Coexistence of clinically significant obstructive sleep apnea with physician-diagnosed asthma or chronic obstructive pulmonary disease: A population study of prevalence and mortality

Abstract

RATIONALE: Despite potential importance, the epidemiology of coexisting obstructive sleep apnea and asthma (OSA/asthma) or OSA and COPD (OSA/COPD) has not been well studied.

OBJECTIVES

To access the trends in prevalence and mortality of coexisting OSA/asthma or OSA/COPD among individuals 35-years or older in Ontario, Canada.

METHODS AND MEASUREMENTS: We conducted a population-based study using provincial health administrative data. Validated case definitions were used to identify individuals with physician-diagnosed asthma or COPD. Individuals with clinically significant OSA were those who initiated positive airway pressure treatment. Age- and sex-standardized annual prevalence and mortality rates were estimated and compared from 2009 to 2015. Generalized linear models were used.

MAIN RESULTS: The standardized prevalence increased from 0.42% to 0.66% for OSA/asthma and from 0.23% to 0.35% for OSA/COPD from 2009 to 2015. The standardized all-cause mortality rates remained stable over time. Both coexistence conditions were associated with higher mortality than OSA alone. Adjusting for age, sex and calendar year, mortality was modestly but statistically significantly higher for OSA/asthma than asthma alone (OR = 1.03; 1.00–1.06) with the highest OR noted in 35-49 years old group (1.85; 1.63–2.09). There was no statistical difference in all-cause mortality among individuals with coexisting OSA/COPD compared to patients with COPD alone. In women only, OSA/COPD was associated with a modestly higher mortality than COPD alone (OR = 1.05; 1.01–1.09).

CONCLUSIONS

In this population-based study of coexisting clinically significant OSA and chronic lung disease, we report population prevalence and mortality, including their age and sex distribution. These findings can alert health care providers and policymakers to the large and increasing burden of these coexisting conditions and high-risk groups.

RÉSUMÉ

JUSTIFICATION: Malgré son importance potentielle, l'épidémiologie de l'apnée obstructive du sommeil et de l'asthme coexistants (AOS / asthme) ou de l'AOS et de la MPOC (AOS / MPOC) n'a pas été suffisamment étudiée.

OBJECTIFS: Accéder aux tendances de la prévalence et de la mortalité des AOS / asthme ou AOS / MPOC coexistants chez les personnes de 35 ans ou plus en Ontario, Canada.

MÉTHODES ET MESURES: Nous avons mené une étude populationnelle à l'aide de données administratives provinciales sur la santé. Des définitions de cas validées ont été utilisées pour répertorier les personnes souffrant d'asthme ou de MPOC diagnostiqué par un médecin. Les personnes présentant un AOS cliniquement significatif étaient celles qui avaient initié un traitement par pression positive des voies aériennes. Les taux de prévalence et de mortalité annuels normalisés selon l'âge et le sexe ont été estimés et comparés pour la période allant de 2009 à 2015. Des modèles linéaires généralisés ont été utilisés.

PRINCIPAUX RÉSULTATS: La prévalence standardisée est passée de 0,42 % à 0,66 % pour l'AOS / asthme et de 0,23 à 0,35 % pour l'AOS / BPCO de 2009 à 2015. Les taux de mortalité standardisés pour toutes causes confondues sont restés stables au fil du temps. Les deux conditions de coexistence étaient associées à une mortalité plus élevée que l'AOS seule. En ajustant l'âge, le sexe et l'année civile, la mortalité était légèrement mais statistiquement significativement plus élevée pour l'AOS / asthme que pour l'asthme seul (OR = 1,03 ; 1,00-1,06), le RC le plus élevé étant noté dans le groupe des 35 - 49 ans (1,85 ; 1,63- 2,09). Il n'y avait pas de différence statistique dans la mortalité toutes causes confondues chez les personnes atteintes d'AOS / BPCO coexistantes par rapport aux patients atteints de BPCO seule. Chez les femmes seulement, l'AOS / MPOC était associée à une mortalité légèrement plus élevée que la MPOC seule (OR = 1,05; 1,01-1,09).

