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. 2021 Feb 22;18(4):2109. doi: 10.3390/ijerph18042109

The Epidemiology of Obstructive Sleep Apnea in Poland—Polysomnography and Positive Airway Pressure Therapy

Wojciech Kuczyński 1,*,†, Aleksandra Kudrycka 1,†, Aleksandra Małolepsza 1, Urszula Karwowska 1, Piotr Białasiewicz 1, Adam Białas 2
Editor: Paul B Tchounwou
PMCID: PMC7927121  PMID: 33671515

Abstract

The aim of this study is to provide a brief summary of the epidemiological data on obstructive sleep apnea syndrome (OSAS) diagnosis and therapy in different regions of Poland from 2010 to 2019. We performed a retrospective study in the sleep center of the Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Poland. We requested data from the National Health Service concerning the number of new diagnoses of OSAS, the polysomnographies (PSGs) that were performed, and reimbursements of positive airway pressure (PAP) therapy in each region of Poland in the period 2010–2019. The constant increase in the number of polysomnographies performed and PAP reimbursements suggests the need to create a national network between regional sleep centers to provide proper care for patients with OSAS, and PAP therapy.

Keywords: epidemiology, obstructive sleep apnea syndrome, OSAS, polysomnography, PSG

1. Introduction

Obstructive sleep apnea syndrome (OSAS) is characterized by repeated episodes of partial or complete breathing cessation during sleep due to pharyngeal airway closure [1]. Common symptoms of OSAS include excessive daytime sleepiness, loud snoring, recurrent arousals during sleep, as well as morning headaches [2]. The prevalence of OSAS in the adult population is estimated to be 3–7% [3]; however, some recent studies suggest that OSAS is considerably more frequent and affects up to approximately 84% of men and 61% of women [4,5]. Pływaczewski et al. estimated the prevalence of obstructive sleep apnea syndrome in Poland at 7.5% on the basis of a group of 676 patients from Warsaw [6]. To our knowledge, information about general epidemiological data on OSAS diagnosis in Poland is limited. We wish to highlight that this is the first OSAS epidemiological study performed in Poland.

To the major risk factors for OSAS we can include obesity, hypertension, male sex, and age. Moreover, OSAS leads to the development of many severe health consequences, such as cardiovascular, cerebrovascular, as well as endocrine and metabolic disorders [2,7,8,9,10,11]. Furthermore, OSAS is related to impairment in work performance and a higher risk of occupational and industrial accidents [12,13]. The number of possible consequences of OSAS shows the importance of both proper diagnosis and adequate treatment.

The American Academy of Sleep Medicine (AASM) defined four types of sleep study devices used for diagnostic testing for sleep disorders [14,15,16]. A Type I study, which is considered as the “gold standard” in OSAS diagnosis, entails polysomnography (PSG). This is an attended, full laboratory examination, which uses at least 7 monitoring channels: electroencephalography, electrocardiography, electromyography, electrooculography, airflow, oxygen saturation, and respiratory effort. However, there are several limitations of PSG, such as low accessibility, high cost, and requirement of highly trained technologists for data collection and interpretation. A Type II study constitutes an unattended, full polysomnography (with at least 7 channels); therefore, it does not require access to a sleep laboratory. A Type III study entails modified, portable apnea testing, which measures at least four parameters: oxygen saturation, two respiratory variables (respiratory movement and airflow), and a cardiac variable (heart rate or electrocardiogram). A Type IV study measures only one or two parameters, usually oxygen saturation or airflow. The OSAS diagnosis is based on the apnea–hypopnea index (AHI) during nocturnal polysomnography. The AHI is defined as the number of apneas and hypopneas per hour of sleep and represents the OSAS severity: mild (AHI of 5–15 events/h), moderate (AHI of 15–30 events/h), and severe (AHI > 30 events/h) [17,18,19].

The AASM propose several options for OSAS treatment in adult patients: positive airway pressure (PAP) treatment options; oxygen therapy; oral appliance therapy; surgical treatment options; hypoglossal nerve stimulators; nasal resistive valves; and pharmacological therapies. Due to the significant body of evidence supporting its impact on clinical outcomes, PAP is considered as a first-line therapy for the management of OSAS [14]. The main limitation to the efficacy of PAP therapy is the willingness of patients to accept PAP therapy up front and, in those who do, remaining adherent to therapy over time. According to the current authors’ knowledge, there are no national data regarding compliance of PAP therapy in the Polish population.

Initially, we performed a retrospective study in the sleep center of the Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Poland. However, we realized that there is neither national nor regional data about the general epidemiology of OSAS in Poland. Therefore, we requested data from the National Health Service to further study this field. We hope that a deeper understanding of this issue will indicate some specific needs and clarify problems associated with diagnostic incidence and treatment of OSAS in Poland, providing material for further discussion and improvement of sleep-related healthcare by the development of dedicated systemic solutions.

