The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men

Abstract

Study objectives: Obstructive sleep apnea is more prevalent and severe in men than women. The American Academy of Sleep Medicine offers 2 definitions for scoring hypopneas: "acceptable" = associated with a ≥ 4% oxygen desaturation, adopted by Center for Medicare and Medicaid Services (CMS), and "recommended" = associated with a ≥ 3% oxygen desaturation and/or an arousal. We hypothesized that CMS vs American Academy of Sleep Medicine scoring criteria would differentially impact continuous positive airway pressure eligibility in women and men.

Methods: We conducted a retrospective review of adult diagnostic in-lab polysomnography at an urban academic institution. All polysomnographies were scored by both CMS and American Academy of Sleep Medicine scoring criteria, and an analysis by sex was performed that considered demographics and other polysomnography variables.

Results: Of 969 polysomnographies reviewed, 674 (69.6%) were in women. Women were younger (51.5 vs 53.3 years old) and had a higher body mass index (38.6 kg/m² vs 33.8 kg/m²) but had similar Epworth Sleepiness Scale scores compared to men. The odds of an American Academy of Sleep Medicine apnea-hypopnea index > 5 events/h being missed by CMS scoring in women was 1.89 (95% confidence interval: 1.40-2.53; P < .001) compared to men and increased to 6.87 among women 40-60 years of age with a body mass index ≥ 40 kg/m². After controlling for age, body mass index, % rapid eye movement sleep, and mean oxygen saturation, the sex effect remained significant (odds ratio 1.87; 95% confidence interval: 1.36-2.58; P < .001).

Conclusions: CMS scoring criteria imparts a sex bias toward women, potentially resulting in denial of therapy to symptomatic women with obstructive sleep apnea. Larger, prospective cohort studies are needed to confirm these findings.

Citation: Khalid F, Ayache M, Auckley D. The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men. J Clin Sleep Med. 2021;17(12):2409-2414.

Keywords: hypopnea definition; obstructive sleep apnea; scoring criteria; sex.