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31.05.

2013

Polysomnography in Patients With Obstructive Sleep Apnea

Polysomnography in Patients With Obstructive Sleep Apnea


An Evidence-Based Analysis

Health Quality Ontario

Executive Summary
Objective
T h e object iv e of t h is h ea lt h t ech n olog y policy a ssessm en t w a s t o ev a lu a t e t h e clin ica l u t ilit y a n d cost -effect iv en ess of sleep st u dies in On t a r io.

Clinical Need: Target Population and Condition


Sleep disor der s a r e com m on a n d obst r u ct iv e sleep a pn ea (OSA ) is t h e pr edom in a n t t y pe. Obst r u ct iv e sleep a pn ea is t h e r epet it iv e com plet e obst r u ct ion (a pn ea ) or pa r t ia l obst r u ct ion (h y popn ea ) of t h e colla psible pa r t of t h e u pper a ir w a y du r in g sleep. T h e sy n dr om e is a ssocia t ed w it h ex cessiv e da y t im e sleepin ess or ch r on ic fa t ig u e. Sev er a l st u dies h a v e sh ow n t h a t OSA is a ssocia t ed w it h h y per t en sion , st r ok e, a n d ot h er ca r diov a scu la r disor der s; m a n y r esea r ch er s believ e t h a t t h ese ca r diov a scu la r disor der s a r e con sequ en ces of OSA . T h is h a s g en er a t ed in cr ea sin g in t er est in r ecen t y ea r s in sleep st u dies.

The Technology Being Reviewed


T h er e is n o g old st a n da r d for t h e dia g n osis of OSA , w h ich m a k es it difficu lt t o ca libr a t e a n y t est for dia g n osis. T r a dit ion a lly , poly som n og r a ph y (PSG) in a n a t t en ded set t in g (sleep la bor a t or y ) h a s been u sed a s a r efer en ce st a n da r d for t h e dia g n osis of OSA . Poly som n og r a ph y m ea su r es sev er a l sleep v a r ia bles, on e of w h ich is t h e a pn ea -h y popn ea in dex (A HI) or r espir a t or y dist u r ba n ce in dex (RDI). T h e A HI is defin ed a s t h e su m of a pn ea s a n d h y popn ea s per h ou r of sleep; a pn ea is defin ed a s t h e a bsen ce of a ir flow for 1 0 secon ds; a n d h y popn ea is defin ed a s r edu ct ion in r espir a t or y effor t w it h 4 % ox y g en desa t u r a t ion . T h e RDI is defin ed a s t h e su m of a pn ea s, h y popn ea s, a n d a bn or m a l r espir a t or y ev en t s per h ou r of sleep. Oft en t h e t w o t er m s a r e u sed in t er ch a n g ea bly . T h e A HI h a s been w idely u sed t o dia g n ose OSA , a lt h ou g h w it h differ en t cu t -off lev els, t h e ba sis for w h ich a r e oft en u n clea r or a r bit r a r ily det er m in ed. Gen er a lly , a n A HI of m or e t h a n fiv e ev en t s per h ou r of sleep is con sider ed a bn or m a l a n d t h e pa t ien t is con sider ed t o h a v e a sleep disor der . A n a bn or m a l A HI a ccom pa n ied by ex cessiv e da y t im e sleepin ess is t h e h a llm a r k for OSA dia g n osis. For pa t ien t s dia g n osed w it h OSA , con t in u ou s posit iv e a ir w a y pr essu r e (CPA P) t h er a py is t h e t r ea t m en t of ch oice. Poly som n og r a ph y m a y a lso u sed for t it r a t in g CPA P t o in div idu a l n eeds. In Ja n u a r y 2 0 0 5 , t h e Colleg e of Ph y sicia n s a n d Su r g eon s of On t a r io pu blish ed t h e secon d edit ion of Independent Health Facilities : Clinical Practice Param eters and Facility Standards : Sleep Medicine, com m on ly k n ow n a s T h e Sleep Book . T h e Sleep Book st a t es t h a t OSA is t h e m ost com m on pr im a r y r espir a t or y sleep disor der a n d a fu ll ov er n ig h t sleep st u dy is con sider ed t h e cu r r en t st a n da r d t est for in div idu a ls in w h om OSA is su spect ed (ba sed on clin ica l sig n s a n d sy m pt om s), pa r t icu la r ly if CPA P or su r g ica l t h er a py is bein g con sider ed. Poly som n og r a ph y in a sleep la bor a t or y is t im e-con su m in g a n d ex pen siv e. W it h t h e ev olu t ion of t ech n olog y , por t a ble dev ices h a v e em er g ed t h a t m ea su r e m or e or less t h e sa m e sleep v a r ia bles in sleep la bor a t or ies a s in t h e h om e. New er CPA P dev ices a lso h a v e a u t o-t it r a t ion fea t u r es a n d ca n r ecor d sleep v a r ia bles in clu din g A HI. T h ese dev ices, if equ a lly a ccu r a t e, m a y r edu ce t h e depen den cy on sleep la bor a t or ies for t h e dia g n osis of OSA a n d t h e t it r a t ion of CPA P, a n d t h u s m a y be m or e cost -effect iv e. Difficu lt ies a r ise, h ow ev er , w h en t r y in g t o a ssess a n d com pa r e t h e dia g n ost ic effica cy of in -h om e
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Polysomnography in Patients With Obstructive Sleep Apnea

PSG v er su s in -la b. T h e A HI m ea su r ed fr om por t a ble dev ices in -h om e is t h e su m of a pn ea s a n d h y popn ea s per h ou r of t im e in bed, r a t h er t h a n of sleep, a n d t h e a bsolu t e dia g n ost ic effica cy of in la b PSG is u n k n ow n . T o com pa r e in -h om e PSG w it h in -la b PSG, sev er a l r esea r ch er s h a v e u sed cor r ela t ion coefficien t s or sen sit iv it y a n d specificit y , w h ile ot h er s h a v e u sed Bla n d-A lt m a n plot s or r eceiv er oper a t in g ch a r a ct er ist ics (ROC) cu r v es. A ll t h ese a ppr oa ch es, h ow ev er , h a v e pot en t ia l pit fa lls. Cor r ela t ion coefficien t s do n ot m ea su r e a g r eem en t ; sen sit iv it y a n d specificit y a r e n ot h elpfu l w h en t h e t r u e disea se st a t u s is u n k n ow n ; a n d Bla n d-A lt m a n plot s m ea su r e a g r eem en t (bu t a r e h elpfu l w h en t h e r a n g e of clin ica l equ iv a len ce is k n ow n ). La st ly , r eceiv er oper a t in g ch a r a ct er ist ics cu r v es a r e g en er a t ed u sin g log ist ic r eg r ession w it h t h e t r u e disea se st a t u s a s t h e depen den t v a r ia ble a n d t est v a lu es a s t h e in depen den t v a r ia ble. T h u s, ea ch v a lu e of t h e t est is u sed a s a cu t -poin t t o m ea su r e sen sit iv it y a n d specificit y , w h ich a r e t h en plot t ed on a n x-y pla n e. T h e cu t -poin t t h a t m a x im izes bot h sen sit iv it y a n d specificit y is ch osen a s t h e cu t -off lev el t o discr im in a t e bet w een disea se a n d n o-disea se st a t es. In t h e a bsen ce of a g old st a n da r d t o det er m in e t h e t r u e disea se st a t u s, ROC cu r v es a r e of m in im a l v a lu e. A t t h e r equ est of t h e On t a r io Hea lt h T ech n olog y A dv isor y Com m it t ee (OHT A C), MA S h a s t h u s r ev iew ed t h e lit er a t u r e on PSG pu blish ed ov er t h e la st t w o y ea r s t o ex a m in e n ew dev elopm en t s.

Methods
Review Strategy T h er e is a la r g e body of lit er a t u r e on sleep st u dies a n d sev er a l r ev iew s h a v e been con du ct ed. T w o la r g e coh or t st u dies, t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy , a r e t h e m a in sou r ces of ev iden ce on sleep lit er a t u r e. T o ex a m in e n ew dev elopm en t s on PSG pu blish ed in t h e pa st t w o y ea r s, MEDLINE, EMBA SE, MEDLINE In -Pr ocess & Ot h er Non -In dex ed Cit a t ion s, t h e Coch r a n e Da t a ba se of Sy st em a t ic Rev iew s a n d Coch r a n e CENT RA L, INA HT A , a n d w ebsit es of ot h er h ea lt h t ech n olog y a ssessm en t a g en cies w er e sea r ch ed. A n y st u dy t h a t r epor t ed r esu lt s of in -h om e or in -la b PSG w a s in clu ded. A ll a r t icles t h a t r epor t ed fin din g s fr om t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy w er e a lso r ev iew ed. Diffusion of Sleep Laboratories T o est im a t e t h e diffu sion of sleep la bor a t or ies, a list of sleep la bor a t or ies licen sed u n der t h e In depen den t Hea lt h Fa cilit y A ct w a s obt a in ed. T h e a n n u a l n u m ber of sleep st u dies per 1 0 0 ,0 0 0 in div idu a ls in On t a r io fr om 2 0 0 0 t o 2 0 0 4 w a s a lso est im a t ed u sin g a dm in ist r a t iv e da t a ba ses.

Summary of Findings
Literature Review A t ot a l of 3 1 5 a r t icles w er e iden t ified t h a t w er e pu blish ed in t h e pa st t w o y ea r s; 2 2 7 w er e ex clu ded a ft er r ev iew in g t it les a n d a bst r a ct s. A t ot a l of 5 9 a r t icles w er e iden t ified t h a t r epor t ed fin din g s of t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy . Prevalence Ba sed on cr oss-sect ion a l da t a fr om t h e W iscon sin Sleep Coh or t St u dy of 6 0 2 m en a n d w om en a g ed 3 0 t o 6 0 y ea r s, it is est im a t ed t h a t t h e pr ev a len ce of sleep-disor der ed br ea t h in g is 9 % in w om en a n d 2 4 % in m en , on t h e ba sis of m or e t h a n fiv e A HI ev en t s per h ou r of sleep. A m on g t h e w om en w it h sleep disor der br ea t h in g , 2 2 .6 % h a d da y t im e sleepin ess a n d a m on g t h e m en , 1 5 .5 % h a d da y t im e sleepin ess. Ba sed on t h is, t h e pr ev a len ce of OSA in t h e m iddle-a g ed a du lt popu la t ion is est im a t ed t o be 2 % in w om en a n d 4 % in m en . Sn or in g is pr esen t in 9 4 % of OSA pa t ien t s, bu t n ot a ll sn or er s h a v e OSA . W om en r epor t da y t im e sleepin ess less oft en com pa r ed w it h t h eir m a le cou n t er pa r t s (of sim ila r a g e, body m a ss in dex [BMI], a n d A HI). Pr ev a len ce of OSA t en ds t o be h ig h er in older a g e g r ou ps com pa r ed w it h y ou n g er a g e g r ou ps. Diagnostic Value of Polysomnography It is believ ed t h a t PSG in t h e sleep la bor a t or y is m or e a ccu r a t e t h a n in www.ncbi.nlm.nih.gov/pmc/articles/PMC3379160/ 2/22

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Polysomnography in Patients With Obstructive Sleep Apnea

