The Circuitous Route to Diagnosing

Sleep Disorders in Women: Health

Care Utilization and Benets of
Improved Awareness for Sleep
Disorders
Katsuhisa Banno, MD
a
, Meir H. Kryger, MD, FRCPC
b,
*
Sleep disorders that are common in women in-
clude insomnia [1], sleep breathing disorders [2],
restless legs syndrome (RLS) [3,4], and sleep dis-
turbance caused by mental conditions such as
depression [5]. It has been shown that there
may be a long interval between the onset of
symptoms and the correct diagnosis of some sleep
disorders [3,4,6]. The increasing demand for the
diagnosis and treatment of sleep-related breathing
disorders has led to long waiting lists for consul-
tation and therapeutic services in clinics and
hospitals [6]. In addition, sleep disorders may
be comorbid with medical problems; when nally
evaluated for their sleep problems, many patients
who have sleep disorders have been found to have
psychiatric and medical conditions [1,711].
Gender differences in symptoms and clinical
presentation [1215] also may result in delayed
diagnosis in women who have a sleep disorder.
The circuitous route to correct diagnosis of a sleep
disorder, or sleep disorders, consequently may
lead to a negative impact on health care systems,
because patients who have untreated sleep disor-
ders may develop new psychiatric and medical
S L E E P
M E D I C I N E
C L I N I C S
Sleep Med Clin 3 (2008) 133140
Supported in part by National Institutes of Health grant RO1 HL082672-01.
a
Sleep Disorders Center, Kitatsushima Hospital, 307 Yomefuri, Heiwa-cho, Inazawa-city, Aichi, 490-1323,
Japan
b
Sleep Research and Education, Gaylord Hospital, 400 Gaylord Farm Road, Wallingford, CT 06492, USA
* Corresponding author.
E-mail address: mkryger@gaylord.org (M.H. Kryger).
- Obstructive sleep apnea syndrome
Health care use in obstructive
sleep apnea syndrome
Factors affecting health care use
in patients who have obstructive
sleep apnea syndrome
Changes in health care use before
treatment and after treatment
Health care use in women who
have obstructive sleep apnea
syndrome
Gender differences in the clinical
presentation of obstructive
sleep apnea syndrome
- Insomnia
Impact of insomnia on health care cost
Association of insomnia with psychiatric
conditions
Gender differences of insomnia
and health care use in women
- Summary
- References
133
1556-407X/08/$ see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jsmc.2007.10.004
sleep.theclinics.com
comorbidities. This article reviews the impact
of sleep disorders in women on health care
utilization and the benets of diagnosis and
treatment.
Sleep disorders are classied into more than 80
diagnostic entities by the International Classica-
tion of Sleep Disorders published in 2005 [16].
Some sleep disorders such as obstructive sleep
apnea syndrome (OSAS), insomnia, and RLS are
prevalent in women and may lead to a negative
impact on the patients health and quality of life
[15]. These disorders may play a role in the devel-
opment of new medical comorbidities and mental
conditions [2,5,8]. Thus untreated and delayed
diagnosis of primary sleep disorders ultimately
may increase health care utilization. Each sleep dis-
order may have an impact on health care systems;
however, few cost analysis data have been reported
for specic sleep disorders. Therefore this article
reviews the impact of common sleep disorders in
women, especially OSAS and insomnia, on health
care utilization.
Obstructive sleep apnea syndrome
OSAS is a common disorder characterized by repet-
itive cessation of breathing during sleep caused by
upper airway obstruction, with consequences of
hypoxemia and fragmented sleep. OSAS has been
reported to affect middle-aged people (4% of men
and 2%of women) [17]. A systemic reviewreported
by Young and colleagues [2] in 2002 showed that
OSAS may affect up to 5% of adults. The prevalence
of OSAS may be higher now, however, because of re-
cent trends of increasing obesity [18] and the
greater awareness of OSAS compared with a decade
ago. Common causes of OSAS include obesity,
craniofacial malformation (eg, retrognathia and mi-
crognathia), and obstruction of upper airway by en-
larged tonsils and adenoids [19]. The abnormal
breathing in sleep consequently leads to daytime
sleepiness and impaired cognitive function, result-
ing in impaired quality of life [20]. Depressive
symptoms may be present in patients who have
OSAS [21]. Hypoxemia and metabolic dysfunction
caused by repetitive apneas have been reported to
play a role in the development of hypertension,
heart failure, stroke, and insulin resistance [2226].
