Determinants Affecting Health-Care Utilization in Obstructive Sleep Apnea Syndrome Patients

doi:10.1378/chest.128.3.1310

Chest

Volume 128, Issue 3, September 2005, Pages 1310-1314

https://doi.org/10.1378/chest.128.3.1310 Get rights and content

Study objective

To investigate determinants of health-care utilization in patients with obstructive sleep apnea syndrome (OSAS).

Design

Case-control prospective study with OSAS patients and a control group. We compared 218 patients with OSAS to those of age-, gender-, geographically-, and family physician-matched control subjects from the general population, matched 1:1 (χ² = 0.999).

Participants

All participants were members of Clalit Health Care Services, a health maintenance organization in the southern region of Israel. All OSAS patients underwent nocturnal polysomnography studies. Indexes of health-care utilization 2 years prior to the polysomnography were analyzed.

Measurements and results

Health-care utilization was 1.7-fold higher (p < 0.001) in the OSAS patients due to more hospitalization days (p < 0.001), consultations (p < 0.001), and cost for drugs (p < 0.05), particularly those for the cardiovascular system. In comparison to men, women consumed significantly more health-care resources (p < 0.001). OSAS patients ≤ 65 of age years consumed 2.2-fold more health-care resources than control subjects (p < 0.001). Polysomnography findings and OSAS severity and body mass index (BMI) did not predict health-care utilization, using multivariate logistic regression analysis. Age > 65 (odds ratio [OR], 2.2; p < 0.04) and female gender (OR, 2.0; p < 0.05) were the leading elements predicting the most costly OSAS patients. Arbitrarily dividing the OSAS group by cost of health-care utilization, the upper 25% (n = 55) of patients who were the “most costly” consumed sevenfold more health-care resources than the lower 75% of the patients. This was due to higher comorbidity, ie, 10 to 30% more hypertension, ischemic heart disease, diabetes mellitus, and pulmonary disease.

Conclusions

OSAS patients are heavy users of health-care resources. Age > 65 years and female gender were the leading elements predicting the most costly OSAS patients, and not necessarily patients with a high BMI and classic OSAS severity indexes.

Section snippets

Materials and Methods

Subjects are enrollees of Clalit Health Care Services (CHS), the largest health maintenance organization in Israel; all had been permanent residents of the southern region for at least 3 years prior to study initiation. Recruited subjects are “typical” OSAS patients (with or without chronic diseases and prescribed medication respectively) and control subjects, entitled to a polysomnographic study and all diagnostic and treatment information free of charge. Control subjects (n = 218) randomly

Data Analysis

Cost data were analyzed¹⁸ using statistical software (SPSS version 11.5; SPSS; Chicago, IL). Statistical power (α = 0.05) was calculated for the women (n = 44, control vs OSAS) and was found to be 0.98. One-way analysis of variance was used to compare between mean values. A Mann-Whitney U test was used to determine statistical significance of cost elements between groups; χ² was used to confirm “population match” and univariate analysis. Multivariate logistic regression analysis was used to

Results

Two hundred eighteen adult OSAS patients were included (mean age, 54.8 ± 10.3 years; 18% >65 years old; 79.8% male gender). The control subjects were perfectly matched (χ² = 0.999) by family physician, age, gender, and address. All symptoms were typical for the OSAS group except for “observed choking” by the spouse, which was reported in 47% of the men vs 25% of women (p < 0.01). The comorbidity of the OSAS group (hypertension, 40.5%; diabetes mellitus, 14.5%; pulmonary diseases, 12.4%) was

Discussion

OSAS patients consumed 1.7-fold more health-care resources than control subjects. The present study describes cost elements previously described in children15, 16 for “typical” adults with OSAS in a health-care system in which all citizens are entitled by law to free access to medical care. Our data on health-care utilization may be difficult to compare with those from other health-care systems that have more than one payer. These data can be compared to similar health-care systems as in

References (22)

