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Copyright 2017 American Medical Association.All rights reserved.ScreeningforObstructiveSleepApneainAdultsUSPreventiveServicesTaskForceRecommendationStatementUSPreventiveServicesTaskForceTheUSPreventiveServicesTaskForce(USPSTF)makesrec-ommendationsabouttheeffectivenessofspecificpreven-tivecareservicesforpatientswithoutobviousrelatedsignsorsymptoms.It bases its recommendations on the evidence of both thebenefits and harms of the service and an assessment of the bal-ance.The USPSTF does not consider the costs of providing a ser-vice in this assessment.TheUSPSTFrecognizesthatclinicaldecisionsinvolvemorecon-siderations than evidence alone.Clinicians should understand theevidence but individualize decision making to the specific patientor situation.Similarly,the USPSTF notes that policy and coveragedecisionsinvolveconsiderationsinadditiontotheevidenceofclini-calbenefitsandharms.SummaryofRecommendationandEvidenceTheUSPSTFconcludesthatthecurrentevidenceisinsufficienttoas-sess the balance of benefits and harms of screening for obstructivesleepapnea(OSA)inasymptomaticadults(Istatement)(Figure1).SeetheClinicalConsiderationssectionforsuggestionsforprac-ticeregardingtheIstatement.RationaleImportanceBased on data from the 1990s,the estimated prevalence of OSAin the United States is 10%for mild OSA and 3.8%to 6.5%forIMPORTANCEBasedondatafromthe1990s,estimatedprevalenceofobstructivesleepapnea(OSA)intheUnitedStatesis10%formildOSAand3.8%to6.5%formoderatetosevereOSA;currentprevalencemaybehigher,giventheincreasingprevalenceofobesity.SevereOSAisassociatedwithincreasedall-causemortality,cardiovasculardiseaseandcerebrovascularevents,diabetes,cognitiveimpairment,decreasedqualityoflife,andmotorvehiclecrashes.OBJECTIVEToissueanewUSPreventiveServicesTaskForce(USPSTF)recommendationonscreeningforOSAinasymptomaticadults.EVIDENCE REVIEWTheUSPSTFreviewedtheevidenceontheaccuracy,benefits,andpotentialharmsofscreeningforOSAinasymptomaticadultsseeninprimarycare,includingthosewithunrecognizedsymptoms.TheUSPSTFalsoevaluatedtheevidenceonthebenefitsandharmsoftreatmentofOSAonintermediateandfinalhealthoutcomes.FINDINGSTheUSPSTFfoundinsufficientevidenceonscreeningforortreatmentofOSAinasymptomaticadultsoradultswithunrecognizedsymptoms.Therefore,theUSPSTFwasunabletodeterminethemagnitudeofthebenefitsorharmsofscreeningforOSAorwhetherthereisanetbenefitorharmtoscreening.CONCLUSIONS AND RECOMMENDATIONTheUSPSTFconcludesthatthecurrentevidenceisinsufficienttoassessthebalanceofbenefitsandharmsofscreeningforOSAinasymptomaticadults.(Istatement)JAMA.2017;317(4):407-414.doi:10.1001/jama.2016.20325Editorialpage368AuthorAudioInterviewRelatedarticlepage415CMEQRAuthor/GroupInformation:TheUSPreventiveServicesTaskForce(USPSTF)membersarelistedattheendofthisarticle.CorrespondingAuthor:KirstenBibbins-Domingo,PhD,MD,MAS().ClinicalReview&EducationJAMA|USPreventiveServicesTaskForce|RECOMMENDATIONSTATEMENT(Reprinted)JAMAJanuary24/31,2017Volume317,Number4407Copyright 2017 American Medical Association.All rights reserved.Downloaded From:http:/ 02/02/2017 Copyright 2017 American Medical Association.All rights reserved.moderate to severe OSA.1-3Current prevalence may be higher,given the increasing prevalence of obesity.4,5The proportion ofpersons with OSA who are asymptomatic or have unrecognizedsymptoms is unknown.Severe OSA is associated with increasedall-cause mortality6;however,the role OSA plays in increasingoverall mortality,independent from other risk factors(older age,higher body mass index BMI,and other cardiovascular risk fac-tors),is less clear.In addition to mortality,other adverse healthoutcomes associated with untreated OSA include cardiovasculardisease and cerebrovascular events,diabetes,cognitive impair-ment,decreased quality of life,and motor vehicle crashes.DetectionEvidence on the use of validated screening questionnairesin asymptomatic adults(or adults with unrecognized symptoms)to accurately identify who will benefit from further testing forOSA is inadequate.The USPSTF identified this as a critical gap inthe evidence.BenefitsofEarlyDetectionandInterventionorTreatmentThe USPSTF found inadequate direct evidence on the benefit ofscreeningforOSAinasymptomaticpopulations.TheUSPSTFfoundnostudiesthatevaluatedtheeffectofscreeningforOSAonhealthFigure1.USPreventiveServicesTaskForceGradesandLevelsofCertaintyWhat the USPSTF Grades Mean and Suggestions for PracticeGradeDefinitionAThe USPSTF recommends the service.There is high certainty that the net benefit is substantial.Offer or provide this service.Suggestions for PracticeBThe USPSTF recommends the service.There is high certainty that the net benefit is moderate,orthere is moderate certainty that the net benefit is moderate to substantial.Offer or provide this service.CThe USPSTF recommends selectively offering or providing this service to individual patientsbased on professional judgment and patient preferences.There is at least moderate certaintythat the net benefit is small.Offer