Content Comparison of Quality-of-Life Instruments Used in Economic Evaluations of Sleep Disorder Interventions: A Systematic Review.

BACKGROUND: Assessment of quality of life (QoL) in people living with sleep disorders using questionnaires is necessary to compare intervention benefits. Knowledge of the content and concepts covered by specific QoL instruments is essential to determine which instruments are best suited for conducting economic evaluations of sleep-related interventions. OBJECTIVES: This review aims to identify the QoL instruments that have been applied in economic evaluations of sleep disorder interventions and compare their conceptual overlap and content coverage using the framework of the International Classification of Functioning, Disability and Health (ICF). METHODS: A systematic review of full economic evaluations in sleep published in peer-reviewed journals from conception to 30 May, 2023 was conducted. MEDLINE, PsychInfo, ProQuest, Cochrane, Scopus, CINAHL, Web of Science and Emcare were searched for eligible studies. Studies incorporating either generic or sleep-specific QoL instruments as the primary or secondary measures of effectiveness within a full economic evaluation were included. Quality appraisal against the JBI Critical Appraisal Checklist for Economic Evaluations and EURONHEED checklists and mapping of QoL items to ICF categories were performed by two reviewers, with a third helping settle any potential differences. RESULTS: Sixteen instruments were identified as having been used in sleep health economic evaluations. The EQ-5D-3L, Epworth Sleepiness Scale, and Insomnia Severity Index were the most widely used, but the latter two are predominantly diagnostic tools and not specifically designed to guide economic evaluations. Other instruments with broader ICF content coverage have been least used, and these include the Sleep Apnea Quality of Life Index, Functional Outcomes of Sleep Questionnaire, 15 Dimensions, Short-Form 6 Dimensions, 12-item Short Form Survey, 36-item Short Form Survey and the GRID Hamilton Rating Scale for Depression. CONCLUSIONS: This study provides an overview of current QoL instruments used in economic evaluations of sleep with respect to their content coverage. A combination of generic and sleep-specific instruments with broader ICF content coverage is recommended for such evaluations.

Trajectory of Food Insecurity and Its Association with Longitudinal Mental Health and Sleep Outcomes in Adolescents from Economically Disadvantaged Families.

BACKGROUND: Adolescence is a critical transition period in the course of human development. Although food insecurity (FI) has been shown to be associated with adverse mental health and sleep outcomes in US adolescents, there is a paucity of research examining the relationships between FI, mental health, and sleep outcomes in Taiwanese adolescents. Furthermore, it is unknown how the change of FI over time (i.e., the trajectory of FI) is related to health outcomes. METHODS: The data come from the Taiwan Database of Children and Youth in Poverty, which is a national longitudinal project measuring FI in five survey waves (2009-2017). We employed group-based trajectory modeling to classify various FI trends over the five waves using STATA. Furthermore, a generalized estimating equation analysis was conducted with FI trajectories as the independent variable to see how FI trajectory is related to mental health and sleep outcomes. RESULTS: In total, 1921 participants aged 12-18 years in the first wave were deemed valid for the analysis. We classified the participants into four FI trajectory groups: persistently low FI (24.8%), persistently moderate FI (64.7%), declining from high to low FI (4.1%), and food-secure groups (6.4%). As compared to food-secure adolescents, the persistently moderate FI group was more likely to have mental problems (ß = 0.30, [95% confidence interval 0.21-0.38]), while the other FI groups were only marginally associated with mental health problems. Moreover, adolescents in the persistently low FI group (ß = 0.13, [0.02-0.23]) and persistently moderate FI group (ß = 0.39, [0.29-0.48]) were found to have more sleep problems than those in the food-secure group. CONCLUSIONS: Our study describes the FI profile of adolescents from economically disadvantaged families and the difficulties they might encounter. With this information, healthcare providers can aid adolescents in the early stages of mental health problems and provide guidance when appropriate.

Socioeconomic Status and Sleep among Couples.

