Dr. Doug’s Top Sleep Articles

Decision Modeling in Sleep Apnea: The Critical Roles of Pretest Probability, Cost of Untreated Sleep Apnea, and Time Horizon

(Moro et al., Journal of Clinical Sleep Medicine)

This is a groundbreaking 2016 healthcare economics article out of Harvard and Mass General, in which it was determined that in populations with a high incidence of Obstructive Sleep Apnea, and where there is also a great economic burden in not treating OSA, the most cost-effective strategy would be to simply provide a machine to everyone at high risk, without any diagnostic testing or exceptions.  These two conditions (high prevalence, high cost of not treating) exactly describe the realities of sleep apnea for Americans over 40, especially men.  The study also demonstrates that the cost-benefit ratio of low-threshold prescribing goes up with an increased willingness to pay for APAP/CPAP therapy.  The article can be found here:

Recommendations for Permanent Sleep Telehealth: An American Academy of Sleep Medicine Position Statement

(Vohra et al., Journal of Clinical Sleep Medicine)

The title of this policy paper almost says it all: Telehealth in the sleep medicine space should stand as the “new normal” in the care of sleep apnea and other sleep disorders. Published in 2024, the policy statement reflects a post-pandemic world that emphasizes access to care, advocating for varied means of telecommunication, remote telemonitoring, more flexible telehealth prescribing regulations, and interstate care. The fact that the paper is advocated by the American Academy of Sleep Medicine offers a reassuring aspect of peer review and credibility. The policy statement can be found here:

Primary Care vs Specialist Sleep Center Management of Obstructive Sleep Apnea and Daytime Sleepiness and Quality of Life: A Randomized Trial

(Chai-Coetzer et al., JAMA)

The elephant in the sleep apnea room has sometimes been posed as a question: Do you really need a sleep medicine specialist to manage sleep apnea? This study, published by the American Medical Association in 2013, found that the answer was “no” – provided that the patient had a straightforward diagnosis and the absence of other complex medical conditions. Patients who were treated by primary care providers who had been provided a single training seminar in OSA care did just as well as the patients treated by a sleep medicine specialist. It also cost the healthcare system about half as much when the primary care provider offered the care, as opposed to the sleep specialist. The article can be found here:

We Beat Sleep Apnea. It Should Be Easier for You to Do It, Too

(Carroll et al., New York Times)

This is not an academic paper, but an economics essay for the general public published by Aaron Carroll, a pediatrician with a Master’s in Public Health, and Austin Frakt, a Ph.D in healthcare economics – both of whom are also patients with Obstructive Sleep Apnea. It is a humorous recount of their circuitous and time-consuming paths to diagnosis and treatment, including the frustration of navigating insurance companies and receiving unexpected bills. The article concludes with a rhetorical question about CPAP machines: Should doctors just give them out? The article can be found here:

Health, Social and Economical Consequences of Sleep-Disordered Breathing: A Controlled National Study

(Jennum et al., Thorax)

This 2011 article published by Danish researchers (who have access to a national patient registry) calculated the cost to the patients themselves when their sleep-disordered breathing goes untreated. Untreated sleep apnea patients incurred financial losses of $5,000 per year – which is generally more than it costs to treat the disease – in the form of medical expenses, missed work and lost job opportunities. More surprisingly, patients who do not have sleep apnea but snore loudly also incur financial losses, with an average of $916 per year spent mostly on devices and remedies to reduce snoring. Though APAP/CPAP is rarely prescribed for snoring – and it is never covered by insurance for this reason – it is nevertheless effective for this indication, and not much more expensive than the unproven remedies that patients try in desperation. The article can be found here:

Burden of Sleep Apnea: Rationale, Design, and Major Findings of the Wisconsin Sleep Cohort Study

(Young et al., Wisconsin Medical Journal)

This 2009 paper also looked at the cost to the patient of untreated sleep apnea – but rather than using financial metrics, the study measured mortality. The results were chilling: for every 1,000 untreated patient years (for example, 1,000 OSA patients are untreated for one year, or 500 patients are untreated for two years), there were at least two excess deaths – and that number went as high as four per 1,000 untreated patient years in patients with severe OSA. The bottom line: Sleep apnea care delayed is sleep apnea care denied. The paper can be found here:

Treatment of Obstructive Sleep Apnea with Nasal Positive Airway Pressure Improves Golf Performance

(Benton et al., Journal of Clinical Sleep Medicine)

At least one academic journal article on the list should be chosen simply for the reason that it is fun. This fits the bill: In a controlled trial of golfers with sleep apnea, half were given CPAP and half were given nothing at all. Guess what happened? The Handicap Index of the control group remained unchanged, whereas the golfers on CPAP saw their HI improve by an average of 11% – with the very best golfers in the study seeing their HI improve by over 30% (which meant that some were shooting in the 70’s). This paper is so poignant because it highlights the impact that sleep apnea has not just on physical health, but on mental sharpness. And the study design utilized nasal masks (not full face masks), which are generally well tolerated. The article can be found here:

Performance of a Commercial Smartwatch Compared to Polysomnography Reference for Overnight Continuous Oximetry Measurement and Sleep Apnea Evaluation

(Browne et al., Journal of Clinical Sleep Medicine)

In the future, this 2024 article will be viewed as the opening of the floodgates on consumer wearable tech in sleep medicine specifically, and perhaps healthcare generally. Researchers at UCSD observed 51 sleep apnea patients and compared the results of the sleep apnea detector on their Samsung Galaxy Watch to those in their overnight sleep lab studies, which has long been considered the gold standard. The study demonstrated that use of this OTC smartwatch, with or without simultaneous sleep questionnaires, demonstrated “excellent to outstanding” discrimination in both identifying OSA and grading its severity. It has long been accepted that someone can walk into a pharmacy, buy a glucometer, and trust its results sufficiently to determine how much insulin they need; likewise, no one needs a prescription to walk into a medical supply store and obtain a blood pressure cuff, which will determine the dosing of numerous cardiac medications. This article is a similar harbinger of how consumer wearable tech will “democratize” sleep apnea evaluation, and possibly other chronic conditions (such as cardiac arrhythmias and hypertension). The abstract can be found here:

Sex Differences in Obstructive Sleep Apnea

(Bonsignore et al., European Respiratory Review)

Obstructive Sleep Apnea has long been considered a condition predominantly found in men. But part of the reason that there is such a disparity in the recognized disease prevalence is that women with sleep apnea present very differently than men do – particularly during menopause and pregnancy – and the diagnostic criteria that focuses on the presentation in men may be leading to under-diagnosis (and under-treatment) in women. This 2019 article, published by three female researchers from three different countries (Italy, Finland and Scotland), addresses the invisible epidemic that exists within the silent one. The article can be found here:

CPAP Therapy Improves Erectile Function in Patients with Severe Obstructive Sleep Apnea

(Schulz et al., Sleep Medicine)

The presence of Erectile Dysfunction is a fairly reliable marker of a man’s overall cardiovascular health, though the treatment of ED focuses on its lifestyle aspects. This 2019 paper established that CPAP treatment of Obstructive Sleep Apnea – a known risk factor for both cardiovascular disease and ED – significantly improved sexual function and overall health. Patients in this study saw improvements in their erectile function, daytime sleepiness, and depression scores – all with the use of CPAP. Nota bene: The use of APAP/CPAP does not preclude the concomitant use of ED medications, mental health medications, or any non-pharmacologic therapies; the effects of combination therapies are additive. The abstract can be found here: