Inequalities in the access to diagnosis and treatment of obstructive sleep apnea in Brazil: a cross-sectional study
                     https://doi.org/10.5664/jcsm.10976
SCIENT IF IC INVEST IGATIONS
Inequalities in the access to diagnosis and treatment of obstructive sleep
apnea in Brazil: a cross-sectional study
Luciano F. Drager, MD, PhD1,2; Ronaldo B. Santos, PhD3; Daniela Pachito, MD, PhD4; Claudia S. Albertini, MSc, PhD5; Fatima H. Sert Kuniyoshi, MSc, PhD6,7;
Alan L. Eckeli, MD, PhD8,9
1Unidades de Hipertens~ao, Instituto do Coraç~ao (InCor) e Disciplina de Nefrologia, Hospital das Clınicas HCFMUSP, Faculdade de Medicina, Universidade de S~ao Paulo,
Sao Paulo, Brazil; 2Brazilian Sleep Association (ABS), Sao Paulo, Brazil; 3Hospital Universitario, Universidade de S~ao Paulo, Sao Paulo, Brazil; 4Prossono, Ribeir~ao Preto,
Sao Paulo, Brazil; 5Laboratorio do Sono, Divis~ao de Pneumologia, Instituto do Coraç~ao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de
S~ao Paulo, Sao Paulo, Brazil; 6ResMed Science Center, San Diego, California; 7Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; 8Departamento
de Neurociências e Ciências do Comportamento, Faculdade de Medicina de Ribeir~ao Preto, Universidade de S~ao Paulo, Ribeir~ao Preto, Sao Paulo, Brazil; 9Brazilian
Association of Sleep Medicine (ABMS), Sao Paulo, Brazil
Study Objectives: Obstructive sleep apnea (OSA) is highly prevalent, and positive airway pressure (PAP) therapy is the primary treatment. This study aimed to
assess the diagnostic and PAP treatment resources for OSA within Brazil’s Unified Health System and to identify potential inequalities and gaps.
Methods: A structured survey was sent to members of the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine to identify sleep
laboratories providing OSA diagnosis and/or treatment within Brazil’s Unified Health System. The numbers of centers, care team structure, sleep studies
availability, PAP accessibility, and follow-up services were characterized in all 5 Brazilian regions.
Results: Forty-seven centers were identified: Midwest (n = 4), Northeast (n = 10), North (n = 3), Southeast (n = 22), and South (n = 8). Most centers (70%)
provided both OSA diagnosis and treatment, mainly in capitals and/or metropolises (87%). Ten out of 27 Brazilian Federal Units lacked sleep services for OSA
management, with the North having the highest proportion of states without a sleep service (71%). The annual number of diagnostic exams for OSA was 14,932,
with significant heterogeneity across regions (Midwest: 240; North: 400; Northeast: 3,564; South: 4,380; Southeast: 6,348). Mean waiting times for diagnosis and
treatment were 11 and 8 months, respectively. Only 46% of PAP treatments were publicly funded, making legal injunctions and out-of-pocket expenditure common
practices.
Conclusions: This study revealed significant disparities in OSA diagnosis and treatment resources across Brazil, with the North region being particularly
underserved. The findings underscore an urgent need for strategies to improve sleep care nationwide.
Keywords: sleep apnea, obstructive, positive airway pressure, polysomnography, health services accessibility
Citation: Drager LF, Santos RB, Pachito D, Albertini CS, Sert Kuniyoshi FH, Eckeli AL. Inequalities in the access to diagnosis and treatment of obstructive sleep
apnea in Brazil: a cross-sectional study. J Clin Sleep Med. 2024;20(5):735–742.
BRIEF SUMMARY
Current Knowledge/Study Rationale: Although obstructive sleep apnea (OSA) is widely prevalent and associated with increased risks for morbidity and
mortality, Brazilian health care systems have not yet fully integrated OSA management into standardized care protocols or guaranteed by federal lines of
care. The main aim of this study was to assess the availability of OSA diagnostic and positive airway pressure treatment resources within Brazil’s Unified
Health System to identify potential disparities and gaps.
