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Kunisaki KM, Khalil W, Koffel E, et al. The Comparative Effectiveness, Harms, and Cost of Care Models for the Evaluation and Treatment of Obstructive Sleep Apnea (OSA): A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2016 Sep.
The Comparative Effectiveness, Harms, and Cost of Care Models for the Evaluation and Treatment of Obstructive Sleep Apnea (OSA): A Systematic Review [Internet].
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| OUTCOME | Strength of Evidence Elementsa | Summary of Findings | |||||
|---|---|---|---|---|---|---|---|
| Risk of Bias | Consistency | Directness | Precision | Publication Bias | Description of Effect | Strength of Evidence Directionb | |
| KQ1: SLEEP PHYSICIAN CARE COMPARED TO MANAGEMENT BY PRIMARY CARE, SLEEP-SPECIALIST NURSES OR OTHER NON-SLEEP PHYSICIANS | |||||||
| Access to care | We found no evidence for this outcome. | Insufficient | |||||
| Epworth Sleepiness Scale (ESS) | Moderate | Consistent | Direct | Precise | Unclear | Based on 4 RCTs (n = 568), improvement from baseline in ESS scores was similar for patients being managed by primary care/sleep-specialist nurses compared to sleep specialist physicians (SMD = 0.06 [95% CI −0.15, 0.26]). One observational study also found ESS scores were similar between groups. | Moderate Similar |
| Quality of life | Moderate | Consistent | Direct | Precise | Unclear | Based on 3 RCTs (n = 524), quality of life measures were similar for patients being managed by primary care/sleep-specialist nurses compared to sleep specialist physicians. SMDs for SF-36 Vitality and Mental Health scores were −0.04 [95% CI −0.22, 0.15]) and − 0.04 [95% CI −0.22, 0.14], respectively | Moderate Similar |
| Compliance, hours per night | Moderate | Consistent | Direct | Precise | Unclear | Based on 4 RCTs (n = 568), compliance was similar for patients being managed by primary care/sleep-specialist nurses compared to sleep specialist physicians (WMD = −0.29 [95% CI −0.71, 0.12]). One observational cohort study also found compliance was similar between groups but one study based on retrospective chart review reported compliance was greater in the sleep specialist physician group compared to the non-sleep specialist group. | Moderate Similar |
| Adverse events | Moderate | Unknown | Direct | Imprecise | Unclear | Based on one RCT (n = 65) that did not report adverse events by treatment arm, the evidence is insufficient to draw conclusions. | Insufficient |
| KQ3: HOME APAP TECHNOLOGY VERSUS STANDARD IN-CENTER MANUAL CPAP TITRATION | |||||||
| Access to care | We found no evidence for this outcome. | Insufficient | |||||
| Epworth Sleepiness Scale (ESS) | Moderate | Consistent | Direct | Precise | Unclear | Based on 2 RCTs (n = 414) with moderate risk of bias, we found improvement from baseline in ESS scores was similar for patients allocated to home APAP titration compared to patients allocated to in-center CPAP titration (SMD = 0.0 [95% CI −0.22, 0.21]). One moderate risk of bias RCT (n = 68) found median change in EES scores from baseline was also similar between groups (MD -1 [95% CI −1, −4]). One observational cohort study also found ESS scores were similar between groups. | Moderate Similar |
| Quality of life | Moderate | Consistent | Direct | Precise | Unclear | Based on two RCTs (n = 414) with moderate risk of bias, we found quality of life measures were similar for patients allocated to home APAP titration compared to patients allocated to in- center CPAP titration. The SMDs for SF-36 Mental Health and Physical Health scores were 0.08 [95% CI −0.14, 0.29] and −0.21 [95% CI − 0.61, 0.20], respectively. Results for the Physical Health scores were imprecise. One moderate risk of bias RCT (n = 68) found median improvement from baseline in the SAQLI was similar between groups (median difference = 0.17 [95% CI −0.6, 0.9]) | Moderate Similar |
