Untreated sleep apnea may cost the UK and US billions annually

Untreated obstructive sleep apnea may be costing the UK and US economies billions of pounds/dollars in lost productivity every year, with a considerable proportion of working age adults experiencing symptoms indicative of the breathing disorder, suggests an analysis published online in the journal Thorax.

Around 1 in 5 adults in both countries may have obstructive sleep apnea, the analysis suggests. And the time has now come to trial workplace screening in those most at risk of harm from the daytime sleepiness associated with the condition, such as professional drivers, argue the authors of a linked editorial.

Obstructive sleep apnea occurs when the throat walls relax and narrow or close for 10 seconds or more during sleep, interrupting normal breathing-sometimes several times an hour throughout the night. Those affected tend to snore or wake up, gasping for breath.

As a "serious and underrecognized condition," the researchers wanted to estimate its prevalence in representative population samples from the UK and the US and assess the societal costs of leaving the condition untreated-associated with cardiovascular disease, diabetes, and dementia.

They drew on 3523 respondents to the 2021 US census and 840 respondents to the 2021 UK census, who reported symptoms often associated with obstructive sleep apnea: breathing pauses during sleep and excessive daytime sleepiness on 3 or more nights of the week. 

To estimate the potential economic impact among workingage adults (18–64 year olds), of untreated obstructive sleep apnea, they used a productivity-based approach that accounts for both absenteeism (missed work) and presenteeism (reduced performance at work).

Their analysis suggests that obstructive sleep apnea affects around 1 in 5 adults-23% in the US and 19.5% in the UK.

The census responses showed that nearly 30% of working age adults in the US and 7% of those in the UK met the study criteria for obstructive sleep apnea, suggesting that the total annual productivity loss in the USA might be as high as US$180.2 billion, they estimate.

This corresponds to an estimated annual productivity loss of US$3727 for each worker affected, measured in terms of gross domestic product (GDP), and compares with the annual estimated cost of treating the condition with an air pressure mask (CPAP)---used for moderate to severe sleep apnea-of US$1661.

The equivalent total annual productivity loss in the UK could be as high as £4.22 billion, representing 0.2% of national GDP, and corresponding to a productivity loss for each affected worker of around £1840 every year, the researchers estimate.

Again, this is more than the estimated cost of CPAP treatment, including associated healthcare resources and supportive care, of £1363/patient, they say.

These costs are probably an underestimate as they don't include the impact on healthcare systems of increased medical expenditure, or the costs of road traffic or workplace accidents, they point out.

The researchers caution that obstructive sleep apnea was identified in their study through proxy measures rather than through objective assessment, so precluding assessment of its severity or the ability to rule out other causes of sleepiness.

Nevertheless, they suggest: "Our analysis, though limited to a small subset of [obstructive sleep apnea]-related costs, highlights that the broader workplace productivity burden of [the condition] likely exceeds the direct costs of screening and effective treatment in both the UK and USA."

And they conclude: "Given the significant yet often overlooked burden of [obstructive sleep apnea] syndrome and its economic impact, we urge policymakers to allocate resources towards developing an effective screening strategy and implementing targeted public health campaigns and policies.

"Early identification and treatment of [obstructive sleep apnea], along with proactive early follow-up, could result in substantial savings, potentially amounting to billions of dollars/pounds annually in productivity costs."

Around 80-85% of those with obstructive sleep apnea remain undiagnosed, point out the authors of a linked editorial. And those who experience daytime sleepiness as a result are twice as likely to be injured at work as those without the condition. They are also likely to be less productive.

But 4 key developments have now made setting up a workplace screening programme for the condition worth serious consideration, they argue.

These are:

● Screening algorithms to identify high risk job roles and industries, such as lorry drivers, construction workers, train drivers, pilots, heavy machinery operators, surgeons and people caring for vulnerable children or adults

● The advent of low cost diagnostic technologies-wireless connectivity home testing devices

● Better understanding of the science of CPAP adherence, which many patients find difficult

● More alternatives to CPAP, including GLP-1 agonists (weight loss drugs), airway surgery, hypoglossal nerve stimulation (an implant to stimulate the tongue nerve), mandibular advancement devices (a mouth guard to keep the airway open), or positional sleeping

There are counterarguments to workplace screening, they say. Workers might fear being penalised if they are unable to tolerate treatment or their condition remains inadequately controlled, and a successful screening programme would probably need to offer some form of employment guarantee, they suggest.

There are other issues to highlight. These include higher medical insurance premiums in countries where these apply, because of the known associations between obstructive sleep apnea and other conditions; restrictions on driving for social purposes; and concerns about personal privacy.

"Ultimately, the way to test whether workplace screening would be a worthwhile strategy would be to select an occupation in which [obstructive sleep apnea] is prevalent and has severe consequences, such as professional driving, and see whether relevant outcomes, such as road traffic accidents and absenteeism are clinically and statistically significantly different in a screened group compared with a standard care group," they suggest.

Given that sleep apnea can now be easily identified, and there are more treatment options, "We suggest the time is now approaching for a trial of workplace screening in an exemplar high-risk occupational group," they conclude.