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IN this issue of Anesthesiology, Sankar et al. report the results of a Monte Carlo simulation comparing the cost-effectiveness of using sleep apnea screening for preventing perioperative complications and improving longterm outcomes in patients with obstructive sleep apnea (OSA). Cost-effectiveness analysis quantifies the incremental cost and benefit of selecting a more expensive and more effective healthcare intervention (OSA screening plus polysomnography) compared to a less costly and less effective intervention (no screening). The incremental cost-effectiveness ratio is the ratio of the difference in cost of two interventions divided by the difference in outcome (where outcome is measured in terms of quality-adjusted life-years). The cost-effectiveness ratio can be thought of as the additional cost of achieving 1 yr of perfect life (the quality-adjusted life-year) using the more effective intervention. Historically, interventions have been considered cost-effective if the incremental cost-effectiveness ratio is less than $50,000, which is the threshold value that society assigns to 1 yr of “perfect” life. Cost-effectiveness analysis can be limited to traditional healthcare-related costs (defined as the healthcare system perspective), or extended to also include costs outside of the healthcare system such as lost wages and the cost of family caregivers (societal perspective). Sankar et al. based their cost-effectiveness analysis on a cohort of 26,068 patients who underwent elective noncardiac surgery (total hip arthroplasty, total knee arthroplasty, prostatectomy, hysterectomy, thyroidectomy, or bowel resection) in a quaternary care hospital network in Canada. They compared the cost effectiveness of four approaches to OSA screening from the perspective of the healthcare system: (1) no screening, (2) STOP-Bang alone, (3) STOP-Bang with portable monitoring, and (4) STOP-Bang with polysomnography. They evaluated the cost-effectiveness of these approaches across two different time frames: (1) the perioperative period and (2) a patient’s lifetime. Although STOP-Bang with polysomnography was the most cost-effective strategy for the perioperative time period compared to no screening, the cost of one additional quality-adjusted life-year for STOPBang with polysomnography was $634,656—which is nearly 13 times higher than what might be considered acceptable. However, when the time frame was shifted to a patient’s lifetime, the cost of one additional quality-adjusted life-year using STOP-Bang with polysomnography was only $2,044 compared to no screening. The results of this analysis suggest that the cost of comprehensive OSA screening is too high if the goal is only to achieve better perioperative outcomes. Moreover, even if cost was not a consideration and patients with OSA could all be identified preoperatively, following “best practices” in managing OSA patients perioperatively may not yield better outcomes. In their analysis, Sankar et al. assumed that an enhanced monitoring protocol, which included a “12-h level 2 intensive care unit stay,” was as equally effective as “long-term OSA treatment.” However, since the most recent clinical practice guidelines from the American Society of Anesthesiologists state that the literature is insufficient to evaluate the benefits of using continuous monitoring with pulse oximetry postoperatively in patients with OSA, it may not be reasonable to assume that the short-term effectiveness of perioperative interventions for OSA patients is equivalent to the effectiveness of long-term interventions. In the absence of robust evidence-based practices to reduce short-term complications in patients diagnosed AQ4 LWW

Preoperative Screening for Obstructive Sleep Apnea to Improve Long-term Outcomes