h om e PSG. In t h e a bsen ce of a g old st a n da r d, h ow ev er , cla im s of a ccu r a cy ca n n ot be su bst a n t ia t ed. In g en er a l, t h er e is poor cor r ela t ion bet w een PSG v a r ia bles a n d clin ica l v a r ia bles. A v a r iet y of cu t off poin t s of A HI (> 5 , > 1 0 , a n d > 1 5 ) a r e a r bit r a r ily u sed t o dia g n ose a n d ca t eg or ize sev er it y of OSA , t h ou g h t h e clin ica l im por t a n ce of t h ese cu t -off poin t s h a s n ot been det er m in ed. Recen t ly , a st u dy of t h e u se of a t h er a peu t ic t r ia l of CPA P t o dia g n ose OSA w a s r epor t ed. T h e a u t h or s st u died h a bit u a l sn or er s w it h da y t im e sleepin ess in t h e a bsen ce of ot h er m edica l or psy ch ia t r ic disor der s. Usin g PSG a s t h e r efer en ce st a n da r d, t h e a u t h or s ca lcu la t ed t h e sen sit iv it y of t h is t est t o be 8 0 % a n d it s specificit y t o be 9 7 %. Fu r t h er , t h ey con clu ded t h a t PSG cou ld be a v oided in 4 6 % of t h is popu la t ion . Obstructive Sleep Apnea and Obesity Obst r u ct iv e sleep a pn ea is st r on g ly a ssocia t ed w it h obesit y . Obese in div idu a ls (BMI >3 0 k g /m 2) a r e a t h ig h er r isk for OSA com pa r ed w it h n on -obese in div idu a ls a n d u p t o 7 5 % of OSA pa t ien t s a r e obese. It is h y pot h esized t h a t obese in div idu a ls h a v e la r g e deposit s of fa t in t h e n eck t h a t ca u se t h e u pper a ir w a y t o colla pse in t h e su pin e posit ion du r in g sleep. T h e obser v a t ion s r epor t ed fr om sev er a l st u dies su ppor t t h e h y pot h esis t h a t A HIs (or RDIs) a r e sig n ifica n t ly r edu ced w it h w eig h t loss in obese in div idu a ls. Obstructive Sleep Apnea and Cardiovascular Diseases A ssocia t ion s h a v e been sh ow n bet w een OSA a n d com or bidit ies su ch a s dia bet es m ellit u s a n d h y per t en sion , w h ich a r e k n ow n r isk fa ct or s for m y oca r dia l in fa r ct ion a n d st r ok e. Pa t ien t s w it h m or e sev er e for m s of OSA (ba sed on A HI) r epor t poor er qu a lit y of life a n d in cr ea sed h ea lt h ca r e u t iliza t ion com pa r ed w it h pa t ien t s w it h m ilder for m s of OSA . Fr om a n im a l m odels, it is h y pot h esized t h a t sleep fr a g m en t a t ion r esu lt s in g lu cose in t oler a n ce a n d h y per t en sion . T h er e is, h ow ev er , n o ev iden ce fr om pr ospect iv e st u dies in h u m a n s t o est a blish a ca u sa l lin k bet w een OSA a n d h y per t en sion or dia bet es m ellit u s. It is a lso n ot clea r t h a t t h e a ssocia t ion s bet w een OSA a n d ot h er disea ses a r e in depen den t of obesit y ; in m ost of t h ese st u dies, pa t ien t s w it h h ig h er v a lu es of A HI h a d h ig h er v a lu es of BMI com pa r ed w it h pa t ien t s w it h low er A HI v a lu es. A r ecen t m et a -a n a ly sis of ba r ia t r ic su r g er y h a s sh ow n t h a t w eig h t loss in obese in div idu a ls (m ea n BMI = 4 6 .8 k g /m 2; r a n g e = 3 2 .3 0 6 8 .8 0 ) sig n ifica n t ly im pr ov ed t h eir h ea lt h pr ofile. Dia bet es w a s r esolv ed in 7 6 .8 % of pa t ien t s, h y per t en sion w a s r esolv ed in 6 1 .7 % of pa t ien t s, h y per lipidem ia im pr ov ed in 7 0 % of pa t ien t s, a n d OSA r esolv ed in 8 5 .7 % of pa t ien t s. T h is su g g est s t h a t obesit y lea ds t o OSA , dia bet es, a n d h y per t en sion , r a t h er t h a n OSA in depen den t ly ca u sin g dia bet es a n d h y per t en sion . Health Technology Assessments, Guidelines, and Recommendations In A pr il 2 0 0 5 , t h e Cen t er s for Medica r e a n d Medica id Ser v ices (CMS) in t h e Un it ed St a t es pu blish ed it s decision a n d r ev iew r eg a r din g in -h om e a n d in -la b sleep st u dies for t h e dia g n osis a n d t r ea t m en t of OSA w it h CPA P. In or der t o cov er CPA P, CMS r equ ir es t h a t a dia g n osis of OSA be est a blish ed u sin g PSG in a sleep la bor a t or y . A ft er r ev iew in g t h e lit er a t u r e, CMS con clu ded t h a t t h e ev iden ce w a s n ot a dequ a t e t o det er m in e t h a t u n a t t en ded por t a ble sleep st u dy w a s r ea son a ble a n d n ecessa r y in t h e dia g n osis of OSA . In Ma y 2 0 0 5 , t h e Ca n a dia n Coor din a t in g Office of Hea lt h T ech n olog y A ssessm en t (CCOHT A ) pu blish ed a r ev iew of g u idelin es for r efer r a l of pa t ien t s t o sleep la bor a t or ies. T h e r ev iew in clu ded 3 7 g u idelin es a n d a ssocia t ed r ev iew s t h a t cov er ed 1 8 a pplica t ion s of sleep la bor a t or y st u dies. T h e CCOHT A r epor t ed t h a t t h e lev el of ev iden ce for m a n y a pplica t ion s w a s of lim it ed qu a lit y , t h a t som e cit ed st u dies w er e n ot r elev a n t t o t h e r ecom m en da t ion s m a de, t h a t m a n y r ecom m en da t ion s r eflect con sen su s posit ion s on ly , a n d t h a t t h er e w a s a n eed for m or e g ood qu a lit y st u dies of m a n y sleep la bor a t or y a pplica t ion s. Diffusion A s of t h e t im e of w r it in g , t h er e a r e 9 7 licen sed sleep la bor a t or ies in On t a r io. In 2 0 0 0 , t h e n u m ber of sleep st u dies per for m ed in On t a r io w a s 3 7 6 /1 0 0 ,0 0 0 people. T h er e w a s a st ea dy r ise in sleep st u dies in t h e follow in g y ea r s su ch t h a t in 2 0 0 4 , 7 6 9 sleep st u dies per 1 0 0 ,0 0 0 people w er e per for m ed, for a t ot a l of 9 6 ,1 3 4 sleep st u dies. Ba sed on pr ev a len ce est im a t es of t h e W iscon sin Sleep
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Polysomnography in Patients With Obstructive Sleep Apnea

Coh or t St u dy , it w a s est im a t ed t h a t 9 2 7 ,1 0 5 people a g ed 3 0 t o 6 0 y ea r s h a v e sleep-disor der ed br ea t h in g . T h u s, t h er e m a y be a 1 0 -fold r ise in t h e r a t e of sleep t est s in t h e n ex t few y ea r s. Economic Analysis In 2 0 0 4 , a ppr ox im a t ely 9 6 ,0 0 0 sleep st u dies w er e con du ct ed in On t a r io a t a t ot a l cost of ~$4 7 m illion (Cdn ). Sin ce obesit y is a ssocia t ed w it h sleep disor der ed br ea t h in g , MA S com pa r ed t h e cost s of sleep st u dies t o t h e cost of ba r ia t r ic su r g er y . T h e cost of ba r ia t r ic su r g er y is $1 7 ,3 5 0 per pa t ien t . In 2 0 0 4 , On t a r io spen t $4 .7 m illion per y ea r for 2 7 0 pa t ien t s t o u n der g o ba r ia t r ic su r g er y in t h e pr ov in ce, a n d $8 .2 m illion for 2 2 5 pa t ien t s t o seek ou t -of-cou n t r y t r ea t m en t . Usin g a Ma r k ov m odel, it w a s con clu ded t h a t sh ift in g cost s fr om sleep st u dies t o ba r ia t r ic su r g er y w ou ld ben efit m or e pa t ien t s w it h OSA a n d m a y a lso pr ev en t h ea lt h con sequ en ces r ela t ed t o dia bet es, h y per t en sion , a n d h y per lipidem ia . It is est im a t ed t h a t t h e a n n u a l cost of t r ea t in g com or bid con dit ion s in m or bidly obese pa t ien t s oft en ex ceeds $1 0 ,0 0 0 per pa t ien t . T h u s, t h e dow n st r ea m cost sa v in g s cou ld be su bst a n t ia l. Considerations for Policy Development W eig h t loss is a ssocia t ed w it h a decr ea se in OSA sev er it y . T r ea t in g a n d pr ev en t in g obesit y w ou ld a lso su bst a n t ia lly r edu ce t h e econ om ic bu r den a ssocia t ed w it h dia bet es, h y per t en sion , h y per lipidem ia , a n d OSA . Pr om ot ion of h ea lt h y w eig h t s m a y be a ch iev ed by a m u lt isect or ia l a ppr oa ch a s r ecom m en ded by t h e Ch ief Medica l Officer of Hea lt h for On t a r io. Ba r ia t r ic su r g er y h a s t h e pot en t ia l t o h elp m or bidly obese in div idu a ls (BMI > 3 5 k g /m 2 w it h a n a ccom pa n y in g com or bid con dit ion , or BMI > 4 0 k g /m 2) lose w eig h t . In Ja n u a r y 2 0 0 5 , MA S com plet ed a n a ssessm en t of ba r ia t r ic su r g er y , ba sed on w h ich OHT A C r ecom m en ded a n im pr ov em en t in a ccess t o t h ese su r g er ies for m or bidly obese pa t ien t s in On t a r io. Ha bit u a l sn or er s w it h ex cessiv e da y t im e sleepin ess h a v e a h ig h pr et est pr oba bilit y of h a v in g OSA . T h ese pa t ien t s cou ld be offer ed a t h er a peu t ic t r ia l of CPA P t o dia g n ose OSA , r a t h er t h a n a PSG. A m a jor it y of t h ese pa t ien t s a r e a lso obese a n d m a y ben efit fr om w eig h t loss. In div idu a lized w eig h t loss pr og r a m s sh ou ld, t h er efor e, be offer ed a n d pa t ien t s w h o a r e m or bidly obese sh ou ld be offer ed ba r ia t r ic su r g er y . T h a t sa id, a n d in v iew of t h e st ill ev olv in g u n der st a n din g of t h e ca u ses, con sequ en ces a n d opt im a l t r ea t m en t of OSA , fu r t h er r esea r ch is w a r r a n t ed t o iden t ify w h ich pa t ien t s sh ou ld be scr een ed for OSA .

Objective
T h e object iv e of t h is h ea lt h t ech n olog y policy a ssessm en t w a s t o ev a lu a t e t h e clin ica l u t ilit y a n d cost -effect iv en ess of sleep st u dies in On t a r io.

Background
Clinical Need: Target Population and Condition
Sleep disor der s a r e com m on a n d obst r u ct iv e sleep a pn ea (OSA ) is t h e pr edom in a n t t y pe. (1 ) Ot h er t y pes in clu de in som n ia , n a r colepsy , r est less leg sy n dr om e, a n d sleepw a lk in g . Obst r u ct iv e sleep a pn ea is a r epet it iv e com plet e obst r u ct ion (a pn ea ) or pa r t ia l obst r u ct ion (h y popn ea ) of t h e colla psible pa r t of t h e u pper a ir w a y du r in g sleep; t h e sy n dr om e is a ssocia t ed w it h ex cessiv e da y t im e sleepin ess or ch r on ic fa t ig u e. (2 ) Sev er a l st u dies h a v e sh ow n t h a t OSA is a ssocia t ed w it h a cciden t r isk , cog n it iv e im pa ir m en t , a n d ca r diov a scu la r disor der s. (3 ) In t u it iv ely , it cou ld be a r g u ed t h a t ex cessiv e da y t im e sleepin ess in OSA pa t ien t s w ou ld low er a t t en t ion spa n a n d m ig h t in cr ea se t h e r isk of a cciden t s com pa r ed w it h people w h o do n ot h a v e OSA . How ev er , m a n y r esea r ch er s believ e t h a t t h e a ssocia t ed ca r diov a scu la r disor der s a r e m or e ser iou s con sequ en ces of OSA . T h is h a s r a ised a w a r en ess on t h e im por t a n ce of OSA dia g n osis. In Ca n a da , 3 7 0 sleep st u dies per 1 0 0 ,0 0 0 popu la t ion a r e per for m ed a n n u a lly on a v er a g e a n d 7 7 6 /1 0 0 ,0 0 0 in On t a r io. Cor r espon din g r a t es in t er n a t ion a lly a r e 4 2 7 /1 0 0 ,0 0 0 in t h e Un it ed
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Polysomnography in Patients With Obstructive Sleep Apnea

St a t es, 4 2 .5 /1 0 0 ,0 0 0 in t h e Un it ed Kin g dom , 1 7 7 /1 0 0 ,0 0 0 in Belg iu m , a n d 2 8 2 /1 0 0 ,0 0 0 in A u st r a lia . (4 ) T h e r a t e of sleep st u dies per for m ed in On t a r io is t h u s v er y h ig h in r ela t ion t o ot h er pr ov in ces in Ca n a da , a s w ell a s ot h er cou n t r ies. T h is pr om pt ed a r equ est t o a ssess sleep la bor a t or ies.

Technology Being Reviewed


Obst r u ct iv e sleep a pn ea , u n lik e ot h er disea ses su ch a s ca n cer , ca n n ot be dia g n osed by a t issu e biopsy . T h u s, t h e a bsen ce of a g old st a n da r d by w h ich t o det er m in e t h e t r u e disea se st a t u s m a k es it difficu lt t o ca libr a t e a n y t est for OSA dia g n osis. T r a dit ion a lly , poly som n og r a ph y (PSG) in a n a t t en ded set t in g (sleep la bor a t or y ) h a s been u sed a s a r efer en ce st a n da r d for t h e dia g n osis of OSA . T h is r equ ir es obser v in g pa t ien t s w h ile t h ey a r e a sleep. (5 ) A pa t ien t st a y s ov er n ig h t in t h e sleep la bor a t or y a n d is con st a n t ly m on it or ed by a t ech n icia n . Poly som n og r a ph y in clu des elect r oen ceph a log r a ph y , elect r ooccu log r a ph y , su bm en t a l elect r om y og r a ph y , elect r oca r diog r a ph y , r espir a t or y m ov em en t or r espir a t or y effor t , n a sa l or or a l a ir flow , pu lse ox im et r y , a n d lim b m ov em en t elect r om y og r a ph y . (6 ) T h u s, PSG m on it or s sleep st a g es, r espir a t or y effor t , ox y g en sa t u r a t ion , h ea r t r a t e, body posit ion , a n d lim b m ov em en t s. T h ese da t a a r e u sed t o ca lcu la t e t h e a pn ea -h y popn ea in dex (A HI) or r espir a t or y dist u r ba n ce in dex (RDI). T h e A HI is t h e su m of a pn ea s a n d h y popn ea s per h ou r of sleep w it h a pn ea defin ed a s t h e a bsen ce of a ir flow for 1 0 secon ds a n d h y popn ea a s r edu ct ion in r espir a t or y effor t w it h 4 % ox y g en desa t u r a t ion . T h e RDI is t h e su m of a pn ea s, h y popn ea s, a n d a bn or m a l r espir a t or y ev en t s per h ou r of sleep. Oft en , t h e t er m s a r e u sed in t er ch a n g ea bly . T h e A HI h a s been w idely u sed t o dia g n ose OSA , a lt h ou g h w it h differ en t cu t -off lev els, t h e ba sis for w h ich a r e oft en u n clea r or a r bit r a r ily det er m in ed. Gen er a lly , a n A HI of g r ea t er t h a n fiv e ev en t s per h ou r of sleep is con sider ed a bn or m a l a n d t h e pa t ien t is con sider ed t o h a v e a sleep disor der . A n a bn or m a l A HI a ccom pa n ied by ex cessiv e da y t im e sleepin ess is t h e h a llm a r k for t h e dia g n osis of OSA . For pa t ien t s dia g n osed w it h OSA , con t in u ou s posit iv e a ir w a y pr essu r e t h er a py (CPA P) is t h e t r ea t m en t of ch oice. Poly som n og r a ph y m a y a lso u sed for t it r a t in g CPA P t o in div idu a l n eeds. In Ja n u a r y 2 0 0 5 , t h e Colleg e of Ph y sicia n s a n d Su r g eon s of On t a r io pu blish ed t h e secon d edit ion of Independent Health Facilities : Clinical Practice Param eters and Facility Standards : Sleep Medicine, com m on ly k n ow n a s T h e Sleep Book . T h e docu m en t w a s desig n ed t o a ssist ph y sicia n s in t h eir clin ica l decision -m a k in g by pr ov idin g a fr a m ew or k for a ssessin g a n d t r ea t in g clin ica l con dit ion s com m on ly ca r ed for by a v a r iet y of specia lt ies. T h e pr im a r y pu r pose w a s t o a ssist ph y sicia n s in dev elopin g t h eir ow n qu a lit y m a n a g em en t pr og r a m a n d t o a ct a s a g u ide for a ssessin g t h e qu a lit y of pa t ien t ca r e pr ov ided in t h ese fa cilit ies. T h e Sleep Book r epor t s t h a t OSA is t h e m ost com m on pr im a r y r espir a t or y sleep disor der a n d fu ll ov er n ig h t sleep st u dy is t h e cu r r en t st a n da r d for t h ose in div idu a ls in w h om OSA is su spect ed (ba sed on clin ica l sig n s a n d sy m pt om s), pa r t icu la r ly if CPA P or su r g ica l t h er a py a r e bein g con sider ed. Poly som n og r a ph y in a sleep la bor a t or y is t im e-con su m in g a n d ex pen siv e. W it h t h e ev olu t ion of t ech n olog y , por t a ble dev ices h a v e em er g ed t h a t m ea su r e m or e or less t h e sa m e sleep v a r ia bles w h et h er in sleep la bor a t or ies or in -h om e. T h e A m er ica n Sleep Disor der s A ssocia t ion cla ssifies t h ese dev ices in t o fou r t y pes: T y pe I dev ices a r e con sider ed t h e st a n da r d la bor a t or y -ba sed PSG. T y pe II dev ices a r e com pr eh en siv e por t a ble PSG dev ices w it h a m in im u m of sev en ch a n n els t h a t m ea su r e t h e sa m e pa r a m et er s a s t h ose by T y pe I dev ices, in clu din g sleep st a g in g . T y pe III dev ices h a v e a m in im u m of fou r ch a n n els a n d m ea su r e on ly t h e ca r dior espir a t or y pa r a m et er s of sleep. T h e A HI ca lcu la t ed fr om t h ese dev ices is ca lcu la t ed per h ou r of t im e in bed, r a t h er t h a n per h ou r of sleep. T y pe IV dev ices m ea su r e on ly ox y g en sa t u r a t ion or a ir flow . New er CPA P dev ices a lso h a v e a u t ot it r a t ion fea t u r es. T h ese dev ices, if equ a lly a ccu r a t e, m a y r edu ce t h e depen den cy on sleep la bor a t or ies for t h e dia g n osis of OSA a n d t h e t it r a t ion of CPA P a n d t h u s m a y be m or e cost -effect iv e. Difficu lt ies a r ise, h ow ev er , w h en t r y in g t o a ssess a n d com pa r e t h e dia g n ost ic effica cy of in -h om e
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Polysomnography in Patients With Obstructive Sleep Apnea

