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Has anyone else noticed that sleep apnea machines are being over-prescribed in the US? They were a rarity ~10 years ago, but now it seems like anyone who goes t

Has anyone else noticed that sleep apnea machines are being over-prescribed in the US? They were a rarity ~10 years ago, but now it seems like anyone who goes to a doctor with sleep complaints are prescribed one.

SketchySeaBeast 3y ago
Isn't your assumption likely flawed? If 40% of Americans are obese and that's highly correlated with sleep apnea, why is it necessary they are over-prescribed?
LostLocalMan 3y ago
I'm fairly certain that you have to undergo a sleep study wherein they monitor your breathing and your blood oxygen levels. If your blood oxygen falls to levels that seem dangerous you will be prescribed. So my understanding is it's not as simple as going to the doctor and saying "I slept funny last night".
- tjohns 3y ago
  Breathing and blood oxygen at a minimum, for the take-home tests. If you go into a sleep lab, they also wire you up to an EEG as well to monitor your brain activity. They're not just looking for blood oxygen to drop. They're also looking at how many times you wake up due to airway obstructions. Even if you wake yourself up before your blood oxygen drops, waking up 50+ times/night (this would be considered "mild", btw) is not good for your brain either. But yes, you need a sleep study to be diagnosed with sleep apnea.
  - NoZebra120vClip 3y ago
    Oh, goody, a test. Let's send in as many people as profi...er possible to have that test. Probably helps to start a few print and TV campaigns to Ask Your Doctor If CPAP Is Right For You. Then, over a few decades, let's gradually move the goalposts so that more positive tests continually maximize our shareh...healthcare values. C'mon, think like a CEO
    - malfist 3y ago
      Except the doctors ordering and performing and evaluating these tests are not CEOs.
      - NoZebra120vClip 3y ago
        Exactly: https://en.wikipedia.org/wiki/Superior_orders https://en.wikipedia.org/wiki/Superior_orders
    - pixl97 3y ago
      "Dad died of a heart attack last night, guess we'll never know why" Health is something that is not just in the doctors purview these days. You can personally buy any number of electronic devices that monitor things like blood oxygen and how often you're waking up that will give you some idea of your sleep quality and likelihood of having apena. Or, you can be a cynical old fart and continue accepting that dying at 60 of a heart attack is perfectly normal. Not everything is a vast conspiracy.
      - NoZebra120vClip 3y ago
        I don't know about "vast conspiracy" and as a techie, I fully support testing in order to diagnose and repair. However I just believe that the incentives are perverse and not improving, and it's begetting corruption. Doctors do not order tests out of personal concern for patient's well-being to start healing them; doctors are mandated top-down to tick boxes on a checklist and improve customer engagement. As a techie, I also recognize how teched-up they are, and question why they need all that. I was shoved into a giant MRI and went through the whole theatrical adventure, and guess what - nobody touched that report. Nobody would read it, nobody would tell me what it meant, nobody would use it for treatment. It was hilarious. So glad it wasn't my pocketbook that time. And I had a real concern, not just a suspicion; my shoulder was bad, and fractures had already been ruled-out by a good old X-ray. High-tech is able to supplant "safe, inexpensive and effective" by virtue of profit margins, patents, marketing, and customer perception. I've been honestly rather shocked once in a while, to see a nurse wearing a stethoscope, or checking BP by sphig. I mean, do you realize how much of a fortune those guys are making by selling adhesive nasal strips, after we all developed a huge concern for apnea? What's that line about the American Space Pen and the Russian pencil???
  - mcpackieh 3y ago
    > waking up 50+ times/night (this would be considered "mild", btw) 50+ a night is mild? I thought I had it bad at 2 or 3. 50 times a night is every couple of minutes, do people who have it even worse than this actually manage to sleep at all?
    - johnchristopher 3y ago
      > do people who have it even worse than this actually manage to sleep at all? It's sleep as in their eyes are closed and they are somehow unconscious but they are drifting on and off between falling asleep and being knocked out. There are no recollections of the events so it seems like sleep but very bad sleep (think: more tired when waking up than when going to bed).
    - vhodges 3y ago
