Content Comparison of Quality-of-Life Instruments Used in Economic Evaluations of Sleep Disorder Interventions: A Systematic Review

BACKGROUND

Assessment of quality of life (QoL) in people living with sleep disorders using questionnaires is necessary to compare intervention benefits. Knowledge of the content and concepts covered by specific QoL instruments is essential to determine which instruments are best suited for conducting economic evaluations of sleep-related interventions.

OBJECTIVES

This review aims to identify the QoL instruments that have been applied in economic evaluations of sleep disorder interventions and compare their conceptual overlap and content coverage using the framework of the International Classification of Functioning, Disability and Health (ICF).

METHODS

A systematic review of full economic evaluations in sleep published in peer-reviewed journals from conception to 30 May, 2023 was conducted. MEDLINE, PsychInfo, ProQuest, Cochrane, Scopus, CINAHL, Web of Science and Emcare were searched for eligible studies. Studies incorporating either generic or sleep-specific QoL instruments as the primary or secondary measures of effectiveness within a full economic evaluation were included. Quality appraisal against the JBI Critical Appraisal Checklist for Economic Evaluations and EURONHEED checklists and mapping of QoL items to ICF categories were performed by two reviewers, with a third helping settle any potential differences.

RESULTS

Sixteen instruments were identified as having been used in sleep health economic evaluations. The EQ-5D-3L, Epworth Sleepiness Scale, and Insomnia Severity Index were the most widely used, but the latter two are predominantly diagnostic tools and not specifically designed to guide economic evaluations. Other instruments with broader ICF content coverage have been least used, and these include the Sleep Apnea Quality of Life Index, Functional Outcomes of Sleep Questionnaire, 15 Dimensions, Short-Form 6 Dimensions, 12-item Short Form Survey, 36-item Short Form Survey and the GRID Hamilton Rating Scale for Depression.

CONCLUSIONS

This study provides an overview of current QoL instruments used in economic evaluations of sleep with respect to their content coverage. A combination of generic and sleep-specific instruments with broader ICF content coverage is recommended for such evaluations.

Socioeconomic Status and Sleep among Couples

Objective/Background: Lower socioeconomic status (SES) is generally associated with poor sleep but little is known about how different SES indices are associated with sleep duration and quality, or about these relations longitudinally or in cohabiting couples. The main objective was to examine longitudinal associations between multiple SES and sleep parameters in cohabiting adults. Participants: Participants were cohabiting couples (N = 135) of women (M age = 37.2 years, SD = 5.93; 76% White/European American, 18% Black/African American) and men (M = 39.9 years, SD = 7.33; 78% White, 18% Black). Methods: Men and women participated twice with a 1-year lag. At Time (T1), participants reported on multiple SES indices including their income, perceived economic well-being, education, employment status, and occupation. Sleep at T1 and T2 was assessed with self-reports and actigraphs (sleep duration from onset to wake time, %sleep from onset to wake, long wake episodes). Results: Actor effects on actigraphy-assessed sleep parameters were evident for both men and women; low SES was associated with shorter duration and poor quality (%sleep, long wake episodes) sleep. These associations were most pronounced for income-to-needs ratio (men and women) and perceived economic well-being (women only). Partner effects were also evident such that men's employment status was associated with women's longer sleep duration and greater sleep quality (%sleep) whereas women's employment predicted increased subjective sleep problems for men. Conclusion: Findings illustrate the need to consider multiple SES and sleep indices, as well as the family context in studies addressing linkages between SES and sleep.

COVID-19 Is Straining Mental Health-Could Technology Be the Answer?

One of the most pernicious side effects of the COVID-19 pandemic is a steep rise in stress and mental health problems. According to a poll by the Kaiser Family Foundation, nearly half of American adults say that worry and stress about the pandemic is hurting their mental health [1]. There are plenty of factors feeding into this phenomenon. People are anxious about getting sick, grieving lost loved ones, and experiencing financial stress, parental stress, and loneliness. The pandemic places additional burdens on essential workers and people of color, both of whom are at greater risk of dying from the disease. COVID-19 itself has been linked to neurological problems as well as anxiety, depression, and sleep disorders [2].

