drowsiness and fatigue are often masked by excessive snacking, caffeine and power/energy drink use, cigarette smoking, and the use of "stackers" (highly caffeinated pills). 

Not until the advent of sleep science some 20 to 25 years ago did anyone suspect there might be something more serious than "sleepiness" going on. OSA is easier to diagnose and treat these days. Treatment can transform a skilled but drowsy and unproductive driver into a healthier, more alert and productive driving powerhouse. 

Currently the U.S. Department of Transportation's Federal Motor Carrier Safety Administration is studying the disorder with the intent of updating guidelines for truckers with sleep apnea. 

According to published accounts, nearly 1.1 million commercial truck drivers are affected by sleep apnea. An FMCSA-sponsored study reports this sleeping disorder affects l in 4 commercial truck drivers. A study from Stanford University revealed an average of 28 percent of all drivers in truck fleets are considered to be at risk for sleep apnea. OSA-affected drivers had a twofold higher accident rate per mile than drivers without the condition. According to this same study, 20 percent of truck accidents in the U.S. are caused by tired or sleepy drivers. 

A survey by the Transportation Research Board found nearly 30 percent of CDL holders suffer from some degree of sleep apnea. In a study published in Sleep Diagnosis and Therapy (April-May 2007), the authors found that as many as 50 percent of transportation workers studied had undiagnosed OSA.

The numbers may change from study to study, but all show a clear and direct connection between the disorder and sleep-deprived truck drivers at high risk for daytime drowsiness, medical disorders and motor vehicle accidents.

"Each undiagnosed employee in the workforce costs an additional $6,000 per year in apnea-related expenses, including increased physician and hospital visits, cardiovascular treatment costs, increased on-the-job injuries, and absenteeism," reports physician Martin Moore-Ede, head of Boston-based Circadian Expert Services. The company is a pioneer in providing 24/7 workforce performance and safety solutions for businesses that operate around the clock. Among its specialties is setting up programs to screen, diagnose and treat sleep apnea patients.

For all the research that shows how dangerous untreated sleep apnea can be, the fix for this disorder is quick, easy, painless, and relatively inexpensive, with huge paybacks in driver retention and in hard costs, like health and liability insurance.

"Treatment is effective on day one," says Wendy Sullivan, vice-president of Houston-based Precision Pulmonary Diagnostics and one of the initiators behind Schneider National's award-winning sleep apnea program. 

Drivers who might have been suffering day-long fatigue and taking frequent naps come out of one night's sleep on a CPAP (continuous positive airway pressure) machine rejuvenated by treatment. One driver likened it to waking up and wanting to do cartwheels. Another simply described it as "night and day."

Schneider National driver Tim Ucciferri, who went through his carrier's screening and treatment program, says, "You couldn't get [the machine] away from me now with a gun to my head."

Still, huge numbers of drivers continue to fear letting anyone - particularly their employer - know they might have the disorder. They fear the treatment, or being "pigeonholed," or losing their job. Drivers interviewed for this story admitted they and their friends look at the Medical Examination Report and "just say no" to the question on sleep disorders. "Otherwise you're off the road for at least six weeks while they test and treat you," said one driver.

This attitude signals a need for the trucking industry to initiate training programs that educate drivers about sleep apnea and treatment. Today's sleep labs can do a study overnight. So can the new medical clinics springing up in travel centers. At Schneider National, where its sleep apnea program has set a standard for the industry, all drivers are screened, treated if required, and sent back on the road with no downtime. 

Landmark Offensive Against OSA

Research, clinical studies, and drivers' surveys all point to the inarguable presence of obstructive sleep apnea in America's commercial driver population. What to do? Wait for a definitive ruling from Washington? Ignore the evidence? 

Schneider National, the largest truckload carrier in the U.S., decided to tackle OSA head-on.

"When government and industry-led sleep apnea studies showed that 28 percent of the nation's 7 million truck drivers were at risk for sleep apnea, we knew this was an area in which we needed to focus," says Don Osterberg, Schneider's vice president of safety and driver training. 