Study Impact: The findings of this study have revealed a fragile structure for managing sleep care within the Unified Health System. The observed disparities
are likely connected to regional economic and political differences across Brazil and represent significant barriers to achieving health equity goals.
INTRODUCTION incorporation of health technologies by assessing their effec-
tiveness, safety, cost-effectiveness, and budgetary impact.
Access to health care is a right granted to Brazilian citizens by Technologies incorporated after the evaluation process become
the Federal Constitution of 1988.1 Currently, approximately part of the National List of Medicines (Relaç~ao Nacional de
71.5% of the population is totally dependent on public health Medicamentos Essenciais (RENAME)) or the National List
care,2 provided by the Unified Health System (Sistema Unico of Equipment and Permanent Fundable Materials for the
de Saude (SUS) from its Portuguese acronym). The process of SUS (Relaç~ao Nacional de Equipamentos e Materiais Perma-
incorporating diagnostic methods and technologies into the nentes financiaveis pelo para o SUS (RENEM)). Together,
SUS is carried out by the National Committee for Health Tech- the list of these products and services is made available to
nology Incorporation (Comiss~ao Nacional de Incorporaç~ao de SUS users in compliance with the recommendations on spe-
Tecnologias no Sistema Unico de Saude (CONITEC)), an cific lines of care presented in the Clinical Protocols of Ther-
agency of the Ministry of Health.3 CONITEC evaluates the apeutic Guidelines.
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 735 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Obstructive sleep apnea (OSA) is a highly prevalent chronic OSA treatment, (21) PAP treatment information, and (16) PAP
disease. In Brazil, it is estimated that OSA affects 50 million funding information. After this pilot, the survey was released
inhabitants.4 OSA is characterized by partial or complete by the Brazilian Sleep Association (ABS) and the Brazilian
obstruction of the upper airways during sleep, contributing Association of Sleep Medicine (ABMS) through their Regional
to fragmented and poor sleep quality.5 More importantly, Centers across the 5 Brazilian macro-regions. Briefly, ABS sent
untreated OSA has a negative impact on quality of life and is several emails and advertisements to its 24 branches (each one
associated with multiple consequences that range from daytime having a board of recognized professionals in the sleep field)
sleepiness and impaired cognitive function to more severe and a database of over 5,000 health care professionals involved
complications, such as increased systemic blood pressure, pul- in the clinical care of patients with sleep disorders (regardless
monary hypertension, arrhythmias, congestive heart failure, of the area). In addition, all authors utilized personal network
diabetes, dyslipidemia, coronary artery disease, stroke, and contacts to identify additional centers. The medical director of
even an increased risk of mortality.6 each identified center was invited to participate in the study and
Attended in-laboratory polysomnography (PSG) is considered provided with a hyperlink to the survey platform (using the
the gold standard for diagnosing OSA. However, due to its com- Research Electronic Data Capture system, REDCap v11.2.5,
plexity and cost, home sleep apnea tests have gained popularity. Nashville, TN, United States).8 All participant centers were
Nevertheless, the American Academy for Sleep Medicine recom- instructed to check their records, searching for data related to
mends the use of PSG over home sleep apnea tests for diagnosing OSA diagnostic tests and treatment procedures covered by SUS
OSA in patients with significant comorbidities, which include car- between 2018 and 2019 (before the coronavirus disease 2019
diorespiratory disease, suspected respiratory muscle weakness [COVID-19] pandemic).
