Using a generic measure of quality of life in patients with obstructive sleep apnea

Spanish version of Jenkins Sleep Scale in physicians and nurses: psychometric properties from a Peruvian nationally representative sample

OBJECTIVE

To evaluate the psychometric properties of the Spanish version of Jenkins Sleep Scale with 4 items (JSS-4) of the Peruvian health system's (PHS) nurses and physicians.

METHODS

We carried out a psychometric study based on secondary analysis in a sample from a nationally representative survey that used acomplex sampling design. The participants were physicians and nurses aged 18-65 years, working in PHS private and public facilities, who have fulfilled all JSS-4 items. We performed a confirmatory factor analysis. Reliability was evaluated via two estimates - classic alpha (α) and categorical omega (ω) coefficients. Also, we tested the invariance across groups of variables. The convergent validity was evaluated based on the relation between JSS-4 and PHQ-2 using Pearson's correlation coefficient and effect size (Cohen's d). Also, we designed normative values based on percentiles.

RESULTS

We included 2100 physicians and 2826 nurses in the analysis. We observed that the unidimensional model has adequate goodness-of-fit indices and values of α and ω coefficients. No measurement invariance was found between the groups of professionals and age groups; however, invariance was achieved between sex, monthly income, work-related illness, and chronic illness groups. Regarding the relation with other variables, the JSS-4 has a small correlation with PHQ-2. Also, profession and age-specific normative values were proposed.

CONCLUSION

JSS-4 Spanish version has adequate psychometric properties in PHS nurses and physicians.

Association between obstructive sleep apnea and health-related quality of life in untreated adults: a systematic review

PURPOSE

The objective of this systematic review was to answer the question: "Is there association between obstructive sleep apnea (OSA) and health-related quality of life (HRQoL) in untreated adults?"

METHODS

We included observational studies that evaluated the health-related quality of life of patients with OSA vs control groups, through generic and disease-specific questionnaires. The searches were conducted in six databases: Embase, Lilacs, PsycINFO, PubMed, Scopus, and Web of Science. Additional search in the grey literature and hand search were performed, and also experts were consulted. Risk of bias was performed by using Joanna Briggs Institute Critical Appraisal Checklist for cross-sectional, cohort, and case-control studies. We analyzed the data using a narrative synthesis. The Grading of Recommendations Assessment, Development, and Evaluation evidence profile was used to verify the overall certainty of the assessed evidence.

RESULTS

Nineteen studies were included for qualitative analysis. Generic questionnaires showed worse HRQoL in the OSA group compared to the control group in at least one domain of the HRQoL questionnaires. The affected domains that showed statistical and clinically relevant differences were physical functioning, physical role, pain, general health, vitality, emotional role, and mental health. The certainty of evidence assessment was very low.

CONCLUSION

The available literature suggests that OSA in untreated adults is associated with worse HRQoL. However, this association seems to disappear when we consider only studies adjusted for related covariates.

REGISTRATION

CRD42018114746.

Reliability and Validity of the Functional Outcomes of Sleep Questionnaire - Spanish Short Version (FOSQ-10SV) in Peruvian Patients With Obstructive Sleep Apnea

STUDY OBJECTIVES

The aim of this study was to verify the reliability and validity of the Spanish short version of the Functional Outcomes of Sleep Questionnaire (FOSQ-10SV) in Peruvian patients with obstructive sleep apnea (OSA).

METHODS

Participants underwent physical examinations, completed the FOSQ-10SV, and polysomnography tests were carried out.

RESULTS

A total of 672 patients were analyzed, 75 females (11%), mean age 50.5 ± 13.8 years. A total of 563 patients (84%) had OSA. The mean FOSQ-10SV score was 15.96 ± 3.23. The FOSQ-10SV Cronbach alpha was 0.84 and two significant factors were extracted in the factor analysis-both factors explained a variance of 43% and 14%. A significant correlation was found between the FOSQ-10SV score and the apnea-hypopnea index. Patients with more severe disease have a lower FOSQ-10SV score (P = .003). Ninety-nine patients with OSA who started continuous positive airway pressure treatment were followed, and we observed an improvement in the FOSQ-10SV score from pretreatment to posttreatment (P < .001).

CONCLUSIONS

The FOSQ-10SV has internal consistency, construct validity, and the sensitivity to change in Peruvian patients with OSA who undergo treatment.