The Cost of Inadequate Sleep among On-Call Workers in Australia: A Workplace Perspective

On-call or stand-by is becoming an increasingly prevalent form of work scheduling. However, on-call arrangements are typically utilised when workloads are low, for example at night, which can result in inadequate sleep. It is a matter of concern that on-call work is associated with an increased risk of workplace injury. This study sought to determine the economic cost of injury due to inadequate sleep in Australian on-call workers. The prevalence of inadequate sleep among on-call workers was determined using an online survey, and economic costs were estimated using a previously validated costing methodology. Two-thirds of the sample (66%) reported obtaining inadequate sleep on weekdays (work days) and over 80% reported inadequate sleep while on-call. The resulting cost of injury is estimated at $2.25 billion per year ($1.71-2.73 billion). This equates to $1222 per person per incident involving a short-term absence from work; $2.53 million per incident classified as full incapacity, and $1.78 million for each fatality. To the best of our knowledge this is the first study to quantify the economic cost of workplace injury due to inadequate sleep in on-call workers. Well-rested employees are critical to safe and productive workplace operations. Therefore, it is in the interest of both employers and governments to prioritise and invest far more into the management of inadequate sleep in industries which utilise on-call work arrangements.

A pilot randomized controlled trial of a tailored cognitive behavioural therapy based intervention for depressive symptoms in those newly diagnosed with multiple sclerosis

BACKGROUND

To examine the effectiveness and acceptability of an 8-week individual tailored cognitive behavioural therapy (CBT) intervention for the treatment of depressive symptoms in those newly diagnosed with multiple sclerosis.

METHODS

The current study presents a pilot, parallel group randomized controlled trial (RCT) with an allocation ratio of 1:1 conducted in a large research and teaching hospital in Melbourne, Australia. 30 individuals with a mean age of 36.93 years (SD = 9.63) who were newly diagnosed with multiple sclerosis (MS) (X = 24.87 months, SD = 15.61) were randomized to the CBT intervention (n = 15) or treatment as usual (TAU) (n = 15). The primary outcome was level of depressive symptoms using the Beck Depression Inventory-II (BDI-II). Secondary outcomes were level of anxiety, fatigue and pain impact, sleep quality, coping, acceptance of MS illness, MS related quality of life, social support, and resilience. Tertiary outcomes were acceptability and adherence to the intervention.

RESULTS

Large between group treatment effects were found for level of depressive symptoms at post and at 20 weeks follow-up (d = 1.66-1.34). There were also small to large group treatment effects for level of anxiety, fatigue and pain impact, sleep quality, MS related quality of life, resilience, and social support at post and at 20 weeks follow-up (d = 0.17-1.63). There were no drop-outs and participants completed all treatment modules. All participants reported the treatment as 'very useful', and most (73.4%) reported that the intervention had addressed their problems 'completely'.

CONCLUSIONS

These data suggest that the tailored early intervention is appropriate and clinically effective for the treatment of depressive symptoms in those newly diagnosed with MS. A larger RCT comparing the CBT intervention with an active comparative treatment with longer term follow-up and cost effectiveness analyses is warranted. The pilot trial has been retrospectively registered on 28/04/2016 with the ISRCTN registry (trial ID ISRCTN10423371).

Co-Morbidity, Mortality, Quality of Life and the Healthcare/Welfare/Social Costs of Disordered Sleep: A Rapid Review

Sleep disorders are frequent (18%-23%) and constitute a major risk factor for psychiatric, cardiovascular, metabolic or hormonal co-morbidity and mortality. Low social status or income, unemployment, life events such as divorce, negative lifestyle habits, and professional requirements (e.g., shift work) are often associated with sleep problems. Sleep disorders affect the quality of life and impair both professional and non-professional activities. Excessive daytime drowsiness resulting from sleep disorders impairs efficiency and safety at work or on the road, and increases the risk of accidents. Poor sleep (either professional or voluntary) has detrimental effects comparable to those of major sleep disorders, but is often neglected. The high incidence and direct/indirect healthcare and welfare costs of sleep disorders and poor sleep currently constitute a major medical problem. Investigation, monitoring and strategies are needed in order to prevent/reduce the effects of these disorders.

