People with insomnia and concomitant obstructive sleep apnea (OSA) represented a fairly common, medically complex group for whom current approaches may be suboptimal, according to one study.

Nationally representative data tallied over 1.07 million Americans with insomnia alone, over 1.27 million with OSA alone, and over 157,000 with comorbid insomnia and OSA, so-called “COMISA.” Results showed that 14.5% of the insomnia population also had OSA, while 23.0% of the OSA population had concomitant insomnia.

The COMISA group had disproportionately more other health conditions, with more dyspnea (25.8%), depression (37.0%), anxiety (40.0%), hyperlipidemia (51.0%), and gastroesophageal reflux disease (30.1%), researchers led by Kate Cole, MS, of ResMed Science Center in San Diego, reported at the SLEEP meeting hosted by the American Academy of Sleep Medicine and the Sleep Research Society.

In turn, healthcare costs in the year after diagnosis were typically higher for this group, averaging nearly $12,500 per COMISA patient compared with around $9,600 for insomnia or OSA alone. These higher costs were driven by outpatient visits, office visits, and prescription costs.

“These findings highlight that patients with COMISA represent a uniquely complex population in terms of both clinical presentation and utilization of the healthcare system compared to those with either condition alone,” Cole told MedPage Today. “This study serves as a compelling call to action for the development of integrated care models tailored to patients with COMISA.”

“The observed clinical and economic burdens suggest that existing approaches, that are often siloed between specialties or focused on a single condition, are sub-optimal for addressing the complex needs of these patients,” she said. “These insights suggest that there is a clear need for multidisciplinary, longitudinal care strategies that can address sleep disorders in tandem with the associated mental and physical comorbidities.”

Study Details

Cole’s group performed a retrospective study using an insurance claims database that included patients diagnosed with insomnia, OSA, or both from 2015 to 2022. The majority had commercial insurance, with about a quarter on Medicaid and a small minority on Medicare Advantage.

The insomnia-only group was predominantly female (64%), whereas the OSA group had more men (59%). In COMISA, there was a more even split in sexes (53% women, 47% men).

The average number of comorbid conditions across insomnia, OSA, and COMISA cohorts was 2.1, 2.6, and 3.3, respectively. The general trend was that each comorbidity — counting cardiac, respiratory, affective, metabolic, and sleep issues — rose in prevalence across these groups.

One limitation of the study was extrapolation of comorbid conditions from ICD diagnosis codes, with potential for misclassification and other limitations of such data reporting.

Cole and colleagues noted that healthcare costs were estimated based on Medicare data.

One “surprising insight was that while inpatient and emergency room costs were relatively similar across groups, the outpatient and prescription costs for COMISA patients were markedly higher, pointing to a perhaps more difficult-to-manage pattern of care rather than episodic crises,” Cole told MedPage Today.

“Together, these results suggest that clinical practice should consider moving toward more integrated, multidisciplinary approaches that can diagnose and manage both insomnia and OSA, rather than addressing them in isolation when both are present,” Cole said. “Additionally, these insights can inform clinical guidelines, healthcare policy, and payer decisions regarding screening, treatment coverage, and care coordination.”

The Growing Literature on COMISA

COMISA was first recognized in the 1970s as the combination of the two most common sleep disorders: insomnia and OSA.

OSA is characterized by repeated gaps in breathing during sleep, and the most effective treatment is considered to be continuous positive airway pressure (CPAP) therapy. For insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for their struggles falling or staying asleep.

COMISA is associated with additive impairments from insomnia and OSA. Notably, insomnia and OSA share several overlapping symptoms — daytime fatigue, for example — complicating the diagnosis and assessment of these individual conditions or COMISA. A major concern regarding insomnia patients with occult OSA has been the prescription of benzodiazepines that can worsen OSA.

“This considerable overlap challenges the conventional approach of viewing insomnia and OSA as mutually exclusive and instead supports the need for concurrent evaluation of both disorders in clinical practice,” Cole said.

Given that many patients with insomnia can be expected to reject CPAP therapy due to the discomfort of the masks, some groups suggest that the COMISA population be referred for insomnia treatment before starting CPAP. Indeed, randomized trial evidence for concurrent CBT-I and CPAP therapy is mixed for COMISA.

In contrast, a randomized trial showed that CBT-I before CPAP reduces the severity of OSA in people with COMISA. In that study, a four-session CBT-I program was better than no treatment for improving sleep parameters and insomnia scores, and it got more patients to accept CPAP in the first 6 months.

“Future research should explore not only treatment efficacy and adherence, but also the impact of integrated care models on patient outcomes and healthcare system costs,” Cole said.

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