Abuse of the Epworth Sleepiness Scale
2013; American Academy of Sleep Medicine; Volume: 09; Issue: 10 Linguagem: Inglês
10.5664/jcsm.3062
ISSN1550-9397
Autores Tópico(s)Dysphagia Assessment and Management
ResumoFree AccessEpworth Sleepiness ScaleAbuse of the Epworth Sleepiness Scale Stuart F. Quan, M.D., F.A.A.S.M. Stuart F. Quan, M.D., F.A.A.S.M. Editor, Journal of Clinical Sleep Medicine; Divisions of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Arizona Respiratory Center, Tucson, AZ Search for more papers by this author Published Online:October 15, 2013https://doi.org/10.5664/jcsm.3062Cited by:9SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONAbuse can be defined as “Improper use or handling” or “An unjust or wrongful practice.”1 By either of these definitions, the Epworth Sleepiness Scale (ESS)2 is being abused. How and by whom you may ask? The answer, insurance companies and their surrogates, and we, sleep clinicians, are complicit in these activities.One of the consequences of the prior authorization process implemented by many insurers for approval of diagnostic sleep testing is the requirement for completion of the ESS on the request form. How this information will be used is usually not documented on these forms, but one could surmise that the ESS is the metric by which the insurer assesses whether or not the patient is sleepy. If this is true, it is a prime example of using a tool for a purpose for which it was not intended. As originally described by Dr. Johns, the “questionnaire should be useful in elucidating the epidemiology of snoring and OSAS, and any associated cardiovascular or cerebrovascular risks.”2 To my knowledge, it was never designed as a sole instrument to determine whether a patient is or is not sleepy for the purpose of approving diagnostic testing. For this purpose, it is actually a poor instrument.Virtually all prior authorization requests to perform a sleep study are for the purpose of confirming a diagnosis of obstructive sleep apnea (OSA). Sleepiness is one of the common symptoms of OSA. However, there are several issues with including a request for the ESS to document sleepiness. First, the correlation of the ESS with physiologic sleepiness is inconsistent. Some studies fail to show an association,3,4 while others have found a relationship albeit imperfect.5,6 Second, only approximately 40% of persons with severe OSA will have an ESS greater than 10 (a commonly used cutoff to denote sleepiness). Importantly, some individuals with low ESS scores will give a positive response to a different question regarding sleepiness.7 Moreover, there are gender differences in the presentation of OSA. Although daytime sleepiness appears to occur with equal prevalence between men and women, women may emphasize fatigue and lack of energy in describing their symptoms.8 This is reflected by a lower likelihood to have an ESS indicative of sleepiness.9 Hence, if the ESS is used to confirm sleepiness and sleepiness is a requirement for a sleep study, this might contribute to a greater gender disparity in the diagnosis of OSA. Finally, the ESS has much less value as a screening tool for OSA than other instruments such as the STOP-BANG questionnaire.10,11Certainly, there needs to be adequate clinical justification for requesting a sleep study of any type. Excessive daytime sleepiness is one of the cardinal symptoms of OSA. Documentation of its presence is important. However, using a tool such as the ESS with inadequate sensitivity and specificity as the sole evidence for sleepiness is inappropriate, especially if a low score results in denial of authorization to perform a sleep study. Sleep clinicians should stop facilitating this practice, and try to educate insurers about what information is useful for making such decisions.DISCLOSURE STATEMENTDr. Quan is the Editor-in-Chief of the Journal of Clinical Sleep Medicine.CITATIONQuan SF. Abuse of the Epworth Sleepiness Scale. J Clin Sleep Med 2013;9(10):987.REFERENCES1 Abuse DefinitionAccessed 8/21/2013 http://www.thefreedictionary.com/abuse. Google Scholar2 Johns MWA new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep; 1991;14:540-5, 1798888. CrossrefGoogle Scholar3 Fong SY, Ho CK, Wing YKComparing MSLT and ESS in the measurement of excessive daytime sleepiness in obstructive sleep apnoea syndrome. J