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Volume 13 No. 05
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Accepted Papers

Scientific Investigations

How Do Sleep-Related Health Problems Affect Functional Status According to Sex?

Allegra Boccabella, MPH; John Malouf, MBBS
The SleepGP, Coolangatta, Australia Study


Study Objectives:

To measure differences in functional status between men and women presenting with sleep-related health problems.


A retrospective clinical audit of 744 Australian patients across 7 private general practices between April 2013 and January 2015 was conducted. Patients completed an electronic survey as part of their routine consultation, which included the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire 10 (FOSQ-10), and other questions relating to the effect of their sleep problem. The proportion of males and females with ESS and FOSQ-10 scores associated with disorders of daytime sleepiness and burden of symptoms due to sleepiness, respectively, were compared, as well as reported differences between the sexes in memory, concentration, issues with relationships, feeling depressed, and trouble sleeping.


On presentation, females were more likely to have sleeping disorders associated with daytime sleepiness (median ESS score of 9 for females versus 8 for males, P = .038; proportion ESS > 9 was 49.0% for females versus 36.9% for males, P = .003). Women were also more likely to report an increased burden of symptoms due to sleepiness compared to men, as shown by lower FOSQ-10 scores (P < .001). Secondary outcome measures showed that females were more likely to feel excessively tired and depressed, have difficulties with memory and concentration, and have trouble sleeping at night. Snoring kept partners awake in roughly the same proportion of males and females, and a larger proportion of the partners of males were forced out of the room.


Sleep-related health issues both manifest in and affect the lives of males and females differently. Sleep health professionals should recognize these differences on all levels of disease prevention and health promotion from patient education, to diagnosis and management to improve quality of life for those with sleep-related health problems.


Boccabella A, Malouf J. How do sleep-related health problems affect functional status according to sex? J Clin Sleep Med. 2017;13(5):685–692.


Sleep disorders significantly affect a patient's health and well-being. Sleep-related problems and sleep deficiency can cause excessive daytime sleepiness, affect mood and concentration, increase the risk of motor vehicle accidents, and lessen one's ability to work effectively and safely.13 Sleep disorders also can cause a range of neurological, cardiovascular, and mental health problems.1 Obstructive sleep apnea (OSA), the most common sleep disorder, is associated with hypertension, cardiovascular disease, and stroke.14 However, sleep disorders do not exclusively affect the patient and their health. People who snore often disrupt their partner's sleep, leading to relationship issues and intimacy problems. In addition to significant personal and social burden, these factors contribute to an increase in health care resource utilization.5

A large body of evidence suggests that sleep disorders, particularly OSA, manifest differently in males and females.3,4,6 These differences exist most notably in the prevalence, pathophysiology, signs, symptoms, and severity of the disease.3,6 Snoring prevalence increases for females in later life, particularly after menopause.7 The reasons for such differences are still debated, but are attributed to hormonal influences, anatomical and physiological differences in the upper airway, different respiratory mechanics, and body fat distribution.4,6,8


Current Knowledge/Study Rationale: Men and women experience sleep-related health problems differently in terms of symptomatology, prevalence, and pathophysiology. The main aim of this study was to understand the difference in functional status between sexes when they present to general practitioners.

Study Impact: Our research shows that men and women do have different functional status on presentation to general practitioners. A larger proportion of women reported issues with depression, trouble sleeping, concentration, memory, and effect on relationships compared to men.

Differences are also seen in the way that OSA is managed. The ratio of males to females attending sleep laboratories has been reported to be between 8:1 and 10:1, despite the ratio of cases being estimated at between 2:1 and 3:1.3,7 Traditionally, sleep research has predominantly been conducted in male populations,3 and consequent evaluative, diagnostic, and management guidelines have been formulated based on such research. It is postulated that females present with nonspecific symptoms that differ from classic symptomatology.4,9 Consequently, females can be misdiagnosed with other illnesses such as depression.4 This sex bias may account for some of the underdiagnosis and mismanagement of OSA in females.3 Other explanations include that females may present less frequently because of the social stigma associated with snoring, as it defies the typical feminine stereotype, or that snoring is more severe in males.4

Prior research has investigated specific pathophysiologic differences between males and females; however, sex differences in functional status and quality of life for patients living with sleep-related health problems have not been well investigated.3 Yin and Davidson argue the importance of functional status because it is valued by the patients themselves and is a component of outcome management.4 It informs management and treatment, and may enable more patient-centered care. As such, they suggest the need for more research addressing this component of sleep medicine. For sleep researchers, it also provides insight into the differences that go beyond the pathophysiology of sleep-related problems.

