Simple Screen for Sleep-Disordered Screening

Simple Four-Variable Screening Tool for Identification of Patients with Sleep-

Disordered Breathing
Misa Takegami, RN, MPH1; Yasuaki Hayashino, MD, PhD1; Kazuo Chin, MD, PhD2; Shigeru Sokejima, MD, PhD3; Hiroshi Kadotani, MD, PhD4;
Tsuneto Akashiba, MD, PhD5; Hiroshi Kimura, MD, PhD6; Motoharu Ohi, MD, PhD7; Shunichi Fukuhara, MD, DMSc, FACP1

Department of Epidemiology and Healthcare Research, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan;
1

Department of Respiratory Care and Sleep Control Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; 3Department of
2

Public Health Policy, National Institute for Public Health, Japan; 4Center for Genomic Medicine, Kyoto University Graduate School of Medicine,
Kyoto, Japan; 5Department of Internal Medicine, Nihon University, School of Medicine, Tokyo, Japan; 6Second Department of Internal Medicine,
Nara Medical University, Nara, Japan; 7Sleep Medical Center, Osaka Kaisei Hospital, Osaka, Japan

Objectives: To aid in the identification of patients with moderate-to-
severe sleep-disordered breathing (SDB), we developed and validated
a simple screening tool applicable to both clinical and community set-
tings.
Methods: Logistic regression analysis was used to develop an integer-
based risk scoring system. The participants in this derivation study
included 132 patients visiting one of 2 hospitals in Japan, and 175 resi-
dents of a rural town. The participants in the present validation study
included 308 employees of a company in Japan who were undergoing
a health check.
Results: The screening tool consisted of only 4 variables: sex, blood
pressure level, body mass index, and self-reported snoring. This tool
(screening score) gave an area under the receiver operating charac-
teristic curve (ROC) of 0.90, sensitivity of 0.93, and specificity of 0.66,
using a cutoff point of 11. Predicted and observed prevalence propor-
tions in the validation dataset were in close agreement across the en-
tire spectrum of risk scores. In the validation dataset, the area under
the ROC for moderate-to-severe SDB and severe SDB were 0.78 and
0.85, respectively. The diagnostic performance of this tool did not sig-
nificantly differ from that of previous, more complex tools.
Conclusion: These findings suggest that our screening scoring sys-
tem is a valid tool for the identification and assessment of moderate-to-
severe SDB. With knowledge of only 4 easily ascertainable variables,
which are routinely checked during daily clinical practice or mass health
screening, moderate-to-severe SDB can be easily detected in clinical
and public health settings.
Keywords: Sleep-disordered breathing, screening, sensitivity, specific-
ity, validation
Citation: Takegami M; Hayashino Y; Chin K; Sokejima S; Kadotani H;
Akashiba T; Kimura H; Ohi M; Fukuhara S. Simple four-variable screen-
ing tool for identification of patients with sleep-disordered breathing.
SLEEP 2009;32(7):939-948.

