Most employers likely think that sleeping on the job is their only worry when it comes to workers' sleep habits. However, new research shows that if employees are sleepless at home, it's a concern for companies as well.

A study finds delaying the diagnosis and treatment of insomnia translates to billions of dollars in health costs, lost productivity and absenteeism. The report estimates that insomnia accounts for at least $42 billion in direct and indirect health care costs each year.

Sponsored by pharmaceutical company Sanofi-aventis U.S. and the Center for Medicine in the Public Interest, the research finds that 70 million Americans may suffer from some form of insomnia. In addition, a startling number of those cases are undiagnosed and untreated, compounding the financial burden on U.S. employers and the health care system.

Insomnia as a 'chronic disease'

"We should treat insomnia as it should be treated: a serious medical condition that has significant health and economic implications," says CMPI Vice President Robert Goldberg, Ph.D."Like other chronic diseases, insomnia has been managed according to the cost of treating patients instead of the cost the disease exacts on individuals, employers and society."

The report, "Waking Up to the Insomnia Crisis: How Insomnia is Costing America More Than $42 Billion a Year and What We Can Do About It," reveals that individuals with insomnia miss work twice as often as those who do not suffer from the condition.

Further, insomnia costs employers about 4.4 days of wages for each untreated person over a six-month period, a figure that does not include money spent on indirect costs, such as lost productivity and treatment of the medical consequences of insomnia, finds a 2007 study in the journal SLEEP.

In the previous year, a study in the same journal found that people with insomnia miss an average of 5.8 days of work each year, compared to nonsufferers, who only miss 2.4 days on average.

Sleep problems affect the healers as well as the sick, as health care professionals-in-training who work recurring 24-hour shifts with little sleep have been discovered to make 36% more serious medical errors and five times as many serious diagnostic mistakes than those whose work is limited to 16 consecutive hours.

The study proffers the following plan of action to curb the escalating costs of insomnia for 2009:

•  Encourage employers to initiate wellness programs that integrate insomnia management.
•  Educate the media, health care insurers and employers about their roles in promoting awareness, improving care and helping to move to a value-based treatment approach.
•  Assemble a coalition of mainstream media, social media, and an array of private, corporate and government partners to raise public awareness of the critical impact insomnia has on the health care system and the American economy.
•  Identify modes for diagnosing and treating insomnia. Treating insomnia before it leads to serious illness, such as cardiovascular trouble, is far less costly than waiting until the problem worsens.
•  Execute targeted outreach to patients and health care providers based on specific criteria stemming from the latest findings in genetics, clinical research and outcomes data. Patients and providers must be able to identify and converse about symptoms and solutions.

The study's authors recommend a carrot approach in dealing with insomnia sufferers, as "they're already getting the stick in the form of growing health care claims and reduced employee productivity," the study notes. One way to do this is through reduced drug copays for comorbid chronic diseases, such as depression, diabetes and asthma.

According to the research paper, studies have shown that, when treated, individuals with chronic insomnia experience dramatic improvements in two key parameters of work performance: output and time management.

Sleep apnea can worsen chronic conditions

Another serious sleep condition that is severely undertreated is sleep apnea, a condition where the individual experiences breathing impairment during sleep and affects 50 million adult Americans, according to Dr. Joseph Ferro, worldwide corporate medical director at Johnson & Johnson.

The disease has serious health repercussions such as diabetes, obesity, high blood pressure, stroke and cardiac death. For example, one sufferer of sleep apnea used to fall asleep at meetings. Luckily, because he was an employee with Johnson & Johnson, he was able to identify his problem and treat it thanks to a pilot program at the consumer health care company.

The company's Sleep Awareness Campaign first educates the working population at their corporate headquarters about the medical condition, then requests a simple scoring chart to determine whether the participant is at risk. If they score significantly, they take home a sleep apnea screening kit to conclusively determine whether they have the disease.

The disease is severely underdiagnosed because, typically, an individual must stay overnight at a lab to be diagnosed. In fact, Ferro estimates that in 90% of cases, sleep apnea goes unrecognized. Thus, "being able to test at home is extremely productive and very easy to do," says Ferro.

Ferro and his team began the program with home screenings a week before EBN interviewed him in mid-November. Yet, already 12 people had been diagnosed. Still, the program is in its infancy with 2,100 employees in the corporate headquarters. He anticipates 50 to 100 people will be diagnosed with medically significant sleep apnea in total.

The company has taken a three-pronged communication approach to the problem with lunch-and-learns, e-mail and temporary booths set up near the cafeteria with posters, brochures and questionnaires. However, about a third, says Ferro, have participated due to word of mouth.

There is no need to bribe participants with monetary rewards as "their reward is that they feel dramatically better - if not the next day, in the next few days," Ferro explains. They feel "like a window opened up," he continues, observing participants are newly infused with greater energy, focus and concentration, not to mention their spouses are happy because at last a disruptive snoring problem has been dealt with. In addition, they have better control over sugar and blood pressure once the sleep apnea has been diagnosed and treated.

Ferro recommends that employers "be aggressive in promoting awareness; don't wait for them to come to you. Let them know that sleep is a medical issue and that you have tools available. As the medical community, and corporate community, we have a tremendous opportunity to educate our employees and patients [about sleep apnea]."

In order to deal with what Ferro estimates is 25% of Johnson & Johnson's working adult population that sleeps too little or too much, the company has installed an online "Overcoming Insomnia" digital coaching program by HealthMedia, a Johnson & Johnson company, into its culture of health. General sleep disturbances are three to four more times common than sleep apnea, but with similar comorbid conditions.

