Running head: SLEEP QUALITY AND THE EFFECT ON FUNCTIONAL OUTCOMES 1

Sleep Quality and the Effect on Functional Outcomes
Sara Ingram
Arizona State University

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Abstract
Introduction: Sleep disorders can go undiagnosed if a provider is not asking the right questions;
they can be characterized by loud snoring with apneic episodes that never fully wake the person,
difficulty falling asleep or daytime fatigue. Poor sleep can affect activities of daily living, job
performance and personal relationships. Poor sleep can be difficult to detect because some may
consider it a symptom because of their lifestyle. The purpose of this study is to assess
participants sleep quality and functional outcomes of poor sleep.
Methods: Primary care providers have an opportunity to screen for sleep disorders as part of the
intake process during an office visit. The Functional Outcomes of Sleep Questionnaire (FOSQ),
has been proposed as guide to determine if a sleep disorder is affecting quality of life. This
descriptive study randomly recruited 20 participants from a community health center. A 10question survey was given to individuals over the age of 18 who can write and speak English and
either have a body mass index (BMI) over 30, hypertension (HTN) or diabetes type II (DMII).
Demographic information evaluated included age, gender, HTN, DMII, BMI>30, marital status,
sleeping alone, employment type, race, type of insurance, how many times do they wake up at
night, the average number of hours slept per night and does the person work night shift.
Results: The study used a qualitative approach with a descriptive methodology; statistical
analysis consisted of proportions, means and standard deviation to describe the study population.
Participant age ranged from 33 to 72 years (M=50.1, SD= 11.32). Sixty percent were both
female and married/living with partner. Despite being married/living with partner, 50% slept
alone. A Mann-Whitney U test showed that there was a significant difference in four of the
questions in the FOSQ-10 in which functional outcomes were not affected by being sleepy or
tired.
Conclusion: The FOSQ-10 may serve a role in identifying patients who might benefit from a
sleep study. The inclusion of a sleep disorder screening tool may increase the specificity and
sensitivity of the intervention and the ability to yield data that will objectively measure
disordered sleep.
Keywords: sleep apnea, sleep apnea screening, primary care provider, hypertension, diabetes,
sleep disorder, impaired quality of life, quality of life screening

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Sleep Quality and the Effect on Functional Outcomes

Sleep apnea can be described as a temporary pause in breathing while someone sleeps
that lasts from ten to ninety seconds. Symptoms include daytime fatigue, difficulty falling asleep
and difficulty staying asleep. Insomnia is characterized by difficulty falling asleep, staying asleep
or going back to sleep. Narcolepsy is a described as daytime sleepiness or unable to stay awake
during the daytime. What do these conditions all have in common? They are all considered sleep
disorders. Treatment for sleep disorders includes medication, positive airway pressure devices,
oral appliances, behavioral treatments and/or surgery (Epstein, et al., 2009; Garg, 2018). The
benefits of treatment include reduced hemoglobin A1c (HbA1c) in diabetes mellitus type 2
(DMII), a decrease in daytime drowsiness, decrease in hypertension (HTN) and a decrease in
disturbed sleep which can result in an improved quality of life. Having untreated sleep disorders
increases the chances of developing other conditions that can affect the social, mental and
physical health of a person, thereby affecting self-care, personal relationships and employment.
Fatigue during the day has been shown to affect employment performance, personal relationships
and activities of daily living and mental health (Guglielmi, Magnavita, & Garbarino, 2017;
Appleton, et al., 2018). Sleep disorders also contribute to cognitive impairment, loss in work
productivity due to injury, and an increase risk of automobile crashes (Hiestand, Britz, Goldman,
& Phillips, 2006; Leng, McEvoy, & Allen, 2017).
Background and Significance
Sleep disorders can be considered a life-threatening condition that affects approximately
17% of population in the United States (Goodson, Wung, & Hedger Archbold, 2012). According
to the American Academy of Sleep Medicine (2015), undiagnosed sleep disorders cost the U.S.
$150 million in 2015. The consequences have been associated with diabetes, hypertension,

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obesity and quality of life (Babu, Herdegen, Fogelfeld, & Shott, 2005; Kemple, O'Toole, &
O'Toole, 2015; Priou, et al., 2015).
Those who have interrupted sleep are more likely to gain weight and have increased risk
of developing obstructive sleep apnea (OSA). Data suggests that the sleep disruption and
intermittent hypoxia can decrease insulin sensitivity, worsen glucose tolerance, create insulin
resistance and pancreatic -cell dysfunction increasing risk for diabetes or contributing to
diabetic complications (Raju, Swaroopa, Yadati, & Alekhya, 2016; Rajan & Greenberg, 2015).
The National Institute of Diabetes and Digestive and Kidney Diseases (2018) reports risk factors
that contribute to insulin resistance include large waist size, elevated triglycerides, elevated
cholesterol, HTN and fasting blood glucose level of >100mg/dl. It can also be noted that sleep
disorder patients with insulin resistance are at an increased risk of diabetes mellitus (Malik,
Masoodi, & Shoib, 2017; Sahin, et al., 2011).
In a prospective analysis of 1,453 non-diabetic participants, severe OSA was associated
with a 71% increased risk of diabetes. This was independent of any other risk factors including
BMI and waist circumference (Nagayoshi, 2016; Ford, Cunningham, Giles, & Croft, 2015).
Untreated sleep disorders in diabetics are associated with poor glycemic control that results in
use of medication that has side effects of weight gain, thereby exacerbating the severity of sleep
disorders and increasing cardiovascular risk (Malik, Masoodi, & Shoib, 2017; Reutrakul &
Mokhlesi, 2017).
The association between sleep disorders and HTN is just as significant. In 2012
cardiovascular diseases cost the United States an average of $317 billion (CDC, 2016). The
constant upper airway obstruction contributes to intermittent hypoxia and hypercapnia which
increases blood pressure and stresses the cardiovascular system (Windland-Brown & Porter,

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2011). Evidence suggests that the repeated strain on the heart and the circulatory system
throughout the night causes a sympathetic nervous system response that can persist during the
day. These patients tend to have higher heart rates, higher blood pressure and arterial stiffness
(Knauert, Naik, Gillespie, & Kryger, 2015).
In a study by Kasei, Floras and Bradley (2012), it was found that in 65% to 80% of the
drug resistant HTN cases, a sleep disorder was present. In general, when there are repeated
apnea events the heart and circulatory system are exposed to harmful stimuli that may initiate or
contribute to the progression of cardiovascular disorders that include heart failure, arrhythmias
and stroke (Kasai, Floras, & Bradley, 2012). In a cohort study by Gami, et al., (2013), 10,701
adults were followed, and the risk of sudden cardiac death after five years was associated with
OSA, this was based not only on the frequency of apnea levels but the severity of oxygen
desaturation while sleeping.
Sleep disorder studies have been performed in several countries and it has been shown to
effect men more than women. The prevalence of sleep disorders in North America, Europe,
Australia, and Asia are not significantly different which suggests that this disease is common
regardless of the development of the country (Cherasse, 2011; Franklin & Lindberg, 2015;
Gottlieb, et al., 2010; Gharibeh & Mehra, 2010).
Currently, there is a family clinic in the Southwestern United States that recently had a
change in the organization and no longer has a sleep medicine provider. A challenge that many
clinics encounter is that there is no specific screening process in place for sleep disorders. There
is not a specific clinical assessment or measurement that can diagnose sleep disorders but
identifying those at risk helps the provider seek further evaluation by a sleep medicine provider.

