Abstract
Insomnia is highly prevalent and is one of the most common sleep disorders among adults and children in the United States. The American Academy of Sleep Medicine convened the Quality Measures Task Force to perform maintenance on this quality measure set, developed to optimize management and care for patients with insomnia, as the measure set was originally developed and published in 2015. The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing quality measures, and performance data highlighting gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. The revised quality measures can be used to evaluate and track initial and follow-up performance measures and to implement continuous quality improvement, especially in outcomes associated with diagnosing and managing insomnia for adults and children.
Citation:
Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of patients with insomnia: 2024 update after measure maintenance. J Clin Sleep Med. 2025;21(3):565–571.
Keywords: insomnia, quality measures, treatment
INTRODUCTION
Insomnia continues to be a highly prevalent sleep disorder, as approximately one-third of the general population presents with at least 1 form of insomnia, with an estimated prevalence of 9–15% overall, and 10–20% among adults.1,2 The approach to the management of insomnia is not standardized, as signs and symptoms differ for each patient. Treatment and management may include psychological and behavioral therapies, pharmacological treatment, and in some instances, a combination of these approaches.3,4 These quality measures describe the processes and outcomes that can be applied to the management of patients with insomnia across a wide range of ages and care settings.
Quality measures for the care of patients with insomnia was originally published in 2015, by the American Academy of Sleep Medicine (AASM), as part of a measure development initiative to address multiple sleep disorders.5 The AASM has since convened the Quality Measures Task Force (Task Force) to review the entire AASM quality measure portfolio and ensure that all quality measures are consistent with current evidence, as defined by clinical practice guideline recommendations, systematic literature reviews, and other studies published in the medical literature. Updating the Insomnia measure set also involved reviewing existing quality measures to ensure harmonization. This process guarantees that the measures are not overlapping or competing with other measures already in use across the health care system. The reviews also include a search for performance data for measures implemented via clinical data registries and national quality-reporting programs, to identify gaps and/or variations in care for patients with insomnia. While no performance data were identified, the medical literature continues to emphasize the challenges that exist in providing high quality care for patients with insomnia.2
METHODS
Literature search
The updated comprehensive literature search for this quality measure set was performed to assemble evidence in support of the diagnosis and treatment pathways highlighted in these quality measures, as well as to identify any contradictory literature. Literature searches were limited to articles published between 2017 and 2021, specific to humans, and in the English language within the PubMed database. Publication types such as news articles, letters, editorials, and case reports were excluded. A total of 243 relevant abstracts and 25 full articles were retrieved for review.
Performance data
In addition to a review of the medical literature, the Task Force searched for performance data, which may demonstrate performance gaps and/or variations in care. No data were identified, as the quality measures had not yet been fully implemented in any clinical data registries and the quality measures are not included in the Merit-Based Incentive Payment System program.
Existing quality measures
As a part of the measure maintenance process, the Task Force also reviewed existing quality measures and determined that there were no existing insomnia quality measures that required measure harmonization. The Centers for Medicare & Medicaid Services defines measure harmonization as standardizing quality measure specifications for related measures when they have the following6:
The same measure focus (ie, numerator criteria)
The same target population (ie, denominator criteria)
Elements that apply to many measures (eg, age designation for children)
Unintended consequences
There were no known unintended consequences identified as a result of reporting these insomnia quality measures.
Review and approval
The updated measures were initially revised and approved for public comment by the AASM Board of Directors. The measures were then posted on the AASM website for a 30-day public comment period and were simultaneously shared with several medical specialty societies for an additional peer review, to ensure that all relevant stakeholders had an opportunity to provide feedback. The Task Force reviewed all stakeholder feedback and made additional revisions, where deemed appropriate. The final revised measures were approved for publication and implementation by the AASM Executive Committee. A driver diagram of the final measures is shown in Figure 1.
Figure 1. Revised insomnia quality measures driver diagram.
