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• W2612155816 abstract "Free AccessSurgeryManagement of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force Indira Gurubhagavatula, MD, MPH, Shannon Sullivan, MD, Amy Meoli, MD, Susheel Patil, MD, Ryan Olson, PhD, Michael Berneking, MD, Nathaniel F. Watson, MD, MS Indira Gurubhagavatula, MD, MPH Address correspondence to: Indira Gurubhagavatula, MD, MPH, Associate Professor of Clinical Medicine, Division of Sleep Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3624 Market Street, Suite 201, Philadelphia, PA 19104 E-mail Address: [email protected] Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania Search for more papers by this author , Shannon Sullivan, MD Department of Psychiatry, Stanford University, Palo Alto, California Search for more papers by this author , Amy Meoli, MD Penn State Sleep Research and Treatment Center, Hummelstown, Pennsylvania Search for more papers by this author , Susheel Patil, MD Johns Hopkins School of Medicine, Baltimore, Maryland Search for more papers by this author , Ryan Olson, PhD Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, Oregon Search for more papers by this author , Michael Berneking, MD Concentra, Inc., Grand Rapids, Michigan Search for more papers by this author , Nathaniel F. Watson, MD, MS University of Washington Medicine Sleep Disorders Center and Department of Neurology, University of Washington, Seattle, Washington Search for more papers by this author Published Online:May 15, 2017https://doi.org/10.5664/jcsm.6598Cited by:37SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTThe American Academy of Sleep Medicine Sleep and Transportation Safety Awareness Task Force responded to the Federal Motor Carrier Safety Administration and Federal Railroad Administration Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA). The following document represents this response. The most salient points provided in our comments are that (1) moderate-to-severe OSA is common among commercial motor vehicle operators (CMVOs) and contributes to an increased risk of crashes; (2) objective screening methods are available and preferred for identifying at-risk drivers, with the most commonly used indicator being body mass index; (3) treatment in the form of continuous positive airway pressure (CPAP) is effective and reduces crashes; (4) CPAP is economically viable; (5) guidelines are available to assist medical examiners in determining whether CMVOs with moderate-to-severe OSA should continue to work without restrictions, with conditional certification, or be disqualified from operating commercial motor vehicles.Citation:Gurubhagavatula I, Sullivan S, Meoli A, Patil S, Olson R, Berneking M, Watson NF. Management of obstructive sleep apnea in commercial motor vehicle operators: recommendations of the AASM Sleep and Transportation Safety Awareness Task Force. J Clin Sleep Med. 2017;13(5):745–758.1.0 BACKGROUNDThe American Academy of Sleep Medicine (AASM) established a Sleep and Transportation Safety Awareness Task Force (STSATF) in 2015 with the goal of engaging transportation stakeholders, including federal and state agencies, to develop educational tools about the dangers of drowsy driving. On March 10, 2016, the Federal Motor Carrier Safety Administration (FMCSA) and Federal Railroad Administration (FRA) issued an Advance Notice of Proposed Rulemaking and request for public comments regarding the evaluation of safety-sensitive personnel for moderate-to-severe obstructive sleep apnea (OSA).1 The STSATF reviewed the Advance Notice of Proposed Rulemaking and submitted comments based on review of available literature from peer-reviewed journals and industry-related studies.2 The paucity of knowledge tailored for sleep medicine professionals became apparent. Therefore, to advance knowledge and provide guidance in this area, the STSATF prepared this article to summarize information submitted to the FMCSA/FRA during the rule-making comment period.2.0 PREVALENCE OF SLEEP APNEA IN THE GENER AL POPULATION VERSUS CMVOs2.1 Moderate-to-Severe OSA Is Common Among the General Adult United States PopulationIn the Wisconsin Cohort Study, Young et al. estimated the prevalence of OSA in middle-aged, working adults in 1994.3 Among women, they found that moderate-to-severe OSA occurred at rates ranging from 3.7% to 4.4%. Among men, rates were two to three times higher, ranging from 6.2% to 11%.3 The strongest risk factor for OSA across both sexes was obesity. An increase in any obesity-related measure of body habitus by one standard deviation above average was associated with a three-fold increase in the risk of having any OSA.Given the strong association between body composition and OSA, and the rising prevalence of obesity in the United States, more recent investigations have sought to update OSA prevalence estimates. Participants in the Wisconsin Sleep Cohort were invited to