Across-country viewpoints on sleepiness during driving

Notwithstanding our geographic differences, we are in agreement about the medical management of the sleepy driver. However, our lack of consensus involves legal and societal issues. As long as differences exist in regional requirements to report sleep apnea patients to the driving authorities, and given the across-country legal differences, it will be not possible to espouse a common, "across-country" clinical decision algorithm to deal with this problem. Patient health concerns must always be first but at some point, public safety must supercede individual concerns. At present, our clinical ability and clinical outcome measures (apnea-hypopnea index, ESS, MSLT, simulator data, etc.) lacks sufficient sensitivity and predictive value to determine an individual's driving risk. Because the majority of sleep apnea patients do not have accidents, we should therefore design studies to be able to reliably identify this low-risk group and then exclude them from concern about driving. This would then leave a smaller, more manageable group on which to concentrate our resources. Finally, the wisdom of mandatory reporting of drivers with sleep apnea must be questioned because such reporting can discourage many sleepy drivers from being evaluated for sleep apnea.