PSG v er su s in -la b. T h e A HI m ea su r ed fr om por t a ble dev ices in -h om e is t h e su m of a pn ea s a n d h y popn ea s per h ou r of t im e in bed, r a t h er t h a n of sleep, a n d t h e a bsolu t e dia g n ost ic effica cy of in la b PSG is u n k n ow n . T o com pa r e in -h om e PSG w it h in -la b PSG, sev er a l r esea r ch er s h a v e u sed cor r ela t ion coefficien t s or sen sit iv it y a n d specificit y , w h ile ot h er s h a v e u sed Bla n d-A lt m a n plot s or r eceiv er oper a t in g ch a r a ct er ist ics (ROC) cu r v es. A ll t h ese a ppr oa ch es, h ow ev er , h a v e pot en t ia l pit fa lls. Cor r ela t ion coefficien t s do n ot m ea su r e a g r eem en t ; sen sit iv it y a n d specificit y a r e n ot h elpfu l w h en t h e t r u e disea se st a t u s is u n k n ow n ; a n d Bla n d-A lt m a n plot s m ea su r e a g r eem en t (bu t a r e h elpfu l w h en t h e r a n g e of clin ica l equ iv a len ce is k n ow n ). La st ly , r eceiv er oper a t in g ch a r a ct er ist ics cu r v es a r e g en er a t ed u sin g log ist ic r eg r ession w it h t h e t r u e disea se st a t u s a s t h e depen den t v a r ia ble a n d t est v a lu es a s t h e in depen den t v a r ia ble. T h u s, ea ch v a lu e of t h e t est is u sed a s a cu t -poin t t o m ea su r e sen sit iv it y a n d specificit y , w h ich a r e t h en plot t ed on a n x-y pla n e. T h e cu t -poin t t h a t m a x im izes bot h sen sit iv it y a n d specificit y is ch osen a s t h e cu t -off lev el t o discr im in a t e bet w een disea se a n d n o-disea se st a t es. In t h e a bsen ce of a g old st a n da r d t o det er m in e t h e t r u e disea se st a t u s, ROC cu r v es a r e of m in im a l v a lu e.

Literature Review on Effectiveness


Research Questions
1 . W h a t is t h e clin ica l u t ilit y of sleep la bor a t or y st u dies? 2 . W h a t is t h e diffu sion of sleep la bor a t or y t ech n olog y in On t a r io? 3 . A r e sleep la bor a t or y st u dies cost -effect iv e?

Review Strategy
T h e object iv e of t h e lit er a t u r e r ev iew w a s t o a ddr ess t h e qu est ion : W h a t is t h e clin ica l u t ilit y of sleep la bor a t or y st u dies? T h er e is a la r g e body of lit er a t u r e on sleep st u dies, a n d sev er a l r ev iew s h a v e been con du ct ed. T w o la r g e coh or t st u dies, t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy , a r e t h e m a in sou r ce of ev iden ce on sleep lit er a t u r e. T h e MA S r ev iew ed a ll lit er a t u r e pu blish ed on PSG ov er t h e pa st t w o y ea r s t o ex a m in e n ew dev elopm en t s in t h e dia g n osis of OSA . MEDLINE, EMBA SE, MEDLINE In -Pr ocess & Ot h er Non -In dex ed Cit a t ion s, t h e Coch r a n e Da t a ba se of Sy st em a t ic Rev iew s a n d Coch r a n e CENT RA L, INA HT A , a n d w ebsit es of ot h er h ea lt h t ech n olog y a ssessm en t a g en cies w er e sea r ch ed. A ll st u dies r epor t in g r esu lt s of a PSG in a sleep la bor a t or y or in -h om e w er e in clu ded. St u dies t h a t did n ot u se PSG w er e ex clu ded. In a ddit ion , t o u n der st a n d t h e clin ica l im por t a n ce of dia g n osin g a n d t r ea t in g OSA , a r t icles t h a t r epor t ed fin din g s fr om t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy w er e a lso r ev iew ed.

Results of Literature Review


A t ot a l of 3 1 5 a r t icles w er e iden t ified t h a t w er e pu blish ed in t h e pa st 2 y ea r s; 2 2 7 w er e ex clu ded a ft er r ev iew in g t it les a n d a bst r a ct s. A t ot a l of 5 9 a r t icles w er e iden t ified t h a t r epor t ed fin din g s of t h e Sleep Hea r t Hea lt h St u dy a n d t h e W iscon sin Sleep Coh or t St u dy . T a ble 1 sh ow s t h e qu a lit y of ev iden ce of in clu ded st u dies. Plea se n ot e t h a t t h e t a ble does n ot a pply t o dia g n ost ic st u dies.

Tab l e 1 :
Quality of Evidence of Included Studies*

Summary of Existing Health Technology Assessments


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Polysomnography in Patients With Obstructive Sleep Apnea

In A pr il 2 0 0 5 , t h e CMS in t h e Un it ed St a t es pu blish ed it s decision a n d r ev iew r eg a r din g sleep st u dies in -h om e com pa r ed w it h in -la b for t h e dia g n osis a n d t r ea t m en t of OSA w it h CPA P. (7 ) In or der t o cov er CPA P, CMS r equ ir es t h a t a dia g n osis of OSA be est a blish ed u sin g PSG in a sleep la bor a t or y . A ft er r ev iew in g t h e lit er a t u r e, CMS con clu ded t h a t t h e ev iden ce w a s n ot a dequ a t e t o det er m in e t h a t u n a t t en ded por t a ble sleep st u dy w a s r ea son a ble a n d n ecessa r y in t h e dia g n osis of OSA . In Ma y 2 0 0 5 , t h e CCOHT A pu blish ed a r ev iew of g u idelin es for r efer r a l of pa t ien t s t o sleep la bor a t or ies. (6 ) T h e r ev iew in clu ded 3 7 g u idelin es a n d a ssocia t ed r ev iew s t h a t cov er ed 1 8 a pplica t ion s of sleep la bor a t or y st u dies. T h e CCOHT A r epor t ed t h a t t h e lev el of ev iden ce for m a n y a pplica t ion s w a s of lim it ed qu a lit y , t h a t som e cit ed st u dies w er e n ot r elev a n t t o t h e r ecom m en da t ion s m a de, t h a t m a n y r ecom m en da t ion s r eflect con sen su s posit ion s on ly , a n d t h a t t h er e w a s a n eed for m or e g ood qu a lit y st u dies of m a n y sleep la bor a t or y a pplica t ion s.

Medical Advisory Secretariat Review


T h e fin din g s of t h e MA S r ev iew a r e pr esen t ed u n der t h e follow in g t h em es: Prevalence A w ell-cit ed a r t icle ba sed on cr oss-sect ion a l da t a fr om t h e W iscon sin Sleep Coh or t St u dy r epor t ed fin din g s on 6 0 2 m en a n d w om en a g ed 3 0 t o 6 0 y ea r s. (2 ) T h e a u t h or s est im a t ed t h a t t h e pr ev a len ce of sleep disor der ed br ea t h in g w a s 9 % in w om en a n d 2 4 % in m en on t h e ba sis of m or e t h a n fiv e A HI ev en t s per h ou r of sleep. A m on g t h e w om en w it h sleep disor der br ea t h in g , 2 2 .6 % h a d da y t im e sleepin ess a n d a m on g t h e m en , 1 5 .5 % h a d da y t im e sleepin ess. Ba sed on t h is, t h e pr ev a len ce of OSA in t h e m iddle-a g ed a du lt popu la t ion is est im a t ed t o be 2 % in w om en a n d 4 % in m en . Sn or in g is pr esen t in 9 4 % of OSA pa t ien t s, bu t n ot a ll sn or er s h a v e OSA . W om en r epor t da y t im e sleepin ess less oft en com pa r ed w it h t h eir m a le cou n t er pa r t s (of sim ila r a g e, BMI, a n d A HI). T h e pr ev a len ce of OSA a lso t en ds t o be h ig h er in older a g e g r ou ps com pa r ed w it h y ou n g er a g e g r ou ps. Ma n y pa t ien t s w it h su spect ed OSA a lso h a v e posit ion a l sleep a pn ea . (8 ) Posit ion a l sleep a pn ea is defin ed a s a 5 0 % r edu ct ion in A HI du r in g n on -su pin e sleep in r ela t ion t o su pin e sleep. In on e st u dy , it w a s est im a t ed t h a t 2 6 % of pa t ien t s w it h a posit iv e sleep t est h a d posit ion a l sleep a pn ea . (8 ) Pa t ien t s w it h posit ion a l sleep a pn ea m a y ben efit fr om posit ion a l t h er a py desig n ed t o pr ev en t t h e su pin e posit ion du r in g sleep. Diagnostic Value of Polysomnography It is believ ed t h a t PSG in -la b is m or e a ccu r a t e t h a n PSG in -h om e. In t h e a bsen ce of a g old st a n da r d, h ow ev er , cla im s of a ccu r a cy ca n n ot be su bst a n t ia t ed. In g en er a l, t h er e is poor cor r ela t ion bet w een PSG v a r ia bles a n d clin ica l v a r ia bles. A v a r iet y of cu t -off poin t s of A HI (> 5 , > 1 0 , a n d > 1 5 ) a r e a r bit r a r ily u sed t o dia g n ose a n d ca t eg or ize sev er it y of OSA . T h u s, t h ese cu t off poin t s h a v e u n det er m in ed clin ica l im por t a n ce. (2 ) Recen t ly , on e st u dy u sed a t h er a peu t ic t r ia l of CPA P t o dia g n ose OSA . (9 ) T h e a u t h or s st u died h a bit u a l sn or er s w it h da y t im e sleepin ess t h a t did n ot h a v e a n y ot h er m edica l or psy ch ia t r ic disor der s. Usin g PSG a s t h e r efer en ce st a n da r d, t h e a u t h or s ca lcu la t ed t h e sen sit iv it y of t h e t est t o be 8 0 % a n d specificit y t o be 9 7 %. T h ey con clu ded t h a t PSG cou ld be a v oided in 4 6 % of t h is popu la t ion . Obstructive Sleep Apnea and Obesity Obst r u ct iv e sleep a pn ea is st r on g ly a ssocia t ed w it h obesit y . (1 0 ;1 1 ) Obese in div idu a ls (BMI > 3 0 k g /m 2) a r e a t a h ig h er r isk for OSA . For ex a m ple, Up t o 7 5 % of OSA pa t ien t s seen a t t h e Un iv er sit y Hea lt h Net w or k in T or on t o a r e obese (Per son a l com m u n ica t ion , Ma r ch 2 0 0 5 ). It is h y pot h esized t h a t obese in div idu a ls h a v e la r g e deposit s of fa t in t h e n eck t h a t ca u ses t h e u pper a ir w a y t o colla pse in t h e su pin e posit ion du r in g sleep. T h e obser v a t ion s r epor t ed fr om sev er a l st u dies su ppor t s t h e h y pot h esis t h a t A HIs (or RDIs) a r e sig n ifica n t ly r edu ced w it h w eig h t loss in obese in div idu a ls. (1 2 -1 4 ) For ex a m ple, Dix on et a l. (1 4 ) pr ospect iv ely follow ed 2 5 sev er ely obese pa t ien t s for 1 7 1 0 m on t h s follow in g ba r ia t r ic su r g er y . T h e m ea n BMI w a s 5 2 .7
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Polysomnography in Patients With Obstructive Sleep Apnea

