Most Americans have experienced sleepiness during the work day - needing that extra cup of coffee to hurdle the foggy, unfocused feeling caused by lack of sleep. It is common knowledge that daytime sleepiness can significantly impact productivity, but employers also need to be aware that it could actually point to a very serious health condition.
Sleep apnea, a disorder in which breathing is briefly and repeatedly interrupted during sleep, causing low blood oxygen levels, affects one in five Americans or up to 18 million people in the U.S. Physicians cannot detect symptoms during routine office visits, and no blood test exists, so the condition often goes undiagnosed. Not only can work performance decrease by 30% percent if it goes untreated, but employees affected by sleep apnea are twice as likely to have a workplace accident.
It is important for employers and their workforces to recognize the symptoms of sleep apnea and know when further testing is necessary. By having programs, services and adequate health care professionals in place to support employees dealing with sleep apnea, employers can help improve health outcomes, increase productivity and lower overall healthcare costs.
The condition's most common form is called obstructive sleep apnea, which occurs when the muscles in the back of the throat relax and the airway intermittently collapses -sometimes hundreds of times a night for up to a minute or more each time. A major symptom is extremely loud snoring; other indications of sleep apnea include obesity, persistent daytime sleepiness and lack of concentration, awakening out of breath during the night, and frequent dry mouth or headache upon waking. When healthy sleep is interrupted in this manner, it puts a strain on the heart and increases the risk of numerous health conditions including high blood pressure, heart attack, stroke, diabetes, memory problems, depression, weight gain and impotence.
OSA occurs in men and women of all ages, but is more common in those who are overweight, over age 40, frequently smoke or drink alcohol, or are of African-American or Hispanic descent. Sleep apnea also shares many of the same cardiovascular and metabolic consequences as Type 2 diabetes and hypertension. It is associated with insulin resistance and glucose intolerance, and studies suggest that up to 40% percent of people with OSA have diabetes, and up to a third of diabetics have OSA, so the International Diabetes Federation strongly recommends that individuals with one condition be screened for the other. Similarly, sleep apnea is prevalent in those with hypertension and in fact, about half of sleep apnea patients suffer from hypertension. Recent guidelines recommend screening for its presence in these individuals.
Employer action plan
The good news is that sleep apnea can be controlled through proper diagnosis and strict adherence to a treatment regimen. A diagnosis is obtained through monitoring conducted during an overnight stay at a sleep lab or, less expensively, through a self-administered home sleep test. Both testing methods are interpreted by a physician certified in sleep medicine and meet the criteria for the diagnosis of OSA.
The standard treatment is positive airway pressure therapy, which is a shoebox-sized device with a mask that fits over the nose and/or mouth and gently blows air into the airway to help keep it open during sleep. Certain lifestyle changes can also be effective ways to mitigate symptoms, including weight loss, changing sleeping position to the side instead of the back, and avoiding alcohol and smoking before bedtime.
Starting therapy upon diagnosis and adhering to treatment is critical, especially since most sleep apnea patients are dealing with the compounding effects of more than one health condition. Annual U.S. medical costs directly resulting from non-adherence to sleep apnea therapy total $3.4 billion. Employers need to take the right steps to provide necessary solutions to help their colleagues manage this chronic condition in order to lower these health care costs and productivity losses - which can reach approximately $5 billion in the United States alone.
Here are some potential solutions worth considering:
Use screening tools
Promote awareness of tools such as OSA screening questionnaires through onsite health clinic promotions or in companywide newsletters. These respected resources can help employees better assess the severity of their condition. A few examples to consider are the Epworth Sleepiness Scale, the Berlin Questionnaire and the STOP Q's (Do you Snore loudly? Do you often feel Tired during the daytime? Has anyone Observed you stop breathing during sleep? Do you have high blood Pressure?).
Consider adding OSA screening to the company's health benefit plan by asking the plan provider to include it as part of the annual health risk assessment. Facilitate understanding of all available diagnostic options. Though covered by health insurance, sleep lab monitoring will incur a higher out of pocket expense for the employee. The use of home sleep tests provides a more cost-effective option without compromising patient health, however the deductible by plan would not change.
Make specialists available
Work with your company's health plan to provide workforce access to sleep medicine healthcare professionals. Compliance with wearing the positive airway pressure mask nightly is a significant factor in effectively treating sleep apnea, and it is estimated that compliance is currently under 50% percent. PAP adherence reduces the length of hospital stays by 58% percent. Sleep specialists and respiratory therapists can implement a comprehensive coaching plan centered on reinforced behavior modification to raise compliance up to 70 or 80% percent. They will be able to provide sleep activity assessments, coaching on appropriate product use (i.e., mask fit, troubleshooting) and compliance, as well as ongoing clinical counseling. Counseling should also entail management of comorbidities associated with sleep apnea including diabetes, hypertension and other cardiovascular conditions.
Implement a program that manages and supports patient adherence. More than $1,300 in shared savings between the health plan and employer can be recognized annually for each adherent patient.
Encourage the health plan to use monitoring and reporting tools to better track adherence rates. Care coordination for comorbid conditions, like diabetes, should also be included. Researchers evaluated the effects of sleep apnea treatment with PAP therapy on blood sugar levels in a group of 25 people with Type 2 diabetes and found that average blood glucose levels were reduced after breakfast and other meals.
Consider engaging a clinical coaching model which provides a clinical health coach who is in consistent contact with the patient. These coaches help navigate the treatment process with scheduled coaching calls, with data monitoring, uncovering and troubleshooting problems (i.e., cleaning and maintenance of PAP equipment), and encouraging compliance. This is a two-way communication model. If the patient has any questions or concerns, he or she can contact the OSA health coach, too.
Keep employees healthy by raising awareness about sleep apnea through all appropriate communications channels. Patient education materials on sleep apnea treatments and testing options should be made available through third parties (e.g., health plans or physicians). Employers may have the capacity to share information, such as fact sheets and online resources, via an intranet site. Also, consider implementing a yearly health survey (i.e., STOP Qs) to keep this condition top of mind and help employees determine whether they should pursue guidance from their doctor.
Pamela K. Fry is senior manager, sleep medicine, with Liberty Medical. She can be reached at firstname.lastname@example.org.
What's your snore score?
The American Sleep Apnea Association lists four self-administered tests people can take to determine if they may suffer from obstructive sleep apnea or some other breathing disorder. Among these is its snore score:
* Are you a loud and/or regular snorer?
* Have you been observed to gasp or stop breathing during sleep?
* Do you feel tired or groggy upon awakening, or do you awaken with a headache?
* Are you often tired or fatigued during the wake time hours?
* Do you fall asleep sitting, reading, watching TV or driving?
* Do you often have problems with memory or concentration?
If you have one or more of these symptoms, you are at higher risk for having obstructive sleep apnea.
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