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Problem statement
Lack of public awareness and provider education are some of the barriers to diagnosing
and treating sleep disorders. The financial and physical consequences of undiagnosed sleep
disorders in adult patients led to the clinical PICO question: In adult primary care patients, how
does the use of a quality of sleep questionnaire compared to clinical judgement/current standard
of care affect sleep disorder referral.
Search Strategy and Methods
To answer the PICOT question, the following databases were searched: Academic
Premier (Appendix A), Cumulative Index of Nursing and Allied Health Literature (CINAHL)
(Appendix B), and PubMed (Appendix C). Key words used to complete each search included:
sleep disorders, screening, questionnaire, primary care, quality of life, cardiovascular, diabetes,
hypertension, obstructive sleep apnea. The searches were conducted using publications dates
from 2012-2018. Setting limits to English languages, regardless of country of origin, and
combining terms produced over 535,426 articles.
In total there were 63 articles that met the criteria and were retained for final review. In
addition to the search of the databases, the references of the selected articles were also examined
for additional studies, however were excluded because they were not published between 2012 –
2018. A search of grey literature was conducted and included position papers, practice
guidelines, doctoral theses and dissertations, statistical reports and opinions papers but were
excluded due to a low level of evidence.
While reviewing the articles for inclusion, it can be noted that many of them had
exclusion criteria that included pregnant subjects, a psychiatric diagnosis, non-English

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publications and those that had participants under 18 years old. These exclusions were applied to
this search as well to locate studies that demonstrated similar populations. Discarded
publications consisted of those that had inconclusive evidence or misleading conclusions. Studies
included had settings in a primary care office, specialty clinic or hospital, had a focus on either
hypertension or diabetes and had screenings tools implemented or validated. Critical appraisal of
47 articles yielded 10 publications that best addressed the PICOT question. These publications
evaluated the relationship between sleep disorders and cardiovascular disease or diabetes.
(Appendix E).
Critical Appraisal and Synthesis
Ten studies have been chosen in this literature review, all studies were evaluated using a
rapid critical appraisal and are presented in the evidence table for analysis of data (Appendix D).
There was very little evidence to support screening or screening tools for sleep disorders in a
primary care provider’s office. To overcome this challenge, the literature collected focused on
current screening questionnaires that would identify a person who is at risk for a sleep disorder.
The final studies for inclusion were comprised of two meta-analysis’s (MA), one randomized
controlled trial (RCT), one systematic review (level of evidence (LOE) I), one experimental
study (LOE III), two cross sectional studies (CSS) (LOE IV) and three cohort studies (CS) (LOE
IV) (Appendix D). It should be noted that the LOE I studies were not specific in the type of
studies that were analyzed but they did have participants from various countries, solidifying how
prevalent sleep disorders are regardless of region. Although level IV evidence is considered
moderately strong, two of the studies could identify that sleep disorders increase the risk of DM
and HTN complications. Overall there was moderate amount of homogeneity in the population,
the majority were men and over the age of 50 years old. This could be considered a weakness,

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however epidemiological facts of sleep disorders state that males are more affected than females
(Franklin & Lindberg, 2015). The samples size of the studies ranged from 200 to 47,978
participants with an age range of 30-63 years old. There was one study that had an outlier
otherwise the average age would have bene closer to 50-63 years old.
Seven of the studies either used or reviewed the screening questionnaires to identify if the
severity of sleep disorders can be detected (Appendix D). In all, there were significant
implications to indicate a screening tool was reliable in a hospital or surgical setting. Studies
chosen were from different countries but all were in English and were published between 20122018 (Appendix E). Theoretical frameworks were not listed in any of the studies but the most
common theoretical framework that could be applied is Pender’s Health Promotion Model
(Appendix F) and Lewin’s Change Theory (Appendix G).
Most of the settings were surgical centers or hospital. This is also where the participants
were recruited from. There were two exceptions, one was an experimental study that took place
in a primary care provider’s clinic and one cohort study was a longitudinal study that used the
participants home for assessment. This could be considered a limitation because it was not
generalizable to the other studies, however this study supported the need for the implementation
of sleep disorder screening in a PCP setting.
Homogeneity was present in the measurement tools used which consisted of the Berlin
Questionnaire (BQ), STOP-Bang questionnaire (SBQ), STOP questionnaire (STOP) and the
Epworth Sleepiness Scale (ESS). Sensitivity and specificity in the BQ, SBQ, STOP and ESS
were noted in some of the studies. If the instrument used did not have the sensitivity and
specificity noted in the article, it used one of the well-known instruments that has specificity and
sensitivity published and verified. The evidence presented suggests that the SBQ had the highest

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sensitivity and specificity among the screening questionnaire’s when the apnea-hypopnea index
(AHI) was >5. The SBQ is also cost effective and has a simple format (Appendix H).
Four of the studies used quality of life questionnaires before and after sleep disorder
treatment. The Functional Outcomes of Sleep Questionnaire (FOSQ) measures the impact of
daytime sleepiness on activities of daily living using five subscale that include general
productivity (concentrating and remembering), activity level (relationships affected, acting in the
morning and evening), vigilance (watching movies, driving long and short distances), social
outcomes and intimacy and sexual relationships (Weaver, et al., 1997). The original
questionnaire consisted of 30 questions, but in 2009 it was revised to a short 10 question form
that still included the subscales of the original questionnaire with an internal consistency of α .87
and would take less than 5 minutes to complete (Chasens, Ratcliffe, & Weaver, 2009).
Purpose and Rationale
The purpose of this evidence-based project is to identify if quality of sleep affects
functional outcomes. Primary care providers can identify those who are at risk for sleep disorders
based on their body mass index more than 30 (BMI >30) or diagnosis of HTN or DMII.
Screening can be completed in the office using a questionnaire. Guidelines that are in place to
screen for sleep disorders are recommendations intended for surgical candidates. There is no
current recommendation for primary care providers which may prove to be a limitation, however
these questionnaires may easily be generalized to a primary care outpatient setting due to the
validity and reliability. The research provided can assist in detecting patients who may be at risk
for sleep disorders based on a medical diagnosis of DM or HTN and obesity. The treatment of
sleep disorders has been shown to reduce the risk of the chronic health consequences of
untreated sleep disorders (Kapur, et al., 2017; Peach, Gaultney, & Reeve, 2015). The change in