Health care use in obstructive sleep apnea
syndrome
For several years before diagnosis, patients who
have OSAS use health care resources at higher rates
than those who do not have OSAS [2731]. In-
creased health care expenditure in patients who
have OSAS may be caused by comorbidities,
because many have been diagnosed with medical
or psychiatric comorbidities before the recognition
of OSAS. Health care utilization was assessed using
total expenditure from physician claims and num-
ber of hospital stays or clinic visits, which are surro-
gates of health care cost [2731]. One of the
problems in estimating health care expenditure in
a particular patient group is the variability of payer
systems for health care in each region; this variabil-
ity may skew data signicantly. Thus a one-payer
system with complete health care data, which
allows accurate tracking of long-term health care
utilization, (eg, the Manitoba Canada health data-
base) [32] is considered appropriate for evaluation
of health care expenditure.
The rst study to conrm that patients who have
OSAS are heavy users of health care was reported by
Kryger and colleagues [27] in 1996. They compared
physician claims and number of hospital stays of
97 obese patients who had OSAS with those of
97 controls for the 2 years before the initial OSAS
diagnosis. Total health care expenditures calculated
from physician claims were $82,238 (Canadian
dollars) for the OSAS group versus $41,018 for the
control group (P<.01). The OSAS group had 251
nights in hospital, compared with 90 nights for
the control group, and they spent between
$100,000 and $200,000 more in services than the
control group. Thus, there is an increased health
care cost in the few years just before evaluation
for OSAS. This result led to the question of how
far back the increased health care cost in the
OSAS group was seen.
The study reported by Ronald and colleagues [28]
in 1999 looked at health care utilization 10 years
before diagnosis using the number of hospital stays
and physician claims in 181 patients who had OSAS
compared with those of age- and gender-matched
controls. Health care expenditure calculated from
physician claims was $686,365 ($3972 per patient)
for the OSAS group, compared with $356,376
($1969 per patient) for the control group for the
10-year period before OSAS diagnosis. In addition,
the OSAS group also had more hospital stays: 1118
nights (6.2 per patient), versus 676 nights (3.7 per
patient) for the control group. The OSAS group
used more health care resources than the control
group in 7 of 10 years before OSAS diagnosis.
In North America most patients who have OSAS
are overweight or obese. The mean body mass index
(BMI) at time of referral to a sleep disorders center
has been reported to be 32.2 0.1 kg/m
2
(SE)
(95% condence interval [CI], 32.032.4) in men
versus 34.5 0.2 kg/m
2
(95% CI, 34.135.0) in
women (P < .0001) [18], indicating a high preva-
lence of obesity in patients who have OSAS. Obesity
also may play a role in the increased health care use
in patients who have OSAS, because obesity, which
Banno & Kryger 134
is associated with metabolic syndrome, is a known
risk factor of ischemic heart diseases, stroke, and
diabetes mellitus [33,34]. These two reports on
heath care utilization in patients who have OSAS
veried increased health care utilization before
OSAS diagnosis. The factors determining the health
care resource have remained unclear, however.
Factors affecting health care use in patients
who have obstructive sleep apnea syndrome
The comorbidities affecting health care utilization
have been reported by Smith and colleagues [10].