9 .5 k g /m 2 a t ba selin e com pa r ed w it h 3 7 .2 7 .2 k g /m 2 a t t h e en d of st u dy ( P < .0 0 1 ); m ea n A HI w a s 6 1 .6 3 1 .9 /h r com pa r ed w it h 1 3 .4 1 3 /h r a t t h e en d of st u dy ( P < .0 0 1 ); 2 3 of t h e 2 5 pa t ien t s(9 2 %) n eeded CPA P a t ba selin e com pa r ed w it h 2 4 % a t t h e en d of st u dy ( P < .0 0 1 ). W eig h t loss is on e of t h e few in t er v en t ion s t h a t m a y cu r e OSA . (1 5 ) T h is m a y be a ch iev ed by m odifica t ion of lifest y le, diet , m edica t ion , a n d ba r ia t r ic su r g er y . T h e cu r r en t epidem ic of obesit y is lik ely t o dr iv e a n in cr ea se in obesit y -r ela t ed sleep disor der s, in clu din g OSA , a s w ell a s ot h er com or bid con dit ion s. T h u s, t h e Ch ief Medica l Officer of Hea lt h for On t a r io h a s r ecog n ized t h e ov er w eig h t a n d obesit y epidem ic a s on e of t h e big g est ch a llen g es, a n d h a s r ecom m en ded a com pr eh en siv e a n d m u lt isect or ia l st r a t eg y t o h elp t h e people of On t a r io a ch iev e a n d m a in t a in a h ea lt h y w eig h t . (1 6 ) In Ja n u a r y 2 0 0 5 , MA S com plet ed a n a ssessm en t of ba r ia t r ic su r g er y , ba sed on w h ich t h e On t a r io Hea lt h T ech n olog y A dv isor y Com m it t ee (OHT A C) r ecom m en ded im pr ov in g a ccess t o t h ese su r g er ies for m or bidly obese pa t ien t s in On t a r io. Obstructive Sleep Apnea and Cardiovascular Diseases A ssocia t ion s bet w een OSA a n d h y per t en sion h a v e been dem on st r a t ed: pa t ien t s w it h a m or e sev er e for m of OSA (ba sed on A HI) h a v e a h ig h er pr ev a len ce of h y per t en sion com pa r ed w it h pa t ien t s w h o h a v e m ilder for m s. (1 7 -2 1 ) It is, a s y et , u n clea r , w h et h er t h ese a ssocia t ion s a r e in depen den t of obesit y . In m ost of t h ese st u dies, pa t ien t s w it h h ig h er A HI v a lu es a lso h a d h ig h er BMI v a lu es com pa r ed t o t h ose pa t ien t s w it h low er A HI v a lu es. Fr om a n im a l m odels, it w a s in it ia lly h y pot h esized t h a t OSA ca n lea d t o su st a in ed h y per t en sion . (2 2 ) In a r ev iew pu blish ed in 2 0 0 0 , h ow ev er , Y ou n g a n d Peppa r d (2 3 ) con clu ded t h a t t h er e w a s n o ev iden ce fr om pr ospect iv e st u dies in h u m a n s t o est a blish a ca u sa l lin k bet w een OSA a n d h y per t en sion . Sin ce t h en , few st u dies h a v e r epor t ed fin din g s fr om pr ospect iv ely collect ed da t a . In 2 0 0 0 , Peppa r d et a l. (2 4 ) pu blish ed t h eir fin din g s fr om t h e W iscon sin Sleep Coh or t St u dy on 8 9 3 pa r t icipa n t s on w h om t h ey h a d follow -u p da t a for a t lea st 4 y ea r s. T h e a u t h or s defin ed h y per t en sion a s a blood pr essu r e of a t lea st 1 4 0 /9 0 m m Hg , or t h e u se of a n t ih y per t en siv e m edica t ion s. T h ey div ided t h e coh or t by ba selin e v a lu es of A HI in t o fou r g r ou ps: 1 ) A HI = 0 ; 2 ) A HI = 0 .1 4 .9 ; 3 ) A HI = 5 1 4 .9 ; a n d 4 ) A HI 1 5 . Usin g t h e fir st g r ou p a s t h e r efer en ce g r ou p, t h ey com pa r ed t h e ot h er g r ou ps for r a t es of h y per t en sion a t t h e en d-poin t v ia log ist ic r eg r ession . A ft er a dju st in g for ba selin e h y per t en sion , BMI, a lcoh ol, a n d cig a r et t e u se, t h ey com pu t ed odds r a t ios (ORs) a n d 9 5 % con fiden ce in t er v a ls (CIs). T h ey fou n d t h a t t h e odds of h y per t en sion w er e h ig h er in g r ou ps 2 t o 4 com pa r ed w it h g r ou p 1 [OR = 1 .4 2 (2 v s. 1 ), 2 .0 3 (3 v s. 1 ), 2 .8 9 (4 v s. 1 ); P = .0 0 2 for t r en d]. A s seen in T a ble 2 , h ow ev er , it is ev iden t t h a t BMI a lso t en ded t o be h ig h er in t h e g r ou ps w it h h ig h er v a lu es of A HI com pa r ed t o g r ou ps w it h low er A HI v a lu es. T h e a u t h or s a lso a ck n ow ledg ed t h a t t h e m ea su r es of body h a bit u s (BMI a n d w a ist a n d n eck cir cu m fer en ce) w er e st r on g con fou n din g v a r ia bles.

Tab l e 2:
Characteristics of the Participants who Completed One or Both Follow-Up Sleep Studies, According to the Apnea-Hypopnea Index at Baseline

In 2 0 0 3 , Ka n ek o et a l. (2 5 ) pu blish ed fin din g s fr om a r a n dom ized con t r olled t r ia l com pa r in g CPA P t o m edica l t r ea t m en t in on ly 2 4 pa t ien t s w it h h ea r t fa ilu r e a n d OSA . T h e m ea n sy st olic blood pr essu r e w a s 1 2 8 [st a n da r d er r or (SE) = 7 ] a t ba selin e, a n d 1 3 4 (SE = 8 ) a t 1 m on t h in t h e m edica l t r ea t m en t g r ou p, com pa r ed w it h 1 2 6 (SE = 6 ) a t ba selin e a n d 1 1 6 (SE = 5 ) a t 1 m on t h in t h e CPA P g r ou p ( P = .0 0 8 ). T h er e w er e n o sig n ifica n t differ en ces in dia st olic blood pr essu r e. How ev er , t h e a u t h or s did n ot r epor t im pa ct on h y per t en sion u sin g t h e con v en t ion a l defin it ion of blood pr essu r e g r ea t er t h a n 1 4 0 /9 0 m m Hg ; t h u s, t h e clin ica l im por t a n ce of t h ese fin din g s is u n clea r . In 2 0 0 4 , Got sopou los et a l. (2 6 ) pu blish ed fin din g s fr om a r a n dom ized cr ossov er t r ia l com pa r in g m a n dibu la r a dv a n cem en t splin t for 4 w eek s t o or a l a pplia n ce (con t r ol) for 4 w eek s, in 6 1 pa t ien t s w it h OSA . A t t h e en d of st u dy , m ea n A HI w a s 1 2 (SE = 2 ) in t h e splin t g r ou p com pa r ed w it h 2 4 (SE
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= 2 ) in t h e con t r ol g r ou p ( P < .0 0 0 1 ). Mea n sy st olic blood pr essu r e w h ile a w a k e w a s 1 3 1 .6 (SE = 1 .5 ) a t ba selin e, w h ich r edu ced t o 1 2 6 .7 (SE = 1 .7 ) in t h e splin t g r ou p com pa r ed w it h 1 3 0 .1 (SE = 1 .5 ) in t h e con t r ol g r ou p a t t h e en d of st u dy ( P = .0 0 3 ). Sim ila r ly , m ea n dia st olic blood pr essu r e r edu ced fr om 8 0 .9 (SE = 1 .0 ) a t ba selin e t o 7 7 .2 (SE = 1 .2 ) in t h e splin t g r ou p com pa r ed w it h 8 0 .7 (SE = 1 .0 ) in t h e con t r ol g r ou p ( P < .0 0 0 1 ). A g a in , t h e clin ica l im por t a n ce of t h ese fin din g s is n ot clea r . In 2 0 0 5 , Du r su n og lu et a l. (2 7 ) in v est ig a t ed a cu t e effect s of a u t om a t ic CPA P on blood pr essu r e in 1 2 pa t ien t s w it h OSA a n d h y per t en sion . T h ey com pa r ed sy st olic a n d dia st olic blood pr essu r e m ea su r em en t s a ft er ov er n ig h t CPA P w it h ba selin e v a lu es. T h er e w er e n o sig n ifica n t differ en ces. A lso in 2 0 0 5 , Her m ida et a l. (2 8 ) pu blish ed t h e r esu lt s of CPA P t h er a py on a m bu la t or y blood pr essu r e a t 2 a n d 4 m on t h s post -CPA P. In t h is st u dy , 6 4 of 8 3 pa t ien t s (7 7 %) t r ea t ed w it h CPA P h a d h y per t en sion a t ba selin e. A ft er 4 m on t h s, 6 1 (7 4 %) w er e st ill h y per t en siv e ( P > .0 5 ). T h e a u t h or s su g g est ed t h a t OSA pa t ien t s m u st be ev a lu a t ed for h y per t en sion a n d t r ea t ed w it h a n t ih y per t en siv e dr u g s r a t h er t h a n CPA P a lon e. Sev er a l st u dies h a v e docu m en t ed a n a ssocia t ion bet w een sleep disor der ed br ea t h in g a n d dia bet es. (2 9 -3 1 ) T h ou g h , a s is t h e ca se w it h h y per t en sion , t h ese a ssocia t ion s a r e ba sed on cr oss-sect ion a l da t a a n d h en ce pr ov ide n o ev iden ce for a ca u se-effect r ela t ion sh ip. On ly on e of t h ese t h r ee st u dies r epor t ed BMI v a lu es st r a t ified by dia bet es st a t u s. Resn ick et a l. (2 9 ) st u died 4 ,8 7 2 pa r t icipa n t s in t h e Sleep Hea r t Hea lt h St u dy . T h ey r epor t ed t h a t t h e m ea n BMI w a s 3 1 .3 [st a n da r d dev ia t ion (SD) = 6 .0 ] in 4 7 0 pa r t icipa n t s w it h dia bet es com pa r ed w it h a BMI of 2 8 .1 (SD = 5 .1 ) in 4 ,4 0 2 n on dia bet ic pa r t icipa n t s ( P < .0 0 1 ). T h e a u t h or s a lso r epor t ed a posit iv e a ssocia t ion bet w een BMI a n d RDI. In 2 0 0 5 , Reich m u t h et a l. pu blish ed fin din g s fr om a lon g it u din a l a n a ly sis of t h e W iscon sin Sleep Coh or t st u dy . (3 2 ) Of t h e 1 ,3 8 2 pa r t icipa n t s st u died a t ba selin e, BMI t en ded t o in cr ea se a cr oss ea ch ca t eg or y of A HI. T h a t is, m ea n BMI w a s 2 7 .9 in t h e g r ou p w it h a n A HI <5 , 3 2 .0 in t h e A HI 5 -1 5 g r ou p, a n d 3 4 .2 in t h e A HI 1 5 g r ou p. Of t h ese 1 ,3 8 2 pa r t icipa n t s (ea ch follow ed for 4 -y ea r follow u p in t er v a ls), 9 7 8 w it h n o dia bet es a t t h e beg in n in g of a follow -u p in t er v a l pr ov ided da t a t o est im a t e t h e r isk of dev elopin g dia bet es. T h e OR for dev elopin g dia bet es w it h a n A HI 1 5 , com pa r ed w it h a n A HI <5 , a ft er a dju st in g for a g e, sex , a n d body h a bit u s, w a s n ot sig n ifica n t . (OR = 1 .6 2 , CI = 0 .6 7 3 .6 5 ; P= .2 4 ). A lso in 2 0 0 5 , A r zt et a l. (3 3 ) pu blish ed fin din g s fr om a cr oss-sect ion a l a n d lon g it u din a l a n a ly sis of t h e W iscon sin Sleep Coh or t st u dy t o ex a m in e t h e a ssocia t ion of sleep-disor der ed br ea t h in g a n d st r ok e. In t h e cr oss-sect ion a l a n a ly sis, t h ey h a d 1 ,4 7 5 pa r t icipa n t s w h om t h ey div ided in t o 3 g r ou ps: 1 ) A HI <5 ; 2 ) A HI 5 -2 0 ; a n d 3 ) A HI 2 0 . T a ble 3 sh ow s t h e ch a r a ct er ist ics of t h is coh or t in w h ich pa r t icipa n t s in g r ou ps 2 a n d 3 h a d h ig h er BMI a n d h ig h er r a t es of h y per t en sion a n d dia bet es com pa r ed w it h g r ou p 1 . T h e a u t h or s r epor t ed t h a t t h e odds of pr ev a len t st r ok es w er e sig n ifica n t ly h ig h er in pa r t icipa n t s w it h a n A HI 2 0 com pa r ed w it h pa r t icipa n t s w it h a n A HI <5 (OR = 3 .8 3 , CI = 1 .1 7 1 2 .5 6 ; P = .0 3 ), a ft er a dju st in g for a g e, sex , BMI, a lcoh ol, sm ok in g , dia bet es, a n d h y per t en sion .
Tab l e 3:
Participant Characteristics (Arzt et al. 2005)