SLEEP-DISORDERED BREATHING (SDB), INCLUDING
OBSTRUCTIVE SLEEP APNEA, WAS INITIALLY CON-
SIDERED A RARE DISORDER; HOWEVER, RECENT
epidemiologic studies have revealed that it is fairly prevalent
in the general adult population.1,2 Apnea and hypopnea during
sleep increase the risk of cardiovascular disease, including hy-
pertension, arrhythmia, and myocardial infarction, as well as
cerebrovascular disease.3 Moreover, because it may lead to mo-
tor vehicle and public transportation accidents, it is now also
considered a serious social concern.4,5 SDB is therefore consid-
ered a problem requiring attention from both clinical and public
health perspectives.
Because SDB is rarely recognized as potentially fatal, howev-
er, and given the difficulty affected patients have in recognizing
their condition, only a small proportion of those with moderate-
to-severe SDB receive appropriate therapy,6 notwithstanding
the availability of several highly effective treatments.7
Regarding the diagnosis of SDB, polysomnography (PSG)
has been used as a gold standard, and cardiorespiratory moni-
toring may be used for diagnosis.8 These machines require
Submitted for publication May, 2008
Submitted in final revised form February, 2009
Accepted for publication April, 2009
Address correspondence to: Misa Takegami, Graduate School of Medicine
and Public Health, Department of Epidemiology and Health Care Research,
Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501 Japan; Tel: +81-075-753-
4646; Fax: +81-075-753-4644; E-mail: takegami-kyt@umin.ac.jp
SLEEP, Vol. 32, No. 7, 2009
overnight sleep testing and are thus time-consuming and bur-
densome, and neither is suitable for community-based screen-
ing. We therefore considered that a user-friendly screening tool
may improve the identification of patients with moderate-to-
severe SDB. To our knowledge, several questionnaires and
prediction rules have been used for mass screening9-12; how-
ever, one includes numerous variables, and the others are not
appropriate in occupational and community settings. Moreover,
a comprehensive comparison of these questionnaires has yet to
be conducted.
Here, we sought to develop and validate a simple, user-
friendly, integer-based, prediction rule with a relatively small
number of variables to screen subjects for moderate-to-severe
SDB. We also wanted to compare the predictive performance of
this model with those previously developed.
METHODS
Subjects and Data Collection
The derivation dataset used to derive the screening tool and
the validation dataset used to test the external validity of this
tool were collected separately. To ensure the generalizability of
the screening tool, derivation data were gathered in 2 settings
(university hospital and community settings). First, we included
consecutive patients undergoing PSG testing in 2 medical univer-
sity hospitals in Japan between July 1999 and December 2002.
These patients underwent pulse oximetry as part of PSG testing,
939 Simple Four-Variable Screening Tool for SDB—Takegami et al
and, when diagnosed with SDB, completed a self-administered
questionnaire. The physician who ordered the PSG also collected
information on patient characteristics and clinical history. Sec-
ond, we included a sample of subjects from a previous popula-
tion-based survey. Of the 5,107 residents who had participated
in the previous survey, we included those who consented to un-
dergo pulse oximetry in the current study. This survey, originally
conducted to clarify the impact of factors related to the subjects’
social and physical environment on health-related quality of life
and/or sleep quality, has been described elsewhere.13 Briefly, the
cohort consisted of all residents 20 years old or older living in
Naie, Hokkaido Prefecture, a rural community in Japan. Partici-
pants in the original survey were invited to voluntarily undergo
pulse oximetry for our study, and those who agreed were invited
to participate in a subsequent overnight study. Public health nurs-
es acquired the history of each participant.
For the validation dataset, a cross-sectional survey was con-
ducted among all employees of a wholesale company in Osaka,
Japan between January 2004 and December 2005.14 The survey
included a self-administered questionnaire and medical exami-
nation, along with sleep tests using a cardiorespiratory monitor
(type 3 portable monitor) and an actigraph to diagnose SDB.
Subjects with a history of treatment for SDB or other sleep
disorders such as narcolepsy, were excluded, as were those who
were unable to complete pulse oximetry or cardiorespiratory
testing because of inappropriate operation of the testing ma-
chine or because it did not work well.
The population-based study in Naie was approved by the In-
stitutional Review Board of the Public Health Research Foun-
dation, and the hospital-based and occupational studies were
authorized by the Institutional Review Board of the Kyoto Uni-
versity Graduate School of Medicine.
SDB Measure
During the derivation process, we defined SDB in accor-
dance with a guideline endorsed by the British Thoracic So-
ciety, namely: ≥ 10 respiratory events per hour and arterial
oxygen desaturation ≥ 4% from the baseline saturation value
obtained during the sleep study.15 It has been reported that, as
the oxygen desaturation index (ODI; measured by overnight
pulse oximetry) increases, the risk of cardiovascular disease in-