REVISED QUALITY MEASURES
Overall revisions
The Task Force reviewed the Insomnia quality measure set and discussed standardizing the measure language for consistency with the AASM quality measure methodology and lexicon. The Insomnia quality measure set was unique within the AASM portfolio for including an exclusion criterion for patients under 7 years old. Unlike the AASM’s typical approach, which generally avoids exclusions and instead uses exceptions to adjust the numerator, the Task Force opted to eliminate this age restriction and specify the preferred patient age in the denominator across the quality measure set. The denominator eligibility was also modified to remove sleep disorders related to substance use, limiting the diagnosis codes to those specifically indicating an insomnia diagnosis. Lastly, the measure exceptions were harmonized for consistency throughout the quality measure set. Patients with unstable medical or psychiatric status were removed from these measures as a medical reason exception, as they would be unable to complete an assessment of sleep satisfaction or quality (SSQ). Patients, including caregivers and parents who decline the assessment or treatment, as well as those who do not return for the follow-up visit were removed from the measure in the patient reason exceptions, as there would be no documented assessment of SSQ in the medical record. In measures that include evidence-based treatment, a system reason exception was included to capture the lack of payer coverage. All other revisions were made to individual quality measures.
Process measure 1—assessment of sleep satisfaction/quality
2015 measure description
Proportion of patients diagnosed with insomnia who received an assessment of sleep quality for each visit at which insomnia is addressed.
Revised measure description
Proportion of patients, ages 7 years or older, diagnosed with insomnia who received an assessment of sleep quality for each visit at which insomnia is addressed.
Exceptions
Medical Reasons: Unstable medical or psychiatric status.
Patient Reasons: Patient or caregiver/parent declines assessment; patient does not return for follow-up visit.
System Reasons: None.
Supporting evidence and rationale for revisions
This measure was originally intended to capture patients who receive an assessment of sleep satisfaction/quality during visits when insomnia is addressed. While the Task Force decided to largely maintain the measure description, the denominator was revised, as it originally included all patients with insomnia who receive evidence-based insomnia management. The Task Force discussed the measure components and reached a consensus that all patients with an insomnia diagnosis should have sleep satisfaction and quality assessed, regardless of whether they are currently receiving insomnia treatment. Therefore, management of insomnia was removed from the denominator language. When reviewing the numerator language, the Task Force noted that the assessment needed to be captured as a definition and required modification, for consistency with current literature and clinical practice. For the purposes of this measure, the assessment of sleep quality must include patient or caregiver/parent-reported sleep quality and satisfaction documented in the patient’s medical record AND at least 1 of the following:
Patient or caregiver/parent-reported sleep schedule including latency or wake time during the middle or end of the night documented in patient’s medical record.
Review of sleep diary or other objective measure of sleep (eg, actigraphy and other sleep tracking technology) that includes daily measures of sleep onset latency, wake time after sleep onset, total sleep time, sleep schedule, and rating of overall sleep quality. This information can be included in the patient’s medical record, but a global summary should be provided by the clinician and documented in the patient’s medical record.
Administration of a validated questionnaire that assesses sleep quality or insomnia severity (eg, Insomnia Severity Index, Pittsburgh Sleep Quality Index). The actual questionnaire completed by the patient can be included in the patient’s medical record, but a global summary or interpretation of the questionnaire results provided by the clinician should be documented in the patient’s medical record.
There were also several edits to the definition of an assessment of sleep quality. While most changes were editorial, the most significant change was to include a review of a sleep diary OR an objective measure of sleep. Having a complete understanding of both sleep perception and objective measures provides clinicians with insights into potential interventions to improve the perceived experiences of sleep. Actigraphy may be useful in estimating sleep parameters in adults with insomnia disorder, and for the assessment of insomnia in children.7 Therefore, the Task Force agreed that it was appropriate to capture both self-reported and objective measures of sleep to assess sleep satisfaction/quality.
Outcome measure 1—Improve SSQ
2015 measure description
Proportion of patients who showed improvement in SSQ after treatment initiation, as measured by at least 1 of the assessment methods listed on the accompanying process measure #1.
Revised measure description
Proportion of patients, ages 7 years or older, diagnosed with insomnia who showed improvement in SSQ after treatment initiation.
Exceptions
Medical reasons: Unstable medical or psychiatric status; treatment initiated for a comorbid condition (eg, chronic pain, obstructive sleep apnea, restless legs syndrome) that may improve insomnia, prior to insomnia-specific treatment.
Patient reasons: Patient or caregiver/parent declines assessment; patient does not return for follow-up visit.