The aim of this study is to provide a brief summary of the epidemiological data on the incidence of OSAS diagnosis and prescribed therapy in different regions of Poland from 2010 to 2019.

2. Materials and Methods

We requested raw epidemiological data from the National Health Service to answer the following questions:

  1. How many new diagnoses of OSAS have been made during 2010–2019 in each region of Poland?

  2. How many PSGs have been performed during 2010–2019 in each region of Poland?

  3. How many reimbursements of PAP therapy have occurred during 2010–2019 in each region of Poland?

The National Health Service in Poland gathers statistical data exclusively on Type I devices; other types of devices (Type II–IV) were excluded from the study. A PSG performed as a nocturnal PAP titration was excluded from the study as well.

The data regarding number of habitants in each region of Poland were obtained from the Central Statistical Office for 2019 and we assumed no significant changes among number of habitants in each of the regions during the previous 10 years. Frequencies in the separate regions were compared using multi-way tables and chi2 tests.

3. Results

All variables of interest are listed in Table 1 and Figure 1. The total number of new diagnoses of OSAS, polysomnographies, and reimbursements were calculated per 100,000 habitants in each of the regions of Poland. The prevalence of OSAS diagnosis per 100,000 habitants is highest in the regions Kujawsko-Pomorskie (N = 1328), Świętokrzyskie (N = 1028), and Mazowieckie (N = 918). A PSG was performed the most frequently in the regions Świętokrzyskie (N = 910), Lubuskie (N = 803), and Opolskie (N = 803). PAP therapy was the most common in the regions Kujawsko-Pomorskie (N = 265), Świętokrzyskie (N = 257), and Lubuskie (N = 244).

Table 1.

Number of patients with a diagnosis of obstructive sleep apnea syndrome (OSAS), the number of polysomnographies, and the number of reimbursements of positive airway pressure (PAP) treatment in all regions of Poland from 2010 to 2019. The bold in number is summary of all data provided.

