Recognition and Treatment of Sleep-Disordered Breathing in Obese Hospitalized Patients May Improve Survival. The HoSMed Database

Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a highly prevalent, yet underdiagnosed, condition. Due to its adverse impact on risk for cardiopulmonary disorders, there is interest in proactive screening of OSA in hospitalized patients. We studied the long-term outcome of such screened patients who were initiated on positive airway pressure therapy.

METHODS

Hospitalized patients who screened positive for OSA and were confirmed with postdischarge polysomnography were dichotomized by positive airway pressure therapy adherence and followed for a period of 12 months to evaluate for the composite end point of hospital readmissions and emergency department visits for cardiopulmonary reasons. Cost analysis between the 2 groups was also conducted.

RESULTS

A total of 2,042 hospitalized patients were assessed for OSA as part of a hospital sleep medicine program from August 2019-June 2023. Of these, 293 patients were diagnosed with OSA and prescribed positive airway pressure therapy. Of these 293 patients, 108 were adherent to therapy and 185 were nonadherent. The overall characteristics of the groups included a mean (standard deviation) age of 58 years (12.82), mean body mass index (kg/m2) of 39.72 (10.71), 57% male sex, and apnea-hypopnea index of 25.49 (26). Of the patients, 78%, 41%, and 43% had hypertension, congestive heart failure, and diabetes mellitus, respectively. The composite end point of hospital readmissions and emergency department visits for cardiovascular and pulmonary reasons was significantly higher in the nonadherent group than in the adherent group (hazard ratio, 1.24; 95% confidence interval, 1-1.54) (P = .03). The cost of care for both hospital billing as well as professional billing was higher for the nonadherent group ($1,455.60 vs $1,723.50, P = .004 in hospital billing cost and $130.90 vs $144.70, P < .001 in professional billing). Length of stay was higher for nonadherent patients (2.7 ± 5.1 days vs 2.3 ± 5.9 days).

CONCLUSIONS

Hospitalized patients diagnosed with OSA and adherent to therapy have reduced readmissions and emergency department visits for cardiopulmonary reasons 12 months after discharge. Adherent patients have reduced cost of health care and length of stay during hospitalizations.

CITATION

Sharma S, Stansbury R, Srinivasan P, et al. Early recognition and treatment of OSA in hospitalized patients and its impact on health care utilization in rural population: a real-world study. J Clin Sleep Med. 2024;20(8):1313-1319.

Pooled prevalences of obstructive sleep apnea and heart failure: a systematic review and meta-analysis

Obstructive sleep apnea (OSA) is a disease with intermittent hypoxemia during sleep. It has been shown that OSA is related to several cardiovascular diseases including heart failure. Both OSA and heart failure have a close association bidirectionally. This study aimed to estimate the pooled prevalence of OSA in patients with heart failure as well as pooled prevalence of heart failure in patients with OSA. This was a systematic review with a meta-analysis. The inclusion criteria were observational or epidemiological studies conducted in adult patients with heart failure to evaluate the prevalence of OSA and patients with OSA to evaluate the prevalence of heart failure. The outcomes of this study were prevalence of OSA in patients with heart failure and prevalence of heart failure in patients with OSA. Four databases were used for systematic searching including PubMed, Science Direct, Scopus, and CINAHL Plus. Manual searches for related studies were also conducted. Proportion meta-analyses using a random-effects model were conducted to identify pooled proportion (prevalence) of heart failure in patients with OSA and vice versa. Among 3,941 articles from the four databases met the study criteria. Thirty-three studies showed the prevalence of OSA in patients with heart failure, while thirteen studies presented the prevalence of heart failure in patients with OSA. The prevalence of OSA in patients with heart failure was 38.4% (95% CI 31.9 to 45.2; I2 of 96.1%). Using a diagnostic criterion of OSA of more than 10 events/hr had the highest prevalence of OSA in patients with heart failure at 53.4% (95% CI 42.0 to 64.5). The highest prevalence of OSA in patients with heart failure was 60.1% (95% CI 51.4 to 68.3) in a report from India. The pooled prevalence of heart failure in patients with OSA was 12.8% (95% CI 8.1 to 19.5; I2 of 94.6%). The prevalence in Romania was highest at 22.6% (95% CI 20.4 to 24.9). The pooled prevalence of OSA in patients with heart failure was higher than the pooled prevalence of heart failure in patients with OSA. The pooled prevalence rates of these associations varied among the diagnostic criteria of OSA and countries.

