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Longer-term impacts of the COVID-19 pandemic on obstructive sleep apnoea (OSA)-related healthcare: a province-based study
  1. Tetyana Kendzerska1,2,3,
  2. Marcus Povitz4,
  3. Andrea S Gershon2,5,6,
  4. Clodagh M Ryan6,7,8,
  5. Robert Talarico2,3,
  6. Mouaz Saymeh3,
  7. Rebecca Robillard9,
  8. Najib T Ayas10 and
  9. Sachin R Pendharkar4,11,12
  1. 1Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  2. 2ICES, Ottawa, Toronto, Ontario, Canada
  3. 3Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  4. 4Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  5. 5Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  6. 6Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  7. 7Sleep Research Laboratory, Toronto Rehabilitation Institute University Health Network, Toronto, Ontario, Canada
  8. 8Centre for Sleep Medicine and Circadian Biology, University of Toronto, Toronto, Ontario, Canada
  9. 9School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
  10. 10Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  11. 11Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  12. 12O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Dr Tetyana Kendzerska; tkendzerska{at}toh.ca

Abstract

Rationale Following marked reductions in sleep medicine care early in the COVID-19 pandemic, there is limited information about the recovery of these services. We explored long-term trends in obstructive sleep apnoea (OSA) health services and service backlogs during the pandemic compared with pre-pandemic levels in Ontario (the most populous province of Canada).

Methods In this retrospective population-based study using Ontario (Canada) health administrative data on adults, we compared rates of polysomnograms (PSGs), outpatient visits and positive airway pressure (PAP) therapy purchase claims during the pandemic (March 2020 to December 2022) to pre-pandemic rates (2015–2019). We calculated projected rates using monthly seasonal time series auto-regressive integrated moving-average models based on similar periods in previous years. Service backlogs were estimated from the difference between projected and observed rates.

Results Compared with historical data, all service rates decreased at first during March to May 2020 and subsequently increased. By December 2022, observed service rates per 100 000 persons remained lower than projected for PSGs (September to December 2022: 113 vs 141, 95% CI: 121 to 163) and PAP claims (September to December 2022: 50 vs 60, 95% CI: 51 to 70), and returned to projected for outpatient OSA visits. By December 2022, the service backlog was 193 078 PSGs (95% CI: 139 294 to 253 075) and 57 321 PAP claims (95% CI: 27 703 to 86 938).

Conclusion As of December 2022, there was a sustained reduction in OSA-related health services in Ontario, Canada. The resulting service backlog has likely worsened existing problems with underdiagnosis and undertreatment of OSA and supports the adoption of flexible care delivery models for OSA that include portable technologies.

  • Sleep apnoea
  • Clinical Epidemiology
  • COVID-19

Data availability statement

Data may be obtained from a third party and are not publicly available. The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, healthcare organisations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytical code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjresp-2024-002476

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • During the initial phases of the COVID-19 pandemic, there was a large worldwide reduction in sleep medicine services; however, information on how the situation evolved thereafter is limited.

    WHAT THIS STUDY ADDS

    • After a marked decrease during the initial pandemic phase compared with pre-pandemic levels, we observed incomplete recovery of obstructive sleep apnoea (OSA)-related health service rates for polysomnograms (PSGs) and positive airway pressure (PAP) claims by December 2022. We observed an additional marked decrease in PAP claims after June 2021, with a minimal and transient reduction in PSG activity, which we speculate was primarily due to a Philips/Respironics device recall combined with shortages in the supply of electronic components. This is one of the largest studies with the longest follow-up period to describe trends in OSA-related health services since the pandemic began.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Our study highlights the difficulties with sleep care delivery that jurisdictions that rely on specialist and laboratory capacity may face, particularly when stressed by public health or other restrictions. With historical care delivery models that have failed to evolve to be more patient-centred and harness modern portable technologies, this analysis highlights the need to incorporate portable technologies for OSA healthcare and consider flexible delivery care models.