The current study aims to explore the functional status of males and females presenting to a general practitioner. Research of this nature has the potential to contribute to better understanding, identification, and treatment of differing severities of disease.3 It also highlights the effect of sleep-related issues in Australia, and demonstrates the importance of sleep health as an emerging medical discipline for general practitioners, researchers, and the community alike.10


This study was a retrospective clinical audit of 744 patients who attended 8 general practitioners across 7 private general practices in 2 states (Queensland and New South Wales) in Australia for sleep-related health care between April 2013 and January 2015. Ethics approval, which included a waiver of consent, was obtained from Bond University HREC in Queensland (RO1891).

General practitioners received specialized training in sleep health care as part of a Royal Australian College of General Practitioners-accredited course. This training educated the general practitioners in sleep health, extending their history, physical examination, investigation, and management skills that go beyond the standard curriculum. General practitioners were trained in sleep hygiene, interpreting sleep studies and a more thorough physical examination including a nasendoscopic examination of the upper airway. With the assistance of an upskilled technician (often a nurse), the general practitioners initiate, educate, and monitor patients on therapies such as continuous positive airway pressure (CPAP) therapy. After training, general practitioners designated a specific portion of their practice time to sleep health care as part of an enterprise called SleepGP. Patients seen by general practitioners, but who were not designated SleepGP patients, were not used in this research. See Appendix 1 for a description of the Australian sleep referral population.

Patient records were collated based on convenience sampling; all patients presenting to general practices as SleepGP patients, who completed an electronic health care record and associated surveys, were included in the analysis. Three patients were excluded because information on their sex was not available.

Patient records were completed electronically using Sloom (Version 1, 2012, SleepGP, Coolangatta, QLD Australia), a software program specifically designed for sleep-related health care. Patients completed a comprehensive questionnaire related to their sleep health as part of a sleep-related consultation. As part of the Sloom questionnaire, patients answered questions relating to the their general medical history, family history of sleep disorders, sleep hygiene, and presence of comorbidities and completed the Epworth Sleepiness Scale (ESS), the Snoring Severity Scale (SSS), and the Functional Outcomes of Sleep Questionnaire 10 (FOSQ-10). Questionnaires were completed by patients to aid diagnosis and management and not primarily for research purposes. Height, weight, and neck circumference measurements were taken and recorded by practice nurses. General practitioners reported that most of their patients came from their existing practice; however, a small proportion presented after seeing sleep-related advertising or were referred from other general practitioners and sleep physicians.

The data were analyzed with the goal of highlighting the differences between males and females in a population seeking sleep-related health care in a primary setting. Consequently, each variable examined was stratified by sex. ESS scores were further categorized into two groups (> 9 or ≤ 9). Scores higher than 9 tend to be associated with sleeping disorders that are known to affect daytime sleepiness.11 Weaver et al. previously used a cutoff of 17.9 to indicate an increased burden of symptoms due to sleepiness using the FOSQ,12 and this value was adopted in the current study for the FOSQ-10, given that it has been established that FOSQ-10 performs in a manner similar to that of the complete version of FOSQ.13 For the FOSQ-10, data were further categorized into the groups ≥ 18 and < 18. The latter category indicates an increased burden of symptoms due to sleepiness. Incomplete questionnaires were not considered in final analysis.

Responses to three specific questions on the FOSQ-10 were also examined individually. These questions were:

  • “Do you have difficulty concentrating on the things you do because you are sleepy or tired?”

  • “Do you generally have difficulty remembering things because you are sleepy or tired?”

  • “Has your relationship with family, friends or work colleagues been affected because you are sleepy or tired?”

Responses to the following freestanding questions were also examined:
  • “Do you feel excessively tired or sleepy in the daytime?”