WittmannV et al.
Health care costs and the sleep apnea syndrome
Sleep Med Rev
(2004)
SmithR et al.
What are obstructive sleep apnea patients being treated for prior to this diagnosis?
Chest
(2002)
PillarG et al.
Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index
Chest
(1998)
BergG et al.
The use of health-care resources in obesity-hypoventilation syndrome
Chest
(2001)
ShaharE et al.
Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study
Am J Respir Crit Care Med
(2001)
NewmanAB et al.
Sleep Heart Health Study Research Group. Relation of sleep-disordered breathing to cardiovascular disease risk factors: the Sleep Heart Health Study
Am J Epidemiol
(2001)
KrygerMH et al.
Utilization of health care services in patients with severe obstructive sleep apnea
Sleep
(1996)
BahammamA et al.
Health care utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment
Sleep
(1999)
RonaldJ et al.
Health care utilization in the 10 years prior to diagnosis in obstructive sleep apnea syndrome patients
Sleep
(1999)
OtakeK et al.
Cardiovascular medication use in patients with undiagnosed obstructive sleep apnoea
Thorax
(2002)

PekerY et al.

Reduced hospitalization with cardiovascular and pulmonary disease in obstructive sleep apnea patients on nasal CPAP treatment

Sleep

(1997)

Cited by (80)