    Introduction

    Obstructive sleep apnoea (OSA), the most common sleep-related breathing disorder, is characterised by repeated episodes of upper airway obstruction during sleep associated with sleep fragmentation and intermittent hypoxaemia. Globally, nearly 1 billion middle-aged adults are estimated to have OSA (425 million with moderate-to-severe disease),1 which is an important modifiable risk factor for several chronic diseases.2–4 Positive airway pressure (PAP) therapy is the treatment of choice for clinically significant OSA.5 6

    In Ontario, Canada, individuals with suspected OSA are referred to registered sleep physicians for diagnosis and management. The standard for OSA diagnosis is in-laboratory overnight polysomnography (PSG),7 which is funded publicly by the provincial insurance plan8 and is required for public coverage of PAP therapy.9 Therapeutic PSG may also be used to titrate therapy. Funding guidelines for PAP stipulate that in-laboratory PSG must precede a physician’s prescription for PAP, but this rule is not enforced. This model of OSA care differs from other Canadian provinces, where limited-channel testing performed in the patient’s home and non-specialist OSA care are common, with variable public coverage.9 10 Despite having the highest number of PSG beds per capita in Ontario compared with other provinces, funding for PSG per capita has remained unchanged for over a decade, potentially limiting access and quality of care. Additionally, therapy for OSA with PAP was limited to only a handful of device manufacturers as many international companies do not apply for Health Canada approval. These characteristics of Ontario’s sleep medicine care system limited its adaptability to a respiratory pandemic.

    During the COVID-19 pandemic, restrictions on non-urgent health services11 and patient hesitancy for in-person visits12 13 adversely impacted the management of OSA.14–21 Management trends in OSA during the pandemic are particularly interesting for two reasons. First, physiological derangements and associated cardiometabolic comorbidities make people with OSA vulnerable to adverse outcomes from COVID-19.22–24 Second, PAP treatment was considered a high-risk aerosol-generating procedure specific to SARS-CoV-2 at the beginning of the pandemic.25 26 During the initial phases of the pandemic, there was a large worldwide reduction in sleep medicine services14–21; however, information on how the situation evolved thereafter is limited (online supplemental table E1). Many published studies are also limited by data collected through questionnaires rather than objective evaluation.14–18 Notably, we previously described that wait times in Ontario for OSA diagnosis and treatment were lengthy and highly variable across the province using health administrative data from 2006 to 2013.27 No significant policy changes to address the system’s shortcomings were implemented despite significant changes in other jurisdictions, which saw the introduction of home testing for OSA and non-specialist OSA care.

    Given these concerns about the system of OSA care in Ontario, we conducted a population-based study to determine long-term temporal changes and to explore backlogs in OSA-related healthcare during the pandemic compared with pre-pandemic. We hypothesised a steep reduction in OSA-related health services during the initial pandemic phase (March to May 2020) compared with pre-pandemic, followed by a slow increase with earlier recovery for diagnostic but not therapeutic PSGs during the later pandemic phase of the pandemic. Due to limited access to PSGs during the initial pandemic phase, we also assessed the proportion of individuals prescribed PAP without PSG since the pandemic.

    Methods

    Study design

    Using Ontario health administrative data on adults, we compared temporal trends in OSA-related healthcare during the pandemic (March 2020 to December 2022), including PSGs, outpatient visits for OSA and purchase claims for PAP therapy, relative to pre-pandemic data (2015–2019). We used seasonal monthly time series auto-regressive integrated moving-average (sARIMA) models to calculate projected rates (per 100 000 persons at risk) based on similar periods in previous years. We considered the start of the pandemic as 17 March 2020.28 Follow-up continued until December 2022.

    ICES is an independent, non-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyse healthcare and demographic data, without consent, for health system evaluation and improvement. The use of anonymised data in this project was authorised under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board.

    Data source

    In Ontario, details on outpatient and inpatient services are retained in individually linked, previously validated,29 30 administrative databases housed at ICES: www.datadictionary.ices.on.ca. For this study, we used: the Registered Persons Database (demographics); the Canadian Census (socioeconomic details); the Ontario Health Insurance Plan (OHIP) database (physician billing and fees for procedures, including PSG); and the Assistive Devices Program (ADP) database (purchase claims for PAP systems). PAP devices are partially funded (~75%) for all Ontario residents who undergo in-laboratory PSG and are diagnosed with OSA by a sleep physician registered with the ADP,31 and fully funded for individuals enrolled in specific social support programmes.32 The selection of PAP therapy (continuous (CPAP), auto-titrating (APAP) or bilevel (BPAP)) is at the discretion of the treating sleep physician.