System reasons: Payer does not cover evidence-based treatment.
Supporting evidence and rationale for revisions
Sleep remains an integral part of maintaining physical, cognitive, and emotional health and well-being, and there is a clear link between sleep satisfaction and older adults’ health care seeking behaviors to cope with sleep problems.8 Additionally, the medical literature indicates that children who sleep well ultimately have “happier lives than those with more disturbed sleep.”9 As one of the primary desired outcomes of this quality measure set, this measure captures patients with insomnia who show improvement in sleep satisfaction and quality, after initiation of evidence-based treatment. There is currently some uncertainty about the magnitude of clinical improvement that should be expected in clinical practice, across different measurement tools for insomnia severity. The Task Force recommends that this measure be used for quality improvement, rather than for implementation in accountability programs. The reference to process measure 1 was also removed for consistency with the AASM measure development methodology.
Process measure 2—recommendation of an evidence-based insomnia treatment plan
2015 measure description
Proportion of patients diagnosed with insomnia who received at least 1 evidence-based treatment.
Revised measure description
Proportion of patients, ages 7 years or older, diagnosed with insomnia who were offered an evidence-based insomnia treatment plan.
Exceptions
Medical reasons: Unstable medical or psychiatric status; treatment initiated for a comorbid condition (eg, chronic pain, obstructive sleep apnea, restless legs syndrome) that may improve insomnia, prior to insomnia-specific treatment.
Patient reasons: Patient or caregiver/parent declines treatment; patient does not return for follow-up visit; patient declines assessment; patients who are unable to participate in treatment.
System reasons: Payer does not cover evidence-based treatment.
Supporting evidence and rationale for revisions
There are multiple options for treatment of insomnia, including psychological and behavioral treatments, as well as pharmacological treatment. Multicomponent cognitive behavioral therapy for insomnia is the only insomnia treatment that currently has a strong recommendation for use in AASM clinical practice guidelines.3 However, prescription medications are still widely used for insomnia treatment and are estimated to account for about 7% of the total direct medical costs of insomnia in the United States, equating to about $1 billion annually.10 Consistent with the AASM clinical practice guidelines, psychological and behavioral and psychological treatments for chronic insomnia disorder in adults3 and pharmacologic treatment of chronic insomnia in adults4 the Task Force revised the definition of evidence-based insomnia treatment. Given that the patient population for these measures also includes children, the evidence-based insomnia treatments also align with the practice parameters for the behavioral treatment of bedtime problems and night wakings in infants and young children, which states that behavioral interventions are recommended and effective in improving secondary outcomes in children with bedtime problems and night wakings.11
The Task Force directly referenced the current AASM clinical practice guideline recommendations when deciding how best to update the most appropriate forms of treatment for inclusion in the definition, which includes both psychological/behavioral and pharmacological treatments. The updated definition for evidence-based insomnia treatment now includes, but is not limited to, cognitive behavioral therapy for insomnia or other forms of treatment (eg, specific cognitive behavioral therapy for insomnia components, approved insomnia medications, or combination insomnia therapies). Approved insomnia medications include, but are not limited to, orexin receptor agonists (eg, suvorexant), benzodiazepine receptor agonist (eg, eszopiclone, zaleplon, zolpidem), benzodiazepines (eg, triazolam, temazepam), melatonin agonists (eg, ramelteon), and heterocyclics (eg, doxepin4). The Task Force also included a note in this measure to indicate that there are currently no Food and Drug Administration-approved insomnia medications for pediatric patients.
The original measure exceptions were harmonized with those in the rest of the measure set. The Task Force also added a medical reason exception to capture treatment initiated for a comorbid condition (eg, chronic pain, obstructive sleep apnea, restless legs syndrome) that may improve insomnia prior to insomnia-specific treatment.
Process measure 3—assessment of daytime functioning
2015 measure description
Proportion of patients diagnosed with insomnia who received an assessment of daytime functioning for each visit at which insomnia is addressed.
Revised measure description
Proportion of patients, ages 7 years and older, diagnosed with insomnia who received an assessment of daytime functioning at each visit where insomnia is addressed.
Exceptions
Medical reasons: Unstable medical or psychiatric status.
