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Contemporary Reviews in Sleep Medicine |

The Effect of OSA on Work Disability and Work-Related InjuriesOSA, Work Disability, and Work-Related Injuries FREE TO VIEW

A. J. Marcus Hirsch Allen, MPH; Nick Bansback, PhD; Najib T. Ayas, MD, MPH
Author and Funding Information

From the Department of Experimental Medicine (Dr Hirsch Allen) and the School of Population and Public Health (Dr Bansback), University of British Columbia; the Division of Respiratory Medicine (Dr Ayas), Vancouver Hospital, and the Sleep Disorders Program (Dr Ayas), University of British Columbia Hospital, Vancouver, BC, Canada.

CORRESPONDENCE TO: Najib T. Ayas, MD, MPH, Division of Respiratory Medicine, Vancouver Hospital and Health Science Centre, 2775 Laurel St, Vancouver, BC, V5Z 3J5, Canada; e-mail: NAyas@providencehealth.bc.ca


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1422-1428. doi:10.1378/chest.14-1949
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OSA is a common yet underdiagnosed respiratory disorder characterized by recurrent upper airway obstruction during sleep. OSA results in sleep fragmentation and repetitive hypoxemia and is associated with a variety of adverse consequences including excessive daytime sleepiness, reduced quality of life, cardiovascular disease, decreased learning skills, and neurocognitive impairment. Neurocognitive impairments that have been linked to poor sleep include memory deficits, decreased learning skills, inability to concentrate, and decreased alertness. Furthermore, the societal and economic costs of OSA are substantial; for example, patients with OSA have a significantly greater risk of motor vehicle crashes, consume more health-care resources, and have associated annual costs in the billions of dollars per year. It is increasingly recognized that OSA may also have substantial economic consequences. Specifically, there is accumulating evidence implicating OSA as an important contributor to work disability (including absenteeism, presenteeism) and work-related injuries. This review summarizes the current state of knowledge in these two areas.

OSA is a common yet underdiagnosed respiratory disorder characterized by recurrent upper airway obstruction during sleep.1,2 The prevalence of sleep apnea in the Western world varies greatly, depending on the presence of symptoms and the diagnostic criteria used, but it is quite high. In 1993, Young et al2 reported a prevalence of 2% in middle-aged women and 4% in middle-aged men, in which cases had both an apnea-hypopnea index (AHI) ≥ 5 as well as daytime hypersomnolence.3 Only 2 decades later, using models that predict OSA prevalence based on increases in obesity, Peppard et al4 now estimate these percentages to be approximately 5% and 14%, respectively, for the same groups. The National Commission on Sleep Disorders research in the United States estimates that OSA affects 7 to 18 million Americans; of these, 92% of the women and 80% of the men remain undiagnosed.5

OSA results in sleep fragmentation and repetitive hypoxemia6 and is associated with variety of adverse consequences that affect virtually every organ system. These consequences include excessive daytime sleepiness (EDS), reduced quality of life, activation of the sympathetic nervous system, endothelial dysfunction, cardiovascular disease, decreased learning skills, and neurocognitive impairment.7 Neurocognitive impairments that have been linked to poor sleep include memory deficits, inability to concentrate, and decreased alertness.8

The broader societal and public health impacts of OSA are receiving increasing attention. For example, patients with OSA have a significantly greater risk of motor vehicle crashes (MVCs),9-16 consume more health-care resources, and have associated annual costs in the billions of dollars per year.17 These associated costs include both direct health-care-related costs and indirect financial and nonfinancial costs. Direct health-care costs refer to those associated with OSA treatment and diagnosis itself in addition to the costs of medical conditions that arise as a result of OSA. The indirect financial costs derive mainly from the non-health-care-related costs of work disability and work-related injuries. The nonfinancial costs relate to loss of life quality and premature death.18,19 There is emerging evidence implicating OSA as an important factor in two important societal issues: work disability and work-related injuries. In this review, we summarize the current state of knowledge in these two areas.

