The Cardinal Manifestations of Sleep Disorders

1. The Cardinal Manifestations of Sleep Disorders Andrew Mouton, PhD, D.ABSM, CBSM Associates in Sleep Medicine, LLC The Center for Sleep Medicine Chicago, IL

2. Associates in Sleep Medicine, LLC • 14 member sleep medicine practice • multidisciplinary (medicine, behavioral health, dentistry) • multispecialty (pulmonology, neurology, psychiatry, internal medicine, pediatrics) • 40 beds in 7 AASM accredited centers • 7,000 sleep studies per year Associates in Sleep Medicine

3. Illinois Trucking Association Mid-West Truckers Association, Inc. 1. seminars for associate members 2. provide educational materials 3. attend monthly safety meetings Associates in Sleep Medicine

4. 350 member companies • Small carriers • Utilize owner/operators as independent contractors • Aware of risks associated with fatigue/sleepiness • Awaiting regulations from FMCSA • No insurance plan • Owner/operators unable to afford cost of screening/diagnosis/treatment Associates in Sleep Medicine

5. 350 member companies • Large carriers • Very aware of costs/dangers associated with fatigue/sleepiness • May have fatigue management program in place • Not waiting for specific guidelines from FMCSA • Have insurance/money to fund program Associates in Sleep Medicine

6. Archer Daniels Midland Co. • Obstructive Sleep Apnea program • Educational materials • Screening by occupational medicine • Encourage drivers to self-identify • 100% insurance coverage for testing/treatment • Paid for testing period Associates in Sleep Medicine

7. Archer Daniels Midland Co. • Assessment/diagnosis/treatment of non-apnea sleep disorders • ASM collaboration with EAP • Coverage at 100% for up to five visits • Behavioral Sleep Medicine focus Associates in Sleep Medicine

8. Kenan Advantage Group, Inc. • One of the largest tank truck/hazmat carriers • 7500 Drivers Plan: All drivers evaluated by a sleep medicine specialist Why? Associates in Sleep Medicine

9. June 26th, 2009Miami, OK • Commercial truck driver going 69 mph • Cruise control on • Hit 6 vehicles • 10 lives lost • 5 injured Associates in Sleep Medicine

10. NTSB Findings • “the driver’s fatigue, caused by the combined effects of acute sleep loss, circadian disruption associated with his shift work schedule, and mild sleep apnea, which resulted in the driver’s failure to react to slowing and stopped traffic ahead” Deborah Hersman NTSB Board Chairperson Associates in Sleep Medicine

11. Acute sleep loss Circadian disruption associates with shift work schedule Mild sleep apnea Insufficient sleep syndrome Shift work sleep disorder Sleep apnea Fatigue caused by: Associates in Sleep Medicine

12. Policy implications: • “develop standard medical exam to screen for sleep disorders and require its use” Hon. Mark Rosekind, PhD NTSB member Associates in Sleep Medicine

13. Cardinal manifestations of sleep disorders: • Insomnia • Difficulty falling asleep • Frequent awakenings • Hypersomnia • Excessive daytime sleepiness • Sleep at inappropriate times/places • Unusual sleep behaviors Associates in Sleep Medicine

14. What if a driver screens positive? • 391.41(b)(5) • A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with the ability to control and drive a commercial motor vehicle safely. Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory function under emergency conditions may be detrimental to safe driving. There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, that in any way is likely to interfere with the driver’s ability to safely control and drive a commercial motor vehicle, the driver must be referred to a specialist for further evaluation and therapy. Associates in Sleep Medicine

15. For sleep disorders: • A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a sleep disorder likely to interfere with the ability to control and drive a commercial motor vehicle safely. Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in alertness under emergency conditions may be detrimental to safe driving. There are many conditions that interfere with alertness and may result in incapacitation, including insomnia, circadian rhythm disorders, sleep apnea, narcolepsy, and hypersomnia. If the medical examiner detects a sleep disorder, that in any way is likely to interfere with the driver’s ability to safely control and drive a commercial motor vehicle, the driver must be referred to a specialist for further evaluation and therapy Associates in Sleep Medicine

16. “the driver must be referred to a specialist for further evaluation and therapy” Associates in Sleep Medicine

17. Advantages: • Allows for comprehensive evaluation of all sleep disorders • Meets standard of care in sleep medicine • Cost effective • Many sleep problems don’t require testing • Testing performed only when indicated following comprehensive sleep evaluation Associates in Sleep Medicine

18. Drawbacks? • Are there enough sleep specialists? • 72 ACGME accredited sleep medicine fellowships • 2700 physicians certified in first two sleep board examination cycles • 3445 specialists credentialed by ABSM Associates in Sleep Medicine

19. Will it cost too much? • 2011 Medicare reimbursement: • 99204 $169.07* • 99214 $110.08* • 95810 $734.78* • 95811 $792.80* * 2011, Cook County, IL Associates in Sleep Medicine