Sleep apnoea and driving: more clarity needed
Authors: None The Lancet Respiratory Medicine
Journal: The Lancet Respiratory Medicine (2017)

The phrase ‘tiredness kills’ will be familiar to anyone who has driven on motorways in the UK—signs bearing the slogan are posted at regular intervals, along with notices encouraging motorists to take a break if they feel drowsy. A recent report by the AAA Foundation for Traffic Safety in the USA lends support to this advice. The study found that drivers who had slept for four hours or fewer within the past 24 hours were 11·5 times more likely to be involved in a road traffic accident compared with people who had slept for seven hours or more. The figures highlight the urgent need to reduce tiredness among motorists. Obstructive sleep apnoea (OSA) is estimated to affect between 3% and 7% of adults. As well as being linked to increased risk of stroke, heart failure and diabetes, the condition can cause chronic daytime sleepiness. Because OSA patients may have decreased alertness, some governments have introduced legislation which means that people with OSA and daytime sleepiness (sometimes referred to as obstructive sleep apnoea syndrome, or OSAS) may have their driver's license suspended. While such legislation is designed to make roads safer, a lack of clarity around diagnosis and treatment means that it could be having the opposite effect. In the UK, the onus is on the patient to report a diagnosis of OSA syndrome to the Driver and Vehicle Licensing Agency (DVLA) or face a hefty fine. After a report is filed, the DVLA requires documentation from the patient's doctor confirming that the condition is being effectively treated. If the patient is not compliant with treatment or the treatment is not working, the DVLA can revoke the driver's license. In practice, symptoms of daytime sleepiness are rarely resolved straightaway—there is often a lag between a patient being diagnosed with OSA and receiving treatment, and a lag between a patient starting treatment and a clinician being confident that they are not excessively tired. In terms of the information in the public domain, there are several areas where clarity is seriously lacking; for example, it is unclear how long patients will be required to wait to receive treatment on the NHS and how long it takes, on average, for treatment to be effective. The Sleep Apnoea Trust Association makes a valiant effort to clarify the timelines involved, but even they seem unclear on some aspects, noting that they were awaiting clarification from the DVLA at the time of writing. For the many people whose livelihoods depend on their driver's license—truck, coach and taxi drivers for example—this uncertainty is likely to detract from their willingness to seek help. A quick internet search reveals widespread confusion and apprehension. Message boards are populated by people who think they might have OSA but are reluctant to get tested in case they are made to wait a long time for treatment, with their driver's license revoked in the interim. The UK's OSA Partnership Group noted this widespread concern among professional drivers. In March 2015, the group called on the Department of Health to issue guidance to Clinical Commissioning Groups, hospitals and general practitioners, asking them to expedite OSA treatment for vocational drivers so that they could be back on the road within four weeks of their first referral. In December 2016 they renewed the call, with the RAC (a member of the OSA Partnership Group), noting that ‘several drivers are currently at risk of losing their jobs as a result of having to wait for months for suitable treatment’. While the problem is most pressing for professional drivers, there are many others who are reliant on their vehicles to get to work; see family; or attend medical appointments for other conditions. Fast-track diagnosis for vocational drivers is a good starting point, but the ultimate goal should be to provide it for everyone. It may seem optimistic to call for NHS resources to be focused on fast-tracking OSA treatment at a time when the organisation is under severe financial strain, but the move could actually save money. A 2014 report by the British Lung Foundation which took into account the cost of road traffic accident trauma, stroke and cardiovascular events caused by OSA found that the NHS could save £55 million annually by treating all people in the UK with moderate to severe OSA. The DVLA legislation is designed to improve road safety and save lives, but there needs to be clear guidance on how long people can expect to wait for treatment and how long they will be unable to drive for. The DVLA and NHS must work together to improve clarity, thereby making the UK's roads safer for everyone.