Absenteeism

Absenteeism commonly refers to the number of missed days or hours of work for employed people. However, the concept of absenteeism can be extended to cover work loss attributable to employment status changes, including a reduction in routine working time; job loss, which can lead to disability benefits; and early retirement. Observational studies, mainly from Scandinavia, have consistently shown that workers with OSA have more work absences compared with control subjects. These work absences and their accompanying financial burden are largely the result of comorbidities associated with OSA, including hypertension, vascular disease, and depression. One study estimated that the total yearly cost of treating OSA in Australia was approximately $657 million, $409 million of which went into treating the aforementioned comorbidities.20 Furthermore, a Danish study observed that when compared with age- and sex-matched control subjects, patients with OSA have significantly higher unemployment rates, and those who are employed have lower average annual incomes.19

A Finnish study compared absenteeism between patients with OSA and control subjects, where absences were caused by medically certified sicknesses (< 9 days) or disability pension.21 In this study, 957 patients with OSA taken from the national hospital discharge register (all admissions with a primary diagnosis of sleep apnea) were compared with 4,785 control subjects matched for age, sex, and illness. There was a greater risk of lost workdays in patients with OSA in the 5 years prior to their diagnosis, compared with control subjects. Specifically, OSA was associated with a mean of 80.5 additional workdays lost in women and 30.0 workdays lost in men in the 5 years prior to diagnosis. The risk of lost workdays was 1.6 times greater in men with OSA (relative risk, 1.61; 95% CI, 1.24-2.09) and 1.8 times greater in women with OSA (relative risk, 1.80; 95% CI, 1.43- 2.28).

Another Finnish study investigated whether the diagnosis of OSA was associated with a greater risk of work loss (all absences from work > 9 days because of sickness) and disability (people collecting disability pensions on national registries) during the first 6 years following diagnosis.22 Researchers investigated 766 employees with a diagnosis of OSA (taken from the hospital discharge registry) and compared them with control subjects (n = 3,827) matched for age, sex, socioeconomic position, type of employment contract, and type of organization. Compared with control subjects, sickness-related absences were greater by 1.7-fold in men with OSA and by 2.1-fold in women with OSA. In addition, both men and women had a twofold-greater risk of being on disability pension compared with control subjects. Regarding cause-specific work disability, employees with OSA had a particularly high risk of disability related to injuries and mental disorders.

Siversten et al23 conducted a prospective study of 7,028 subjects aged 40 to 45 years in Norway and showed that self-reported symptoms of OSA such as snoring, breathing cessation, and daytime sleepiness were significant predictors of an absence from work because of sickness of > 14 days and an award of disability pension by the Norwegian National Insurance Administration. During follow-up, patients with symptoms of OSA were almost twice as likely to miss work using sick leave when compared with control subjects after adjusting for sex alone (OR, 1.78; 95% CI, 1.42-2.20). Those with symptoms of OSA also showed an OR more than double that of control subjects when it came to subsequent disability awards (OR, 2.20; 95% CI, 1.26-3.85).

Similarly, Omachi et al24 carried out a study in this field of research. They investigated self-reported work disability, 4-week cumulative incidence of missed work days, and work duty modifications, missed promotions, and changes in job duties, job schedule, or job pay specifically attributed to sleep, in 183 consecutive patients who were referred to their clinical center in California. Patients were tested for sleep apnea using polysomnography and were grouped into one of four categories, based on the presence or absence of either sleep apnea or EDS or the presence or absence of both. They found that patients with both EDS (defined as an Epworth Sleepiness Scale [ESS] score > 10) and OSA (AHI > 5 events/h) had a markedly greater risk of both recent work disability (OR, 13.7; 95% CI, 3.9-48) and long-term work duty modification (OR, 3.6; 95% CI, 1.1-12) than did patients with neither. When either OSA or EDS were absent, the relationship was much weaker. However, patients with OSA were still at greater risk than those without OSA in terms of recent work disability (OR, 2.6; 95% CI, 1.2-5.8). The researchers concluded that these results supported the long-held suspicion that OSA is associated with work disability.