In t h e lon g it u din a l a n a ly sis of follow -u p da t a con du ct ed a t 4 -y ea r in t er v a ls, t h er e w er e 1 ,1 8 9 pa r t icipa n t s. T h e in ciden ce r a t e of st r ok e w a s 1 .3 3 /1 ,0 0 0 per son -y ea r in t h e g r ou p w it h a n A HI <5 ; 0 .5 4 /1 ,0 0 0 per son -y ea r s in t h e g r ou p w it h a n A HI of 5 2 0 ; a n d 5 .7 5 /1 ,0 0 0 per son -y ea r s in t h e g r ou p w it h a n A HI of 2 0 . T h e OR for t h e g r ou p w it h a n A HI 2 0 com pa r ed w it h t h e g r ou p w it h a n
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A HI <5 w a s n ot sig n ifica n t a ft er a dju st in g for BMI (OR = 3 .0 8 , CI = 0 .7 4 1 2 .8 1 ; P = .1 2 ). T h e a u t h or s r epor t ed a w ea k a ssocia t ion bet w een BMI a n d in ciden t st r ok es ( coefficien t = 0 .0 4 9 4 ; P = .0 6 3 ). Un for t u n a t ely , A r zt et a l. did n ot specifica lly ex a m in e t h e effect of obesit y by dich ot om izin g BMI v a lu es u sin g a cu t -poin t of 3 0 k g /m 2. In fa ct , t h e con sist en t obser v a t ion t h a t a m or e sev er e for m of OSA is a ssocia t ed w it h h ig h er BMI v a lu es su g g est s t h a t obesit y lea ds t o ca r diov a scu la r con sequ en ces a s w ell a s OSA , a n d t h a t t h is r isk m a y be h ig h er in obese pa t ien t s in t h e pr esen ce of OSA . In 2 0 0 5 , Doh er t y et a l. (3 4 ) r epor t ed lon g -t er m effect s of CPA P on ca r diov a scu la r ou t com es in OSA pa t ien t s com pa r ed w it h u n t r ea t ed OSA pa t ien t s follow ed for a n a v er a g e of 7 .5 y ea r s. T h e u n t r ea t ed g r ou p w a s com pr ised of pa t ien t s w h o w er e n on com plia n t w it h CPA P. In t h e coh or t of 1 0 7 pa t ien t s t r ea t ed w it h CPA P, t h er e w er e eig h t dea t h s: t h r ee r ela t ed t o ca n cer , t w o r ela t ed t o isch em ic h ea r t disea se, a n d on e ea ch du e t o su icide a n d lu n g disea se. In t h e coh or t of 6 1 u n t r ea t ed pa t ien t s, t h er e w er e n in e dea t h s: t h r ee w er e su dden dea t h s pr esu m a bly of ca r dia c ca u se, t w o w er e du e t o st r ok e, t w o w er e du e t o m y oca r dia l in fa r ct ion , a n d on e du e t o h ea r t fa ilu r e. Su r v iv a l w a s sig n ifica n t ly decr ea sed in t h e u n t r ea t ed g r ou p ( P = .0 0 9 ). T h e a u t h or s con clu ded t h a t CPA P h a s a pr ot ect iv e effect a g a in st ca r diov a scu la r m or t a lit y . T h ey defen ded t h eir con clu sion by st a t in g t h a t t h e g r ou ps w er e sim ila r a t ba selin e ( P v a lu es w er e n on sig n ifica n t for com pa r ison s of ba selin e ch a r a ct er ist ics) a n d t h a t pa t ien t s a r e u su a lly n on com plia n t w it h CPA P beca u se t h ey feel cla u st r oph obic a n d h a v e block ed n a sa l pa ssa g es, n ot beca u se of a n eg a t iv e a t t it u de t ow a r d t h er a py in g en er a l. A n u m ber of obser v a t ion s a r e r elev a n t t o t h ese fin din g s. Fir st , n on sig n ifica n t P v a lu es for com pa r ison s of ba selin e ch a r a ct er ist ics u su a lly r epr esen t a la ck of st a t ist ica l pow er a n d t h u s m a y n ot su ppor t t h e cla im of sim ila r it y bet w een g r ou ps. Secon d, t h e fa ct s t h a t t h r ee dea t h s in t h e u n t r ea t ed g r ou p occu r r ed a m on g pa t ien t s w it h pr e-ex ist in g h ea r t disea se a n d t h r ee pa t ien t s in t h e u n t r ea t ed g r ou p h a d ca r dia c a r r h y t h m ia a t ba selin e com pa r ed w it h on ly on e pa t ien t in t h e CPA P g r ou p, in dica t e t h a t t h e pa t ien t s in t h e u n t r ea t ed g r ou p h a d r ela t iv ely poor h ea lt h pr ofile com pa r ed w it h t h e CPA P g r ou p. La st , t h e n ot ion t h a t m ost OSA pa t ien t s a r e n on com plia n t w it h CPA P beca u se of cla u st r oph obia or block ed n a sa l pa ssa g es defea t s t h e ca se for t h e u se of CPA P in OSA pa t ien t s. Fu r t h er m or e, t h er e w a s n o m en t ion r eg a r din g possible la ck of com plia n ce in t h e u n t r ea t ed g r ou p w it h m edica t ion s for com or bid con dit ion s. T w o pr ospect iv e coh or t st u dies h a v e ex a m in ed t h e effect of OSA on ca r diov a scu la r ou t com es defin ed a s a com posit e en d poin t of st r ok e or dea t h . Ma r in et a l. (3 5 ) r ecr u it ed 3 7 7 sim ple sn or er s (A HI <5 ), 4 0 3 u n t r ea t ed pa t ien t s w it h m ild t o m oder a t e OSA (A HI 5 3 0 ), 2 3 5 u n t r ea t ed pa t ien t s w it h sev er e OSA (A HI >3 0 ), 3 7 2 pa t ien t s t r ea t ed w it h CPA P w h o w er e a lso com plia n t (in clu din g 3 4 9 pa t ien t s w it h a n A HI >3 0 a n d 2 3 w it h a n A HI 5 3 0 ), a n d 2 6 4 h ea lt h y m en . Un t r ea t ed pa t ien t s w er e t h ose w h o r efu sed CPA P t h er a py . Hea lt h y m en w er e m a t ch ed for a g e a n d BMI w it h u n t r ea t ed pa t ien t s w h o h a d sev er e OSA . Ba selin e ch a r a ct er ist ics a r e sh ow n in T a ble 4 .

Tab l e 4:
Participant Characteristics (Marin et al. 2005)

By m a t ch in g for a g e a n d BMI, t h e a u t h or s w er e a ble t o ba la n ce t h e g r ou ps (a s seen in T a ble 4 ). A sig n ifica n t ly h ig h er pr opor t ion of OSA pa t ien t s w er e fou n d t o h a v e h y per t en sion , dia bet es, a n d ca r diov a scu la r disea se, com pa r ed w it h h ea lt h y m en (con t r ol g r ou p). New ca r diov a scu la r ev en t s occu r r ed m or e fr equ en t ly in u n t r ea t ed pa t ien t s w it h sev er e OSA com pa r ed w it h h ea lt h y m en ( Fig u r e 1 ). T h e a u t h or s u sed a m u lt iple log ist ic r eg r ession m odel t o a dju st for a g e, pr esen ce of ca r diov a scu la r disea se, h y per t en sion , dia bet es, lipid disor der s, sm ok in g st a t u s, a lcoh ol u se, sy st olic a n d dia st olic blood pr essu r e, blood g lu cose, t ot a l ch olest er ol, t r ig ly cer ides, a n d cu r r en t u se of
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a n t ih y per t en siv e, lipid low er in g , a n d a n t idia bet ic dr u g s. A ft er a dju st in g for t h ese v a r ia bles, OR w a s 2 .8 7 (CI = 1 .1 7 7 .5 1 ) for t h e u n t r ea t ed sev er e OSA g r ou p com pa r ed w it h t h e con t r ol g r ou p. A g e (OR = 1 .0 9 ; CI = 1 .0 4 1 .1 2 ) a n d pr e-ex ist in g ca r diov a scu la r disea se (OR = 2 .5 4 ; CI = 1 .3 4 .9 9 ) w er e a lso sig n ifica n t pr edict or s of n ew ca r diov a scu la r ev en t s in t h is m odel. T h e a u t h or s con clu ded t h a t sev er e OSA pa t ien t s a r e a t h ig h er r isk of ca r diov a scu la r ev en t s com pa r ed w it h h ea lt h y m en a n d t h a t CPA P t r ea t m en t r edu ces t h is r isk .

Fi gur e 1 :
Cumulative Percentage of Individuals With New Fatal (A) and Nonfatal (B) Cardiovascular Events in Each of the Five Groups

T h e r esu lt s of t h is st u dy sh ou ld be seen in t h e con t ex t of it s lim it a t ion s a s it w a s n ot a r a n dom ized t r ia l. Obst r u ct iv e sleep a pn ea pa t ien t s h a d poor er h ea lt h pr ofiles a t ba selin e com pa r ed w it h h ea lt h y m en . How ev er , t h e r epor t ed ba selin e ch a r a ct er ist ics of pa t ien t s w it h sev er e u n t r ea t ed OSA w er e sim ila r t o CPA P-t r ea t ed pa t ien t s. T h u s, it cou ld be a r g u ed t h a t t h e low er ev en t r a t e in CPA P t r ea t m en t g r ou p w a s du e t o CPA P t h er a py . It cou ld a lso be a r g u ed t h a t t h e pa t ien t s w h o w er e com plia n t w it h CPA P t h er a py w er e a lso com plia n t w it h t h e m edica l m a n a g em en t of com or bid con dit ion s, w h ile pa t ien t s w h o r efu sed CPA P t h er a py w er e a lso n on com plia n t w it h ot h er for m s of t h er a py . T h is cou ld h a v e bia sed t h e r esu lt s in fa v ou r of CPA P t h er a py . In a ddit ion , t h er e m a y be cor r ela t ion s a m on g m a n y of t h e v a r ia bles in clu ded in t h e m u lt iv a r ia t e a n a ly ses. T h e a u t h or s did n ot r epor t w h et h er t h ey ch eck ed for m u lt icollin ea r it y or w h et h er t h ey per for m ed a n y ot h er m odel dia g n ost ics. T h ese a r e st a n da r d pr ocedu r es for com plex a n a ly ses t o en su r e t h a t t h e r obu st n ess of r esu lt s. Y a g g i et a l. (3 6 ) en r olled 1 ,0 2 2 pa t ien t s w h o u n der w en t PSG a n d r ecor ded su bsequ en t ev en t s (st r ok e a n d dea t h ). Of t h eir t ot a l sa m ple, 6 9 7 (6 8 %) h a d OSA (A HI > 5 ) a n d 3 2 5 did n ot h a v e OSA (con t r ols). T h eir ba selin e ch a r a ct er ist ics a r e sh ow n in T a ble 5 .
Tab l e 5:
Baseline Characteristics of Patients With Obstructive Sleep Apnea Syndrome and Controls

Ou t of 6 9 7 pa t ien t s in t h e OSA g r ou p, 1 2 4 (1 8 %) w er e lost t o follow -u p a n d ou t of 3 2 5 pa t ien t s in t h e con t r ol g r ou p, 5 6 (1 7 %) w er e lost t o follow -u p. T h e ev en t r a t e of st r ok e or dea t h w a s 3 .4 8 /1 0 0 per son -y ea r s in t h e OSA g r ou p a n d 1 .6 0 /1 0 0 per son -y ea r s in t h e con t r ol g r ou p. A ft er a dju st in g for a g e, sex , r a ce, sm ok in g st a t u s, a lcoh ol con su m pt ion , BMI, dia bet es, h y per lipidem ia , a t r ia l fibr illa t ion , a n d h y per t en sion , t h e h a za r d r a t io w a s 1 .9 7 (CI = 1 .1 2 3 .4 8 ). T h e a u t h or s con clu ded t h a t OSA sig n ifica n t ly in cr ea ses t h e r isk of st r ok e a n d dea t h a n d t h e in cr ea se is in depen den t of ot h er r isk fa ct or s. T h ese r esu lt s sh ou ld a lso be u sed in t h e sa m e con t ex t of lim it a t ion s a s of Ma r in et a l. T h e OSA g r ou p h a d a poor er h ea lt h pr ofile com pa r ed w it h t h e con t r ol g r ou p. Ma n y of t h e v a r ia bles in clu ded in t h e m u lt iv a r ia t e a n a ly ses m ig h t be cor r ela t ed bu t t h e a u t h or s m a k e n o m en t ion of m odel ch eck in g ; t h er efor e, t h e differ en ce in st r ok e or dea t h ca n n ot be solely a t t r ibu t ed t o OSA . T h e effect of obesit y h a s been fu r t h er su bst a n t ia t ed by a m et a -a n a ly sis (1 3 ) of ba r ia t r ic su r g er y , w h ich dem on st r a t ed t h a t w eig h t loss in obese in div idu a ls (m ea n BMI = 4 6 .8 5 k g /m 2; r a n g e = 3 2 .3 0 6 8 .8 0 ) sig n ifica n t ly im pr ov es h ea lt h pr ofiles; h y per t en sion w a s r esolv ed in 6 1 .7 % of
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pa t ien t s, dia bet es w a s r esolv ed in 7 6 .8 % of pa t ien t s, h y per lipidem ia im pr ov ed in 7 0 % of pa t ien t s, a n d OSA r esolv ed in 8 5 .7 % of pa t ien t s. T h is su g g est s t h a t obesit y lea ds t o OSA , dia bet es, a n d h y per t en sion , r a t h er t h a n OSA in depen den t ly ca u sin g h y per t en sion , dia bet es, or st r ok e.

Economic Analysis
Economic Literature Review: Summary
T h e Medica l A dv isor y Secr et a r ia t lit er a t u r e sea r ch iden t ified 3 a r t icles t h a t con t a in ed som e for m of econ om ic a n a ly sis in OSA pa t ien t s. In t h e fir st a r t icle, Pellet ier -Fleu r y et a l. (3 7 ) com pa r ed cost s a n d sleep ou t com es bet w een 8 2 pa t ien t s r a n dom ized t o im m edia t e PSG, w it h 8 9 pa t ien t s r a n dom ized t o PSG w it h in 6 m on t h s. Cost s (in Eu r os) w er e r ela t ed t o com or bid con dit ion s (a n d m edica t ion s) in clu din g h y per t en sion , st r ok e, a n g in a , dia bet es, h y per lipidem ia , a n d depr ession . Ou t com es w er e sleepin ess a s m ea su r ed by t h e Epw or t h Sleepin ess Sca le, per cen t a g e of posit iv e r espon ses t o Not t in g h a m Hea lt h Pr ofile it em s, a n d scor es of t h e fiv e dim en sion s of t h e Not t in g h a m Hea lt h Pr ofile. T h e a u t h or s st r a t ified OSA pa t ien t s in t o t w o su bg r ou ps: 1 ) A HI < 3 0 ev en t s/h ou r ; a n d 2 ) A HI 3 0 ev en t s/h ou r , a n d ca lcu la t ed cost s per pa t ien t a ssocia t ed w it h a differ en ce of 1 -poin t decr ea se in t h e Epw or t h scor e, 1 % decr ea se in posit iv e r espon ses t o t h e Not t in g h a m Hea lt h Pr ofile, or 1 poin t decr ea se in t h e fiv e dim en sion s of t h e Not t in g h a m Hea lt h Pr ofile. T h ey fou n d t h a t t h e in cr em en t a l cost -effect iv en ess r a t ios w er e low er in t h e su bg r ou p w it h a n A HI 3 0 ev en t s/h ou r . T h e a u t h or s a r g u ed for ea r ly m a n a g em en t of pa t ien t s w it h a m or e sev er e for m of OSA . A lba r r a k et a l. (3 8 ) com pa r ed 1 0 -y ea r u t iliza t ion r a t es of h ea lt h r esou r ces in 3 4 2 pa t ien t s w it h OSA (ca ses), t o pa t ien t s w it h ou t OSA (a g e m a t ch ed con t r ols), u sin g t h e Ma n it oba Hea lt h Da t a ba se. T h ey h a d da t a fr om 5 y ea r s pr ior t o t h e dia g n osis of OSA t o 5 y ea r s post -CPA P in OSA pa t ien t s. T h er e w a s a sig n ifica n t differ en ce in ph y sicia n v isit s (m ea n = 1 .8 5 , SE = 0 .5 2 ; P < .0 5 ) a n d ph y sicia n fees bet w een ca ses a n d con t r ols (m ea n = $6 1 .4 4 (Cdn ), SE = 2 9 .5 1 ; P < .0 5 ). Mea n v isit s a n d fees w er e h ig h er in ca ses com pa r ed w it h con t r ols, h ow ev er , t h er e w a s a sig n ifica n t dr op in ph y sicia n v isit s a n d ph y sicia n fees in t h e ca ses fr om 1 y ea r pr ior t o dia g n osis t o 2 a n d 5 y ea r s post dia g n osis. T h is w a s m ost ly du e t o a r edu ct ion in u t iliza t ion of psy ch ia t r ic a n d r espir a t or y ser v ices. A y a s et a l. (3 9 ) a ssessed cost -effect iv en ess of CPA P t h er a py in r ela t ion t o n o t h er a py in OSA pa t ien t s. T h ey a ssu m ed t h a t CPA P t h er a py w ou ld r edu ce a cciden t r a t es in OSA pa t ien t s a n d u sed a Ma r k ov m odel t o r ela t e cost s w it h qu a lit y of life ov er 5 y ea r s. Fr om a t h ir d-pa r t y pa y er s per spect iv e, t h e in cr em en t a l cost of CPA P w a s $3 ,3 5 4 (US) per qu a lit y -a dju st ed life y ea r (QA LY ) g a in ed; fr om a societ a l per spect iv e t h is v a lu e w a s $3 1 4 (US). T h e a u t h or s con clu ded t h a t CPA P t h er a py w a s econ om ica lly a t t r a ct iv e in OSA pa t ien t s. T h e r esu lt s pu blish ed by Pellet ier -Fleu r y et a l. (3 7 ) a r e n ot u sefu l for clin ica l or policy decision m a k in g a s t h e clin ica l r elev a n ce of t h e r epor t ed ou t com es is a m big u ou s. T h e fin din g s of A lba r r a k et a l. (3 8 ) su g g est t h a t u n t r ea t ed OSA pa t ien t s m a y u n n ecessa r ily u t ilize psy ch ia t r ic a n d r espir a t or y ser v ices. T h u s, CPA P m a y be cost -sa v in g beca u se w h en OSA pa t ien t s a r e t r ea t ed, ot h er r esou r ces a r e fr eed u p. T h e A y a s et a l. (3 9 ) m odel did n ot ca pt u r e t h is a spect of cost -sa v in g . T h ey m odelled t h e effect of CPA P on a cciden t r a t es on ly . T o est im a t e t h is effect t h ey u sed befor e-a ft er da t a on a cciden t r a t es in pa t ien t s on CPA P a n d con du ct ed a m et a -a n a ly sis. In t u it iv ely , t h is a ppr oa ch ov er est im a t es t h e effect a s m ost in div idu a ls w ou ld a pply g r ea t er ca u t ion w h ile dr iv in g a ft er becom in g in v olv ed in a n a cciden t ; t h u s, r edu ct ion in a cciden t r a t es in a befor e-a n d-a ft er desig n ca n n ot be solely a t t r ibu t ed t o CPA P t h er a py .