The emerging role of telemedicine in diagnosing and treating sleep disorders

Over one-third of adults are at risk of developing sleep disorders. Telemedicine is emerging as an effective tool in sleep medicine by allowing people to undergo sleep studies without overnight hospital stays (e.g. monitoring at home). Telemedicine has the potential to overcome several obstacles in the diagnosis and treatment of sleep disorders by offering increased access to sleep specialists, enhancing health-care support for patients in their homes and providing cost-effective professional education. The initial costs for telemedicine equipment and training are not insignificant; however, the benefits may outweigh the expense over time. However, recapturing the initial costs cannot be assumed.

Low socioeconomic status negatively affects sleep in pregnant women

OBJECTIVE

To evaluate the effect of socioeconomic status on measures of sleep quality, continuity, and quantity in a large cohort of pregnant women.

DESIGN

Prospective, longitudinal study.

PARTICIPANTS

One hundred seventy (170) pregnant women at 10-20 weeks gestation.

METHODS

Sleep quality was assessed with the Pittsburgh Sleep Quality Index. Sleep duration and continuity (sleep fragmentation index [SFI]) were assessed with actigraphy at 10-12, 14-16, and 18-20 weeks gestation. Because sleep did not significantly differ across time, averages across all three time points were used in analyses. Socioeconomic status (SES) was defined by self-reported annual household income. Linear regression analyses were used to model the independent associations of SES on sleep after adjusting for age, race, parity, marital status, body mass index (BMI), perceived stress, depressive symptoms, and financial strain.

RESULTS

On average, women reported modestly poor sleep quality (M = 5.4, SD = 2.7), short sleep duration (391 [55.6] min) and fragmented sleep (SFI M = 33.9, SD = 10.4. A household income < $50,000/year was associated with poorer sleep quality (β = -.18, p < 0.05) and greater sleep fragmentation (β = -.18, p < 0.05) following covariate adjustment.

CONCLUSIONS

Low SES was associated with poorer sleep quality and fragmented sleep, even after statistical adjustments. Perceived stress and financial strain attenuated SES-sleep associations indicating that psychosocial situations preceding pregnancy are also important to consider.

Baby Business: a randomised controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression

BACKGROUND

Infant crying and sleep problems (e.g. frequent night waking, difficulties settling to sleep) each affect up to 30% of infants and often co-exist. They are costly to manage and associated with adverse outcomes including postnatal depression symptoms, early weaning from breast milk, and later child behaviour problems. Preventing such problems could improve these adverse outcomes and reduce costs to families and the health care system. Anticipatory guidance-i.e. providing parents with information about normal infant sleep and cry patterns, ways to encourage self-settling in infants, and ways to develop feeding and settling routines before the onset of problems-could prevent such problems. This paper outlines the protocol for our study which aims to test an anticipatory guidance approach.

METHODS/DESIGN

750 families from four Local Government Areas in Melbourne, Australia have been randomised to receive the Baby Business program (intervention group) or usual care (control group) offered by health services. The Baby Business program provides parents with information about infant sleep and crying via a DVD and booklet (mailed soon after birth), telephone consultation (at infant age 6-8 weeks) and parent group session (at infant age 12 weeks). All English speaking parents of healthy newborn infants born at > 32 weeks gestation and referred by their maternal and child health nurse at their first post partum home visit (day 7-10 postpartum), are eligible. The primary outcome is parent report of infant night time sleep as a problem at four months of age and secondary outcomes include parent report of infant daytime sleep or crying as a problem, mean duration of infant sleep and crying/24 hours, parental depression symptoms, parent sleep quality and quantity and health service use. Data will be collected at two weeks (baseline), four months and six months of age. An economic evaluation using a cost-consequences approach will, from a societal perspective, compare costs and health outcomes between the intervention and control groups.

DISCUSSION

To our knowledge this is the first randomised controlled trial of a program which aims to prevent both infant sleeping and crying problems and associated postnatal depression symptoms. If effective, it could offer an important public health prevention approach to these common, distressing problems.

Economic implications of sleep disorders

Sleep disorders such as insomnia, obstructive sleep apnoea (OSA), excessive daytime sleepiness (EDS) and fatigue, sleep deprivation and restless legs syndrome (RLS) are increasingly seen in clinical practice. Sleep is considered vital for preserving daytime cognitive function and physiological well-being. Sleep insufficiency may have deleterious effects on work-life balance, overall health and safety. The consequential economic burden at both the individual and societal levels is significant. Moreover, sleep disorders are commonly associated with other major medical problems such as chronic pain, cardiovascular disease, mental illness, dementias, gastrointestinal disorders and diabetes mellitus. Thus, in order to properly care for patients presenting with sleep-related morbidity, and to reduce the consequential economic burden, accurate screening efforts and efficacious/cost-effective treatments need to be developed and employed.