complete additional sleep studies at 4-year intervals, and the prevalence of OSA was estimated at follow-up time points as a function of age, sex, and body mass index (BMI). These models were extrapolated to the distribution of BMI scores from a large sample of United States adults participating in the National Health and Nutrition Examination Surveys (NHANES). Estimates of OSA prevalence based on BMI data from the 1988–1994 NHANES were compared against combined data from NHANES 2007–2008 and 2009–2010. These investigations estimated the prevalence of at least moderate OSA to be at 10% and 17% among men aged 30–49 years and 50–70 years, respectively; among women in the same age groups, the respective prevalence rates were 3% and 9%. These more current estimates are substantially higher than they were two decades ago, and reflect proportional increases in prevalence ranging from 14% to 55%, depending on the demographic subgroup of interest.4Even these newer estimates of OSA prevalence likely underestimate the commonness of the full spectrum of breathing abnormalities during sleep in CMVOs, which also contribute to adverse medical and other consequences. Such consequences include daytime sleepiness, cognitive dysfunction, and cardiovascular disease.5 These other breathing abnormalities include milder OSA, as well as respiratory effort-related arousals, or arousals from sleep due to other phenomena, including snoring or smaller reductions in airflow.2.2 The Prevalence of OSA Is Higher Among Commercial Truck Drivers Than in the General PopulationThe prevalence of OSA among commercial truck drivers is estimated to be substantially higher than in the general population. This elevated prevalence is generally attributed to three major risk factors for OSA that are common among commercial drivers; the majority are male, obese, and middle-aged. In studies of commercial truck drivers, OSA prevalence estimates have ranged from 28% to 78%.6–9 In a study commissioned by the FMCSA and conducted in the Philadelphia area, 4,280 commercial drivers were invited to complete a survey, and 1,392 responded. Among respondents, a subgroup of 407 at-risk drivers underwent in-laboratory attended polysomnography (PSG) for OSA. The resulting estimated prevalence of OSA was 28%. In another study of 3,268 commercial truck drivers in Australia, with similar proportion of men and higher proportion of responders, 60% had OSA confirmed by PSG. Further, 24% reported excessive sleepiness, which was related to increased crash risk.7 In a third study conducted with truck drivers employed by a single company in California, 78% were suspected of having OSA based on overnight oximetry.9 This sample had a higher prevalence of obesity than the Australian cohort. In a large study of more than 19,371 drivers at Schneider,6 an online screening tool identified 5,908 individuals (30%) as having high risk for OSA. In subsequent PSG testing, the diagnosis of OSA was made in 2,103 (80%) of those high-risk drivers. A more recent study of 104 individuals who self-identified as holding a commercial drivers' license in the Philadelphia area10 found that almost one-third had severe OSA and 61% had at least moderate OSA based on PSG. Drivers in this more recent sample also had a higher prevalence of obesity relative to samples from prior studies.2.3 OSA Is Common Among Rail OperatorsAlthough no studies based on objective testing have been done on United States rail workers, data from Brazil indicate that 35% of rail workers have OSA based on PSG.11 In the United States, some data on the prevalence of OSA among rail operators is available as a result of screening programs implemented by Metro-North in New York, after a serious train crash in the Bronx on December 1, 2013. The crash resulted in 4 deaths and 59 nonfatal injuries. An investigation by the National Transportation Safety Board determined that the cause was excessive sleepiness due to untreated, severe OSA.12 A pilot screening program tested all 438 Metro-North engineers and engineers-in-training. Because of the findings of the pilot program, screening was expanded to include conductors and other safety-sensitive personnel. Subsequently, the Human Factors Research Division of the FRA published survey data indicating that 7% of rail employees in safety-sensitive positions report having OSA.13 This self-reported estimate is likely to be low.As we await the estimates of OSA prevalence for employees working in safety-sensitive transportation positions outside of commercial trucking, the methodology outlined by Peppard et al.4 provides a validated empirical method to extrapolate the prevalence of moderate-to-severe OSA using BMI, age, and sex predictors.3.0 UNTREATED OSA IS LINKED TO CR ASHES IN BOTH PASSENGER CAR AND COMMERCIAL TRUCK DRIVERS, AND TREATMENT REDUCES THIS RISKIn a meta-analysis commissioned by the FMCSA, data from 10 studies were pooled to estimate