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practice would be to use a screening tool to detect sleep disorders earlier. The benefit would be
that an early diagnosis could decrease complications associated with diabetes and hypertension.
The increased benefit of this screening program would include how it could potentially affect
other aspects of the patient’s life.
Conceptual Framework and Evidence Based Practice Model
The Health Promotion Model (HPM) (Appendix F) will guide the proposed change in a
primary care office. It is focused on achieving a higher level of wellbeing and self-actualization.
Individuals want to actively be involved in their care and continually make decisions based on
their environment to improve their health. This model notes that each person has unique personal
characteristics and experiences that affect actions and there are modifiable factors that can affect
the behavior (Galloway, 2003). Health care providers can influence the commitment and
engagement of health promoting behaviors. It is beneficial to provide support and assistance to
achieve the desired outcome (Pender, 2011).
The Rosswurm and Larrabee Model (Appendix I) will be used to execute this proposed
practice change. This framework uses six steps to implement and support a change in practice.
Identifying the need for change (sleep disorder screening, identifying a sleep disorder) would
initially include a combination of internal (identifying sleep disorder) and external data (effects
of sleep disorder on DM and HTN) and how it would affect stakeholders (provider, staff and
patients). This data would be used to identify interventions (sleep disorder screening) and guide
the literature search to design the practice change (sleep disorder screening) and define desired
outcomes (decrease complications from DM and HTN, improve quality of life). This initial study
will be conducted to evaluate the process (screening), identify a need for practice change or
process improvement and identify education needs (Rosswurm & Larrabee, 1999).

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Project Methods

This initiative was implemented using a qualitative approach with a descriptive
methodology at a community health clinic. Patients already scheduled with the provider were
used as an opportunity for recruitment. Inclusion criteria were individuals over 18 years old,
BMI over 30, HTN or DMII, and write and speak in English. Exclusion criteria were those who
are unable to consent and pregnant women. The Functional Outcomes of Sleep Questionnaire
(FOSQ-10), was given to every candidate after a signed consent was completed, the
questionnaire included demographic information (Appendix J). Demographic information
consisted of age, gender, marital status, sleep alone, employment, race, insurance type, how
many times does the person wake up at night, average number of hours of sleep and do they
work night shift. Due to time limitations, recruitment was conducted over three business days
and 20 surveys were obtained. There was not any additional cost to participate in the survey and
all candidates were voluntary without compensation.
Project Results
Descriptive statistics were conducted using SPSS to summarize study sample
characteristics. Mann-Whitney tests were used to examine whether the total score of FOSQ-10
was significantly different by demographic and health-related variables. The age of participants
ranged from 33 to 72 years (M=50.1, SD= 11.32). More than half of the sample was female
(60%) and married/living with partner (60%). Despite being married/living with partner, half of
the sample slept alone (50%). Half of the sample were white and employed (50%). Less than half
of the participants had Medicaid (AHCCCS) (45%). The average numbers of times a person
woke up was 2 (M=2.05, SD=1.25). The average number of hours slept per night was 6.6 hours
(M=6.63, SD=1.54). Nearly all of the working participants, did not work at night (95%). More

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than half of the sample had HTN (55%), most of the participants did not have DMII (80%) and
most of the participants had a BMI>30 (85%). Out of the 20 surveys, the total score for questions
1-10 (Q) had a maximum of 20 and minimum of 13.67 (M 17.02, SD = 1.97) Subscales has a
maximum of 4 and minimum of 1.l Subscales for general productivity included concentrating
(Q1) and remembering (Q2), with a maximum 4.00 and minimum of 2.00 (M = 3.50, SD = 0.67).
Subscale activity included relationships affected (Q3), activity in the morning (Q4), activity in
the evening(Q5), maximum of 4.00 and minimum of 3.00 (M = 3.77, SD = 0.34). Subscale
Vigilance driving short distances (Q6), driving long distances (Q7), watching movies (Q8),
maximum 4.00 and minimum of 2.67 (M = 3.50, SD = 0.41).
The demographic portion of the questionnaire had categories with only one case. Those
categories were merged to generate more meaningful data and interpretation of the FOSQ-10
total score and demographics. A Mann-Whitney test on the recoded data showed statistical
significance. People being married/significant other had significantly lower total score of
FOSQ-10 compared to not being married significant other (M = 6.25 vs M = 13.3, U = 14.0, p =
.008). In other words, people being married/significant other had less functional disability than
individuals not being married/significant other. Sleeping alone had a higher total score compared
to those who did not sleep alone (M = 13.70 vs. M = 7.30, U=18.0, p = .015), meaning that
individuals sleeping alone has less functional disability than those who do not sleep alone.
Questions on the FOSQ-10 also had categories with only one answer, those one answers
were recoded to determine if significance was present. Individuals with little to extreme
difficulty in concentrating showed a lower total score compared to those with no difficulty in
concentrating (M = 6.29 vs. M = 12.77, U=16.0, p = .019). Those who had little difficulty
remembering had a lower score compared to those with no difficulty remembering (M = 6.38 vs.

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M = 13.256, U = 15.0, p = .011). Individuals with a little too extreme difficulty being as active in
the morning had a lower score than those who had no difficulty (M = 7.30 vs. M = 13.90 U 16.0,
p = .009). The category for little to extreme difficulty desire for intimacy had a lower total score
than those who had no difficulty (M = 6.60 vs. M = 14.40, U = 11.0, p = .003).
Discussion
The increased benefit of a sleep disorder screening would include how it would affect
other aspects of the patient’s life that include personal relationships, job performance and mental
health (Park, Yoo, & Bae, 2013). Literature already presented for sleep disorders identified how
it can affect comorbidities; increased HbA1c, uncontrolled HTN, obesity. In addition, health care
professionals are part of this change and can provide education and guidance for well informed
decisions to be made that could affect HTN and DM outcomes.
In a study by Lou et al (2015) poor sleep and DMII impacted quality of life and
suggested that screening for sleep disorders can influence sleep quality in diabetic patients.
Evidence based literature also supports that quality of sleep correlates with body size and
composition, cardiovascular health, and poor glycemic control (Bani-issa, Al-Shujairi, & Patrick,
2018; Bruno, et al., 2013; Lou, et al., 2014).
The FOSQ-10 may serve a role in identifying patients who might benefit from a sleep
evaluation. Time was a factor to consider, a major strength of the study is the FOSQ-10 was
only ten questions and patients were able to complete the questionnaire in less than five minutes.
Patients did not have to be recruited from an outside source, they were already at the clinic for
another medical reason increasing the chances of capturing data.
A limitation to the study was the lack of a sleep disorder screening tool, for example the
SBQ, ESS or a validated tool that is specific to sleep disorders. In this study the SBQ was

