Part 1: Examining the scale of OSA and delays in access to care

Q: You once expressed that “The epidemiology of OSA is overwhelming.” Could you elaborate on this?

Professor Grote: We have impressive epidemiological data on sleep apnea. For example, the Benjafield paper pulls together the global numbers, estimating that about 1 billion people have sleep apnea.¹

According to the Swedish population study SCAPIS, nearly half the middle-aged population meets the criteria for obstructive sleep apnea (OSA) using an apnea-hypopnea index (AHI) cutoff of 5², although realistically, not all of these cases can be clinically meaningful. Still, even among those with more severe sleep apnea (AHI >15), evidence indicates that only one in five have actually been identified.³

When we look at data on healthcare consumption from the West Sweden region, which is home to about 1.4 million people, the diagnosis of sleep disorders, including sleep apnea and insomnia, has nearly doubled in the past ten years. Sleep disorder diagnoses are now outpacing asthma, diabetes, and COPD, and are even nearing hypertension in terms of prevalence and healthcare utilization.

Awareness is growing among both patients and doctors, and more people are seeking care, which puts increasing pressure on the healthcare system. It’s become a matter of discerning which patients have significant, clinically meaningful sleep apnea and concentrating resources there.

In our population study of 10,000 individuals aged 50–65, about 20% of men and 10% of women had an AHI above 15 using relatively simple testing methods–level four sleep devices like flow and oximetry recordings, not even polysomnography.

The epidemiology is simply overwhelming. There is so much sleep apnea being identified.

Q: In Sweden, waiting times can be monitored annually across different hospitals. How have these waiting times evolved over the years, and what do the current averages look like for diagnosis and treatment?

Professor Grote: Monitoring waiting times is possible at regional and center levels in Sweden. Historically, the entire sleep field has faced long waiting times. During the COVID-19 pandemic, things worsened in most places, though some regions managed to reduce waiting times more quickly through targeted efforts

On average, diagnostic waiting time is around 100 to 120 days. Some centers manage 30 days, while others exceed 500. For treatment, the average wait is 90–100 days. Swedish law mandates OSA diagnosis within 90 days of clinical suspicion, and a treatment offered within 90 days from when the treatment decision is made. Despite these regulations and similar recommendations in national guidelines, many centers still exceed these timelines year after year.

Importantly, there are systematic disparities. Women wait longer than men, even when you control for factors like socioeconomic status, symptoms, and comorbidities. People born in Sweden or to Swedish-born parents also have shorter waiting times compared to those born abroad or with foreign-born parents.

For example, a woman not born in Sweden might wait 20–25% longer than a Swedish-born man for both diagnosis and treatment.

Interestingly, in centers where median waiting times are below 60 days, those gender and socioeconomic differences largely disappear. In such cases, clinical factors like degree of obesity and comorbidities are what play a more prominent role in prioritization.

Q: What are the consequences of long waiting times for patients?

Professor Grote: No one wants long waiting lists. Most people can accept waiting up to three months for a sleep apnea evaluation. But from a patient’s perspective, the entire journey often starts long before that. There are often significant delays between the occurrence of first symptoms and when they accelerate and worsen enough to prompt them to seek medical help. Then come delays in diagnosis and treatment. Some estimates suggest it may take up to 20 years from first symptoms to formal diagnosis.

These delays negatively impact patients. Many may be on sick leave, experience increased accident risk or suffer from untreated comorbidities. For instance, we estimated, based on objective data for car accidents, that having 1,000 untreated patients waiting for one year in West Sweden could lead to approximately 30–40 additional accidents.

Q: How do long wait times impact clinicians and the overall healthcare system?

Professor Grote: For clinicians, these backlogs create ethical dilemmas. Do you prioritize diagnosis or treatment? If you diagnose more, the treatment queue grows, and vice versa. Everything is interconnected.

From a healthcare system perspective, untreated sleep apnea is costly and contributes to unnecessary patient suffering. So, the societal challenge becomes: How much access is feasible and necessary, given competing demands from conditions like diabetes, cancer, depression and other chronic diseases which cause a lot of hardship?