Objective/Background: Lower socioeconomic status (SES) is generally associated with poor sleep but little is known about how different SES indices are associated with sleep duration and quality, or about these relations longitudinally or in cohabiting couples. The main objective was to examine longitudinal associations between multiple SES and sleep parameters in cohabiting adults. Participants: Participants were cohabiting couples (N = 135) of women (M age = 37.2 years, SD = 5.93; 76% White/European American, 18% Black/African American) and men (M = 39.9 years, SD = 7.33; 78% White, 18% Black). Methods: Men and women participated twice with a 1-year lag. At Time (T1), participants reported on multiple SES indices including their income, perceived economic well-being, education, employment status, and occupation. Sleep at T1 and T2 was assessed with self-reports and actigraphs (sleep duration from onset to wake time, %sleep from onset to wake, long wake episodes). Results: Actor effects on actigraphy-assessed sleep parameters were evident for both men and women; low SES was associated with shorter duration and poor quality (%sleep, long wake episodes) sleep. These associations were most pronounced for income-to-needs ratio (men and women) and perceived economic well-being (women only). Partner effects were also evident such that men's employment status was associated with women's longer sleep duration and greater sleep quality (%sleep) whereas women's employment predicted increased subjective sleep problems for men. Conclusion: Findings illustrate the need to consider multiple SES and sleep indices, as well as the family context in studies addressing linkages between SES and sleep.

Sleep Duration and Health Care Expenditures in the United States.

OBJECTIVE: To estimate the average incremental health care expenditures associated with habitual long and short duration of sleep as compared with healthy/average sleep duration. DATA SOURCE: Medical Expenditure Panel Survey data (2012; N=6476) linked to the 2010-2011 National Health Interview Survey. STUDY DESIGN: Annual differences in health care expenditures are estimated for habitual long and short duration sleepers as compared with average duration sleepers using 2-part logit generalized linear regression models. PRINCIPAL FINDINGS: Habitual short duration sleepers reported an additional $1400 in total unadjusted health care expenditures compared to people with average sleep duration (P<0.01). After adjusting for demographics, socioeconomic factors, and health behavior factors, this difference remained significant with an additional $1278 in total health care expenditures over average duration sleepers (P<0.05). Long duration sleepers reported even higher, $2994 additional health care expenditures over average duration sleepers. This difference in health care expenditures remained significantly high ($1500, P<0.01) in the adjusted model. Expenditure differences are more pronounced for inpatient hospitalization, office expenses, prescription expenses, and home health care expenditures. CONCLUSIONS: Habitual short and long sleep duration is associated with higher health care expenditures, which is consistent with the association between unhealthy sleep duration and poorer health outcomes.

COVID-19 Is Straining Mental Health-Could Technology Be the Answer?

One of the most pernicious side effects of the COVID-19 pandemic is a steep rise in stress and mental health problems. According to a poll by the Kaiser Family Foundation, nearly half of American adults say that worry and stress about the pandemic is hurting their mental health [1]. There are plenty of factors feeding into this phenomenon. People are anxious about getting sick, grieving lost loved ones, and experiencing financial stress, parental stress, and loneliness. The pandemic places additional burdens on essential workers and people of color, both of whom are at greater risk of dying from the disease. COVID-19 itself has been linked to neurological problems as well as anxiety, depression, and sleep disorders [2].

Association of sleep-disordered breathing with total healthcare costs and utilization in older men: the Outcomes of Sleep Disorders in Older Men (MrOS Sleep) study.

STUDY OBJECTIVES: To determine the associations of sleep-disordered breathing (SDB) with subsequent healthcare costs and utilization including inpatient and post-acute care facility stays among community-dwelling older men. METHODS: Participants were 1,316 men (mean age 76.1 [SD = 5.7] years) in the Outcomes of Sleep Disorders in Older Men (MrOS sleep) study (from December 2003 to March 2005), who were enrolled in a Medicare Fee-For-Service plan. Primary SDB measures including apnea hypopnea index (AHI) and oxygen desaturation index (ODI) were collected using in-home level 2 polysomnography. Incident healthcare costs and utilization were determined from claims data in the subsequent 3-year period post-MrOS sleep visit. RESULTS: Five hundred and twenty-nine (40.2%) men had at least one hospitalization in the 3-year period. Compared with those without sleep apnea (AHI < 5/hour), men with moderate to severe sleep apnea (AHI ≥ 15/hour) had a higher odds of all-cause hospitalization (odds ratio [OR] adjusted for age and site 1.43, 95% confidence interval [CI]: 1.07-1.90). This association was slightly attenuated after further adjustment for traditional prognostic factors including education, body mass index, comorbid medical conditions, and health status (OR = 1.36; 95% CI: 1.01-1.83). Similar associations were observed for ODI. However, measures of SDB were not related to subsequent healthcare costs (total or outpatient) or odds of post-acute skilled nursing facility stay. CONCLUSIONS: Older men with SDB have an increased risk of hospitalization, not entirely explained by the greater prevalence of comorbid conditions, but not higher subsequent total healthcare costs. These findings indicate a need to evaluate the impact of SDB treatment on subsequent healthcare utilization.