    These data sets were linked using unique encoded identifiers.

    Populations of interest

    We included all adult Ontario residents (18 years and older) eligible for provincial coverage with available data from January 2015 to December 2021. An open cohort sampling was implemented: individuals who met inclusion criteria at the beginning of each month within the study period were considered for inclusion.

    Setting and relevant timelines

    On 15 March 2020, Ontario’s Minister of Health requested to ramp down non-emergent clinical activities to liberate health system capacity;33 34 as a result, most sleep laboratories in Ontario were closed. Temporary billing codes were introduced to allow remote outpatient sleep clinical visits to continue. Following re-opening on 27 April 2020, many sleep laboratories began performing mostly diagnostic PSGs since therapeutic PSG involving PAP titration was considered a high-risk aerosol-generating procedure. The peak of COVID-19 cases in Ontario occurred in January 2022 (Omicron wave), with the number of new cases during that month being over three times higher than the peak from April to May 2021.35

    Furthermore, during the later pandemic period, the supply of PAP devices was diminished for two major reasons. First, a voluntary recall on PAP devices was issued by one of the largest PAP manufacturers, Philips Respironics, on 14 June 2021,36 37 affecting at least 18% of devices used in Ontario.38 Second, the resulting demand for devices from other manufacturers could not be met due to the pandemic’s impact on the production of microchips required for PAP devices.39

    In Ontario, face mask and vaccination mandates were lifted on 21 March 2022, due to a reduced number of new cases, unofficially ending the pandemic.40

    Outcomes

    Primary

    Monthly rates in OSA-related health services. (1) PSGs: (a) any, and (b) by study type (diagnostic or therapeutic); (2) outpatient visits for OSA: (a) total, (b) by visit type (virtual or in-person) and (c) primary care versus specialist visits; and (3) purchase claims for PAP therapy: (a) any, (b) by device type (CPAP, APAP or BPAP) and (c) in the subgroup of individuals on social support.

    Secondary

    Proportion of individuals who claimed PAP purchase without PSG in the last 5 years.

    Details on the outcome’s definitions are presented in online supplemental table E2.

    Statistical analyses

    We aggregated individual-level data into a monthly time series from January 2015 to December 2021 to model temporal trends in OSA-related health services. Monthly data were aggregated into 3–4 month groups to display statistics in tabular format. We first calculated and compared time-matched unadjusted rates with rate ratios (RR) and 95% Wald CIs. We then used sARIMA models41 to understand underlying trends and predict future data points. We used SAS software’s adaption of the US Census Bureau’s X-13ARIMA-SEATS programme, which includes an automated model selection procedure (see details in the online supplemental E-Text). We used the final model for each outcome to project monthly rates from March 2020 to December 2021. Observed rates outside the projected 95% CIs were considered to be significantly different.42

    In explanatory analysis, cumulative service backlog as an absolute number was calculated based on the monthly difference between projected and observed rates, given the population at risk.

    We stratified analyses by sex, age group (18–24, 25–34, 35–49, 50–64, 65–79, 80+ years old), neighbourhood income (low (lower three quintiles) vs high (upper two quintiles)) and rural versus urban residence.

    All analyses were performed in the secure environment at ICES following Ontario privacy standards using SAS Enterprise Guide V.7.1., SAS V.9.4 (SAS Institute, Cary, North Carolina, USA).

    The patient and public involvement

    ICES has a dedicated public and community engagement, knowledge translation office which provides resources and support for scientists and staff who are interested in engaging with the public. In addition, ICES has a Public Advisory Council whose members provide insight and feedback on various corporate and project-level initiatives and can also be leveraged to provide public perspectives on the research project as needed. The patient and public were not involved in this study.

