sleep: a health and performance imperative

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“Sleep that knits up the ravelled sleeve of care …. Sore labor’s bath, the balm of hurt minds .…”

These lines from Shakespeare’s MacBeth – used here with literary license – describe with poetic richness the holistic health benefits of sleep to the body and the mind – physically, mentally and emotionally. Yet the expanding global arena of corporate wellness generally fails to provide a place for this missing pillar of human health – no less foundational than physical activity or proper nutrition. This is surprising, given the substantial evidence from numerous studies of the impact of sleep disorders and deprivation on health and work.

This failure to address sleep as a major health and performance issue has led the Institute for Health and Productivity Management – in collaboration with founding sponsor ResMed and supporting sponsors Optum and Sleep Data – to create a WorkPlace Center for Sleep Health & Wellness™ with the objective to establish sleep as a pillar of work place health.

The medical bill for the most significant sleep disorders – insomnia and Obstructive Sleep Apnea (OSA) – is mounting and becoming more apparent to employers; the larger total economic costs of sleep-related safety incidents and lost productivity in the work place, however, are just starting to be understood. The WorkPlace Center will be closing this knowledge gap, and helping employers take action to address its consequences for employee health, safety and productivity – and for corporate financial performance. Sleep: A Health and Performance Imperative

Sleep is not well understood, even though essential for human survival – providing rest and recovery, improving cognition and neural functioning, and bolstering the immune function. An estimated 70 million Americans have chronic sleep disorders as well as sleep disturbances associated with other chronic conditions – illnesses and addictions (according to the National Center on Sleep Disorders Research, part of the National Heart, Blood and Lung Institute). And the National Sleep Wellness Association puts the estimate as high as 100 million -- the wide range due to half or more of these people being undiagnosed.

Sleep disorders usually involve excessive daytime sleepiness (EDS), fatigue or difficulty initiating or maintaining sleep. Untreated, they contribute to impaired performance at work and in school, to auto and industrial accidents, personal relationship and memory problems, and mood disturbances. (A Centers for Disease Control and Prevention survey reports that one in 25 adults say they recently fell asleep while driving). And sleep disorders frequently lead to or exacerbate a range of serious medical conditions – physical and neurological.

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Poor sleep health results from: (1) primary sleep disorders – the most prevalent and significant in their workplace impact being chronic insomnia, moderate-to-severe-obstructive sleep apnea (OSA) and shift work disorder; and (2) the increasing number of people living with chronic sleep debt – a state of inadequate or mistimed sleep with disrupted human circadian rhythms, independent of a primary sleep disorder. External factors contributing to chronic sleep debt include longer work hours and commuting times and, for an estimated 20 percent of the work force, shift work schedules that disrupt normal sleep habits and increase the risk of illness.

Sleep debt and accompanying excessive daytime sleepiness from whatever cause is reported to interfere with the daily activities of more than 40 per cent of adults at least several days each month – and with the activities of 20 per cent of adults at least several days each week. (National Sleep Foundation 2000 Omnibus Sleep in America Poll) The problem causing EDS can be “too little sleep” (e.g., because of insomnia or chronic depression), “fragmented sleep” (e.g., because of sleep-disordered breathing from obstructive sleep apnea or Restless Leg Syndrome), or “mistimed sleep” because of circadian rhythm disorder from shift work or jet lag).

Inadequate, fragmented, poor quality or mistimed sleep – all can lead to EDS and resultant impaired functionality that has multiple consequences in the work place:

• longer reaction times/slower processing speed • lapses in attention and concentration • poor short-term memory • errors of omission • fatigue • accidents • increased co-morbidities of depression, diabetes, hypertension, obesity

“Short sleep” also has been associated with increased mortality. In 2007, the International Agency for Research on Cancer classified shift work as a probable human carcinogen. Shorter sleep durations and night shift work both have been associated with increased risk of breast, colorectal and prostate cancers.

For employers, the increased medical cost, productivity loss, and safety risk consequences of sleep issues are serious, and can be profound – with several recent fatal rail accidents featured in news reports.

Insomnia – Prevalence, Comorbidities and Costs

A half dozen published studies showed an average prevalence of severe insomnia – defined as “sleep disturbance every night for 2 weeks or more” or similarly stringent criteria – in the general adult population of more than 12 per cent, or about 1 in 8 persons. Another study found that about half the population reported at least one symptom of insomnia several nights each week. And the incidence of insomnia is higher for older persons, women, smokers, shift workers and people with various chronic health issues – particularly depression and pain.

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Five published studies found that persons with insomnia had a three times higher risk of developing major depression (a sixth study of just women found a nine times higher risk). Insomnia is a prominent symptom of depression, and the two exhibit a bi-directional relationship in which the existence of either condition increases the likelihood of the other developing.

Sleep and pain interact in complex ways that impact biological and behavioral capacity. As with depression, there is a bi-directional relationship between sleep and pain – lack of sleep exacerbating pain just as chronic pain contributes to severe sleep disturbances. And to complicate relationships further, insomnia also is associated with the development of depression in those with chronic pain – and results from opioid treatment of chronic pain.

