The following originally appeared on The Upshot (copyright 2019, The New York Times Company). It also appeared on page A25 of the print edition on December 10, 2019.
Both of us have sleep apnea, and both of us receive treatment that makes a world of difference.
It could make a big difference in your life, too. Sleep apnea is quite common, with estimates that it affects up to 17 percent of men and 9 percent of women ages 50 to 70, and 10 percent of men and 3 percent of women 30 to 49.
But there’s a problem. In the American health system, we often make it hard for people to get care, and the same is true here.
Obstructive sleep apnea is when the upper airway collapses during sleep, leading to periods of, well, not breathing. About 24 million Americans have sleep apnea and don’t know it, research suggests, and many who do know don’t get treatment.
The consequences can be severe. It’s a leading cause of vehicle accidents, as apnea-afflicted drivers fall asleep behind the wheel. Snoring and sleep apnea are on the same spectrum and are associated with Type 2 diabetes in adults. Treatment is associated with improvements in insulin resistance. Having sleep apnea, and not treating it, increases the risk of postoperative cardiovascular surgery complications.
Treating sleep apnea improves sleep duration and quality. People who sleep better are much happier and healthier in general. Reducing snoring also helps partners sleep better.
How hard is it to get used to a mask?
We were treated with continuous positive airway pressure (CPAP).
It’s intrusive, though not nearly as much as we had feared. Each night we strap on masks connected to CPAP machines. The modern machines are silent. And we both use masks that cover only our nostrils, though others need full face masks. The air that the machines push through the masks keeps our airways open. It takes some getting used to, but we adapted within a week. This isn’t to say that it’s not a big deal for many people — it can be. But it’s not as scary as many fear.
The difference in sleep is well worth the effort of adjustment. It’s easier both to fall and stay asleep. We feel more refreshed and less tired all day. The machines these days come with apps that track and grade your use of them, and both of us (being the obsessives we are) manage to squeak out a nearly perfect score nightly. Since being prescribed the therapy, we have used it pretty much every single night, and even bought smaller machines for travel.
But many people avoid diagnosis or, once diagnosed, don’t follow through with therapy. Others find therapy harder than we did and give up. We can sympathize. Though we adapted to our machines relatively easily, we had considerable trouble getting them in the first place. Giving up would have been the easy, short-term thing to do.
There are some alternatives to CPAP with evidence of effectiveness. Some people sleep better with oral appliances or nasal patches. Some are treated with surgery, but that’s usually reserved for the worst cases.
How much does it cost?
A diagnosis of obstructive sleep apnea requires an overnight sleep study. Until recently, this meant sleeping in a lab, attached to measuring machines all night long. It was expensive, hard to schedule, and usually left you tired the next day. Austin did this, and it was one of the worst nights of sleep in his life. Still, he considers it worth it because it confirmed the diagnosis and made the need for treatment clear.
These days, sleep studies can be done at home with machines lent to you. Aaron was diagnosed at home, though it still required an appointment to explain how to use the testing machines. It cost a fair amount, and he had to return the machines the next day. All of this took time. Austin might have been diagnosed at home, but the machines he was given for home testing failed, another source of frustration and wasted time.
After the results came back confirming sleep apnea, we both had to have another appointment with a sleep specialist. That took more time and another co-payment, though its only purpose seemed to be to get a prescription for therapy. After that, we had to deal with a sleep center or respiratory device supplier for another appointment for equipment training and distribution.
All of this wasn’t cheap, neither for equipment nor for the time missed from work for the appointments. We’re lucky that we could do all this, but for many it is a barrier to care.
Insurance companies don’t make things easy, either. Each device can easily run $1,000; insurers don’t want to pay for equipment that isn’t used. To justify the expense, insurance companies usually monitor the machines’ use to make sure they’re being employed. While we enjoyed the app that told us how compliant we were being, others have found themselves being refused coverage by their insurance because the app reported they failed to use the machine enough.
Should doctors just give them out?
All of these issues make obstructive sleep apnea a condition that is hard to get a handle on. There’s failure on both ends. Many people who receive the diagnosis don’t make use of a therapy that might improve their lives. But even more go undiagnosed. This is not uncommon in the health system: Americans complain that many conditions, like attention deficit hyperactivity disorder and even breast cancer, are both under- and over-diagnosed at the same time.
Still, because of the number of cases of sleep apnea going untreated, some have proposed universal screening. Officials at the U.S. Preventive Services Task Force weighed in two years ago. They noted that the benefits of screening would include earlier diagnosis, leading to better sleep and quality of life. The harms include treatment side effects like discomfort in the nose or mouth area from using a mask.
Given such a trade-off, it seems like screening would be a good idea. But there was too little evidence to recommend looking for it in people who have no symptoms. The task force issued an “I,” which calls for more research.
Another thought: that we not even bother with the sleep studies. The CPAP machines are now so sophisticated that they can record sleep apnea episodes and fix them. Doctors could just give the machines out — instead of ordering home sleep studies — and use them to determine if patients (1) need the devices and (2) would actually use them. Given how expensive sleep studies are, this might even save money. For now, though, this is just an idea, not anything anyone has put into practice.
Many Americans complain about their sleep. They turn to medications, like Ambien. They turn to supplements, like melatonin. They turn to devices and software. These days, they even seem to turn to unproven solutions like CBD oil. Many, however, probably suffer from sleep apnea. What they need are open airways while they sleep, and a health care system that makes it easier for them to get them.
@aaronecarroll and @afrakt