Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to Require Sleep Apnea Testing in Commercial Transportation Operators

In another move favoring business interests and against the common good, the Trump administration’s Department of Transportation announced recently that they are rescinding plans to require testing for obstructive sleep apnea (OSA) in train and commercial motor vehicle operators (1). As exemplified by its withdrawal from the Paris climate accords, this decision is another example of how the current administration disregards scientific findings and present-day events in establishing policy that will be detrimental to Americans.

Let us step back for a moment and briefly review the evidence that the Trump administration has ignored.

• It is well established that obstructive sleep apnea (OSA) can result in daytime sleepiness (2) and that sleepiness is detrimental to safe operation of a train or motor vehicle.
• Many studies have established that persons with OSA have an increased risk of motor vehicle crashes (3).
• Studies in commercial truck drivers have observed that this population has a high prevalence of OSA (4).
• It is estimated that OSA costs the American economy $150 billion annually (5).
• There now are relatively easy and inexpensive protocols to screen high risk individuals for OSA (4).
• Obstructive sleep apnea is a treatable condition, and treatment mitigates OSA impairment in sleepiness and reduces crash risk (6,7). In contrast, non-compliance with treatment is associated with a five-fold increase in crash risk (6).
• The costs of diagnosis and treatment are much lower than the costs that ensue when OSA persists untreated (5). For example, significant healthcare savings result from successful treatment of truck drivers (8).
• Failure to recognize and treat OSA has resulted in several high-profile transportation accidents. The following are some recent incidents:
  • September 2016: A commuter rail train slammed into the station at Hoboken, NJ killing a female bystander and leaving a child without a mother. The engineer had undiagnosed severe OSA (9).
  • December 2013: A Metro North commuter rail engineer fell asleep and his train sped around a curve resulting in a crash that killed 4 and injured 70 (10). The National Transportation Safety Board determined that undiagnosed severe OSA was the probable cause of the accident. The lack of a policy which required sleep disorder screening was further determined to be a contributing factor (11).
  • September 2013: A Greyhound bus overturned on Interstate 70 because the driver fell asleep resulting in multiple injuries. The driver was later found to have untreated OSA (12).
  • June 2009: A tractor-trailer traveling at a high speed did not see stopped cars ahead on Interstate 44 resulting in a crash that killed 10 and injured 6. It was later determined that the truck driver had mild OSA contributing to fatigue (13).

Despite the weight of the aforementioned evidence, the current administration has chosen to ignore it in favor of letting private industry regulate itself implying the current regulations are sufficient. As illustrated by the incidents cited above, recent events have proven them wrong. As Sir Winston Churchill once said “Those who fail to learn from history are doomed to repeat it”. Continuing with the current policy will inevitably result in further preventable disasters and more loss of life.

What can be done? At the federal level, one should consider advocating to your own congressional representatives for reconsideration of this poorly considered policy. On a personal level, federal policy is ultimately guided by the “ballot box”, which is something to consider for the next election. Finally, be aware that the next time you are driving down the interstate, the truck or bus driver approaching you from behind may have untreated OSA!

Stuart F. Quan, M.D.^1,2, Laura K. Barger, Ph.D.¹, Matthew D. Weaver, Ph.D.¹, and Charles A. Czeisler, Ph.D., M.D.¹

