Guideline 73 Annex 2

Management of obstructive sleep apnoea/hypopnoea syndrome in adults Annex 2

Resource Implications of recommendations

Guideline section	Recommendation / Good practice point		Likely resource implication
3.1		All patients who have suspected sleep apnoea and their partners should complete an Epworth questionnaire to subjectively assess the degree of pretreatment sleepiness.	There is a need for awareness raising about the Epworth Sleepiness Scale and its use, particularly in primary care.
3.2		Patients with symptoms suggestive of OSAHS, who are sleepy whilst driving or working with machinery, or are employed in hazardous occupations should be considered for urgent referral to a sleep centre, as should those with ventilatory failure.	Prevalence of OSAHS in adults in Scotland aged 30-65 can be estimated in the range from 18,000 to 25,000. Experience from the Sleep Centre at Edinburgh Royal Infirmary suggests a referral rate of approximately 600/780,000 population – this equates to 4,000 referrals per annum in Scotland. During 2001/2 there were 1,529 referrals to the Edinburgh sleep centre. Approximately 800-1000 patients were referred to the other centres in total. These figures suggest an increase in referrals per annum in the region of 1,500 to 1,700 across Scotland. It is unlikely that such a significant increase in referrals could be achieved within existing facilities.
3.6		Limited sleep studies to assess respiratory events are an adequate first line method for diagnostic assessment for OSAHS.	There are 6 centres in Scotland with dedicated sleep beds, with a total of 13 available beds. A further 3 centres provide facilities for investigations (British Sleep Society survey 2002). Approximately 50% referrals result in hospital based studies. This would equate to a requirement for approximately 2,000 hospital based studies each year. It is likely therefore that full implementation of this recommendation would require expansion in workload of the existing centres or new centres being set up
4.3.1		CPAP is the first choice therapy for patients with moderate or severe OSAHS that is sufficiently symptomatic to require intervention.	CPAP use requires an initial purchase of the appliance, annual maintenance and replacement at the end of the machine's lifespan (expected to be 10 years). In addition, there are costs associated with clinical review and an annual mask replacement. Experience from the Royal Infirmary of Edinburgh Sleep Centre suggests that between 30 and 50% of referrals lead to CPAP use. This would equate to between 1,200 and 2,000 new patients on CPAP per annum. An increase in referral to sleep centres is likely to lead to an increase in the numbers of CPAP appliances being used in Scotland.
4.3.4		Intra-oral devices are an appropriate therapy for snorers and for patients with mild OSAHS with normal daytime alertness.	Intra-oral devices are custom made for individuals and last around two years. In addition to the cost of the device there will be costs associated with annual review of patients.
		Intra-oral devices are an appropriate alternative therapy for patients who are unable to tolerate CPAP.	An increase in referral to sleep centres is likely to lead to an increase in the numbers of intra-oral devices used in Scotland.