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Abstract & Commentary
Synopsis: Sleepiness, obesity, hypertension, witnessed apneas, and frequent snoring are prevalent in the general population; demand for diagnostic and treatment services for sleep apnea is likely to skyrocket.
Source: Netzer NC, et al. Chest. 2003;124:1406-1414.
This study was done to determine the prevalence of classic findings of sleep apnea in a geographically and socioeconomically diverse primary care population. For this study, 26 US sites and 14 European sites distributed Berlin Questionnaires to consecutive patients who were at least 15 years old when they visited a primary care physician for any reason. The patients completed the questionnaires in the physicians’ office, and completed questionnaires were returned to the central analysis site (Cleveland, Ohio) for data entry and analysis. The Berlin Questionnaire has previously been shown to have a positive predictive value of 89% for a Respiratory Distress Index (RDI) of more than 5 events per hour of sleep, if at least 2 of the following are present:1 frequent symptoms of snoring and/or witnessed apneas, frequent symptoms of sleepiness, or self-reported hypertension and/or a Body Mass Index (BMI) of > 30 kg/m2. Care was taken to translate the questionnaire and to validate it in the European countries involved in this project. Frequency distributions and proportions were used to calculate prevalence rates. Most variables were dichotomized for analysis, and important confounders were controlled for—in calculating odds ratios and logistic regression.
There was an incredible 78% usable response rate (n = 6223), which was similar between the United States and Europe. The mean age of the respondents was 51.3 ± 17 years; obesity was more common in the United States than in Europe (27.9 vs 17.2%). The US population was also more likely to endorse "not rested after sleep" (36% vs 16%) and drowsy driving (17% vs 7%). Spaniards were the least sleepy of all Europeans, and Southerners were least sleepy of all Americans. Men were more likely than were women to report snoring, witnessed apneas, and drowsy driving. Women were more likely to complain of daytime sleepiness. Probability estimates of sleep apnea were 16.4% for the United States and 6.7% for Europe.
Comment by Barbara A. Phillips, MD, MSPH
If I were a health insurance administrator, these data and several studies like it2-5 would make me rethink my policy about testing and treatment for sleep apnea. The fact is, sleep apnea is very prevalent and getting more so, since our population is getting older and fatter.6,7 Further, we spend more on diagnosis than on treating this condition (a sleep study costs about 3 times what a Continuous Positive Airway Pressure [CPAP] machine does). CPAP is extraordinarily safe, cheap, and effective and has been shown to reverse most of the consequences of sleep apnea. A logical, safe, and cost-effective approach would be to reimburse treatment with autotitrating CPAP without testing for a month or two if a knowledgeable physician ordered it on the basis of a relevant history and physical examination. Documentation of follow-up and compliance, including sleepiness symptoms, nasal symptoms, hours of use, blood pressure, and weight would be required for purchase of the machine at that point. If the patient were not using or benefiting from the CPAP at follow-up, then he or she could take a trip to the sleep lab to find out if some other condition were present, to retitrate CPAP, and to work on issues related to CPAP compliance. Time, money, and lives would be saved.
In the meantime, primary care physicians need to know that the burden of our obesity epidemic includes a skyrocketing rate of sleep apnea.7 Snoring, sleepiness, witnessed apneas and hypertension are fairly good predictors of the likelihood of sleep apnea in the obese patient. In particular, the likelihood of sleep-disordered breathing ought to be carefully considered in obese patients with hypertension, since CPAP has unequivocally been shown to lower blood pressure in hypertensive patients with sleep apnea, especially those with drug-resistant sleep apnea.8-12 It is important to remember that in patients with heart failure, CPAP improves blood pressure and cardiac function even if the patients are not sleepy.11
It’s time we got past the notion that the main treatable consequence of sleep apnea is sleepiness, and focused on preventing the excess cardiac mortality that results. Insurance company administrators, CPAP is actually cheaper than antihypertensive therapy and monitoring. Please listen! Our current system is cumbersome, overly expensive, and deadly.
Dr. Phillips, Professor of Medicine, University of Kentucky; Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, is Associate Editor of Internal Medicine Alert.
1. Netzer NC, et al. Ann Intern Med. 1999;131:485-491.
2. Maislin G, et al. Sleep. 1995;18:158-166.
3. Kushida CA, et al. Ann Intern Med. 1997;127:581-587.
4. Tsai WH, et al. Am J Respir Crit Care Med. 2003;167:1427-1432.
5. Rowley JA, et al. Sleep. 2000;23:929-938.
6. Tishler PV, et al. JAMA. 2003;289:2230-2237.
7. Young T, et al. Am J Respir Crit Care Med. 2002;165:1217-1239.
8. Logan AG, et al. J Hypertens. 2001;19:2271-2277.
9. Logan AG, et al. Eur Respir J. 2003;21:241-247.
10. Chobanian AV, et al. JAMA. 2003;289:2560-2572.
11. Kaneko Y, et al. N Engl J Med. 2003;348:1233-1241.
12. Becker HF, et al. Circulation. 2003;107:68-78.
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