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Sleep Medicine

Screening for Obstructive Sleep Apnea in AdultsUpdated Evidence Report and Systematic Review for the US Preventive Services Task Force

To identify the key insights or developments described in this article

1 Credit CME

JAMA

Published Online: November 15, 2022

US Preventive Services Task Force

Article Information and Disclosures

Cynthia Feltner, MD, MPH^1,2,3;

Ina F. Wallace, PhD^1,4;

Shannon Aymes, MD, MPH²;

Jennifer Cook Middleton, PhD^1,3;

Kelli L. Hicks, MD, MPH⁵;

Manny Schwimmer, MPH^1,6;

Claire Baker^1,3;

Casey P. Balio, PhD⁷;

Daniel Moore, MPH²;

Christiane E. Voisin, MSLS^1,6;

Daniel E. Jonas, MD, MPH^1,6

Author Affiliations

¹RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center
²Department of Medicine, University of North Carolina at Chapel Hill
³Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
⁴RTI International, Research Triangle Park, North Carolina
⁵Department of Otolaryngology–Head and Neck Surgery, University of North Carolina at Chapel Hill
⁶Department of Internal Medicine, The Ohio State University, Columbus
⁷Center for Rural Health Research, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City

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Abstract

Importance Obstructive sleep apnea (OSA) is associated with adverse health outcomes.

Objective To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force.

Data Sources PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022.

Study Selection English-language studies of screening test accuracy, randomized clinical trials (RCTs) 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.

Data Extraction and Synthesis Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials.

Main Outcomes and Measures Test accuracy, excessive daytime sleepiness, sleep-related and general health–related quality of life (QOL), and harms.

Results Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score >10) 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). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score 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 36-Item Short Form Health Survey (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). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, −1.67 [95% CI, 2.09 to −1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg).

Conclusions and Relevance The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health–related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.

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Article Information

Corresponding Author: Cynthia Feltner, MD, MPH, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 Martin Luther King Jr Blvd, CB#7295, Chapel Hill, NC 27599 (cindy_feltner@med.unc.edu).

Accepted for Publication: September 19, 2022.

Author Contributions: Dr Feltner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Feltner, Wallace, Hicks, Voisin, Jonas.

Acquisition, analysis, or interpretation of data: Feltner, Wallace, Aymes, Cook Middleton, Hicks, Schwimmer, Baker, Balio, Moore, Jonas.

Drafting of the manuscript: Feltner, Wallace, Aymes, Cook Middleton, Hicks, Schwimmer, Baker, Moore, Voisin, Jonas.

Critical revision of the manuscript for important intellectual content: Feltner, Wallace, Hicks, Balio, Jonas.

Statistical analysis: Feltner, Wallace, Aymes, Hicks.

Obtained funding: Feltner, Jonas.

Administrative, technical, or material support: Feltner, Cook Middleton, Schwimmer, Baker, Moore, Voisin, Jonas.

Supervision: Feltner, Jonas.

Conflict of Interest Disclosures: Dr Aymes reported receiving a Health Resources and Services Administration Preventive Medicine Training Grant. No other disclosures were reported.

Funding/Support: This research was funded under contract HHSA-75Q80120D00007, Task Order 01, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope, analytic framework, and key questions for this review. AHRQ had no role in study selection, quality assessment, or synthesis. AHRQ staff provided project oversight, reviewed the evidence review to ensure that the analysis met methodological standards, and distributed the draft for public comment and review by federal partners. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We gratefully acknowledge the following individuals for their contributions to this project, including AHRQ staff (Justin Mills, MD, MPH, and Tracy Wolff, MD, MPH) and RTI International–University of North Carolina–Chapel Hill Evidence-based Practice Center (EPC) staff (Carol Woodell, BSPH, Roberta Wines, MPH, Staci Rachman, BA, Sharon Barrell, MA, Loraine Monroe, and Teyonna Downing). The USPSTF members, expert reviewers, and federal partner reviewers did not receive financial compensation for their contributions. Ms Woodell, Ms Wines, Ms Rachman, Ms Barrell, Ms Monroe, and Ms Downing received compensation for their role in this project.

Additional Information: A draft version of the full evidence review underwent external peer review from 3 content experts (Sean M. Caples, DO, MS, Mayo Clinic; Jon-Erik C. Holty, MD, MS, Stanford University; Paul E. Peppard, PhD, MS, University of Wisconsin-Madison) and 5 federal partner reviewers (Centers for Disease Control and Prevention; National Institute of Dental and Craniofacial Research; National Heart, Lung, and Blood Institute; National Institute on Minority Health and Health Disparities; and National Institutes of Health Office of Research on Women’s Health). Comments from reviewers were presented to the USPSTF during its deliberation of the evidence and were considered in preparing the final evidence review. USPSTF members and peer reviewers did not receive financial compensation for their contributions.

Editorial Disclaimer: This evidence review is presented as a document in support of the accompanying USPSTF recommendation statement. It did not undergo additional peer review after submission to JAMA.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.