[The US Government's effort in decreasing the cost of sleep-related problems and its outcome]

Sleepiness and inattention caused by sleep and circadian rhythm disorders or inadequate sleep habits adversely affect workers in many industries as well as the general public, and these disorders are likely to lead to public health and safety problems and adversely affect civilian life. Evidence is accumulating that these sleep related problems are contributing factors not only in many errors of judgement and accidents, but also related to some highly prevalent diseases, such as diabetes, obesity and hypertension. For each of these societal concerns, sleep science must be translated to the general public and to those in policy positions for improving public policy and public health awareness. In the United State, the National Commission for Sleep Disorders Research (established by the US Congress in 1998) completed a comprehensive report of its findings in 1993 to address these problems. The commission estimated that sleep disorders and sleepiness cost the United States $50 billion and called for permanent and concentrated efforts in expanding basic and clinical research on sleep disorders as well as in improving public awareness of the dangers of inadequate sleep hygiene. As a result of these efforts, the number of sleep centers has increased steadily and the total of the NIH (National Institutes of Health) funding for sleep research has also grown. In response to this progress in the US (together with appeals by Japanese Sleep Specialists), the Science Council of Japan published "The Recommendation of Creation of Sleep Science and Progression of Research" in 2002. In this article, we introduce and detail to the Japanese readers the US Government's efforts focusing on the report of the National Commission for Sleep Disorders Research, and we believe that the US Government's effort is a good example for the Japanese society to follow.

[Sleep disorders and hypnotic agents: medical, social and economical impact]

Insomnia is a subjective complaint relating to approximately 30% of the adult population in France, described by the patient as a difficulty of initiating and/or maintaining sleep. Its prevalence increases with age and sex: women are more affected than men (24% vs 14%). Insomnia is either occasional (20%), or chronic (10%). Chronic insomnia has an important impact on patients' everyday life e.g. fatigue, perturbed diurnal waking state, impaired quality-of-life... which results in lower work productivity and drowsiness as well as relational difficulties, absenteeism. About 80% of patients consult their general practitioner first. The aim of a hypnotic agent is to obtain sleep as physiological as possible. Benzodiazepines and benzodiazepines-like agents (zopiclone, zolpidem, zaleplon) are the most widely used hypnotics. However, their indications must be limited to occasional insomnia with a limited duration: less than four weeks. There is no advantage with using a combination of hypnotic agents, a practice which should be prohibited. Adverse effects can be serious, e.g. diurnal somnolence associated with risks of road accidents and, in the elderly, the risk of falls. After chronic use, hypnotics can be addictive, as their effects wear off in three to four weeks. After withdrawal, insomnia rebound is frequent. Use of hypnotics in association with alcohol is a well-known drug-addiction behavior. According to the French health insurance fund, 9% of the general population use hypnotics and about half of them regularly. Insurance refunds for hypnotics and sedatives reach more than 110 million euros annually. The efficiency of hypnotics wears off, quickly for benzodiazepines (three - four weeks), or less quickly for zopiclone and zolpidem (a few months). Insomnia is a major public health issue, each year 10% of the incident cases of insomnia treated by hypnotics joint the group of subjects with chronic insomnia. This failure to treat insomnia properly can be explained, at least in part, by several insufficiencies: physicians and pharmacists training, medical profession awareness, research, public information on the rules of good sleep (public health campaigns, booklets, role of physicians and the pharmacists).

Socioeconomic status predicts objective and subjective sleep quality in aging women

OBJECTIVE

To test the hypothesis that socioeconomic status (SES) would be associated with sleep quality measured objectively, even after controlling for related covariates (health status, psychosocial characteristics). Epidemiological studies linking SES and sleep quality have traditionally relied on self-reported assessments of sleep.

