The Sleep Wellness Institute is currently investigating the association between healthcare cost and Obstructive Sleep Apnea. Subjects are still being recruited for this longitudinal project. The primary goal of this study is to determine if treatment of OSA with continuous positive airway pressure (CPAP) therapy reduces healthcare cost (hospitalizations, office visits, medication, etc).

    Obstructive sleep apnea (OSA) is defined as “repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction occurring during sleep” (“ICSD-2,” 2005, p. 51). These obstructions are caused by tissue blocking the airway. Respiratory disturbances must be a minimum of 10 seconds in duration. An oxygen desaturation and/or minimum three-second shift in electroencephalography (EEG) normally occur along with these events (“ICSD-2,” 2005). Common complaints for sufferers are non-restorative sleep, excessive daytime somnolence, snoring, and difficulty concentrating. Many comorbid conditions are also associated with OSA: cardiovascular disorders, cerebrovascular events, diabetes, and psychiatric disorders.

Pagel (2007), in a PubMed-based meta-analysis, suggests a comorbid relationship between OSA and the following conditions: obesity, hypertension, congestive heart failure, coronary heart disease, cerebral vascular syndrome, and metabolic syndrome. Patients diagnosed with OSA were found to be more likely to have cardiovascular diagnoses (hypertension, congestive heart failure, and cardiac arrhythmia), chronic obstructive pulmonary disease, and depression within five years prior to the diagnosis of OSA (Smith et al., 2002). Recent findings suggest a link between metabolic syndrome, diabetes, and OSA (Parish, Adam, & Facchiano, 2007; Babu, Herdegen, Fogelfeld, Shott, & Mazzone, 2005).

Continuous Positive Airway Pressure is considered the gold standard treatment for OSA.  A small mask is placed over the nose and sometimes mouth. Room air is then forced into the lungs, causing a pneumatic splint, which keeps the airway open. The opening of the airway diminishes respiratory disturbances that cause EEG arousals and oxygen desaturations.

Adjusting to CPAP therapy can be difficult for some patients. Common complaints include difficulty falling asleep, dry mouth, claustrophobia, mask leak, nasal congestion, and difficulty tolerating air pressure. Objective CPAP compliance data has been difficult to collect until recent wireless technologies were developed. Data was subjective, machine run time only, or missing due to the method in which it was collected. Wireless technology now allows the collection of objective data without the previous issues. Prior research has not used reliable objective data when monitoring compliance and healthcare cost. 


Compliance to CPAP therapy has been linked to a reduction of the severity of the comorbid conditions associated with OSA. The reversal of acute and chronic hypertension during sleep that Fletcher (1996) suggests may have some effect on the findings by Marin and colleagues (2005) that show a reduced risk of fatal and non-fatal cardiovascular events by treatment of OSA with CPAP therapy. Compliance, use of CPAP for greater than four hours per night, may also lead to improved glycemic control and a significant reduction in HbA1C. CPAP use has also shown improvement in the control of Type 2 Diabetes (Babu, Herdegen, Fogelfeld, Shott, & Mazzone 2005).

      Patients who have been diagnosed with OSA have been shown to utilize a higher degree of healthcare (Ronald, Delaive, Roos, Manfreda, & Kryger 1998; Kapur et al., 1999; Berger et al., 2006). Approximately twice the amount of spending on healthcare has been suggested (Tarasiuk et al., 2005).  Peker and colleagues (1997) show a reduction in hospitalization for cardiovascular and pulmonary disease with subjective compliance to continuous positive airway pressure.

      Tarusiak et al. (2005) suggest that healthcare utilization is 1.7 times more in OSA patients when compared to the control. When comparing patients within the group, the top 25% consumed about 70% of the entire OSA group’s cost. These patients’ degree of comorbidity, hypertension, ischemic heart disease, diabetes mellitus, and pulmonary disease helps to explain this increase in spending (Tarasiuk et al., 2005). 

      Ronald and colleagues (1998) conclude that an increase in healthcare utilization can be traced back ten years. Physician claims were close to half in the control group when compared to the patient group (60 for each control, 109 for each patient) during this ten-year period. The cost for hospitalization in the patient group was $1,118,000 and $676,000 for the control physician claims; hospital admissions increased significantly approximately four years prior to diagnosis of OSA (Ronald et al., 1998).

      Schneider National Inc. allowed 348 of their employees to participate in a study that shows CPAP intervention to reduce 47.8% of per member per group healthcare spending in drivers with OSA (Berger, Sullivan, Owen, & Wu, 2006). Preventable driving accidents were reduced by 73% in compliant drivers.

      A reduction of healthcare cost from the treatment of obstructive sleep apnea may indicate that there is a reduction in comorbid conditions. These comorbid conditions utilize a high degree of healthcare resources. CPAP treatment may be a viable solution to these healthcare costs. This study hopes to improve the understanding between OSA and healthcare cost by using technology and study design. ResMed ResTraxx is tracking CPAP compliance of the subjects wirelessly. The study design will also help in minimizing unknown variables that could affect the outcome.      

Luke Goodpaster, BA, RPSGT, Technical Coordinator    

 

 

Reference:

American Academy of Sleep Medicine. (2005) The International Classification of Sleep Disorders, 2nd ed.: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine.

Babu A., Herdegen J., Fogelfeld L., Shott S., Mazzone T. (2005). Type 2 Diabetes, Glycemic Control, and Continuous Positive Airway Pressure in Obstructive Sleep Apnea. Arch Intern Med. 165, 447-452.

Berger M., Sullivan W., Owen R., & Wu C. (2005, November). A corporate Driven Sleep Apnea Detection and Treatment Program: results and Challenges. Proceedings from the 2005 International Truck & Bus Safety & Security Symposium, Alexandria, Virginia.

Fletcher E. (1996). Can Treatment of Sleep Apnea Syndrome Prevent the Cardiovascular Consequences? Sleep, 19(9), S67-S70

Kapur V., Blough D., Sandblom R., Hert R., de Maine J. B., Sullivan S.D., & Psaty B. M. (1999). The Medical Cost of Undiagnosed Sleep Apnea. Sleep, Vol.22, No. 6, 749-755

Marin J., Carrizo S., Vicente E., & Agusti A. (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365, 1046-1053.

Pagel J. (2007). Obstructive Sleep Apnea (OSA) in Primary Care: Evidence-based Practice. Journal of the American Board of Family Medicine. Vol. 20 No. 4, 392-398

Parish J., Adam T., Facchiano L. (2007). Relationship of Metabolic Syndrome and Obstructive Sleep Apnea. The Journal of Clinical Sleep Medicine, Vol. 3 No. 5, 467-472.

Peker Y., Hedner J., Johansson A., & Bende M. (1997) Reduced Hospitalization with Cardiovascular and Pulmonary Disease in Obstructive Sleep Apnea Patients on Nasal CPAP Treatment. Sleep, 20(8), 645-653

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