Cost-effectiveness Analysis of Nocturnal Oximetry as a Method of Screening for Sleep Apnea-Hypopnea Syndrome

doi:10.1378/chest.113.1.97

Chest

Volume 113, Issue 1, January 1998, Pages 97-103

https://doi.org/10.1378/chest.113.1.97 Get rights and content

Study objective

Determine the utility of nocturnal oximetry as a screening tool for sleep apnea-hypopnea syndrome (SAHS) compared with polysomnography (PSG).

Design

Cost-effectiveness analysis based on retrospective review of overnight sleep studies.

Setting

United States Air Force tertiary teaching hospital.

Patients

One hundred consecutive patients evaluated for SAHS by overnight sleep study.

Intervention

Participants underwent PSG and oximetry on the same night. Patients with obstructive sleep apnea had a continuous positive airway pressure trial.

Measurements

Oximetry was abnormal when ≥10 events per hour occurred. Two criteria were evaluated. A “deep” pattern of >4% change in oxyhemoglobin saturation to ≤90%, and a “fluctuating” pattern of repetitive short-duration fluctuations in saturation. The diagnostic accuracy of both methods was compared with PSG. Cost-effectiveness of screening oximetry was compared with PSG alone and use of split-night studies.

Results

The fluctuating pattern had a greater sensitivity and negative predictive value, while the deep pattern had a greater specificity and positive predictive value. Oximetry screening using the fluctuating pattern was not as sensitive as PSG for detecting patients with mild disease; 17 of 28 patients (61%) with normal oximetry results had treatable conditions detected by PSG. Cost analysis showed that screening oximetry would save $4,290/100 patients but with considerable loss of diagnostic accuracy.

Conclusion

Screening oximetry is not cost-effective because of poor diagnostic accuracy despite increased sensitivity using the fluctuating pattern. Greater savings, without loss of diagnostic accuracy, may be achieved through increased utilization of split-night PSGs.

Section snippets

Patients

We retrospectively reviewed the sleep studies of 100 consecutive patients referred for evaluation for possible sleep-disordered breathing (SDB) who underwent PSG in our sleep center. We studied 93 men and seven women, ages 19 to 72 years (mean, 39.3 years), with a mean body mass index (BMI) of 28.2±4.4 kg/m² (mean±SD). Our referral base consists primarily of active duty military personnel, but also includes family members and retired military members. Patients were referred to the sleep center

Results

A diagnosis of SAHS was made by PSG in 53 of the 100 patients studied, with a mean AHI of 32.4±22.1. The ability of oximetry to detect SAHS varied according to the diagnostic criteria used, and is shown in Table 1. A comparison of the diagnostic accuracy of the two oximetry criteria for detecting an AHI>10/h, and the effect of weight on diagnostic accuracy, is summarized in Table 2. Use of the fluctuating pattern for oximetry interpretation resulted in a higher sensitivity and negative

Discussion

This study compared two different diagnostic criteria for interpreting nocturnal pulse oximetry with standard PSG evaluation for the detection of SAHS. In addition, we evaluated the cost-effectiveness of pulse oximetry as a screening tool for the detection of SAHS. We found that the use of screening pulse oximetry resulted in only a small cost savings with a significant reduction in diagnostic accuracy.

Our study confirms the findings of Series et al⁴ that using a less rigid criterion for

Acknowledgments

The authors thank William Beninati, MD, and Isabel Diaz for assistance in data collection, and James H. Henderson, MD, and Dorothy Cunningham, MD, for their editorial assistance.