overall crash risk among drivers with untreated OSA.14 Overall, the odds that a driver with untreated OSA will have a crash is 243% higher than a driver without OSA. The meta-analysis estimated that 95% of drivers with untreated OSA have a crash risk that ranges from 21% to as high as 489% higher than those without OSA. Furthermore, the same FMCSA-commissioned researchers found that treatment of OSA with continuous positive airway pressure (CPAP)15 (1) lowers crash risk to the same level as that seen in individuals without OSA (risk ratio = 0.278, 95% confidence interval: 0.22 to 0.35; P < .001); (2) improves sleepiness in as few as 2 days, and (3) improves performance on a driving simulator in as few as 2 to 7 days.More recently, Schneider tracked three groups of commercial truck drivers longitudinally by using a mandatory program that required universal screening under nonpunitive conditions. The Somni-Sage questionnaire was used to screen for the presence or absence of OSA risk, followed by PSG in those at high risk. They compared 1,603 drivers with OSA confirmed by PSG, 403 without OSA based on PSG, and 2,016 matched control drivers who were unlikely to have OSA based on screening. They offered positive airway pressure (PAP) therapy to drivers confirmed to have OSA, and monitored objective adherence rates using builtin monitoring systems. They also tracked preventable, reportable crashes per 100,000 miles driven. Those who did not meet the PAP adherence criterion had a crash rate that was five-fold higher than that of drivers in the matched control group; drivers with OSA who met the PAP adherence criterion had crash rates statistically equivalent to the matched control group.16A follow-up study at Schneider17 found that, of 255 CMVOs with a diagnosis of OSA and treated with CPAP, 75% had a preventable crash during the study period (pre- or post-CPAP). Among the drivers with crashes, 93% experienced their crash before treatment for OSA, whereas 25% were involved in a crash after CPAP treatment (a 73% reduction in total crashes). In this report, 91% of drivers assessed for CPAP adherence were using CPAP 6 to 7 nights per week. Despite the lack of detail regarding apnea-hypopnea index (AHI) values for those who received a diagnosis of OSA, the report indicated that 44% of drivers with a diagnosis of OSA at the single testing site had severe OSA (AHI range from 34–112 events/h of sleep).These data suggest a relationship between untreated or under-treated OSA and increased crash risk. Furthermore, the evidence that PAP treatment for OSA lowers crash risk to levels similar to those of drivers who are unlikely to have OSA provides compelling evidence that OSA likely plays a causal role in crashes.4.0 OSA IS LINKED WITH MORBIDITY AND MORTALITY, WHICH IMPROVE WITH PAP THER APYOSA is associated with an increase in all-cause mortality.18,19 A meta-analysis of over 25,000 individuals in 12 studies showed relative increased risks of 1.79 for cardiovascular disease, 2.15 for fatal and nonfatal stroke, and 1.92 for death from all causes.20 Among those with OSA, Nieto and colleagues21 found that, compared to individuals who had an AHI < 1.5 events/h, the adjusted odds of hypertension were 20%, 25%, and 37% higher for individuals in mild (5 to 15 events/h), moderate (15 to 30 events/h), and severe (> 30 events/h) AHI categories, respectively.21 OSA is also a cause of “resistant” hypertension,22 defined as failure of hypertensive control despite the use of at least three blood pressure-lowering medications. OSA has been shown to be an independent risk factor for the development of diabetes,23 which is a known risk factor for cardiovascular disease. Cerebrovascular disease is strongly and independently associated with OSA of any severity.24–26 OSA is also associated with reduced quality of life based on a number of measures including physical function, vitality, and health perception.27 There is good evidence OSA is associated with depression,28 with some limited evidence of association with other mental health disorders.Evidence shows that PAP treatment reverses daytime hypertension in the first few weeks after starting treatment,29–31 reduces mortality after stroke,32 and improves quality of life.33 CPAP also reduces fatal and nonfatal cardiac events,34 and reduces recurrence of atrial fibrillation.355.0 THE COST OF SLEEPINESS-RELATED LARGE TRUCK AND R AIL CR ASHES IS HIGHAs previously indicated, treatment of OSA can reduce the risk of crashes. Although commercial truck drivers are safer per vehicle-mile traveled compared to passenger car drivers,36,37 large vehicle crashes are particularly deadly, disabling, and expensive. Commercial truck crashes are estimated to cost between $304,500 to $7 million depending on the size of the truck and severity of the incident.17 These costs are generated by property and vehicular damage, lost wages from absenteeism, and insurance and related