¹Division of Sleep and Circadian Disorders

Brigham and Women’s Hospital

Harvard Medical School, Boston, MA USA

²Asthma and Airway Disease Research Center

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Federal Register. Evaluation of safety sensitive personnel for moderate-to-severe obstructive sleep apnea. Last updated: 2017. Available at: https://federalregister.gov/d/2017-16451 (Accessed: August 10, 2017)
2. Committee on Sleep Medicine and Research Board on Health Sciences Policy. Sleep disorders and Sleep Deprivation--An Unmet Public Health Problem. Washington, D.C.: National Academies Press, 2006; 404.
3. Tregear S, Reston J, Schoelles K, Phillips B.Obstructive sleep apnea and risk of motor vehicle crash: systematic review and meta-analysis. J Clin Sleep Med. 2009 Dec 15;5(6):573-81. [PubMed]
4. Kales SN, Straubel MG.Obstructive sleep apnea in North American commercial drivers. Ind Health. 2014;52(1):13-24. [CrossRef] [PubMed]
5. Anonymous. Hidden health crisis costing America billions. Underdiagnosing and undertreating obstructive sleep apnea draining healthcare system. Last updated: 2016. Available at: http://www.aasmnet.org/sleep-apnea-economic-impact.aspx (Accessed: August 15, 2017)
6. Burks SV, Anderson JE, Bombyk M, et al. Nonadherence with employer-mandated sleep apnea treatment and increased risk of serious truck crashes. Sleep. 2016 May 1;39(5):967-75. [CrossRef] [PubMed]
7. Tregear S, Reston J, Schoelles K, Phillips B.Continuous positive airway pressure reduces risk of motor vehicle crash among drivers with obstructive sleep apnea: systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1373-80. [CrossRef] [PubMed]
8. Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D. The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med. 2010 May;52(5):473-7. [CrossRef] [PubMed]
9. Anonymous Hoboken train crash investigation hampered by heavy damage. CBS News. 2016; Available at: http://www.cbsnews.com/news/hoboken-train-crash-investigation-hampered-heavy-damage/ (Accessed: August 15, 2017)
10. Anonymous. December 2013 Spuyten Duyvil derailment. Last updated: 2017. Available at: https://en.wikipedia.org/wiki/December_2013_Spuyten_Duyvil_derailment (Accessed: August 10 , 2017)
11. National Transportation Safety Board. ​Metro-North Railroad Derailment. Last updated: 2014. Available at: https://www.ntsb.gov/investigations/AccidentReports/Pages/RAB1412.aspx (Accessed: August 15, 2017)
12. Lee D.  Sleep Test Leads to $6M Greyhound Settlement. Last updated: 2016. Available at: http://oldarchives.courthousenews.com/2016/03/09/sleep-test-leads-to-6m-greyhound-settlement.htm (Accessed: March 9, 2017)
13. National Transportation Safety Board. Highway Accident Report: Truck‐Tractor Semitrailer Rear‐End Collision Into Passenger Vehicles on Interstate 44 Near Miami, Oklahoma June 26, 2009. Last updated: 2010. Available at: https://www.ntsb.gov/investigations/AccidentReports/Reports/HAR1002.pdf (Accessed: August 10, 2017)

Cite as: Quan SF, Barger LK, Weaver MD, Czeisler CA. Saving lives or saving dollars: The Trump administration rescinds plans to require sleep apnea testing in commercial transportation operators. Southwest J Pulm Crit Care. 2017;15:84-6. doi: https://doi.org/10.13175/swjpcc102-17 PDF 

Disclosures 

Editor's note: In 2016 Dr. Quan authored an editorial titled "Screening for Obstructive Sleep Apnea in the Transportation Industry—The Time is Now" in SWJPCC. The editorial encouraged screeening of transportation workers for sleep apnea.

CMS Penalizes 758 Hospitals for Safety Incidents

The Centers for Medicare and Medicaid Services (CMS) is penalizing 758 hospitals with higher rates of patient safety incidents, and more than half of those were also fined last year, as reported by Kaiser Health News (1).

Among the hospitals being financially punished are some well-known institutions, including Yale New Haven Hospital, Medstar Washington Hospital Center in DC, Grady Memorial Hospital, Northwestern Memorial Hospital in Chicago, Indiana University Health,  Brigham and Womens Hospital, Tufts Medical Center, University of North Carolina Hospital, the Cleveland Clinic, Hospital of the University of Pennsylvania, Parkland Health and Hospital, and the University of Virginia Medical Center (Complete List of Hospitals Penalized 2016). In the Southwest the list includes Banner University Medical Center in Tucson, Ronald Reagan UCLA Medical Center, Stanford Health Care, Denver Health Medical Center and the University of New Mexico Medical Center (for list of Southwest hospitals see Appendix 1). In total, CMS estimates the penalties will cost hospitals $364 million. Look now if you must, but you might want to read the below before on how to interpret the data.

