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331 Editorial—Howard et al. Normalizing cognitive function is key to optimizing road and workplace safety and is one of the main reasons why clinicians identify and treat obstructive sleep apnea (OSA). Whilst numerous studies have found that OSA increases the risk of motor vehicle crashes, few have applied ideal research designs to conclusively validate the relationship,1 and importantly, to demonstrate that treatment of OSA reduces the risk of motor vehicle crashes.2 In this issue of SLEEP, Karimi and colleagues3 attempt to redress the limitations of past research with respect to OSA and motor vehicle crash risk, for the first time assessing the impact of CPAP treatment adherence. Karimi et al. highlight an elevated risk of crash associated with OSA, reflecting previous findings.1 The authors extend the current literature by using an objective measure of crash (police reports) and assess crash risk using two perspectives, both retrospective and prospective, among a cohort of patients referred for suspected OSA compared to an external cohort. There are several challenges in optimally designing crash risk studies for OSA. While objective crash statistics are preferable, the low rate of police reported crashes necessitates a large sample. Clinical equipoise to leave a range of OSA patients untreated to assess crash risk is challenging because of safety concerns for severely sleepy patients.4 Bias may occur when a clinical population is used in that some patients may present because they have had a crash. Using a prospective community cohort, the Wisconsin cohort study found an increased road crash risk in men with OSA, but not women.5 Case (road crash drivers) control (drivers who have not had a crash) studies are an alternative, with assessment of OSA after the crash, and support increased crash risk in those with OSA.6 The findings of Karimi et al.3 are consistent with these previous studies. Some limitations must be acknowledged, though, including the potential for presentation bias that might increase the risk estimate in a clinical sample. OSA, sleepiness, and other confounders were not measured in the control cohort; hence it could have included some drivers with OSA and excessive sleepiness.3 Nevertheless, the study by Karimi is one of only a few controlled investigations to assess and identify a reduction in crash risk with CPAP treatment,2,7,8,3 EDITORIAL

Who Needs Sleep Apnea Treatment for Safety Critical Tasks—Are We There Yet?