Psychosom Res; 2005;58:55-60, 15771871. CrossrefGoogle Scholar4 Benbadis SR, Mascha E, Perry MC, Wolgamuth BR, Smolley LA, Dinner DSAssociation between the Epworth sleepiness scale and the multiple sleep latency test in a clinical population. Ann Intern Med; 1999;130:289-92, 10068387. CrossrefGoogle Scholar5 Aurora RN, Caffo B, Crainiceanu C, Punjabi NMCorrelating subjective and objective sleepiness: revisiting the association using survival analysis. Sleep; 2011;34:1707-14, 22131609. CrossrefGoogle Scholar6 Johns MWSleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep; 1994;17:703-10, 7701181. CrossrefGoogle Scholar7 Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJSleepiness in patients with moderate to severe sleep-disordered breathing. Sleep; 2005;28:472-7, 16171292. CrossrefGoogle Scholar8 Ye L, Pien GW, Weaver TEGender differences in the clinical manifestation of obstructive sleep apnea. Sleep Med; 2009;10:1075-84, 19403333. CrossrefGoogle Scholar9 Baldwin CM, Kapur VK, Holberg CJ, Rosen C, Nieto FJSleep Heart Health Study GroupAssociations between gender and measures of daytime somnolence in the Sleep Heart Health Study. Sleep; 2004;27:305-11, 15124727. CrossrefGoogle Scholar10 Vana KD, Silva GE, Goldberg RPredictive abilities of the STOP-Bang and Epworth Sleepiness Scale in identifying sleep clinic patients at high risk for obstructive sleep apnea. Res Nurs Health; 2013;36:84-94, 23007730. CrossrefGoogle Scholar11 Silva GE, Vana KD, Goodwin JL, Sherrill DL, Quan SFIdentification of patients with sleep disordered breathing: comparing the four-variable screening tool, STOP, STOP-Bang, and Epworth Sleepiness Scales. J Clin Sleep Med; 2011;7:467-72, 22003341. LinkGoogle Scholar Next article FiguresReferencesRelatedDetailsCited by Fashanu O and Quan S When to Treat with CPAP and How to Define Success CPAP Adherence, 10.1007/978-3-030-93146-9_1, (3-12), . The Effect of Gender on Epworth Sleepiness Scale Scoring and Objective Measures of SleepPackard A, Bautista R, Greco J and Gautam S Sleep and Vigilance, 10.1007/s41782-021-00137-5 Gender differences in Epworth Sleepiness Scale revealed by paired patient–spouse scoringPackard A, Bautista R, Smotherman C and Gautham S Epilepsy & Behavior, 10.1016/j.yebeh.2020.107272, , (107272), Online publication date: 1-Jul-2020. Low repeatability of Epworth Sleepiness Scale after short intervals in a sleep clinic populationGrewe F, Roeder M, Bradicich M, Schwarz E, Held U, Thiel S, Gaisl T, Sievi N and Kohler M Journal of Clinical Sleep Medicine, Vol. 16, No. 5, (757-764), Online publication date: 15-May-2020. Clinical and Polysomnographic Correlates of Subjective Sleepiness in Mild Obstructive Sleep ApneaOmobomi O, Batool-Anwar S and Quan S Sleep and Vigilance, 10.1007/s41782-019-00068-2, Vol. 3, No. 2, (131-138), Online publication date: 1-Dec-2019. Suitability of the Epworth Sleepiness Scale (ESS) for Economic Evaluation: An Assessment of Its Convergent and Discriminant ValidityKaambwa B, Mpundu-Kaambwa C, Adams R, Appleton S, Martin S and Wittert G Behavioral Sleep Medicine, 10.1080/15402002.2016.1228647, Vol. 16, No. 5, (448-470), Online publication date: 3-Sep-2018. A Requiem for the Clinical Use of the Epworth Sleepiness ScaleOmobomi O and Quan S Journal of Clinical Sleep Medicine, Vol. 14, No. 05, (711-712), Online publication date: 15-May-2018. Association of daytime sleepiness with obstructive sleep apnoea and comorbidities varies by sleepiness definition in a population cohort of menAdams R, Appleton S, Vakulin A, Lang C, Martin S, Taylor A, McEvoy R, Antic N, Catcheside P and Wittert G Respirology, 10.1111/resp.12829, Vol. 21, No. 7, (1314-1321), Online publication date: 1-Oct-2016. Screening for obstructive sleep apnoea in cardiac rehabilitation: A position statement from the Australian Centre for Heart Health and the Australian Cardiovascular Health and Rehabilitation AssociationLe Grande M, Neubeck L, Murphy B, McIvor D, Lynch D, McLean H and Jackson A European Journal of Preventive Cardiology, 10.1177/2047487316652975, Vol. 23, No. 14, (1466-1475), Online publication date: 1-Sep-2016. Volume 09 • Issue 10 • October 15, 2013ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Published onlineOctober 15, 2013 Information© 2013 American Academy of Sleep MedicinePDF download
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