OSA and Work Impairment

Not only is OSA associated with work absence, the presence of OSA also seems to contribute to decreased performance while at work, often referred to as presenteeism. This is not surprising given that OSA is associated with myriad adverse cognitive impairments including deficits in verbal functioning, problem solving, and executive functions25,26 and impaired memory, attention, vigilance, and psychomotor skills.27,28 Researchers from the United States demonstrated that the productivity losses associated with sleep disorders accounted for approximately two-thirds of the total financial costs on society (all costs excluding those associated with lost disability-adjusted life years).29 A recent review by Guglielmi et al8 concluded that although more methodologically rigorous studies are needed, studies consistently found relationships between OSA and work limitations in patients (ie, difficulties maintaining attention, learning new tasks, or performing monotonous tasks).

Furthermore, EDS, a cardinal symptom of OSA, is strongly associated with work impairment in non-sleep apnea populations.30 The impairment in work productivity because of EDS is similar to that found with other chronic conditions such as diabetes, depression, and arthritis.31,32 For example, in a survey study, 1,758 people with a self-reported physician diagnosis of OSA, depression, narcolepsy, or multiple sclerosis, or who did shift work, were compared with a group of 1,977 people without these conditions. The groups were assessed using the Work Productivity and Impairment Scale and several other surveys, including the Cognitive Function Scale and the Short Form (SF)-36. The results indicated that EDS (considered present with any one of the following: ESS score > 10, self-reported physician diagnosis of hypersomnolence, or self-reported problems of sleepiness and a response of > 3 on a five-point scale regarding symptom severity during the previous 4 weeks) in both groups was associated with highly significant impairments in health status, daily activities, and work productivity. In the first group, patients who had EDS reported lower mean scores on both the SF-12 (42.3 vs 45.5, P < .0001) and the six-item Cognitive Function Scale (68.8 vs 79.8, P < .0001) than did patients without EDS. The same trend was seen in the second group, in which participants with EDS once again scored lower on both the SF-12 (47.7 vs 51.4, P < .0001) and the six-item Cognitive Function Scale (82.3 vs 89.5, P < .0001). Researchers concluded that EDS likely has a measurable negative impact on work productivity above that of the diseases studied.29

Mulgrew et al3 found a clear relationship between excessive sleepiness and decreased work productivity in a population referred for suspected sleep-disordered breathing. They studied patients who underwent full polysomnography and were then assessed using the Work Limitations Questionnaire and the ESS questionnaire. Data were collected on 498 patients who had an average AHI of 21 events/h. Although there was no significant relationship between the severity of OSA and overall work limitation, a significant relationship was found between blue-collar workers with mild OSA (AHI, 5-15/h) vs severe OSA (AHI > 30/h), in the domain of time management (limited 23.1% of the time vs 43.8% of the time, P = .05) and mental/personnel interactions (17.9% vs 33.0%, P = .05). There were also strong associations between subjective sleepiness and three of the four scales of work limitation.

Ulfberg et al33 studied a random sample of the general population (n = 285; 223 nonsnorers and 62 snorers) and compared them with 351 patients (289 snorers, 62 patients with OSA) referred to a sleep disorders clinic for suspected OSA. After adjustment for age and BMI, patients with OSA (defined as patients with obstructive periodic breathing exceeding 45% of total sleep time in combination with an oxygen desaturation index > 6), compared with nonsnoring control subjects, were significantly more likely to complain of difficulty doing their job because of tiredness/sleepiness (prevalence of 82% vs 8.1%, OR = 37). Furthermore, patients with OSA were significantly more likely to complain of great or very great difficulties in concentrating on new tasks (prevalence of 48% vs 0.9%, OR = 7.5), learning new tasks (prevalence of 40% vs 2.7%, OR = 9.1), and performing monotonous tasks (prevalence of 31% vs 5.8%, OR = 20).

Nena et al34 also performed a study assessing work productivity in patients with OSA. Work productivity was assessed using the Endicott Work Productivity Scale, which was given to 115 patients of working age with polysomnographically confirmed OSA (AHI > 5/h) without comorbidities. Daytime sleepiness was measured using the ESS (where presence of EDS exists if ESS > 10). The mean Endicott Work Productivity Scale scores were significantly higher in somnolent vs nonsomnolent patients with OSA (31.2 ± 16.2 vs 20.8 ± 11, respectively; P < .001).