Validation of the Chinese Version of the Functional Outcomes of Sleep Questionnaire-10 in Pregnant Women

We evaluated the psychometric properties of a Mandarin Chinese version of the Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) in pregnant women. A total of 228 first-trimester pregnant women participated in the study, which was conducted in an outpatient obstetric clinic at a medical center in Taipei, Taiwan. The Chinese version of the FOSQ-10 demonstrated satisfactory internal consistency (Cronbach alpha = .85), adequate corrected item-total correlations (from .40 to .67), and acceptable test-retest reliability over 7 days (ICC = .73). Construct validity was supported by exploratory factor analysis showing a one-factor structure with item loadings between .49 and .77. Significant associations with the Medical Outcomes Study Short-Form Health Survey 12 version 2 and Pittsburgh Sleep Quality Index supported criterion-related and convergent validity. Significant differences in the Chinese version of the FOSQ-10 total scores were found between women with clinically significant daytime sleepiness and those without, suggesting adequate discriminant validity. Ceiling effects were observed for all items, but no floor or ceiling effects were found for total scores. Findings suggest that the Chinese version of the FOSQ-10 is a valid and reliable instrument to identify important effects of sleep-related impairment in Chinese women during pregnancy. Further testing is needed in more diverse pregnant women, such as women with complicated pregnancies and those with sleep disorders. © 2016 Wiley Periodicals, Inc.

Psychiatry Resident Quality of Life

OBJECTIVE

The objective of this study was to evaluate psychiatry resident physician quality of life.

METHODS

A voluntary, anonymous, 10-min survey was e-mailed to residents from all 14 Accreditation Council for Graduate Medical Education (ACGME)-accredited programs in Pennsylvania, New Jersey, and Delaware. Included in the survey was the Multi-Cultural Quality of Life Inventory (MQLI).

RESULTS

Response rate was 112 (34.1%). Internal consistency of the MQLI was high (Cronbach's alpha 0.92), and follow-up exploratory factor analysis extracted only one underlying factor (60.1% variance among all 10 items). Average total MQLI score was 80.6. No significant difference in MQLI total was found for therapy status, sex, or race. Post-graduate year (PGY) 4 residents scored higher on total MQLI score (86.7) (F = 2.80, p = 0.04) and ranked occupational functioning and community and services support subscales significantly higher (occupation F = 2.73, p = 0.048, community F = 3.11, p = 0.030). Total MQLI score for residents over the age of 40 (n = 3) was significantly lower (F = 3.45, p = 0.019).

CONCLUSION

Despite the stresses of residency training, residents from a variety of programs in one geographic area report an encouraging quality of life on the MQLI. Psychiatry resident quality of life is similar to that reported in other populations of mental health professionals.

Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure

BACKGROUND

Obstructive sleep apnoea-hypopnoea (OSAH) causes excessive daytime sleepiness (EDS), impairs quality of life (QoL) and increases cardiovascular disease and road traffic accident risks. Continuous positive airway pressure (CPAP) treatment is clinically effective but undermined by intolerance, and its cost-effectiveness is borderline in milder cases. Mandibular advancement devices (MADs) are another option, but evidence is lacking regarding their clinical effectiveness and cost-effectiveness in milder disease.

OBJECTIVES

(1) Conduct a randomised controlled trial (RCT) examining the clinical effectiveness and cost-effectiveness of MADs against no treatment in mild to moderate OSAH. (2) Update systematic reviews and an existing health economic decision model with data from the Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea-hypopnoea (TOMADO) and newly published results to better inform long-term clinical effectiveness and cost-effectiveness of MADs and CPAP in mild to moderate OSAH.

TOMADO

A crossover RCT comparing clinical effectiveness and cost-effectiveness of three MADs: self-moulded [SleepPro 1™ (SP1); Meditas Ltd, Winchester, UK]; semibespoke [SleepPro 2™ (SP2); Meditas Ltd, Winchester, UK]; and fully bespoke [bespoke MAD (bMAD); NHS Oral-Maxillofacial Laboratory, Addenbrooke's Hospital, Cambridge, UK] against no treatment, in 90 adults with mild to moderate OSAH. All devices improved primary outcome [apnoea-hypopnoea index (AHI)] compared with no treatment: relative risk 0.74 [95% confidence interval (CI) 0.62 to 0.89] for SP1; relative risk 0.67 (95% CI 0.59 to 0.76) for SP2; and relative risk 0.64 (95% CI 0.55 to 0.76) for bMAD (p < 0.001). Differences between MADs were not significant. Sleepiness [as measured by the Epworth Sleepiness Scale (ESS)] was scored 1.51 [95% CI 0.73 to 2.29 (SP1)] to 2.37 [95% CI 1.53 to 3.22 (bMAD)] lower than no treatment (p < 0.001), with SP2 and bMAD significantly better than SP1. All MADs improved disease-specific QoL. Compliance was lower for SP1, which was unpopular at trial exit. At 4 weeks, all devices were cost-effective at £20,000/quality-adjusted life-year (QALY), with SP2 the best value below £39,800/QALY.