Patient reasons: Patient or caregiver/parent declines assessment; patient does not return for follow-up visit; patient is unable to engage in assessment.
System reasons: None.
Supporting evidence and rationale for revisions
The assessment of daytime functioning is an integral part of insomnia treatment and management, and may therefore, lead to treatment modification. The Task Force reviewed and updated the list of methods for assessing daytime functioning captured in this measure, for consistency with standard clinical practice and to update the list of commonly used validated instruments. The list of acceptable assessments was updated to the following:
Patient-reported and/or clinician-evaluated level of daytime functioning in at least 1 or more of the following domains: fatigue/daytime sleepiness; energy/motivation; family/social/educational/occupational functioning; mood; or cognitive function.
-
Administration of a validated questionnaire that assesses domains of daytime functioning. The actual questionnaire completed by the patient can be included in the patient’s medical record, but a global summary or interpretation of the questionnaire results provided by the clinician must be included. Examples of validated questionnaires to assess daytime functioning or quality of life may include but are not limited to:
◦ Mood/affective disturbances: Validated measures of mood/affective disturbances such as the Patient Health Questionnaire-9, Profile of Mood States, or Center for Epidemiologic Studies Depression Scale; child measures: Children’s Depression Inventory.
◦ Anxiety: Generalized Anxiety Disorder-7 from the Patient Health Questionnaire/Primary Care Evaluation of Mental Disorders; child measures: Screen for Child Anxiety Related Disorders.
◦ Fatigue: Fatigue Severity Scale, Multidimensional Fatigue Inventory.
◦ Sleepiness: Epworth Sleepiness Scale.
◦ Somatic complaints: Patient Health Questionnaire Scale.
◦ Overall functioning and quality of life: Sheehan Disability Scale, 36-Item Short Form Survey, 12-Item Short Form Survey, RAND-12.
◦ Broadband measures of children’s adaptive and problem behaviors: Child Behavior Checklist; Connor’s Rating Scale 3.
◦ Patient-Reported Outcomes Measurement Information System scales.
In the original language, an assessment needed to include medical record documentation of patient-reported level of daytime functioning in at least 1 of the domains listed in the measure language. However, the language was modified to include clinician-evaluated information as well, since clinical observations and judgment may be included in the assessment. The language was also modified to include 1 or more of the domains, as multiple domains are generally affected by insomnia. While the clinician ratings of global daytime functioning in the domains were removed as a requirement in the assessment, a global summary or interpretation of the questionnaire results in the documentation was included instead. The original measure also included a finite list of validated instruments that may be used for the assessment, but the Task Force determined that there are more instruments available and, after adding the 12-item Short Form Survey, language was added to emphasize that this is not an exhaustive list.
Outcome measure 2—improve daytime functioning
2015 measure description
Proportion of patients who showed improvement in at least 1 domain of daytime functioning after treatment initiation as measured by at least 1 of the assessment methods listed on the accompanying process measure #3.
Revised measure description
Proportion of patients, ages 7 years and older, diagnosed with insomnia who received evidence-based insomnia treatment and showed improvement in at least 1 domain of daytime functioning after treatment initiation.
Exceptions
Medical reasons: Unstable medical or psychiatric status.
Patient reasons: Patient or caregiver/parent declines treatment; patient does not return for a follow-up visit.
System reasons: Payer does not cover evidence-based treatment.
Supporting evidence and rationale for revisions
The second primary outcome of this quality measure set is to improve insomnia daytime impairments. Effective insomnia treatment can lead to improvements in fatigue, reduced attention, impaired cognitive functioning, irritability, anxiety, and low mood.12 Improvement in these symptoms would significantly improve quality of life for patients with insomnia. Measuring improvement in these symptoms will demonstrate the effectiveness of the evidence-based treatment recommended for patients, as captured in the previous process measure.
While the original denominator language specified the initiation or renewal of insomnia treatments during visits, the revised language has been simplified to capture patients who are receiving evidence-based insomnia treatment, regardless of initiation or renewal, as the goal is to see improvement in daytime functioning in this patient population as a result of implementing the treatment plan. The numerator language was modified to capture improvement in at least 1 domain of daytime functioning after treatment initiation to demonstrate the effectiveness of the treatment. The Task Force, once again, recommends that this measure be used for quality improvement, rather than for implementation in accountability programs, since there is uncertainty about the magnitude of clinical improvement that should be expected in clinical practice, across different measurement tools for insomnia severity. The assessment methods and list of examples of validated instruments have been harmonized for alignment with those included in the aforementioned process measure.