creases, as it does with an increase in the apnea-hypopnea index
(AHI; measured by PSG).15 The guideline uses an ODI of ≥ 10
to diagnose sleep apnea, without confirmation by PSG16,17 and
recommends treatment at this level.15
For validation, the respiratory disturbance index (RDI: num-
ber of apneas and hypopneas per hour of sleep) was calculated
from data obtained from both the actigraph and cardiorespirato-
ry (type 3 portable monitor).14 To improve the accuracy of RDI
measurement, the validation study used a type 3 portable moni-
tor rather than a pulse oximeter. Type 3 monitors are defined as
devices with a minimum of 4 monitored channels,18 including
ventilation or airflow (with at least 2 channels of respiratory
movement, or respiratory movement and airflow), heart rate
or electrocardiogram, and oxygen saturation. In our validation
study, a type 3 monitor recorded chest and abdominal respira-
tory movements, nasal pressure, oxygen saturation, heart rate,
and body position. Type 3 monitors are considered standard in
SLEEP, Vol. 32, No. 7, 2009
sleep studies and an alternative to PSG in diagnosing SDB.19
Given that type 3 monitors are sometimes unable to measure
sleep duration, however, this variable was measured using an
actigraph on the basis of the similarity in findings between
measurement of sleep duration in bed using an actigraph and
PSG.20 Sleep duration at night was measured by wrist actigraph
tracing21 in conjunction with a sleep diary, which documented
when the participant went to bed at night and arose in the morn-
ing. Sleep onset was estimated by noting the sustained cessa-
tion of movement of the wrist on the actigraphy tracing, and
rousing was noted by the appearance of wrist movements on
the tracing. With regard to type 3 monitor analysis, sleep dura-
tion was defined as the estimated time duration between sleep
onset and final rousing. SDB analyses incorporated the main
segments of comprehensible type 3 monitor recordings within
the estimated sleep spans. Apneas (cessation of breathing ≥ 10
sec) and hypopneas ( ≥ 50% reduction in respiratory effort with
≥ 3% oxygen desaturation for ≥ 10 sec) were visually scored by
at least 2 medical doctors specializing in respiratory medicine.
Subjects with an RDI of ≥ 15 and ≥ 30 were considered to have
moderate-to-severe SDB or severe SDB, respectively.
Measurement and Definition of Independent Variables
Potential candidate variables for predictors were identified
based on a review of the literature, clinical relevance, and rou-
tine availability; the selection of variables for abstraction was
further guided by physicians specializing in sleep medicine. Po-
tential candidate variables were classified as demographic char-
acteristics, comorbid conditions, and clinical features (including
symptoms). Comorbid conditions included diabetes mellitus,
cardiovascular disease, and cerebrovascular disease. Clinical
features included snoring, body mass index (BMI), and blood
pressure. Laboratory features, such as blood tests and spirom-
etry test data, were excluded because these are unsuitable for
screening the general population. Symptoms were assessed us-
ing a self-administered questionnaire which asked about morn-
ing headaches, daytime sleepiness, vitality related to daytime
sleepiness, and psychological well-being. Subjective daytime
sleepiness was assessed using the Epworth Sleepiness Scale
(ESS), a valid and reliable self-administered questionnaire in-
strument for measuring subjective daytime sleepiness.22,23 The
ESS score can then help clinicians to separate patients into
those who are clinically normal or those who are excessively
sleepy and may have sleep disorders, using a cutoff point of 10.
Vitality and psychological well-being was assessed using the
Vitality (VT) and Mental Health (MH) subscales of the Medi-
cal Outcome Study Short-Form 36-Item Health Survey (SF-
36). The SF-36 is a valid and reliable instrument for measuring
health-related quality of life.24,25
Statistical Analysis
The association between SDB and candidate variables was
determined using the t-test for continuous variables and Pear-
son’s χ2 test for categorical variables. BMI values were grouped
into 6 categories, with the cutoff points modified using reported
research data applicable to Japanese.26 Blood pressure values
were categorized using the cutoff points described in the World
940 Simple Four-Variable Screening Tool for SDB—Takegami et al
Health Organization Hypertension guideline.27 We examined
the strength and shape of the relationships of continuous vari-
ables with the log odds of SDB using cubic spline plots.28 These
functions were then used to develop and refine the multivari-
able regression models reported previously.29 Candidate vari-
ables with P-values < 0.10 were included as covariates in a
multiple logistic regression model,30 and those with P-values <
0.05 were retained in the final multivariable logistic regression
model.31 Because our aim was to develop a simple and practi-
cal tool for screening, we excluded predictors determined on
discussion with clinicians to be clinically unimportant. Model
discrimination was assessed by the area under the receiver op-
erating characteristic (ROC) curve,32 and calibration was as-
sessed using the Hosmer-Lemeshow χ2 statistic.30
An integer score-based prediction rule for the prevalence of