META-ANALYSIS

A MEDLINE, EMBASE and Science Citation Index search updating two existing systematic reviews (one from November 2006 and the other from June 2008) to August 2013 identified 77 RCTs in adult OSAH patients comparing MAD with conservative management (CM), MADs with CPAP or CPAP with CM. MADs and CPAP significantly improved AHI [MAD -9.3/hour (p < 0.001); CPAP -25.4/hour (p < 0.001)]. Effect difference between CPAP and MADs was 7.0/hour (p < 0.001), favouring CPAP. No trials compared CPAP with MADs in mild OSAH. MAD and CPAP reduced the ESS score similarly [MAD 1.6 (p < 0.001); CPAP 1.6 (p < 0.001)].

LONG-TERM COST-EFFECTIVENESS

An existing model assessed lifetime cost-utility of MAD and CPAP in mild to moderate OSAH, using the revised meta-analysis to update input values. The TOMADO provided utility estimates, mapping ESS score to European Quality of Life-5 Dimensions three-level version for device cost-utility. Using SP2 as the standard device, MADs produced higher mean costs and mean QALYs than CM [incremental cost-effectiveness ratio (ICER) £6687/QALY]. From a willingness to pay (WTP) of £15,367/QALY, CPAP is cost-effective, although the likelihood of MADs (p = 0.48) and CPAP (p = 0.49) being cost-effective is very similar. Both were better than CM, but there was much uncertainty in the choice between CPAP and MAD (at a WTP £20,000/QALY, the probability of being the most cost-effective was 47% for MAD and 52% for CPAP). When SP2 lifespan increased to 18 months, the ICER for CPAP compared with MAD became £44,066. The ICER for SP1 compared with CM was £1552, and for bMAD compared with CM the ICER was £13,836. The ICER for CPAP compared with SP1 was £89,182, but CPAP produced lower mean costs and higher mean QALYs than bMAD. Differential compliance rates for CPAP reduces cost-effectiveness so MADs become less costly and more clinically effective with CPAP compliance 90% of SP2.

CONCLUSIONS

Mandibular advancement devices are clinically effective and cost-effective in mild to moderate OSAH. A semi-bespoke MAD is the appropriate first choice in most patients in the short term. Future work should explore whether or not adjustable MADs give additional clinical and cost benefits. Further data on longer-term cardiovascular risk and its risk factors would reduce uncertainty in the health economic model and improve precision of effectiveness estimates.

TRIAL REGISTRATION

This trial is registered as ISRCTN02309506.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 67. See the NIHR Journals Library website for further project information.

Sleepiness and nocturnal hypoxemia in Peruvian men with obstructive sleep apnea

PURPOSE

To evaluate the intensity of nocturnal hypoxemia associated with sleepiness in Peruvian men with a diagnosis of obstructive sleep apnea (OSA).

METHODS

We carried out a secondary data analysis based on a study which includes patients with OSA who were seen in a private hospital in Lima, Peru from 2006 to 2012. We included male adults who had polysomnographic recordings and who answered the Epworth sleepiness scale (ESE). The intensity of nocturnal hypoxemia (oxygen saturation ≤90%) was classified in four new categories: 0, <1, 1 to 10 and >10% total sleep time with nocturnal hypoxemia (NH). When the ESE score was higher than 10, we used the definitions presence or absence of sleepiness. We used Poisson regression models with robust variance to estimate crude and adjusted prevalence ratios (PR) for association between sleepiness and NH.

RESULTS

518 male patients with OSA were evaluated. Four hundred and fifty-two (87%) patients had NH and 262 (51%) had sleepiness. Of the 142 (27.4%) patients who had >10% total sleep time with NH, 98 (69.0%) showed sleepiness and had a greater probability of sleepiness prevalence, with a crude PR of 1.82 (95% CI 1.31-2.53). This association persisted in the multivariate models.

CONCLUSIONS

We found an association between NH and sleepiness. Only patients with the major intensity of NH (over 10% of the total sleep time) had a greater probability of sleepiness. This suggests that sleepiness probably occurs after a chronic process and after overwhelming compensatory mechanisms.