The Role of Obstructive Sleep Apnea in Hypercapnic Respiratory Failure Identified in Critical Care, Inpatient, and Outpatient Settings

An emerging body of literature describes the prevalence and consequences of hypercapnic respiratory failure. While device qualifications, documentation practices, and previously performed clinical studies often encourage conceptualizing patients as having a single "cause" of hypercapnia, many patients encountered in practice have several contributing conditions. Physiologic and epidemiologic data suggest that sleep-disordered breathing-particularly obstructive sleep apnea (OSA)-often contributes to the development of hypercapnia. In this review, the authors summarize the frequency of contributing conditions to hypercapnic respiratory failure among patients identified in critical care, emergency, and inpatient settings with an aim toward understanding the contribution of OSA to the development of hypercapnia.

Sleep-disordered Breathing and Inpatient Outcomes in Nonsurgical Patients: Analysis of the Nationwide Inpatient Cohort

Rationale: Sleep-disordered breathing (SDB) is associated with increased complications and length of stay (LOS) after surgery. SDB-related adverse consequences for nonsurgical admissions are not well defined. Objectives: Evaluate associations between SDB and subtypes and LOS, cost, and mortality in nonsurgical patients. Methods: This retrospective cohort analysis used adult nonsurgical admissions from the 2017 National Inpatient Sample of the Healthcare Costs and Utilization Project. SDB associations with LOS (primary outcome), costs, and mortality were evaluated via logistic regression. Covariates included age, sex, Elixhauser Comorbidity Index, socioeconomic status, hospital type, and insurance type. Results: The cohort included 6,046,544 hospitalizations. Compared with those without SDB, patients with SDB were older (63.6 ± 13.5 vs. 57.4 ± 20.7 yr), higher proportion male (55.8% vs. 40.9%), and more likely to be White (75.7% vs. 66.5%). SDB was associated with increased odds of increased LOS and hospitalization costs (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.16-1.17 and OR, 1.67; 95% CI, 1.66-1.67 in adjusted analyses, respectively) but lower mortality (OR, 0.79; 95% CI, 0.77-0.81). The results for obstructive sleep apnea (OSA) echoed those for SDB. Obesity hypoventilation syndrome had substantially increased LOS (OR, 3.05; 95% CI, 2.98-3.13), mortality (1.76; 95% CI, 1.66-1.86), and costs (OR, 2.67; 95% CI, 2.60-2.73) even after adjustment. Conclusions: Obesity hypoventilation syndrome is associated with higher LOS, mortality, and costs during hospitalization, whereas OSA, despite higher LOS and costs, is associated with decreased mortality. Investigation is warranted on whether paradoxically higher costs but lower mortality in OSA may be indicative of less vigilance in hospitalized patients with undiagnosed SDB.

How to interpret a negative high-resolution pulse oximetry in hospitalized patients screened for obstructive sleep apnea: an exploratory analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is a highly prevalent disorder that often is unrecognized. Recently, a novel protocol for screening hospitalized patients for OSA resulted in early initiation of positive airway pressure (PAP) therapy and early post-discharge follow-up. The protocol utilizes a combination of high-resolution pulse oximetry (HRPO) and home sleep apnea tests (HSATs); the former has been well-validated in previous studies against HSAT and polysomnography. While a definitive treatment plan can be generated for patients with a positive HRPO for OSA, it is less clear how best to manage patients with a negative HRPO.