due to neuromuscular condition, awake hypoventilation or suspi- In the study’s second phase, from December 3, 2020, to
cion of sleep-related hypoventilation, chronic opioid medication February 2, 2022, one of the authors (R.B.S) made individual con-
use, history of stroke, or severe insomnia.7 tact with additional centers identified following the presentation
Positive airway pressure (PAP) therapy is considered the of our preliminary data at the Brazilian Sleep Congress. While
most effective treatment for moderate to severe cases of OSA.5 this phase took place during a period of significant interruption
Despite its high prevalence and association with morbidity and due to the COVID-19 pandemic, which posed some challenges in
mortality, assistance to patients with this disease is not included accessing all the information needed because most of the centers
in care protocols or guaranteed by federal lines of care or were partially closed during the period, it did not affect the survey
networks nationally established in Brazil. Although PAP tech- results because participating centers were directed to review their
nology is officially part of RENAME, with provision for dis- records for data pertaining the period from 2018 to 2019.
pensation by municipalities or federative units, the effective At the discretion of each center, the survey was self-
provision of the technology depends on local terms of coopera- completed or could rely on instruction from the same author.
tion with responsible bodies, which may lead to different levels The approach used in data collection, combining primary and
of access to PAP therapy. secondary phases, aimed to increase the scope of the universe
Considering the lack of national data on OSA care, the main of respondents to guarantee the representativeness of the data.
aim of this study was to evaluate OSA diagnostic and PAP treat- If a center was identified in the second phase but had not been
ment resources within the Brazilian SUS to identify potential included in the first phase, attempts were made to contact them
inequalities and gaps. We hypothesized that access to the diag- via email and telephone to disseminate the research and request
nosis and treatment of OSA is variable and insufficient in Brazil. the completion of the study’s survey instrument.
Data analysis
METHODS Descriptive analysis was conducted using SPSS 24.0 (IBMCor-
poration, Armonk, NY). The results are presented as numbers
The study was reviewed by the Ethics Committee for the Pro- and percentages by administrative regions (Midwest, Northeast,
tection of Human Subjects of the Heart Institute (InCor), North, Southeast, and South) as well as federative units, which
University of Sao Paulo Medical School, Brazil (CAAE comprise 26 states and the Federal District.
31626120.5.0000.0068) and deemed exempt from oversight. Federative units were categorized into different levels
Informed consent was waived as no personal data were col- according to the availability of diagnostic resources and access
lected. The study was conducted in accordance with the rele- to PAP treatment, as described below. Regarding the diagnosis,
vant guidelines and regulations. 3 levels of resources were defined:
The present study has a cross-sectional design using a 1. Federative units without diagnostic centers for OSA cov-
2-phase approach. In the first phase, a survey instrument devel- ered by the SUS.
oped by the study authors was tested in 2 sleep laboratories that 2. Federative units with centers offering PSG exams (type I
provide OSA diagnosis and treatment within the SUS to verify and II monitoring devices) covered by the SUS.
the intelligibility of the questions and the response time. The 3. Federative units with centers offering PSG (type I and II
survey contained 191 closed and open questions to address the monitoring devices) as well as other simplified diagnos-
following: (15) general information about the center, (95) care tic resources (type III and IV monitoring devices) cov-
team structure, (29) OSA diagnostic capabilities, (15) available ered by the SUS.
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 736 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Regarding treatment, 3 levels of care were defined: All data were analyzed in a secure, anonymized database physi-
1. Federative units without PAP distribution/setup service cally separated from the main production server.
for the treatment of OSA covered by the SUS.
2. Federative units with 1 or more locations providing PAP
distribution/setup service for the treatment of OSA cov- RESULTS
ered by the SUS but lacking an active patient follow-up
program. A total of 50 centers providing diagnosis and/or treatment of
3. Federative units with 1 or more locations providing PAP OSA predominantly or exclusively for the SUS were identified in
service covered by the SUS for OSA treatment and an the first phase. Of these, 2 centers chose not to participate in the
active patient follow-up program. study, and 1 did not complete the questionnaire. These 3 centers
In our cross-sectional survey, we collected data on the num- were located in the Southeast region. Therefore, responses from
ber of diagnostic tests and patients treated on a monthly basis. 47 centers were included in the analysis. Figure 1 demonstrates
From these monthly figures reported by the respondents, we the flow for identified and evaluated centers.