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removed due to proprietary reasons, the inclusion of a sleep disorder screening tool may increase
the specificity and sensitivity of the intervention and the ability to yield data that will objectively
measure disordered sleep. The FOSQ-10 could be used before and after treatment if a sleep
provider determined a sleep treatment is necessary, thereby measuring how treatment affected
quality of sleep and functional outcomes.
Time was also a consideration, as noted by two potential participants who declined to
participate, the appointments are for 20 minutes and this includes the time the medical assistant
uses for the intake process which can take up to five minutes to complete. Candidates did not like
the idea of going to another provider at a different clinic, nor did they want to spend the night at
a facility if they were required to complete a sleep study. The cost associated with seeing a
specialty provider was not as big of a factor to participate in the questionnaire.
In this sample it is evident that marriage/significant other can influence sleep quality and
the functional outcomes. Sleeping alone also affected sleep quality, factors to consider are
whether the partner snores or has a movement disorder that disrupts the partners sleep.
Individuals that did have lower total FOSQ-10 scores had little to extreme difficulty compared to
those who had no difficulty. This is opposite of expectation, but this was also only a small
sample of the population and it may warrant more education regarding sleep disorders and how
to identify them. To better serve the clinic, a larger sample that more closely relates to the target
population would provide a better description of sleep and how it affects functional outcomes.
There is a need for further research to test the complete screening procedure with
participants more closely matched with the target population: male, hypertension, diabetes
mellitus II, obesity. Interventions for sleep disorders that address cultural and socioeconomic

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barriers could also be evaluated that would include education and resources for low income and
vulnerable populations.
Conclusion
This qualitative approach with a descriptive methodology evidence-based project used a
quality of life questionnaire that contained ten questions to measure the impact of daytime
sleepiness on activities of daily living. The FOSQ-10 was brief and simple to complete, most of
the participants agreed to complete the questionnaire, but the sample size was also smaller than
expected. Although identifying functional limitations cannot predict a sleep disorder, it can help
a provider identify a patient that requires further evaluation.

Running head: SLEEP QUALITY AND THE EFFECT ON FUNCTIONAL OUTCOMES 16

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Nagayoshi, M. (2016). Obstructive sleep apnea and incident type 2 diabetes. Sleep Medicine, 25:
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SLEEP QUALITY

23
Appendix A

Academic Premier

SLEEP QUALITY

24
Appendix B

CINAHL

SLEEP QUALITY

25
Appendix C

PubMed

SLEEP QUALITY

26
Appendix D

Table 1
Evaluation Table
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Chiu (2017)
Diagnostic
accuracy of the
Berlin
questionnaire,
STOP-BANG,
STOP, and
Epworth
sleepiness scale
in detecting
obstructive
sleep apnea: A
bivariate metaanalysis

Not stated: Lewin’s
Change Theory can
be applied

Design: MA

N: 100

IV1: BQ
IV2: SBQ
IV3: STOP
IV4: ESS

BQ
SBQ
STOP
ESS

QUADAS-2

Level: 1

DV1: dx of
OSA
DV2: Mild
OSA AHI >5
DV3:
Moderate
OSA AHI
>15 DV4:
Severe OSA
AHI >30

Data extraction
forms

Pooled sensitivity
(95% CI)
AHI >5
BQ (n=32) 0.76
(0.71-0.81)
SBQ (n=27) 0.88
(0.83-0.91)
STOP (n=10) 0.87
(0.81-0.92)
ESS (n=15) 0.54
(0.45-0.63)

Country:
United States &
Taiwan
Funding:
Ministry of

Purpose:
Estimate the
summary
sensitivity,
specificity and
DOR of BQ,
SBQ, STOP
and ESS against
AHI or RDI
(severity of
OSA)

Demographics:
Avg age
BQ - 51.7 y
SBQ – 55.5 y
STOP – 50.8 y
ESS – 52.3 y
Inclusion
criteria:
Studies
examining
sensitivity and
specificity of
BQ, SBQ,
STOP and ESS
against AHI or
RDI
Access to full
text in English

Bivariate
statistical
analysis.
Metaregression
and moderator
analysis
Stata Version
14.0 with midas
and metandi
user written
command and
SAS version
9.0.2 with Proc
Mixed module
Chi squared test

AHI>15
BQ (n=34) 0.77
(0.73-0.81)
SBQ (n=32) 0.90
(0.86-0.93)
STOP (n=12) 0.89
(0.81-0.94)
ESS (n=8) 0.47 (0.350.59)

Strengths:
Large sample
Weaknesses:
Blinding and
test
reproducibility
were not fully
reported, can
alter reliability.
Heterogeneity
among studies.
Diagnostic
properties of the
questionnaires
for certain
population were
unavailable.

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY
Science and
Technology
Bias: None

27
or Chinse
published in a
peer reviewed
journal. Or
portable
monitoring
Full overnight
in lab PSG, in
home PSG

Exclusion
criteria: NonEnglish or
Chinese text,
not published in
peer reviewed
journal,
children,
adolescents,
pregnant
women

AHI >30
BQ (n=19) 0.84
(0.79-0.88)
SBQ (n=26) 0.93
(0.89 -.95)
STOP (n=10) 0.90
(0.84 -0.93)
ESS (n= 6) 0.58
(0.48-0.67)

Conclusion:
SBQ is superior
for detecting
mild, moderate,
severe OSA.
Inexpensive tool
when PSG not
available

Pooled specificity
AHI >5 (95%CI)
BQ (n=32) 0.59
(0.48-0.66)
SBQ (n=27) .42 (0.35
-0.50)
STOP (n=10) 0.42
(0.29-0.56)
ESS (n=15) 0.65
(0.57-0.72)
AHI >15 BQ
BQ (n=34) 0.44
(0.38-0.51)
SBQ (n=32) 0.36
(0.29 -0.44)
STOP (n=12) 0.32
(0.19-0.48)
ESS (n=8) 0.62 (0.560.68)
AHI >30
BQ (n=19) 0.38 (0.31

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

28
-0.56)
SBQ (n=26) 0.35
(0.28 -0.44
STOP (n=10) 0.28
(0.18 -0.40)
ESS (n= 6) 0.60
(0.53-0.68)
Pooled DOR (95%
CI)
AHI >5 (95%CI)
BQ (n=32) 4.30
(2.96-6.24)
SBQ (n=27) 5.13
(4.25-6.29)
STOP (n=10) 4.85
(2.50-9.41)
ESS (n=15) 2.18
(1.39-3.40)
AHI >15 BQ
BQ (n=34) 2.68
(2.19-3.29)
SBQ (n=32) 5.05
(3.65-7.00)
STOP (n=12) 3.71
(2.73-5.06)
ESS (n=8) 1.45 (0.942.24)
AHI >30
BQ (n=19) 3.10
(2.57-3.73)

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

29
SBQ (n=26) 6.51
(5.05-8.40)
STOP (n=10) 3.37
(2.10-5.39)
ESS (n= 6) 2.10
(1.76-2.52)

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Coman (2016)
Obstructive
Sleep Apnea
Syndrome and
the Quality of
Life

Not stated: Health
Promotion Model
could be applied

Design: CSS

n: 79

IV: SAQLI

SAQLI

MedCalc
Statistical
Software
version 15.8

IV on DV1: SAQLI
pretreatment
3.11+0.32, mean total
post treatment 4.24
+0.39

Level: 4

Country:
Romania
Funding:
European social
Fund through
the Sectorial
Operational
Programme
Human
Resources

Purpose:
Assess OSA
patients QOL
before and after
therapy.