CONCLUSIONS: Dans cette étude basée sur la population de l'AOS coexistante cliniquement significative et de la maladie pulmonaire chronique, nous rapportons la prévalence et la mortalité de la population, y compris leur répartition par âge et sexe. Ces résultats peuvent alerter les prestataires de soins de santé et les décideurs sur le fardeau important et croissant de ces affections coexistantes et des groupes à haut risque.

Keywords:

• Sleep apnea
• obstructive
• pulmonary disease
• chronic obstructive
• asthma
• prevalence
• mortality

Acknowledgments

Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions and statements expressed herein are those of the author and not necessarily those of CIHI.

Guarantor statement

A. Gershon and T. Kendzerska had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. A. Gershon (the senior responsible author) affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Author's contributions

All coauthors were involved in the following: study conception and design, interpretation of the data, critically revising the manuscript for the accuracy and important intellectual content and final approval of the version to be published. T. Kendzerska was involved in the literature search, obtaining administrative data, analyses of data and drafting of the manuscript. A. Gershon was involved in the research ethics board application, obtaining administrative data and analyses of data. M. Povitz was involved in the literature search and the dataset creation plan. X. Bai was involved in the literature search and data visualization. A. Gershon and T. Kendzerska had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors had full access to statistical reports and tables.

Role of sponsors

The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario Ministry of Health and Long-Term Care (MOHLTC) is intended or should be inferred.

Other contributions

The Canadian Respiratory Research Network Scientific Steering Committee members are:

Shawn Aaron (lead author for the group, email: [email protected]): The Ottawa Hospital Research Institute, University of Ottawa; James Martin: McGill University; Teresa To: University of Toronto; Andrea Gershon: University of Toronto; Christopher Carlsten: University of British Columbia; Andrew Halayko: University of Manitoba; Don Sin: University of British Columbia; Jean Bourbeau: McGill University; Francine Ducharme: Universite de Montreal; Mohsen Sadatsafavi: University of British Columbia; Denis O’Donnell: Queen’s University; Grace Parraga: University of Western Ontario; Wan Tan: University of British Columbia.

Data availability and sharing statement

The dataset from this study is held securely in coded form at ICES. While data sharing agreements prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS. The full dataset creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

Disclosure of interest statement

All authors have no potential conflict of interest to disclose. At that time, T. Kendzerska was supported by the Canadian Respiratory Research Network (CRRN) Fellowship Training Award. Funding for training of graduate students and new investigators within the Network was supported by grants from the Canadian Institutes of Health Research (CIHR) - Institute of Circulatory and Respiratory Health; Canadian Lung Association (CLA)/Canadian Thoracic Society (CTS); British Columbia Lung Association; and Industry Partners Boehringer-Ingelheim Canada Ltd, AstraZeneca Canada Inc., Novartis Canada Ltd. and GlaxoSmithKline Inc. Marcus Povitz had a salary support from AMOSO (the Academic Medical Organization of Southwestern Ontario). The funding sponsors had no role in the study design, data collection and analysis or preparation of the manuscript. No other relationships or activities that could appear to have influenced the submitted work.

Notation of prior abstract publication/presentation

Some of the results of this study have been previously presented at the SLEEP 2017, the 31st Annual Meeting of the Associated Professional Sleep Societies (APSS), Boston, MA (June 3–7, 2017) as a poster and reported in the form of an abstract.⁷⁷

Additional information

Funding

This study was supported by the Canadian Respiratory Research Network (CRRN), Godfrey S Pettit Block Term Grants, from the Division of Respirology, University of Toronto and by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The CRRN is supported by grants from the Canadian Institutes of Health Research - Institute of Circulatory and Respiratory Health; Canadian Lung Association/Canadian Thoracic Society; British Columbia Lung Association; and Industry Partners Boehringer-Ingelheim Canada Ltd, AstraZeneca Canada Inc., and Novartis Canada Ltd. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.