MATERIALS AND METHODS

A retrospective analysis of a registry of patients screened for OSA was conducted. Consecutive patients with HRPO-derived ODI (oxygen desaturation index) < 5/h who underwent same-night HRPO and HSAT were identified. The demographic and clinical characteristics of patients with ODI < 5/h and AHI (apnea hypopnea index) < 5/h were compared with patients with ODI < 5/h and AHI ≥ 5/h.

RESULTS

The analysis revealed 190 patients with ODI < 5/h. Only 23 (12%) of these patients had AHI ≥ 5/h. When compared with patients who had ODI < 5/h and AHI < 5/h, there was no difference in most testing and patient characteristics. However, antiplatelet use and total time in minutes with saturation < 88% greater than 100 min were associated with a higher likelihood of discordant ODI and AHI.

CONCLUSION

HRPO-derived ODI has a low rate of false negativity. Clinicians should be aware of the possibility of a false negative ODI for patients with antiplatelet use and time with saturation < 88% greater than 100 min and antiplatelet therapy.

Sleep-Disordered Breathing in Hospitalized Patients: A Game Changer?

Sleep disorders, including sleep apnea, have become a significant health issue in the United States. It is estimated that 22 million Americans have sleep apnea, with 80% of cases of moderate and severe OSA going undiagnosed. This number continues to increase with the obesity epidemic. Sleep-disordered breathing (SDB) is associated with multiple cardiopulmonary diseases and has been shown to affect disease outcomes adversely. Hospitalized patients have a disproportionately high prevalence of cardiovascular and respiratory diseases. Screening for SDB in hospitalized patients provides an opportunity to identify the disease in individuals whose disease otherwise may go unrecognized. Data suggest that identification of SDB in hospitalized individuals may have a positive impact on a patient's course after hospitalization. Unfortunately, sleep medicine currently remains an ambulatory practice. Hospital sleep medicine addresses this separation. Herein, we discuss our experience and the future potential of hospital sleep medicine programs.

Underrecognition of sleep-disordered breathing and other common health conditions in the West Virginia Medicaid population: a driver of poor health outcomes

STUDY OBJECTIVES

To assess the prevalence rates of sleep-disordered breathing (SDB) in a high-risk and rural-dwelling Medicaid population with significant comorbidities.

METHODS

Our study analyzed anonymized administrative claims data from West Virginia (WV) Medicaid. Claims data from 2019 were aggregated at the individual level to assess the overall prevalence of SDB and related conditions among adult Medicaid beneficiaries. The prevalence rate of SDB, specifically among individuals who had comorbid congestive heart failure, chronic obstructive pulmonary disease, or obesity, was determined. Finally, we compared our prevalence estimates from this Medicaid database with prevalence rates from national datasets including the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System.

RESULTS

Of the total 413,757 Medicaid enrollees ≥ 18 years old analyzed, 36,433 had a diagnosis code of SDB for an overall prevalence of 8.8%. Based on national datasets and our study cohort characteristics, we conservatively estimated the prevalence of SDB in this WV Medicaid population to be 25%. For our secondary analyses, we determined the prevalence of SDB in specific disease cohorts of congestive heart failure (SDB prevalence 45%), chronic obstructive pulmonary disease (SDB prevalence 27%), and obesity (SDB prevalence 14%).

CONCLUSIONS

Our analysis of WV Medicaid claims data indicates that SDB and other important medical conditions are underrecognized in this vulnerable, high-risk, primarily rural population. Interestingly, SDB was identified at high rates in the disease cohorts of interest. Our team believes SDB represents an ideal target/model for addressing the growing health disparities in the United States, which is a major concern for all stakeholders in health care.

CITATION

Stansbury R, Strollo P, Pauly N, et al. Underrecognition of sleep-disordered breathing and other common health conditions in the West Virginia Medicaid population: a driver of poor health outcomes. J Clin Sleep Med. 2022;18(3):817-824.