| Compliance, hours per night | Moderate | Inconsistent | Direct | Precise | Unclear | Based on two RCTs (n = 414) with moderate risk of bias, we found compliance was similar for patients allocated to home APAP titration compared to patients allocated to in-center CPAP titration (WMD = 0.02 [95% CI −0.41, 0.45]). One moderate risk of bias RCT (n = 68) found median compliance was better in the APAP group versus the CPAP group (MD −1.1 [95% CI −2.0, −0.2]). One observational cohort study found compliance was similar between groups | Low Similar |
| Adverse events | Moderate | Unknown | Direct | Imprecise | Unclear | Based on the findings of one RCT (n = 245) that reported no “important differences” in adverse events between the home APAP and in-lab CPAP and groups, the evidence is insufficient to draw conclusions. | Insufficient |
| KQ3: APAP VERSUS CPAP TREATMENT | |||||||
| Access to care | We found no evidence for this outcome. | Insufficient | |||||
| Epworth Sleepiness Scale (ESS) | Moderate | Consistent | Direct | Precise | Unclear | Based on four parallel group RCTs (n = 327) with aggregate moderate risk of bias, we found improvement from baseline in ESS scores was similar for patients allocated to APAP treatment compared to patients allocated to CPAP treatment (SMD = 0.18 [95% CI −0.06, 0.43]). Two parallel group trials not pooled (reported as a median or data not shown) also found improvement from baseline in ESS scores similar between groups. Ten crossover RCTs (n = 269) reported similar improvements between groups and two (N = 227) reported greater improvement with APAP. | Moderate Similar |
| Quality of life | Moderate | Consistent | Direct | Precise | Unclear | Based on 3 parallel group RCTs (n = 202) with aggregate moderate risk of bias, we found quality of life measures (SF-36, SAQLI) were similar for patients allocated to APAP treatment compared to patients allocated to CPAP treatment (data were not pooled due to variation in reporting of results, ie, reported as medians). Six crossover RCTs (n = 393) also reported no differences in most of the quality of life measures between the treatment groups. | Moderate Similar |
| Compliance, hours per night | Moderate | Consistent | Direct | Precise | Unclear | Based on 5 parallel group RCTs (n = 279) with aggregate moderate risk of bias, we found compliance was similar for patients allocated to APAP treatment compared to patients allocated to CPAP treatment (WMD = −0.08 [95% CI −0.55, 0.38]). One parallel group RCT reporting median compliance, most of the remaining crossover RCTs, and one observational study also found compliance was similar between groups. | Moderate Similar |
| Adverse events | Moderate | Consistent | Direct | Imprecise | Unclear | Adverse events were infrequently reported. One parallel group RCT (n = 109) reported adverse events, chest pain in 12% and 9% of APAP and CPAP patients, respectively. Five crossover trials reported adverse events for both APAP and CPAP treatments. One trial (n = 55) reported a higher frequency of total number of events and another trial (n = 34) reported a higher incidence of pressure discomfort with CPAP therapy arm compared with the APAP treatment. Three trials (n = 112) reported no differences in adverse events between the treatment groups. | Low Similar |
AHI = apnea–hypopnea index; APAP = Auto-adjusted (autoregulated) continuous positive airway pressure; CPAP = continuous positive airway pressure; RCT = randomized controlled trial; SF-36 = Short Form-36; SMD = standardized mean difference; WMD = weighted mean difference
- a
Strength of Evidence Elements28
Precision: Degree of certainty surrounding an effect estimate; in meta-analysis, the confidence interval around the summary effect size
Consistency: Degree to which reported effect sizes appear to have the same direction of effect
Directness: Whether the evidence links the interventions directly to health outcomes
Risk of bias: Degree to which includes studies have a high likelihood of protection against bias; 2 main elements are study design and aggregate quality of the studies
- b
Direction of difference between groups
- STRENGTH OF EVIDENCE - The Comparative Effectiveness, Harms, and Cost of Care Mo...STRENGTH OF EVIDENCE - The Comparative Effectiveness, Harms, and Cost of Care Models for the Evaluation and Treatment of Obstructive Sleep Apnea (OSA): A Systematic Review
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