medical expenses. Rail safety incidents can cost much more.38,396.0 COSTS AND BENEFITS OF SCREENING, EVALUATION, AND MANAGEMENT OF OSA IN SAFETY-SENSITIVE TR ANSPORTATION WORKERS6.1 Models and Empirical Evidence Available Estimate Potential Costs of Untreated OSA and Cost Savings of OSA TreatmentThe AASM recently commissioned Frost & Sullivan, a market research and analytics firm, to perform cost modeling of the economic burden of OSA.40 The total cost of OSA in the United States was divided into four components: medical and mental health comorbidities, workplace accidents, productivity, and motor vehicle accidents. Disease epidemiology, health care utilization and cost, and access to care were factors that contributed to these estimates. Confidence levels were assigned to each component reflecting Frost & Sullivan's assessment of the low- and high-end cost estimates for these components. The total economic effect of commercial and noncommercial accidents in the United States where undiagnosed OSA was a contributing factor was estimated at $26.2 billion in 2015. Cost savings can be realized from comprehensive OSA diagnosis and treatment and include reduction of vehicular damages, lost wages from corresponding absenteeism, property damage, rising insurance premiums, and medical expenses.When aggressive OSA screening, diagnosis, and treatment are implemented, annual savings to a small trucking company (∼1,000 drivers) is estimated at $19.1 million and, to a large trucking company (∼11,000 drivers), $1.2 billion.6.2 Costs Incurred by the Safety-Sensitive Transportation Worker: Screening, Testing, and TreatmentAlthough actual costs to drivers are underreported and likely vary, some cost considerations are presented here.OSA screening would not be anticipated to incur signifi-cant incremental cost to the pre-employment physical that is conducted by a trained medical examiner at the time of the operator's initial certification. For those requiring additional work-up, total costs to workers come from several sources. These sources include: a sleep medical evaluation (which may be covered in the operator's certification examination; or additional examination may be required), sleep diagnostic testing, potential income loss during the evaluation and initial treatment phase, and if a diagnosis is confirmed, treatment and monitoring. Out-of-pocket costs may be reduced by health insurance coverage, though operators are still responsible for copay or deductible costs, depending on the specifics of the health plan. Substantial variability may exist in these costs, based on region and payer. Some employers have implemented internal programs that cover the cost of evaluation, testing, and treatment, with positive results.6One approach that has helped reduce the costs of testing is the use of home-based technologies, which are more widely available, and generally more affordable than PSG. Home sleep apnea testing (HSAT) has replaced PSG as the initial diagnostic approach in some regions. Equally, in-laboratory testing to determine best therapeutic PAP pressures has been supplanted in some cases by use of auto-adjusting devices, though in-laboratory PAP testing remains critically important for some patients. HSAT is associated with specific controversies in the CMVO population (see Section 8.2).After testing and the establishment of a diagnosis of OSA, treatment costs involve medical follow-up and procurement and use of a PAP device and supplies. The cost of PAP typically is covered by health insurance when at least moderate OSA is demonstrated, and even for mild OSA if comorbid conditions are present. Cash prices may range from ∼$400 or higher for a new device with heated humidification and adherence monitoring, plus recurring costs for supplies (mask, tubing, filters) every 3 to 6 months. Typically, these supplies are covered by insurance, with prices starting at ∼$120 for mask/headgear, tubing, and filters. Private sources of assistance are available for procuring CPAP if financial hardship exists, including free or low-cost PAP assistance programs. Multiple commercial entities also offer significantly discounted preowned PAP devices.Many health insurances also cover the cost of oral appliance (OA) therapy, which may be appropriate for commercial drivers who have milder forms of OSA. After treatment with an OA, a follow-up sleep study may be recommended by the health provider, which may add to the cost of this treatment approach. An important consideration is that PAP therapy requires a power source or battery to operate, whereas OAs generally do not. Access to an adequate power source may be problematic in some settings.Finally, in evaluating the economic effectiveness of diagnosing and treating OSA, the long-term costs of not treating known OSA should be considered.41 As mentioned, treatment of OSA can improve crash risk and comorbid conditions, including cardiovascular