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

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

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

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

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

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

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

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

10. Associates in Sleep Medicine 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” “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

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

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

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

14. Associates in Sleep Medicine What if a driver screens positive? 391.41(b)(5) 391.41(b)(5) A person is physically qualified to drive a commercial motor vehicle if that person: 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.

15. Associates in Sleep Medicine For sleep disorders: A person is physically qualified to drive a commercial motor vehicle if that person: 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

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

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

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

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