Stay Alert to Sleep Apnea Burden in the Military

Obstructive sleep apnea (OSA) was associated with a significantly increased risk for adverse health outcomes and healthcare resource use among military personnel in the US, according to data from approximately 120,000 active-duty service members.

OSA and other clinical sleep disorders are common among military personnel, driven in part by demanding, nontraditional work schedules that can exacerbate sleep problems, but OSA’s impact in this population has not been well-studied, Emerson M. Wickwire, PhD, of the University of Maryland School of Medicine, Baltimore, and colleagues wrote in a new paper published in Chest.

In the current health economic climate of increasing costs and limited resources, the economic aspects of sleep disorders have never been more important, Wickwire said in an interview. The data in this study are the first to quantify the heath and utilization burden of OSA in the US military and can support military decision-makers regarding allocation of scarce resources, he said.

To assess the burden of OSA in the military, they reviewed fully de-identified data from 59,203 active-duty military personnel with diagnoses of OSA and compared them with 59,203 active-duty military personnel without OSA. The participants ranged in age from 18 to 64 years; 7.4% were women and 64.5% were white individuals. Study outcomes included new diagnoses of physical and psychological health conditions, as well as healthcare resource use in the first year after the index date.

Approximately one third of the participants were in the Army (38.7%), 25.6% were in the Air Force, 23.5% were in the Navy, 5.8% were in the Marines, 5.7% were in the Coast Guard, and 0.7% were in the Public Health Service.

Over the 1-year study period, military personnel with OSA diagnoses were significantly more likely to experience new physical and psychological adverse events than control individuals without OSA, based on proportional hazards models. The physical conditions with the greatest increased risk in the OSA group were traumatic brain injury and cardiovascular disease (which included acute myocardial infarction, atrial fibrillation, ischemic heart disease, and peripheral procedures), with hazard ratios (HRs) 3.27 and 2.32, respectively. The psychological conditions with the greatest increased risk in the OSA group vs control individuals were posttraumatic stress disorder (PTSD) and anxiety (HR, 4.41, and HR, 3.35, respectively).

Individuals with OSA also showed increased use of healthcare resources compared with control individuals without OSA, with an additional 170,511 outpatient visits, 66 inpatient visits, and 1,852 emergency department visits.

Don’t Discount OSA in Military Personnel

“From a clinical perspective, these findings underscore the importance of recognizing OSA as a critical risk factor for a wide array of physical and psychological health outcomes,” the researchers wrote in their discussion.

The results highlight the need for more clinical attention to patient screening, triage, and delivery of care, but efforts are limited by the documented shortage of sleep specialists in the military health system, they noted.

Key limitations of the study include the use of an administrative claims data source, which did not include clinical information such as disease severity or daytime symptoms, and the nonrandomized, observational study design, Wickwire told Medscape Medical News.

Looking ahead, the researchers at the University of Maryland School of Medicine and the Uniformed Services University, Bethesda, Maryland, are launching a new trial to assess the clinical effectiveness and cost-effectiveness of telehealth visits for military beneficiaries diagnosed with OSA as a way to manage the shortage of sleep specialists in the military health system, according to a press release from the University of Maryland.

“Although the association between poor sleep and traumatic stress is well-known, present results highlight striking associations between sleep apnea and posttraumatic stress disorder, traumatic brain injury, and musculoskeletal injuries, which are key outcomes from the military perspective,” Wickwire told Medscape Medical News.

“Our most important clinical recommendation is for healthcare providers to be on alert for signs and symptoms of OSA, including snoring, daytime sleepiness, and morning dry mouth,” said Wickwire. “Primary care and mental health providers should be especially attuned,” he added.

Results Not Surprising, but Research Gaps Remain

“The sleep health of active-duty military personnel is not only vital for optimal military performance but also impacts the health of Veterans after separation from the military,” said Q. Afifa Shamim-Uzzaman, MD, an associate professor and a sleep medicine specialist at the University of Michigan, Ann Arbor, Michigan, in an interview.

The current study identifies increased utilization of healthcare resources by active-duty personnel with sleep apnea, and outcomes were not surprising, said Shamim-Uzzaman, who is employed by the Veterans’ Health Administration, but was not involved in the current study.

The association between untreated OSA and medical and psychological comorbidities such as cardiovascular disease, diabetes, and mood disorders such as depression and anxiety is well-known, Shamim-Uzzaman said. “Patients with depression who also have sleep disturbances are at higher risk for suicide — the strength of this association is such that it led the Veterans’ Health Administration to mandate suicide screening for Veterans seen in its sleep clinics,” he added.

“We also know that untreated OSA is associated with excessive daytime sleepiness, slowed reaction times, and increased risk of motor vehicle accidents, all of which can contribute to sustaining injuries such as traumatic brain injury,” said Shamim-Uzzaman. “Emerging evidence also suggests that sleep disruption prior to exposure to trauma increases the risk of developing PTSD. Therefore, it is not surprising that patients with sleep apnea would have higher healthcare utilization for non-OSA conditions than those without sleep apnea,” he noted.

In clinical practice, the study underscores the importance of identifying and managing sleep health in military personnel, who frequently work nontraditional schedules with long, sustained shifts in grueling conditions not conducive to healthy sleep, Shamim-Uzzaman told Medscape Medical News. “Although the harsh work environments that our active-duty military endure come part and parcel with the job, clinicians caring for these individuals should ask specifically about their sleep and working schedules to optimize sleep as best as possible; this should include, but not be limited to, screening and testing for sleep disordered breathing and insomnia,” he said.

The current study has several limitations, including the inability to control for smoking or alcohol use, which are common in military personnel and associated with increased morbidity, said Shamim-Uzzaman. The study also did not assess the impact of other confounding factors, such as sleep duration and daytime sleepiness, that could impact the results, especially the association of OSA and traumatic brain injury, he noted. “More research is needed to assess the impact of these factors as well as the effect of treatment of OSA on comorbidities and healthcare utilization,” he said.

This study was supported by the Military Health Services Research Program.

Wickwire’s institution had received research funding from the American Academy of Sleep Medicine Foundation, Department of Defense, Merck, National Institutes of Health/National Institute on Aging, ResMed, the ResMed Foundation, and the SRS Foundation. Wickwire disclosed serving as a scientific consultant to Axsome Therapeutics, Dayzz, Eisai, EnsoData, Idorsia, Merck, Nox Health, Primasun, Purdue, and ResMed and is an equity shareholder in Well Tap.

Shamim-Uzzaman is an employee of the Veterans’ Health Administration.