Clinical foundation for efficient treatment of obstructive sleep apnea

Only a few decades ago, the entity known as obstructive sleep apnea (OSA) was unknown and untreated. Now, there is a rush to put literally millions of Americans on continuous positive airway pressure devices. Community practice standards are changing yearly under pressure from strong forces based on economic incentives for industry, government, and physicians, independent of the actual medical evidence supporting treatment and efficacy. Medicare has lowered the diagnostic threshold for diagnosis and reimbursement; the International Classification of Sleep Disorders, Revision 2 (2005) has allowed OSA to be diagnosed exclusively by a laboratory test without the patient having clinical symptoms of excessive daytime sleepiness; and industry is poised to have the public buy computer-assisted continuous positive airway pressure machines without need of a physician prescription. Because of this paradigm shift away from physician-directed diagnosis and treatment, this article will critically evaluate the present state of medical evidence regarding the clinical foundation for treatment of OSA.