  • “Do you often have trouble getting to sleep at night?”

  • “Do you feel depressed?”

  • “Does your snoring keep your partner awake?”

  • “If you have a partner, has snoring forced one of you out of the room?”

Sleep health-related electronic health records were centralized and analyzed using IBM SPSS Statistics for Windows (Version 22.0, 2013, IBM Corp., Armonk, New York, United States). FOSQ-10 and ESS scores were graded and the median scores of each sex category were calculated because the data were not normally distributed. To test for evidence of a difference in median FOSQ-10 and ESS scores between males and females, the Wilcoxon rank-sum test was used. Two separate chi-square tests were performed to test for evidence of a difference in proportion of male and female FOSQ-10 scores < 18 and the proportion of ESS scores > 9. To avoid issues of multiplicity, statistical tests were only performed on these primary outcome measures.


For data regarding the age, body mass index (BMI), median ESS scores, median FOSQ-10 scores, and severity classifications for the study population, see Table 1.

Age, body mass index, median Epworth Sleepiness Scale, and median Functional Outcomes of Sleep Questionnaire 10 scores and severity classifications for study population.


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Table 1

Age, body mass index, median Epworth Sleepiness Scale, and median Functional Outcomes of Sleep Questionnaire 10 scores and severity classifications for study population.

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For data regarding excessive tiredness, concentration, memory, trouble sleeping, and feelings of depression, see Table 2.

Reported feelings of excessive tiredness, difficulty concentrating due to sleepiness, difficulty remembering due to sleepiness, depression, and trouble sleeping in study population.


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Table 2

Reported feelings of excessive tiredness, difficulty concentrating due to sleepiness, difficulty remembering due to sleepiness, depression, and trouble sleeping in study population.

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Effect on Relationships (Table 3)

Responses to questions relating to effect on relationships due to sleepiness and effects on partner due to snoring.


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Table 3

Responses to questions relating to effect on relationships due to sleepiness and effects on partner due to snoring.

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Of the 744 patients, age was recorded for 98.9% of patients (n = 736). BMI was recorded for 94.4% of participants (n = 702); 82.7% of patients completed the FOSQ-10 (n = 615). We found that there was no statistical difference in age (P = .47), BMI (P = .2), and sex (P = .6) between those who did and did not complete the FOSQ-10. However, there was a statistically significant difference in the proportion of patients who reported an ESS higher than 9 among those who did and did not complete the FOSQ-10 (26.3%, n = 15 vs. 41.9%, n = 257, P = .02).

There was very strong evidence of a difference in median FOSQ-10 scores between males and females (P < .001). There was very strong evidence of a difference in proportion of female and male patients whose FOSQ-10 scores were less than 18 (P < .001, χ21 = 21.23).

There was evidence of a difference in median ESS scores between males and females (P = .038). There was strong evidence of a different in proportion of males and female who had ESS scores > 9 (χ21 = 8.61, P = .003).

Of those who reported that their snoring was keeping their partner awake (n = 397), 60.4% (n = 240) then also said that it had forced one partner of the couple out of the room. When comparing by sex, 53.7% of females (n = 51) who reported keeping their partner awake also reported forcing either themselves or their partners out of the room, whereas this was the case for 62.8% of males (n = 189).


The mean age of the participants was 52.7 years, which suggests that people tend to present for sleep problems later in life. Although females made up only one-third of the study population, these estimates mirror the 2:1 ratio of cases reported by Larsson et al.7

The mean BMI for this sample was 31.5 kg/m2, which is just above the lower limit for class 1 obesity and was the same for both sexes. Obesity is a strong risk factor for OSA6 and therefore this demonstrates that in a health care-seeking population, there is a need for weight management regardless of sex.

Epworth Sleepiness Scale

ESS scores > 9 are associated with sleeping disorders known to affect daytime sleepiness.11 Although it was hypothesized that those presenting would have ESS scores associated with sleep issues (> 9), the median scores were 8 for males and 9 for females. There was evidence of a statistical difference in mean ESS scores between males and females (P = .038); however, a difference of one unit has little clinical significance. It could be inferred that a significant proportion of patients within this category sought sleep health care either before the disease had serious effects on daytime sleepiness or for reasons other than excessive daytime somnolence, such as snoring. However, when comparing the proportion of those affected, the results tell a different story. Although the median ESS scores were similar, the proportion of patients presenting with ESS scores associated with sleepiness provided better insight into the sex breakdown of those with scores more likely to indicate disease. Therefore, the proportions may have been a better measure in this dataset due to the data distribution.

