Accuracy and clinical utility of obstructive sleep apnea screening tools uncertain in primary care settings – US Preventive Services Task Force

1. Positive airway pressure was associated with a significant improvement in Epworth sleepiness scale score (ESS) from baseline, sleep-related quality of life (QoL), and general health-related QoL, compared with inactive control.

2. The use of mandibular advancement devices was associated with a significantly larger ESS score change when compared with controls.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Obstructive sleep apnea (OSA) is a sleep disorder characterized by the narrowing and subsequent obstruction of the upper airway during sleep, leading to impairment of breathing. In particular, OSA is defined as more than 5 events per hour of either partial or total upper airway obstruction. Apnea consists of total airway obstruction (>90%) for more than 10 seconds. Evidence surrounding the benefits and harms of screening for OSA in asymptomatic adults is limited. Hence the objective of this study was to review the evidence on screening for OSA in such populations to inform the US Preventative Services Task Force. In this systematic review, searches were performed in PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 2021, with a total of 86 studies included. The main outcomes included test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harm. The screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome measured as the area under the curve in 2 studies (n = 702) was 0.80 and 0.83. Positive airway pressure was associated with significant improvement in ESS score from baseline, sleep-related QoL, and general health-related QoL. Mandibular advancement technology was also associated with a significantly larger ESS score compared with controls. A strength of this study was its large sample size and systematic methodology. A limitation was that studies that focused on the benefits and harms of treatment were limited to those of first-line treatments for persons with newly detected OSA.

Click to read the study in JAMA

Click to read an accompanying editorial in JAMA

Relevant Reading: Obstructive sleep apnea in adults

In-Depth [systematic review]: This study reviewed the evidence on screening for OSA in asymptomatic adults to inform the US Preventative Services Task Force. Databases searched included PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 2021, with surveillance through September 2022. Inclusion criteria included studies in English, randomized clinical trials of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores. A total of 86 studies were included in this review (N=11 051). No studies directly compared screening with no screening, and five studies assessing the accuracy of other screening tools were found to be heterogenous with inconsistent results. Screening accuracy of the Multivariable Apnea Prediction score and the unattended home sleep testing for severe OSA syndrome measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Positive airway pressure was found to be associated with a significant improvement in ESS from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QoL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QoL measured by the SF-36 mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345), and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Compared with controls, the use of advanced mandibular devices was associated with a larger ESS score change (pooled mean difference, -1.67 [ 95% CI, 2.09 to -1.25]; 10 trials; n = 1540). None of the included trials found a significant benefit associated with the treatment on mortality, cardiovascular events, or motor vehicle accidents.

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