Newly Published
Perioperative Medicine  |   June 2020
Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery
Author Notes
  • From the Department of Anesthesiology and Pain Medicine (A.S., L.S., M.S.), the Institute of Health Policy, Management and Evaluation (A.S., P.R.D., L.S., J.R.d.A.), and the Department of Otolaryngology–Head and Neck Surgery (P.R.D., J.R.d.A.), University of Toronto, Toronto, Ontario, Canada; the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York (S.G.M.); the Department of Anesthesiology and Health Policy and Research, Weill Cornell Medical College, New York, New York (S.G.M.); the Department of Anesthesiology, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada (M.S.); the Department of Anesthesiology, Women’s College Hospital, Toronto, Ontario, Canada (M.S.); and the Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada (M.S.).
  • A.S. and P.R.D. contributed equally to this article.
    A.S. and P.R.D. contributed equally to this article.×
  • Submitted for publication November 2, 2019. Accepted for publication May 27, 2020.
    Submitted for publication November 2, 2019. Accepted for publication May 27, 2020.×
  • Correspondence: Address correspondence to Dr. Singh: Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, Ontario M5T 2S8, Canada. mandeep.singh@uhn.ca. Anesthesiology’s articles are made freely accessible to all readers on www.anesthesiology.org, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Central and Peripheral Nervous Systems / Respiratory System / Sleep Medicine
Perioperative Medicine   |   June 2020
Cost-effectiveness Analysis of Preoperative Screening Strategies for Obstructive Sleep Apnea among Patients Undergoing Elective Inpatient Surgery
Anesthesiology Newly Published on June 26, 2020. doi:https://doi.org/10.1097/ALN.0000000000003429
Anesthesiology Newly Published on June 26, 2020. doi:https://doi.org/10.1097/ALN.0000000000003429
Abstract

Background: Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study’s objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients’ remaining lifespans.

Methods: An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio.

Results: In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses.

Conclusions: The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.

Editor’s Perspective:

What We Already Know about This Topic:

  • Obstructive sleep apnea is common, frequently undiagnosed, and associated with increased risk of postoperative complications.

  • This risk may be mitigated if obstructive sleep apnea is identified preoperatively.

  • Several screening modalities are available. Polysomnography is the gold standard but expensive. The STOP-Bang questionnaire and portable monitors are cheaper but less accurate alternatives.

What This Article Tells Us That Is New:

  • In a Canadian single healthcare payer model, the cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon.

  • Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon.