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By: Geoff Eade, RPSGT, CCSH, Ashley Gould, CRT, and Bretton Lane, BS, RPSGT on October 27th, 2022

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The Underperformance of Sleep Screening

sleep apnea | obstructive sleep apnea | OSA

Many studies have been done to assess the North American population for the presence of obstructive sleep apnea (OSA). These studies have shown that up to 80% of all patients with moderate to severe sleep apnea have not yet been diagnosed.1 With the population aging and obesity on the rise, we are not making a dent into this statistic, despite the growing awareness and the advancements in home sleep testing.

The importance of diagnosing and treating sleep apnea cannot be understated. All of us working in the sleep industry witness daily the improvement of patient’s sleepiness and quality of life when their OSA is treated. The study of comorbidities and their association with sleep apnea has been prevalent over the past years. These studies have identified that 80% of patients with OSA have multiple comorbidities2 ranging from cardiovascular, stroke, chronic obstructive pulmonary disease (COPD), diabetes Type 2, asthma, cancer, metabolic diseases, mental health and more.

There are several studies and papers that describe regular positive airway pressure (PAP) usage may exert a protective effect against cardiovascular events.2 Just recently, the Mayo Clinic published a paper that showed a 32-month population of patients who suffered from cardiovascular disease. In this population, only .28% underwent a diagnostic sleep test.3 Additionally, the Mayo Clinic reported that Medicare patients with cardiovascular disease (CVD) and OSA who are adherent to PAP treatment reduce annual health care related expenses by 40%.3

There has also been a significant number of studies regarding the relationship between OSA and hypertension. It has been documented that OSA, especially in patients who present as resistant to anti-hypertensive medications, is causal for hypertension. Higher nocturnal blood pressure, independent of daytime hypertension, may play a significant role in the development of cardiovascular complications.4

Another body of work has shown that patients with sleep apnea have increased glucose levels and increased insulin resistance. It has been estimated that 86% of obese, Type 2 diabetic patients suffer from sleep apnea.5 With all of this evidence regarding the importance of treating sleep apnea, we continue to ask ourselves, why is screening for sleep apnea so underperformed and fragmented, when the mere presence of one or more comorbidities should trigger a sleep assessment?

From September to October of 2021, Idorsia Pharmaceuticals U.S. conducted an online survey through The Harris Poll. The subjects consisted of 300 primary care physicians (PCPs), 152 psychiatrists and 1,001 U.S. adults ages 18 and older who have difficulty sleeping or have been diagnosed with insomnia. The survey, Wake Up America: The Night & Day Impact of Insomnia,6 produced interesting results. Although the study was primarily focused on insomnia, it reviews the disparity of screening for sleep disorders in general. One of the highlights showed 98% of PCPs and 91% of adults surveyed agreed that sleep is one of the three pillars of health in addition to exercise and diet.6 Although that is a strong indicator, unfortunately only 66% of PCPs and a mere 27% of adults surveyed reported discussing sleep during their clinic visit.6 The adults surveyed reported a rate of 29% that struggle at work, 27% that struggle financially and 19% ending an important relationship due to sleep problems.6 On average, the survey reported adults estimated a loss of eight hours of work per week.6 This information indicates millions of dollars in lost revenue for organizations, not to mention the potential in lost wages for employees. More studies like this need to be conducted to update the persistent lack of awareness of sleep disorders. We need to close the gap to capture the undiagnosed and suffering population.

In 2015, Miller and Berger published results of a study that focused on the screening and assessment of OSA in primary care.7 They concluded that the methods of screening and assessing patients for OSA in primary care was “fragmented and ineffective.” 7 These methods are still used today with the Epworth Sleepiness Scale, STOP-Bang questionnaire and Berlin questionnaire, which have been tried and tested screening tools, although may sometimes be subjective. They may also be intimidating for providers and health care workers unfamiliar with sleep-specific signs and symptoms. This can result in inaccurate results, which may hinder a patient from being properly screened. It is also additional work for the staff to perform when they are already swamped in the chaos of a medical clinic. Could there be another way to screen patients for sleep disorders?

Many sleep centers have resorted to using known conditions that are empirically correlated with sleep disorders to create new and innovative screening tools. Once the screening tool brochure/card is distributed to primary care clinics, patients view these conditions (e.g. high blood pressure, diabetes, cardiac conditions, breathing problems or obesity) and then notify their PCP or call the sleep center to request a sleep evaluation. Once the patient gets to the sleep center or clinic for a sleep evaluation, more detailed questionnaires may be completed in addition to the evaluation by the sleep provider. At this point, the sleep provider will determine the means of diagnostic testing, diagnosis and treatment of the potential sleep disorder.