      When I did my study they said it as >90 times an hour when sleeping on one side and something like >60 on the other. I did a pulse ox test first and the results recommended a sleep study (which was not all that conducive to a good sleep they way it's performed) Note, you don't actually regain consciousness that often (but if you wake up every 90-120 minutes to pee, and/or snore a lot, your body is telling you something) but it does keep you from getting a deeper sleep. I hadn't dreamed in years because I'd never drop into REM state. I used to sleep 4-6 hours a night (but rarely felt tired) now I sleep 5.5 - 7 and am much better rested.
    - calfuris 3y ago
      From what I remember an apnea/hypopnia index of up to 5 is considered normal, 5-15 is mild, 15-30 is medium, and 30+ is severe. That's what I learned when I had severe sleep apnea, but it spontaneously resolved years ago so perhaps definitions have shifted. I'd be pretty shocked if 50 were "mild" now, though. I had an AHI of ~90 at diagnosis, and I couldn't figure out why I was so damn tired all the time. My sleep was very badly disrupted, but since an apnea doesn't typically bring you all the way awake it can be hard to notice.
      - calfuris 3y ago
        Outside the edit window: I just realized that I missed the mention of the timescale. The apnea/hypopnea index is measured in terms of events per hour, and my doctors never discussed it in any other terms, so I automatically interpreted those numbers as per hour.
- jaak 3y ago
  It's almost that simple. There are many online medical equipment providers that will send you an at home sleep study kit. Their goal is basically to sell you a PAP machine (plus ongoing related supplies), pretty much anyone can get one if they make a minimum of effort.
MengerSponge 3y ago
It's only over-prescription if the prevalence hasn't changed. Your friends are 10 years older now than they were a decade ago. There's more awareness of sleep apnea, and when you look at the risk of treatment vs the risk of it going untreated, things strongly favor throwing a CPAP at a patient. The other thing that's happened over the last decade is American obesity rates have continued to climb. Overweight is correlated with sleep apnea, so all things equal you'd expect to see a corresponding rise in sleep apnea rates too.
- pixl97 3y ago
  >It's only over-prescription if the prevalence hasn't changed. Actually you've missed one other classification. Was it previously under diagnosed? So we have underdiagnosis, increase in base rate, increase in fraudulent diagnosis. At least anecdotally based on the older people in my family that seem to snore hard and have poor sleep habits, underdiagnosis seems pretty likely to me, but I guess we'd need to see studies of randomly selected patients to know for sure.
  - EricMausler 3y ago
    I posted directly to the original comment, but there is very strong evidence that sleep apnea was severely (~90%!) undiagnosed in 2008. 10 years ago was 2013, so hopefully that number improved between 2008 and 2013, but I'd imagine it was still a large problem.
  - MengerSponge 3y ago
    Oh yes, this is a critical point that I missed. Thanks for clarifying it!
  - TylerE 3y ago
    Yes, it was very very undergianosed, and still is in some populations (read: women). Men are diagnosed at a rate several times higher, but there is no physiological reason that would support there being anywhere close to that much.
LordKeren 3y ago
“Over-prescribed” is an overused phrase that is usually tantamount to little more than “things are different than they were before” It’s hard to quantify meaningful over-prescribing. It seems like the majority of people are in support of lowering the barrier to entry for most forms of medicine. Especially those that are non-drug therapies like sleep apnea machines. The counter point over-prescribing is the idea that restricting these kinds of therapies very likely cause a significant amount of people to have a demonstrably worse quality of life. Just because something is more common now does not necessarily mean it is overprescribed. It can just as easily be seen as a mistake in the past to under-prescribe, or the cost of treatment was too high, or access to treatment was inadequate
rc5150 3y ago
Over-prescription matters with things like opioids or other habit-forming medications, or medications that have a negative effect after sustained use. Getting unobstructed oxygen intake during sleep is not something that should be policed even if the patient doesn't necessarily "need it". Furthermore, as others have mentioned, you need a sleep study to get a prescription for it. You're looking for a problem where there really isn't one.
- onemoresoop 3y ago
