A Tale of Two Headlines in the Screening for Obstructive Sleep Apnea
This morning I sat down at my computer and searched for “sleep apnea screening.” The first headline was “MTA to Expand Sleep Apnea Screening to Include LIRR and NYCT.”1 I took a sip of my medium roast Sumatra Mandheling and, nodding my head, said to myself, “yes, yes, screening is good.” The next headline was “USPSTF Fails to Endorse Routine Sleep Apnea Screening.”2 Out came the coffee in a fine spray on my iMac Retina 5K display.
U.S. Preventative Services Task Force Report
After cleaning up I followed the links to the U.S. Preventive Services Task Force (USPSTF) report, because I always go to the original source. I went to the recommendation statement that summarizes the results of the evaluation, which states: “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults.”3
Two things caught my attention. The first is that the USPSTF is charged with making recommendations about the effectiveness of preventive care services is patients without obvious related signs or symptoms. This means that their recommendations apply to asymptomatic adults.
Second, it is important to note that the recommendation is “I” meaning that there is insufficient evidence to support screening of all asymptomatic patients. This doesn’t mean that there is evidence against screening or that screening is harmful. In fact, the analysis weighs only the harms and benefits. An analysis that includes costs and benefits might have come to a more forceful conclusion.
Need For More Data
I also reviewed the evidence report4, because anyone who knows me knows that I am a big fan of meta-analysis. It did not disappoint and provides a comprehensive summary of data available at the time of the analysis. A further search led me to several editorials5-8, including one from Susan Redline. It will come as no surprise that each of these sources pointed to a need for more data. I think JAMA does an excellent job of presenting evidence and publishing a wide range of editorials exploring the impact of the USPSTF report.
One of the links that I followed sent me to a podcast9 featuring Howard Bauchner, MD, Editor in Chief of JAMA interviewing Alex H. Krist, MD, MPH, Task Force member and co-author of the recommendation statement. If you follow none of the other links for information, this podcast will give you a comprehensive and intelligent summary of the task force process and conclusions. It is well worth the 24 minutes it takes to listen.
The main goal of the USPSTF is to imagine that every man and woman in the US was evaluated for OSA. Would this result in a benefit that would outweigh potential harms? Dr. Krist begins by saying that we don’t have data on this, because none of the studies in the literature begin with random assignment of subjects to evaluation or no evaluation and end with treatment provided to those who test positive for OSA. The podcast explores the data in between these endpoints, evaluating the accuracy of questionnaires and tests in making a diagnosis and the efficacy of treatments in reversing the consequences of untreated apnea.
None of the members of the Task Force, including Dr. Krist, are sleep specialists and therefore they have no bias in the interpretation of the data. For those of us who make a living by diagnosing and treating OSA it would be easy to overlook the negatives associated with an incorrect diagnosis or aggressive treatment of mild disease. And as I have pointed out in recent Case of the Month andJournal Club discussions, we may also be guilty of ignoring data that does not agree with our preconceived notions of the efficacy of treatment. An unbiased approach is clearly preferable.
Although not a sleep specialist, Dr. Krist is a well-informed physician and at the end of the podcast provides his views on a clinical approach to the patients in his practice. He says that when a patient comes to his office with a complaint of loud snoring and daytime sleepiness, he will follow up with additional questions and decide whether a sleep test is needed. He will then evaluate the severity of the patient’s disease and decide on an appropriate treatment. In making his decisions, Dr. Krist is aware of the controversy surrounding treatment of mild OSA and recent data that fail to support the efficacy of CPAP in reducing cardiovascular events.
The "Asymptomatic" Modifier
If I have one complaint about this report, it is that the accompanying “JAMA Patient Page”10 is titled “Screening for Obstructive Sleep Apnea in Adults” and omits the very important “asymptomatic” modifier. What makes for a symptomatic patient, given that most patients do not spontaneously report sleepiness or snoring as a medical complaint? Dr. Redline and others worry that the USPSTF report will give patients the impression that these symptoms are not important and that even if they do complain to their physician the evidence is insufficient to make a recommendation of treatment. This is not what the report says, but it is easy to see how it might be misinterpreted.
The report is a wakeup call for the field of sleep medicine. If we want to expand sleep apnea screening to asymptomatic adults, including those in high risk occupations such as train drivers, then we need to provide data that shows it is worthwhile.
3 US Preventive Services Task Force., Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, García FA, Herzstein J, Kemper AR, Krist AH, Kurth AE, Landefeld CS, Mangione CM, Phillips WR, Phipps MG, Pignone MP, Silverstein M, Tseng CW. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Jan 24;317(4):407-414. doi: 10.1001/jama.2016.20325.
4 Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, Lux L, Harris RP. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2017 Jan 24;317(4):415-433. doi: 10.1001/jama.2016.19635.
5 Redline S. Screening for Obstructive Sleep Apnea: Implications for the Sleep Health of the Population. JAMA. 2017 Jan 24;317(4):368-370. doi: 10.1001/jama.2016.18630. No abstract available.
6 Pendharkar SR, Clement FM. Screening for Obstructive Sleep Apnea: Important to Find, but How Hard Should We Look? JAMA Intern Med. 2017 Jan 24. doi: 10.1001/jamainternmed.2016.9538.
7 Yaremchuk K. USPSTF Recommendation for Obstructive Sleep Apnea Screening in Adults. JAMA Otolaryngol Head Neck Surg. 2017 Jan 24. doi: 10.1001/jamaoto.2016.4720.
8 Carter GS. Screening for Improvement of Health Outcomes in Asymptomatic Obstructive Sleep Apnea. JAMA Neurol. 2017 Jan 24. doi:10.1001/jamaneurol.2016.5975.
10 Jin J. Screening for Obstructive Sleep Apnea in Adults. JAMA. 2017 Jan 24;317(4):450. doi: 10.1001/jama.2016.20362.