METHODS

Ninety-four women, 61 to 90 years of age, participated in this study. SES was determined by pretax household income and years of education. Objective and subjective assessments of sleep quality were obtained using the NightCap sleep system and the Pittsburgh Sleep Quality Index (PSQI), respectively. Health status was determined by subjective health ratings and objective measures of recent and chronic illnesses. Depressive symptoms and neuroticism were quantified using the Center for Epidemiological Studies Depression Scale and the Neuroticism subscale of the NEO Personality Inventory, respectively.

RESULTS

Household income significantly predicted sleep latency and sleep efficiency even after adjusting for demographic factors, health status, and psychosocial characteristics. Income also predicted PSQI scores, although this association was significantly attenuated by inclusion of neuroticism in multivariate analyses. Education predicted both sleep latency and sleep efficiency, but the latter association was partially reduced after health status and psychosocial measures were included in analyses. Education predicted PSQI sleep efficiency component scores, but not global scores.

CONCLUSIONS

These results suggest that SES is robustly linked to both subjective and objective sleep quality, and that health status and psychosocial characteristics partially explain these associations.

The economic cost of sleep disorders

STUDY OBJECTIVES

To determine the economic cost of sleep disorders in Australia and relate these to likely costs in similar economies.

DESIGN AND SETTING

Analysis of direct and indirect costs for 2004 of sleep disorders and the fractions of other health impacts attributable to sleep disorders, using data derived from national databases (including the Australian Institute of Health and Welfare and the Australian Bureau of Statistics).

MEASUREMENTS

Direct health costs of sleep disorders (principally, obstructive sleep apnea, insomnia, and periodic limb movement disorder) and of associated conditions; indirect financial costs of associated work-related accidents, motor vehicle accidents, and other productivity losses; and nonfinancial costs of burden of disease. These were expressed in US dollars (dollar).

RESULTS

The overall cost of sleep disorders in Australia in 2004 (population: 20.1 million) was dollar 7494 million. This comprised direct health costs of dollar 146 million for sleep disorders and dollar 313 million for associated conditions, dollar 1956 million for work-related injuries associated with sleep disorders (net of health costs), dollar 808 million for private motor vehicle accidents (net of health costs), dollar 1201 million for other productivity losses, dollar 100 million for the real costs associated with raising alternative taxation revenue, and dollar 2970 million for the net cost of suffering.

CONCLUSIONS

The direct and indirect costs of sleep disorders are high. The total financial costs (independent of the cost of suffering) of dollar 4524 million represents 0.8% of Australian gross domestic product. The cost of suffering of dollar 2970 million is 1.4% of the total burden of disease in Australia.

Effect of shifting costs to patients on specialty evaluation for sleep disorders

OBJECTIVE

To determine whether the introduction of out-of-pocket expenses to medical center employees would lead to decreased use of sleep disorder services.

PATIENTS AND METHODS

We retrospectively analyzed and compared the clinical and medical accounting data from visits by Mayo Clinic employees to the Sleep Disorders Center from January 1 to March 31, 2003, with that of January 1 to March 31, 2004, le, before and after a January 2004 increase in co-payments for evaluation and testing.

RESULTS

The total number of new patients evaluated in the first quarters of 2003 and 2004 was similar (113 vs 119; P = .37). Snoring, restless legs symptoms, hypertension, atrial fibrillation, and prior overnight oximetry testing were more prevalent in 2004 than in 2003 (P = .05, P = .01, P < .001, P = .003, P = .02, respectively). In contrast, insomnia and parasomnia complaints were less common in 2004 (P < .001). The mean apnea-hypopnea index, minimum oxygen saturation, and percentage of time with oxygen saturation less than 90% were all more severe in 2004 (P = .01, P = .001, P < .001, respectively). Sleep-related breathing disorders were more commonly diagnosed in 2004 (83.2% vs 67.2%; P = .02), whereas the diagnoses of nonbreathing disorders declined.

CONCLUSION

The insurance policy changes that resulted in larger employee co-payments shifted the spectrum of diagnoses seen at the Sleep Disorders Center toward more symptomatic patients, with more associated comorbidities, and patients who had more severe sleep-related breathing disorders. Total utilization did not decrease.