Correlates of quality of life in mothers of children with diagnosed epilepsy.

Contrary to a plethora of studies on the quality of life (QoL) of parents caring for children with chronic conditions, information regarding parents of children with epilepsy remains limited. The main purpose of the current study was to explore associations between children's biomedical characteristics, mothers' sociodemographic characteristics, mothers' situational factors, and QoL among mothers of children with epilepsy. One hundred and fifty mothers of children with epilepsy completed valid and reliable measures. The study was conducted at a large outpatient clinic for children with epilepsy in a central hospital in southern Israel. Sense of mastery and optimism emerged as significant predictors of all four domains of QoL; self-rated health (SRH) and mothers' socioeconomic status were significant predictors of three QoL domains; mothers' sleeping disturbances and children's behavioral problems predicted one QoL component. These results highlight the pivotal role that mastery and optimism play in securing the QoL of mothers caring for children with epilepsy. Moreover, mother's socioeconomic status and SRH should also be screened to deal with possible socioeconomic deprivation. In addition, health professionals should screen mothers and children for sleeping disturbances, and provide information about sleep hygiene. Psychosocial interventions need to be developed and offered to parents, in an attempt to address the social and behavior problems of children with epilepsy.

Sedentary behaviour and sleep problems among 42,489 community-dwelling adults in six low- and middle-income countries.

There is a lack of multinational research investigating the association between sleep problems and sedentary behaviour. In this study, we investigated the relationship between the time spent sedentary during waking hours and sleep problems in six low- and middle-income countries. Cross-sectional, community-based data from the Study on Global Ageing and Adult Health survey were analysed. Adjusted logistic regression analyses were undertaken to explore the relationship between self-reported sleep problems (such as difficulties falling asleep, waking up frequently during the night or waking up too early in the morning) in the last 30 days and self-reported sedentary time (categorized as <4, 4 to <8, 8 to <11 or ≥11 hr/day). Among 42,489 individuals aged ≥18 years (mean age=43.8 ± 14.4 years; 50.1% women), those who were sedentary for 8 to <11 hr/day (n = 2,782) and ≥11 hr/day (n = 674) had a 1.61 (95% confidence interval =1.03-2.50) and 1.75 (95% confidence interval =1.17-2.62) times higher odds of having sleep problems, respectively, compared with those being sedentary for less than 4 hr per day (n = 24,637). The strongest associations were observed among those aged 50-64 years. The observed associations were independent of a wide range of sociodemographic factors, physical and mental health conditions and physical activity behaviour. Considering the social and occupational costs of sleep problems, it is important that future longitudinal research should consider the directionality of the data.

The Cost of Inadequate Sleep among On-Call Workers in Australia: A Workplace Perspective.

On-call or stand-by is becoming an increasingly prevalent form of work scheduling. However, on-call arrangements are typically utilised when workloads are low, for example at night, which can result in inadequate sleep. It is a matter of concern that on-call work is associated with an increased risk of workplace injury. This study sought to determine the economic cost of injury due to inadequate sleep in Australian on-call workers. The prevalence of inadequate sleep among on-call workers was determined using an online survey, and economic costs were estimated using a previously validated costing methodology. Two-thirds of the sample (66%) reported obtaining inadequate sleep on weekdays (work days) and over 80% reported inadequate sleep while on-call. The resulting cost of injury is estimated at $2.25 billion per year ($1.71-2.73 billion). This equates to $1222 per person per incident involving a short-term absence from work; $2.53 million per incident classified as full incapacity, and $1.78 million for each fatality. To the best of our knowledge this is the first study to quantify the economic cost of workplace injury due to inadequate sleep in on-call workers. Well-rested employees are critical to safe and productive workplace operations. Therefore, it is in the interest of both employers and governments to prioritise and invest far more into the management of inadequate sleep in industries which utilise on-call work arrangements.