Ontario-Based Economic Analysis


Notes and Disclaimer

T h e MA S u ses a st a n da r dized cost in g m et h odolog y for a ll of it s econ om ic a n a ly ses of t ech n olog ies.
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T h e m a in cost ca t eg or ies a n d t h e a ssocia t ed m et h ods fr om t h e pr ov in ces per spect iv e a r e a s follow s:


Hospital: On t a r io

Ca se Cost in g In it ia t iv e (OCCI) cost da t a is u sed for a ll pr og r a m cost s

w h en t h er e a r e 1 0 or m or e h ospit a l sepa r a t ion s, or on e-t h ir d or m or e of h ospit a l sepa r a t ion s in t h e m in ist r y s da t a w a r eh ou se a r e for t h e desig n a t ed In t er n a t ion a l Cla ssifica t ion of Disea ses-1 0 dia g n osis codes a n d Ca n a dia n Cla ssifica t ion of Hea lt h In t er v en t ion s pr ocedu r e codes. W h er e a ppr opr ia t e, cost s a r e a dju st ed for h ospit a l-specific or peer -specific effect s. In ca ses w h er e t h e t ech n olog y u n der r ev iew fa lls ou t side t h e h ospit a ls t h a t r epor t t o t h e OCCI, Pr og r a m A ssig n m en t Code (PA C)-1 0 w eig h t s con v er t ed in t o m on et a r y u n it s a r e u sed. A dju st m en t s m a y n eed t o be m a de t o en su r e t h e r elev a n t ca se m ix g r ou p is r eflect iv e of t h e dia g n osis a n d pr ocedu r es u n der con sider a t ion . Du e t o t h e difficu lt ies of est im a t in g in dir ect cost s in h ospit a ls a ssocia t ed w it h a pa r t icu la r dia g n osis or pr ocedu r e, MA S n or m a lly defa u lt s t o con sider in g dir ect t r ea t m en t cost s on ly . Hist or ica l cost s h a v e been a dju st ed u pw a r d by 3 % per a n n u m , r epr esen t in g a 5 % in fla t ion r a t e a ssu m pt ion less a 2 % im plicit ex pect a t ion of efficien cy g a in s by h ospit a ls.
Non-Hospital: T h ese

in clu de ph y sicia n ser v ices cost s obt a in ed fr om t h e Pr ov ider Ser v ices

Br a n ch of t h e On t a r io Min ist r y of Hea lt h a n d Lon g -T er m Ca r e, dev ice cost s fr om t h e per spect iv e of loca l h ea lt h ca r e in st it u t ion s, a n d dr u g cost s fr om t h e On t a r io Dr u g Ben efit for m u la r y list pr ice.
Discounting: For

a ll cost -effect iv e a n a ly ses, discou n t r a t es of 5 % a n d 3 % a r e u sed a s per t h e cost a v oida n ce a n d cost sa v in g s a r e ba sed on a ssu m pt ion s of

CCOHT A a n d t h e W a sh in g t on Pa n el of Cost -Effect iv en ess, r espect iv ely .


Downstream Cost Savings: A ll

u t iliza t ion , ca r e pa t t er n s, fu n din g , a n d ot h er fa ct or s. T h ese m a y or m a y n ot be r ea lized by t h e sy st em or in div idu a l in st it u t ion s. In ca ses w h er e a dev ia t ion fr om t h is st a n da r d is u sed, a n ex pla n a t ion h a s been g iv en a s t o t h e r ea son s, t h e a ssu m pt ion s, a n d t h e r ev ised a ppr oa ch . T h e econ om ic a n a ly sis r epr esen t s a n est im a t e on ly , ba sed on a ssu m pt ion s a n d cost in g m et h ods t h a t h a v e been ex plicit ly st a t ed a bov e. T h ese est im a t es w ill ch a n g e if differ en t a ssu m pt ion s a n d cost in g m et h ods a r e a pplied for t h e pu r pose of dev elopin g im plem en t a t ion pla n s for t h e t ech n olog y . Diffusion of Sleep Laboratories T h e object iv e of t h is a n a ly sis w a s t o a ddr ess t h e secon d r esea r ch qu est ion : W h a t is t h e diffu sion of sleep la bor a t or y t ech n olog y in On t a r io? A list of sleep la bor a t or ies licen sed u n der t h e Independent Health Facilities Act w a s obt a in ed. In a ddit ion , t h e a n n u a l n u m ber of sleep st u dies per 1 0 0 ,0 0 0 in div idu a ls in On t a r io fr om 2 0 0 0 t o 2 0 0 4 w a s est im a t ed u sin g a dm in ist r a t iv e da t a ba ses. Cu r r en t ly , t h er e a r e 9 7 licen sed sleep la bor a t or ies in On t a r io in in depen den t h ea lt h fa cilit ies a n d sev er a l in On t a r io h ospit a ls. In 2 0 0 0 , t h e n u m ber of sleep st u dies per for m ed in On t a r io w a s 3 7 6 /1 0 0 ,0 0 0 people. Sin ce t h en , t h er e h a s been a st ea dy r ise in t h e a n n u a l v olu m e of st u dies, su ch t h a t in 2 0 0 4 , 7 6 9 per 1 0 0 ,0 0 0 people w er e per for m ed, for a t ot a l of 9 6 ,1 3 4 sleep st u dies. Ba sed on pr ev a len ce est im a t es of t h e W iscon sin Sleep Coh or t St u dy , it is est im a t ed t h a t in On t a r io, 9 2 7 ,1 0 5 people a g ed 3 0 t o 6 0 y ea r s h a v e sleep disor der ed br ea t h in g . T h u s, t h er e m a y be a 1 0 - fold r ise in t h e r a t e of sleep t est s ov er t h e n ex t few y ea r s. Of t h e 7 2 ,9 4 1 pa t ien t s (m ea n a g e = 4 8 y ea r s) w h o u n der w en t sleep st u dies bet w een 2 0 0 0 a n d 2 0 0 4 , t h e n u m ber of st u dies/pa t ien t s r a n g ed fr om t w o (qu a r t ile 1 ) t o fou r (qu a r t ile 3 ). In 6 0 ,8 2 2 (8 3 %) pa t ien t s, PSG w a s per for m ed. Ma n y pa t ien t s h a d m u lt iple dia g n oses. Of 8 3 ,2 5 4 pa t ien t dia g n oses, 3 8 ,3 8 3 (4 6 %) w er e u n k n ow n , 3 1 ,2 7 3 (3 7 %) w er e r ela t ed t o psy ch ia t r ic con dit ion s (e.g ., a n x iet y , depr ession ), 1 1 ,8 2 7 (1 4 %) w er e r ela t ed t o con g en it a l con dit ion s, a n d t h e r est w er e r ela t ed t o ot h er sy st em s.
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In 2 0 0 4 , a t lea st on e PSG (lev el 1 ) w a s don e in 6 2 ,4 9 8 pa t ien t s. Of t h ese, 1 0 ,7 0 2 (1 7 %) pa t ien t s u n der w en t CPA P t it r a t ion st u dy (w h ich in dica t es t h a t t h ey w er e dia g n osed w it h OSA ), 1 2 (0 .0 2 %) pa t ien t s h a d lev el 2 PSG, 2 ,6 7 7 (4 %) pa t ien t s h a d m u lt iple sleep la t en cy t est s (in dica t ed w h en n a r colepsy is su spect ed), a n d 7 6 2 (1 .2 %) pa t ien t s h a d m a in t en a n ce of sleep w a k efu ln ess t est s (in dica t ed t o det er m in e t h e a bilit y t o st a y a w a k e in select ca ses, for ex a m ple, fa ct or y w or k er s/t r u ck dr iv er s). T h u s, t h e u t ilit y of PSG in 4 8 ,3 4 5 (7 7 %) pa t ien t s is u n clea r . T h is r a ises t h e qu est ion w h et h er PSG is bein g a ppr opr ia t ely u t ilized in On t a r io. Budget Impact Analysis In 2 0 0 4 , a ppr ox im a t ely 9 6 ,0 0 0 sleep st u dies w er e con du ct ed in On t a r io a t a t ot a l cost of ~$4 7 m illion (Cdn ). T h e cost of ba r ia t r ic su r g er y is $1 7 ,3 5 0 (Cdn ) per pa t ien t . In 2 0 0 4 , On t a r io spen t $4 .7 m illion (Cdn ) per y ea r for 2 7 0 pa t ien t s t o u n der g o ba r ia t r ic su r g er y in t h e pr ov in ce, a n d $8 .2 m illion (Cdn ) for 2 2 5 pa t ien t s t o seek ou t -of-cou n t r y t r ea t m en t . Sh ift in g cost s fr om sleep st u dies t o ba r ia t r ic su r g er y w ou ld ben efit m or e pa t ien t s w it h OSA a n d m a y a lso pr ev en t h ea lt h con sequ en ces r ela t ed t o dia bet es, h y per t en sion , a n d h y per lipidem ia . It is est im a t ed t h a t t h e a n n u a l cost of t r ea t in g com or bid con dit ion s in m or bidly obese pa t ien t s oft en ex ceeds $1 0 ,0 0 0 (Cdn ) per pa t ien t . T h u s, t h e dow n st r ea m cost sa v in g s cou ld be su bst a n t ia l. Cost-Effectiveness Analysis T h e object iv e of t h is a n a ly sis w a s t o a ddr ess t h e t h ir d r esea r ch qu est ion : A r e sleep la bor a t or y st u dies cost -effect iv e? T h e a n a ly sis focu sed on OSA , t h e pr edom in a n t t y pe of sleep disor der , w h ich , in con t r a st t o lit er a t u r e-ba sed est im a t es, is dia g n osed in a ppr ox im a t ely 2 3 % of a ll pa t ien t s t est ed w it h PSG in On t a r io. T h e m ea n a g e of OSA pa t ien t s is 5 0 1 0 y ea r s a n d m ea n BMI is 2 9 4 .5 k g /m 2. Usin g cu m u la t iv e den sit y fu n ct ion a n d a ssu m in g t h a t BMI a r e n or m a lly dist r ibu t ed, it w a s est im a t ed t h a t ou t of t h ese 2 3 %, 1 1 % h a v e a BMI g r ea t er t h a n 3 5 k g /m 2 (m or bid obesit y ). T h e t r ea t m en t of ch oice for OSA pa t ien t s is CPA P a n d t h e t r ea t m en t of ch oice for m or bidly obese pa t ien t s is ba r ia t r ic su r g er y . T h e t r ea t m en t of com or bid con dit ion s is u su a lly v ia ph a r m a colog ica l m ea su r es. T h r ee st r a t eg ies w er e com pa r ed: 1 . T h e cu r r en t pr a ct ice of r efer r in g a ll sleepy pa t ien t s t o a sleep la bor a t or y for PSG. Pa t ien t s in w h om OSA is dia g n osed a r e follow ed u p w it h a CPA P t it r a t ion t est a n d life-lon g CPA P t h er a py w it h y ea r ly sleep t est s a n d CPA P dev ice r epla cem en t ev er y 5 y ea r s. 2 . A n a lt er n a t e st r a t eg y t h a t lin k s t h e cu r r en t pr a ct ice w it h obesit y con t r ol st r a t eg y : 8 % of OSA pa t ien t s w h o a r e a lso m or bidly obese a r e offer ed ba r ia t r ic su r g er y ea ch y ea r a s per cu r r en t ca pa cit y . 3 . A n ew st r a t eg y in w h ich sleep t est s a r e n ot offer ed bu t a CPA P t r ia l is offer ed. Pa t ien t s dia g n osed w it h OSA a r e t r ea t ed w it h CPA P t h er a py a n d 9 0 % of OSA pa t ien t s w h o a r e a lso m or bidly obese a r e offer ed ba r ia t r ic su r g er y ea ch y ea r . Usin g a Ma r k ov m odel (Fig u r e 2 ), a coh or t (m ea n a g e = 5 0 y ea r s) w a s follow ed for it s en t ir e life spa n , i.e., fr om 5 0 t o 8 5 y ea r s of a g e (a t ot a l follow -u p of 3 5 y ea r s). It w a s a ssu m ed t h a t :