A pilot study of inexpensive sleep-assessment devices

Polysomnography (PSG), the gold standard sleep-assessment methodology, is impractical for many applications. Although alternative assessment methodologies are available, it is not clear which most correlates with PSG measures. This study compared sleep log (SL), actigraphy (ACT), and the REMview (RV) device for estimating PSG sleep measures. Thirty-three participants with various sleep-disorder diagnoses underwent 1 night of monitoring with PSG, RV, ACT, and SL. RV provided accurate estimates of most sleep variables. The accuracy of ACT and SL estimates depended on the sleep variable. These findings indicate that the selection of an alternative methodology should consider the sleep measure of interest in addition to the relative merits and drawbacks of each device.

[Diagnosis of sleep disorders and medical sleep-related diseases--a review]

A person's well-being and health are greatly affected by disorders of sleep and wakefulness. It is of the utmost importance to diagnose and treat such conditions, since the associated daytime sleepiness is a major risk factor for accidents. Early establishment of the correct diagnosis paves the way to achieving an excellent therapeutic outcome. Health-economic requirements of appropriateness and necessity mandate the specific use of cost- and time-intensive examinations in the sleep laboratory. In accordance with the guidelines for "non-restorative sleep", severe and chronic sleep disorders can be diagnosed outside the sleep lab if the underlying cause can already be identified on the basis of the patient's history. Such is usually the case in sleep disorders caused by external influences, disturbed circadian rhythm or pre-existing neurological, psychiatric or internal disorders. Standardized questionnaires are used to record and evaluate the patient's complaints, and vigilance testing to assess impaired sustained attention during the day. Excessive daytime sleepiness is quantified by the multiple sleep latency test (MSLT). In the case of some disorders such as apnoea, or periodic leg movements, simplified ambulatory methods have been developed to enable their detection at an early stage. The gold standard for the diagnosis of sleep disorders in the sleep lab is cardiorespiratory polysomnography. The relevant biosignals for the assessment of sleep, respiration, heart function, the cardiovascular system and movement are well established. Some of the sensors employed need further improvement. Numerous methods for signal analysis are still undergoing development, and currently available automatic evaluation systems are not yet reliable enough to obviate the need for manual interpretation.

The prevalence, cost implications, and management of sleep disorders: an overview

The International Classification of Sleep Disorders distinguishes more than 80 different disorders, which can be effectively treated. Problems with falling asleep or daytime sleepiness affect approximately 35 to 40% of the U.S. adult population annually and are a significant cause of morbidity and mortality. However, the prevalence, burden, and management of sleep disorders are often ignored or overlooked by individuals and society in general. This leads to an underappreciation and undertreatment of sleep disorders, making this group of illnesses a serious health concern. Sleep medicine is a young discipline, and as such the full implications of treating sleep disorders and the extent of sleep-related problems are not well delineated. As a result of high prevalence, severe complications, and concomitant illnesses in untreated cases, the cost implications are immense. The costs can be direct, indirect, related, and intangible. However, relatively little has been published on the economic implications of sleep disorders. Economic analysis can help evaluate available resources to set priorities and maximize management strategies for cost control without sacrificing safety, efficacy, or effectiveness. There has been considerable evidence of the cost-effectiveness of treating patients with obstructive sleep apnea, especially considering its high prevalence, morbidity, mortality, and concomitant health care consumption. We review the economic balance sheet of sleep disorders and conclude that sleep medicine education (among general population and health care professionals) and the availability of diagnostic and therapeutic facilities to treat sleep disorders will reduce the profound socioeconomic implications of untreated sleep disorders.

Sleep complaints and risk factors for excessive daytime sleepiness in adult males in Northern Ireland

The prevalence of sleep complaints in Northern Ireland is unknown. Sleep disruption can result in excessive daytime sleepiness (EDS), with significant socioeconomic consequences. The aim of this study was to assess the prevalence of sleep complaints and to determine risk factors for EDS in a Northern Irish community. From an urban and rural community of 499,111 people, a random sample of 3391 adult men were sent a questionnaire by mail. Questions were asked regarding sleep, EDS and medical history. There were 2364 completed questionnaires returned (response rate 70%). The mean age of respondents was 46.0 years (range 18--91 years). 26.7% of men were not satisfied with their usual night's sleep and 68% of men woke up at least once during the night. Based on pre-defined criteria, 24.6% of the population had insomnia and 19.8% had EDS. The strongest risk factor identified for EDS was a history of snoring loudly (odds ratio 2.62; 95% CI 1.82--3.77). Other risk factors included ankle swelling, feeling sad or depressed stopping sleep, experiencing vivid dreams while falling asleep, waking up feeling unrefreshed and age > 35 years. The prevalence rates of sleep complaints and EDS in this community-based study is high, although this does depend directly on the criteria used to define insomnia and EDS. Recognition of risk factors for EDS may help to identify and treat those affected.