Oximetry Indices in the Management of Sleep Apnea: From Overnight Minimum Saturation to the Novel Hypoxemia Measures

Obstructive sleep apnea (OSA) is a multidimensional disease often underdiagnosed due to the complexity and unavailability of its standard diagnostic method: the polysomnography. Among the alternative abbreviated tests searching for a compromise between simplicity and accurateness, oximetry is probably the most popular. The blood oxygen saturation (SpO₂) signal is characterized by a near-constant profile in healthy subjects breathing normally, while marked drops (desaturations) are linked to respiratory events. Parameterization of the desaturations has led to a great number of indices of severity assessment commonly used to assist in OSA diagnosis. In this chapter, the main methodologies used to characterize the overnight oximetry profile are reviewed, from visual inspection and simple statistics to complex measures involving signal processing and pattern recognition techniques. We focus on the individual performance of each approach, but also on the complementarity among the great amount of indices existing in the state of the art, looking for the most relevant oximetric feature subset. Finally, a quick overview of SpO₂-based deep learning applications for OSA management is carried out, where the raw oximetry signal is analyzed without previous parameterization. Our research allows us to conclude that all the methodologies (conventional, time, frequency, nonlinear, and hypoxemia-based) demonstrate high ability to provide relevant oximetric indices, but only a reduced set provide non-redundant complementary information leading to a significant performance increase. Finally, although oximetry is a robust tool, greater standardization and prospective validation of the measures derived from complex signal processing techniques are still needed to homogenize interpretation and increase generalizability.

Opiate Use and Escalation of Care in Hospitalized Adults with Acute Heart Failure and Sleep-disordered Breathing (OpiatesHF Study)

Rationale: Sleep-disordered breathing (SDB) is highly prevalent in adults hospitalized with acute heart failure. Data are limited on the implications of inadvertent opiate use in this population.Objectives: To determine the prevalence and impact of in-hospital opiate use in adults hospitalized for acute heart failure.Methods: From a prospective sleep registry, we selected a sequential group of adult participants who were admitted to the hospital for acute heart failure and received a portable sleep study (PSS) after screening for SDB using the STOP-BANG questionnaire. A retrospective review of charts was performed to assess use of opiates, need for escalation of care (defined as transfer to the intensive care unit [ICU]), 30-day readmission, and length of stay. A logistic regression model was used to calculate propensity scores for each participant with a screening apnea-hypopnea index (AHI) greater than or equal to 10/h. Study endpoints, including escalation of care to the ICU and 30-day hospital readmission, were compared using a χ² test with stabilized inverse probability-weighted propensity scores to control for potential confounding variables.Results: A total of 301 consecutive adults admitted with acute heart failure between November 2016 and October 2017 underwent PSS after SDB screening. Overall, 125 of 301 (41.5%) received opiates in the hospital, and 149 (49.5%) patients had an AHI greater than or equal to 10/h by PSS (high risk of SDB). In this high-risk group, 47 of 149 (32%) received opiates. Among those with an AHI greater than or equal to 10/h, escalation of care occurred in 12 of 47 (26%) of those who received opiates versus 4 of 102 (4%) of those who did not (P < 0.001; weighted estimate of treatment difference, 23.5%; 95% confidence interval [CI], 9.9 to 37.2). Similarly, readmission within 30 days occurred in 7 of 47 (15%) of those who received opiates versus 9 of 102 (9%) of those who did not (P = 0.14; weighted estimate of treatment difference, 8.3%; 95% CI, -4.0 to 20.6). Mean length of stay (days) did not differ between groups (P = 0.61; weighted estimate of treatment difference, -0.3 d; 95% CI, -1.4 to 0.8).Conclusions: In adults admitted with acute heart failure and found to be at high risk of SDB, opiate use in the hospital was highly prevalent and was associated with a greater likelihood of escalation of care.

Hospital screening for obstructive sleep apnea in patients admitted to a rural, tertiary care academic hospital with heart failure

BACKGROUND

Rural communities represent a vulnerable population that would significantly benefit from hospital-based OSA screening given these areas tend to have significant health-care disparities and poor health outcomes. Although inpatient screening has been studied at urban hospitals, no study to date has assessed this approach in rural populations.

