On Jan. 24, the U.S. Preventive Services Task Force (USPSTF) published a final recommendation statement(www.uspreventiveservicestaskforce.org) and evidence report(www.uspreventiveservicestaskforce.org) on screening asymptomatic adults for obstructive sleep apnea (OSA) in primary care settings. The task force concluded there was insufficient evidence to assess the balance of benefits and harms of screening for OSA in asymptomatic adults -- an "I" statement(www.uspreventiveservicestaskforce.org).
"This is the first time that the task force has reviewed the evidence on screening for OSA," said USPSTF member Alex Krist, M.D., M.P.H., in a news bulletin(www.uspreventiveservicestaskforce.org)."OSA represents a major health concern; it affects 10 to 15 percent of the U.S. population and is associated with heart disease, diabetes, reduced quality of life and increased risk of death.
"Primary care doctors want to know if screening is beneficial for patients. Unfortunately, right now, there is not enough evidence to know."
The AAFP also released its own final recommendation statement, which mirrors that of the task force.
- On Jan. 24, the U.S. Preventive Services Task Force published a final recommendation statement and evidence report on screening asymptomatic adults for obstructive sleep apnea (OSA) in primary care settings.
- The task force concluded there was insufficient evidence to assess the balance of benefits and harms of screening for OSA in asymptomatic adults -- an "I" statement.
- The AAFP released its own final recommendation statement, which mirrors that of the task force.
The USPSTF's recommendation doesn't apply to adults who have symptoms of or concerns about OSA; people who have been referred for evaluation or treatment of suspected OSA; or those who have an acute condition that could trigger the onset of OSA, such as stroke. It also doesn't apply to children, adolescents or pregnant women.
Among those at increased risk for OSA are men and postmenopausal women, as well as patients who are overweight or obese; this risk increases between the ages of 40 and 70.
"The task force is calling for more research among primary care patients on whether screening adults without known symptoms leads to improvements in health outcomes," said Jessica Herzstein, M.D., M.P.H., a co-author of the recommendation, in the bulletin. "Clinicians should use their clinical judgment when deciding whether or not to screen their patients for OSA."
Scope of Review
The USPSTF commissioned a systematic review(www.uspreventiveservicestaskforce.org) to evaluate the evidence on the accuracy, benefits and potential harms of screening for OSA in asymptomatic adults seen in primary care, including those with unrecognized symptoms.
The review also evaluated the evidence regarding the benefits and harms of OSA treatment on intermediate outcomes (e.g., change in apnea-hypopnea index, sleepiness and blood pressure) and health outcomes (e.g., mortality, quality of life, cardiovascular and cerebrovascular events, and cognitive impairment) in adults 18 and older.
Researchers found that OSA is more common in men than women and that it increases with age through the sixth and seventh decades and then plateaus. Also, the prevalence difference between men and women narrows after menopause.
In addition, observational studies found the prevalence of OSA progressively increases as body mass index increases in both men and women. Specifically, using data from the Wisconsin Sleep Cohort Study, one study found a 10 percent increase in weight was associated with a six-fold increase in risk of incident OSA during four years of follow-up.
Response to Public Comment
A draft version of this recommendation statement was posted for public comment on the USPSTF website from June 14 to July 11, 2016.
Some commenters said they were concerned that the definition of "asymptomatic" was unclear, that they didn't agree that an asymptomatic population is the same as patients with unrecognized symptoms, and that many symptomatic patients don't report symptoms to their physician.
The recommendation statement explained the USPSTF had discussed its approach to defining "asymptomatic" when it created the research plan. This plan established that patients without symptoms or with unrecognized symptoms were the population of interest when it came to identifying potentially unrecognized OSA.
In response to other commenters, the task force described common symptoms of OSA (e.g., excessive daytime sleepiness, snoring, insomnia, fatigue, and fatigue-induced problems such as issues with memory and concentration) and defined what is meant by "persons with unrecognized symptoms."
Additionally, some commenters suggested that a number of key studies that linked OSA treatment to improved health outcomes were omitted.
"The USPSTF examined these studies and found they were either already included in the review, did not meet eligibility criteria for inclusion in the review or were otherwise outside the scope of the review," the recommendation statement explained.
A few commenters said patients who work in safety-sensitive transportation occupations (e.g., truck drivers or rail operators) have unique testing needs.
"Clinicians seeking information on testing persons who work in these occupations can consult the appropriate agency's guidelines," said the statement. "The U.S. Department of Transportation recently sought public input related to the evaluation of moderate to severe OSA among persons with these occupations."
Family Physician Expert's Take
When the USPSTF released its draft recommendation statement in June 2016, AAFP News spoke with Mandeep Ghuman, M.D., attending physician at the Dignity Health Family Medicine Residency Program at Northridge Hospital in Northridge, Calif., who wrote about the clinical indicators of OSA in a May 2011 article in American Family Physician.
"We still don't have great screening tools in primary care for symptomatic patients to make a diagnosis of OSA, so the benefit of screening asymptomatic patients is probably going to be minimal at best," Ghuman said.
Furthermore, he added, "Since there is a lack of evidence on improvement in long-term health outcomes with treating OSA (both in symptomatic and asymptomatic patients) and no adequate screening tool for use in a primary care setting for asymptomatic patients, it would be difficult for me to institute the screening of asymptomatic patients within my primary care clinic setting," he said.
Related AAFP News Coverage
AHRQ Clinician, Patient Guides on Sleep Apnea Review Diagnosis, Management
Evidence Points to CPAP Devices as Most Effective Treatment