Economic evaluation of strategies for managing crying and sleeping problems

AIMS

To estimate the financial cost to the NHS of infant crying and sleeping problems in the first 12 weeks of age and to assess the cost effectiveness of behavioural and educational interventions aimed at reducing infant crying and sleeping problems relative to usual services.

METHODS

A cost burden analysis and cost effectiveness analysis were conducted using data from the Crying Or Sleeping Infants (COSI) Study, a three armed prospective randomised controlled trial that randomly allocated 610 mothers to a behavioural intervention (n = 205), an educational intervention (n = 202), or existing services (control, n = 203). Main outcome measures were annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks, and incremental cost per interruption free night gained for behavioural and educational interventions relative to control.

RESULTS

The annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks was 65 pound sterling million (US$104 million). Incremental costs per interruption free night gained for the behavioural intervention relative to control were 0.56 pound sterling (US$0.92). For the educational intervention relative to control they were 4.13 pound sterling (US$6.80).

CONCLUSIONS

The annual total cost to the NHS of infant crying and sleeping problems is substantial. In the cost effectiveness analysis, the behavioural intervention incurred a small additional cost and produced a small significant benefit at 11 and 12 weeks of age. The educational intervention incurred a small additional cost without producing a significant benefit.

Comorbidities associated with overactive bladder

Overactive bladder (OAB), defined as symptoms of frequency, urgency, and urge incontinence, that occur singly or in any combination in the absence of local pathologic or metabolic factors, is a highly prevalent disorder with an unknown etiology. Few risk factors for OAB have been elucidated through epidemiologic studies, and even less is known about the contribution of OAB to other morbidities. An overview is provided of the impact of OAB on other problems now known to coexist with OAB including falls and fractures, urinary tract and skin infections, sleep disturbances, and depression.

Insurance coding for the diagnosis and treatment of obstructive sleep disorders

In order to assist the physician in obtaining reimbursement for the treatment of patients with sleep disordered breathing, this article presents a few simple guidelines on insurance coding for various procedures.

Opportunities for improving managed care for individuals with dementia: Part 1--The issues

In this first part of a two-part article, we review the prevalence of, costs associated with, and treatments for Alzheimer's disease and related dementias, a leading cause of disability in the elderly. New, innovative, and costly drugs to combat dementia are being introduced, causing pharmacy costs to rise. These new drugs, however, may reduce overall medical costs and improve the quality of life of patients with dementia and their caregivers. Issues of cost, excessive service utilization, and quality of life will have significant impact on managed care organizations in the near future as the rapidly aging population experiences significant disability and illness related to dementia. In the second part of this article, we describe the framework for a disease management program for patients with dementia, similar to programs in existence for diabetes and other chronic diseases, that could enable managed care organizations to effectively care for these patients.

Clinical economics and sleep disorders

Sleep disorders have been shown to have substantial psychosocial sequelae with large economic impact. Numerous studies have examined the psychosocial aspects of sleep disorders; however, there has been little published on the associated economic implications. With increasing pressure to contain health care expenditures and provide value for the dollar, clinical economics is playing an important role in the decision-making process about alternative strategies within health care organizations. There are several strategies one may pursue to examine the economics of medical interventions. The predominant strategies include: cost identification, cost effectiveness, cost utility, and cost benefit. This review provides a basis for performing clinical economic evaluations in sleep disorders.