Setting: Sleep
Laboratory
Inclusion
criteria:
Adults with
OSA who have
CPAP at home
and consented.
Exclusion
Criteria:
Subjects
refused, mental
or cognitive
disorders

DV: Any
participant
with an =or>
MiOSA

3 months of
CPAP treatment
ESS was only
used to measure
daytime
sleepiness
Somnologia
Studio 5.0 as
scoring platform
Manual of
American
Academy of
Sleep Medicine

When
applicable:
Paired-t test,
Wilcoxon test or
ANOVA.
Between groups
student t test,
Mann-Whitney
test

Strength:
Patients already
diagnosed with
CPAP and
aware of
treatment.
Objective data
collected
regarding
compliance
using CPAP
compliance
card.

Sig level .05

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

30
Weakness:
Specific
population.
Central apnea
was not
evaluated
separately

Bias: None

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Silva (2016)
Obstructive
Sleep Apnea
and Quality of
Life:
Comparison of
the SAQLI,
FOSQ and SF36
Questionnaires

None stated:
Pender’s Health
Promotion Model
can be applied

Design: Cohort

n:884

IV1: SAQLI

Country:
United States
Funding:

Purpose:
Compare
instruments to
each other to
assess whether
they were able
to detect
differences in
QOL among
groups with
different
severities of
OSA and

Setting:
Sleep Heart
Health Study
Population:
Participants
from Tucson
and
Framingham
sites of the
Sleep Heart
health Study
that initially

IV2: FOSQ
IV3: SF-36
MCS
IV4: SF-36
PCS
DV: OSA
treatment

Conclusion:
QOL is impaired
by OSA
Level/Quality
of Evidence;
Decision for
practice/
application to
practice

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Stat SE version
13.0 for
windows

Total scores

Level: 4

Sleep Habits
Questionnaire

IV1 on DV: Total 6.0
(.82). No OSA 6.0
(.78), Mild-moderate
OSA 6.0 (.83), SOSA
5.8 (.8)

Strength:
Cohort was part
of longitudinal
study resulted in
high compliance
because they
knew
importance of
compliance

Fisher’s
chi-square test
SF-36 (MCS
ANOVA
mental component) Pearson’s
correlations
SF-36 (PCS
Multivariate
physical
linear regression
component)
models
Spearman’s
FOSQ
Sig level 0.05
ESS

IV2 on DV: Total
11.5 (.82), No OSA
53.8 (8.0) Mildmoderate OSA 11.5
(.84), SOSA 11.4
(.91)

Weakness:
Participants
from

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY
NHLBI grant
HL 06237305A2

31
whether there
were
differences
between
genders

Bias: None

completed the
QOL
instruments

SAQLI

IV3 on DV: Total
54.0 (8.2), No OSA
53.8 (8.0), Mildmoderate OSA 54.4
(8.4), SOSA 55.3
(7.4)

Inclusion
criteria:
Participated in
original
Framingham
sites of the
Sleep Heart
Health Study.
Completed
QOL
questionnaires
in original
Framingham
study, live in
Tucson

IV4 on DV: Total
47.1 (10.8), No OSA
48.5 (10.5), Mildmoderate OSA 46.5
(11.0), SOSA 45.1
(10.3)

Exclusion
criteria: did not
participate in
Framingham
study

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

longitudinal
study, may not
be
representative of
US adult
population.
Those who do
not have OSA
were also
included in QOL
questionnaire.
QOL
questionnaires
are specific to
different aspects
of QOL, hard to
compare when
they are
measuring
different areas
of life
Conclusion:
QOL poorer in
females with
SOSA.

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Level/Quality
of Evidence;
Decision for
practice/
application to

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

32
practice

Miller (2015)
Screening and
assessment for
obstructive
sleep apnea in
primary care
Country:
United States
Funding: None
Bias: None

Not indicated but
Lewin's Change
Theory

Design: NE SR

Purpose:
Evaluate the
screening and
assessment for
OSA in primary
care setting

N: 17
Setting: 14
nonexperimental
and 3
experimental
designs
Inclusion
criteria:
English
language,
primary care
setting/internal
medicine, OSA
screening
process,
compared
screening tools,
management of
OSA
Exclusion
criteria: Sleep
disorders other
than OSA,
pediatric
patients

IV:
Screening of
OSA in PCP
office
DV1: BQ
DV2: ESS
DV3: STOP
DV4: SBQ

SBQ, SB, ESS,
STOP

Cronbach's
alpha

AASM clinical
guidelines task
force

Testretest reliability

Reliability (95% CI)
BQ: Cat 1 α = 0.92
Cat 2 α = 0.63
ESS α = 0.88

Level:1
Strengths:
Screening tools
identify at risk
patients for OSA

STOP k = 0.93
SBQ none reported
SBQ
Sensitivity/Specificity
(95% CI) (AHI _ 15
events/hr)
0.54/0.97
0.79
(0.67, 0.88)/
0.51
(0.41, 0.62)
0.95
(0.91, 0.98)/
0.07
(0.01e0.24)
PPV/NPV (95% Cl)
(AHI _ 15 events/hr)
PPV = 0.97
0.51
(0.42, 0.61)/0.78
(0.67, 0.87)
0.87
(0.82, 0.91)/0.20

Weakness: Not
all screening
tools have been
reported to be
reliable and
valid.

Conclusion: A
screening and
assessment
process in PCP’s
office is lacking.
PCP’s aware
health effects
but do not
recognize or
refer
Need large
scale,
nationwide
studies to assess
implementation
in PCP settings

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

33
ESS
Sensitivity/Specificity
(95% CI) (AHI _ 15
events/hr)
0.39, 0.71
0.76
(0.69e0.82)/0.48
(0.29, 0.68)
PPV/NPV (95% Cl)
(AHI >15 events/hr)
0.91
(0.85, 0.95)/
0.23
(0.13, 0.36)
SQ
Sensitivity/Specificity
(95% CI) (AHI > 15
events/hr)
0.74
(0.62, 0.84)/0.53
(0.43, 0.63)
0.62/0.56
0.95
(0.89, 0.97)/0.26
(0.11, 0.46)
PPV/NPV (95% Cl)
(AHI > 15 events/hr)
0.51
(0.41, 0.60)/0.76
(0.64,0.85)
0.89
(0.84, 0.93)/0.41
(0.18, 0.67)

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

34

SBQ
Sensitivity/Specificity
(95% CI) (AHI > 15
events/hr)
0.93
(0.84, 0.98)/0.43
(0.33, 0.53)
0.87, 0.43
0.98
(0.94, 0.99)/0.03
(0.006, 0.19)
PPV/NPV (95% Cl)
(AHI > 15 events/hr)
PPV/NPV (95% Cl)
(AHI > 15 events/hr)
0.52
(0.43, 0.61)/0.90
(0.79, 0.97)
0.87
(0.81, 0.91)/0.20
(0.03, 0.71)
Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Tan (2016)
Predicting
obstructive
sleep apnea

Not stated: Pender's
Health Promotion
Model can be
applied

Design: CS

Setting:
Outpatient
cardiology
clinic - Brigham

IV: SBQ

SBQ

R V.3.2.1.

