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Dr. Littner is Faculty, Pulmonary, Critical Care, and Sleep Medicine, VA Greater Los Angeles Healthcare System, and Professor of Medicine, UCLA School of Medicine. Dr. Alessi is Faculty, Geriatric Medicine, VA Greater Los Angeles Healthcare System, and Associate Professor of Medicine, UCLA School of Medicine.
Correspondence to: Michael Littner, MD, FCCP, Chief, Pulmonary and Critical Care Medicine, Sepulveda VAMC, 16111 Plummer St, Sepulveda, CA 91343-2036
It has long been suspected that there is a gross underrecognition of sleep disorders by health-care providers. Attempts to identify and remedy this date back, in part, to the National Commission on Sleep Disorders Research (NCSDR), which met over 18 months from 1990 to 1991, and released volume one of its report in January 1993, and volume two in 1995.1 In volume one, the commission concluded that "millions of Americans are affected by sleep disorders" (page 17) and that "18 million people in the United States" (page 33) were estimated to have obstructive sleep apnea with an apnea/hypopnea index > 5/h of sleep. The commission also concluded that "evidence ... suggests that the vast majority of Americans with sleep disorders remain undiagnosed and untreated" (page 17).
The current article in CHEST (see page 1741) details information gathered through the National Ambulatory Medical Care Survey (NAMCS).2 The NAMCS is an ongoing, representative, annual survey of a stratified random sample of office-based physician practices in the United States. Conducted by the National Center for Health Statistics (NCHS), the NAMCS collects data recorded by the physician (or office staff) after all ambulatory care visits (or a portion of visits in larger practices) during a randomly assigned week. The unit of analysis in the database is the patient visit, not the patient, so the data may not adequately measure prevalence, but may be a good estimate of visit patterns over time. National estimates are produced by assigning a weight to each visit, and the NCHS provides relative SEs of the estimates as a measure of reliability. Outpatient care provided in hospital settings, by telephone, by nonphysician providers, and by federal physicians is excluded. NAMCS data used in the current article included physician diagnoses recorded for that visit, simple patient characteristics, and physician specialty. Diagnoses listed for the patient visits were not necessarily new conditions.
The results of the current article provide ample support for the findings of the commission on sleep apnea. Based on the NAMCS, approximately 110,000 patient visits had sleep apnea listed as a diagnosis in 1990. Since this number has risen to > 1.3 million in 1998, this suggests that in 1990 the vast majority of cases were undiagnosed and untreated. Assuming that the prevalence of sleep apnea has remained relatively stable, as of 1998 this situation was vastly improved; if the projected improvement in recognition has continued, underdiagnosis of sleep apnea, at least, is being addressed.
We can only speculate as to why greater recognition of sleep apnea has occurred. The authors suggest that the growth in sleep-disorders centers and publication of scientific articles are at least partly responsible based on the correlation of these factors with the increase in sleep apnea listed as a diagnosis. However, we propose that there are other possible contributions. A visual inspection of Figures 1, 2 indicates that the majority of the increase in patient visits came in two steps, namely from 1992 to 1993 and 1994 to 1996. These dates coincide with the release of the NCSDR reports (volumes one and two) and information at the National Institutes of Health of the National Center on Sleep Disorders Research in the National Heart, Lung, and Blood Institute in 1993.3 Since 1990, there has been an increase in organizations, both professional and lay, that have addressed the interests of patients with sleep apnea. For example, the National Sleep Foundation4 and the American Sleep Apnea Association5 have publicized the extent of the health-care issue, and have directly helped patients with sleep apnea, as well as other sleep disorders. In addition, the American Academy of Sleep Medicine (formerly known as the American Sleep Disorders Association) grew in membership from approximately 2,250 in 1993 to approximately 3,200 in 1998, and approximately 4,100 by 2000. In 1993, there were 648 diplomates of the American Board of Sleep Medicine, by 1998 there were 1,186 diplomates, and by 2001 there were 1,721 diplomates (personal communication). This activity and growth including the increase in sleep-disorders centers is likely to have raised awareness and increased access to care for patients with sleep apnea and sleep disorders in general.
Based on the data presented in the current article (Fig 1, 2), there appears to be a plateau in the number of patient visits with sleep apnea listed as a diagnosis. This is despite evidence6 that the prevalence of sleep apnea is much higher than the 1.3 million patient visits reported in 1998. Only further surveillance of health-care provider recognition of sleep apnea will determine whether identification of this problem has reached a plateau, or whether awareness will continue to rise. The future of sleep medicine will depend, in part, on accurate recognition and assessment of needs in order to improve care, not only for sleep apnea, but also for other sleep disorders that require specialized diagnosis and management. The challenges that face both professionals and patients are to pursue funding for public and professional education, training of health-care professionals, delivery of health care, and research. There should be a matching of the availability (a level most likely greater than present) of diagnostic and treatment modalities with documented needs, and development of diagnostic techniques that are cost-effective. An often overlooked but clearly necessary aspect of the care of sleep apnea patients is documentation that diagnosis and treatment produces desirable outcomes. There are currently several well-designed randomized controlled studies documenting that treatment with continuous positive airway pressure improves patient outcomes, such as improvement in quality of life, over a relatively short period of time.7 However, there are few studies that prospectively address outcomes such as reduction in health-care utilization, improvement in quality of life, reduction in sleepiness, reduction in mortality, and reduction in untoward events such as strokes, myocardial infarctions, and motor vehicle accidents in an actual clinical practice and over a prolonged period of time. It is these outcomes that will continue to convince health-care providers of the importance to recognize and treat the important problem of obstructive sleep apnea and related syndromes.
References
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