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Portable evaluation of obstructive sleep apnea in adults: A systematic review
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Obstructive sleep apnea (OSA) is a significant healthcare burden affecting approximately one billion people worldwide. The prevalence of OSA is rising with the ongoing obesity epidemic, a key risk factor for its development. While in-laboratory polysomnography (PSG) is the gold standard for diagnosing OSA, it has significant drawbacks that prevent widespread use. Portable devices with different levels of monitoring are available to allow remote assessment for OSA. To better inform clinical practice and research, this comprehensive systematic review evaluated diagnostic performances, study cost and patients’ experience of different levels of portable sleep studies (type 2, 3, and 4), as well as wearable devices and non-contact systems, in adults. Despite varying study designs and devices used, portable diagnostic tests are found to be sufficient for initial screening of patients at risk of OSA. Future studies are needed to evaluate cost effectiveness with the incorporation of portable diagnostic tests into the diagnostic pathway for OSA, as well as their application in patients with chronic respiratory diseases and other comorbidities that may affect test performance.
Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea in the adult population: a systematic review
2022, Sleep Medicine Reviews
Citation Excerpt :
Following abstract screening, 85 full-text articles were selected for review. A total of 31 assessing L3 vs PSG [25–55] and four studies examining L4 vs PSG [56–59] were included in the final analysis. An overview of the characteristics of the included studies is presented in Tables 1–3.
Evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home polysomnography (PSG) in diagnosing obstructive sleep apnoea (OSA) is unclear. Eligible studies were systematically sought across the following databases: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane, Emcare, Web of Science and ProQuest. Title and abstracts were screened before full-text review. Only full and partial economic evaluations reporting at least one economic outcome were included. A standardised template was used for critical appraisal and data extraction. Relevant findings were summarised using a qualitative approach adhering to economic reporting standards. Literature searches identified 999 non-duplicate abstracts, where 85 studies were retrieved for full-text review. The number of studies that met eligibility criteria and were included in the final analyses was 35, of which 31 investigated Level 3 and four assessed Level 4 tests. Based on the dominance ranking framework, both Level 3 and Level 4 tests were cost-effective compared to PSG. Although study designs and methodologies differ broadly, the findings indicated that using limited channel diagnostic sleep tests for OSA is associated with lower costs and non-inferior health outcomes relative to PSG. Limited channel tests also resulted in shorter waiting times and improved access to diagnostic services for patients with OSA.
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Ensemble-learning regression to estimate sleep apnea severity using at-home oximetry in adults
2021, Applied Soft Computing
Overnight pulse oximetry has shown usefulness to simplify obstructive sleep apnea (OSA) diagnosis when combined with machine-learning approaches. However, the development and evaluation of a single model with ability to reach high diagnostic performance in both community-based non-referral and clinical referral cohorts are still pending. Since ensemble-learning algorithms are known for their generalization ability, we propose a least-squares boosting (LSBoost) model aimed at estimating the apnea–hypopneaindex (AHI), as the correlate clinical measure of disease severity. A thorough characterization of 8,762 nocturnal blood-oxygen saturation signals (SpO ₂) obtained at home was conducted to extract the oximetric information subsequently used in the training, validation, and test stages. The estimated AHI derived from our model achieved high diagnostic ability in both referral and non-referral cohorts reaching intra-class correlation coefficients within 0.889–0.924, and Cohen’s $κ$ within 0.478–0.663 when considering the four OSA severity categories. These resulted in accuracies ranging 87.2%–96.6%, 81.1%–87.6%, and 91.6%–94.6% when assessing the three typical AHI severity thresholds, 5 events/hour (e/h), 15 e/h, and 30 e/h, respectively. Our model also revealed the importance of the SpO ₂ predictors, thereby minimizing the ‘black box’ perception traditionally attributed to the machine-learning approaches. Furthermore, a decision curve analysis emphasized the clinical usefulness of our proposal. Therefore, we conclude that the LSBoost-based model can foster development of clinically applicable and cost saving protocols for detection of patients attending primary care services, or to avoid full polysomnography in specialized sleep facilities, thus demonstrating the diagnostic usefulness of SpO ₂ signals obtained at home.
Role of Screening in Sleep Disordered Breathing (SDB)
2021, Encyclopedia of Respiratory Medicine, Second Edition
Sleep-disordered breathing is a common disorder associated with detrimental effects on quality of life and some cardiovascular and metabolic outcomes. Obstructive sleep apnea and hypoventilation during sleep can effectively be treated with nocturnal positive airway pressure therapy to improve symptoms and patient outcomes, whereas there a less defined treatment targets for central sleep apnea with Cheyne Stokes Respiration. Screening for sleep-disordered breathing in the general population is not recommended, however, it is common practice to screen specific at risk populations, such as bariatric patients. Screening may include disease specific questionnaires and ambulatory sleep studies, as well as confirmative in-laboratory polysomnography. The level of evidence for screening is low, but recommendations are available for pre-operative surgical and bariatric patients, patients with certain cardio- or cerebrovascular comorbidities as well as for patients with some neuromuscular diseases.
