Abstract Non-Adherence with Employer-Mandated Sleep Apnea Treatment and Increased Risk of Serious Truck Crashes


Stephen V. Burks, PhD1,3,4;, Jon E. Anderson, PhD2; Matthew Bombyk, MS1; Rebecca Haider, BA1; Derek Ganzhorn, JD1; Xueyang Jiao, MS1; Connor Lewis2; Andrew Lexvold, BA2; Hong Liu, BA1; Jiachen Ning, BA1s; Alice Toll, BA2; Jeffrey S. Hickman, PhD5; Erin Mabry, PhD5; Mark Berger, MD, FCCP6; Atul Malhotra, MD7; Charles A. Czeisler, MD, PhD8,9; Stefanos N. Kales, MD, MPH9,10,11

Author Affiliations

1Division of Social Science, University of Minnesota, Morris, MN; 2Division of Science and Math, University of Minnesota, Morris, MN; 3Center for Transportation Studies, University of Minnesota; 4Institute for the Study of Labor (IZA), Bonn, DE; 5Virginia Tech Transportation Institute, Blacksburg, VA; 6Precision Pulmonary Diagnostics, Houston, TX; 7Division of Pulmonary and Critical Care Medicine, School of Medicine, University of California, San Diego, San Diego, CA; 8Division of Sleep Medicine and Circadian Disorders, Department of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA; 9Division of Sleep Medicine, Harvard Medical School, Boston, MA; 10Department of Environmental and Occupational Medicine and Epidemiology, Harvard TH Chan School of Public Health, Boston, MA; 11Occupational Medicine, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA

Study Objectives

To evaluate the effect of an employer-mandated obstructive sleep apnea (OSA) program on the risk of serious preventable truck crashes.


Data are from the first large-scale, employer-mandated program to screen, diagnose, and monitor OSA treatment adherence in the US trucking industry. A retrospective analysis of cohorts was constructed: polysomnogram-diagnosed drivers (OSA positive n = 1,613, OSA negative n = 403) were matched to control drivers unlikely to have OSA (n = 2,016) on two factors affecting crash risk, experience-at-hire and length of job tenure; tenure was matched on the date of each diagnosed driver's polysomnogram. Auto-adjusting positive airway pressure (APAP) treatment was provided to all cases (i.e. OSA positive drivers); treatment adherence was objectively monitored. Cases were grouped by treatment adherence: "Full Adherence" (n = 682), "Partial Adherence" (n = 571), or "No Adherence" (n = 360). Preventable Department-of-Transportation-reportable crashes/100,000 miles were compared across study subgroups. Robustness was assessed.


After the matching date, "No Adherence" cases had a preventable Department of Transportation-reportable crash rate that was fivefold greater (incidence rate ratio = 4.97, 95% confidence interval: 2.09, 10.63) than that of matched controls (0.070 versus 0.014 per 100,000 miles). The crash rate of "Full Adherence" cases was statistically similar to controls (incidence rate ratio = 1.02, 95% confidence interval: 0.48, 2.04; 0.014 per 100,000 miles).


Nontreatment-adherent OSA-positive drivers had a fivefold greater risk of serious preventable crashes, but were discharged or quit rapidly, being retained only one-third as long as other subjects. Thus, the mandated program removed risky nontreatment-adherent drivers and retained adherent drivers at the study firm. Current regulations allow nonadherent OSA cases to drive at another firm by keeping their diagnosis private.