DV1:
MSOSA dx

PSG type 3

General
demographics

IV on DV1:
Prevalence 28.1%
BMI >35
BMI >30 BMI > 27.5

Purpose:
Determine if

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level:4
Strengths:
High NPV in

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY
using the
STOP-Bang
questionnaire in
the general
population
Country:
Malaysia
Funding:
FY2014 Health
Services
Research and
Quality
Improvement
Grant of Ng
Teng Fong
General
Hospital,
Jurong Health
Service
Bias: None

35
untreated
severe OSA is
associated with
elevated
ambulatory
blood pressure
in patients with
high
cardiovascular
risk despite
medical
management

and Women's
Hospital, Case
Medical Center,
Johns Hopkins
Medical Center,
Veterans
Affairs Boston
Healthcare
System
Inclusion
criteria: high
risk for CV
disorders. CAD
>3 months
prior, >3 CV
risk factors
(PCP treated
HTN SBP
>140mmhg or
DBP >90mmhg
or AHTN meds,
DM, BMI, DLP

DV2: SOSA
dx
Time frame:
7 months

2012 AASM
respiratory
scoring
World Health
Organization
cutoff to define
obesity in Asian
individuals

Anthropometrics

Sn: 66.2, 73%, 70.1%
Sp: 74.7%, 73.0%,
70.1%
PPV: 50.6%, 50.0%,
48.0%
NPV: 85%, 85.8%,
86%
ROC: 0.704, 0.711,
0.704
IV on D2
Prevalence 10.7%
BMI >35
BMI >30 BMI > 27.5
Sn: 69.2, 73.1%,
73.1%
Sp: 67.1%, 65.3%,
62.5%
PPV: 20.2%, 20.2%,
19.0%
NPV: 94.8%, 95.3%,
95.1%
ROC: 0.682, 0.692,
0.678

SBQ
Weakness:
Portable sleep
studies used
instead of in lab
PSG.
NPV could be
inflated due to
underestimation
of portable
monitors.
Oversampled
snorers.
Conclusion:
SBQ can be
used as a
screening tool to
prioritize
individuals for
further testing.

BMI 27.5-30

Exclusion
criteria: HF
with EF <30%
or NYHA class
>2, BP
>170/100
mmHg, HbA1c
Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

36
>9%, prior
stroke with
functional
impairment,
severed
uncontrolled
medical
problems,
medications
that

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Walia (2014)
Association of
severe
obstructive
sleep apnea and
elevated blood
pressure despite
antihypertensive
medication use

Not stated: Pender’s
Health Promotion
Model can be used

Design: CS

n: 284

IV: OSA

AASM 2007
guidelines

p<0.05

Purpose:
Determine if
untreated
severe OSA is
associated with
elevated
ambulatory BP
in patients with
high CVD risk
despite medical
management

Demographics:
M age: 63.1 +
7.2 CBP=SBP
<130 and DBP
<80.
EBP=SBP>130
or DBP >80
WIAR,
WOIAR, REBP
WIAR, UEBP
WIAR

DV1: CBP
WOIAR
DV2: CBP
WIAR
DV3: EBP
REBP WIAR
DV4: EBP
UEBP
WOIAR
DV5: WIAR
CBP
DV6: WIAR
REBP
DV7:
WOIAR

Univariate and
multivariable
logistic
regression

Country:
United States
Funding: None
Bias: None

Setting:
Outpatient

Spacelabs 90217
Ambulatory
Blood Pressure
Monitors
Measure BP
every 20 minutes
from 0600-2200
and every 30
between 22000600 for 24hr
period
Resting BP after

IV on DV1: 45.8%
IV on DV2: 15.8%

Kruskal-Wallis
test

IV on DV3: 9.9%

SAS version 9.2

IV on DV4: 28.5%
IV on DV5: 15.8%

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level:4
Strengths:
Multiple clinical
settings (makes
more general)
24 ambulatory
BP monitoring
is more reliable
than spot office
BP
measurements

IV on DV6: 9.9%
IV on DV7: 45.8%
IV on DV8: 28.5%

Weakness: No
ability to
compare those
without sleep

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

37
cardiology
clinic - Brigham
and Women's
Hospital, Case
Medical Center,
Johns Hopkins
Medical Center,
Veterans
Affairs Boston
Healthcare
System
Inclusion
criteria: high
risk for CV
disorders. CAD
>3 months
prior, >3 CV
risk factors
(PCP treated
HTN SBP
>140mmhg or
DBP >90mmhg
or AHTN meds,
DM, BMI, DLP

CBP
DV8:
WOIAR
UEBP

sitting quietly for
>5 minutes
JNC7 guidelines

apnea.
Not able to
assess if those
with MiOSA or
MOSA with
those without
OSA.
Medication
dosages,
compliance info
not available.
Conclusion:
There is an
association of
untreated SOSA
and REBP.

Exclusion
criteria: HF
with EF <30%
or NYHA class
>2, BP
>170/100
mmHg, HbA1c
>9%, prior
Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

38
stroke with
functional
impairment,
severe
uncontrolled
medical
problems,
medications
that might
influence
measurements
or impair ability
to participate

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Wang (2013)
Obstructive
sleep apnoea
and the risk of
type 2 diabetes:
A meta-analysis
of prospective
cohort studies

None stated:
Pender’s Health
Promotion can be
used

Design: MA

N: 6

Country: China

Funding:

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

IV: Risk of
DM

Stata version
11.2

DV1: MOSA
DV2:
MSOSA

Publication bias:
Begg’s test and
Egger’s test.
Heterogeneity:
Cochrane Q-test
and I2 test

RR of DM for those
with MSOSA 1.63
(95% CI: 1.09-2.45, P
= 0.018)

n: 5953
Purpose:
Assess the
association
between the
severity of OSA
and the risk of
type 2 diabetes

Setting: LR
using Metaanalysis of
Observational
Studies in
Epidemiology
group
Inclusion
criteria:

Time frame:
follow up
period 2.7-16
years

P < 0.10

Pooled risk estimate
MiOSA and DM 1.22
(95% CI: 0.91-1.63, P
= 0.193)

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level:1
Strengths: All
studies used
objective
measurements.
Defined the
severity of OSA
according to
AHI and ODI.
Weakness:
Definitions of

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

39

Shandong
Province
Natural Science
Foundation of
China
Bias: None

prospective
cohort studies
OSA was
assessed with
objective
measurements.
OSA and the
outcome of
interest was
DM

OSA were not
uniform.

