Diagnostic performance of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea in different ethnic groups

Abstract

Study objectives: The STOP-Bang questionnaire is a concise and easy screening tool for obstructive sleep apnea (OSA). Using modified body mass index (BMI), we assessed the diagnostic performance of the STOP-Bang questionnaire in predicting OSA in ethnically different groups of patients undergoing surgery.

Methods: This was a multicenter prospective cohort study involving patients with cardiovascular risk factors who were undergoing major noncardiac surgery. Patients underwent home sleep apnea testing. All patients completed the STOP-Bang questionnaire. The predictive parameters of STOP-Bang scores were calculated against the apnea-hypopnea index.

Results: From 4 ethnic groups 1,205 patients (666 Chinese, 161 Indian, 195 Malay, and 183 Caucasian) were included in the study. The mean BMI ranged from 25 ± 4 to 30 ± 6 kg/m² and mean age ranged from 64 ± 8 to 71 ± 10 years. For the Chinese and Indian patients, diagnostic parameters are presented using BMI threshold of 27.5 kg/m² with the area under curve to predict moderate-to-severe OSA being 0.709 (0.665-0.753) and 0.722 (0.635-0.808), respectively. For the Malay and Caucasian, diagnostic parameters are presented using BMI threshold of 35 kg/m² with the area under curve for predicting moderate-to-severe OSA being 0.645 (0.572-0.720) and 0.657 (0.578-0.736), respectively. Balancing the sensitivity and specificity, the optimal STOP-Bang thresholds for the Chinese, Indian, Malay, and Caucasian groups were determined to be 4 or greater.

Conclusions: For predicting moderate-to-severe OSA, we recommend BMI threshold of 27.5 kg/m² for Chinese and Indian patients and 35 kg/m² for Malay and Caucasian patients. The optimal STOP-Bang threshold for the Chinese, Indian, Malay and Caucasian groups is 4 or greater.

Clinical trial registration: Registry: ClinicalTrials.gov; Name: Postoperative Vascular Events in Unrecognized Obstructive Sleep Apnea; URL: https://ichgcp.net/clinical-trials-registry/NCT01494181; Identifier: NCT01494181.

Keywords: STOP-Bang questionnaire; body mass index; obstructive sleep apnea; screening tool; surgery.

Conflict of interest statement

All authors have seen and approved the manuscript. Chung reported receiving grants from the Ontario Ministry of Health and Long-term Care, University Health Network Foundation, to which the STOP-Bang questionnaire is proprietary. Dr. Chan is a member of the journal’s editorial board. The other authors report no conflicts of interest. The study was funded through grants from the Health and Medical Research Fund (09100351), Hong Kong, National Healthcare Group-Khoo Teck Puat Hospital, Small Innovative Grants (12019, 15201), University Health Network Foundation (Ontario, Canada), University of Malaya, High Impact Research Grant (UM.C/625/1/HIR/067), Malaysian Society of Anaesthesiologists K Inbasegaran Research Grant and Auckland Medical Research Foundation, New Zealand. ResMed has supplied the ApneaLink devices and PULSOX-300i oximeter wristwatch in all sites as an unrestricted loan. These were returned at the end of the study. The study funders/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

© 2021 American Academy of Sleep Medicine.

Figures

Figure 1. Receiver operating curve for the STOP-Bang questionnaire using optimal BMI of 27.5 kg/m2 for Chinese and Indian patients, and optimal BMI of 35 kg/m2 for Malay and Caucasian patients for predicting moderate-to-severe and severe OSA.

Moderate-to-severe OSA defined as AHI ≥ 15 events/h and severe OSA defined as AHI ≥ 30 events/h. AH = apnea-hypopnea index, AUC, area under curve.

Figure 2. The predicted probabilities for sleep apnea using the STOP-Bang score with the optimal BMI thresholds for Chinese, Indian, Malay, and Caucasian patients for moderate-to-severe and severe OSA.

Vertical bars represent standard errors of the mean. Moderate-to-severe OSA defined as AHI ≥ 15 events/h and severe OSA defined as AHI ≥ 30 events/h. AHI = apnea-hypopnea index, BMI = body mass index, OSA = obstructive sleep apnea.