Why I Won't Be Screening All Adults for Sleep Apnea

Kenneth W. Lin, MD, MPH


March 08, 2023

I'm Dr Kenny Lin. I am a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, and I blog at Common Sense Family Doctor.

Kenneth W. Lin, MD, MPH

In February, the American Academy of Sleep Medicine (AASM) and several other medical organizations launched the "More than a Snore" campaign to raise awareness about undiagnosed obstructive sleep apnea in the United States. Although sleep apnea is estimated to affect around 30 million US adults, 4 in 5 people with this condition are not aware that they have it, according to the AASM.

Disrupted sleep can cause daytime fatigue and increase blood pressure, leading to billions of dollars in healthcare costs each year. No doubt the "More than a Snore" campaign will encourage some patients with unrecognized sleep apnea symptoms to visit their doctors and be appropriately diagnosed and treated. However, I am concerned that the campaign may also lead to unnecessary care that won't help many patients feel better or live longer.

There's a world of difference between visiting one's doctor because fatigue or snoring is impairing the patient's or a bed partner's quality of life and having that doctor specifically ask each patient about sleep apnea symptoms. The latter is called screening, and even though screening tools for sleep apnea exist, last year the US Preventive Services Task Force (USPSTF) found insufficient evidence to assess the benefits and harms of routine screening. A systematic review found insufficient evidence of the accuracy of screening questionnaires in the general adult population, small effects of treating symptomatic patients on sleep quality and quality of life, and no effects on cardiovascular events or mortality.

A 2016 study that assessed the prevalence of sleep apnea in a general population of adults aged 40-65 years, defined as an apnea-hypopnea index (AHI) of at least 15, found that 20% met criteria for moderate to severe disease, but most of them had no noticeable symptoms. It's hard to make patients feel better who already feel fine, but it's easy to make them feel worse, as more than 1 in 3 patients who are prescribed continuous positive airway pressure (CPAP) end up discontinuing use of the device. It's hardly a stretch to imagine that CPAP adherence would be even lower in a screen-detected population. Positional therapy is an alternative for some patients, but is it really necessary to undergo a home or laboratory sleep study to be told to try not to sleep on your back?

Another problem is that despite the existence of a conflict-of-interest free clinical practice guideline, a systematic review from the Agency for Healthcare Research and Quality found that a consistent definition of obstructive sleep apnea is lacking. As Dr Aaron Holley noted in a previous Medscape commentary, "For the majority of patients, hypopneas constitute the majority of the AHI. … But no one, including the AASM, knows what a hypopnea is." Because physicians who face diagnostic uncertainty are conditioned to err on the side of caution, it's likely that many patients with borderline results will be diagnosed with sleep apnea even though they are unlikely to benefit from treatment.

The AASM and other organizations supporting the "More than a Snore" campaign might argue that they are not advocating screening for sleep apnea per se, and technically that's correct. But whenever we in medicine are urged to look harder for an underdiagnosed condition, such as thyroid cancer or prediabetes, many of the newly detected cases will be asymptomatic or mild, running the risk for widespread overdiagnosis. Before sending large numbers of patients off for sleep studies, family physicians would do well to remember that a snore may, indeed, be just a snore.

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