Economic & Social Costs of Sleep Apnea

More than a 100 million people live with obstructive sleep apnea (OSA) worldwide, 80% of whom remain undiagnosed, according to “Sleep: A Global Perspective,” a research report produced by Philips earlier this year.

Obstructive sleep apnea occurs when the upper airways are repeatedly obstructed during sleep, depriving the heart, brain and other organs of oxygen. This can, in turn, trigger and exacerbate a broad spectrum of other serious chronic conditions including high blood pressure, stroke, diabetes, depression and even increased risk of death. While the health consequences of OSA are widely known, the socioeconomic burden of OSA is less apparent and often overlooked.

When OSA goes undiagnosed and untreated, it severely diminishes the quality of life for patients of all ages. Patients who do not regularly receive proper medical care for their sleep apnea often end up needing costly emergency room visits, hospitalizations, frequent doctors’ appointments, as well as other expensive treatments for comorbidities and related conditions such as hypertension, heart disease and sudden cardiac death. Healthcare costs of children with untreated OSA are 215% higher compared to children without OSA. One of the many hidden costs of untreated OSA patients is that they are much less productive at work and in school.

Delayed or Incorrect Diagnoses Drive Up Costs
A big part of the problem is that many patients go undiagnosed and untreated or are incorrectly diagnosed and suboptimally treated. The medical costs of this group can be staggering. Misdiagnosed OSA can compromise patients’ health as well. For example, according to the American Academy of Pediatrics, attention deficit/hyperactivity disorder (ADHD) and sleep apnea share many of the same symptoms such as poor concentration, difficulty maintaining focus and poor school performance. As a result, a child might be mistakenly diagnosed as having ADHD and be prescribed medications such as stimulants while their OSA goes unmanaged.

Patients With OSA More Likely to Have Work-Related Accidents
Many people with untreated OSA are less productive at work, call in sick more often, perform poorly in school and are more accident-prone. Patients with limited productivity and mental alertness also run the risk of losing their jobs and compromising their financial security, their own physical safety as well as the safety of others. Patients with untreated OSA are also more likely to be involved in motor vehicle collisions (MVCs).

Data from insurance records, self-reported MVCs and driving-simulator performances consistently support this. In the study, “Maintenance of Wakefulness Test, obstructive sleep apnea syndrome, and driving risk,” sleepiness measures were compared to real-life driving performance among patients with untreated OSA. The ability to stay awake for less than 34 minutes was associated with worse driving performance with equal deficits seen between sleepy (staying awake only 20-33 minutes) and very sleepy (0-19 minutes) groups. The crash rate in patients with untreated OSA is comparable to those with moderate-severe dementia or with blood alcohol levels of 0.05 to 0.70 mg/dL. Treatment of OSA should be strongly considered to reduce these risks.

SEE ALSO: Pregnancy & Sleep Apnea

Other Overlooked Costs of Untreated OSA
OSA can take its toll not only on patients, but also their families, employers, insurance carriers, healthcare providers and other stakeholders. For example, employers’ annual healthcare costs for each employee with sleep apnea increases from $3,200 to $4,000, according to “The Price of Fatigue,” a 2011 study produced by the Harvard Medical School’s Division of Sleep Medicine and McKinsey. The same report found that employees with untreated OSA were six times more likely to miss a full day of work and five times more likely to miss a partial day. According to “Insomnia and the Performance of U.S. Workers,” a report published by Harvard Medical School’s Department of Health Care Policy that such declines in work performance – approximately 11 days of missed work – could account for as much as $63.2 billion in lost productivity when generalized to the U.S. workforce.
Many Diagnostic and Treatment Options
Continuous positive airway pressure (CPAP) is most often prescribed as the first course of treatment for adults diagnosed with obstructive sleep apnea, and adenotonsillectomies are often recommended for children with OSA. Each patient may present with different symptoms, comorbidities, medical needs and access to healthcare, and treatment choices has to be individualized. However, below are examples of diagnostic testing and treatment options for obstructive sleep apnea:

  • Diagnostic testing
  • Home sleep tests (HST)
  • In-lab polysomnography (PSG)
  • Treatment options
  • Continuous positive airway pressure (CPAP)
  • Removal of tonsils (adenotonsilectomy)
  • Uvulopalatopharyngoplasty and palatopharyngeal and other surgeries that increase the width of the airway at the throat opening
  • Oral appliances
  • Weight management
  • Positional therapy

Some researchers have found that home sleep tests (HSTs) are more cost-effective than in-lab polysomnography. At the same time, other studies have found that in-lab PSG with CPAP titration is more cost-effective over the long-term than HSTs, mainly because of its detailed diagnostic accuracy. The randomized controlled HomePAP trial found that patients who used HST combined with auto-titrating CPAP had lower upfront diagnostic costs and were more likely to use their CPAP than those who were tested in-laboratory PSG.

Various surgical approaches are also among the treatment options for OSA. For example, both upper airway stimulation and palatopharyngeal surgery have been shown to be cost-effective treatments for OSA. In children, first-line therapy for OSA is often adenotonsillectomy. Surgery may reduce annual healthcare costs by one-third, hospital admissions by 60%, emergency room visits by 39%, number of consultations by 47% and costs of prescription medications by 22%.

“OSA can take its toll not only on patients, but also their families, providers and other stakeholders.”

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Lower Costs, Improved Care and Productivity Depend on Early Diagnosis and Treatment
Untreated, obstructive sleep apnea is associated with significant direct and indirect medical costs and workplace productivity losses. Patients with untreated OSA also pose a danger to their coworkers and other drivers on the road because there are more likely to get into motor vehicle collisions. The good news is that with diagnosis and treatment, people living with OSA do not need to generate such high healthcare costs and are likely to be more productive in the workplace and less dangerous behind the wheel.

The first step toward lowering costs and improving care is routine screenings for sleep disorders such as OSA, including asking patients about their sleep habits. Primary care and emergency room clinicians can play a key role in ensuring that patients living with sleep apnea are diagnosed early enough to reduce its most serious effects and prevent other chronic conditions and comorbidities from taking hold. Preventing the escalation of the disease and related chronic conditions also depends on the willingness among stakeholders, including employers, to actively promote routine screening and support multiple treatment options.

David G. Ingram, MD, specializes in sleep medicine at Children’s Mercy Hospital in Kansas City, Mo. Teofilo Lee-Chiong, MD, is Chief Medical Liaison, Philips.

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