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Volume 14 No. 11
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Accepted Papers

Letters to the Editor

Arousal-Based Scoring for Obstructive Sleep Apnea

Raman K. Malhotra, MD1; Douglas B. Kirsch, MD2; Kelly A. Carden, MD3; Ilene M. Rosen, MD, MS4; Kannan Ramar, MD5
1Sleep Medicine Center, Washington University School of Medicine, St. Louis, Missouri; 2Carolinas Healthcare Medical Group Sleep Services, Charlotte, North Carolina; 3Saint Thomas Medical Partners - Sleep Specialists, Nashville, Tennessee; 4Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; 5 Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota

We greatly appreciate Dr. Kapoor's support1 for the recent American Academy of Sleep Medicine (AASM) position statement on the importance of arousal-based scoring in the evaluation of patients with obstructive sleep apnea (OSA).2 We concur with his concern about the consequences of failure to make a diagnosis in patients suspected of having OSA when using oxygen desaturation criteria alone to score respiratory events. Misdiagnosis by the medical provider of these patients can, unfortunately, lead to further unnecessary testing or an incorrect diagnosis and treatment, which can be costly, ineffective, or worse yet, harmful to the patient. We hope our position statement encourages clinicians to include respiratory events resulting in arousal when evaluating patients for OSA.

The mission of the AASM and its membership is to improve sleep health and promote high-quality, patient-centered care. Therefore, the AASM encourages sleep medicine providers to use arousal-based scoring when making a diagnosis in patients with OSA. We agree with Dr. Kapoor that the AASM and its members should engage payers, policymakers, and other relevant stakeholders, in discussions to address areas where our clinical practice guidelines, scoring criteria, or diagnostic criteria differ from payer policies. These areas of disagreement can negatively affect the health of our patients and can significantly increase unnecessary costs for our health care system. The AASM has already begun to engage in these types of discussions with payers through our Payer Policy Review Committee. This committee communicates with payers to encourage correct interpretation and adoption of AASM clinical practice guideline recommendations and extends an open channel for payers to discuss concerns they have with coverage determinations related to sleep medicine. AASM leadership also continued discussions with officials at the Centers for Medicare & Medicaid Services this past June to address some of these issues and were encouraged to collect more evidence.

As a specialty, we need to continue to advance knowledge by supporting research in our field to help better identify and manage patients who can be effectively treated for OSA. As mentioned in Dr. Kapoor's letter, ongoing research in alternative methods of identifying arousals, as well as understanding other clinical or polysomnographic markers, will be crucial to demonstrating the value of counting events, such as arousals, when scoring. This additional evidence can be used to support our position and inform stakeholders about the importance of aligning their policies with our scoring criteria and recommendations. By being able to efficiently and accurately identify patients with OSA, sleep medicine providers can provide cost-effective, quality care to patients with sleep disorders.


The authors represent the 2018 – 2019 Executive Committee of the AASM. This letter to the editor is intended by the AASM to help physicians and other health care providers make decisions about the appropriate treatment of patients with OSA. It is to be used for educational and informational purposes only.


Malhotra RK, Kirsch DB, Carden KA, Rosen IM, Ramar K. Arousal-based scoring for obstructive sleep apnea. J Clin Sleep Med. 2018;14(11):1963–1964.


The Executive Committee thanks AASM staff members who assisted with this letter to the editor.



Kapoor M. Hypopnea scoring criteria: time to move toward a single standardized definition. J Clin Sleep Med. 2018;14(11):1961–1962


Malhotra RK, Kirsch DB, Kristo DA, et al. Polysomnography for obstructive sleep apnea should include arousal-based scoring: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018;14(7):1245–1247. [PubMed Central][PubMed]