DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening

Abstract

Study objectives: Patients with obstructive sleep apnea (OSA) have a disproportionate increase in postoperative complications and medical emergency team activation (META). We previously introduced DOISNORE50 (Diseases, Observed apnea, Insomnia, Snoring, Neck circumference > 18 inches, Obesity with BMI > 32, R = are you male, Excessive daytime sleepiness, 50 = age ≥ 50) from sleep questionnaire ISNORED using features associated with increased odds of META in perioperative patients. Performance of DOISNORE50 (DOISNORE) had yet to be tested.

Methods: The performance of DOISNORE was tested along with questionnaire ISNORED and STOP-BANG questionnaires among 300 out of 392 participants without known OSA referred to the sleep lab. In study 2, the performance of DOISNORE was tested among 64,949 lives screened in perioperative assessment clinic from 2016 to 2020.

Results: Receiver operating characteristic curve demonstrated that best performance was achieved with responses, with area under curve of 0.801. DOISNORE's predictability of OSA risk remained stable from 2018 to 2020 with area under curve of 0.78 and a Cronbach alpha of 0.65. Patients at high risk for OSA (DOISNORE ≥ 6) were associated with an increase of META (odds ratio 1.30, 95% confidence interval 1.12-1.45). Higher relative risk was noted among patients with congestive heart failure and hypercapnia.

Conclusions: DOISNORE is predictive of OSA and postoperative META. Perioperative strategies against META should consider DOISNORE questionnaire and focused screening among patients with heart failure and hypercapnia.

Citation: Namen AM, Forest D, Saha AK, et al. DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening. J Clin Sleep Med. 2022;18(8):1909-1919.

Keywords: DOISNORE; STOP-BANG; medical emergency team activation; obstructive sleep apnea; risk assessment; sleep questionnaire; sleep screen.

Figure 1. Inclusion and exclusion criteria for study 2.

Low Risk, At Risk, and High Risk for OSA is defined by DOISNORE50 < 4, ≥ 4 and < 6, and ≥ 6, respectively. OSA = obstructive sleep apnea, SNC/PAC = surgical navigation center and perioperative assessment clinic, WFBMC = Wake Forest Baptist Medical Center.

Figure 2. Comparison of ROC curves between DIS, SB, and IS.

ROC curves highlight sensitivity over 1 minus specificity and establish the probability of best performance of DOISNORE ≥ 6 (AUC 0.801), in comparison to SB ≥ 5 (AUC 0.772), or IS ≥ 4 (AUC 0.701). AUC = area under curve, DIS = DOISNORE50, IS = ISNORED, ROC = receiver operating characteristic, SB = STOP-BANG.

Figure 3. Overall ROC curves of DOISNORE50 from 2018, 2019, and 2020.

ROC curves demonstrate stable predictability across years of preoperative screening regardless of other initiatives that were conducted within the PAC/SNC environment. In a mixed model of sleep questionnaire delivery, by phone or face-to-face contact, and during the COVID-19 pandemic, performance of the questionnaire did not wane. ROC = receiver operating characteristic, SNC/PAC = surgical navigation center and perioperative assessment clinic.

Figure 4. Box plot showing varying risks of META (top) and RRT (bottom) for different DOISNORE groups in comparison to propensity-matched non-DOISNORE controls after adjustment for comorbidities.

META = medical emergency team activation, OSA = obstructive sleep apnea, RRT = rapid response team.