The group investigated health care resources and
medical diagnoses made before the diagnosis of
OSAS in 773 patients and found that patients
who have OSAS are more likely to receive a diagno-
sis of hypertension before the OSAS diagnosis is
made (odds ratio [OR], 2.5; 95% CI, 2.0 to 3.3)
[10]. Otake and colleagues [35] reported that
many patients who have OSAS are taking antihyper-
tensive medications before their OSAS diagnosis is
made: the OR of OSAS patients taking medications
indicated for the treatment of systemic hyperten-
sion was 2.71 (95% CI, 1.963.77) compared
with controls. The use of medications indicated
for the treatment of systemic hypertension was
predicted by age, BMI, and apnea-hypopnea index.
Patients who have OSAS also are at higher risk for
congestive heart failure (OR, 3.9; 95% CI, 1.78.9),
cardiac arrhythmias (OR, 2.2; 95% CI, 1.24.0),
chronic obstructive airways disease (COPD) (OR,
1.6; 95% CI, 1.22.0), and depression (OR, 1.4;
95% CI, 1.01.9) [10]. Age and BMI signicantly
predicted diagnoses of cardiovascular diseases and
arthropathy in patients who had OSAS. Male gen-
der predicted ischemic heart disease (OR, 2.98;
95% CI, 1.366.54). In contrast, female gender
was a signicant predictor for COPD (OR, 2.63;
95% CI, 1.853.72) and depression (OR, 2.24;
95% CI, 1.453.44).
Tarasiuk and colleagues [36], in another single-
payer system (Israel), reported increased health
care utilization in the 2 years before OSAS diagnosis
in patients who had OSAS compared with a control
group. The increased expenses particularly resulted
from hospital stays (P<.001), consultations
(P<.001), and cost of drugs (P<.05), especially for
cardiovascular diseases. They also concluded that
women who had a diagnosis of OSAS consumed
more health care resources than men. In addition,
patients who had OSAS and were older than
65 years consumed 2.2-fold more health care
resources than controls (P<.001). The same research
group reported that older age, use of antipsychotic
and anxiolytic drugs, and asthma contribute signif-
icantly to the higher health care cost in women who
have OSAS [37]. Age and female gender may be
possible factors affecting health care utilization in
patients who have OSAS.
Changes in health care use before treatment
and after treatment
The rst report on a change of health care utiliza-
tion by treatment intervention for OSAS was by
Bahammam and colleagues [29], who used the
Manitoba health database. The group compared
physician claims and hospital stays of 344 men
who had OSAS with those of controls from the gen-
eral population, matched for age and geographic
location, 1 and 5 years before treatment and for 2
years after treatment. The effect of continuous
positive airway pressure (CPAP) adherence on
health care resources was examined also. The differ-
ence in health care expenditure between the entire
OSAS group and the control group 2 years after
diagnosis and treatment ($174 32 per year) was
less than the difference in the year before diagnosis
($260 36 per year) (P 5.038). There was a signif-
icant difference in physician claims between the
282 patients adhering to CPAP therapy and con-
trols: $267 37 1 year before diagnosis versus
$181 36 2 years after treatment (P 5 .05). In
contrast, a signicant difference in physician claims
was not observed between the 62 patients not
adhering CPAP treatment: $236 1041 year before
treatment, versus $141 72 2 years after treatment
(P 5.44). Interestingly, in the 5 years before OSAS
diagnosis, patients not adhering to CPAP treatment
spent more on physician claims than patients
adhering to CPAP treatment for cardiovascular dis-
orders ($75.76 25.97 versus $31.54 3.41 per
year; P 5 .0019) and genitourinary disorders
($13.39 3.91 versus $6.93 1.28 per year; P 5
.05). The noncompliant patients also were older
and had a lower apnea-hypopnea index, which
might have made adherence to therapy more prob-
lematic for this group.
Albarrak and colleagues [30] assessed the effect of
long-term use of CPAP on health care utilization.
