Anesthesiology. 2020 Oct 1;133(4):787-800. doi: 10.1097/ALN.0000000000003429.
Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study's objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients' remaining lifespans.
An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio.
In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses.
The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.
手术患者中阻塞性睡眠呼吸暂停的诊断不足。阻塞性睡眠呼吸暂停筛查的成本效益尚不清楚。本研究的目的是评估术前阻塞性睡眠呼吸暂停筛查（1）围手术期和（2）包括患者剩余寿命的成本效益。
构建了个体水平的马尔可夫模型，以模拟接受择期住院手术的患者的围手术期和寿命。从单一支付者医疗体系的医院角度计算了成本（2016 年加拿大元）。剩余模型参数来源于结构化文献检索。候选策略包括：（1）不筛查；（2）仅使用 STOP-Bang 问卷；（3）STOP-Bang 后进行多导睡眠图（STOP-Bang +多导睡眠图）；和（4）STOP-Bang 后使用便携式监测仪（STOP-Bang +便携式监测仪）。基于 STOP-Bang 截断值（至少 3 分）为阳性的筛查患者接受术后治疗修改和加速明确测试。有效性在围手术期分析中表示为质量调整生命月，在终生分析中表示为质量调整生命年。主要结果是增量成本效益比。
在围手术期和终生分析中，不筛查的成本最低，效果最差。STOP-Bang +多导睡眠图是最有效的策略，与 STOP-Bang +便携式监测仪和 STOP-Bang 单独相比，在两种分析中均更具成本效益。在围手术期分析中，与不筛查相比，STOP-Bang +多导睡眠图在 4167 美元/质量调整生命月的阈值下没有成本效益（增量成本效益比为 52888 美元/质量调整生命月）。在概率敏感性分析的大多数迭代中，超过 90%的迭代都倾向于不筛查。相比之下，在终生分析中，与不筛查相比，STOP-Bang +多导睡眠图在 50000 美元/质量调整生命年的阈值下更具成本效益（增量成本效益比为 2044 美元/质量调整生命年）。在概率敏感性分析中，在高于 2000 美元/质量调整生命年的阈值下，STOP-Bang +多导睡眠图在大多数迭代中都具有优势。
术前阻塞性睡眠呼吸暂停筛查的成本效益因时间范围而异。使用 STOP-Bang 进行术前筛查，并立即进行多导睡眠图确认测试是终生有效的，但在围手术期无效。基于 STOP-Bang 和多导睡眠图的术前筛查的整合是减轻阻塞性睡眠呼吸暂停长期疾病负担的一种具有成本效益的方法。