  Pharma/med are run like a business so there's always in incentive to squeeze in as much as profit as possible. Not saying that CPAP are overprescribed because I really have no evidence of that but it's surely possible.
  - pixl97 3y ago
    I mean, it is possible if you take the most cynical outlook and avoid looking at any other evidence. Now, I would counter that a number of significant changes have occurred, some mentioned in this thread already... 1. Increase in obesity rate... yea, not good for health and is a causation. 2. Increase in user monitoring technology. My watch for example shows wakefullness and blood oxygen levels. Alerts from this may be sending more people to the doctor. 3. More doctor awareness of dangers of sleep apnea leading to more testing. None of those need a vast conspiracy to cause increase diagnosis.
  - malfist 3y ago
    Not everything is a conspiracy. It's also highly unlikely that a doctor prescribing a sleep apnea machine gets any sort of kick back for "selling" the device.
    - nisegami 3y ago
      But doctors do generally get a ton of follow up visits to tune the patient's settings, so there is an incentive there. It doesn't have to be a conspiracy (in the literal sense) if everyone acting in their own interests brings about the same result.
lostlogin 3y ago
I looked to see what the obesity rate has done in the last 10 years. It is up a lot. Severe obesity isn’t far off a doubling in the last decade. https://www.advisory.com/daily-briefing/2020/12/17/obesity https://www.advisory.com/daily-briefing/2020/12/17/obesity
EricMausler 3y ago
There was a study done in 2008 where surgeons wanted to find out how many surgical patients were undiagnosed with sleep apnea, presumably because it had an impact on the operating table. The results were that 20% of patients had sleep apnea and 90% of them were not diagnosed. Source: https://pubmed.ncbi.nlm.nih.gov/19186102/ https://pubmed.ncbi.nlm.nih.gov/19186102/ Additionally, let's assume a person has a 15% likelihood of being a surgical patient Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765448/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765448/. That means in 2008, when the population of the US was about 300 million, there were between 8.1 million and 54 million people undiagnosed with sleep apnea. The range being dependent on how representative the surgical patient study is on the general population (from assuming ALL people with sleep apnea are also surgical patients to assuming surgery is completely independent of apnea), so likely closer to 50 million than 8 million imo. 20% of today's population is 68million. Informal Google searching puts yearly CPAP sales at 8million per year in the US. Recommended use is for 5 years. This puts 8million sales per year in line for treating 40 million people with sleep apnea. Looks to me like we actually might have room to increase our prescription rate still. Fun fact, I am part of that diagnosis statistic. I was diagnosed in 2016, and estimated to have had it pretty much my whole life, so I was undiagnosed in 2008 and I also never had surgery. Turns out you don't need to be medically obese to have sleep apnea either. I'd say we are actually fixing one of the countries major medical problems and not overprescribing CPAP machines at all.
jrm4 3y ago
As a user, I think you have two factors going on here: 1) They work. They help a LOT of people. It's just really hard to argue against "getting more oxygen and waking up less when you sleep." 2) They're horribly and outrageously gatekept. I'm sure I'm going to hear from many people who say you have to be careful because they're medical equipment -- and having used them for literal decades, I just don't believe that (as in, compared to what other dangerous medical stuff you can get OTC, obviously there's SOME hazards, just not enough to justify this level of gatekeeping.) I would love to see what this industry could look like if you just let people get them OTC; I strongly predict you'd get across the board better and cheaper results with minimal danger to patients.
michael1999 3y ago
I struggle to imaging someone putting up with the bother of a sleep study, and then wearing a mask in bed, unless there were a problem. I find it much easier to believe that people are less mobile, with less muscle tone, and heavier than ever.
deleted 3y ago
[deleted]
taylodl 3y ago
Couple things come to mind: 1. Aging population. Sleep apnea's effects are more noticed in older folks. 2. Better awareness of sleep apnea's detrimental effects to one's health. It's not just "obnoxious snoring." It's having serious impacts on your cardiovascular health. I've been using a CPAP since April of this year and OMFG! I had no idea I felt bad. The effects are so gradual you think it's all just a part of getting old. The CPAP has been a complete game-changer that I didn't know I needed!

