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December 13, 2019

Why millions of Americans' sleep apnea goes undiagnosed—and untreated

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on Oct. 19, 2022.

    Sleep apnea affects millions of Americans, but for many, proper diagnosis and treatment are out of reach, Austin Frakt and Aaron Carroll write for the New York Times' "The Upshot." Frakt and Carroll discuss their own experiences with the condition and explain how more Americans can access "treatment that makes a world of difference."

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    Frakt holds positions at the Department of Veterans AffairsBoston University's School of Public Health, and the Harvard T.H. Chan School of Public Health. Carroll is a professor of pediatrics at Indiana University School of Medicine.

    What is sleep apnea?

    Obstructive sleep apnea is a "common" condition in which the upper airway collapses during sleep, Carroll and Frakt explain. People with sleep apnea go through periods where they're not breathing during sleep, which can lead to sleepless nights and poor health outcomes—and "the consequences can be severe," Carroll and Frakt write. The condition is the leading cause of vehicle accidents and is also associated with Type 2 diabetes in adults, they note, adding that untreated sleep apnea can also increase the risk of postoperative cardiovascular surgery complications.

    Carroll and Frakt cite research that suggests roughly 24 million Americans have sleep apnea but aren't aware they have it. "[A]nd many who do know don't get treatment," they write.

    Both Carroll and Frakt have the condition, and saw improvement after being treated with continuous positive airway pressure (CPAP).

    "Each night we strap on masks connected to CPAP machines," which are silent, Carroll and Frakt explain. The machines are designed to push air through masks to keep users' airways open while they sleep.

    Frakt and Carroll admit the treatment "takes some getting used to" but say it took them both about a week to adapt. "This isn't to say that it's not a big deal for many people—it can be. But it's not as scary as many fear," they write. Plus, the improvement in their sleep was "well worth the effort of adjustment," they write. "We feel more refreshed and less tired all day."

    The cost of sleep apnea

    But while Frakt and Carroll saw improvement with their machines, they recognize that some people have "considerable trouble getting them in the first place," which is why a large percentage of people with sleep apnea avoid or delay treatment.

    For one, they note that being diagnosed with the condition can be troublesome.

    To be diagnosed with obstructive sleep apnea, patients have to participate in an overnight sleep study.  Frakt did this in a lab, while Carroll did it at home and had a follow-up appointment afterward.

    Once testing confirmed Frakt and Carroll had sleep apnea, they had to schedule and pay for an appointment with a sleep specialist to get a prescription for CPAP therapy. Then they had to go to a sleep center for equipment training.

    "All of this wasn't cheap, neither for equipment nor for the time missed from work for the appointments," they write. "We're lucky that we could do all this, but for many it is a barrier to care."

    And even if patients do manage to jump all of these hurdles to get a prescription for the device, the machines can be costly, Carroll and Frakt note. Each device costs about $1,000, but insurance companies will only cover the device if it's in use. "To justify the expense, insurance companies usually monitor the machines' use to make sure they're being employed," they write.

    What's the solution?

    The diagnosis process and the accessibility of care make obstructive sleep apnea a difficult condition to treat, Frakt and Carroll contend. 

    So how do we fix it?

    Some experts recommend universal screening, Frakt and Carroll note.The U.S. Preventive Services Task Force two years ago said earlier screenings could lead to an earlier diagnosis and better quality of life, but there wasn't enough evidence to recommend the screenings for people without symptoms, Carroll and Frakt note.

    Another idea is to do away with the sleep studies altogether, which could increase efficiency of the diagnosis and save money, Carroll and Frakt write.  "The CPAP machines are now so sophisticated that they can record sleep apnea episodes and fix them. Doctors could just give the machines out—instead of ordering home sleep studies—and use them to determine if patients (1) need the devices and (2) would actually use them," they write.

    These solutions could potentially help the many Americans who complain about their sleep, but either don't know they have sleep apnea or are unable to access treatment, Carroll and Frakt write. "What they need are open airways while they sleep, and a health care system that makes it easier for them to get them" Carroll and Frakt conclude (Frakt/Carroll, "The Upshot," New York Times, 12/9).

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