calculated the annual totals by aggregating the data over the Of these 47 centers, 32 (68%) reported the capability to per-
12-month period. This method allowed us to estimate the yearly form both diagnosis and treatment of OSA, 12 (26%) could
activity from the monthly cross-sectional data provided by the only provide treatment, and 3 (6%) could only perform diagnos-
survey participants. The number of diagnostic tests and patients tic testing only. The Southeast region had the highest number
treated per capita was calculated by dividing these procedures of centers (22), followed by the Northeast (10), South (8),
performed per year by the regions’ population obtained from Midwest (4), and North (3). However, each region had a
the Brazilian Institute of Geography and Statistics (IBGE).9 similar number of centers per 100,000 population (Table 1).
Figure 1—Study flow diagram.
Eligible (n=50)
Excluded (n=2)
 Refusal
Questionnaires sent (n= 48)
Brazilian regions: Excluded (n=1)
 Incomplete filling
Midwest (n=4)
Northeast (n=10)
North (n=3) Total number of centers 
(n= 47)
Southeast (n=22)
South (n=8)
Diagnosis only Treatment only Diagnosis and treatment
(n = 32)
(n = 3) (n = 12)
Northeast (n=1) Midwest (n=2) Midwest (n=2)
Southeast (n=2) Northeast (n=2) Northeast (n=7)
North (n=1) North (n=2)
Southeast (n=7) Southeast (n=13)
South (n=8)
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 737 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Table 1—Number of centers, diagnostic tests, and patients treated according to Brazilian administrative regions.
Centers Diagnostic Test Patients Treated
Administrative
Regions Populationa OSA Riskb Number n /100,000 n/y n/y/100,000 n/y n/y/100,000
Midwest 16,707,336 1,921,344 4 0.02 240 1 2,544 15
Northeast 57,667,842 6,631,802 10 0.02 3,564 6 3,600 6
North 18,906,962 2,174,301 3 0.02 400 2 528 3
Southeast 89,632,912 10,307,785 22 0.02 6,348 7 13,032 15
South 30,402,587 3,496,298 8 0.03 4,380 14 4,656 15
Total 213,317,639 24,531,530 47 0.02 14,932 7 24,360 11
aEstimate from the Brazilian Institute of Geography and Statistics (IBGE). bEstimate based on the global data frequency of moderate to severe OSA.3
OSA = obstructive sleep apnea.
Table 1 also displays the annual number of diagnostic tests per exclusively after diagnostic PSG, a significant portion (36%)
100,000 population with the lowest relative rates in the North frequently relied on clinical parameters to determine the need
andMidwest regions. for treatment.
Among Brazil’s 27 federative units, 16 states and the PAP therapy was available in the majority (93%) of the
Federal District (63%) had centers offering diagnostic tests surveyed centers. Surgical procedures were available in 52% of
and/or treatment for OSA through the SUS. On the other hand, the centers. Other available treatments included mandibular
10 states did not have any center with these capabilities. The advancement devices (43%) and myofunctional (23%) and
states with the highest number of centers were S~ao Paulo with positional therapy (45%). Despite the availability of different
12, Rio de Janeiro with 6, and Minas Gerais, Parana, and Ceara therapies, on average, 80% of patients received treatment exclu-
with 4 centers each. Table 1 and Figure 2 show the distribu- sively through PAP.
tion of centers by macro-regions. Table S1 in the supplemen- Forty-three percent of the centers followed established clini-
tal material shows the distribution of centers and the annual cal protocols to guide the indication for the treatment of OSA.
number of diagnoses and treatments per 100,000 inhabitants In other cases, the treatment decision was made by the attending
in each federative unit. physician (36%) or depended on the availability of resources
Considering the centers with diagnostic availability, (21%).
in-laboratory full PSG (type I) was the most frequently available With regard to PAP funding information, the primary finan-
diagnostic test present in 84% of the centers, followed by the cial coverage for PAP therapy predominantly relied on public
simplified type III test available in 39% of centers. Type II funds (46%), 32% of patients did not have access to PAP
(home full PSG) and type IV (oximetry) tests had a low fre- treatment, and 22% paid out-of-pocket to access the therapy.