disease.34,35 Cost savings realized through reduced accidents and improved health may counterbalance the cost of OSA detection and treatment, because these medical conditions are costly to manage, as detailed in the following paragraphs.6.3 Diagnosing and Treating OSA in Commercial Truck Drivers Is Less Expensive Than Leaving OSA Undiagnosed and UntreatedSleep apnea is an expensive disorder to neglect. In non-CMVO populations, unidentified and/or untreated OSA incurs two-fold higher medical expenses, largely associated with cardiovascular disease.42 To the extent that commercial drivers have been studied, this group appears to be no exception. In a study of commercial drivers undergoing a corporate-driven OSA detection and treatment program, CPAP intervention in 348 drivers with sleep-disordered breathing resulted in a 47.8% reduction in per-member per-month health care spending.43 Treatment of OSA with CPAP resulted in an average savings of $550 per driver per month.43 Hospital admissions were reduced by almost 25% and overall health care dollars spent were cut in half. There was a 73% reduction in preventable driving accidents after instituting a comprehensive OSA screening, diagnosis and treatment program. In another recent study conducted with the Union Pacific Railroad Employees Health Systems, a focused educational campaign on OSA improved health outcomes and led to a measureable reduction in medical expenses—a differential cost savings of $4.9 million for the 2-year study period.44On a larger scale, undiagnosed OSA cost the United States approximately $149.6 billion in 2015, of which $12.4 billion was related to diagnosis.40 The average cost of treating a patient is $1,190, which is less than the cost of a single emergency department visit for a “moderate” health complaint ($1,200).40 Detailed analyses indicate that treating OSA results in costs that are ∼33% of not treating the disorder, indicating that treatment results in a sizable cost savings.Costs related to sleepiness-related crashes are summarized in Section 5.0.7.0 CONSENSUS-BASED OSA SCREENING GUIDELINES LIKELY CAPTURE ONLY A SMALL PORTION OF CASES OF OSAGuidelines available for screening for OSA in CMVOs have been proposed by several entities, including: (1) a Joint Task Force composed of the National Sleep Foundation, American College of Chest Physicians, and the American College of Occupational and Environmental Medicine;45 and by groups convened by the FMCSA: (2) a Medical Expert Panel,46 a Medical Review Board,47 and jointly by the Medical Review Board and Motor Carrier Safety Advisory Committee48,49 of the FMCSA. They have been summarized recently.50All of these groups offer ways to keep drivers in service while undergoing evaluation and treatment for OSA. All suggest the use of objective measures, such as BMI, neck size, or the presence of hypertension to identify high-risk individuals who should undergo sleep studies to evaluate for OSA. The emphasis on objective measures is due to the unreliability of self-reported symptoms of OSA, which has been shown in multiple studies.51–53 In one study, even though 78% of those screened had confirmed OSA, none admitted to the common symptoms of snoring and sleepiness.51 Another study of 187 individuals deemed to be at high risk based on physical examination criteria found negative response to Commercial Driver Medical Examination Center (CDME) form questions regarding snoring, sleep disorders, observed apnea and daytime sleepiness.53 In another study, among all individuals with severe OSA, (defined as AHI ≥ 30 events/h) only one reported sleepiness using Ep-worth Sleepiness Scale (ESS) score.52 Finally, Schneider used their own version of an online questionnaire to screen drivers for risk for OSA, and also found that self-reported symptoms were not useful, and cited a specific instance of a driver with an AHI of 164 events/h and a normal ESS.6To date, we know of no specific recommendations for screening of rail workers in the United States, though studies of foreign rail workers suggests a prevalence of OSA similar to that of commercial drivers.11 The government of Australia requires CMVOs to have a sleep study if they meet either of these conditions: (1) BMI ≥ 40 kg/m2; (2) BMI ≥ 35 kg/m2 AND diabetes OR hypertension needing at least two medications for control. In addition, the Australian government requires a sleep evaluation for any CMVO with evidence of a sleep disorder, such as sleepiness or involvement in a sleepiness-related incident.54Data show that, by using existing guidelines, health care providers are only capturing the “tip of the iceberg” in terms of the actual numbers of potential OSA cases.51–53,55 By using guidelines provided by the Joint Task Force (which rely on the same BMI threshold of ≥ 35 kg/m2, which was recommended by the Medical Review Board of the Motor Carrier Safety Advisory Committee), only 10% to 13% of commercial truck