Part 1. Number of Patients with a Diagnosis of Obstructive Sleep Apnea Syndrome (OSAS) during 2010–2019 in All Regions of Poland.
Region Year
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 * Total Number of Habitants N/100,000 Habitants
Dolnośląskie 1264 1502 1694 1670 1807 2087 2489 2825 3031 1819 20,188 2,901,225 696
Kujawsko-Pomorskie 2063 2126 2191 2457 2437 2776 3224 3702 3942 2678 27,596 2,077,775 1328
Lubelskie 529 606 719 823 463 589 1001 1199 1374 961 8264 2,117,619 390
Lubuskie 367 434 549 760 369 734 908 1202 1448 1105 7876 1,014,548 776
Łódzkie 1478 1579 1695 2040 2024 2337 2649 2828 3124 2170 21,924 2,466,322 889
Małopolskie 1336 1304 1379 1418 1455 1841 2392 3240 3679 2390 20,434 3,400,577 601
Mazowieckie 3133 3817 4388 4905 4996 5343 5478 6137 6776 4618 49,591 5,403,412 918
Opolskie 244 357 462 637 670 943 885 960 1188 771 7117 986,506 721
Podkarpackie 765 910 1209 1578 1693 1790 1968 2231 2471 1617 16,232 2,129,015 762
Podlaskie 744 747 766 767 794 1061 1346 1480 1640 947 10,292 1,181,533 871
Pomorskie 1328 1245 959 1193 1313 1582 1939 2318 2436 1565 15,878 2,333,523 680
Śląskie 2545 2934 3098 3322 2602 3024 3567 3677 4463 2943 32,175 4,533,565 710
Świętokrzyskie 251 745 943 1192 1490 1409 1793 1900 1850 1194 12,767 1,241,546 1028
Warmińsko-Mazurskie 527 847 868 939 1081 1219 1807 1995 2153 1399 12,835 1,428,983 898
Wielkopolskie 1072 1123 1220 1362 1646 1910 2223 2587 2907 1535 17,585 3,493,969 503
Zachodniopomorskie 341 474 593 992 1272 1367 1494 1526 1464 929 10,452 1,701,030 614
Poland Summary 17,987 20,750 22,733 26,055 26,112 30,012 35,163 39,807 43,946 28,641 291,206 38,411,148 758
* 2019 from January to June
Part 2. Number of Polysomnographies during 2010–2019 in All Regions of Poland.
Region Year
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 * Total Number of Habitants N/100000 Habitants
Dolnośląskie 1650 3071 2387 2541 1640 1638 2111 2419 3138 1595 22,190 2,901,225 765
Kujawsko-Pomorskie 1842 1744 1624 1427 907 1059 1212 1375 1359 814 13,363 2,077,775 643
Lubelskie 663 668 856 926 413 591 852 920 1067 661 7617 2,117,619 360
Lubuskie 528 584 655 899 490 838 1003 1154 1236 758 8145 1,014,548 803
Łódzkie 1156 1093 1118 1215 1300 1294 1693 1610 1648 881 13,008 2,466,322 527
Małopolskie 1584 1668 1430 1430 1055 1287 1548 2084 2221 1372 15,679 3,400,577 461
Mazowieckie 2614 3423 3613 3480 3617 3718 3287 3481 3721 2165 33,119 5,403,412 613
Opolskie 284 424 561 818 766 1174 946 1013 1144 789 7919 986,506 803
Podkarpackie 643 769 1052 1378 1296 1071 1008 1142 987 596 9942 2,129,015 467
Podlaskie 540 589 581 744 470 369 399 478 542 307 5019 1,181,533 425
Pomorskie 1126 414 503 593 655 866 958 1096 1193 648 8052 2,333,523 345
Śląskie 2581 2631 2551 2639 1494 1986 2142 2076 2467 1260 21,827 4,533,565 481
Świętokrzyskie 265 717 800 995 1248 1290 1811 1800 1598 778 11,302 1,241,546 910
Warmińsko-Mazurskie 460 630 634 693 788 878 1423 1474 1366 583 8929 1,428,983 625
Wielkopolskie 958 988 1038 1103 1346 1367 1507 1701 1673 723 12,404 3,493,969 355
Zachodniopomorskie 169 185 415 597 711 622 399 369 345 190 4002 1,701,030 235
Poland Summary 17,063 19,598 19,818 21,478 18,196 20,048 22,299 24,192 25,705 14,120 202,517 38,411,148 527
* 2019 from January to June
Part 3. Number of Reimbursements by the National Health Service of Positive Airway Pressure (PAP) in the Therapy of Obstructive Sleep Apnea Syndrome (OSAS).
Region Year
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 * Total Number of Habitants N/100,000 Habitants
Dolnośląskie 269 334 432 379 373 466 667 841 1019 1330 6110 2,901,225 211
Kujawsko-Pomorskie 257 407 456 397 446 423 480 626 794 1222 5508 2,077,775 265
Lubelskie 92 96 140 161 166 231 298 337 479 504 2504 2,117,619 118
Lubuskie 115 112 125 149 161 233 279 368 397 533 2472 1,014,548 244
Łódzkie 220 256 298 230 321 477 655 750 790 970 4967 2,466,322 201
Małopolskie 255 243 280 319 479 565 809 1222 1468 1714 7354 3,400,577 216
Mazowieckie 492 637 643 723 857 996 1249 1541 1878 2212 11,228 5,403,412 208
Opolskie 34 58 88 116 83 114 115 155 274 258 1295 986,506 131
Podkarpackie 50 137 273 273 299 394 414 584 634 689 3747 2,129,015 176
Podlaskie 35 42 48 72 89 109 108 166 212 271 1152 1,181,533 98
Pomorskie 199 178 149 177 179 273 330 492 543 631 3151 2,333,523 135
Śląskie 373 369 374 424 420 588 755 884 1091 1396 6674 4,533,565 147
Świętokrzyskie 108 153 198 247 362 369 395 398 444 490 3164 1,241,546 255
Warmińsko-Mazurskie 122 149 136 136 149 209 282 461 471 475 2590 1,428,983 181
Wielkopolskie 177 192 206 259 338 346 507 572 744 674 4015 3,493,969 115
Zachodniopomorskie 43 56 75 110 153 143 115 154 196 274 1319 1,701,030 78
Poland Summary 2841 3419 3921 4172 4875 5936 7458 9551 11,434 13,643 67,250 38,411,148 175
* 2019 from January to June
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Figure 1.

Figure 1

Figure 1

Open in a new tab

Number of patients with a diagnosis of obstructive sleep apnea syndrome (OSAS), the number of polysomnographies, and the number of reimbursements of positive airway pressure (PAP) treatment in regions of Poland from 2010 to 2019. (A) Number of patients with a diagnosis of obstructive sleep apnea syndrome during 2010–2019 in all regions of Poland. (B) Number of polysomnographies during 2010–2019 in all regions of Poland. (C) Number of reimbursements by the National Health Service for the positive airway pressure (PAP) therapy for obstructive sleep apnea. (D,E) The relationship and the trends between the number of patients with an OSAS diagnosis, the PSG performed, and PAP reimbursements for the years 2010–2019. * 2019 from January to June.