or provide this service for selectedpatients depending on individualcircumstances.DThe USPSTF recommends against the service.There is moderate or high certainty that the servicehas no net benefit or that the harms outweigh the benefits.Discourage the use of this service.I statementThe USPSTF concludes that the current evidence is insufficient to assess the balance of benefitsand harms of the service.Evidence is lacking,of poor quality,or conflicting,and the balance ofbenefits and harms cannot be determined.Read the Clinical Considerations sectionof the USPSTF RecommendationStatement.If the service is offered,patients should understand theuncertainty about the balance of benefitsand harms.USPSTF Levels of Certainty Regarding Net BenefitLevel of CertaintyDescriptionHighThe available evidence usually includes consistent results from well-designed,well-conducted studies in representative primary carepopulations.These studies assess the effects of the preventive service on health outcomes.This conclusion is therefore unlikely to bestrongly affected by the results of future studies.ModerateThe available evidence is sufficient to determine the effects of the preventive service on health outcomes,but confidence in the estimateis constrained by such factors as the number,size,or quality of individual studies.inconsistency of findings across individual studies.limited generalizability of findings to routine primary care practice.lack of coherence in the chain of evidence.As more information becomes available,the magnitude or direction of the observed effect could change,and this change may be largeenough to alter the conclusion.The USPSTF defines certainty as“likelihood that the USPSTF assessment of the net benefit of a preventive service is correct.”The net benefit is defined asbenefit minus harm of the preventive service as implemented in a general,primary care population.The USPSTF assigns a certainty level based on the natureof the overall evidence available to assess the net benefit of a preventive service.LowThe available evidence is insufficient to assess effects on health outcomes.Evidence is insufficient because ofthe limited number or size of studies.important flaws in study design or methods.inconsistency of findings across individual studies.gaps in the chain of evidence.findings not generalizable to routine primary care practice.lack of information on important health outcomes.More information may allow estimation of effects on health outcomes.ClinicalReview&Education USPreventiveServicesTaskForceUSPSTFRecommendation:ScreeningforObstructiveSleepApneainAdults408JAMAJanuary24/31,2017Volume317,Number4(Reprinted)Copyright 2017 American Medical Association.All rights reserved.Downloaded From:http:/ 02/02/2017 Copyright 2017 American Medical Association.All rights reserved.outcomes.TheUSPSTFfoundatleastadequateevidencethattreat-ment with continuous positive airway pressure(CPAP)and man-dibularadvancementdevices(MADs)canimproveintermediateout-comes(eg,the apnea-hypopnea index AHI,Epworth SleepinessScale ESS score,and blood pressure)in populations referred fortreatment.However,the applicability of this evidence to screen-detectedpopulationsislimited.Theadequacyoftheevidencevar-ies based on the type of intervention and the reported intermedi-ateoutcomes.TheUSPSTFfoundinadequateevidenceonthelinkbetweenchangeintheintermediateoutcome(eg,AHI)andreduc-tion in the health outcome(eg,mortality).The USPSTF found evi-dence that treatment with CPAP can improve general and sleep-relatedqualityoflifeinpopulationsreferredfortreatment,buttheapplicabilityofthisevidencetoscreen-detectedpopulationsisun-known.The USPSTF found inadequate evidence on whethertreatment with CPAP or MADs improves other health outcomes(mortality,cognitive impairment,motor vehicle crashes,and car-diovascularorcerebrovascularevents).TheUSPSTFalsofoundin-adequateevidenceontheeffectoftreatmentwithvarioussurgicalproceduresinimprovingintermediateorhealthoutcomes.HarmsofEarlyDetectionandInterventionorTreatmentThe USPSTF found inadequate evidence on the direct harms ofscreeningforOSA.TheUSPSTFfoundadequateevidencethattheharms of treatment of OSA with CPAP and MADs are small.Re-portedharmsincludeoralornasaldryness;eyeorskinirritation;rash;epistaxis;pain;excesssalivation;andoralmucosal,dental,andjawsymptoms.The USPSTF found inadequate evidence on the harmsofsurgicaltreatmentofOSA.USPSTFAssessmentThe USPSTF concludes that the current evidence is insufficient toassess the balance of benefits and harms of screening for OSA inasymptomaticadults.Evidenceonscreeningtoolstoaccuratelyde-tectpersonsinasymptomaticpopulationswhoshouldreceivefur-ther testing and treatment of subsequently diagnosed OSA to im-prove health outcomes is lacking,and the balance of benefits andharmscannotbedetermined.ClinicalConsiderationsPatientPopulationUnderConsiderationThisrecommendationappliestoasymptomaticadults(18yearsandolder).ItalsoappliestoadultswithunrecognizedsymptomsofOSA(Figure2).Thisincludespersonswhoarenotawareoftheirsymp-toms