This issue of JCSM includes a provocative paper by Elgar et al.1 that has implications for all of us who drive. These investigators analyzed responses of more than 3,000 individuals from the face-to-face South Australian Health Omnibus Survey, and concluded that 9% would avoid diagnosis, lie to their doctor or doctor shop in order to keep their license. About a third of respondents were unaware of the legislated requirement to self-report or of the potential to jeopardize insurance support if they failed to do so. On the other hand, the number who said they would try to avoid detection fell to about 4% (theoretically) if they were educated about required self-report legislation and the risk of insurance loss. Although this survey was about mandatory reporting of medical conditions in general, it has obvious implications for the diagnosis and treatment of obstructive sleep apnea (OSA), which is a risk for motor vehicle crash.2 Besides highway safety, another critical issue that hangs in the balance is the willingness of patients to seek diagnosis and treatment for OSA (or any medical condition), which ultimately affects public health.
Currently, non-commercial drivers with OSA in the United States are not required to self-report, unless required to under US state statutes as discussed by Elgar et al., and generally are not subject to reporting by diagnosing clinicians. For high risk drivers, The American Thoracic Society recommends “that polysomnography be performed and, if indicated, treatment initiated as soon as possible.”3 The findings of the paper by Elgar et al. would support educating non-commercial drivers with suspected OSA about the driving (and health) risks; their paper suggests that this may be more likely to result in improved health and safety than mandatory physician report.
Support for the self-report notion is also evident in studies of the effect of stigma, defined as “the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised.”4 Stigma clearly has a negative and corrosive effect on public health,4 and mandatory physician reporting and potential loss of driver's license might be considered to be a form of stigma.
In that regard, we were curious about how burdensome self-reporting might be, in terms of time and money for study participants. We queried Mr. Elgar by email about insurance coverage for OSA diagnosis and treatment. He responded, “In Australia…the majority of disqualifying medical conditions would be able to be diagnosed and treated in a manner affordable to all, albeit over potentially widely varying time frames,” which might be as long as 2 years, though usually shorter. Two years without driving could definitely be considered a form of stigma.
On the other hand, the negative effects of stigma need to be balanced against the potential harms of conditions which might be stigmatized. Although this survey likely included mostly non-professional drivers, the findings are particularly relevant to commercial drivers, who have a financial incentive not to self-report, are more likely to be male, and drive vehicles which carry much more serious consequences if they crash.5
John and Wanda Lindsay were traveling on I-30 when they were struck by a semi-truck driven by a driver with recently-diagnosed severe uncontrolled sleep apnea. John did not survive the crash.6 On June 26, 2009, a tractor trailer crashed into a line of stopped vehicles, killing seven people. Post-crash polysomnography of the driver showed an AHI of 15/h. The driver had recently been released from the hospital with discharge recommendations to be evaluated for sleep apnea (which he declined).7 These cases involved commercial drivers in the US, where self-report is required under federal statute and failure to report is a felony.8 These and several other tragedies might have been prevented if mandatory reporting by physicians had been in place for commercial drivers.
But what are the downsides to mandatory physician reporting? In addition to the health and safety costs of avoiding diagnosis is the degradation of the patient physician relationship. Trust is needed to ensure patients fully and accurately describe their conditions and symptoms. Multiple studies have shown commercial drivers generally do not report their symptoms when their job is on the line.9 The US experience with air traffic controllers in the Federal Aviation Administration (FAA) confirmed this to be true, especially when loss of job was involved. Prior to 2010, OSA was a disqualifying condition to remain an air traffic controller. The FAA found fewer than 0.1% of air traffic controllers reported OSA during that time period!10
On the other hand, Platt11 and others12 have reported that driver self-report of symptoms that is obtained in a non-punitive environment improved the sensitivity and negative predictive value of OSA screenings.
Another significant concern that we have with mandatory reporting of OSA by physicians is the tendency to focus on sleep apnea and overlook other important medical condition related causes of crash, such as medications,13 (antihistamines,14 antidepressants,15 sleeping pills,16 and narcotics,14 which are among the drugs associated with increased risk of crash). Sleep deprivation is also a risk for crash and is more prevalent than sleep apnea.17 And there are many other documented risks for crash that are not addressed with an approach that is focused sleep apnea.
We believe that a comprehensive approach, with an emphasis on personal responsibility and education, is more likely to improve health and safety on our highways than mandatory reporting. An example of such an approach is the North American Fatigue Management Program, which is a joint US-Canadian online educational resource that aims to educate truck drivers, family members, trucking management, shippers, and receivers about the roles they all play in managing causes of driver fatigue, including sleep apnea.18
In the end, it is a hard balance to strike. We simply don't have enough data to make an evidence-based decision about this complex issue. The paper by Elgar et al. provides some grist for the mill.
Dr. Phillips has served as a consultant to the Medical Advisory Board of the Federal Motor Carrier Safety Administration and is the Medical Director of a Sleep Disorders Center. Mr. Statnton is a working US truck driver with OSA and co-coordinator of a support group for truck drivers with OSA, Truckers for a Cause, http://truckersforacause.com.