Theycomparedphysicianclaims andphysicianvisits
for 342 men who had OSAS with those of matched
controls for whom there were utilization data for 5
years before initial OSAS diagnosis and for 5 years
of CPAP treatment. In the patients who had OSAS,
physician visits increased by 3.46 0.2 (95% CI,
2.574.36) during the year immediately before diag-
nosis comparedwiththe fthyear preceding diagno-
sis and then decreased for the 5 years of treatment by
1.03 0.49 (95% CI, 1.99 to 0.07; P<00,001).
Physician claims also increased by $148.65
27.27 (95%CI, 95.12202.10) in the 5 years leading
up to diagnosis in the patient group and decreased
over the next 5 years by $13.92 27.94 (95%
CI, 68.68 to 40.83; P 5.0009).
Diagnosing Sleep Disorders in Women 135
Thus, these two reports emphasize that early di-
agnosis and treatment result in long-term as well
as short-term cost benets. Patients who have
OSAS, however, may already have been diagnosed
with a comorbid condition that could affect health
care use before OSAS diagnosis and after treatment.
Smith and colleagues [10] reported that cardiovas-
cular diseases, especially hypertension and heart
failure, were more frequently diagnosed in both
men and women who had OSAS than in their
controls during the 5 years before OSAS diagnosis.
Pre-existing ischemic heart disease at the time of
OSAS diagnosis has been reported to predict about
a vefold increase in health care expenditure
between the second and fth year of treatment [30].
Health care use in women who have
obstructive sleep apnea syndrome
Increasing trends in health care utilization before
diagnosis and decreasing trends in physician claims
and ambulatory clinic visits after assessment and
treatment of OSAS have been found in women
who have OSAS [31]. There was an increase in
fees of $123.43 25.01 in the 2 years before diag-
nosis and a reduction in fees of $37.96 21.35 in
the 2 years after diagnosis of OSAS (P<.0001). The
number of clinic visits by women who had OSAS
also increased by 2.32 0.43 visits in the 2 years
before diagnosis and decreased by 1.48 0.42 visits
during the next 2 years (P<.0001). Thus early diag-
nosis and treatment recommendation help stem
the consumption of health care resources in women
who have OSAS. A change in health care utilization
after long-term use of CPAP is not yet clear in
women who have OSAS, however.
Gender differences in the clinical
presentation of obstructive sleep apnea
syndrome
Some differences in the clinical presentation of
OSAS between men and women have resulted in
a referral bias to sleep clinics in favor of men
[13,3844]. Young and colleagues [45] reported
that more than 90% of women who had moderate
to severe OSAS may be undiagnosed. Larsson and
colleagues [46] estimated the referral rate for men:-
women, after correction for population and preva-
lence of symptoms, may be 1.25:1 (P 5 .012).
Men who have OSAS are more likely to have symp-
toms of snoring, observed apnea, or sleepiness,
whereas women who have OSAS have more symp-
toms of depression or morning headache
[10,38,39]. Women rst diagnosed as having
OSAS are more likely than men to have been diag-
nosed previously with depression or COPD [10].
Comparing the clinical presentations before OSAS
diagnosis of women with those of men matched
for sleep apnea severity, subjective sleepiness, BMI,
and age, Shepertycky and colleagues [13] concluded
that a history of depression and hypothyroid disease
and a presenting complaint of insomnia were seen
more frequently in women; men were more likely
to have a history of witnessed apnea and greater caf-
feine and alcohol consumption. Another study also
reported that women who have OSA are more likely
than men who have OSA to be diagnosed with hy-
pothyroidism(OR, 4.7; 95%CI, 2.310) or arthrop-
athy (OR, 1.6; 95% CI, 1.12.2), but the women
had a lower risk for comorbid cardiovascular disease
(OR, 0.7; 95% CI, 0.50.91) [37].
Different clinical presentations may result in
fewer referrals of women to a sleep clinic, resulting
in more undiagnosed OSAS in women. Women
diagnosed as having OSAS are more obese than
men who have OSAS [47,48] and are more likely
to have comorbid mental disorders such as depres-
sion [10,49]. The updated data published in 2007
by Greenberg-Dotan and colleagues [37] on gender
differences in health care use among patients who
have OSAS showed that women who had OSAS
received more antidepressants, hypnotics, and anxi-
olytics before OSAS diagnosis than men who had
OSAS matched for age, BMI, and apnea-hypopnea
index. In addition, the investigators concluded
that health care expenditure for drugs was 1.3 times
higher in women who had OSAS than in men who
had OSAS (P<.0001).