SDB was developed from the logistic regression model using a
regression coefficient-based scoring method.33,34 To generate a
simple integer-based point score for each predictor variable, the
coefficient scores were assigned by dividing the β-coefficients
by the criterion value, which is the sum of the smallest and
second-smallest coefficients in the model multiplied by 0.4 and
rounded up to the nearest integer. To achieve a value of 1 for
the variable with the smallest coefficient score, the denominator
was selected. Missing predictor variables were replaced with
a zero. The overall risk score was calculated by summing all
component scores for each participant.35,36
To assess the performance of the screening tool in the deri-
vation dataset, we calculated the sensitivity, specificity, and
likelihood ratios for positive and negative test results, post-test
probability of positive and negative results, and area under the
ROC curve by varying the positive threshold of our screening
score (total risk score ≥ 9, ≥ 11, or ≥ 14). Screening scores were
also assigned to different risk classes by quartile, and the preva-
lence of SDB observed in each was compared using the χ2 test
for trend. We validated the screening tool internally using the
leave-one-out cross-validation method, in which all cases but
one were used to train the screening tool. The rule was then
applied to the single excluded case.37-39 This procedure was re-
peated for every case, until each had been left out once.40
We externally validated the screening score by separately
assessing model performance in the validation dataset in the
same manner as in the derivation dataset for outcomes of mod-
erate-to-severe SDB, or severe SDB. We also tested model
performance for outcome of the definition of SDB using 4%
desaturation with pulse oximetry. In addition, we used the hy-
pothetical screening strategies proposed by Gurubhagavatula et
al.41 in the validation dataset by combining our screening score
with the pulse oximetry results to determine if the subject un-
dergoes PSG or continuous positive airway pressure (CPAP)
titration, thereby dividing the participants into 3 groups accord-
ing to risk score. We evaluated 2 different strategies by varying
the risk score threshold. For strategy 1, subjects in the high-
risk group (scores ≥ 14 [upper threshold]) underwent PSG or
CPAP titration, whereas subjects in the low-risk group (scores <
9 [lower threshold]) underwent no further testing. The remain-
ing participants (intermediate group) were subjected to pulse
oximetry, and, if their ODI was ≥ 10, they also underwent PSG
or CPAP titration; otherwise, no further testing was done. In
strategy 2, the upper and lower thresholds were set at 14 and 11,
SLEEP, Vol. 32, No. 7, 2009
Patients with Suspected SDB (n=132)
Residents in Naie (n=175)
Screening Score (n=307)
Positive Result, Screening Score, ≥11 Negative Result, Screening Score, <11
n=193 n=114
Pulse Oximetry (n=193) Pulse Oximetry (n=114)
SDB, ODI, ≥10 No SDB, ODI, <10 SDB, ODI, ≥10 No SDB, ODI, <10
n=139 n=54 n=10 n=104
Figure 1—A Flow diagram of subjects in the study of derivation.
SDB = sleep-disordered breathing, ODI = oxygen desaturation
index.
respectively. Test performance for these strategies (sensitivity,
specificity, area under the ROC, likelihood ratio) was evaluated
by defining each as positive if subjects were in the high or inter-
mediate risk groups with ODI ≥ 10, using moderate-to-severe
SDB or severe SDB as the reference.
We also compared the area under the ROC curves of our
screening score to those of other reported diagnosis tools, such
as the Multivariable Apnea Risk Index (MAP) and Sleep Apnea
Clinical Score (SACS),9,10 using Egger’s method (algorithm de-
scribed by DeLong, et al.).42 For this analysis, statistical signifi-
cance was defined at the P < 0.05 level.
All analyses were performed using SAS statistical software
version 8.02 (SAS Institute Inc., Cary, NC, USA) and STATA
statistical software version 9.2 (Stata Corp. LP, College Station,
TX, USA).
RESULTS
Subject Characteristics in the Derivation and Validation Datasets
The derivation dataset contained 307 subjects (132 subjects
visiting hospitals and 175 local residents). Subject participation
in the derivation study is illustrated by a flow diagram (Fig-
ure 1). The validation dataset contained 308 workers; 16 were
excluded from the current analysis because of incomplete car-
diorespiratory monitor testing. Table 1 shows the demographic
and clinical characteristics of the subjects in the 2 data sets. The
percentage of women in the derivation and validation data sets
was 33.9% and 1.0%, respectively. In the derivation dataset,
149 of 307 subjects were diagnosed as having SDB (ODI ≥
10), while a total of 128 (97.0%) of the 132 subjects who vis-
ited the hospital and 21 (12.0%) of the 175 volunteers residing
in the rural area were diagnosed with SDB. The prevalence of
moderate (RDI ≥ 15) and severe (RDI ≥ 30) SDB in the exter-
nal validation dataset was 22.4% (n = 69) and 6.8% (n = 21),
respectively.
Predictors of SDB
The results of univariate analysis for all potential predictors
are shown in Table 2. Multivariable logistic regression analy-
sis revealed that sex, BMI, blood pressure, snoring, and vitality
941 Simple Four-Variable Screening Tool for SDB—Takegami et al
 Table 1—Subject Characteristics of the Derivation and Validation Datasets