Individual and societal impact of hypersomnolence
2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
Hypersomnolence is excessive sleepiness with impaired vigilance and it is important to identify the cause to guide appropriate management. Excessive sleepiness has a negative impact on health, society, family and increased risk of accidents at work and driving. Appropriate management must be provided not only to improve quality of life, but also to assist patients to continue taking part in their family and professional lives. Excessive sleepiness causes increased cardiovascular risk, mood disorders, metabolic disorders, alter reproductive function and hormonal changes leading to increased health care costs. Recognizing and treating hypersomnia is associated with improved health and social outcomes.
Lessons from healthcare utilization in children with obstructive sleep apnoea syndrome
2017, Acta Otorrinolaringologica Espanola
El síndrome de apnea-hipopnea del sueño (SAHS) pediátrico engloba alteraciones multisistémicas que afectan al estado general de salud, valorado indirectamente mediante el estudio de la demanda asistencial. Objetivo: cuantificar la frecuentación de consultas médicas en niños con SAHS durante 5 años y compararla con una población sana.
Estudio casos-control longitudinal ambispectivo en un hospital del sistema nacional de salud. Reclutamos a 69 niños remitidos por SAHS sin otras patologías para que la demanda asistencial fuera predominantemente atribuida al SAHS. Se seleccionó a otros 69 niños sanos como grupo control. Obtuvimos datos de frecuentación durante 5 años: el año en el que se realizó el tratamiento del SAHS («año 0»), 1 y 2 años antes («año –1» y «año –2»), y 1 y 2 años tras el tratamiento («año +1» y «año +2»).
El índice de frecuentación (IF), descrito como cociente entre demanda asistencial por los niños con SAHS y niños sanos, fue 1,89 durante el año –2 y 2,15 durante el año –1 (p < 0,05). El tratamiento disminuyó la utilización, con IF de 1,59 durante el año +1 y 1,72 en el año +2 (p < 0,05). Las principales causas de sobrefrecuentación fueron otorrinolaringológicas y neumológicas.
Los niños con SAHS muestran mayor demanda asistencial, al menos 2 años antes del tratamiento, lo que implica un deterioro de la salud global que pudiera estar presente años antes de que la abordemos. El tratamiento repercute en una mejora, aunque permanece alta tras el tratamiento, sugiriendo enfermedad residual o secuelas.
Paediatric Obstructive Sleep Apnoea-Hypopnoea Syndrome (OSAS) is a multisystemic condition affecting child's health status that may be investigated analyzing demand for healthcare. Objective: to quantify the frequency of medical consultations in children with OSAS over a 5-year period, compared to a healthy population.
A longitudinal, case-control, ambispective study was conducted at a hospital pertaining to the national public health system. 69 consecutive children referred for OSAS were recruited with no diseases other than OSAS so that healthcare demand was purely attributed to this condition. Matched healthy control children were selected to compare these data. Data regarding frequency of the medical consultations were obtained over 5 years: the year of the treatment (“Year0”), 1 and 2 years before (“Year -1” and “Year -2” respectively), and 1 and 2 years after treatment (“Year +1” and “Year +2”)
Frequentation Index (FI), as ratio between the use of health services by OSAS children and healthy controls was 1.89 during Year-2, and 2.15 during Year-1 (P<.05). Treatment diminishes utilization, with FI of 159 during year +1 and 1.72 during year +2 (P<.05). The main causes of attendance were otolaryngological and pneumological diseases, improving after treatment.
Children suffering from OSAS demand more healthcare services, at least 2 years before treatment, implying that the disease could be present years before we manage it. Therapeutic actions improve healthcare services utilization, although remain higher than for controls, which suggests OSAS sequelae or residual disease.
Impact of diagnosing and treating obstructive sleep apnea on healthcare utilization
2017, Sleep Medicine
Obstructive sleep apnea (OSA) contributes to an increased risk for multiple co-morbidities and decreased quality of life. As a result, OSA patients may have higher usage of healthcare resources which can be mitigated with effective treatment. This study evaluates changes in healthcare utilization (HCU) following the initiation of therapy for OSA.
We conducted a retrospective study of newly diagnosed OSA patients. To assess total HCU, we incorporated the sum total of outpatient clinic encounters, laboratory tests, and medication prescriptions into a composite HCU score. Healthcare utilization for twelve months prior to positive airway pressure (PAP) was compared with twelve months after initiation of therapy. Reductions in HCU were correlated with PAP adherence.
650 consecutive patients were included. Mean age, gender, BMI, AHI, and ESS were 47.2 ± 8.8 years, 77.2% (men), 30.7 ± 4.9 kg/m², 37.1 ± 30.3, and 13.1 ± 5.1, respectively. Prior to PAP, mean outpatient visits, laboratory studies, medication prescriptions, and HCU composite score were 11.6 ± 10.4, 13.7 ± 11.0, 4.7 ± 3.2, and 29.7 ± 18.6, respectively. Following initiation of treatment, a 32.8% reduction in non-sleep outpatient visits was identified (p = 0.01) and a 16.4% decrease in laboratory studies (p = 0.02) was observed. There was a 19.9% reduction (p = 0.002) in HCU composite score. Those who were adherent with PAP had a 25.7% reduction in HCU composite score versus a 4.9% increase in those who discontinued PAP therapy (p < 0.001).