By proportion, there was strong evidence that females were more likely to have an ESS score associated with sleeping disorders linked with daytime sleepiness (> 9) compared to males (χ21 = 8.61, P = .003). Almost half of females (49.0%) obtained a score > 9 compared to 36.2% of males. This suggests women are more likely to present with a sleeping disorder associated with daytime sleepiness. Alternatively, this could represent a difference in responses between sexes, as Chervin and Aldrich demonstrated that after adjusting for disease severity and age, males consistently predicted a two-point-lower ESS score.14 Conversely, Baldwin et al.15 observed a reduced likelihood of having an ESS score associated with sleepiness in females despite reporting similar rates of sleepiness.4 Baldwin et al. concluded that the ESS may be more sensitive for males.15 Lin et al. also suggest that the ways in which women report feelings of sleepiness is different than that of men.4 However, in this sample, 65.5% of males and 77.3% of females reported feeling excessively tired or sleepy in the daytime showing, that approximately 30% of participants in each sex category reported feeling excessively tired but did not have ESS scores > 9.


In the current study population, there was evidence of a difference in median FOSQ-10 score between males and females (P < .001), whereas women had a median score of 15. This was lower than the median score of 16.5 observed for males (Table 1). This suggests that females have an increased burden of symptoms due to sleepiness compared to males. There was also evidence of a difference in the proportion of males and females with FOSQ-10 scores < 18 (P = .001, χ21 = 21.23). The proportion of males with FOSQ-10 scores < 18 was 69.2% compared to 87.8% of females. This suggest that females are more likely to have increased burden of symptoms due to sleepiness, which is consistent with what has been reported in other studies. Other research has demonstrated that females reported lower perceived health status and poorer functional status, as measured by the FOSQ-10, compared to males with similar OSA severity.3

Excessive Tiredness

As outlined earlier in this article, 77.3% of females reported feeling excessively tired or sleepy in the daytime compared to 65.5% of males (Table 2). It is plausible that more females experience excessive tiredness or sleepiness before presenting because the symptoms of the disease are worse in females, or females delay seeking sleep-related health care until their symptoms are noticeably worse. Larsson et al. reported that female snorers reported more daytime sleepiness than male snorers, which would suggest the former.7 The current findings are limited in their ability to clarify this concept and should be repeated using polysomnography results as a confirmation of disease severity. However, at presentation, regardless of underlying cause, the evidence suggests that women are more likely to experience excessive daytime tiredness or sleepiness.

Concentration and Memory

In both males and females, the majority of participants reported some degree of difficulty concentrating due to tiredness or sleepiness. However, there was a much greater proportion of women reporting some degree of concentration difficulty compared to males (88.9% of females versus 73.5% of males) (Table 2). Furthermore, females tended to report more severe symptoms (Table 2). Females also experienced a greater burden of memory issues compared to males. Of females, 79.3% experienced some degree of memory difficulty due to their tiredness compared to 57.5% of males. This suggests that in a health-seeking population, females presenting are more likely to have increased difficulty concentrating or difficulty with remembering things relating to their sleepiness compared to males.

Feeling Depressed

Less than half of the overall population reported feeling depressed either occasionally, frequently, or always (as opposed to rarely or never). However, a much larger proportion of females reported some level of feeling depressed compared to males. The proportion of females reportedly feeling depressed occasionally was 55.7% compared to 38.6% of males. The proportion of females reportedly feeling depressed frequently was 12.9% compared to 6.7% of males. The proportion of females reportedly always feeling depressed was 4% compared to 0.7% of males (Table 2). These results support Lin et al.'s postulation that females present with more symptoms of depression compared to males.4 However, as depression is more prevalent in females than males in the general population,16 these differences may not be as a result of sleep-related health problems. Nevertheless, general practitioners should be aware of the increased prevalence of depressive symptoms in females seeking sleep-related health care compared to men.