Accattoli et al35 investigated work performance among 331 workers with OSA compared with 100 nonapneic control subjects and found that the workers with OSA reported more impairment in work performance than did the nonapneic workers. These impairments included difficulties with memory, vigilance, concentration, performing monotonous tasks, responsiveness, and learning new tasks. Several other studies have corroborated much of the evidence showing OSA to be related to considerable problems at work,36 including difficulties staying awake37; deficits in executive functioning, problem solving, and verbal functioning26; and issues with mood.5

Occupational injuries are a major societal problem. In 2005, there were 5,702 work-related fatalities in the United States, with a death rate of four per 100,000 workers per year.38 As has been discussed, sleepiness caused by OSA negatively affects both vigilance and work performance.39 Indeed, the neurocognitive impairments discussed above lead to errors while driving and result in a greater risk of MVCs, including a high rate of collisions in patients who drive as a part of their occupations.40 Howard et al40 found that in a large sample (n = 2,342) of commercial vehicle drivers, drivers with OSA (diagnosed based on symptoms) had a higher rate of self-reported MVCs compared with control subjects (OR = 1.30). It would thus not be surprising if patients with OSA would suffer a greater risk of other work-related injuries.

A recent meta-analysis performed by Uehli et al41 investigated the relationship between general sleep problems (defined as all sleep disorders described in the International Classification of Sleep Disorders, Second Edition) and work injuries. They found that individuals with sleep problems had a 1.62 times greater risk of injury compared with individuals without sleep problems. Focusing specifically on OSA, Table 1 summarizes some of the literature concerning the impact of OSA on occupational injuries; all five studies found significant associations between either a diagnosis of OSA or symptoms of OSA and occupational injuries. Multiple studies reported rates of occupational injuries that were between two and three times higher in patients with OSA than in control subjects.42-44

Table Graphic Jump Location
TABLE 1 ]  OSA and Work-Related Injuries

AOR = adjusted OR; EDS = excessive daytime sleepiness.

The study by Ulfberg et al42 in Table 1 was particularly important because all patients were tested for OSA using simultaneous nocturnal recording and oximetry during a minimum of 4 h of sleep. OSA was defined as obstructive periodic breathing exceeding 45% of total sleep time in combination with an oxygen desaturation index > 6. This group of researchers studied the association between sleep-disordered breathing and occupational injuries in a 10-year retrospective comparison in Sweden. Injury rates for 704 consecutive patients suffering from sleep-disordered breathing were compared with the rates for an employed, age-matched random sample of 580 subjects drawn from the general population. The risk of being involved in an occupational accident was about twofold greater among male heavy snorers compared with referents, and was 50% greater than referents among men suffering from OSA. For women, the risk was at least threefold greater in heavy snorers and patients with OSA. The authors proposed that reduced vigilance and attention due to sleep-disordered breathing could account for the increased rate of accidents.

Accattoli et al35 demonstrated similar results in another retrospective study in 2008, investigating 100 referent workers without OSA (50 blue-collar and 50 white-collar) and 331 workers with self-reported OSA (144 blue-collar and 187 white-collar). Workers affected by OSA were involved in occupational injuries more often than those without OSA (27.2% vs 20%). The average number of injuries per year in blue-collar workers with OSA was slightly higher than in the control subjects. In the white-collar workers, the rate of occupational injuries was significantly higher (P = .013) in participants with OSA than in the referents.

In a population-based study, Lindberg et al43 studied 2,874 men aged 30 to 64 years who answered questions on snoring and daytime sleepiness. Ten years later, respondents answered a follow-up questionnaire that included work-related questions. Men who reported snoring and EDS at baseline were at a higher risk of occupational injury (adjusted OR, 2.2; 95% CI, 1.3-3.8).

Finally, Spengler et al44 and Heaton et al45 studied the relationship between occupational injuries and OSA in groups of farmers in the southern United States. Both studies relied on self-reported survey data for both the presence of OSA symptoms and occupational injuries and both found higher rates of occupational injuries in patients suffering from symptoms of OSA.