Association Between Costs Related to Productivity Loss and Modified Risk Factors Among Users of the Brazilian National Health System.

OBJECTIVES: The aim of this study was to investigate the associations between costs related to productivity losses and its risk factors among users of the Brazilian National Health System. METHODS: The public cost associated with productivity losses of 342 adults has been estimated, taking into account a period of 18 months. Costs related to productivity loss were estimate using data provided by the Brazilian National Health System (disability retirements) and absenteeism. Modifiable risk factors and unhealthy behaviors were assessed through interviews (physical inactivity, alcohol consumption, and smoking) and clinical assessments (obesity). RESULTS: Smoking and physical inactivity affected significantly the amount of money lost with productivity losses related to absenteeism. The presence of obesity generated higher expenditures with disability retirement, while low back pain and sleep disorder were the most relevant confounders in multivariate models for disability retirement and absenteeism. CONCLUSIONS: Among users of the Brazilian National Health System, obesity, smoking, and physical inactivity seem to have a significant effect on productivity losses associated with health problems. Moreover, low back pain and sleep quality seem variables few explored but with potential to affect health care costs.

Legal and Regulatory Aspects of Sleep Disorders.

Sleep disorders may interact with the law, making awareness important. Insufficient sleep and obstructive sleep apnea (OSA) are prevalent and associated with excessive sleepiness. Patients with excessive sleepiness may have civil or criminal liability if they fall asleep and cause a motor vehicle accident. Awareness of screening and treatment of OSA is increasing in certain industries. Parasomnia associated sleep-related violence represents a challenge to clinicians, who may be called on to consider parasomnia as a contributing, mitigating, or exculpatory factor in criminal proceedings. Improving access to sleep medicine care is an important aspect in reducing the consequences of sleep disorders.

Socioeconomic Impact of Pediatric Sleep Disorders.

Pediatric disorders tend to affect the immediate support unit, adults and children. High costs for direct consumption of medical care are offset by early diagnosis and treatment of pediatric sleep disorders. Pediatric sleep disorders are underdiagnosed and undertreated. Attention-deficit/hyperactivity disorder may result from insufficient or fragmented sleep. Delaying school start time resulted in decreased car crashes in teen drivers and improved mood.

Neurologic Diseases and Sleep.

Sleep disorders and neurologic illness are common and burdensome in their own right; when combined, they can have tremendous negative impact at an individual level as well as societally. The socioeconomic burden of sleep disorders and neurologic illness can be identified, but the real cost of these conditions lies far beyond the financial realm. There is an urgent need for comprehensive care and support systems to help with the burden of disease. Further research in improving patient outcomes in those who suffer with these conditions will help patients and their families, and society in general.

Living status, economic hardship and sleep disturbance were associated with subjective shoulder pain in survivors of the Great East Japan Earthquake: A cross sectional study.

BACKGROUND: The Great East Japan Earthquake and devastating Tsunami hit hard everything on the northeastern coast of Japan. This study aimed to determine socio-psychological factors for "subjective shoulder pain" of the survivors at 2 years evaluated by a self-report questionnaire. METHODS: Between November 2012 to February 2013, survivors replied to the self-report questionnaire, and 2275 people consented to join this study. Living status was divided into 5 categories (1. same house as before the earthquake (reference group), 2. temporary small house, 3. apartment, 4. house of relatives or acquaintance, 5. new house) and economic hardship was divided into 4 categories (1. normal (reference group), 2. a little bit hard, 3. hard, 4. very hard). Gender, age, body mass index, living areas, smoking and drinking habits, complications of diabetes mellitus and cerebral stroke, working status, and walking time were considered as the confounding factors. Kessler Psychological Distress Scale of ≥10/24 and Athens Insomnia Scale of ≥6/24 points were defined as a presence of psychological distress and sleep disturbance, respectively. We used multiple logistic regression analysis to examine the association of shoulder pain with living environment, economic hardship, psychological distress, and sleep disturbance at 2 years after the earthquake. RESULTS: There were significant differences in the risk of having shoulder pain in those with "apartment" (OR = 1.74, 95% CI = 1.03-2.96), "house of relatives or acquaintance" (OR = 2.98, 95% CI = 1.42-6.25), economic hardship of "hard" (OR = 1.71, 95% CI = 1.08-2.7) and "very hard" (OR = 2.51, 95% CI = 1.47-4.29), and sleep disturbance (OR = 2.96, 95% CI = 2.05-4.27). CONCLUSIONS: Living status of "apartment" and "house of relatives or acquaintance", economic hardship of "hard" and "very hard", and "sleep disturbance" were significantly associated with shoulder pain.