Process measure 4—assessment of side effects of treatments
2015 measure description
Proportion of patients diagnosed with insomnia who received an assessment of treatment-related side effects at each visit in which insomnia is addressed.
Revised measure description
Proportion of patients, ages 7 years or older, diagnosed with insomnia who receive evidence-based insomnia treatment and have an assessment of treatment-related side effects at each visit in which insomnia is addressed.
Exceptions
Medical reasons: Unstable medical or psychiatric status.
Patient reasons: Patient and/or caregiver/parent declines assessment; patient does not return for a follow-up visit.
System reasons: Payer does not cover evidence-based treatment.
Supporting evidence and rationale for revisions
Commonly reported side effects of pharmacological treatment include, but are not limited to, dizziness, headache, somnolence, taste perversion, amnesia, dependency/withdrawal, and cognitive impairment.4 Additionally, when undergoing psychological or behavioral treatment, patients with insomnia may experience increased daytime sleepiness and fatigue.3 Therefore, side effects should be regularly assessed, to ensure that the evidence-based treatment intended to improve insomnia symptoms is effective and is not causing adverse effects/events for the patient.
Updates to this quality measure are consistent with revisions made throughout the quality measure set, including the following:
Removal of the focus on initiation or renewal of insomnia treatments and instead highlighting the receipt of evidence-based treatment.
Updated definition for evidence-based insomnia treatment.
Updated list of approved insomnia medications.
Addition of a note to highlight that there are no Food and Drug Administration-approved insomnia medications for pediatric patients.
No other substantive changes were made to the measure language.
IMPLEMENTATION STRATEGIES
This revised quality measure set can be included in a clinical data registry. Reporting these measures through a registry would provide data that can be used for quality measure validation, testing scientific acceptability, benchmarking, quality improvement activities, and research.
FUTURE DIRECTIONS
Digitalized data collection has enhanced the ability to collect process measure data and to analyze outcomes-related data with the goal of improving patient care. These data allow practice benchmarks to be collected and analyzed for quality improvements and practice interventions to improve patient outcomes. Further, the aggregation of local benchmarks allows practices to recognize national quality measure benchmarks, to acknowledge and understand areas for practice quality-improvement interventions, and to continue quality measure reassessments over time. Collection of patient-reported outcomes has increased with e-questionnaires delivered through electronic health record patient portals, and some practices have integrated testing and therapy monitoring data into the electronic health record. Collection and analysis of quality measure “big data” will become increasingly useful in the future to direct improved personalized care models and standards of practice. With this current set of updated measures, the Task Force continued to recognize a standard approach that includes practices transitioning from paper to electronic quality measure documentation. The future includes understanding that quality measures will continue to require updates as rapid changes in technologies, data accuracy, and reporting are occurring for diagnostic testing, evidence-based therapeutic options, and remote data-monitoring capabilities.
DISCLOSURE STATEMENT
Dr. Revana is currently the principal investigator of a phase 2 clinical trial at Harmony Biosciences, LCC, and a consultant at Trend, LLC. Dr. Donald holds stock in the following entities: Becton, Dickinson and Company, Medtronic, Pfizer, and Zimmer Biomet Holdings, Inc. Dr. Junna is Secretary of the Minnesota Sleep Society Board of Directors. Ms. Crawford and Ms. Gray are employed by the American Academy of Sleep Medicine. The other authors report no conflicts of interest.
Supplemental Materials
ACKNOWLEDGMENTS
The AASM thanks the Society of Behavioral Sleep Medicine and the American Psychiatric Association for their review of these measures and providing feedback and suggestions for additional revisions to capture the true intent of the measures. The AASM did not seek or receive endorsement of these measures from these organizations.
ABBREVIATIONS
- AASM
American Academy of Sleep Medicine
- SSQ
sleep satisfaction or quality
- Task Force
Quality Measures Task Force
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