2021 MBHR Measure: Sleep Quality Screening and Sleep Response at 3-months

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Justification

Sleep problems are common. In fact, large scale epidemiologic and population studies show that sleep deprivation and disorders affect more individuals than previously thought.[1, 2] Insomnia is the most common sleep disorder, with up to a third of adults reporting some difficulty falling or staying asleep in the past year and approximately 10% reporting chronic insomnia.[3] The prevalence of obstructive sleep apnea, characterized with respiratory difficulties during sleep is also high, with estimates of 9-21% in women and 24-31% in men.[4] These rates may be higher among individuals with serious mental illness, such as major depressive disorder, bipolar disorder, and schizophrenia.[5] Sleep problems can lead to other undesired outcomes. For example, sleep problems are associated with accidents and human error, including significant motor vehicle and occupational accidents. [6-8] The direct and indirect costs of disordered sleep are staggering, with some estimates as high as $100 billion attributable to insomnia alone. [9-11] Although causal mechanisms are not well-known, there is also increasing awareness of the association between disordered sleep and health, including general wellbeing, performance, daytime sleepiness, and fatigue. We also know that sleep disorders can contribute to premature mortality, cardiovascular disease, obesity, and many medical and psychological disorders. [12-15] Unfortunately, sleep problems may increase over time due to decreases in sleep duration, increases in chronic illnesses associated with poor sleep quality, and an aging population.[1, 4, 12]

1. Ivanenko, A. and B.R. Gururaj, Classification and epidemiology of sleep disorders. Child Adolesc Psychiatr Clin N Am, 2009. 18(4): p. 839-48.
2. Owens, J., Classification and epidemiology of childhood sleep disorders. Prim Care, 2008. 35(3): p. 533-46, vii.
3. Brown, W. and T. Lee-Chiong, Insomnia: prevalence and daytime consequences, in Sleep: A Comprehensive Handbook. 2006, Wiley and Sons. p. 93-98.
4. Ferrie, J.E., et al., Sleep epidemiology–a rapidly growing field. Int J Epidemiol, 2011. 40(6): p. 1431-7.
5. Stubbs, B., et al., The prevalence and predictors of obstructive sleep apnea in major depressive disorder, bipolar disorder and schizophrenia: A systematic review and meta-analysis. J Affect Disord, 2016. 197: p. 259-67.
6. Garbarino, S., et al., Sleep Apnea, Sleep Debt and Daytime Sleepiness Are Independently Associated with Road Accidents. A Cross-Sectional Study on Truck Drivers. PLoS One, 2016. 11(11): p. e0166262.
7. Garbarino, S., et al., Risk of Occupational Accidents in Workers with Obstructive Sleep Apnea: Systematic Review and Meta-analysis. Sleep, 2016. 39(6): p. 1211-8.
8. Hassani, S., et al., Association between Occupational Accidents and Sleep Apnea in Hospital Staff. Tanaffos, 2015. 14(3): p. 201-7.
9. Botteman, M., Health economics of insomnia therapy: implications for policy. Sleep Med, 2009. 10 Suppl 1: p. S22-5.
10. Wickwire, E.M., F.T. Shaya, and S.M. Scharf, Health economics of insomnia treatments: The return on investment for a good night’s sleep. Sleep Med Rev, 2016. 30: p. 72-82.
11. Leger, D., The cost of sleep-related accidents: a report for the National Commission on Sleep Disorders Research. Sleep, 1994. 17(1): p. 84-93.
12. Carmona, R.H., Frontiers of knowledge in sleep and sleep disorders: opportunities for improving health and quality of life. J Clin Sleep Med, 2005. 1(1): p. 83-9.
13. Matricciani, L., et al., Rethinking the sleep-health link. Sleep Health, 2018. 4(4): p. 339-348.
14. Medic, G., M. Wille, and M.E. Hemels, Short- and long-term health consequences of sleep disruption. Nat Sci Sleep, 2017. 9: p. 151-161.
15. Stone, K.L. and Q. Xiao, Impact of Poor Sleep on Physical and Mental Health in Older Women. Sleep Med Clin, 2018. 13(3): p. 457-465.

The Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (2008)1 stated that insomnia is an important public health problem that requires accurate diagnosis and effective treatment (Standard) and that instruments which are helpful in the evaluation and differential diagnosis of insomnia include self-administered questionnaires, at-home sleep logs, symptom checklists, psychological screening tests, and bed partner interviews. (Guideline). Assessment instruments that may aid in the baseline evaluation and outcomes follow-up of patients with chronic insomnia include measures of subjective sleep quality, psychological assessment scales, daytime function, quality of life, and dysfunctional beliefs and attitudes. (Consensus). In addition to clinical reassessment, repeated administration of questionnaires and survey instruments may be useful in assessing outcome and guiding further treatment efforts. (Consensus) Ideally, regardless of the therapy type, clinical reassessment should occur every few weeks and/or monthly until the insomnia appears stable or resolved, and then every 6 months, as the relapse rate for insomnia is high. (Consen-sus). The American College of Physicians (ACP) provided recommendations in 2016 for treatment of chronic insomnia in adults.2 The ACP Guideline stated Cognitive behavior therapy (CBT) should be the initial treatment option in persons with chronic insomnia before prescribing medications. Although data were limited overall regarding psychological therapies, moderate-quality evidence indicated that CBT (e.g., in-person therapy, telephone and web-based therapy, self-help books) improved remission, response to treatment, wake after sleep onset, sleep onset latency, and sleep efficiency and quality. However, data were insufficient to establish whether one psychological treatment method was superior. Similarly, Practice parameter guidelines from the American Academy of Sleep Medicine (2006)3 states that psychological and behavioral interventions are effective in the treatment of both chronic primary insomnia (Standard) and secondary insomnia (Guideline). Stimulus control therapy, relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of chronic insomnia
(Standard) and sleep restriction therapy, multicomponent therapy (without cognitive therapy), biofeedback and paradoxical intention are individually effective therapies in the treatment of chronic insomnia (Guideline).

1. Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008 ;4(5):487-504.
2. Amir Qaseem, MD, PhD, MHA; Devan Kansagara, MD, MCR; Mary Ann Forciea, MD; Molly Cooke, MD; Thomas D. Denberg, MD, PhD; for the Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. July 19, 2016; 165(2):125-133
3. Morgenthaler T; Kramer M; Alessi C et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. SLEEP 2006; 29(11): 1415-1419.