Sleeping at Night

One-third of patients reported trouble getting to sleep at night. As seen with many of the other parameters measured, there was a larger proportion of females who experienced issues sleeping at night. Almost half of the female population (47.8%) reported often having trouble sleeping at night compared to 26.7% of males. This observation is consistent with that of Wahner-Roedler et al., who found that difficulty falling asleep was observed more frequently in females.9

Snoring and Relationships

More than three-fourths of patients who had partners reported that their snoring kept their partner awake, and 48.3% reported that their snoring forced either themselves or their partners out of the room (Table 3). Overall, both keeping a partner awake and forcing a partner out of the bedroom occurred in a greater proportion of males (77.6% for keeping partners awake and 50.3% for forcing one person in the couple out of the room) compared to females (75.4% for keeping partners awake and 42.3% for forcing one person in couple out of the room). Sixty percent of patients who reported that their snoring was keeping their partner awake then also said that it had forced one partner of the couple out of the room. This proportion was greater in males than females (62.8% compared to 53.7%). The reason for this difference can only be speculated, but it is most likely due to how the person's partner tolerates the snoring. If it is assumed that these patients have partners of the opposite sex, it could be speculated that women are more susceptible to their partner's snoring, or, conversely, that men are more likely to tolerate snoring. However, these data highlight the burden that sleep-disordered breathing has on those who report symptoms of the disease, and also on those with whom they share close proximity. It also demonstrates that regardless of sex, sleep-disordered breathing affects other areas of a patient's life. Separate bedrooms because of snoring may affect a couple's intimacy and may have the potential to affect overall well-being.

Of the parameters measured, this was the only aspect of effect on lifestyle where prevalence was greater in males. Larsson et al.7 found that a greater proportion of males stated that relatives had witnessed and were concerned about witnessed apneas compared to females in their survey of a representative sample of the general population.4

Although the burden of snoring affected a larger proportion of the partners of males, a larger proportion of females reported that their relationships with family, friends, or work colleagues were affected to some degree because of sleepiness or tiredness (Table 3). The proportion who reported that their relationship with others was affected “a little” was similar for males (26.2%) and females (28.2%), but a larger proportion of females reported moderate (17.6% compared to 11.7% of males) and extreme effects (5.3% compared to 2.8% of males). This suggests that females within a health care-seeking population experience a greater burden in their relationships with others compared to males. However, different sleep disorders may have varying effects on the social lives of patients. In a recent case control study, Reishtein et al. found that compared to 8% of females with chronic insomnia, 41% of females with sleep-disordered breathing attributed their divorce, dissolution of a romantic relationship, and/or social isolation to their sleep-related problem.17

In this SleepGP population, patients presented to designated SleepGP clinics. These patients' primary complaints were sleep-related. They were either self-referrers, or they were referred by other general practitioners in the clinic. This may highlight an important moment for patient education. The literature increasingly describes the nonspecific symptoms that women carry when experiencing sleep-disordered breathing and other sleep-related problems. Accordingly, it is important that sleep-related problems are included in the general practitioner's differential diagnosis in a patient with nonspecific symptoms such as memory or concentration difficulties. Furthermore, increased patient education about sleep disorders could empower patients with the knowledge to recognize that their sleep may be affecting their health.


This research possesses several limitations. Those who completed the FOSQ-10 were more likely to have an ESS score > 9 that indicates that they also have a problem with their sleep. This may have overestimated the severity of FOSQ-10 scores. Furthermore, this population is composed of health care-seeking individuals who have not yet received a diagnosis of OSA or other sleep-related disorders. Therefore, some people in this sample will have OSA diagnosable through polysomnography and others will not. This limits the conclusions that can be drawn about the symptoms reported and their relationship to the severity of disease that these patients may go on to be diagnosed with. This article demonstrates the quality of life and symptomatology of patients when they first present to a general practitioner. Potential confounders such as baseline medical conditions were also not taken into account. Disease severity and duration of symptoms were not taken into account; consequently, it is difficult to completely understand the reasons for the observed differences in males and females. Further research should be undertaken.