Fi gur e 2:
Markov Model

CPA P t r ia l is a s a ccu r a t e a s PSG in dia g n osin g OSA ; Pa t ien t s w h o a r e t r ea t ed w it h CPA P w ou ld h a v e im pr ov ed qu a lit y of life bu t w ou ld r equ ir e lifelon g CPA P t h er a py ; 1 % t o 5 % of pa t ien t s on CPA P m a y be cu r ed of OSA t h r ou g h lifest y le m odifica t ion (diet a n d
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ex er cise); 8 7 % of pa t ien t s w h o w ou ld u n der g o ba r ia t r ic su r g er y w ou ld be cu r ed of OSA a n d w ou ld n o lon g er r equ ir e CPA P (t h ey w ou ld a lso n o lon g er r equ ir e m or bid obesit y -r ela t ed ca r e); a n d A ll pa t ien t s w ou ld be a liv e du r in g 3 5 y ea r s of follow -u p. T h e cost s of sleep t est s ($5 0 6 /t est ), CPA P dev ices ($8 1 7 /dev ice), a n d of ba r ia t r ic su r g er y ($1 7 ,0 0 0 /pa t ien t ) a r e a ll ex pr essed in Ca n a dia n dolla r s. A n n u a l cost s r ela t ed t o m or bid obesit y ($1 0 ,0 0 0 /pa t ien t ) w er e a lso in clu ded; h ow ev er , t h e m odel w a s r u n bot h w it h a n d w it h ou t m or bid obesit y -r ela t ed cost s. T h e ou t com e w a s QA LY , w h ich w a s com pu t ed u sin g t h e T u ft s-New En g la n d Medica l Cen t er , In st it u t e for Clin ica l Resea r ch a n d Hea lt h Policy St u dies Catalog of Preference Scores . (40) T h u s, t h e u t ilit y v a lu e of u n t r ea t ed OSA w a s 0 .6 3 , CPA P-t r ea t ed OSA w a s 0 .8 7 , a n d cu r ed OSA or n o OSA w a s 1 .0 0 . T h e m odel ev a lu a t ed t h r ee st r a t eg ies in a sleepy pa t ien t (a g e = 5 0 y ea r s) in a Ma r k ov pr ocess of t im e cy cle. Ea ch cy cle w a s of 1 -y ea r du r a t ion . In t h e fir st st r a t eg y , t h e pa t ien t w en t t h r ou g h st a n da r d sleep la bor a t or y t est in g , follow in g w h ich t h e pa t ien t cou ld t r a n sit in t o on e of t w o Ma r k ov st a t es: OSA or No OSA . T h e pr oba bilit y of en t er in g a n OSA st a t e w a s 2 3 %, a n d t h e pr oba bilit y of en t er in g No OSA w a s 7 7 % (a com plem en t a r y pr oba bilit y den ot ed by t h e # sig n ). No OSA w a s a n a bsor bin g st a t e; t h e pa t ien t cou ld n ot r et u r n fr om t h a t st a t e. If t h e pa t ien t h a d OSA , t h en t h e pa t ien t cou ld g et CPA P t h er a py w it h 9 9 % pr oba bilit y . T h er e w a s a 1 % ch a n ce t h a t t h e pa t ien t w ou ld n ot r eceiv e t h er a py (e.g ., in ca se t h e pa t ien t r efu sed). T h er e w a s a 1 % ch a n ce t h a t t h e pa t ien t m ig h t be cu r ed of OSA (t h r ou g h lifest y le m odifica t ion ). If t h e pa t ien t w a s cu r ed, t h e pa t ien t beg a n t h e n ex t t im e cy cle in t h e No OSA st a t e. If t h e pa t ien t w a s n ot cu r ed, t h e pa t ien t beg a n t h e n ex t t im e cy cle in t h e OSA st a t e a n d w en t t h r ou g h t h e sa m e pr ocess. A t t h e en d of ea ch t im e cy cle, t h e pa t ien t a ccu m u la t ed som e v a lu e for QA LY depen din g u pon t h e cou r se t h e pa t ien t t ook du r in g t h a t cy cle. In t h e secon d st r a t eg y , t h er e w er e t h r ee Ma r k ov st a t es, t h e t h ir d of w h ich a r ose fr om a su bdiv ision of OSA st a t e in t o OSA (w it h ou t m or bid obesit y ) st a t e a n d OSA _MO st a t e t o dist in g u ish m or bidly obese pa t ien t s fr om n on -m or bidly obese OSA pa t ien t s. T h e m or bidly obese pa t ien t cou ld g et ba r ia t r ic su r g er y , w h ich w ou ld cu r e or n ot cu r e t h e con dit ion . If cu r ed, t h e pa t ien t beg a n t h e n ex t cy cle in t h e No OSA st a t e, ot h er w ise in t h e OSA st a t e or OSA _MO st a t e, depen din g u pon t h e pa t ien t s cu r r en t st a t e. In t h e t h ir d st r a t eg y , t h e pa t ien t w en t t h r ou g h t h e sa m e br a n ch in g ca sca de a s in t h e secon d st r a t eg y . T o a ccou n t for u n cer t a in t y in pa r a m et er est im a t es, pr oba bilist ic sen sit iv it y a n a ly ses w er e per for m ed by ca r r y in g ou t 1 0 ,0 0 0 Mon t e Ca r lo sim u la t ion s u pon t h e Ma r k ov m odel. In t h is pr ocess, v a lu es w er e sim u lt a n eou sly sa m pled for a ll u n cer t a in pa r a m et er s fr om a ppr opr ia t e dist r ibu t ion s. A ll fu t u r e cost s a n d QA LY s w er e discou n t ed a t a 3 % a n n u a l r a t e. T h e soft w a r e pa ck a g e u sed for t h ese a n a ly ses w a s Tree Age Pro 2005. T h e r esu lt s a r e su m m a r ized in T a ble 6 a n d g r a ph ica lly pr esen t ed in Fig u r e 3 .

Tab l e 6:
Results of the Cost-Effectiveness Analyses*

Fi gur e 3:
Probabilistic Analyses

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Polysomnography in Patients With Obstructive Sleep Apnea

T h e r esu lt s sh ow t h a t w h en m or bidit y cost s w er e in clu ded, t h e m ea n in cr em en t a l cost (Cdn ) of t h e secon d st r a t eg y com pa r ed w it h t h e fir st w a s -$3 ,1 6 8 (9 5 % pr oba bilit y in t er v a l = -$2 ,5 7 0 t o $3 ,7 6 1 ), a n d t h e m ea n in cr em en t a l cost of t h e t h ir d st r a t eg y com pa r ed w it h t h e fir st st r a t eg y w a s $6 ,9 0 8 (-$6 ,0 3 8 t o -$7 ,7 6 5 ). W h en m or bidit y cost s w er e ex clu ded, t h e cor r espon din g m ea n in cr em en t a l cost s w er e -$1 4 2 (-$1 1 6 t o -$1 6 8 ) a n d -$2 ,5 1 3 (-$2 ,4 6 5 t o -$2 ,5 6 3 ). T h u s, bot h t h e secon d a n d t h ir d st r a t eg ies a r e cost -sa v in g com pa r ed w it h t h e fir st st r a t eg y (cu r r en t pr a ct ice) a n d t h is con clu sion does n ot ch a n g e by in clu sion or ex clu sion of m or bid obesit y cost s, a lt h ou g h cost sa v in g s a r e g r ea t er w h en t h ese cost s a r e in clu ded. T h e r esu lt s a lso sh ow t h a t t h e m ea n in cr em en t a l QA LY s for t h e secon d st r a t eg y com pa r ed w it h t h e fir st w a s 0 .2 6 (0 .2 4 0 .2 7 ), a n d t h e m ea n in cr em en t a l QA LY s for t h e t h ir d st r a t eg y com pa r ed w it h t h e fir st st r a t eg y w a s 0 .2 8 (0 .2 7 0 .3 0 ). Hen ce, lin k in g sleep clin ics t o obesit y clin ics w ou ld n ot on ly r esu lt in g a in s in QA LY s bu t a lso cost -sa v in g .

Comparison of Ontario-Based Economic Analysis With Other Economic Studies


T h e On t a r io r esu lt s a r e n ot dir ect ly com pa r a ble t o pr ev iou s econ om ic a n a ly ses beca u se of differ en ces in a n a ly t ic a ppr oa ch es. T h a t sa id, bot h Pellet ier -Fleu r y et a l. (3 7 ) a n d A lba r r a k et a l. (3 8 ) fou n d t h a t cost s w er e h ig h er in OSA pa t ien t s pa r t ly du e t o h ig h er u t iliza t ion of h ea lt h ca r e r esou r ces secon da r y t o com or bid con dit ion s. It w a s dem on st r a t ed t h a t t h ese cost s cou ld be m in im ized by lin k in g sleep clin ics t o obesit y clin ics. A y a s et a l. (3 9 ) ex a m in ed t h e effect of CPA P t h er a py on a cciden t r a t es com pa r ed w it h n o t h er a py . A cciden t r a t es w er e n ot m odeled in t h e MA S m odel beca u se in t h e t h r ee ex a m in ed st r a t eg ies, pa t ien t s r eceiv ed CPA P t h er a py . T h u s, in t h is m odel a ll pa t ien t s h a d a sim ila r a t t en t ion spa n .

Conclusions
Obesit y , r a t h er t h a n OSA , lea ds t o ca r diov a scu la r con sequ en ces. T r ea t in g a n d pr ev en t in g obesit y w ou ld su bst a n t ia lly r edu ce t h e econ om ic bu r den a ssocia t ed w it h dia bet es, h y per t en sion , h y per lipidem ia , a n d OSA . Pr om ot ion of h ea lt h y w eig h t m a y be a ch iev ed by a m u lt isect or ia l a ppr oa ch a s r ecom m en ded by t h e Ch ief Medica l Officer of Hea lt h for On t a r io. Ba r ia t r ic su r g er y h a s a m a jor r ole in m or bidly obese in div idu a ls (BMI > 3 5 k g /m 2 a n d a com or bid con dit ion , or BMI > 4 0 k g /m 2). Ha bit u a l sn or er s w it h ex cessiv e da y t im e sleepin ess h a v e a h ig h pr et est pr oba bilit y of h a v in g OSA . T h ese pa t ien t s m a y be offer ed a t h er a peu t ic t r ia l of CPA P t o dia g n ose OSA , r a t h er t h a n a PSG. A m a jor it y of t h ese pa t ien t s a r e a lso obese a n d m a y ben efit fr om w eig h t loss. T h u s, in div idu a lized w eig h t loss pr og r a m s sh ou ld be offer ed, a n d pa t ien t s w h o a r e m or bidly obese sh ou ld be offer ed ba r ia t r ic su r g er y . T h a t sa id, a n d in v iew of t h e st ill ev olv in g u n der st a n din g of t h e ca u ses, con sequ en ces a n d opt im a l t r ea t m en t of OSA , fu r t h er r esea r ch is w a r r a n t ed t o iden t ify w h ich pa t ien t s sh ou ld be scr een ed for OSA .

Appendix
Sea r ch da t e: Febr u a r y 2 8 , 2 0 0 6 Da t a ba ses sea r ch ed: OV ID MEDLINE, MEDLINE In -Pr ocess & Ot h er Non -In dex ed Cit a t ion s, EMBA SE, Coch r a n e Libr a r y , INA HT A Da t a ba se: Ov id MEDLINE(R) <1 9 9 6 t o Febr u a r y W eek 3 2 0 0 6 > Sea r ch St r a t eg y : -------------------------------------------------------------------------------1 . *Sleep A pn ea , Obst r u ct iv e/ (2 5 6 6 )
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Polysomnography in Patients With Obstructive Sleep Apnea

2 . (sleep a dj (a pn ea or a pn oea ) a dj3 (r esist a n ce or obst r u ct i$)).m p. [m p=t it le, or ig in a l t it le, a bst r a ct , n a m e of su bst a n ce w or d, su bject h ea din g w or d] (4 8 2 8 ) 3 . 1 or 2 (4 8 2 8 ) 4 . ex p Poly som n og r a ph y / (4 9 4 3 ) 5 . 3 a n d 4 (1 7 3 1 ) 6 . lim it 5 t o (h u m a n s a n d en g lish la n g u a g e a n d y r = 2 0 0 4 - 2 0 0 6 ) (4 0 9 ) 7 . (sy st em a t ic r ev iew $ or m et a a n a ly sis or m et a -a n a ly sis).m p. [m p=t it le, or ig in a l t it le, a bst r a ct , n a m e of su bst a n ce w or d, su bject h ea din g w or d] (2 2 1 1 3 ) 8 . 6 a n d 7 (2 ) 9 . 6 (4 0 9 ) 1 0 . lim it 9 t o (ca se r epor t s or com m en t or edit or ia l or let t er or r ev iew ) (8 0 ) 1 1 . 9 n ot 1 0 (3 2 9 ) 1 2 . 8 or 1 1 (3 3 0 ) 1 3 . lim it 1 2 t o dia g n osis (sen sit iv it y ) (2 1 5 ) Da t a ba se: EMBA SE <1 9 8 0 t o 2 0 0 6 W eek 0 8 > Sea r ch St r a t eg y : -------------------------------------------------------------------------------1 . *Sleep A pn ea Sy n dr om e/ (7 8 5 7 ) 2 . (obst r u ct i$ or r esist a n ce).m p. [m p=t it le, a bst r a ct , su bject h ea din g s, h ea din g w or d, dr u g t r a de n a m e, or ig in a l t it le, dev ice m a n u fa ct u r er , dr u g m a n u fa ct u r er n a m e] (4 0 8 4 0 4 ) 3 . 1 a n d 2 (5 3 6 1 ) 4 . ex p POLY SOMNOGRA PHY / (6 1 8 7 ) 5 . 3 a n d 4 (1 9 2 9 ) 6 . lim it 5 t o (h u m a n a n d en g lish la n g u a g e a n d y r = 2 0 0 4 - 2 0 0 6 ) (4 0 5 ) 7 . (sy st em a t ic r ev iew $ or m et a -a n a ly sis or m et a a n a ly sis).m p. [m p=t it le, a bst r a ct , su bject h ea din g s, h ea din g w or d, dr u g t r a de n a m e, or ig in a l t it le, dev ice m a n u fa ct u r er , dr u g m a n u fa ct u r er n a m e] (3 6 8 5 0 ) 8 . 6 a n d 7 (4 ) 9 . 6 (4 0 5 ) 1 0 . lim it 9 t o (edit or ia l or let t er or n ot e or r ev iew ) (8 5 ) 1 1 . Ca se Repor t / (8 7 5 3 5 1 ) 1 2 . 9 n ot (1 0 or 1 1 ) (2 8 8 ) 1 3 . lim it 1 2 t o dia g n osis (sen sit iv it y ) (1 5 3 ) Glossary A pn ea -h y popn ea in dex Body h a bit u s Body m a ss in dex T h e su m of a pn ea s a n d h y popn ea s per h ou r of sleep.

