The US Preventive Services Task Force (USPSTF) recommendation on screening for obstructive sleep apnea (OSA) was recently released1 along with its supporting evidence report and systematic review.2 The USPSTF concludes that “the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults (I statement),”1 including those with previously unrecognized symptoms. The I statement indicates that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. With this statement, the USPSTF recommends that if the service is offered, patients should understand the uncertainty about the balance of benefits and harms.3 While screening for OSA is an important area to have considered, this recommendation leaves front-line clinicians who are trying to provide evidence-informed primary care wondering what is the right thing to do. In this Editorial, we outline why primary care physicians should identify OSA and other sleep disorders in symptomatic patients, but we caution that with the current level of evidence, screening for OSA in asymptomatic patients is likely to lead to unnecessary diagnostic testing and higher health care costs without clear evidence of benefit.
The World Health Organization (WHO) has developed principles to inform the decisions to screen populations for disease: (1) the condition should be an important health problem; (2) the disease (latent stages and natural history) should be adequately understood; (3) effective treatments should be available; and (4) the cost of screening (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.4 The USPSTF has adopted the WHO’s clinical and epidemiologic criteria in providing recommendations for OSA screening, but the USPSTF does not consider the costs of testing or treatment.1
Obstructive sleep apnea is an important health problem. In their statement, the USPSTF notes data from the Wisconsin Sleep Cohort Study,5 estimating that OSA was present in 9% of women and 24% of men and reaching moderate or worse severity in 4% and 9%, respectively.1 A follow-up analysis accounting for the obesity epidemic estimated the population prevalence to be 26%, of which 10% would be classified as moderate to severe.6 Symptoms include snoring, witnessed cessation of breathing, gasping or choking at night, excessive daytime sleepiness, impaired cognition, and mood changes. Untreated OSA is associated with a higher risk of motor vehicle crashes, occupational accidents, depression, and in severe cases is associated with cardiovascular and cerebrovascular disease and shortened survival.7- 11 While the proportion of patients who are asymptomatic may be difficult to determine, prevalence studies indicate at least 75% of patients with OSA do not report daytime sleepiness (the most commonly recognized symptom).12 Thus, it is estimated that over 80% of individuals with OSA remain undiagnosed.13 However, no studies have assessed whether general population screening would effectively identify this asymptomatic population.1
There are effective diagnostic tools for OSA. Portable monitoring and traditional laboratory-based polysomnography studies are established diagnostic strategies in appropriately risk-stratified patients.14 Treatment options include continuous positive airway pressure (CPAP), oral appliances, and upper-airway surgery. As noted by the USPSTF, there are conflicting findings of the benefit of these treatment strategies on mortality and cardiovascular or cerebrovascular events.1 However, CPAP and oral appliances have been shown to improve daytime sleepiness, reduce depressive symptoms, improve workplace productivity, and mitigate the risk of motor vehicle collisions.14 While these are “soft outcomes,” evidence suggests that they are meaningful for patients.15 However, as the USPSTF focuses on prevention in asymptomatic persons, improvement in symptoms, even patient-centered ones, is not relevant, and the focus is appropriately on mortality.
Despite the rationale for case-finding among symptomatic patients, the USPSTF recommendation statement does not apply to patients with suspected OSA.1 It focuses instead on asymptomatic patients (ie, those not presenting with fatigue or snoring, among other possible presentations). Other evidence-informed clinical policy agencies, such as the National Institute for Care and Health Excellence (United Kingdom), the Canadian Agency for Drugs and Technologies in Health (Canada), and the Washington State Health Technology Assessment Program have developed recommendations for the diagnosis and treatment of OSA. However, as the USPSTF focuses on prevention, it is the only body that has considered screening in asymptomatic persons for OSA. Unlike many other policy agencies, the USPSTF does not consider the balance of benefits and costs. A high-level analysis of the anticipated impact of general population screening highlights the incomplete picture considered when costs are excluded. In September 2016, 57.1 million people were enrolled in Medicare.16 With a sensitivity of 90.9% and specificity of 64.4% for the multivariable apnea prediction score,1 and a disease prevalence of 26%, we would expect up to 40.5 million Medicare beneficiaries to screen positive for apnea, among whom only 13.1 million would be expected to have mild, moderate, or severe OSA. The remaining 27.4 million people would be exposed to the costs and complications of unnecessary follow-up diagnostic testing. Given that the cost of a single laboratory-based polysomnography test is approximately $782, this would lead to $21 billion in wasted out-of-pocket and system health care costs.17 Even if all patients who screened positive were tested with a home-based portable monitoring device at a cost of $162 each, the increase in health care costs would be an estimated $4.4 billion. When costs are considered alongside the low diagnostic accuracy of screening tests and the lack of evidence of treatment benefit in asymptomatic patients, the balance tips heavily against screening in the general population.
Nonetheless, the USPSTF’s efforts present an opportunity to identify key knowledge and clinical practice gaps. As the report outlines, patients are unlikely to spontaneously discuss sleep-related symptoms with a primary care clinician.1 Given the importance of sleep as a determinant of health, this report highlights the importance of initiating conversations with patients about sleep habits. The work of the USPSTF also serves as a reminder that physicians should remain vigilant about conditions that might indicate the presence of severe OSA, such as uncontrolled hypertension or depression, and about assessing risk in individuals who work in safety-critical occupations and for whom a missed diagnosis could be catastrophic.7,8 Finally, the USPSTF highlights the need for (1) validated tools to identify patients at high risk of OSA, (2) controlled studies of OSA therapies in screen-detected individuals, and (3) studies documenting the natural history of mild disease and the long-term health outcomes of untreated OSA in asymptomatic individuals. The call for more research into these areas could direct the academic community toward needed advances in understanding of OSA.
Corresponding Author: Fiona M. Clement, PhD, Department of Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Dr, GD3 Ste 18, Third Floor TRW, Calgary, AB T2N 4Z6 Canada (email@example.com).
Published Online: January 24, 2017. doi:10.1001/jamainternmed.2016.9538
Conflict of Interest Disclosures: Dr Pendharkar is remunerated for sleep study interpretation by Alberta Health Services and VitalAire Canada. No other discosures are reported.
Pendharkar SR, Clement FM. Screening for Obstructive Sleep ApneaImportant to Find, but How Hard Should We Look?. JAMA Intern Med. Published online January 24, 2017. doi:10.1001/jamainternmed.2016.9538