Thus it is possible that undiagnosed OSAS in
women may impact health care systems more sig-
nicantly than undiagnosed OSAS in men. The
prevalence of OSAS in men has been reported to
be about double that in women [17]; however, over-
all health care utilization between the genders may
be similar or greater in women than in men because
of more severe obesity and the greater prevalence of
comorbid psychiatric conditions in women. Early
treatment of OSAS may contribute to the reduced
consumption of health care resources in men.
Insomnia
Insomnia is characterized by difculty in sleep
initiation, maintenance, duration, or quality that
occurs despite adequate time and opportunity for
sleep, along with daytime impairments such as
fatigue, attention impairment, sleepiness, mood
disturbance, and social dysfunction [1,16,50,51].
Insomnia is classied into two types: idiopathic
insomnia and comorbid insomnia. The former
has no identied specic cause; in contrast, the
latter refers to insomnia symptoms that are related
to comorbid medical and psychiatric conditions
or drugs [1,16,51]. Insomnia often may accompany
acute or chronic medical conditions; changes in the
Banno & Kryger 136
sleep-wake schedule, pain, dyspnea, urinary incon-
tinence, and the use of certain medications may
lead to insomnia symptoms. Stress, symptoms of
depression, or anxiety in reaction to the medical
conditions and primary sleep disorders such as
OSAS and RLS also may cause sleep disturbances.
Impact of insomnia on health care cost
Insomnia is a major public health problem affect-
ing millions of individuals, along with their fami-
lies and communities, in European countries,
North America, and Australia [5258]. The cost of
medications used to treat insomnia has been
reported to total $1.97 billion in the United States
in 1995 [52]. Epidemiologic data reported by Leger
and colleagues [53] estimated the total cost of
insomnia in France at $2 billion, which was spent
for hypnotics and fees for physicians and sleep
specialists for treatment in outpatient clinics. The
National Institutes of Health, in their Science Con-
ference statement in 2005, concluded that the direct
and indirect annual cost for chronic insomnia in
adults was estimated to be tens of billions of dollars
[1]. Updated data on the cost analysis for untreated
insomnia in the United States by Ozminkowski and
colleagues [59] published in 2007 showed that the
average direct and indirect costs for younger adults
who had insomnia were about $924 greater than
for patients who did not have insomnia: $4755
for patients treated for insomnia, versus $3831 for
controls (P < .01); among the elderly, direct costs
were about $1143 greater for patients who had
insomnia: $5790 for patients treated for insomnia,
versus $4648 for controls (P < .01). Thus insomnia
is a costly medical condition that burdens health
care systems.
Association of insomnia with psychiatric
conditions
Psychiatric conditions may result in sleep distur-
bance in many women. Starting from puberty until
menopause, women are at twice the lifetime risk of
developing major depression than men [60,61].
Sleep disturbance is common in depression; the
most common subjective complaint is insomnia,
including difculty falling asleep, frequent awaken-
ings, and early morning awakenings [7,62,63]. Psy-
chiatric disturbance such as depression is a risk
factor for insomnia in women [6466]. People
who have insomnia have been reported to be 9.82
times more likely to have clinically signicant de-
pression than people who do not have insomnia
[7]. The risk of insomnia has been reported to be
higher in patients who have depression (mild
insomnia: OR, 2.6; 95% CI, 1.93.5; P<.001; severe
insomnia: OR, 8.2; 95% CI, 5.712.0; P<.001) [67].
Breslau and colleagues [8] concluded that the
relative risk for new-onset depression in people
who had insomnia was 4.0 (95% CI, 2.27.0).