Exclusion
criteria: CSS,
LR and studies
that used self
reported
surrogate
parameters

Methods to dx
DM were
different for
each study

Citation

Theory/Conceptual
Framework

Design/Method

Sample/Setting

Wang (2016)
Association of
obstructive
sleep apnea plus

None stated:
Pender's Health
Promotion can be
applied

Design: CSS

n: 1889

Influenced by
referral bias
(false
impression of
the significance
of association
with DM)

Conclusion:
MSOSA
increases the
risk of DM,
risks increase
with severity of
OSA
Major
Variables &
Definitions

IV: OSA
Purpose: To
evaluate the

Setting:
Inpatient

DV1: HTN

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Log for
statistical
analysis

IV on DV1: HTN no
OSA (OR: 1.808,
95% CI: 1.207-2.707)
HTN with MiOSA

Level/Quality
of Evidence:
Decision for
practice/
application to
practice
Level: 4
Strengths:
Large sample

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY
hypertension
and prevalent
cardiovascular
disease
Country: China
Funding: Not
stated
Bias: None

40
association of
OSA plus HTN

cardiovascular
ward
n=773
Normotension
M age 54.7 +
12.4 Male: 570
n=1116 HTN M
age 58.7 + 11.9
Male: 841
Inclusion
criteria: pt
agreed to
participate,
spouses
reported
snoring during
sleep, no
previous OSA
dx
Exclusion
criteria: pt did
not agree,
previous OSA
dx

1-way ANOVA
Mann-Whitney
U
Chi-square
Fisher exact test
Logistic
regression
analysis
SPSS 18.0
P < 0.05

(OR: 2.003, 95% CI:
1.346-2.980)
HTN with MSOSA
(OR: 1.834, 95% CI:
1.214-2.770)

size.
All participants
were from the
same ward.
Standard and
similar BP
methods were
used on all
participants.
Weakness:
HTN patients
were older in
age.
Blood pressure
used was at
admission, this
could have been
elevated due to
white coat
syndrome.
Conclusion:
There may be a
synergistic
adverse effect of
OSA and HTN

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

41

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Weaver (2012)
Continuous
positive airway
pressure
treatment of
sleepy patients
with milder
obstructive
sleep apnea:
Results of the
CPAP apnea
trial north
American
program
(CATNAP)
randomized
clinical trial

None stated: Can
use Pender’s Health
Promotion Model

Design: RCT

n:223

IV: OSA

ESS to measure
sleepiness

Purpose:
Evaluate
efficacy of
CPAP to
improve
functional
status in sleep
patients with
MiOSA and
MOSA

Setting: Active
or Sham CPAP
for home use
randomized to 8
weeks of study
at home

DV1:
Sham CPAP

Last
Observation
Carried Forward

Country: U.S.
Funding:
National
Institutes for
Health, National
heart, Lung and
Blood Institute,
Sleep Medicine
Education and

Inclusion: New
diagnosis of
MiOSA, no
previous CPAP
use, stable
medically for 4
months, no
history of sleep
disorders,
pregnancy,
substance use,
sleepiness
related driving
accident or
sleepiness
sensitive
occupation

DV2: Active
CPAP

SF-36
Psychomotor
Vigilance task
Total Mood
Disturbance Scale
on the Profile of
Moods States,
Mean 48 hour
ambulatory blood
pressure

Findings/
Results

Baseline
IV on DV1: FOSQ
total score 13.91 +
3.02

Paired t tests
Effect size 0.36
Sig 0.05

IV on DV2: FOSQ
total score 14.43 +
2.78
(P=0.18)

Final treatment
mean change
IV on DV1: FOSQ
-0.06

FOSQ
IV on DV2: FOSQ
0.89
(p = .0006)
Adjusted difference
in mean changes (SE)
0.95 (0.34)
Lower and upper
95% CI 0.27, 1.62

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level:1
Strength: Large
sample size.
Low dropout
rate
Weakness:
mean daily
CPAP use was 4
hours and 3
hours per day,
desired 6 hours
of use.
Multisite double
blind RCT that
is first of its
kind.

Conclusion:
CPAP therapy
for sleep patient
with milder
OSA can have
significant
health benefits

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

42

Research
Foundation,
Respironics
Sleep and
Respiratory
Research
Foundation,
Cepahlon, Inc

Exclusion:
Those that did
not meet
inclusion
criteria

Bias:
Equipment
provided but
does not say if
compensation
or if was given
in the form of a
grant

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables &
Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Williams (2017)
Implementation
of an
obstructive
sleep apnea
screening
program at an
overseas
military hospital

Not stated:
Lewin's Change
Theory can be
applied

Design:
experimental

n: 200

Education OSA
(PowerPoint
presentation)

Descriptive
statistics

P = .05

Setting: U.S.
Naval Hospital
in Okinawa,
Japan

IV:
Education
regarding
OSA
screening
using SBQ

Inclusion
criteria: All

DV1:
increase

Purpose:
Determine
whether
educating
nurses on OSA
and

2 test

IV on DV1: 1.18 +
1.02 vs 0.91 + 0.68
(P = .03)
IV on DV2: 5% to 26
% (P = .0001)

Level/Quality
of Evidence;
Decision for
practice/
application to
practice
Level:3
Strengths:
Findings
significant to
identify those at
risk for OSA,
decrease
perioperative

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

Country:
United States
Funding; Not
stated
Bias: disclaimer
study was
independent of
US Naval
Department

43
incorporating
SBQ into the
preoperative
screening
process was
associated with
an increase in
Identification of
pt with
suspected OSA
and increase in
nurse generated
anesthesia
consults for
OSA

charts
regardless of
OSA dx

identification
of suspected
OSA

Exclusion
criteria:
cesarean
deliveries,
younger than 18
years,
emergency
surgery

DV2:
Increase
frequency of
nurse
generated
anesthesia
consults for
OSA
Time frame:
1 month

complications.
Weakness:
Older version of
preop forms
were used
Inconsistent
recording of
apnea.
symptoms.
Type of surgery
not listed.
No PSG
available for
those who
scored 3 or
higher on SBQ
Small sample
Short timeframe
Conclusion:
Using the SBQ
increased the
identification of
patients at high
risk for OSA.
Improve patient
safety.

Key: AC – Accuracy, AASM – American Academy of Sleep Medicine, AHTN – antihypertensive, AHI – apnea-hypopnea index, AVG – average, BMI – body max index, BP – blood pressure, BQ –
Berlin questionnaire, CV – cardiovascular, CVD – cardiovascular disease, CBP – controlled blood pressure, CI – confidence interval, CAD – coronary artery disease, , CS – cohort study, CSS – cross
sectional study, DBP - diastolic blood pressure, DOR – diagnostic odds ratio, DLP – dyslipidemia, DM – diabetes mellitus, DV- dependent variable, dx - diagnosis, EBP – elevated blood
pressure, EF – ejection fraction, EHR – electron health record, ESS – Epworth sleepiness scale, FOSQ- Functional Outcomes of Sleep Questionnaire, HgA1c – glycated hemoglobin, HF – heart
failure, HTN – hypertension, IAR – intensive antihypertensive regimen, IV- independent variable, LR – literature review, M - mean , MA – meta-analysis, MiOSA – mild obstructive sleep apnea
AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, Nuero – neurological, NPV – negative predictive value, N-number
of studies; n- number of participants, NYHA – New York Heart Association, OR - odds ratio, OS – observational study, OSA – obstructive sleep apnea, ODI – oxygen desaturation index, pt –
patient, PCP – primary care provider, PPV – positive predictive value, PSG – polysomnography, PRISMA – preferred reporting items for systematic reviews and meta-analysis, PSQI – Pittsburgh
Sleep Quality Index, PSY – psychological, QOL- quality of life, REBP – resistant elevated blood pressure, RDI – respiratory disturbance index, ROC – receiver operating characteristic, RR – relative
risk, SAQLI – Calgary Sleep Apnea Quality of Life Index, SBQ – STOP-Bang questionnaire, SD – standard deviation, SF-36 – Short Form of the Medical Outcomes Survey, SOSA – severe sleep
apnea AHI > 30, Sn - Sensitivity, Sp – Specificity, SR – systematic review, STOP – STOP questionnaire, SBP – systolic blood pressure, UEBP -uncontrolled elevated BP, WIAR – with intensive
hypertension regimen, WOIAR – without intensive hypertension regiment