The economic burden of insomnia starts with higher utilization of health care – several studies showing insomnia patients with daytime impairments linked to increased visits to physicians and emergency rooms. One leading recent study (Kleinman et.al., Journal of Clinical Psychiatry, August 2009) shows incremental annual medical and pharmacy costs of nearly $1500 for employees with insomnia.

But another larger and less understood impact of insomnia is on employers’ costs of lost time and productivity. The same study shows incremental absence-related costs of more than $550 annually, but a recent leading study of “presenteeism” – or lost productivity while still at work – shows an equivalent loss of nearly 8 days annually of work performance for employees with insomnia (controlling for co-morbid conditions), which translates into about $2300 of lost productivity value. And yet another study found the average cost of insomnia-related accidents and errors at work to be nearly 50 percent greater than the cost of other accidents and errors – higher than for any other chronic condition.

Putting all these pieces together, the total work place cost of insomnia adds up to a substantial sum – and a large enough cost-saving target to be worth employers’ closer attention.

Obstructive Sleep Apnea (OSA): Costs, Prevalence and Comorbidities

A meta-analysis by the Harvard Medical School Division of Sleep Medicine and McKinsey & Company estimated that adults with unmanaged moderate-to-severe Obstructive Sleep Apnea (OSA) incur between $3200 and $4000 of incremental annual healthcare costs. Absenteeism costs were estimated only at the national level (at $5 to $15 billion), as were OSA-associated non-medical costs of workplace accidents (at $5 to $20 billion) – totaling a range of estimated lost-time costs of $10 to $35 billion. No effort was made to assess the likely even larger costs of presenteeism, but even without those costs the estimated total economic cost of moderate-to-severe OSA ranges from $65 billion to as much as $165 billion annually. (Young et.al., Sleep, 1997, 20(9):705-706; Engleman et.al., Sleep Medicine Review, 2003, 7(1):81-99)

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OSA is the most common form of sleep disordered breathing, especially in men as they age. Nearly a quarter of American males (but less than 10 per cent of women) aged 30 to 60 – the prime working years – are estimated to have mild-to-severe OSA (Young et.al., NEJM, 1993, (328) 1230-5), but a large majority of them remain undiagnosed (the true prevalence is likely three times greater then the number of those who have been diagnosed).

Other chronic health risk factors are associated with the development of OSA. Studies examining the comorbid conditions causing healthcare utilization during the five years before OSA was diagnosed found that patients had significantly increased odds of a diagnosis if they already had other diseases; the highest odds were for congestive heart failure (3.9), followed by cardiovascular disease (2.6), hypertension (2.5) and arrhythmias (2.2). Other chronic health risks and conditions associated with the development of OSA include obesity, diabetes, atrial fibrillation, stroke, depression and Metabolic Syndrome.

There is a need to develop a model of bidirectional causality similar to that for insomnia and its comorbidities; this is especially so because of data from epidemiological studies and randomized clinical trials suggesting that OSA is a common and treatable (with CPAP) risk factor for the development of cardiovascular disease.

OSA patients also have a higher prevalence of depression, and many symptoms of the two overlap – leading to under-diagnosis of OSA in depressed patients. The mechanism of the relationship between OSA and depression is complex and remains unclear. Increased knowledge of this relationship would improve diagnostic accuracy as well as treatment outcomes for both OSA and depression.

Historically, insomnia and sleep-related breathing disorders have been kept in separate research silos. But evidence from clinical and research samples consistently suggests high rates of comorbidity between insomnia disorder and sleep-disordered breathing (most importantly, OSA) – and with additive negative effects. Clinical experience and emerging empirical data suggest that the best outcomes are obtained when patients are treated for both independent conditions. Whether treatment of these disorders should be sequential or simultaneous, however, has yet to be clearly determined.

Workers in the transportation industry are known to have a high prevalence of OSA and resulting high medical and sleep-related accident costs. The Union Pacific Railroad Employees Health Systems Plan used an educational intervention for members diagnosed with OSA to increase CPAP use from 23 to 54 percent to make a significant dent in rising health care costs – stabilizing the trend for the treated population (albeit at a higher level than for plan members without OSA). This intervention saved Union Pacific about $5 million dollars over two years for 23,000 plan members.

The incremental annual healthcare costs of employees with OSA are large enough by themselves to make it a worthwhile cost-saving target, even as more evidence is assembled on the related work place costs of lost productivity.

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WorkPlace Center for Sleep Health & Wellness™

IHPM’s WorkPlace Center for Sleep Health & Wellness gathers and shares the best available evidence on the full costs of the two most significant sleep disorders – insomnia and OSA – and the most effective treatments that produce the best clinical outcomes and total work place cost savings. In addition, the Center conducts original field research on best practices in sleep management to improve work place health and productivity. And, eventually, additional work will be undertaken to determine best practices in addressing the serious work place cost impact of shift work disorder.

In the coming months, members of the Center’s Advisory Board will provide expert knowledge and opinion on these subjects, in pursuit of its education and research mission. Look for periodic future eNews briefs like this one, making the case for sleep programs as a critical component of any comprehensive corporate health and wellness strategy.

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For more information visit the WorkPlace Center for Sleep Health & Wellness:

http://www.ihpm.org/workplace-centers/sleep-health-and-wellness/

sleep: a health and performance imperative

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