Characteristic Derivation Validation P value

Dataset Dataset
(n = 307) (n = 308)
Age, mean (SD) 49.9 (14.4) 43.8 (8.3) < 0.001
Men, % 66.1 99.0 < 0.001
Body mass index (kg/m2), mean (SD) 25.5 (4.2) 23.7 (3.3) < 0.001
Smoking history < 0.001‡
Present smoker, % 31.4 55.4
Never smoker, % 43.1 19.7
Snoring, % 80.5 48.9 < 0.001
Excessive daytime sleepiness
Epworth Sleepiness Scale, mean (SD) 7.1 (4.3) 6.6 (3.7) 0.165
Hypertension , % 48.9 16.1 < 0.001
Systolic blood pressure (mm Hg), mean (SD) 128.2 (19.3) 129.0 (14.3) 0.562
Diastolic blood pressure (mm Hg), mean (SD) 82.5 (12.5) 80.9 (10.8) 0.081
Diabetes, % 4.6 9.3 0.037
Cerebrovascular disease, % 3.6 1.8 0.127
Cardiovascular disease, % 5.5 3.6 0.337
Oxygen desaturation index*, mean (SD) 22.1 (28.3) 7.9 (10.1) < 0.001
Respiratory disturbance index†, mean (SD) NA 10.7 (11.6) NA

*Oxygen desaturation index is defined as a fall of greater than 4% per hour in arterial oxygen saturation during sleep study. †Respiratory
disturbance index is the number of apneas and hypopneas per hour of sleep study. ‡P value for trend, χ2 test.