METHODS

This study utilized the Electronic Medical Record (EMR) to generate a list of potential candidates by employing inclusion/exclusion criteria as screening. Subjects identified were then approached and offered information regarding the study. Screening for OSA entailed a tiered approach utilizing the sleep apnea clinical score (SAC) and portable sleep testing. Individuals identified as high risk (SAC ≥ 15) for OSA underwent evaluation with a portable sleep testing system while hospitalized. All participants with an apnea-hypopnea index (AHI) ≥5 events/h confirmed by a sleep medicine physician were considered screen positive for OSA. If approved/available, subjects screening positive for OSA were provided with an auto-titrating continuous positive airway pressure (PAP). Patient characteristics were analyzed using descriptive statistics. Categorical data were described using contingency tables, including counts and percentages. Continuously scaled measures were summarized by median with range. This study was registered with ClinicalTrials.gov. Identifier: NCT03056443.

RESULTS

Nine hundred and fifty-eight potential subjects were identified. The three most common reasons for exclusion included previous OSA diagnosis or exposure to PAP therapy (n = 357), advanced illness (n = 380), and declined participation by the individual (n = 68). The remaining 31 subjects underwent further evaluation for obstructive sleep apnea. Twenty-three subjects had a high sleep apnea clinic score. Per our study protocol, 13 subjects who screened positive for OSA were initiated on APAP therapy. Conclusion: Our study provides important insight into the burden of sleep-disordered breathing (SDB) and unique challenges of hospital-based OSA screening/treatment in a rural setting. Our study identified barriers to successful screening in a rural population that may be well addressed by adapting previous research in hospital sleep medicine.

Sleep Disordered Breathing in Hospitalized African-Americans

RATIONALE

Sleep-disordered breathing (SDB) is a common disorder in general population, with higher prevalence in population with comorbid cardiovascular disease, and yet it remains frequently undiagnosed. Prior published data show that hospitalized obese patients have a high incidence of unrecognized SDB. However, limited data exists on the incidence, prevalence, and impact of SDB in hospitalized obese African-American (AA) patients. This study was performed to better understand the burden of undiagnosed SDB in hospitalized AA patients and its implications on readmission.

METHODS

A total of 1243 consecutive obese AA patients admitted to medical or telemetry service were screened utilizing a screening questionnaire (STOP/STOPBANG) from October 2016 to October 2017. If the results of the screening questionnaire were positive, the patients were offered inpatient testing with either High Resolution Pulse Oximetry (HRPO), or a type 3 portable monitor (PM). SDB was suspected if the Oxygen Desaturation Index (ODI) or Apnea Hypopnea Index (AHI) ≥ 5. We collected 30-day readmission and emergency department (ED) visit data on all patients and requested a formal outpatient sleep study for patients identified as SDB positive.

RESULTS

Of the 1243 AA patients screened, 852 (68.5%) patients screened positive for SDB. Of these high-risk screens, 538 (63.1%) patients underwent inpatient testing with either High Resolution Pulse Oximetry (HRPO) or PM. Of these 538 patients, 319 (59.3%) were found to have suspected obstructive sleep apnea (OSA) based on ODI/AHI >5. Mild SDB (AHI 5-14) was present in 149 (46.7%) patients; moderate (AHI 15-29) in 74 (23.2%) patients; and severe (AHI >30) in 96 (30.1%) patients. The patients with suspected SDB were educated and encouraged to get an out-patient polysomnogram (PSG) but only 32 (10.0%) returned to undergo a formal PSG. The 30-day readmission rate/ED visits for patient with SDB was 13.5% compared to 13.7% of patients without SDB.

CONCLUSION

This is the largest SDB registry that included obese hospitalized AA patients in a tertiary care academic center and reveals a high prevalence of undiagnosed SDB in this cohort. Despite proactive screening and patient education only 3.8% (32/852) of patients returned post-discharge for formal polysomnography. The presence of SDB did not impact the 30-day readmission rate/ED visit rate in this cohort.