T h e ph y siqu e or body bu ild. A n in dex t h a t r ela t es body w eig h t t o h eig h t . T h e body m a ss in dex (BMI) is A t ech n iqu e of r espir a t or y t h er a py in w h ich a ir w a y

obt a in ed by div idin g a per son s w eig h t in k ilog r a m s (k g ) by t h eir h eig h t in m et er s (m ) squ a r ed. Con t in u ou s posit iv e a ir w a y pr essu r e pr essu r e is m a in t a in ed a bov e a t m osph er ic pr essu r e t h r ou g h ou t t h e r espir a t or y cy cle by pr essu r iza t ion of t h e v en t ila t or y cir cu it . Obst r u ct iv e sleep a pn ea Poly som n og r a ph y T h e r epet it iv e com plet e obst r u ct ion (a pn ea ) or pa r t ia l obst r u ct ion (h y popn ea ) of t h e colla psible pa r t of t h e u pper a ir w a y du r in g sleep. Sim u lt a n eou s a n d con t in u ou s m on it or in g of n or m a l a n d a bn or m a l ph y siolog ica l a ct iv it y du r in g sleep, in clu din g t h e a pn ea -h y popn ea in dex (A HI) a n d r espir a t or y dist u r ba n ce in dex (RDI). Respir a t or y dist u r ba n ce in dex per h ou r of sleep.
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T h e su m of a pn ea s, h y popn ea s, a n d a bn or m a l r espir a t or y ev en t s

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Polysomnography in Patients With Obstructive Sleep Apnea

Notes
Suggested Citation
T h is r epor t sh ou ld be cit ed a s follow s: Medica l A dv isor y Secr et a r ia t . Poly som n og r a ph y in pa t ien t s w it h obst r u ct iv e sleep a pn ea : a n ev iden ce-ba sed a n a ly sis. Ontario Health Technology As s es s m ent Series 2 0 0 6 ;6 (1 3 ).

Permission Requests
A ll in qu ir ies r eg a r din g per m ission t o r epr odu ce a n y con t en t in t h e Ontario Health Technology As s es s m ent Series sh ou ld be dir ect ed t o MA Sin fo.m oh /a t /on t a r io.ca .

How to Obtain Issues in the Ontario Health Technology Assessment Series


A ll r epor t s in t h e Ontario Health Technology As s es s m ent Series a r e fr eely a v a ila ble in PDF for m a t a t t h e follow in g URL: w w w .h ea lt h .g ov .on .ca /oh t a s. Pr in t copies ca n be obt a in ed by con t a ct in g MA Sin fo.m oh /a t /on t a r io.ca .

Conflict of Interest Statement


A ll a n a ly ses in t h e On t a r io Hea lt h T ech n olog y A ssessm en t Ser ies a r e im pa r t ia l a n d su bject t o a sy st em a t ic ev iden ce-ba sed a ssessm en t pr ocess. T h er e a r e n o com pet in g in t er est s or con flict s of in t er est t o decla r e.

Peer Review
A ll Medica l A dv isor y Secr et a r ia t a n a ly ses a r e su bject t o ex t er n a l ex per t peer r ev iew . A ddit ion a lly , t h e pu blic con su lt a t ion pr ocess is a lso a v a ila ble t o in div idu a ls w ish in g t o com m en t on a n a n a ly sis pr ior t o fin a liza t ion . For m or e in for m a t ion , plea se v isit h t t p://w w w .h ea lt h .g ov .on .ca /en g lish /pr ov ider s/pr og r a m /oh t a c/pu blic_en g a g e_ov er v iew .h t m l.

Contact Information
T h e Medica l A dv isor y Secr et a r ia t Min ist r y of Hea lt h a n d Lon g -T er m Ca r e 2 0 Du n da s St r eet W est , 1 0 t h floor T or on t o, On t a r io CA NA DA M5 G 2 N6 Em a il: MA Sin fo.m oh /a t /on t a r io.ca T eleph on e: 4 1 6 -3 1 4 -1 0 9 2 ISSN 1 9 1 5 -7 3 9 8 (On lin e) ISBN 9 7 8 -1 -4 2 4 9 -4 3 1 6 -6 (PDF)

About the Medical Advisory Secretariat


T h e Medica l A dv isor y Secr et a r ia t is pa r t of t h e On t a r io Min ist r y of Hea lt h a n d Lon g -T er m Ca r e. T h e m a n da t e of t h e Medica l A dv isor y Secr et a r ia t is t o pr ov ide ev iden ce-ba sed policy a dv ice on t h e coor din a t ed u pt a k e of h ea lt h ser v ices a n d n ew h ea lt h t ech n olog ies in On t a r io t o t h e Min ist r y of
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Polysomnography in Patients With Obstructive Sleep Apnea

Hea lt h a n d Lon g -T er m Ca r e a n d t o t h e h ea lt h ca r e sy st em . T h e a im is t o en su r e t h a t r esiden t s of On t a r io h a v e a ccess t o t h e best a v a ila ble n ew h ea lt h t ech n olog ies t h a t w ill im pr ov e pa t ien t ou t com es. T h e Medica l A dv isor y Secr et a r ia t a lso pr ov ides a secr et a r ia t fu n ct ion a n d ev iden ce-ba sed h ea lt h t ech n olog y policy a n a ly sis for r ev iew by t h e On t a r io Hea lt h T ech n olog y A dv isor y Com m it t ee (OHT A C). T h e Medica l A dv isor y Secr et a r ia t con du ct s sy st em a t ic r ev iew s of scien t ific ev iden ce a n d con su lt a t ion s w it h ex per t s in t h e h ea lt h ca r e ser v ices com m u n it y t o pr odu ce t h e Ontario Health Technology As s es s m ent Series .

About the Ontario Health Technology Assessment Series


T o con du ct it s com pr eh en siv e a n a ly ses, t h e Medica l A dv isor y Secr et a r ia t sy st em a t ica lly r ev iew s a v a ila ble scien t ific lit er a t u r e, colla bor a t es w it h pa r t n er s a cr oss r elev a n t g ov er n m en t br a n ch es, a n d con su lt s w it h clin ica l a n d ot h er ex t er n a l ex per t s a n d m a n u fa ct u r er s, a n d solicit s a n y n ecessa r y a dv ice t o g a t h er in for m a t ion . T h e Medica l A dv isor y Secr et a r ia t m a k es ev er y effor t t o en su r e t h a t a ll r elev a n t r esea r ch , n a t ion a lly a n d in t er n a t ion a lly , is in clu ded in t h e sy st em a t ic lit er a t u r e r ev iew s con du ct ed. T h e in for m a t ion g a t h er ed is t h e fou n da t ion of t h e ev iden ce t o det er m in e if a t ech n olog y is effect iv e a n d sa fe for u se in a pa r t icu la r clin ica l popu la t ion or set t in g . In for m a t ion is collect ed t o u n der st a n d h ow a n ew t ech n olog y fit s w it h in cu r r en t pr a ct ice a n d t r ea t m en t a lt er n a t iv es. Det a ils of t h e t ech n olog y s diffu sion in t o cu r r en t pr a ct ice a n d in pu t fr om pr a ct icin g m edica l ex per t s a n d in du st r y a dd im por t a n t in for m a t ion t o t h e r ev iew of t h e pr ov ision a n d deliv er y of t h e h ea lt h t ech n olog y in On t a r io. In for m a t ion con cer n in g t h e h ea lt h ben efit s; econ om ic a n d h u m a n r esou r ces; a n d et h ica l, r eg u la t or y , socia l a n d leg a l issu es r ela t in g t o t h e t ech n olog y a ssist policy m a k er s t o m a k e t im ely a n d r elev a n t decision s t o opt im ize pa t ien t ou t com es. If y ou a r e a w a r e of a n y cu r r en t a ddit ion a l ev iden ce t o in for m a n ex ist in g ev iden ce-ba sed a n a ly sis, plea se con t a ct t h e Medica l A dv isor y Secr et a r ia t : MA Sin fo.m oh /a t /on t a r io.ca . T h e pu blic con su lt a t ion pr ocess is a lso a v a ila ble t o in div idu a ls w ish in g t o com m en t on a n a n a ly sis pr ior t o pu blica t ion . For m or e in for m a t ion , plea se v isit h t t p://w w w .h ea lt h .g ov .on .ca /en g lish /pr ov ider s/pr og r a m /oh t a c/pu blic_en g a g e_ov er v iew .h t m l.

Disclaimer
T h is ev iden ce-ba sed a n a ly sis w a s pr epa r ed by t h e Medica l A dv isor y Secr et a r ia t , On t a r io Min ist r y of Hea lt h a n d Lon g -T er m Ca r e, for t h e On t a r io Hea lt h T ech n olog y A dv isor y Com m it t ee a n d dev eloped fr om a n a ly sis, in t er pr et a t ion , a n d com pa r ison of scien t ific r esea r ch a n d/or t ech n olog y a ssessm en t s con du ct ed by ot h er or g a n iza t ion s. It a lso in cor por a t es, w h en a v a ila ble, On t a r io da t a , a n d in for m a t ion pr ov ided by ex per t s a n d a pplica n t s t o t h e Medica l A dv isor y Secr et a r ia t t o in for m t h e a n a ly sis. W h ile ev er y effor t h a s been m a de t o r eflect a ll scien t ific r esea r ch a v a ila ble, t h is docu m en t m a y n ot fu lly do so. A ddit ion a lly , ot h er r elev a n t scien t ific fin din g s m a y h a v e been r epor t ed sin ce com plet ion of t h e r ev iew . T h is ev iden ce-ba sed a n a ly sis is cu r r en t t o t h e da t e of pu blica t ion . T h is a n a ly sis m a y be su per seded by a n u pda t ed pu blica t ion on t h e sa m e t opic. Plea se ch eck t h e Medica l A dv isor y Secr et a r ia t W ebsit e for a list of a ll ev iden ce-ba sed a n a ly ses: h t t p://w w w .h ea lt h .g ov .on .ca /oh t a s.

List of Tables
Tab l e 1 : Qual i ty of Ev i denc e of Inc l uded Studi es* Tab l e 2: Char ac ter i sti c s of the Par ti c i pants w ho Compl eted One or Both Fol l ow -U p Sl eep Studi es, A c c or di ng to the A pneaHy popnea Index at Basel i ne Tab l e 3: Par ti c i pant Char ac ter i sti c s (A r zt et al . 2005)

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Tab l e 4: Par ti c i pant Char ac ter i sti c s (Mar i n et al . 2005) Tab l e 5: Basel i ne Char ac ter i sti c s of Pati ents W i th Ob str uc ti v e Sl eep A pnea Sy ndr ome and Contr ol s Tab l e 6: Resul ts of the Cost-Ef f ec ti v eness A nal y ses*

List of Figures
Fi gur e 1 : Cumul ati v e Per c entage of Indi v i dual s W i th N ew Fatal (A ) and N onf atal (B) Car di ov asc ul ar Ev ents i n Eac h of the Fi v e Gr oups Fi gur e 2: Mar k ov Model Fi gur e 3: Pr ob ab i l i sti c A nal y ses

Abbreviations
A HI BMI CI CMS CPA P OCCI OR OSA PSG QA LY RDI ROC SD SE A pn ea h y popn ea in dex Body m a ss in dex Ca n a dia n Coor din a t in g Office of Hea lt h T ech n olog y A ssessm en t Con fiden ce in t er v a l Cen t er s for Medica r e a n d Medica id Ser v ices Con t in u ou s posit iv e a ir w a y pr essu r e On t a r io Ca se Cost in g In it ia t iv e Odds r a t io Obst r u ct iv e sleep a pn ea Poly som n og r a ph y Qu a lit y -a dju st ed life y ea r Respir a t or y dist u r ba n ce in dex Receiv er oper a t in g ch a r a ct er ist ics St a n da r d dev ia t ion St a n da r d er r or

CCOHT A

Article information
Ont Health Technol Assess Ser. 2006; 6(13): 138. Published online 2006 June 1. PMCID: PMC3379160 Health Quality Ontario Copyright 2006, The Medical Advisory Secretariat Articles from Ontario Health Technology Assessment Series are provided here courtesy of Health Quality Ontario

References
1. Y ou n g T, Pal ta M, Dem psey J, Skatru d J, Weber S, Badr S. Th e occu rren ce of sl eep-di sordered breath i n g am on g m i ddl e-aged adu l ts. N En gl J Med. 1993;328(17):12301235. [Pu bMed] 2. Col l op N A . Obstru cti v e sl eep apn ea: wh at does th e cardi ov ascu l ar ph y si ci an n eed to kn ow? A m J Cardi ov asc Dru gs. 2005;5(2):7181. [Pu bMed] 3. Tran D, Wal l ace J. Obstru cti v e sl eep apn ea sy n drom e i n a pu bl i cl y fu n ded h eal th care sy stem . J N atl Med A ssoc. 2005;97(3):370374. [PMC free arti cl e] [Pu bMed] 4. Fl em on s WW, Dou gl as N J, Ku n a ST, Roden stei n DO, Wh eatl ey J. A ccess to di agn osi s an d treatm en t of pati en ts wi th su spected sl eep apn ea. A m J Respi r Cri t Care Med. 2004;169(6):668672. [Pu bMed] 5. A m eri can A cadem y of Sl eep Medi ci n e Task Force. Sl eep-rel ated breath i n g di sorders i n adu l ts: recom m en dati on s for sy n drom e defi n i ti on an d m easu rem en t tech n i qu es i n cl i n i cal research . Th e Report of an A m eri can A cadem y of Sl eep Medi ci n e Task Force. Sl eep. 1999;22(5):667689. [Pu bMed]
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