were significant variables in the identification of SDB. Because
no significant association between vitality and SDB could be
determined when analysis was restricted to the local residents
only (P = 0.792), vitality was not included in the final multiple
logistic regression model. Although univariate analysis corre-
lated daytime sleepiness with SDB, there was no significant ef-
fect on other factors after adjustment in the multivariable model
(P = 0.216). The factors described above were independently
associated with a final diagnosis of SDB. Sex, BMI, blood pres-
sure, and snoring remained in the final multivariable model for
predicting SDB (Table 3).
Screening Score
An integer-based score was assigned to each variable ac-
cording to the β-coefficient estimated in the final model (Table
3), after which the risk score for each subject was calculated.
With regard to variables, sex was set at 1 for males and 0 for
females; body mass index ( < 21.0, 21.0–22.9, 23.0–24.9, 25.0–
26.9, 27.0–29.9, ≥ 30) was assigned a value between 1 and 6;
blood pressure (systolic blood pressure [SBP] < 140 or diastolic
blood pressure [DBP] < 90, SBP 140–159 or DBP 90–99, SBP
160–179, or DBP 100–109, SBP ≥ 180 or DBP ≥ 110) was as-
signed a value between 1 and 4; and snoring was assigned 1 for
a response of snoring almost every day or often, and 0 for snor-
ing sometimes, almost never, or unknown. Overall risk for each
participant was calculated by adding the component scores for
each variable, with missing predictor variables replaced by a
zero. The range of the overall risk score was from 2 to 18. The
mean risk score in the derivation dataset was 11.1 (SD = 4.2).
In the derivation dataset, a positive linear trend was observed
between risk score quartile and prevalence of SDB; the preva-
lence of moderate-to-severe SDB was 2.7% for quartile 1 (with
a corresponding score of ≤ 7), 31.3% for quartile 2 (score: 8
SLEEP, Vol. 32, No. 7, 2009
to 11), 63.2% for quartile 3 (score: 12 to 14), and 91.0% for
quartile 4 (score: ≥ 15) (χ2 test for trend, P < 0.001) (Figure 2).
We observed similar trends for risk of both moderate-to-severe
SDB and severe SDB in the validation dataset (χ2 test for trend,
P < 0.001 and P < 0.001, respectively).
Test Performance According to Derivation Data
Table 4 presents the model performance indices. In the
derivation set, the area under the ROC curve was 0.90 (95%
confidential interval [95% CI]: 0.87 to 0.94) for the logistic re-
gression model (n = 305), and 0.90 (95% CI: 0.87 to 0.93) for
the screening score (n = 307; the value of missing data was
zero). In the derivation dataset, the area under the ROC curve
was higher for females (0.90 [n = 104]) than males (0.82 [n =
203]), and the value for community residents in the same dataset
was 0.83 (n = 175). The area under the ROC curve of BMI was
0.82. BMI alone showed a sensitivity of 0.79 and a specificity
of 0.73 when a cutoff point of 25 was used. A large percentage
of positive results were attained at this cutoff point (52.1%),
and 31 subjects (10.1%) were underdiagnosed.
Model Validation
The discriminative ability of the model was maintained with
an area under the ROC curve value of 0.88 for the logistic mod-
el, and 0.88 for the internal validation exercise screening score.
For the external validation set (n = 308), an area under the ROC
curve value of 0.78 (95% CI: 0.72 to 0.84) indicated moderate-
to-severe SDB, while a value of 0.85 (95% CI: 0.77 to 0.92)
indicated severe SDB. The area under the ROC curve for out-
come of the definition of SDB using the model development
was similar to that measured for moderate-to-severe SDB (0.76
[95% CI: 0.69 to 0.82]). The sensitivity and specificity values
942 Simple Four-Variable Screening Tool for SDB—Takegami et al
 Table 2—Univariate Predictors of Sleep Disordered Breathing in the Derivation Dataset (n = 307)