CPAP therapy is the main treatment of OSA and is known to significantly improve both objective and subjective sleepiness in patients suffering from OSA. Consistent with these results, the use of CPAP seems to improve work performance in patients with OSA.

Ulfberg et al46 evaluated 152 patients with substantial OSA (AHI > 20) who answered four questions concerning self-perceived work performance before and after CPAP use. After CPAP, patients were significantly less likely to report difficulty concentrating on new tasks, learning new tasks, and performing monotonous tasks (P < .01). The authors concluded that “given that OSA patients are motivated in using CPAP, the results from this open label study indicate that CPAP treatment may be effective in improving subjective work performance.”46

Similar results were obtained from Mulgrew et al,3 who looked at 33 patients with OSA (AHI > 5) who were using CPAP. In this study, in CPAP-treated patients, there were significant improvements in time management (limited 26% of the time vs 9%; P < .001), mental interpersonal relationships (16% vs 11%, P < .009), and work output dimensions on the Work Limitations Questionnaire.

Scharf et al47 also investigated 316 patients in Ohio, where they saw CPAP use increase subjective work productivity from 6.8 to 8.4 (P < .001) (as measured on a 10-point scale). Although there exists a plausible hypothesis that CPAP could lead to reductions in occupational injuries,48 we did not find any publications to support this.

OSA is associated with increased absenteeism and work-related injuries and decreased work performance. This evidence is well summarized by Teng and Won,11 who stated, “The consequences of OSA pose a danger to public safety not only for workers but for those whom they serve.”

Although increasing research has strengthened the knowledge base in the aforementioned areas, several limitations of this research should be noted. In terms of evidence on work disability, many of the studies have been performed in Scandic countries where social security and other mechanisms may influence rates of absenteeism. In addition, few studies have used validated questionnaires that measure the full spectrum of work disability outcomes, including costing their impact.49 In terms of evidence on occupational injury, many of the studies relied on subjective symptoms (eg, snoring and sleepiness) rather than on objective criteria. Subjective assessments of sleepiness are not always reliable. In certain arenas, underreporting of symptoms among patients may be driven by economic gain (eg, in commercial motor vehicle operators).6

There appears to be promise for CPAP therapy to reduce work disability and occupational injuries,50 but the lack of randomized control trials or large prospective epidemiologic studies in this area leaves a substantial gap in the literature. Given the degree to which OSA is underdiagnosed, the potential occupational health and economic productivity gains to be made if a population was more actively screened and treated for OSA could be substantial.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Ayas has received money to be a speaker at a symposium about sleep apnea given to family doctors by a CPAP homecare company and has received peer-reviewed funding from Canadian Institutes of Health Research to study sleep apnea. Drs Hirsch Allen and Bansback report that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

AHI

apnea-hypopnea index

EDS

excessive daytime sleepiness

ESS

Epworth Sleepiness Scale

MVC

motor vehicle crash

SF

Short Form

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Scharf MB, Stover R, McDannold MD, Spinner O, Berkowitz DV, Conrad C. Outcome evaluation of long-term nasal continuous positive airway pressure therapy in obstructive sleep apnea. Am J Ther. 1999;6(6):293-297. [CrossRef] [PubMed]
 
George CF. Reduction in motor vehicle collisions following treatment of sleep apnoea with nasal CPAP. Thorax. 2001;56(7):508-512. [CrossRef] [PubMed]
 
Zhang W, Bansback N, Anis AH. Measuring and valuing productivity loss due to poor health: a critical review. Soc Sci Med. 2011;72(2):185-192. [CrossRef] [PubMed]
 
Wright J, Johns R, Watt I, Melville A, Sheldon T. Health effects of obstructive sleep apnoea and the effectiveness of continuous positive airways pressure: a systematic review of the research evidence. BMJ. 1997;314(7084):851-860. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  OSA and Work-Related Injuries

AOR = adjusted OR; EDS = excessive daytime sleepiness.

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