There are lifetime associations of insomnia with
anxiety disorder and with depression [68]. Among
those who have comorbid disorders, anxiety disor-
ders preceded insomnia 73% of the time, whereas
insomnia occurred rst in 69% of patients who
had comorbid insomnia and depression [68].
Using the Hospital Anxiety and Depression scale,
Lindberg and colleagues [69] concluded that anxi-
ety affected women more frequently than men
(32.8% for women, versus 18.9% for men;
P < .001).
Thus these reports suggest that a causal link
between insomnia and psychiatric conditions
seems to be bi-directional. Medical conditions
may lead to the development of insomnia
[1,16,51,63]; conversely, women who have primary
sleep disorders such as OSAS and RLS also have
been reported to be diagnosed more frequently
with depression or to be treated with antidepres-
sants [9,10,13]. Because these sleep disorders may
manifest with insomnia caused by depressive symp-
toms, delayed referral to a sleep clinic may have an
adverse impact on health care utilization by
women.
Gender differences of insomnia and health
care use in women
Insomnia is more common in women than in men
[64,65]. The gender differences in risk factors for
insomnia and in clinical presentations of insomnia
may affect health care use in women. Li and
colleagues [64] reported that women were at about
1.6 times higher risk for insomnia than men. Gen-
der differences in insomnia may include differences
in the prevalence of psychiatric morbidities, symp-
tom endorsement, gonadal steroids, socio-cultural
factors, and coping strategies. Su and colleagues
[65] reported that factors associated with insomnia
for both genders were nocturia and regular use of
hypnotics. Risk factors for men included pulmo-
nary disease, single status, excessive daytime sleepi-
ness, and mental illness, whereas lack of education
and body pain were risk factors in women. Depres-
sion was strongly associated with insomnia in older
women. A report by Chung and Tang [70] showed
that somatic complaints, psychologic symptoms,
and perceived stress were independent risk factors
for sleep disturbance; women who had those symp-
toms had four to six times greater risk of reporting
disturbed sleep. Women seem more likely than
men to have insomnia, which is associated with
psychiatric conditions.
Women who have insomnia may have more im-
pact on health care systems than men who have
insomnia. Rasu and colleagues [71] investigated
Diagnosing Sleep Disorders in Women 137
health care use in patients who have insomnia and
found that that men who had insomnia were less
likely to receive a prescription for a medication
than women who had insomnia (OR, 0.61; 95%
CI, 0.450.81). Simon and VonKorff [72] investi-
gated characteristics of outpatients who had insom-
nia in the United States and found that women
were 1.5 times more likely to have insomnia-related
physician visits (P<.001). Sleep disturbance was
most frequently attributed to medical conditions
(55.8%), depression and/or anxiety (27.3%), and
primary insomnia (9.8%) (P<.001). In addition,
they found that patients who had insomnia spent
more on health care services during the 3 months
before and the 3 months after a screening visit to
a clinic than those who did not have insomnia
($2287 versus $1418, respectively) [72].
Insomnia is responsible for increased health care
expenditure, but comprehensive cost-effectiveness
analyses of different diagnostic and treatment strat-
egies is challenging because of the variability in the
denition of insomnia and methods of assessment
for direct and indirect costs. Martin and colleagues
[73] concluded that effective insomnia manage-
ment holds promise as a cost-effective health care
intervention. Some drugs for insomnia manage-
ment have been reported to contribute to the reduc-
tion of health care cost in patients who have
insomnia [74,75].
Summary
The different clinical presentations of OSAS and
low suspicion for it in women may lead to delayed
diagnosis. Women diagnosed as having OSAS tend
to be more obese and to have depression more
frequently than men. Women, in whom insomnia
is more common, also have a higher incidence of
anxiety and depression than men. Sleep disorders
may impact womens health care expenditures. A
cost burden is incurred by untreated and delayed
sleep disorders. Increased awareness, and thus early
diagnosis, of a sleep disorder may contribute to cost
savings and improve the patients quality of life.
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