"I think it's important to not just focus on the most costly patients; I think we want to look in the regular population and make sure that we can do a good job of preventing something," emphasizes Dr. Richard Bedrosian, Ph.D., director of behavioral health at HealthMedia.

"For example, if you have somebody now who's not sleeping well, and you can catch them now and not two years from now when the problems are more chronic, then you can probably deliver an inexpensive service to them and prevent a lot of other expenses downstream. Because face-to-face services are expensive to deliver, they might only be available for the people who are more seriously ill. The beauty of what we're doing with our digital coaching is that it's so cost-effective and scalable that you can deploy these things for really low cost, and it won't sacrifice care for people who need high-touch services," he adds.

The program teaches employees the importance of sleep hygiene - that is, tips like avoiding doing work while in bed, making the bedroom cooler and darker, and avoiding alcohol before bed. The program also uses cognitive therapy techniques to help people change the negative thoughts that create anxiety about sleep.

Once the employee assesses their sleep habits, the digital coach offers a customized plan based on that information, delivered over time. It is not a static Web site, but rather a morphing and individualized plan portal.

"We're trying to take very sophisticated models for assessing behavior, and changing behavior and building them into our 'fusion engine' so that we can make an intervention based on the way a clinician would think about a particular person," says Bedrosian.

Though the digital coach is no substitute for face-to-face counseling (the program begins with a personal consultation), it does have some advantages. For example, there is no human error, but rather the program uses information about a patient in a completely consistent, predictable way.

Among the statistical successes that HealthMedia has recorded, individuals in the program have experienced:

•  35-minute increase in average sleep time.
•  26% reduction in fatigue levels.
•  21% reduction in anxiety levels.
•  39% decrease in difficulty falling asleep.
•  33% decrease in difficulty staying asleep.
•  43% improvement in quality of sleep.
•  21% increase in the confidence to manage insomnia.
•  $3,903 in productivity savings per year per participant.

One company, Baystate Health, an integrated health management system in Springfield, Mass., implemented the digital coaching solution among its workforce - 37% of its 10,000 employees, who slept fewer than six hours each night in 2008.

Baystate realized that these employees were costing them a great deal of money, as people sleeping six or fewer hours reported a 50% greater productivity loss than those getting the recommended seven or eight hours.

Further, unhealthy sleep costs the company $385 more in annual medical and drug claims for people sleeping fewer than six hours than for those with seven hours. In addition, night-shift employees sleeping fewer than six hours had twice the cost for workers' comp than their healthy sleeping colleagues.

"Be aware of impacts of unhealthy sleep, because it affects people on a personal level," advises Barbara Pelletier, MS, RD, director of health, wellness and workplace solutions at Baystate Health.

Unhealthy sleep "increases risk for high blood pressure, obesity, and diabetes, [as well as an] increasing risk for gum disease. Also, it's linked to safety and accident risks," says Pelletier.

Baystate Health held face-to-face workshops for their employees, developed a self-directed booklet for those who couldn't attend and then bolstered their Power of Sleep program with the online Overcoming Insomnia digital coaching program through HealthMedia.

Almost 700 employees completed the online program. For the 90-day follow-up, participants noted that their sleep time increased by 28 minutes, on average; there was an 18% lower fatigue level; and they increased their confidence in managing insomnia by 20%.

In the end, participants received the added bonus of accumulating 25 points toward a wellness credit that, when the individual earns 200 points, they translate into a $200 wellness credit toward health benefits. They used the additional reward to motivate employees to make healthy lifestyle changes.

"There are a ton of benefits to healthy sleep, because [individuals] do have more energy," Pelletier concludes. "They have more concentration. They get along better with other people. There's improved productivity, fewer errors. Don't underestimate the impact that healthy sleep can have on your workforce and their ability to meet your customer needs."

In 2008, a British research study found that the nap was the most effective solution in coping with "the afternoon hump," more preferable to using caffeine or increasing nighttime sleep.

According to a recent edition of the newsletter Harvard Health Letter, several studies have discovered that if people are asked to memorize something - for example, a list of words - and then take a nap, they'll remember more of it than they would have if they hadn't had a short snooze. Amazingly, even catnaps of six minutes (not counting the average five minutes it takes to fall asleep) have been shown to aid people in retaining information.

They might even make people more effective problem solvers, says Robert Stickgold, a Harvard sleep researcher. His work shows that taking a nap that includes REM sleep (the phase during which dreaming occurs) may help people become better at making connections between seemingly unrelated words.

Stickgold and his colleagues are clamoring for employer policies that actively encourage napping. Some companies have, in fact, set up nap rooms, such as Google, who provides employees with "nap pods" that block out light and sound.

The Epworth Sleepiness Scale is used to gauge the level of daytime sleepiness: 10 or more is considered sleepy; 18 or more is very sleepy. If you score 10 or more on this test, discuss these issues with your physician. Use the following scale:

0 = would never doze or sleep

1 = slight chance of dozing or sleeping

2 = moderate chance of dozing or sleeping

3 = high chance of dozing or sleeping

Sitting and reading ____

Watching TV ____

Sitting inactive in a public place ____

Being a passenger in a motor vehicle for an hour or more ____

Lying down in the afternoon ____

Sitting and talking to someone ____

Sitting quietly after lunch (no alcohol) ____

Stopped for a few minutes in traffic while driving ____

Total ____

Source: University of Maryland Sleep Disorders Center

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