Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms?

Abstract

Study objectives: Obstructive sleep apnea (OSA) is a heterogeneous condition covering many clinical phenotypes in terms of the diversity of symptoms. Patient-based OSA screening questionnaires used in routine practice contain significantly varying contents that can impact the reliability and validity of the screening. We investigated to what extent common patient-based OSA screening questionnaires differ or overlap in their item content by conducting a rigorous, methodical, and quantified content overlap analysis.

Methods: We conducted an item content analysis of 11 OSA screening questionnaires validated in adult populations and characterized their overlap using a 4-step approach: (1) selection of OSA screening questionnaires, (2) item extraction and selection, (3) extraction of symptoms from items, and (4) assessment of content overlap with the Jaccard index (from 0, no overlap, to 1, full overlap).

Results: We extracted 72 items that provided 25 distinct symptoms from 11 selected OSA questionnaires. The overlap between them was weak (mean Jaccard index: 0.224; ranging from 0.138 to 0.329). All questionnaires contained symptoms of the "OSA symptom" dimension (eg, snoring or witnessed apneas). The STOP-BANG (0.329) and the Berlin (0.280) questionnaires exhibited the highest overlap content. Ten symptoms (40%) were investigated in only 1 questionnaire.

Conclusions: The heterogeneity of content and the low overlap across these questionnaires reflect the challenges of screening OSA. The different OSA questionnaires potentially capture varying aspects of the disorder, with the risk of biased results in studies. Suggestions are made for better OSA screening and refinement of clinical OSA phenotypes.

Citation: Gauld C, Baillieul S, Martin VP, et al. Symptom content analysis of OSA questionnaires: time to identify and improve relevance of diversity of OSA symptoms? J Clin Sleep Med. 2024;20(7):1105-1117.

Keywords: content analysis; obstructive sleep apnea; questionnaires; sleep disorders; sleep symptoms; symptom overlap.

Figure 1. Frequency of symptoms and clinical characteristics identified in the 11 OSA questionnaires.

(Top) Plot organized from the most frequent to the least frequent for all dimensions. (Bottom) Plot organized from the most frequent to the least frequent regarding the 3 dimensions as identified previously.^,, BMI = body mass index, HBP = high blood pressure, OSA = obstructive sleep apnea.

Figure 2. Distribution of the symptoms found in each questionnaire across the 3 dimensions.

The color bar corresponds to the percentages of symptoms per questionnaire according to the 3 dimensions. AS = Apnea Score, ASA = American Society of Anesthesiologists checklist, GOAL = Gender, Obesity, Age, Loud snoring, NoSAS = Neck Circumference, Obesity, Snoring, Age, and Sex scores, OSA = obstructive sleep apnea, OSA-50 = Obstructive Sleep Apnea 50 questionnaire, Wisconsin Q = Wisconsin questionnaire, SA-SDQ = Sleep Apnea Scale of the Sleep Disorders Questionnaire, STOP = Snoring, Tiredness, Observed apnea, high blood Pressure, STOP-BANG = Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, Age, Neck circumference, Gender.

Figure 3. Jaccard index overlap of item content of the 11 OSA questionnaires for each pair of questionnaires.

The numbers from 0 to 1 in the color bar refer to the corresponding percentages. AS = Apnea Score, ASA = American Society of Anesthesiologists checklist, GOAL = Gender, Obesity, Age, Loud snoring, NoSAS = Neck Circumference, Obesity, Snoring, Age, and Sex scores, OSA = obstructive sleep apnea, OSA-50 = Obstructive Sleep Apnea 50 questionnaire, Wisconsin Q = Wisconsin questionnaire, SA-SDQ = Sleep Apnea Scale of the Sleep Disorders Questionnaire, STOP = Snoring, Tiredness, Observed apnea, high blood Pressure, STOP-BANG = Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, Age, Neck circumference, Gender.

Figure 4. Content overlap of the OSA symptoms in the 11 selected OSA questionnaires.

The figure illustrates the symptom overlap between questionnaires: each concentric circle represents a questionnaire, and each point represents a symptom. When there are several “points” on the same “radius,” this means that there is significant overlap between several OSA questionnaires. Colored circles for a symptom indicate that this is a specific symptom, while empty circles indicate that this is a compound symptom. See also the interactive version of this figure online: https://chart-studio.plotly.com/~vincent.martin/41/#/. AS = Apnea Score, ASA = American Society of Anesthesiologists checklist, BMI = body mass index, GOAL = Gender, Obesity, Age, Loud snoring, NoSAS = Neck Circumference, Obesity, Snoring, Age, and Sex scores, HBP = high blood pressure, OSA = obstructive sleep apnea, OSA-50 = Obstructive Sleep Apnea 50 questionnaire, Wisconsin Q = Wisconsin questionnaire, SA-SDQ = Sleep Apnea Scale of the Sleep Disorders Questionnaire, STOP = Snoring, Tiredness, Observed apnea, high blood Pressure, STOP-BANG = Snoring, Tiredness, Observed apnea, high blood Pressure, BMI, Age, Neck circumference, Gender.

Figure 5. Sunburst plot indicating the hierarchical arrangement of the symptoms according to subdimensions and dimensions.

This hierarchization of symptoms, subdimensions, and dimensions is a purely exploratory proposal for making it easier to visualize symptoms. Yellow: clinical characteristic dimension; red: sleep-related symptom dimension; blue: OSA symptom dimension. Also see the interactive version of this figure online: https://chart-studio.plotly.com/~vincent.martin/43/#/. BMI = body mass index, HBP = high blood pressure, OSA = obstructive sleep apnea.