Today the Green Bay, Wis.-based carrier tests all its 15,000 drivers, treats those found to have the sleep disorder, and picks up the entire bill. "By eliminating costs for drivers, we're taking barriers off the table and encouraging [Schneider drivers] to come forward without having to worry about a monetary impact," Osterberg says.

"While the company routinely covered sleep studies recommended by physicians at 100 percent, we decided that a full-scale program to screen drivers and provide treatment was the right thing to do for our employees' health and for the overall safety of the motoring public." 

Its testing program, developed with the help of Precision Pulmonary Diagnostics, is a role model for all those that will follow. Schneider was honored in 2007 by the American Sleep Apnea Association, which commended the carrier for its sleep apnea detection and treatment program.

Wendy Sullivan, Schneider's former occupational health manager, first picked up on a trend in symptoms for fatigue and its possible connection to obstructive sleep apnea more than five years ago. That was a red flag for Sullivan and her staff, because drivers who suffer from sleep apnea are two to seven times more likely to have an accident.

"We recognized a trend among our drivers. Many of them seemed to 'fit the bill' and had related symptoms such as diabetes, high blood pressure and acid reflux disease. These drivers were more likely to be suffering from sleep apnea, and were probably not even aware of it," she says.

Sullivan sent a driver for treatment at Precision Pulmonary Diagnostics and he returned praising the treatment he received there. Before long, Sullivan and her staff were conversing regularly with PPD's founder, physician Mark Berger. A noted sleep scientist, he started his company in 2003 specifically to work within the trucking industry, identifying and treating commercial drivers with sleep-disordered breathing.

"We were immediately impressed with Dr. Berger's knowledge of sleep apnea and of its significance in the commercial trucking industry," Sullivan says. "He understood the lifestyle of truck drivers, as well as the challenge we were facing. He also knew how to remedy the situation."

Within five years, Berger and Sullivan had put together the Schneider National Sleep Apnea program. "The entire organization was engaged," she says. "That was the goal. Schneider implemented it."

Schneider began by screening more than 8,000 drivers during one of the company's two annual mandatory training sessions. Nearly 20 percent of the drivers screened were found to be at high risk for sleep apnea.

Drivers identified through screening to be at risk for OSA are routed for a overnight study at an accredited diagnostic facility. For those diagnosed with the disorder, a CPAP machine is made available immediately as well as an inverter for their truck. Then the drivers return to work.

"Among drivers being treated for sleep apnea, we've reduced our health care costs an average of 58 percent and saw a 30 percent reduction in accident frequency," Osterberg notes in a case study of the program. "We've also reduced the number of claims by 50 percent. The PPD sleep apnea detection and treatment program has been a huge success for us." 

The carrier is experiencing a savings of $538 to $780 in health care costs per driver per month after treatment.

The program does not take the driver out of service, Sullivan says. That fact alone has gone far in easing drivers' fears of being diagnosed.

In the early days of setting up the program at Schneider, Sullivan recalls fleet drivers "as a group were resistant and fearful of this diagnosis. They'd beg me not to put them out of service.

"We didn't want the program to drive them away. I knew if a driver turns over, he'd still drive for someone else and move the problem. I had the industry as well as Schneider National at heart. It didn't drive them away; their longevity has improved."

Berger says he was "amazed at how the drivers' attitude at Schneider National has changed. The word is out that the testing is a beneficial thing that the carrier is doing on [the drivers'] behalf." 

According to the program's case study, Schneider National has benefited by reducing risk of highway accidents, enhancing overall driver health and performance, and reducing insurance premiums and health costs. 

Schneider National also found a 65 percent increase in retention rates in drivers who were diagnosed and treated versus the overall employee population.

The decision to pursue fleetwide screening for sleep apnea was heavily influenced by a cost analysis of 339 Schneider National drivers who were treated for the condition between January 2003 and December 2005. That study, presented at the 2005 International Truck and Bus Safety and Security Symposium, demonstrated a 91 percent reduction in hospitalizations after CPAP treatment.