A pilot randomized controlled trial of a tailored cognitive behavioural therapy based intervention for depressive symptoms in those newly diagnosed with multiple sclerosis.

BACKGROUND: To examine the effectiveness and acceptability of an 8-week individual tailored cognitive behavioural therapy (CBT) intervention for the treatment of depressive symptoms in those newly diagnosed with multiple sclerosis. METHODS: The current study presents a pilot, parallel group randomized controlled trial (RCT) with an allocation ratio of 1:1 conducted in a large research and teaching hospital in Melbourne, Australia. 30 individuals with a mean age of 36.93 years (SD = 9.63) who were newly diagnosed with multiple sclerosis (MS) (X = 24.87 months, SD = 15.61) were randomized to the CBT intervention (n = 15) or treatment as usual (TAU) (n = 15). The primary outcome was level of depressive symptoms using the Beck Depression Inventory-II (BDI-II). Secondary outcomes were level of anxiety, fatigue and pain impact, sleep quality, coping, acceptance of MS illness, MS related quality of life, social support, and resilience. Tertiary outcomes were acceptability and adherence to the intervention. RESULTS: Large between group treatment effects were found for level of depressive symptoms at post and at 20 weeks follow-up (d = 1.66-1.34). There were also small to large group treatment effects for level of anxiety, fatigue and pain impact, sleep quality, MS related quality of life, resilience, and social support at post and at 20 weeks follow-up (d = 0.17-1.63). There were no drop-outs and participants completed all treatment modules. All participants reported the treatment as 'very useful', and most (73.4%) reported that the intervention had addressed their problems 'completely'. CONCLUSIONS: These data suggest that the tailored early intervention is appropriate and clinically effective for the treatment of depressive symptoms in those newly diagnosed with MS. A larger RCT comparing the CBT intervention with an active comparative treatment with longer term follow-up and cost effectiveness analyses is warranted. The pilot trial has been retrospectively registered on 28/04/2016 with the ISRCTN registry (trial ID ISRCTN10423371).

Co-Morbidity, Mortality, Quality of Life and the Healthcare/Welfare/Social Costs of Disordered Sleep: A Rapid Review.

Sleep disorders are frequent (18%-23%) and constitute a major risk factor for psychiatric, cardiovascular, metabolic or hormonal co-morbidity and mortality. Low social status or income, unemployment, life events such as divorce, negative lifestyle habits, and professional requirements (e.g., shift work) are often associated with sleep problems. Sleep disorders affect the quality of life and impair both professional and non-professional activities. Excessive daytime drowsiness resulting from sleep disorders impairs efficiency and safety at work or on the road, and increases the risk of accidents. Poor sleep (either professional or voluntary) has detrimental effects comparable to those of major sleep disorders, but is often neglected. The high incidence and direct/indirect healthcare and welfare costs of sleep disorders and poor sleep currently constitute a major medical problem. Investigation, monitoring and strategies are needed in order to prevent/reduce the effects of these disorders.

Trouble Sleeping Associated With Lower Work Performance and Greater Health Care Costs: Longitudinal Data From Kansas State Employee Wellness Program.

OBJECTIVE: To examine the relationships between employees' trouble sleeping and absenteeism, work performance, and health care expenditures over a 2-year period. METHODS: Utilizing the Kansas State employee wellness program (EWP) data set from 2008 to 2009, multinomial logistic regression analyses were conducted with trouble sleeping as the predictor and absenteeism, work performance, and health care costs as the outcomes. RESULTS: EWP participants (N = 11,698 in 2008; 5636 followed up in 2009) who had higher levels of sleep disturbance were more likely to be absent from work (all P < 0.0005), have lower work performance ratings (all P < 0.0005), and have higher health care costs (P < 0.0005). Longitudinally, more trouble sleeping was significantly related to negative changes in all outcomes. CONCLUSIONS: Employees' trouble sleeping, even at a subclinical level, negatively impacts on work attendance, work performance, and health care costs.