USPSTF Finds Evidence Insufficient for Sleep Apnea Screening

January 26, 2017

A new statement from the US Preventive Services Task Force (USPSTF) has concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea in asymptomatic adults and those with unrecognized symptoms.

But the statement has provoked concern from some sleep medicine experts that it might inadvertently be giving the wrong message to primary care doctors, who they believe need to be doing more to identify the large population of symptomatic patients who are going unrecognized.

The USPSTF statement, published in the January 24/31 issue of JAMA, reports that based on data from the 1990s, it is estimated that 10% of the US population have mild sleep apnea and 3.8% to 6.5% have a moderate to severe form, although current prevalence may be higher, given the increasing prevalence of obesity.

The authors point out that severe sleep apnea is associated with increased all-cause mortality, cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes.

The USPSTF reviewed the evidence on the accuracy, benefits, and potential harms of screening for sleep apnea in asymptomatic adults seen in primary care, including those with unrecognized symptoms, and for effects of treatment of the condition on intermediate and final health outcomes.

They found insufficient evidence on screening for or treatment of sleep apnea in asymptomatic adults or adults with unrecognized symptoms and therefore were "unable to determine the magnitude of the benefits or harms of screening or whether there is a net benefit or harm to screening."

They note that although severe sleep apnea is associated with increased all-cause mortality, the role sleep apnea plays in increasing overall mortality, independent from other risk factors (older age, higher body mass index, and other cardiovascular risk factors), is less clear.

"Although numerous studies evaluated the effectiveness of treatment with CPAP [continuous positive airway pressure] and mandibular advancement devices to improve intermediate outcomes (eg, the AHI [apnea-hypopnea index], ESS [Epworth Sleepiness Scale] score, or blood pressure) in patients already receiving care or referred for care at a sleep clinic, the clinical significance of these changes and the applicability of this evidence to asymptomatic, screen-detected populations are unclear," they say.

Three Editorials

The statement has attracted much comment from sleep experts, with three separate editorials having been published in different JAMA journals alone.

In the main editorial accompanying publication of the statement in JAMA, Susan Redline, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts, states: "The current recommendations, if misinterpreted, could negatively influence public health if they are used to discourage direct questioning or deployment of short screening questionnaires for identifying patients at high risk for obstructive sleep apnea."

"The crux of the issue is that this statement is directed at the question of screening asymptomatic patients," she commented to Medscape Medical News. "But I think they are focusing on the wrong issue.

"A much more relevant concern right now is the large proportion of patients who do have significant symptoms of sleep apneas and therefore are at increased risk of cardiovascular disease but are not being picked up," Dr Redline said. "There is a huge opportunity here to improve recognition of this group in primary care by asking a few simple questions, and they can then be treated relatively easily and their cardiovascular risks reduced."

She added: "Patients who are diagnosed with sleep apnea commonly report that they had been having symptoms such as excessive daytime sleepiness for up to 10 years before the condition was actually diagnosed. They didn't ask about it as they didn't think it was a major issue. Partners of the patients often complain of loud snoring or gasping during sleep but also don't realize that this could be a medical problem.

"The other patient group we need to do more about is those with risk factors for sleep apnea — hypertension, obesity, diabetes — they will often have sleep apnea and again but may not know it. They are a group who may need to be screened with home sleep monitors."

"My concern is that primary care doctors may read this statement and take away the message that they don't need to be doing anything else to look for sleep apnea," she noted. "This is absolutely not the case. We have a big problem in not recognizing this condition, and primary care doctors have a major role to identify symptomatic patients and those at high risk. This is easy to do by taking a brief history, and it would be of great benefit to both patients and public health if these individuals were identified, and tested and treated."

Coauthors of another editorial in JAMA Internal Medicine, Sachin R. Pendharkar, MD, and Fiona M. Clement, PhD, University of Calgary, Alberta, Canada, make many of the same points and write that the USPSTF recommendation "leaves front-line clinicians who are trying to provide evidence-informed primary care wondering what is the right thing to do."

They suggest that primary care physicians need to do more to identify patients with symptoms of sleep apnea, but screening in asymptomatic patients is probably not justified.

"This statement has lumped together all asymptomatic patients and those with unrecognized symptoms, and they conclude there is not enough evidence to recommend or nor recommend screening," Dr Pendharkar elaborated to Medscape Medical News. "To me this is confusing. I think it would be better just to have said there is not enough evidence to recommend screening for all asymptomatic patients at the moment. And in my opinion there do need to be some guidelines advising primary care doctors to routinely ask their patients about quality of sleep and daytime sleepiness and then, if they find out that there are actually symptoms, this is the group to test further."

In a third editorial in JAMA Neurology, Gregory S. Carter, MD, University of Texas Southwestern Medical Center, Dallas, points out that the six authors of the USPSTF current statement are not sleep-medicine clinicians and they are reviewing the clinical evidence from the viewpoint of public health and primary care practice.

But he says that trying to evaluate evidence on asymptomatic patients or those with unrecognized symptoms is particularly difficult because most studies dealing with treatment outcomes are conducted in sleep medicine specialty centers, and the participants are symptomatic patients.

"In summary," Dr Carter concludes, "the USPSTF seeks to set future research needs to address the public health threat of untreated OSA [obstructive sleep apnea] in the general population and develop accurate and reliable tools for primary care to identify asymptomatic individuals or individuals with unrecognized symptoms who would benefit from further evaluation and intervention to improve health outcomes. This is a goal worthy of the support of all clinicians, but it will be challenging."

American Academy of Sleep Medicine Statement

In addition to the three JAMA editorials, the American Academy of Sleep Medicine (AASM) issued a statement recommending that patients who have a high risk for obstructive sleep apnea should be screened.

The AASM statement reads: "Primary care providers are in the best position to identify patients with symptoms of obstructive sleep apnea, such as excessive daytime sleepiness and snoring, gasping, choking or pauses in breathing during sleep. Indicators of high risk for sleep apnea include obesity, heart problems such as congestive heart failure and atrial fibrillation, treatment resistant hypertension, Type 2 diabetes and stroke."

It adds: "Identification by primary care providers of patients who have a high risk for sleep apnea, followed by appropriate referral to a board-certified sleep medicine physician for a comprehensive sleep history and evaluation, could significantly reduce the frequency of undiagnosed sleep apnea. Screening high-risk populations could improve the quality of life and health outcomes for these patients while also reducing the individual and public health burden of untreated sleep apnea."

The AASM estimates that diagnosing and treating every patient in the United States who has obstructive sleep apnea would produce an annual economic savings of $100.1 billion.

The USPSTF statement does include a section at the end where it refers to recommendations from other organizations — including the AASM — which advise more efforts to identify symptomatic patients for further testing.

The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF. Conflict of interest disclosures for authors can be found here.

JAMA 2017;317:407-414. Published online January 24, 2017. Statement, Editorial full text

JAMA Intern Med. Published online January 24, 2017. Editorial full text

JAMA Neurol. Published online January 24, 2017. Editorial full text

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