Looking at the preventable accident rate in a group of drivers 365 days before and after treatment, the study showed a 30 percent reduction in preventable accidents and 48 percent reduction in median costs of those accidents. Having a sleep apnea program on board is a favorable consideration taken into effect at the time of insurance premium renewal, experts say, because treating sleep apnea reduces the risk of accidents.

In 2006 there were 368,000 commercial motor vehicle crashes of varied severity, damage and injury reported on the FMCSA website. The average cost of a large truck fatal crash can rise into the millions of dollars with litigation. "It doesn't take a lot of prevented big catastrophic accidents to pay for the program," Berger notes. "As far as insurance goes, it looks favorable in a court of law when the carrier is doing due diligence to make highways safer."

Berger is talking to a lot more interested fleets these days. The message is getting out that it's smart business to start managing OSA in-house for the health and well-being of their drivers and the motoring public, and before lawyers looking to sue a carrier can sneak up and bite them. 

"They can bury their heads in sand, suffer diminished productivity and greater risk, or embrace treatment [of fleet drivers] and derive the return," he says.

Benefits of moving forward with aggressive screening and treatment protocols are spelled out in Berger's study, "A Corporate Driven Sleep Apnea Detection and Treatment Program: Results and Challenges," (March 2007) which looked at 225 truckers with OSA treated with a CPAP machine and found:

- 73 percent reduction in preventable driving accidents, 

- 48 percent reduction in annual health care costs, 

- 2.29 times greater retention rate for this group of treated drivers as compared to companywide driver retention rates, 

- Reduction in collision and liability insurance premiums 

Berger's pitch is simple. "You're asking [fleets] to spend up front to get a return on their investment down the line. From the data we acquired at Schneider National, we believe the return on investment is huge and justifies the upfront costs."

Sulllivan left Schneider last year to become PPD's vice president of project implementation and health and safety consultative services. She intends to spread the word about the company's sleep apnea programs to other trucking companies, anticipating even more accidents will be averted and drivers' lives saved. 

Osterberg is clearly enthusiastic about the program's results. 

"Our sleep apnea detection and treatment program is now part of providing the best package of benefits we can offer our drivers," he says. "For this effort to succeed, it has been essential to work with an expert like Precision Pulmonary Diagnostics and to foster a companywide partnership that includes drivers and executive support. The PPD program is designed for trucking. They understand the drivers' world, and that was very important to us and to the success of the program."

Regulatory Efforts 

The Federal Motor Carrier Safety Administration is committed to review and begin updating all of its medical fitness standards for commercial drivers and guidelines for medical examiners by 2009. At present, no federal guidelines define obstructive sleep apnea. The FMCSA is currently reviewing a huge menu of ailments, including diabetes, vision and heart disease. OSA is just one of the many areas of interest. 

Although the recommendations of the FMCSA's Medical Review Board on OSA earlier this year were widely reported, the likelihood of any of them being adopted into actual regulations is years away, and that only after undergoing rigorous scrutiny through public hearings. The FMCSA has no timetable to work on them and has the option to act on recommendations in whole, in part, or not at all. 

Nothing will happen immediately, but "conversation is engaged" and the government is aware of the issues, says FMCSA spokesman Duane J. DeBruyne. 

The minutes of the January recommendations presentation meeting were passed in April, and the next meeting is in July. 

Controversial points in the MRB recommendations include the Body Mass Index, which sets the standard for obesity and will affect vast numbers of drivers, plus the amount of time a driver is supposed to be off the road for evaluation and treatment (from one week to several months), and recertification guidelines. 

Fifty percent of America's truck drivers are obese, and under the Medical Review Board's recommendations, roughly 5 million to 6 million drivers could be required to undergo a sleep study if they have a BMI of 30 or greater. This recommendation alone has enormous potential to impact the trucking industry and cause traffic jams at all the nation's sleep labs. 