Characteristic Non-SDB SDB

(n = 158) (n = 149) P value
Age, mean (SD) 49.6 (15.2) 50.3 (13.6) 0.666
Men, % 41.1 92.6 < 0.001
Body mass index (kg/m2), % < 0.001‡
< 21.0 22.8 2.0
21.0-22.9 26.0 6.1
23.0-24.9 24.7 12.8
25.0-26.9 12.6 18.2
27.0-29.9 10.8 32.4
≥ 30.0 3.2 28.4
Blood pressure (mm Hg), % < 0.001‡
SBP < 140 and DBP < 90 71.5 39.9
140 ≤ SBP < 160 or 90 ≤ DBP < 100 21.5 37.2
160 ≤ SBP < 180 or 100 ≤ DBP < 110 6.3 18.2
SBP ≥ 180 or DBP ≥ 110 0.6 4.7
Snoring, % 65.2 96.6 < 0.001
Current smoker, % 28.1 34.9 0.204
Comorbid condition
Diabetes, % 5.1 4.0 0.664
Cerebrovascular disease, % 4.4 2.7 0.411
Cardiovascular disease, % 7.0 4.0 0.261
Symptom
Excessive daytime sleepiness (ESS > 11), % 19.9 44.4 < 0.001
Vitality† (SF-36), mean (SD) 50.6 (9.5) 46.2 (10.6) < 0.001
Mental Health† (SF-36), mean (SD) 50.9 (9.0) 48.5 (9.7) 0.029

*SDB = sleep-disordered breathing; SBP = systolic blood pressure; DBP = diastolic blood pressure; ESS = Epworth Sleepiness Scale; SF-36 = Medi-
cal outcome study short-form 36-item health survey. †Vitality and mental health is the norm score of the SF-36 domain. ‡P value for trend, χ2 test

at a cutoff point of 11 were 0.73 and 0.67, respectively. The

predicted and observed prevalence proportions in the validation
dataset were in close agreement across the entire spectrum of
screening scores (Figure 2).
In the workplace sample of the validation dataset for mod-
erate-to-severe SDB, the respective post-test probabilities of
positive and negative results were 0.39 and 0.10 using a cutoff
point of 11; 0.31 and 0.06 using a cutoff point of 9; and 0.62
and 0.17 using a cutoff point of 14. The sensitivity and specific-
ity values for severe SDB were similar for moderate-to-severe
SDB (Table 4).
When 3 criteria with 2 cutoff points (9 and 14) were ap-
plied, the strategy showed a sensitivity of 0.83 (95% CI: 0.72
to 0.91), specificity of 0.92 (95% CI: 0.87 to 0.95), and posi-
tive likelihood ratio of 9.87 for moderate-to-severe SDB. Ap-
plication of the 3 criteria with the cutoff points of 11 and 14
produced a similar specificity but lower sensitivity. For severe
SDB, both strategies showed high sensitivity and specificity
(Table 4).
The post-test probabilities were affected by the prevalence
of the target population, which is same as pre-test probabilities.
Figure 3 shows the change in the post-test probability of the
positive and the negative tests, based on pre-test probability.
Comparison of Our Screening Score with Other Tools
Table 3—Multivariable Predictors of Screening for Sleep-Disor-
dered Breathing and Associated Risk Scoring System*
Characteristic β Regression Screening
Coefficient Score
(95% CI) Assigned
Sex
women ref 0
men 2.33 (1.52–3.14) +4
Body mass index, kg/m2 † 0.68 (0.45–0.91) +1
Blood pressure, mm Hg ‡ 0.73 (0.27–1.20) +1
Snoring §
no or unknown ref 0
yes 2.02 (0.84–3.21) +4
*Screening score was assigned by dividing the β-coefficient by the
absolute value of two-fifths of the amount added for the smallest
and second-smallest coefficients in the model and rounding up to
the nearest integer. †Body mass index categories: < 21.0, 21.0–
22.9, 23.0–24.9, 25.0–26.9, 27.0–29.9, ≥ 30. ‡Blood pressure cat-
egories: systolic blood pressure (SBP) < 140 or diastolic blood
pressure (DBP) < 90, SBP 140–159 or DBP 90–99, SBP160–179
or DBP 100–109, SBP ≥ 180 or DBP ≥ 110. §Snoring: snoring
almost everyday or often is considered “yes,” and snoring some-
times or almost never is considered “no”. **Hosmer-Lemeshow
statistics, 3.76 (degree of freedom = 7, P = 0.81).