Sleep-disordered breathing in hospitalized patients with congestive heart failure: a concise review and proposed algorithm

Congestive heart failure (CHF) is the most common cause of hospital admission in the USA costing the taxpayers billions of dollars. Sleep-disordered breathing (SDB) is a common co-morbid condition associated with CHF with prevalence estimated to be 60-70%. Despite substantial evidence supporting the negative impact of SDB on CHF, the condition is underrecognized and undertreated. Patients admitted to the hospital with CHF and SDB are prime candidates for intervention with positive airway pressure (PAP) therapy as they form a "captive audience," and timely intervention and education may mitigate sub-optimal outcomes. In conclusion, this review explores emerging data on the cost effectiveness and outcome of early intervention with PAP in hospitalized CHF patients.

Recognition and Treatment of Sleep-disordered Breathing in Obese African American Hospitalized Patients may Improve Outcome

PURPOSE

The HoSMed Database recently demonstrated a high prevalence of obstructive sleep apnea (OSA) in hospitalized obese patients. Based on a long-term follow-up, this study showed an improved survival among patients who were adherent with the therapy. In this post-hoc analysis we explore the characteristics, associations, and mortality outcome of OSA in the African American (AA) population.

METHODS

These subset analyses included obese AA patients screened in the hospital as high-risk for OSA. Stepwise logistic regression analysis was used to identify predictors of OSA. Patients who had polysomnography (PSG) and were initiated on positive airway pressure (PAP) therapy were followed and dichotomized to adherent versus non-adherent groups based on compliance data. Mortality rates in both groups were compared.

RESULTS

Of the total of 2022 AA patients screened, 1370 (60.7% females) were identified as high risk for OSA. Of these, 279 had PSG diagnosed OSA (mean AHI = 36/hour) and were initiated on PAP therapy. Adherence in AAs was significantly lower than for Caucasians (21% versus 45%, Chi-square p < 0.0001). The following statistically significant predictors of OSA were found: heart failure, chronic kidney disease, hypertension and asthma/COPD, BMI and age. A Log-rank survival analysis of AAs on CPAP showed non-significant benefit of adherence (HR: 0.22; 95% CI 0.03-1.7, p = 0.11); a propensity analysis of AAs and Caucasians that adjusted for race and potential confounding variables found a statistically significant benefit of adherence (HR: 0.29; 0.13-0.64; p = 0.002).

CONCLUSION

This large database of hospitalized patients confirms a high prevalence and lower adherence to PAP therapy in African Americans. Adherent patients, however, showed mortality benefit similar to Caucasians.

Portable Sleep Monitoring for Diagnosing Sleep Apnea in Hospitalized Patients With Heart Failure

BACKGROUND

Sleep apnea is an underdiagnosed condition in patients with heart failure. Efficient identification of sleep apnea is needed, as treatment may improve heart failure-related outcomes. Currently, use of portable sleep monitoring in hospitalized patients and those at risk for central sleep apnea is discouraged. This study examined whether portable sleep monitoring with respiratory polygraphy can accurately diagnose sleep apnea in patients hospitalized with decompensated heart failure.

METHODS

Hospitalized patients with decompensated heart failure underwent concurrent respiratory polygraphy and polysomnography. Both recordings were scored for obstructive and central disordered breathing events in a blinded fashion, using standard criteria, and the apnea-hypopnea index (AHI) was determined. Pearson's correlation coefficients and Bland-Altman plots were used to examine the concordance among the overall, obstructive, and central AHI values derived by respiratory polygraphy and polysomnography.

RESULTS

The sample consisted of 53 patients (47% women) with a mean age of 59.0 years. The correlation coefficient for the overall AHI from the two diagnostic methods was 0.94 (95% CI, 0.89-0.96). The average difference in AHI between the two methods was 3.6 events/h. Analyses of the central and obstructive AHI values showed strong concordance between the two methods, with correlation coefficients of 0.98 (95% CI, 0.96-0.99) and 0.91 (95% CI, 0.84-0.95), respectively. Complete agreement in the classification of sleep apnea severity between the two methods was seen in 89% of the sample.

CONCLUSIONS

Portable sleep monitoring can accurately diagnose sleep apnea in hospitalized patients with heart failure and may promote early initiation of treatment.