The BMI is the relationship between weight and height that is associated with body fat and health risk. Circadian's Moore-Ede notes that a person with a BMI of 30 or more is likened to a 6-foot individual weighing more than 220 pounds, and has two times greater prevalence of sleep apnea than someone who is not obese. 

"The idea is not to drive people off the road or fire a significant part of the work force," says Allan Pack, director of the Center for Sleep and Respiratory Neurobiology at the University of Pennsylvania and one of the Medical Review Board's advisors. "[The idea] is to identify these drivers and get them on a CPAP." 

Pack says the data from a study conducted in 2004 of BMI in commercial vehicle drivers showed that 30 percent of drivers had a BMI of 30-35, 14 percent had a BMI between 35-40 and 6 percent had a BMI above 40.

The BMI of 30 or higher was accepted as the MRB's "magic number" and the vote carried four to one. 

One doctor offers this analysis of the vote: "The BMI could still be up in the air due to the huge volume of truckers that would be affected if a BMI of 30 or greater was used, so 33 or greater might eventually be chosen even though risk factors for OSA start at a BMI of greater than 28." 

Another recommendation for the guidelines was a qualifying description of the medical professional who would look at a driver's potential for OSA. The change: "a qualified physician with relevant expertise in sleep apnea." This would require the driver see a sleep specialist for testing.

FMCSA's Medical Review Board recommendations are not law. To become official, every point in the recommendations must go through a period of publication and public hearings before coming up for a Congressional vote.

Until that happens, nothing will change in the Medical Examination Report for Commercial Driver Fitness Determination. It will continue to carry the "Yes or No" question into 2009 and beyond. Currently it's up to the driver to check a "Yes or No" question asking if the symptoms of OSA are present. As noted earlier, many drivers do not answer truthfully.

If any change in screening and treating drivers is going to happen on a speedier timetable, it will have to come from the trucking companies themselves aggressively educating and testing their drivers, and getting them the treatment that will make them safer, healthier, and more productive.

"That kind of forward thinking is a real model - not only does it contribute to improving the quality of life for its workforce, but it also helps to keep the most highly experienced drivers behind the wheel and productive," FMCSA's DeBruyne says.

The Big Picture

Sleep specialists who talk regularly with truck fleets report bumping into a wall of inertia in many places, as if management is waiting for something to happen at the government level, or waiting to have guidelines specifically addressing all aspects of this problem appear on an easy-to-use menu. In these tough economic times, cost is an issue as well. But there is some forward movement, they report. Some carriers have been receptive to in-house screening and are initiating programs.

As word spreads about drowsy driving and apnea-inclined drivers, states have begun looking at the trucking industry and contemplating taking steps of their own to ensure that semi drivers are screened and treated. If trucking companies don't take the initiative, they may eventually be legislated into doing so.

Meanwhile, the amount spent for an in-house sleep apnea program is becoming more economical as technology makes diagnostics and CPAP machines smaller and cheaper. Medicare recently ruled to accept in-home (and by extension, in-bunk) testing for reimbursement, and a lot of insurance companies follow Medicare's lead. 

"If we tackle the problem, we could save these employees, which is absolutely smart," says G. Vernon Pegram, director of the Sleep Disorders Center of Alabama and diplomat of the American Board of Sleep Medicine. "Keeping a good core of drivers is increasingly difficult if you keep tossing out your seasoned drivers because of a potential sleep disorder."

The diagnosis and treatment of OSA, and allowable conditions for certification, are addressed in the the most recent publication of American College of Occupational and Environmental Medicine-Commercial Driver Medical Examiner, available on the FMCSA web site.The detailed list of 14 guidelines addressing OSA (none adopted yet by the FMCSA) shows the full commitment of the MRB and FMCSA to get their arms around the enormous problem of sleep apnea and other sleep disorders. 

The attention paid to all aspects of the problem shows promise that expert guidelines eventually will be available for anyone who wants to be licensed to drive a semi and has obstructive sleep apnea.

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