    Results

    In March 2020, there were 11 712 641 adults in Ontario: 51.3% women, 22.1% aged 65 years and older, 59.9% residing in low-income neighbourhoods and 10.1% in rural areas.

    Tables 1–3 and online supplemental tables E3–E16 demonstrate crude rates and RR of OSA-related health services compared with similar periods in previous years; online supplemental tables E17–31, figures 1–4, and online supplemental figures E1–E6 demonstrate observed versus projected monthly rates estimated by ARIMA models.

    View this table:
    Table 1

    Monthly crude rates per 100 000 person-months of OSA-related health services since the COVID-19 pandemic (March 2020 to February 2021) with the crude rate ratios (RR) and CI to compare to similar periods in previous years

    Figure 1
    Figure 1

    Forest plot of the rate ratio of projected based on historical pre-pandemic data estimated by ARIMA models to observed rates for sleep apnoea health services: PSG (any polysomnograms), PAP (any positive airway pressure (PAP) claims) and any outpatient obstructive sleep apnoea (OSA) visits. For example, for March 2020 to May 2020 the historical pre-pandemic data forecasts a PSG rate that is four times higher than what actually was observed in Ontario (Canada) during this time period.

    Figure 2
    Figure 2

    Cumulative service backlog and observed versus projected monthly rates per 100 000 people at-risk for polysomnograms (PSGs): (A) diagnostic PSGs estimated by ARIMA model (0,1,1) X (0,1,1); and (B) therapeutic PSGs estimated by ARIMA model (2,0,0) × (0,1,1). Cumulative service backlog as an absolute number was calculated based on the monthly difference between projected and observed rates, given the population at risk.

    Figure 3
    Figure 3

    Observed versus projected monthly rates per 100 000 people at-risk for any outpatient visits for OSA estimated by ARIMA model (3,0,3) × (0,1,1). OSA, obstructive sleep apnoea.

    Figure 4
    Figure 4

    Cumulative service backlog and observed versus projected monthly rates per 100 000 people at-risk for any positive airway pressure (PAP) therapy claim estimated by ARIMA model (1,1,1) × (1,0,1). Cumulative service backlog as an absolute number was calculated based on the monthly difference between projected and observed rates, given the population at risk.

    View this table:
    Table 2

    Monthly crude rates per 100 000 person-months of OSA-related health services since the COVID-19 pandemic (March 2021 to February 2022) with the crude rate ratios (RR) and CI to compare to similar periods in previous years

    View this table:
    Table 3

    Monthly crude rates per 100 000 person-months of OSA-related health services since the COVID-19 pandemic (March 2022 to December 2022) with the crude rate ratios (RR) and CI to compare to similar periods in previous years

    Trends in diagnostic and therapeutic PSG

    Compared with pre-pandemic data, rates of diagnostic and therapeutic PSGs decreased dramatically during the initial phase of the pandemic (March to May 2020), with some improvement approaching September 2020 and a second smaller reduction in December 2021 to February 2022. Rates of PSG did not return to the projected by December 2022: in September to December 2022, observed rates of any PSGs were 113 versus projected 141 (95% CI: 121 to 163). Diagnostic studies returned to the projected by March 2022. Therapeutic PSGs decreased further and recovered to a lesser extent than diagnostic studies (figures 1 and 2).

    By December 2022, the estimated backlog was 193 078 PSG (95% CI: 139 294 to 253 075), comprising 64 771 (95% CI: 45 131 to 85 657) diagnostic and 91 239 (95% CI: 78 103 to 105 341) therapeutic studies.

    Trends in outpatient visits for OSA

    Outpatient visits for OSA decreased in March to May 2020, improved starting in September 2020 and returned to projected rates in June 2021. A 37–77% reduction in in-person visits occurred during the study period, with a 24–45-fold increase in virtual visits, peaking in March to May 2021 and December to February 2022. In-person visit rates remained below projected by December 2022. Rates of primary care visits remained as projected throughout the pandemic. Specialist visit rates decreased initially and returned to the projected by September 2020 (figures 1 and 3).