We observed statistically significant differences among regions according to the number of new diagnoses of OSAS (chi2 = 22,052, p < 0.001), polysomnographies (chi2 = 19,242, p < 0.001), and reimbursements (chi2 = 5631, p < 0.001).

The diagnosis of OSAS assumes an AHI of >5 events/h. The data do not indicate the severity of the disease.

4. Discussion

Our data provide a general overlook of the epidemiology of diagnosis and PAP therapy of OSAS in Poland from 2010 to 2019. Our data suggest that, depending on the region, OSAS diagnoses range from 390 to 1328/100,000 habitants (p < 0.001). As expected, the regions differ significantly according to the number of new diagnoses of OSAS, polysomnographies, and PAP reimbursements. The economic, social, and demographic differences will be investigated in additional studies. To the author’s knowledge, this is the first study that summarizes the epidemiology of obstructive sleep apnea in Poland and provides a general overlook of the epidemiological data.

The data highlight that, in each region of Poland, the number of performed PSGs increases continuously with every year, as presented in Figure 1D,E. This trend is followed by an increase in the number of newly diagnosed OSAS cases. The number of reimbursements of PAP therapy is lower than the number of performed PSGs and diagnoses of OSAS. However, this trend was not observed for the Kujawsko-Pomorskie, Lubuskie, Łódzkie, Małopolskie, Mazowieckie, and Śląskie regions, where the increase in the number of PAP reimbursements is accompanied by a decrease in the number of polysomnographies performed. One of the reasons that can be discussed in this context is an increasing number of polygraphies (PGs), which are often performed instead of an PSG. Indeed, PG is one of the most available tools to screen for OSAS, but is limited by the lack of professional training for physicians to perform and score the PG results, which may lead to diagnostic pitfalls.

Another important issue is that, in Poland, there are just a few sleep centers specialized in sleep-related disorders other than sleep-related breathing disorders, which may lead to limited comprehensiveness of the diagnostic process.

There are no data on compliance with PAP usage at home. Non-invasive mechanical ventilation (NIV) is an important player in this field. Implementation of the “National program to reduce mortality from chronic respiratory diseases by creating NIV units in the years 2016–2019” (acronym: POL-VENT) provided numerous departments of general pulmonology with PSG and PG equipment. This fact may explain a continuous increase in the number of PSGs performed, as well as the number of new patients with an OSAS diagnosis. The constant increases in the number of polysomnographies performed and PAP reimbursements suggest the need to create a national network between regional sleep centers to provide proper care for patients with OSAS, and PAP therapy. It should be discussed whether there are conditions to propose a new medical specialization in sleep medicine, as what the AASM or European Sleep Research Society (ESRS) provides, that would emphasize the need for providing diagnoses and therapy to conditions other than sleep-related breathing disorders. Undoubtedly, obtaining an international, European-level certification would be beneficial for increasing the knowledge and standards of sleep medicine in Poland. Such an opportunity is offered by the ESRS in the form of an examination in sleep medicine, the passing of which results in the title of somnologist—an expert in sleep medicine. Currently, the database of this society shows that there is only one certified somnologist in Poland. It also seems reasonable to focus on creating national guidelines on sleep medicine, especially on sleep diagnostic procedures, to regulate, among others, the usage of PG.

Our study has some limitations. First of all, the data provided in this summary are based on data available from the National Health Service and do not refer to particular sleep centers. There also are no data on diagnostic types other than PSG, distinguished by the AASM to make a diagnosis of OSAS. Moreover, the data do not cover the private sector, which is a potentially significant player in this field. Furthermore, as we previously mentioned, the data do not provide detail on the severity of the disease.

5. Conclusions

To summarize, the data in this study underestimate the epidemiology of OSAS in Poland but illustrate the overall landscape of this issue and open the debate in this field.

Author Contributions

The contribution of the first two authors is equivalent and accounts for 80% of the contribution to this research; W.K. conceived the idea of the study; W.K. and A.K. wrote the manuscript; W.K., A.K., A.M. and U.K. were involved in data collection and creation of the database; P.B. and A.B. were involved in reviewing the manuscript. All authors have read and agreed to the published version of the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of the Medical University of Lodz, Poland (protocol code RNN/393/19/KE 12 September 2019).

Informed Consent Statement

Not applicable.

Data Availability Statement

Data available in a publicly accessible repository that does not issue DOIs Publicly available datasets were analyzed in this study. This data can be found in the National Health Service in Poland.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

Data available in a publicly accessible repository that does not issue DOIs Publicly available datasets were analyzed in this study. This data can be found in the National Health Service in Poland.

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