SketchySeaBeast 3y ago

Isn't your assumption likely flawed? If 40% of Americans are obese and that's highly correlated with sleep apnea, why is it necessary they are over-prescribed?

LostLocalMan 3y ago

I'm fairly certain that you have to undergo a sleep study wherein they monitor your breathing and your blood oxygen levels. If your blood oxygen falls to levels that seem dangerous you will be prescribed. So my understanding is it's not as simple as going to the doctor and saying "I slept funny last night".

tjohns 3y ago
Breathing and blood oxygen at a minimum, for the take-home tests. If you go into a sleep lab, they also wire you up to an EEG as well to monitor your brain activity. They're not just looking for blood oxygen to drop. They're also looking at how many times you wake up due to airway obstructions. Even if you wake yourself up before your blood oxygen drops, waking up 50+ times/night (this would be considered "mild", btw) is not good for your brain either. But yes, you need a sleep study to be diagnosed with sleep apnea.
- NoZebra120vClip 3y ago
  Oh, goody, a test. Let's send in as many people as profi...er possible to have that test. Probably helps to start a few print and TV campaigns to Ask Your Doctor If CPAP Is Right For You. Then, over a few decades, let's gradually move the goalposts so that more positive tests continually maximize our shareh...healthcare values. C'mon, think like a CEO
  - malfist 3y ago
    Except the doctors ordering and performing and evaluating these tests are not CEOs.
    - NoZebra120vClip 3y ago
      Exactly: https://en.wikipedia.org/wiki/Superior_orders https://en.wikipedia.org/wiki/Superior_orders
  - pixl97 3y ago
    "Dad died of a heart attack last night, guess we'll never know why" Health is something that is not just in the doctors purview these days. You can personally buy any number of electronic devices that monitor things like blood oxygen and how often you're waking up that will give you some idea of your sleep quality and likelihood of having apena. Or, you can be a cynical old fart and continue accepting that dying at 60 of a heart attack is perfectly normal. Not everything is a vast conspiracy.
    - NoZebra120vClip 3y ago
      I don't know about "vast conspiracy" and as a techie, I fully support testing in order to diagnose and repair. However I just believe that the incentives are perverse and not improving, and it's begetting corruption. Doctors do not order tests out of personal concern for patient's well-being to start healing them; doctors are mandated top-down to tick boxes on a checklist and improve customer engagement. As a techie, I also recognize how teched-up they are, and question why they need all that. I was shoved into a giant MRI and went through the whole theatrical adventure, and guess what - nobody touched that report. Nobody would read it, nobody would tell me what it meant, nobody would use it for treatment. It was hilarious. So glad it wasn't my pocketbook that time. And I had a real concern, not just a suspicion; my shoulder was bad, and fractures had already been ruled-out by a good old X-ray. High-tech is able to supplant "safe, inexpensive and effective" by virtue of profit margins, patents, marketing, and customer perception. I've been honestly rather shocked once in a while, to see a nurse wearing a stethoscope, or checking BP by sphig. I mean, do you realize how much of a fortune those guys are making by selling adhesive nasal strips, after we all developed a huge concern for apnea? What's that line about the American Space Pen and the Russian pencil???
- mcpackieh 3y ago
  > waking up 50+ times/night (this would be considered "mild", btw) 50+ a night is mild? I thought I had it bad at 2 or 3. 50 times a night is every couple of minutes, do people who have it even worse than this actually manage to sleep at all?
  - johnchristopher 3y ago
    > do people who have it even worse than this actually manage to sleep at all? It's sleep as in their eyes are closed and they are somehow unconscious but they are drifting on and off between falling asleep and being knocked out. There are no recollections of the events so it seems like sleep but very bad sleep (think: more tired when waking up than when going to bed).
  - vhodges 3y ago
    When I did my study they said it as >90 times an hour when sleeping on one side and something like >60 on the other. I did a pulse ox test first and the results recommended a sleep study (which was not all that conducive to a good sleep they way it's performed) Note, you don't actually regain consciousness that often (but if you wake up every 90-120 minutes to pee, and/or snore a lot, your body is telling you something) but it does keep you from getting a deeper sleep. I hadn't dreamed in years because I'd never drop into REM state. I used to sleep 4-6 hours a night (but rarely felt tired) now I sleep 5.5 - 7 and am much better rested.
  - calfuris 3y ago
    From what I remember an apnea/hypopnia index of up to 5 is considered normal, 5-15 is mild, 15-30 is medium, and 30+ is severe. That's what I learned when I had severe sleep apnea, but it spontaneously resolved years ago so perhaps definitions have shifted. I'd be pretty shocked if 50 were "mild" now, though. I had an AHI of ~90 at diagnosis, and I couldn't figure out why I was so damn tired all the time. My sleep was very badly disrupted, but since an apnea doesn't typically bring you all the way awake it can be hard to notice.
    - calfuris 3y ago
      Outside the edit window: I just realized that I missed the mention of the timescale. The apnea/hypopnea index is measured in terms of events per hour, and my doctors never discussed it in any other terms, so I automatically interpreted those numbers as per hour.
jaak 3y ago
It's almost that simple. There are many online medical equipment providers that will send you an at home sleep study kit. Their goal is basically to sell you a PAP machine (plus ongoing related supplies), pretty much anyone can get one if they make a minimum of effort.