[Economic aspects of sleep medicine]

According to its rules it is the task of the German Sleep Research Society (DGSM) to promote scientific research in the area of Sleep Medicine in Germany and to transform scientific results into clinical practice for the benefit of patient care. The international classification of sleep disorders (ICSD) distinguishes more than 80 different disorders which can be treated due to scientific progress which has been made over the last 50 years. The conversion of established scientific knowledge in the field of sleep medicine into an improved clinical management of patients should not be prevented by the lack of sufficiently equipped sleep units. The federal government has stated that, due to financial constraints, it would not consent to any measures which might lead to a budget increase, such as case oriented special payments for certain diseases. Thus, an adequate number of sleep units can only be provided by integrating these units into the budget of the respective hospitals and departments, paid by the local insurance companies, thus providing the necessary financial resources to the sleep units. Many services in the area of sleep medicine can be covered by the existing reimbursement system. In some cases, however, a definite diagnosis can only be made by the use of complete polysomnography (PSG). For a complete PSG the additional costs have been calculated by the DGSM to be 1195,-DM per 24 h. Sleep units dealing with both diagnostically and therapeutically complex cases such as patients requiring complex forms of nasal ventilation, depend on an increase in the reimbursement by the insurance companies to cover the expenses involved. For each sleep unit, a "case-mix" can be calculated which will include both complex and less complex cases. The costs using this case mix will be considerably lower than the cost for a complete PSG. Sleep units provide the basis for education and quality assessment which are necessary for competent patient management in the future. Adequate diagnostic and therapeutic facilities in sleep medicine provide the basis for patient care, contribute to improved health standards and, thus, reduce social costs of these frequent diseases.

The cost of sleep-related accidents: a reanalysis

This journal published a special report titled "The Cost of Sleep-Related Accidents: A Report for the National Commission on Sleep Disorders Research". The report estimated that sleep-related accidents were annually associated with 23,318 fatalities, between 1,907,072 and 2,474,430 disabling injuries and costs between $43.15 billion and $56.02 billion. This paper reanalyzes the data base and assumptions underlying these estimates and concludes that they greatly overestimated the probable relationship between sleepiness and accidents. A more moderate estimate of this important relationship is proposed.

Sleep problems and their correlates in a working population

OBJECTIVE

To measure the prevalence of sleep problems in a working population and examine their association with health problems, health-related quality-of-life measures, work-related problems, and medical expenditures. Also, to explore the usefulness of a sleep-problems screen for mental health conditions and underlying sleep disorders.

DESIGN

Cross-sectional survey administered via voice mail and telephone interview.

SETTING

A San Francisco Bay Area telecommunications firm.

PARTICIPANTS

Volunteer sample of 588 employees who worked for a minimum of six months at the company and were enrolled in its fee-for-service health plan.

MEASUREMENTS AND MAIN RESULTS

Thirty percent of respondents reported currently experiencing sleep problems and were found to have worse functioning and well-being (general health, cognitive functioning, energy), more work-related problems (decreased job performance and lower satisfaction, increased absenteeism), and a greater likelihood of comorbid physical and mental health conditions than were the respondents who did not have sleep problems. They also demonstrated a trend toward higher medical expenditures.

CONCLUSIONS

Self-perceived sleep problems were common among the respondents and were associated with poorer health and health-related quality of life. A single question about sleep problems may serve as an effective screen for identifying primary care patients with mental health problems, as well as underlying sleep disorders.

The cost of sleep-related accidents: a report for the National Commission on Sleep Disorders Research

This report, prepared for the National Commission on Sleep Disorders Research, explores the economic implications of sleepiness in relation to accidents. In Part One, I describe the frequency of accidents in the United States and explain a method for estimating the economic cost of these of accidents. Accidents are the fourth leading cause of mortality in the United States, and motor-vehicle accidents represent 51% of total deaths caused by accidents. The method used for calculating the cost of accidents is called "the human capital approach". It is based on the principle that "one person produces a sum of output during his/her life-time, which can be approximated by his/her earnings". It is necessary to understand that this estimate of human value is not intended to reduce human beings to a sum of earnings during his/her lifetime. It does, however, serve as a useful indicator in making decisions regarding public health policy for the country. The results of the total cost of accidents and the relative costs for work-related, home-based and public accidents in 1988 are discussed. In Part Two, I explore the role sleepiness plays in contributing to the total number of accidents. The difficulty of researching this subject is compounded by the fact that reports of rates of accidents related to sleepiness differ significantly from author to author. This is true both for drivers with sleep disorders and those without. We have calculated two different rates for estimating the number of motor-vehicle accidents caused by sleepiness.(ABSTRACT TRUNCATED AT 250 WORDS)

ABC of sleep disorders. Impact and epidemiology of sleep disorders

Images