OOIDA: MRB’s apnea cart is before the horse

| 12/9/2011

Two advisory committees agreed Wednesday to approve recommendations that could pull millions of truck drivers from the road and require billions of dollars to be spent on sleep medicine industry products and services.

In a meeting conducted jointly between the FMCSA’s Medical Review Board and Motor Carrier Safety Advisory Committee, both groups agreed to recommend that drivers with a body mass index of 35 or greater be required to “be evaluated for obstructive sleep apnea,” and that other drivers with potential sleep problems be immediately disqualified from driving.

Wednesday’s meeting, however, appeared to include little exchange of information between experts on both panels.

Instead, medical doctors on the Medical Review Board appeared to ignore points of concern brought by commercial vehicle experts, MCSAC members, and even medical experts seated in the audience.

Medical Review Board members used a mixture of anecdotal truck crash descriptions and presentations from researchers before moving forward with the BMI recommendation. MRB members appeared to rarely acknowledge dissenting opinion.

OOIDA Executive Vice President Todd Spencer led a chorus of trucking industry and health professionals who questioned the rampant speed with which some MRB members were pushing for an immediate recommendation.

“I think the cart is way ahead of the horse on this issue,” Spencer said. “Everyone we have heard from has had an economic interest in expanding what they characterize as an epidemic.”

Spencer pointed out that examiners aren’t given guidance to look at other sleep disorders, or a simple lack of sleep because of myriad factors U.S. truckers face on a daily basis.

“Unquestionably, apnea is fairly common in society,” Spencer added later. “Does apnea result in very many crashes? Real accident analysis suggests it doesn’t. It’s going to be far more likely that somebody just didn’t have the opportunity to get restorative sleep because that’s not an easy thing for truck drivers to do.

“Every day those who are on the road – their struggle is to find someplace where they can stop and sleep. And where they won’t get bothered, rousted and run out. Those things people need to do to maintain alertness we’re discouraged from. Drivers don’t set their own schedules; they work around everyone else’s.”

Others agreed.

“I take issue with a lot of the data presented this morning,” said Rob Abbott, vice president for safety policy at American Trucking Associations. “I think it’s inaccurate and misleading.”

Others questioned the need to approve a recommendation the very day it was presented.

“I do have a problem rushing this,” said MCSAC member Calvin Sturdivant. “This is too important to rush. I don’t understand why you need to put out guidance now, when you have an agency that’s willing to do this and do it the right way. ‘We need to do it before we leave the room?’ I don’t get it.”

Aside from the timing, an FMCSA regulation that could require millions to be tested might have unintended consequences. ATA’s Abbott said removing drivers who may possibly be at risk for apnea also will severely shrink the truck driver pool.

“We have to approach this very cautiously,” Abbott said. “30 percent of the 6 million (CDL holders) would be affected? I submit that that may be a concern. … This industry is 98 percent small business, and you don’t have the same sort of health benefits for drivers. What you’re doing is pushing them out of the industry. When we push them out of the industry, we’re inviting others in.”

One presenter, Andrew Mouton of Associates in Sleep Medicine, told the group he treats truck drivers for apnea.

Mouton appeared to question why apnea was the sole focus of the two committees.

“It’s not just apnea in truck drivers,” Mouton said. “Sleep is probably a larger issue. … Apnea is probably not the single greatest cause of sleepiness in this population. We need to be screening for sleep disorders.”

Edward Grandi, executive director of the American Sleep Apnea Association cautioned members of both committees about the ramifications of their recommendations. Grandi pointed out that apnea carries a stigma that can both hurt a driver and motivate CDL holders to keep personal health concerns underground.

Diagnosing or red-flagging an individual for sleep concerns is “putting someone on a long journey – a journey that will probably be with them for the rest of their lives,” he said.

“You have to keep in mind there are going to be drivers who will struggle with being compliant,” Grandi said. “Make it a safe place both for drivers to disclose that they have problems and to show they’re compliant.”

Ben Hoffman, chief medical officer for General Electric Healthcare and chairman of the MRB, signaled that he wasn’t interested in dialogue about whether apnea causes truck crashes.

“The train is out of the station, folks,” Hoffman said. “It’s a matter of trying to make this final regulation something that’s palatable to a large number of parties.”

Later, as MRB members quibbled over the required number of nightly hours drivers with apnea would need to demonstrate compliance, Hoffman noted how arbitrary it was to define a specific number.

“But then,” Hoffman said, “all of this is arbitrary in a sense.”

Under the recommended guidance, medical examiners won’t be required to send drivers with a BMI of 35 to sleep labs, but the guidance would serve as a strong hint.

In addition to the guidance, the committees agreed to approve a recommendation that drivers would be immediately disqualified from driving if they admit to falling asleep behind the wheel; have a fatigue-related crash; have an apnea-hypopnea index greater than 20 until they’re treated by CPAP; have undergone apnea surgery, until post-surgical evaluation; and don’t comply with CPAP treatment.

The FMCSA Medical Review Board is advisory in nature, and cannot approve its suggestions. The MRB’s recommendations are forwarded to FMCSA, which can choose to adopt, amend or ignore the recommendations.

A 5-foot-9-inch person weighing 237 pounds has a BMI of 35. The average U.S. female height is 5-foot-4-inches. A 204-pound person at that height has a BMI of 35 and would be subject to the recommended sleep apnea exam.

Larry Minor, FMCSA Designated Federal Official, clarified the power of guidance by saying medical examiners would be told: “If you encounter this situation, you should consider deferring the granting of a medical card.”

“At least you should delay granting a medical card to this individual,” Minor said. “Let’s defer issuing this person’s medical card until he sees someone to get a proper diagnosis.”