or do not report symptoms as being a concern to their clini-cian.This recommendation does not apply to persons presentingwith symptoms(eg,snoring,witnessed apnea,excessive daytimesleepiness,impairedcognition,moodchanges,orgaspingorchok-ing at night)or concerns about OSA,persons who have been re-ferredforevaluationortreatmentofsuspectedOSA,orpersonswhohaveacuteconditionsthatcouldtriggertheonsetofOSA(eg,stroke).Careofthesepersonsshouldbemanagedasclinicallyappropriate.Thisrecommendationalsodoesnotapplytochildren,adolescents,orpregnantwomen.SuggestionsforPracticeRegardingtheIStatementPotentialPreventableBurdenBased on data from the 1990s,the estimated prevalence of OSAin the United States is 10%for mild OSA and 3.8%to 6.5%formoderate to severe OSA.1-3Current prevalence may be higher,given the increasing prevalence of obesity.4,5Extrapolation fromlong-term follow-up data from the Wisconsin Sleep Cohort Study(1988-1994 to 2007-2010)results in an estimated prevalence of16%for mild OSA and 10%for moderate to severe OSA.4TheFigure2.ScreeningforObstructiveSleepApneainAdults:ClinicalSummaryPopulationRecommendation Asymptomatic adults,including those with unrecognized symptomsNo recommendation.Grade:I(insufficient evidence)Risk AssessmentScreening TestsTreatment andInterventionsBalance of Benefitsand HarmsFor a summary of the evidence systematically reviewed in making this recommendation,the full recommendation statement,and supporting documents,pleasego to https:/www.uspreventiveservicestaskforce.org.Risk factors associated with obstructive sleep apnea(OSA)include male sex,older age(40 to 70 y),postmenopausal status,higherbody mass index,and craniofacial and upper airway abnormalities.Evidence on other risk factors,such as smoking,alcohol andsedative use,and nasal congestion,is sparse or mixed.Evidence on the use of validated screening questionnaires in asymptomatic adults(or adults with unrecognized symptoms)toaccurately identify who will benefit from further testing for OSA is inadequate.Treatment with continuous positive airway pressure or mandibular advancement devices can improve intermediate outcomes(apneahypopnea index,Epworth Sleepiness Scale score,and blood pressure)in populations referred for treatment.However,theapplicability of this evidence to screen-detected populations is limited.The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA inasymptomatic adults.USPSTFRecommendation:ScreeningforObstructiveSleepApneainAdultsUSPreventiveServicesTaskForce ClinicalReview&E(Reprinted)JAMAJanuary24/31,2017Volume317,Number4409Copyright 2017 American Medical Association.All rights reserved.Downloaded From:http:/ 02/02/2017 Copyright 2017 American Medical Association.All rights reserved.prevalence of severe OSA in asymptomatic persons is unknown.In the Wisconsin Sleep Cohort Study,approximately 6%of adultswith no or mild OSA progressed to moderate to severe OSA over4 years.7Risk factors associated with OSA include male sex,older age(40 to 70 years),postmenopausal status,higher BMI,and cranio-facial and upper airway abnormalities.The evidence on other riskfactors,such as smoking,alcohol and sedative use,and nasal con-gestion,issparseormixed.1Observationalstudieshavereportedanassociationbetweense-vereOSAandmortalityrisk.8Intheory,screeningforOSAcouldim-prove mortality by identifying OSA early and providing treatmentbefore it can adversely influence mortality.Although studies gen-erally show that treatment of OSA with CPAP and MADs improvesintermediate outcomes,such as AHI and ESS score,there is a lackofstudiesdemonstratingthatchangeinAHIorESSscoreimproveshealthoutcomes,andnowell-controlledtrialshavedemonstratedanimprovementinmortalitywithtreatmentofOSA.In trials reviewed by the USPSTF,treatment with CPAP effec-tivelyreducedAHItonormal(5)ornear-normal(10).17Among patients with hypertension,the MVAP tool had asensitivity of 91.5%and a specificity of 43.9%to predict severeOSAS.18Whenunattended,in-homeportablesleepmonitortestingwasadded,thesensitivityoftheMVAPtooltopredictsevereOSASincreased to 90.9%and specificity increased to 75.7%17;in thestudy of Medicare patients,while sensitivity decreased to 88.2%,specificity increased to 71.6%among patients with hypertension.18The 2 studies that evaluated the MVAP tool were conducted inpopulations that had a high prevalence of OSAS(and thus weremore likely to be symptomatic)and a high risk of spectrum bias(ie,the study population does not represent the general primarycarepopulation).The USPSTF also evaluated the evidence on the accuracy ofdiagnostic tests for OSA.In particular,it evaluated the evidenceon the various types of portable sleep monitors compared withpolysomnography.Evidence was obtained from 2 systematicreviews and 19 additional studies.1Most studies evaluated type IIIand type IV portable monitors.The USPSTF reviewed evidencefrom 3 studies(n=160)on type II portable monitors,21 studies(n=1691)
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