    Trends in PAP claims

    After an initial decrease during March to May 2020, rates of any PAP claims returned to the projected during December 2020 to May 2021, but then decreased even more dramatically after June 2021. The lowest rates of PAP claims were observed during March to May 2022 (30 vs 59, 95% CI: 50 to 68) with some improvement during September to December 2022, but these did not return to projected by December 2022: observed of 50 versus projected 60, 95% CI: 51 to 70 (figures 1 and 4).

    Among different PAP types, CPAP claim rates returned to projected rates between December 2020 and May 2021, but then dramatically decreased after June 2021 and remained far below projected by December 2022: observed rates during September to December 2022 of 4 versus projected 55, 95% CI: 47 to 62. APAP claim rates remained as projected from the start of the pandemic through September 2021, but then dramatically increased and remained well above projected by December 2022: observed rates during September to December 2022 of 44 versus projected 3, 95% CI: 2 to 4. BPAP claim rates returned to projected as of December 2020, but then decreased after June 2021 and remained below projected as of December 2022.

    By December 2022, the estimated backlog for PAP claims was 57 321 (95% CI: 27 703 to 86 938), with the greatest backlog for CPAP devices (93 576, 95% CI: 68 266 to 118 895).

    Non-compliance with public funding guidelines

    The rates for any PAP claims without PSG in the last 5 years were above projected since the beginning of the pandemic and remained approximately 80% above projected from December 2020 to February 2021, returning to projected by December 2022.

    Subgroup analyses

    Rates of diagnostic PSGs did not return to projected by December 2022 for women, those residing in high-income and rural neighbourhoods and those 18–24, 35–49 and 65 years and older. Similar trends by subgroups were noted for therapeutic PSGs and OSA outpatient visits.

    Rates of any PAP claim did not return to projected by December 2022 for those 50–79 years old and who resided in urban areas. Rates for different PAP type claims varied between subgroups, but trends were similar. Rates of PAP claims remained as projected in individuals on social support since the beginning of the pandemic until September 2021, then rates decreased and remained below projected until December 2022.

    Discussion

    In this population-based study, we described trends in OSA-related health services through nearly 3 years after the COVID-19 pandemic began. After a marked decrease during the initial pandemic phase compared with pre-pandemic levels, we observed incomplete recovery of OSA-related health service rates for PSGs and PAP claims by December 2022. This is one of the largest studies with the longest follow-up period to describe trends in OSA-related health services since the pandemic began and suggests a critical gap in care for Ontarians with OSA.

    We estimated a service backlog of over 190 000 PSGs (~ 65 000 diagnostic) and 57 000 PAP claims based on differences between observed and projected rates. Historical data between 2015 and 2019 in Ontario show a monthly average of 10 076 diagnostic PSGs. Thus, under the current system, we estimate that double capacity would be needed for 4 (45 131/10 076) to 9 (85 657/10 076) months to address this backlog. Similarly, given the estimated backlog of PAP claims and a monthly average of 5579 PAP claims based on historical data between 2015 and 2019, 5–16 months of double capacity are required.

    The finding of a sharp reduction in OSA-related health services in the initial pandemic phase was expected and aligned with other studies with a greater impact on therapeutic PSG than diagnostic studies.14–17 43 The significant increase in virtual outpatient visits for OSA14 16 19 21 and parallel reduction in in-person visits14 during the pandemic have also previously been reported.

    The persistent reduction in OSA-related health services after the initial pandemic phase may be attributable to continued efforts to prevent viral transmission at sleep laboratories and staffing reductions.14 In our experience, some patients were also reluctant to attend in-person clinical visits or undergo in-laboratory sleep studies due to fear of contracting COVID-19. Moreover, the referral process from primary care physicians may have been disrupted by the pandemic due to some offices being closed, the transition to virtual care and prioritisation of other medical issues.

