Coping with shiftwork becomes more challenging for individuals whose sleep is disturbed by an untreated sleep disorder. Obstructive Sleep Apnea Syndrome (OSAS) is one of the more common sleep disorders. It consists of episodes of interrupted breathing during sleep, resulting in sleep fragmentation and daytime sleepiness. OSAS is a disorder affecting 2% of women and 4% of men in middle-aged adults. Besides biological factors such as gender and age, lifestyle traits like obesity and tobacco and alcohol use have been identified as risk factors. In addition, some studies suggest that occupational factors may also play a role. For example, an elevated prevalence of OSAS has been documented in the industrial and transportation sectors where shiftwork and/or irregular hours are common.
With these groups, it is not unusual to find OSAS prevalence rates of 15-18% of the total workforce.
Individuals with sleep apnea may also be at an increased risk for hypertension, cardiovascular and cerebrovascular diseases and other medical disorders. OSAS patients have been found to be heavy users of health care resources in the years prior to their diagnosis and treatment. In addition, OSAS results in increased risk of driving accidents and performance problems at work. However, OSAS can usually be treated effectively, resulting in improved alertness, cognitive performance and mood as well as improved health and quality of life.
Despite its relatively high prevalence, most OSAS cases are unrecognized by the medical community, and at least 80% of moderate to severe OSAS in middle-aged adults is likely to be missed. Some factors may increase the problem in the shiftworker population. Individuals are less likely to consult their doctors about their fatigue and sleepiness problems, because they are often considered to be a logical side effect of their working schedules. In addition, many workers in 24-h operations have safety-sensitive positions, so they
may be more reluctant to identify themselves as having sleep problems due to fear of job security.
Circadian has developed a turn-key OSAS screening and treatment program for shiftworkers that includes education, pre-screening, case management and patient counseling. The program was first implemented in one division of a major
US railway, with 2,386 employees, across four states and in more than 20 locations.
The voluntary program was open to all employees and medical costs were usually covered by the employee’s health insurance. Individual results were kept confidential, and the company received only aggregate participation and treatment results. The program had two phases: 1) pre-screening offered to all employees and 2) case management of diagnosis and treatment for at-risk individuals.
1. Pre-screening
A package containing educational information about sleep apnea and a pre-screening questionnaire was mailed to each employees home. Employees returned the completed questionnaires directly to Circadian. A total of 248 completed questionnaires (response rate 10.4%) were returned. Among the 248 questionnaires returned, 136 employees (54.8%) were found at risk for sleep apnea.
2. Diagnosis and treatment
All employees were informed about their results. At-risk employees were contacted by phone to discuss their results. Although the majority of employees expressed initial interest in a sleep evaluation, ultimately only 56 individuals (41% of the “at risk” group”) decided to go to a sleep lab for a full study and objective diagnosis. The reasons given for not participating included having other more urgent medical problems, lacking time and interest, and not believing there was a problem. For those who did participate, sleep studies were coordinated with the insurance carrier, primary care doctor and sleep lab. Primary care doctors were in charge of referring patients to the sleep labs. The diagnoses for the 56 employees who had a sleep evaluation were as follows:
- 43 (76%) had mild/moderate/severe sleep apnea requiring CPAP (Continuous Positive Air Pressure) treatment or surgery.
- 11 (20%) had mild apnea or primary snoring, with treatment options including oral devices, losing weight and better sleep hygiene.
- One case of narcolepsy and one case of shiftwork sleep disorder
Follow-up was conducted with all participants. Individuals using the CPAP treatment device experienced the usual problems adapting to the equipment, but the ongoing counseling helped to maintain compliance. Most employees reported “usually” using their CPAP machines when they slept, for an average of 5-6 hours. Some were not able to adapt to their CPAPs by the end of the program and continued to work with their physicians on alternative options. Support and counseling that was provided for 3 months after the treatment served to increase treatment compliance. Primary care doctors were in charge of assuring long-term follow-up.
Summary of Results
Total employees | 2,386 | |
Pre-screening questionnaires completed | 248 | 10.4% of total |
Employees at-risk | 136 | 54.8% of those who returned questionnaires |
Sleep studies performed | 56 | 41% of those identified at risk |
Confirmed OSAS | 43 | 76% of those who had a sleep study |
Table 1. Summary of participation rates and sleep studies results.
Conclusions
- The pre-screening questionnaire is a valid tool, since 76% of those individuals identified at-risk with the questionnaire had OSAS confirmed by the sleep lab evaluation.
- Although the response rate for the pre-screening survey may seem relatively low (10.4% of the employee population), it actually is much higher than response rates to other surveys, and it is important to take into account that the questionnaire asked employees health and lifestyle data, and they had to identify themselves. In addition, employees who do not have any of the symptoms described are not likely to complete the questionnaire, while those who recognized some symptoms are most likely to respond. The fact that 61% of respondents reported habitual snoring and 20 % hypertension supports this assumption. Moreover, slightly more than half of respondents were identified as “at risk.” The fact that respondents are a self-selected group allows focusing the program on those employees who most need it.
- Among individuals identified “at-risk”, almost half decided to have a sleep evaluation through the program. While at the beginning some employees were somewhat reluctant to undergo a sleep evaluation in a sleep lab, once the first employees were successfully treated they became champions of the program, and participation rates increased significantly. In addition, additional information through contacts with local sleep labs proved that a number of employees used the information provided to consult their doctors and get treated outside the program.
- At the completion of the program, slightly more than half of the suspected cases of sleep apnea were diagnosed, treated, and returned to normal. Given that sleep apneacs cost a company more than $6,000 per year in health and wellness costs over and above the average employee – the program provided significant return-on-investment.