quency of use at 3% and 13%, respectively. Notably, 13% of the Figure 4 shows the availability of public funding in the
centers provided only type III and IV monitoring, while 58% 5 administrative regions. This scenario contributes to the
exclusively provided type I monitoring. None of the centers observed legal injunction (such as judicialization for getting
offered only type II monitoring. continuous PAP). Among the 35 centers where public funds
The annual number of diagnostic exams for OSA was were utilized, a significant number (56%) relied on legal actions
14,932, with significant heterogeneity across different regions. or administrative processes to provide PAP treatment access for
The Southeast region led the statistics with 6,348 procedures patients needing therapy. Specific federal programs dedicated
per year, followed by the South (4,380/y) and the Northeast to providing PAP equipment were observed in only 1 center
(3,564/y). In contrast, the North region performed 400 proce- (2%). At the state level, such programs were available in 11
dures per year, and the Midwest only 240 per year. The mean centers (26%), and at the municipal level, they were available
waiting period from the initial consultation to OSA diagnosis in 15 centers (35%).
was 11 months, and the average waiting time from diagnosis to Out of the 44 centers that offered any form of OSA treat-
treatment initiation was 8 months. Figure 3 shows a detailed ment, only 11 acquired equipment and/or supplies for OSA
breakdown by region. treatment using either leasing (5 centers) or direct purchases
With regard to PAP treatment, Table 1 displays the number (6 centers). The replacement of supplies was implemented in
of patients treated with PAP per 100,000 population annually. 10 centers, with a frequency of semiannual (3 centers), annual
Among the responding centers, the average number of patients (3 centers), or on-demand (4 centers). Remarkably, only 3 cen-
receiving treatment for OSA was 24,360 per year. Regional var- ters reported a technical assistance plan in place for the equip-
iations were evident, with the North treating 528 patients annu- ment. Patient and treatment information was organized in
ally, the Midwest 2,544, the Northeast 3,600, the South 4,656, digital databases in 10 centers. Furthermore, all centers unani-
and the Southeast 13,032 per year. While the majority (64%) of mously considered the provision of treatment for sleep apnea to
the centers reported that treatment for OSA was initiated be insufficient in meeting the demand.
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 738 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Figure 2—Distribution of centers for diagnosis and/or treatment of OSA.
Distribution of centers for diagnosis and/or treatment of OSA by Brazilian macroregion (A); annual number of diagnostic tests for OSA per year/100,000 population
(B); and annual number of treatments for OSA per year/100,000 population (C). OSA = obstructive sleep apnea.
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 739 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Figure 3—Average waiting periods (in months) between the first office appointments at specialized sleep medicine center and
the diagnosis of OSA (blue) and the subsequent initiation of OSA treatment (green) across different regions of Brazil.
Regional disparities are illustrated, with the national average in the last row. Totals for each region are displayed in white. OSA = obstructive sleep apnea.
exams per 100,000 people is not entirely clear, Flemons and
DISCUSSION
colleagues12 estimated that approximately 2,310 polysomno-
grams per 100,000 people per year would be required to ade-
This is the first study that has attempted to identify OSA diag-
quately address the demand for diagnosis and treatment of
nostic and treatment resources provided by the Brazilian SUS.
We found that only 32 centers across Brazil offer OSA diagno- patients with suspected OSA of at least moderate severity. This
sis through the SUS. Although the number of centers seems to estimation assumes a conservative estimate that 50% of PSGs
be homogeneously distributed across regions when considering would be positive for OSA.