    Literature on the impact of the pandemic on PAP initiation is limited and controversial. Reductions in PAP treatment initiation since the beginning of the pandemic have been demonstrated,20 while other studies demonstrating increased prescriptions for APAP suggest that ambulatory PAP titration replaced in-laboratory therapeutic studies.15 We observed reductions in all PAP claims, but APAP claims remained as expected and exceeded projections after May 2020, likely reflecting a similar increase in ambulatory titration due to limited access to therapeutic PSG. While PAP therapy was considered a likely high-risk aerosol-generating procedure at the beginning of the pandemic, a rapid review of aerosol-generated procedures conducted on behalf of the UK Infection Prevention and Control Cell in 2022 did not demonstrate non-invasive ventilation (NIV), including CPAP, to be associated with aerosol levels that were greater than natural respiratory activities, and recommended the removal of NIV from the list.44 However, studies included in the review were limited by small sample size, being conducted in healthy volunteers, with a high individual variation and high heterogeneity in the data collection and analysis, reporting of aerosol levels and interventions across the included studies,44 suggesting a need for future research to address this question. We observed an additional marked decrease in PAP claims after June 2021, with a minimal and transient reduction in PSG activity, which we speculate was primarily due to a large Philips device recall combined with shortages in the supply of electronic components.39 45 In response to the shortage of PAP devices, PAP manufacturers increased production of APAP over CPAP devices as APAP devices automatically adjust pressure levels to meet a patient’s breathing needs and can be easily converted to a fixed pressure (CPAP)—this pattern was confirmed in our study.

    Our data suggest that pandemic-related service reductions have likely exacerbated pre-existing delays for OSA care in Ontario.27 Ontario’s current system of OSA care, which relies on in-laboratory testing and sleep specialist assessment, differs from other Canadian provinces in which ambulatory models using limited-channel home sleep testing and/or primary care management of OSA have been widely implemented and have had positive impacts on wait times for diagnosis and treatment and patient experience.10 46–48 Such models are evidence-based and cost-effective, and have been incorporated into clinical guidelines and management pathways in other jurisdictions but have not been adopted in Ontario.7 49–51 We speculate that increased flexibility in OSA diagnostic pathways (eg, through increased use of portable technologies) will enable post-pandemic recovery of OSA-related health services. Unfortunately, the lack of data on sleep medicine services in other provinces precludes an evaluation of the impact of the pandemic on OSA care in other provinces and the potential benefits of ambulatory models of care. A standardised approach to OSA management in Canada rather than the current fragmented approach might also help mitigate the impact of future pandemics.

    A related issue is the funding of sleep services in Ontario. Currently, PSGs and PAP therapy are funded through provincial programmes. This funding model allows any Ontario resident to obtain a diagnosis of OSA and initiate treatment and likely reduces health disparities based on socioeconomic status. However, in a budget-constrained healthcare climate, reliance on resource-intensive models for OSA care will present difficulties in overcoming the backlogs resulting from pandemic restrictions. We propose that further exploration of cost-effective models of OSA management, such as the ambulatory models described above, could improve access with a lesser impact on healthcare expenditures than the current model of care. Moreover, OSA testing and treatment incorporates several digital technologies that could enable telemedicine care; this is a promising area of sleep medicine that could be used to improve access to high-quality and cost-effective care for many geographically and socially marginalised individuals.52 53 We propose that these models be implemented within the publicly funded healthcare system to minimise the challenges that may arise with private models of OSA care delivery.10

    In Canada, PAP is the primary therapy for OSA and is the only treatment for which government funding is available (in three Canadian provinces). Our data demonstrated a marked reduction in PAP claims starting in June 2021, corresponding to a simultaneous major device recall from the largest manufacturer of PAP devices and supply chain issues impacting other PAP manufacturers. While further analysis of these data is required, these preliminary findings highlight the need to consider other evidence-based, cost-effective, but currently unfunded treatments for OSA, such as mandibular advancement devices.54 55 In addition to providing alternatives in case of problems with device supply, these treatments may be preferred or better tolerated by certain individuals than PAP.