The penalties, created by the 2010 health law, are the toughest sanctions CMS has taken on hospital safety. Patient safety advocates worry the fines are not large enough to alter hospital behavior and that they only examine a small portion of the types of mistakes that take place. On the other hand, hospitals say the penalties are counterproductive and unfairly levied against places that have made progress in safety but have not caught up to most facilities. They are also bothered that the health law requires CMS to punish a quarter of hospitals each year. CMS plans to add more types of conditions in future years.

I would like to raise two additional concerns. First, is the data accurate? The data is self-reported by the hospitals and previously the accuracy of these self reports has been questioned (2). Are some hospitals being punished for accurately reporting data while others rewarded for lying? I doubt that CMS will be looking too closely since bad data would invalidate their claims that they are improving hospital safety. It seems unlikely that punishing half the Nation's hospitals will do much except encouraging more suspect data.

Second, does the data mean anything? Please do not misconstrue or twist the truth that I am advocating against patient safety. What I am advocating for is meaningful measures. Previous research has suggested that the measures chosen by CMS have no correlation or even a negative correlation with patient outcomes (3,4). In other words, doing well on a safety measure was associated with either no improvement or a negative outcome, in some cases even death. How can this be? Let me draw an analogy of hospital admissions. About 1% of the 35 million or so patients admitted to hospitals in the US die. The death rate is much lower in the population not admitted to the hospital. According to CMS' logic, if we were to reduce admissions by 5% or 1.75 million, 17,500 lives (1% of 1.75 million) would be saved. This is, of course, absurd.

Looking at hospital acquired infections which make up much of CMS' data, CMS' logic appears similar. For example, insertion of urinary catheters, large bore central lines or endotracheal intubation in sick patients is common. The downside is some will develop urinary, line or lung infections as a complication of these insertions. Many of these sick patients will die and many will have line infections. The data is usually reported by saying hospital-acquired infections have decreased saving 50,000 lives and saved $12 billion in care costs (5). However, the truth is that hospital-acquired infections are often either not the cause of death or the final event in a disease process that caused the patient to be admitted to the hospital in the first place. If 50,000 lives are saved that should be reflected in the hospital death rates or a savings on insurance premiums. Neither has been shown to my knowledge.

So look at the data if you must but look with a skeptical eye. Until CMS convincingly demonstrates that the data is accurate and that their incentives decrease in-hospital complications, mortality and costs-the data is suspect. It could be as simple that the hospitals receiving the penalties are those taking care of sicker patients. What this means is that some hospitals, perhaps the ones that need the money the most, will have 1% less CMS reimbursement, which might make care worse rather than better.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Rau J. Medicare penalizes 758 hospitals for safety incidents, Kaiser Health News. December 10, 2015. Available at: http://khn.org/news/medicare-penalizes-758-hospitals-for-safety-incidents/ (accessed 12/11/15).
2. Robbins RA. The Emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care 2012;5:203-5.
3. Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86
4. Lee GM, Kleinman K, Soumerai SB, et al. Effect of nonpayment for preventable infections in U.S. hospitals. N Engl J Med. 2012;367(15):1428-37. [CrossRef] [PubMed]
5. Department of Health and Human Services. Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided. December 2, 2014. Available at: http://www.hhs.gov/about/news/2014/12/02/efforts-improve-patient-safety-result-1-3-million-fewer-patient-harms-50000-lives-saved-and-12-billion-in-health-spending-avoided.html (accessed 12/11/15).

Cite as: Robbins RA. CMS penalizes 758 hospitals for safety incidents. Southwest J Pulm Crit Care. 2015;11(6):269-70. doi: http://dx.doi.org/10.13175/swjpcc153-15 PDF