12 In our investigation, despite an
the population in each region, Brazil’s vast geographical apparent homogeneity in the availability of sleep studies within
expanse and a population exceeding 212 million people are the Brazilian SUS, the reported number of sites and the number
matters of great concern. In addition, there was substantial of sleep studies per 100,000 people are far below the aforemen-
regional variability, with diagnostic tests ranging from 1 to 14 tioned evidence, supporting the reported long waiting lists,
diagnostic tests per year per 100,000 population and the number which is almost 3-fold higher than those observed in Canada.
12
of treated patients ranging from 3 to 15 patients treated per year Conventional PSG was the most commonly available (84%)
per 100,000 population. Moreover, the number of patients start- type of sleep study in the Brazilian SUS. This finding contrasts
11
ing PAP is only 21,672 per year, and our data also revealed sub- with previous reports in Spain (53%). This method is labor-
intensive, time-consuming, and expensive, requiring sleep tech-
stantial variability across the 5 macro-regions. Inequality is also
nicians available for night shifts.13,14 Despite the importance of
observed in funding analysis: there is substantial variability in
PSG for the most difficult cases and other sleep disorders, sim-
PAP coverage, making no coverage, legal injunction, and out-
plified methods, such as type III, are validated for those patients
of-pocket expenditure common in Brazil. Taken together, these
with a high pretest probability of OSA and may surpass this
national data underscore significant barriers to accessing OSA
important limitation in clinical practice.15–17 Therefore, our
diagnosis and treatment within Brazil.
results call attention to the need for a paradigm shift to stream-
Due to the complexity of an ideal SUS in one of the largest
line OSA diagnosis in Brazil.
countries in the world, it is conceivable that several hurdles
The performance for OSA diagnosis seems to pave the way for
contribute to this unfavorable sleep care scenario, including,
the challenging reality of OSA treatment in Brazil: a low number of
but not limited to, low awareness about sleep disorders, lack of sleep centers translates to limited access to PAP treatment with sig-
implementation of screening tools, financial limitations, limited nificant inequalities among regions. Although it is intuitive that the
access to health care, and diagnostic availability. It is estimated primary financial coverage for PAP therapy relies on public funds,
that the prevalence of OSA in Brazil is approximately 30% of the current rate (46%) is clearly insufficient. Decentralization is
the adult population4,10; however, the mean number of diagnos- also challenging, with specific federal programs dedicated to pro-
tic tests observed in our study was far behind what would be viding PAP equipment observed in only 1 center (2%), at the state
considered reasonable. For the sake of comparison, data from level in 11 centers, and at the municipal level in 15 centers. The
Spain, a country where health care is provided mainly by the observed rate of legal injunctions and out-of-pocket acquisition to
public health system, reported 219 hospitals performing sleep access the therapy adds blunt arguments for fragile and unstable
studies in 2003.11 While the ideal number of sleep centers and OSA care in Brazil.
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 740 May 1, 2024
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LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Figure 4—Availability of public resources for the diagnosis and/or treatment of OSA by the 27 federative units of Brazil.
Federative units without centers for OSA covered by the Unified Health System (SUS) represented by white. OSA = obstructive sleep apnea.
While our study has several strengths, it also has limitations confirming the evidence we obtained by our structured survey.
that need to be addressed. Currently, there are limited publica- However, there are significant challenges in pursuing these data
tions describing OSA diagnostic and treatment resources col- in our country. Moreover, most patients in clinical practice do
lected from public health systems in other countries. Previous not have OSA-related ICD-10 codes unless they are referred to
investigations are outdated by more than 10 years and may not sleep studies or have a prior diagnosis in our public health sys-
accurately reflect the actual global landscape. In addition, data tem. Additionally, we did not capture the burden of patients
on access and inequalities in OSA care from developing coun- looking for other alternatives for OSA diagnosis and treatment
tries are missing, highlighting the importance of the current through legal injunctions or out-of-pocket expenses. We have
investigation. recently reported that CPAP legal injunctions in Brazil are an
However, it is important to acknowledge certain limitations important issue requiring dialogue with the Brazilian Health
in the present investigation. Despite our comprehensive strat- authorities.3 With regard to private access to diagnosis and
egy to cover all available centers nationwide and a very low treatment, we anticipated that the impact would be modest, con-
refusal rate (< 3%), the information was obtained from a self- sidering the overall low income observed in Brazil. Finally, it is
reported questionnaire. To overcome this potential limitation, conceivable that OSA prevalence may vary in the Brazilian
we conducted a guided interview and encouraged cross- macro-regions, but representative data on prevalence in each
referencing with records, especially for all absolute numbers macro-region are lacking.