SLEEP QUALITY

44
Appendix E
Synthesis Table

Author
Year
Study Design/Level of
Evidence
Setting
PCP Office

Chiu
2016
MA
LOE: 1
U.S./Chi
na
x

Hospital/Surgery Center

x

Sleep Clinic

x

Coman
2015
CSS
LOE: 4
Romania

Miller
2015
SR
LOE: 1
U.S.

Silva
2016
CS
LOE: 4
U.S.

Tan
2016
CS
LOE: 4
Malaysia

Walia
2014
CS
LOE: 4
U.S.

Wang
2013
MA
LOE: 1
China

Wang
2016
CSS
LOE: 4
China

x

x

Weaver
2012
RCT
LOE: 2
U.S.

Williams
2017
Experimental
LOE: 3
U.S.

x
x
x

x

Home

x

x
x

x

Sample Size
N
n

79

17

884

47978

242

284

6
5953

121/118

200

Gender
Male

59

421

122

207

1411

Female

20

463

120

77

478

54.13

61.6

48.3

63.1

x

x
x

55%/63%

Average Age in Years
52.5

30-69

54.7

49.5/51.7

Screening Questionnaires
SBQ
ESS
SQ
BQ

x
x
x
x

MiOSA

+

+

+

+

MSOSA

+

+

+

+

+

+

SOSA

+

+

+

+

+

+

HTN

x

x

x

x

DM

x

x

x

x

x

x
x
x
x

x
x

Detection of OSA
+

+

+

+

+

+

+

+

+

+

Presence of

QOL Questionnaire

x

x

x

x
x

x
x

*Blank boxes indicate it was not applicable
Key: BQ – Berlin questionnaire, CS – cohort study, CSS – cross sectional study, DM – diabetes mellitus, , ESS – Epworth sleepiness scale, HTN – hypertension, LOE – level of evidence, MA – metaanalysis, MiOSA – mild obstructive sleep apnea AHI >5 but <15, MOSA – moderate sleep apnea AHI >15 but <30, MSOSA – moderate-severe sleep apnea, NE – non-experimental, N-number of
studies; n- number of participants, OS – observational study, OSA – obstructive sleep apnea, PCP – primary care provider, SBQ – STOP-Bang questionnaire, SOSA – severe sleep apnea
AHI > 30, SR – systematic review, STOP – STOP questionnaire, + diagnosed.

SLEEP QUALITY

45
Appendix F
Pender’s Health Promotion Model

SLEEP QUALITY

46
Appendix G
Lewin's Change Theory

SLEEP QUALITY

47
Appendix H

SLEEP QUALITY

48
Appendix I
Rosswurm and Larrabee’s Model

SLEEP QUALITY
Appendix J
Demographics
Please answer each question in the space provided
1. Age: _________
2. Gender
_____ Male _____ Female
3. Marital Status
_____ Single
_____ Married/Living with Partner
_____ Divorced
_____ Widowed
4. Do you sleep alone?
_____ Yes
_____ No
5. Are you
_____ Employed
_____ Retired
_____ Disabled
_____ Student
6. Race
_____ White
_____ Black or African American
_____ Hispanic or Latino
_____ American Indian or Alaska Native
_____ Asian
_____ Native Hawaiian or other Pacific Islander
_____ Other
7. Insurance
Medicare _____
Medicaid (AHCCCS) _____
Private Insurance _____
No Insurance _____
8. On average, how many times do you wake up at night? ________
9. What is the average number of hours you sleep per night? _______
10. Do you work night shift? _____ Yes _____ No

SLEEP QUALITY

50
FUNCTIONAL OUTCOMES OF SLEEP QUESTIONNAIRE (FOSQ)

Some people have difficulty performing everyday activities when they feel tired or sleepy. The purpose of this questionnaire is to find
out if you generally have difficulty carrying out certain activities because you are too sleepy or tired. In this questionnaire, when the
words “sleepy” or “tired” are used, it means the feeling that you can’t keep your eyes open, your head is droopy, that you want to “nod
off”, or that you feel the urge to take a nap. These words do not refer to the tired or fatigued feeling you may have after you have
exercised.
DIRECTIONS: Please put a Check Mark in the box for your answer to each question. Select only one answer for each question.
Please try to be as accurate as possible. All information will be kept confidential.
(0)
I don’t do this
activity for
other reasons

(4)
No difficulty

(3)
Yes, a little
difficulty

(2)
Yes,
moderate
difficulty

(1)
Yes, extreme
difficulty

(0)
I don’t do this
activity for
other reasons

(4)
No difficulty

(3)
Yes, a little
difficulty

(2)
Yes,
moderate
difficulty

(1)
Yes, extreme
difficulty

1. Do you have difficulty concentrating on the things you
do because you are sleepy or tired?
2. Do you generally have difficulty remembering things,
because you are sleepy or tired?

3. Do you have difficulty operating a motor vehicle for
short distances (less than 100 miles) because you become
sleepy or tired?
4. Do you have difficulty operating a motor vehicle for
long distance (greater than 100 miles) because you become
sleepy or tired?
5. Do you have difficulty visiting with your family or
friends in their home because you become sleepy or tired?
6. Has your relationship with family, friends or work
colleagues been affected because you are sleepy or tired?

SLEEP QUALITY

51
(0)
I don’t do this
activity for
other reasons

(4)
No difficulty

(3)
Yes, a little
difficulty

(2)
Yes,
moderate
difficulty

(1)
Yes, extreme
difficulty

(0)
I don’t engage
in sexual
activity for
other reasons

(4)
No

(3)
Yes, a little

(2)
Yes,
moderately

(1)
Yes,
extremely

7. Do you have difficulty watching a movie or videotape
because you become sleepy or tired?
8. Do you have difficulty being as active as you want to be
in the evening because you are sleepy or tired?
9. Do you have difficulty being as active as you want to be
in the morning because you are sleepy or tired?

10. Has your desire for intimacy or sex been affected
because you are sleepy or tired?