drivers screen positive,51–53,55 despite the fact that the estimated prevalence of OSA in this group is much higher (see Section 2.2). Furthermore, none of those identified as high-risk then marked “yes” to the question about sleep disorders on the CDME form53; of those identified as high risk who completed the recommended PSG testing, 79% to 100% had confirmed OSA51–53,55; only one individual returned and showed adherence with PAP therapy52; and 34% to 81% did not return to the medical examiner for follow-up evaluation.51–53,55 No trials have explored the reasons for PAP non-adherence in this group, or ways to address it. Programs that mandate treatment,6,16 however, such as the one by Schneider, have shown that adherence improves crash rates.16Therefore, a recommendation for PSG using existing guidelines yields high rates of positive diagnoses, suggesting that the BMI threshold of ≥ 35 kg/m2 leaves high numbers of at-risk drivers untested. The failure of individuals with confirmed OSA to accept PAP therapy or return for follow-up evaluation suggests that doctor shopping was an issue. The FMCSA has since required that medical examiners undergo training and certification, and be listed in a national registry, to address the issue of doctor shopping.56,57 Investigations are needed to determine whether this registry increases the likelihood of case identification and effective treatment. These collective data support a need for mandated screening, testing, and compliance with therapy.8.0 SCREENING FOR OSA IN CMVOs AND OTHER SAFETY-SENSITIVE EMPLOYEES8.1 Screening: General ConsiderationsIt is the opinion of the AASM STSATF that transportation workers with safety-sensitive duties be required to undergo screening for OSA. By safety-sensitive we mean that if the operator were to become suddenly impaired or incapacitated, the operator would pose significant danger to himself or herself, the public, or the environment. CMVOs, therefore, are in this group, because untreated OSA puts them at risk for fall-asleep crashes. However, sleepiness-related crashes (see Section 3.0) do not require that the driver actually fall asleep; driver impairment may take the form of compromised decision making, reduced short-term memory and vigilance, increased impulsivity and risk-taking, and prolonged reaction time.58,59Currently, both the FRA and FMCSA have existing guidelines regarding who should be screened for OSA. The FRA guidelines include any personnel involved in train movement, dispatching, signal operation, and equipment maintenance who also have key risk factors for OSA, such as obesity. The FMCSA defines drivers as safety-sensitive employees. At this time, the AASM STSATF does not recommend expanding screening beyond these defined groups of safety-sensitive employees.8.2 Frequency of Screening for OSA Among Transportation Workers With Safety-Sensitive Duties, and Methods of Establishing the Diagnosis of OSARoutine screening should be conducted as part of the preexisting required fitness-for-duty medical evaluation. If this screening suggests high risk for OSA, we believe a comprehensive sleep evaluation should be performed by a board-certified sleep medicine physician.60 Criteria for referral are summarized in Table 1.Table 1 Indications for evaluation by a sleep medicine physician.Table 1 Indications for evaluation by a sleep medicine physician.Primary criteria: We recommend that drivers who meet any of the following three criteria be considered high-risk individuals who should be referred to a board-certified sleep medicine specialist for clinical sleep evaluation and diagnostic testing. Individuals with a BMI ≥ 40 kg/m2Individuals who have admitted fatigue or sleepiness during the duty period OR who have been involved in a sleepiness-related crash or accident; Factors suggesting a sleepiness-related crash or accident, including a single-vehicle crash, off-road deviation, or rear-ending another vehicleIndividuals with a BMI ≥ 33 kg/m2 and either Hypertension requiring two or more medications for control; orType 2 diabetes Published data indicate that individuals having either resistant hypertension61,62 or obesity combined with type 2 diabetes63 experience a positive predictive value of having OSA that exceeds 80%.The aforementioned criteria are recommended as the first or primary determinants of which individuals should undergo referral to a sleep medicine specialist for clinical evaluation and diagnostic testing. These criteria are recommended to capture the most at-risk individuals, the so-called “tip of the iceberg.” Secondary criteria should then be considered in order to capture the next tier of at-risk individuals. Secondary criteria for recommending diagnostic" @default.
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• W2612155816 title "Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force" @default.
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