    The strengths of our study include its use of real-world, population-level data, which enables system-level assessment of trends in OSA-related healthcare services before and during the pandemic. In Ontario, the ADP database affords the distinct advantage of accurately capturing publicly funded PAP claims. Our study also has a long time frame to evaluate three important time periods for OSA-related healthcare services during the pandemic: (1) the first year of the pandemic, when significant restrictions were put in place in sleep medicine healthcare services and there was a rapid shift from in-person to virtual care; (2) at least 1 year since Philips Respironics, one of the largest PAP manufacturers in Ontario, issued a voluntary recall on 14 June 2021, in combination with the pandemic’s impact on the production of microchips required for PAP devices; and (3) the peak of COVID-19 cases in Ontario occurred in January 2022 (Omicron wave). Finally, the granularity of available data allows the exploration of effects on different PAP types and clinical subgroups.

    However, this study has several limitations. While the OHIP and ADP databases provided complete information on coverage across the pandemic, and the service reimbursement models were not changed within the study time frame, OSA outpatient visits may be more prone to error since the diagnostic code for OSA is heterogeneous. Further, information on OSA severity was unavailable; however, in Ontario, the prescription of PAP is based on clinician judgement and does not depend on OSA severity. Next, backlogs for PAP claims were calculated independently of outpatient services and PSGs. Future studies with sophisticated modelling are required to accurately calculate OSA-related health services backlogs and the time and resources required for recovery, as was done for surgical backlogs.56 Our data also cannot be used to calculate the backlogs pre-pandemic as we used pre-pandemic for comparisons; thus, we cannot exclude pre-existing backlogs. Future studies are also required to describe recovery post-pandemic, given that only 6 months post-pandemic were covered in our study. Finally, the differences between Ontario and other jurisdictions9 may affect the generalisability of our findings. However, independent of diagnostic pathways, there are similar trends in PSG use worldwide.14 This analysis highlights the difficulties with care delivery that other jurisdictions that rely on specialist and laboratory capacity may face, particularly when stressed by public health or other restrictions. With historical care delivery models that have failed to evolve to be more patient-centred and harness modern portable technologies, this analysis highlights the need to incorporate portable technologies for OSA healthcare and consider flexible delivery care models.

    Conclusion

    As of December 2022, there was a sustained reduction in OSA-related health services in Ontario, Canada. The resulting service backlog has likely worsened existing problems with underdiagnosis and undertreatment of OSA and supports the adoption of flexible care delivery models for OSA that include portable technologies.

    Data availability statement

    Data may be obtained from a third party and are not publicly available. The dataset from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, healthcare organisations and government) prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS (email: das@ices.on.ca). The full dataset creation plan and underlying analytical code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    We thank Dr Dennys Andrea Franco Avecilla (the University of Ottawa, The Ottawa Hospital) for her help with the literature review.

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    Supplementary materials

    Footnotes

    • Contributors All coauthors were involved in the following: study conception and design, interpretation of the data, critically revising the manuscript for accuracy and important intellectual content and final approval of the version to be published. TK was also involved in obtaining administrative data and drafting the manuscript. RT was additionally involved in data analyses, visual data presentation and drafting the method section. Guarantor Statement: TK is responsible for the overall content (as guarantor). Together, TK and RT had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. They affirm that the manuscript is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted; any discrepancies from the study as planned have been explained. All authors had full access to statistical reports and tables.

    • Funding This study was supported by the Lung Health Foundation Breathing as One Young Investigators Research Award, the Ontario Health Data Platform (OHDP), a Province of Ontario initiative to support Ontario's ongoing response to COVID-19 and its related impacts and by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH) and the Ministry of Long-Term Care (MLTC). The grant/award numbers are not available. Parts of this material are based on data and information compiled and provided by the Canadian Institute for Health Information (CIHI). This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. Parts of this material are based on data and information compiled and provided by the Ontario Ministry of Health. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Specifically, no endorsement by the OHDP, its partners or the Province of Ontario, and ICES, CIHI or the Ontario MOH and/or MLTC is intended or should be inferred.

    • Competing interests All authors declare they have no potential conflict of interest. TK and ASG are supported by the PSI (Physicians' Services Incorporated) foundation. Outside of the submitted work, SP has received honoraria from Jazz Pharmaceuticals, Paladin Labs and the International Centre for Professional Development in Health and Medicine for participation in educational activities and grant funding from Jazz Pharmaceuticals. RR received honoraria from Eisai and Boehringer Ingelheim Pharma GmbH & Co.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.