As research highlights that males and females experience different symptomatology in sleep disorders such as OSA, this article supports the notion that females and males who present for sleep-related primary health care also experience different effects on their life. At presentation, females are more likely to have more severe symptoms of depression, trouble sleeping at night, higher ESS scores and lower FOSQ-10 scores, excessive daytime sleepiness, and a higher degree of difficulty concentrating and remembering things due to sleepiness or tiredness compared to males. Females are also more likely to feel that their relationship has been negatively affected due to feeling sleepy or tired. In contrast, males are more likely to keep their partner awake and to have one partner being forced out of the room compared to females.

Despite the differences in sex, the aforementioned results highlight that sleep medicine is an area of important concern, particularly for general practitioners, because of its effects on many areas of a person's physical, emotional, and social health.

This article contributes to the current body of evidence in several ways. It begins to document characteristics of a sleep health-seeking population in an Australian primary health care setting. As it is hypothesized that the future of sleep medicine involves a substantial primary health care component, this article helps elucidate the perceived burden of sleep-related health problems for patients when presenting. General practitioners, whether upskilled in sleep health or not, provide the gateway to specialist services in Australia. To address the known issue of underdiagnosis, general practitioners should be informed of the less specific symptoms with which women with OSA or other sleep-related problems may present.

The current study also focuses on the quality of life and functional outcome differences by sex, which has received less attention in the literature compared to focusing on sex differences in symptomatology, pathophysiology and other clinical measures. This is important because, as Hesselbacher et al.18 highlight:

“…as the practice of sleep medicine moves out of the sleep laboratory, and sometimes out of the sleep center entirely, history-taking and personalization of the treatment regimen become more important.”

Such personalized treatment undoubtedly includes addressing the psychosocial effects of disease and overall wellbeing of a patient.

The current study also shows that sleep-related health problems cause a multitude of symptoms and therefore needs multifactorial management. This highlights the need to prioritize sleep-related health care, to improve quality of life for patients with sleep-related problems, particularly for women.


This research was conducted at The SleepGP, 2/3 McLean St, Coolangatta QLD 4225, Australia. This research received no financial support. The authors have indicated no financial conflicts of interest.



body mass index


continuous positive airway pressure


Epworth Sleepiness Scale


Functional Outcomes of Sleep Questionnaire 10


Human Research Ethics Committee


obstructive sleep apnea


Snoring Severity Scale


standard deviation



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The Population

Research for the current study took place within the primary care setting. In Australia, there is a gateway referral system whereby patients must visit a general practitioner to gain a referral for additional specialist care except in an emergency. This includes gaining a referral to a sleep clinic for a sleep study and/or a sleep physician. Therefore, a general practitioner is often the first point of contact when a patient seeks help for their sleep-related problem. Previous research also indicates that only a minor proportion of patients from the health care-seeking population are referred to a SleepGP from other medical specialists,1 and so referral bias is unlikely. It is therefore likely to capture a broader range of patients compared to those represented in a sleep clinic population because it also includes those who have mild or absent clinical disease but still report sleep-related problems. Given the issue of underdiagnosis, it is important to examine populations of this kind.

Further, while Australia has a universal health care system, there is a two-tiered system whereby patients may seek private health care at dedicated private providers. Contrary to the United States, Australian health insurance can only be invoked for inpatient care. There is no contribution from private health insurance for care provided in a doctor's practice (primary care or specialist). In this setting, the government contributes a percentage of all consultations under the Medicare benefits schemes and the remainder is contributed by the patient. In general practice, a patient may attend a “bulk-billing consultation,” which is where Medicare accepts the full benefit for service. Otherwise the patient makes a contribution in a private clinic while the rest is covered by Medicare. The SleepGP clinics do not “bulk-bill.” Those who attend private clinics are more likely to be of higher socioeconomic status and so this dataset is unlikely to be representative of socioeconomic status in the general practice population. A SleepGP population is likely to be healthier, older, and have better health literacy than the overall general practice population.



Malouf J, Boccabella A. Understanding why patients present for sleep-related primary healthcare: a multicentre retrospective analysis of 747 Australian patients from 2013 to 2015. J Sleep Res. 2016;25 S2:81