MengerSponge 3y ago

It's only over-prescription if the prevalence hasn't changed. Your friends are 10 years older now than they were a decade ago. There's more awareness of sleep apnea, and when you look at the risk of treatment vs the risk of it going untreated, things strongly favor throwing a CPAP at a patient. The other thing that's happened over the last decade is American obesity rates have continued to climb. Overweight is correlated with sleep apnea, so all things equal you'd expect to see a corresponding rise in sleep apnea rates too.

pixl97 3y ago
>It's only over-prescription if the prevalence hasn't changed. Actually you've missed one other classification. Was it previously under diagnosed? So we have underdiagnosis, increase in base rate, increase in fraudulent diagnosis. At least anecdotally based on the older people in my family that seem to snore hard and have poor sleep habits, underdiagnosis seems pretty likely to me, but I guess we'd need to see studies of randomly selected patients to know for sure.
- EricMausler 3y ago
  I posted directly to the original comment, but there is very strong evidence that sleep apnea was severely (~90%!) undiagnosed in 2008. 10 years ago was 2013, so hopefully that number improved between 2008 and 2013, but I'd imagine it was still a large problem.
- MengerSponge 3y ago
  Oh yes, this is a critical point that I missed. Thanks for clarifying it!
- TylerE 3y ago
  Yes, it was very very undergianosed, and still is in some populations (read: women). Men are diagnosed at a rate several times higher, but there is no physiological reason that would support there being anywhere close to that much.

LordKeren 3y ago

“Over-prescribed” is an overused phrase that is usually tantamount to little more than “things are different than they were before” It’s hard to quantify meaningful over-prescribing. It seems like the majority of people are in support of lowering the barrier to entry for most forms of medicine. Especially those that are non-drug therapies like sleep apnea machines. The counter point over-prescribing is the idea that restricting these kinds of therapies very likely cause a significant amount of people to have a demonstrably worse quality of life. Just because something is more common now does not necessarily mean it is overprescribed. It can just as easily be seen as a mistake in the past to under-prescribe, or the cost of treatment was too high, or access to treatment was inadequate

rc5150 3y ago

Over-prescription matters with things like opioids or other habit-forming medications, or medications that have a negative effect after sustained use. Getting unobstructed oxygen intake during sleep is not something that should be policed even if the patient doesn't necessarily "need it". Furthermore, as others have mentioned, you need a sleep study to get a prescription for it. You're looking for a problem where there really isn't one.