For SACS, the areas under the ROC curve (0.82 [95% CI: from the screening score (n = 209, P = 0.786, P = 0.833, respec-
0.75 to 0.89]) for moderate-to-severe SDB and severe SDB tively). For moderate-to-severe SDB, SACS had a sensitivity of
(0.86 [95% CI: 0.79 to 0.93]) were not significantly different 0.81, a specificity of 0.72, and a likelihood ratio of 2.91 when
SLEEP, Vol. 32, No. 7, 2009 943 Simple Four-Variable Screening Tool for SDB—Takegami et al
 Derivation data set Validation data set

100 100
90 90
Prevalence of SDB, %

Prevalence of SDB, %
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Screening Score Quartiles Screening Score Quartiles
Figure 2

its cutoff point was 7. For severe SDB, SACS had a sensitivity 1

of 0.88, specificity of 0.65, and likelihood ratio of 2.49 at the 0.9

same cutoff point.
For MAP, the areas under the ROC curve (0.79 [95% CI: 0.8

0.73 to 0.85]) for both moderate-to-severe SDB and severe

Post-test probability of SDB

0.7
SDB (0.86 [95% CI: 0.79 to 0.93]) were not significantly dif-
ferent from the screening score (n = 302, P = 0.600, P = 0.571, 0.6

respectively). For severe SDB, MAP had a sensitivity of 0.80, 0.5

specificity of 0.72, and positive likelihood ratio of 2.86 when its
cutoff point was 0.30. When its cutoff point was 0.55, MAP had 0.4

a sensitivity of 0.35, specificity of 0.96, and positive likelihood 0.3

ratio of 8.97.
0.2

DISCUSSION 0.1

In this study, we developed and validated a markedly simple 0

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
screening tool for SDB consisting of only four variables: sex, Pre-test probability of SDB
BMI, blood pressure, and self-reported snoring. Three of these Cutoff, 9, + Cutoff, 11, + Cutoff, 14, + Strategy1, + Strategy2, +
four variables (snoring excluded) are routinely checked dur- Cutoff, 9, - Cutoff, 11, - Cutoff, 14, - Strategy1, - Strategy2, -

ing mass screenings or during daily clinical practice. Because

it requires only the simple addition of a question on snoring
to the regular subject record during periodic health checkups,
this screening score is thus suitable for use in mass screening
in occupational and community settings, and also in primary
care settings. The screening score performed well during the
derivation process, as well as in internal and external valida-
tion, and may be used to identify patients with asymptomatic
and undiagnosed SDB.
Screening Tool Variables
This screening tool included the clinically important vari-
ables as well as sex, BMI, blood pressure, and snoring. Cor-
relations between the respective variables and SDB have been
reported previously,43 and are commonly used for clinical diag-
nosis.15 BMI proved to be the most powerful indicator, with an
SLEEP, Vol. 32, No. 7, 2009
Figure 3—Post-test probabilities of positive and negative re-
sults of moderate-to-severe sleep-disordered breathing for differ-
ent pre-test probabilities using the different cutoff points of the
screening score.
area under the ROC curve value of 0.82. This value is similar to
that reported by Gurubhagavatula et al., who reported an area
under the ROC curve for BMI of 0.80. Although the BMI cutoff
point of 32.7 indicated high sensitivity and specificity in their
study population, 25.0 was the appropriate cutoff point in our
derivation dataset. These results suggest that the suitable cutoff
point differs between Asians and Caucasians.
Although a model using BMI alone presents a simple, at-
tractive alternative to current models, we chose a model com-
bining BMI with other variables in multivariable prediction
over a screening model using BMI alone for two reasons. First,
944 Simple Four-Variable Screening Tool for SDB—Takegami et al