Diagnosing OSA and initiating PAP therapy resulted in a significant decrease in healthcare resource utilization. This reduction was greatest among those with higher baseline healthcare usage and those most adherent with therapy.
The Benefits of Perioperative Screening for Sleep Apnea in Surgical Patients
2017, Sleep Medicine Clinics
Cost-effectiveness of Continuous Positive Airway Pressure Treatment in Moderate-Severe Obstructive Sleep Apnea Syndrome
2016, Archivos de Bronconeumologia
El síndrome de apnea-hipopnea durante el sueño (SAHS) supone un gran impacto socioeconómico. El objetivo de este estudio es evaluar el coste-efectividad del tratamiento del SAHS con presión positiva continua de la vía aérea superior (CPAP) y estimar la influencia que tiene el cumplimiento de la CPAP.
Estudio retrospectivo de «casos cruzados» de 373 pacientes SAHS tratados con CPAP. Se calcularon variaciones en costes, puntuación en el test de Epworth y calidad de vida relacionada con la salud (cuestionario EQ-5D) entre el año previo al tratamiento y el año después del mismo. Se estimó la ratio de coste-efectividad incremental (RCEI) para el primer año de tratamiento y se realizó una proyección para el segundo año bajo distintos escenarios de efectividad y costes.
La puntuación de la escala visual analógica del cuestionario EQ-5D aumentó en 5 puntos y el test de Epworth disminuyó en 10 puntos al año del tratamiento con CPAP, con una ganancia media en años de vida ajustados por calidad (AVAC) de 0,05 por paciente y año (p < 0,001): 0,07 en cumplidores y –0,04 en no cumplidores. La RCEI fue de 51.147 €/AVAC durante el primer año de tratamiento con CPAP y de 1.544 €/AVAC el segundo año.
El tratamiento con CPAP en pacientes con SAHS moderado-grave mejora la calidad de vida de los pacientes cumplidores y es coste-efectivo a partir del segundo año.
The socioeconomic impact of obstructive sleep apnea-hypopnea syndrome (OSAHS) is considerable. The aim of this study was to evaluate the cost-effectiveness of treating OSAHS with continuous positive airway pressure (CPAP) and the impact of CPAP compliance.
This was a retrospective, case-crossover study of 373 patients with OSAHS receiving CPAP. We compared changes in costs, Epworth score and health-related quality of life (EQ-5D questionnaires) between the year before treatment and the year after treatment. The incremental cost-effectiveness ratio (ICER) for the first year of treatment was estimated, and projections were made for the second year, using different effectiveness and cost scenarios.
The visual analog scale score for the EQ-5D questionnaire increased by 5 points and the Epworth score fell by 10 points during the year of CPAP treatment. Mean gain in quality-adjusted life years (QALY) was 0.05 per patient per year (P < .001): 0.07 among compliers and –0.04 among non-compliers. ICER was € 51,147/QALY during the first year of CPAP treatment and € 1,544/QALY during the second year.
CPAP treatment in patients with moderate-severe OSAHS improves the quality of life of compliant patients, and is cost-effective as of the second year.
Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome
2015, World Journal of Otorhinolaryngology - Head and Neck Surgery
To provide an overview of the healthcare and societal consequences and costs of untreated obstructive sleep apnea syndrome.
PubMed database for English-language studies with no start date restrictions and with an end date of September 2014.
A comprehensive literature review was performed to identify all studies that discussed the physiologic, clinical and societal consequences of obstructive sleep apnea syndrome as well as the costs associated with these consequences. There were 106 studies that formed the basis of this analysis.
Undiagnosed and untreated obstructive sleep apnea syndrome can lead to abnormal physiology that can have serious implications including increased cardiovascular disease, stroke, metabolic disease, excessive daytime sleepiness, work-place errors, traffic accidents and death. These consequences result in significant economic burden. Both, the health and societal consequences and their costs can be decreased with identification and treatment of sleep apnea.
Treatment of obstructive sleep apnea syndrome, despite its consequences, is limited by lack of diagnosis, poor patient acceptance, lack of access to effective therapies, and lack of a variety of effective therapies. Newer modes of therapy that are effective, cost efficient and more accepted by patients need to be developed.

View all citing articles on Scopus

: Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

View full text

Chest

Clinical InvestigationsDeterminants Affecting Health-Care Utilization in Obstructive Sleep Apnea Syndrome Patients

Study objective

Design

Participants

Measurements and results

Conclusions

Section snippets

Materials and Methods

Data Analysis

Results

Discussion

Sleep Med Rev

Chest

Chest

Chest

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Am J Respir Crit Care Med

Sleep Heart Health Study Research Group. Relation of sleep-disordered breathing to cardiovascular disease risk factors: the Sleep Heart Health Study

Am J Epidemiol

Utilization of health care services in patients with severe obstructive sleep apnea

Sleep

Health care utilization in males with obstructive sleep apnea syndrome two years after diagnosis and treatment

Sleep

Health care utilization in the 10 years prior to diagnosis in obstructive sleep apnea syndrome patients

Sleep

Cardiovascular medication use in patients with undiagnosed obstructive sleep apnoea

Thorax

Reduced hospitalization with cardiovascular and pulmonary disease in obstructive sleep apnea patients on nasal CPAP treatment

Sleep

Clinical Investigations
Determinants Affecting Health-Care Utilization in Obstructive Sleep Apnea Syndrome Patients