The Respiratory Fluctuation Index: A global metric of nasal airflow or thoracoabdominal wall movement time series to diagnose obstructive sleep apnea
2019, Biomedical Signal Processing and Control
Citation Excerpt :
However, in place of event detection and counting, it is possible to diagnose OSA syndrome directly by feeding statistical moments, spectral, and nonlinear features of the nasal airflow into a predictive machine learning model (e.g. logistic regression, linear discriminant analysis, or regression tree) [15,16]. Alternatively, quantification of regularity and variability [17,18] or fluctuations and drops [19] in overnight SpO2 provides a simple way of diagnosing OSA syndrome. Finally, one research group has been able to measure AHI and OSA severity through linear regression modeling based on nonlinear indexes derived from nasal airflow and thoracic movement, as well as the percentage of time with SpO2<90% [20].
Polysomnography (PSG) recordings provide comprehensive physiological data to diagnose obstructive sleep apnea (OSA), a common breathing disorder. OSA severity is usually diagnosed using the apnea hypopnea index (AHI), the frequency of episodes of breathing cessation or reduction. This study proposes a new global measure, the Respiratory Fluctuation Index (RFI), which accurately characterizes the distribution of respiratory drops in a PSG time series without the need for hand-counting episodes. We test two approaches: linear regression models to estimate the hand-scored AHI from one or more RFIs, and threshold detection models to diagnose OSA severity based on a single RFI. Based on PSG data recorded from 60 adults, we find very good agreement between both types of models and the ground truth. Regression models based on the RFI derived from nasal airflow had the best agreement with manually scored AHIs, visualized with Bland-Altman plots. In addition, threshold detection models based on the RFI of nasal airflow achieved the highest sensitivities (78.97%, 87.50% and 92.31%) and specificities (78.26%, 86.46% and 91.82%) in detecting OSA with AHI ≥ 5, AHI ≥ 15 and AHI ≥ 30, respectively. The strong performance of the models demonstrates the efficacy of the proposed RFI metric for OSA assessment.
Diagnostic accuracy of overnight oximetry for the diagnosis of sleep-disordered breathing in atrial fibrillation patients
2018, International Journal of Cardiology
Sleep-disordered breathing (SDB) is highly prevalent in patients with atrial fibrillation (AF) and its treatment can improve rhythm control. Polysomnography (PSG) is the gold standard for the diagnosis of SDB but its high cost and limited availability constrain its role as a standard SDB screening tool. We sought to assess the diagnostic utility of overnight oximetry in predicting SDB in AF patients.
We analyzed prospectively collected data on 439 patients with documented AF (62% paroxysmal AF) who underwent PSG. Overnight oximetry was used to determine the oxygen desaturation index (ODI, number of desaturation/h) by a novel automated computer algorithm. ODI was validated against PSG derived apnea-hypopnea index (AHI).
The sample consisted of 69% men with a mean age of 59.9 ± 11.3 years and body mass index of 30 ± 5 kg/m². The median AHI was 9.5 [3.6–21.0]/h and the prevalence of moderate (AHI 15–29/h) and severe SDB (AHI ≥ 30/h) was 17.3% and 16.6% respectively. The ODI was able to detect moderate-to-severe SDB (AHI ≥ 15/h; area under the receiver-operating-characteristic curve (AUC): 0.951, 95% CI: 0.929–0.972) and severe SDB (AHI ≥ 30/h; 0.932, 95% CI: 0.895–0.968) with high diagnostic accuracy. An ODI cut-off of 4.1/h resulted in a 91% sensitivity and 83% specificity in discriminating between patients with and without AHI ≥ 15/h. An ODI of 7.6/h yielded a sensitivity and specificity for AHI ≥ 30/h of 89% and 83%, respectively.
ODI derived from a simple and low-cost overnight oximetry can be used as an accessible and reliable screening tool, particularly to rule out SDB.

View all citing articles on Scopus

: The views expressed in this article are those of the authors and do not reflect official policy of the Department of Defense or other Departments of the US Government. Manuscript received January 7, 1997; revision accepted July 1.

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Chest

Clinical InvestigationsCost-effectiveness Analysis of Nocturnal Oximetry as a Method of Screening for Sleep Apnea-Hypopnea Syndrome

Study objective

Design

Setting

Patients

Intervention

Measurements

Results

Conclusion

Section snippets

Patients

Results

Discussion

Acknowledgments

Chest

Chest

Lancet

Chest

Chest

The occurrence of sleep disordered breathing among middle-aged adults

N Engl J Med

Sleep apnea and periodic movements in an aging sample

J Gerontol

Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome

Ann Intern Med

A manual of standardized terminology, techniques, and scoring system for sleep stages of human subjects

EEG arousals: scoring rules and examples

Sleep

Adequacy of prescribing positive airway pressure therapy by mask for sleep apnea on the basis of a partial-night trial

Am Rev Respir Dis

Single night studies in obstructive sleep apnea

Sleep

Clinical Investigations
Cost-effectiveness Analysis of Nocturnal Oximetry as a Method of Screening for Sleep Apnea-Hypopnea Syndrome