onemoresoop 3y ago
Pharma/med are run like a business so there's always in incentive to squeeze in as much as profit as possible. Not saying that CPAP are overprescribed because I really have no evidence of that but it's surely possible.
- pixl97 3y ago
  I mean, it is possible if you take the most cynical outlook and avoid looking at any other evidence. Now, I would counter that a number of significant changes have occurred, some mentioned in this thread already... 1. Increase in obesity rate... yea, not good for health and is a causation. 2. Increase in user monitoring technology. My watch for example shows wakefullness and blood oxygen levels. Alerts from this may be sending more people to the doctor. 3. More doctor awareness of dangers of sleep apnea leading to more testing. None of those need a vast conspiracy to cause increase diagnosis.
- malfist 3y ago
  Not everything is a conspiracy. It's also highly unlikely that a doctor prescribing a sleep apnea machine gets any sort of kick back for "selling" the device.
  - nisegami 3y ago
    But doctors do generally get a ton of follow up visits to tune the patient's settings, so there is an incentive there. It doesn't have to be a conspiracy (in the literal sense) if everyone acting in their own interests brings about the same result.

lostlogin 3y ago

I looked to see what the obesity rate has done in the last 10 years. It is up a lot. Severe obesity isn’t far off a doubling in the last decade. https://www.advisory.com/daily-briefing/2020/12/17/obesity https://www.advisory.com/daily-briefing/2020/12/17/obesity

EricMausler 3y ago

There was a study done in 2008 where surgeons wanted to find out how many surgical patients were undiagnosed with sleep apnea, presumably because it had an impact on the operating table. The results were that 20% of patients had sleep apnea and 90% of them were not diagnosed. Source: https://pubmed.ncbi.nlm.nih.gov/19186102/ https://pubmed.ncbi.nlm.nih.gov/19186102/ Additionally, let's assume a person has a 15% likelihood of being a surgical patient Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765448/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765448/. That means in 2008, when the population of the US was about 300 million, there were between 8.1 million and 54 million people undiagnosed with sleep apnea. The range being dependent on how representative the surgical patient study is on the general population (from assuming ALL people with sleep apnea are also surgical patients to assuming surgery is completely independent of apnea), so likely closer to 50 million than 8 million imo. 20% of today's population is 68million. Informal Google searching puts yearly CPAP sales at 8million per year in the US. Recommended use is for 5 years. This puts 8million sales per year in line for treating 40 million people with sleep apnea. Looks to me like we actually might have room to increase our prescription rate still. Fun fact, I am part of that diagnosis statistic. I was diagnosed in 2016, and estimated to have had it pretty much my whole life, so I was undiagnosed in 2008 and I also never had surgery. Turns out you don't need to be medically obese to have sleep apnea either. I'd say we are actually fixing one of the countries major medical problems and not overprescribing CPAP machines at all.

jrm4 3y ago

As a user, I think you have two factors going on here: 1) They work. They help a LOT of people. It's just really hard to argue against "getting more oxygen and waking up less when you sleep." 2) They're horribly and outrageously gatekept. I'm sure I'm going to hear from many people who say you have to be careful because they're medical equipment -- and having used them for literal decades, I just don't believe that (as in, compared to what other dangerous medical stuff you can get OTC, obviously there's SOME hazards, just not enough to justify this level of gatekeeping.) I would love to see what this industry could look like if you just let people get them OTC; I strongly predict you'd get across the board better and cheaper results with minimal danger to patients.

michael1999 3y ago

I struggle to imaging someone putting up with the bother of a sleep study, and then wearing a mask in bed, unless there were a problem. I find it much easier to believe that people are less mobile, with less muscle tone, and heavier than ever.

deleted 3y ago

[deleted]

taylodl 3y ago

Couple things come to mind: 1. Aging population. Sleep apnea's effects are more noticed in older folks. 2. Better awareness of sleep apnea's detrimental effects to one's health. It's not just "obnoxious snoring." It's having serious impacts on your cardiovascular health. I've been using a CPAP since April of this year and OMFG! I had no idea I felt bad. The effects are so gradual you think it's all just a part of getting old. The CPAP has been a complete game-changer that I didn't know I needed!