Another difficult challenge for sleep screening is informing the PCP of additional ways to detect possible sleep disorders in their patients. Many providers listen for the primary complaints of insomnia and snoring, and maybe even witnessed apnea. Unfortunately, they may not be aware of other symptoms or how they correlate with medical conditions. The wrong approach to a provider could be perceived as an attack on their medical knowledge or that someone is attempting to instruct them on how to assess their patient. This is a very tricky situation for sleep center marketers, and the objective should be to give them more “red flags” to look for during the regular evaluation to trigger a sleep referral. Once trust is established with the provider and positive results of a referred patient are witnessed, the provider may open up to suggestions on other means of assessing sleep disorders. This process may take time but will be rewarding in the end.

On the other hand, PCPs may not be interested in assessing sleep disorders as they may feel this would require them to perform sleep-specific follow-up clinic visits. One option for this situation is to develop a way for patients to be screened and referred to a sleep center before the patient gets to the PCP. Involve the provider in that decision process and assure them the test results and office visit notes will be sent to their office to maintain the continuity of care with their referred patient.

In an interview conducted with Bill Kleiman, vice president of marketing at BetterNight, he spoke about a recent appointment he had with his own cardiologist and the relevance of screening for OSA. This is a prime example of the need to create awareness to PCPs, and the general population alike, to integrate the discussion of sleep as a staple in everyday medical practice. Kleiman himself has been using a PAP device for 20 years and holds 30 years of experience in the sleep industry, so it was a surprise that at the conclusion of his visit, his cardiologist had failed to ask about the nature of his sleep or OSA.

Upon further discussion about the lack of screening done by his cardiologist, it was revealed that Kleiman’s doctor “had no idea his staff was not asking patients about their sleep habits.” Kleiman further inquired when his doctor screens a patient for OSA, to which his cardiologist said screening usually occurred “when a patient proactively tells him they are feeling fatigued.” In-turn, Kleiman shared that “being reliant on the patient telling you they are feeling this way, when we know people with OSA are walking around with no clue, how can you not test what we are spending one-third of our lives doing every day?” With all the research and the number of patients that are seen every day, it poses a serious disservice to patients. How many unnecessary medical events or deaths occur daily because of the underperformance of sleep screening?

With about 80% of the population being left undiagnosed, it is imperative to improve the awareness and understanding of the importance of screening for sleep disorders. When asked to reflect on how being in the sleep industry has changed him, Kleiman stated, "The biggest charge I get out of this is knowing that I am affecting so many human beings' lives in a positive way at the end of the day, just through increasing the number of physicians who consistently screen their patients for sleep disorders."

With all of the studies and reports that have been conducted and are currently being conducted, we in the sleep industry need to work together to find better ways to communicate with providers. We must also determine better and more effective methods to screen for sleep disorders. Awareness of sleep disorders and the correlation with health conditions is the key to informing providers and patients alike. We face a larger challenge than the other two pillars of health as the general population is already aware of the importance of diet and exercise. By working together, we can develop new and innovative ways to drive awareness to the importance of sleep and sleep disorders.

References

  1. Lee W, Nagubadi S, Kryger MH and Mokhlesi B. Epidemiology of Obstructive Sleep Apnea: A Population-based Perspective. Expert Review of Respiratory Medicine. 2008;2(3):349-364. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2727690/#:~:text=A%20multitude%20of%20studies%20have,care%20%5B5%E2%80%937%5D
  2. Bonsignore MR, Baiamonte P, Mazzuca E, Castrogiovanni A, and Marrone O. Obstructive sleep apnea and comorbidities: A dangerous liaison. Multidisciplinary Respiratory Medicine. 2019. Article number 8. Retrieved from https://mrmjournal.biomedcentral.com/articles/10.1186/s40248-019-0172-9
  3. Bock JM, Needham KA, Gregory DA, et al. Continuous Positive Airway Pressure Adherence and Treatment Cost in Patients With Obstructive Sleep Apnea and Cardiovascular Disease. Mayo Clinic Proceedings. 2022;6(2):166-175. Retrived from https://www.mcpiqojournal.org/article/S2542-4548(22)00002-9/fulltext
  4. Kapa S, Sert Kuniyoshi FH, and Somers VK. Sleep Apnea and Hypertension: Interactions and Implications for Management. Hypertension. 2008;51:605-608. Retrieved from https://www.ahajournals.org/doi/10.1161/hypertensionaha.106.076190
  5. Foster GD, Sanders MH, Millman R, et al. Obstructive sleep apnea among obese patients with type 2 diabetes. Diabetes Care. 2009;32:1017–1019. [PMC free article] [PubMed] [Google Scholar] [Ref list]
  6. Results Announced from Largest U.S. Survey of People with Trouble Sleeping, as well as Doctors, to Better Understand the Hidden Toll of Insomnia. Released April 5, 2022. Retrieved from https://www.idorsia.us/documents/us/media-releases/220405_wake-up-america-survey_fnal.pdf
  7. Miller JN, and Berger, AM. Screening and assessment for obstructive sleep apnea in primary care. Sleep Med Rev. 2016 Oct;29:41-51. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26606318/