pertaining to diagnostic and treatment procedures. The use of In conclusion, the analysis of the current Brazilian situation
the International Classification of Diseases, 10th Revision regarding access to OSA diagnosis and treatment has revealed
(ICD-10), codes or procedure codes for OSA may be useful for an insufficient number of centers, especially considering
Journal of Clinical Sleep Medicine, Vol. 20, No. 5 741 May 1, 2024
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Copyright 2025 American Academy of Sleep Medicine. All rights reserved. 
LF Drager, RB Santos, D Pachito, et al. Access to diagnosis and treatment of OSA in Brazil
Brazil’s vast geographical expanse and population. In addition, 10. Tufik S, Santos-Silva R, Taddei JA, Bittencourt LR. Obstructive sleep apnea
significant gaps exist in all regions, especially in the North, syndrome in the Sao Paulo Epidemiologic Sleep Study. Sleep Med. 2010;11(5):
441–446.
which highlights the challenges faced by individuals seeking
11. Duran-Cantolla J, Mar J, de La Torre Mu~necas G, Rubio Aramendi R, Guerra L.
appropriate care for OSA under the Brazilian SUS. Considering
The availability in Spanish public hospitals of resources for diagnosing and treating
the cost utility of CPAP compared with usual care for OSA in sleep apnea-hypopnea syndrome. Arch Bronconeumol. 2004;40(6):259–267.
the public health system in Brazil,18 these results underscore 12. Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J. Access to
the urgent need for strategies to improve sleep care in Brazil diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit
and ensure equitable access to necessary diagnostic and treat- Care Med. 2004;169(6):668–672.
ment services for patients. 13. Hirshkowitz M. Polysomnography challenges. Sleep Med Clin. 2016;11(4):403–411.
14. Lim DC, Mazzotti DR, Sutherland K, et al; SAGIC Investigators. Reinventing
polysomnography in the age of precision medicine. Sleep Med Rev. 2020;52:101313.
ABBREVIATIONS
15. Ng SS, Chan TO, To KW, et al. Validation of Embletta portable diagnostic system
for identifying patients with suspected obstructive sleep apnoea syndrome
OSA, obstructive sleep apnea (OSAS). Respirology. 2010;15(2):336–342.
PAP, positive airway pressure 16. Pinheiro GDL, Cruz AF, Domingues DM, et al. Validation of an overnight wireless
PSG, polysomnography high-resolution oximeter plus cloud-based algorithm for the diagnosis of obstruc-
SUS, Unified Health System tive sleep apnea. Clinics (S~ao Paulo). 2020;75:e2414.
17. Collop NA, Anderson WM, Boehlecke B, et al; Portable Monitoring Task Force of
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Author contributions: L.F.D. and R.B.S. are the guarantors of the content of the
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manuscript. All authors contributed substantially to the study design, data analysis,
and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir
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5. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet.
2014;383(9918):736–747. SUBMISSION & CORRESPONDENCE INFORMATION
6. Drager LF, McEvoy RD, Barbe F, Lorenzi-Filho G, Redline S; INCOSACT Initiative
(International Collaboration of Sleep Apnea Cardiovascular Trialists). Sleep apnea Submitted for publication September 19, 2023
and cardiovascular disease: lessons from recent trials and need for team science. Submitted in final revised form December 21, 2023
Circulation. 2017;136(19):1840–1850. Accepted for publication December 22, 2023
Address correspondence to: Luciano F. Drager, MD, PhD, Av. Eneas de Carvalho
7. Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for
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[email protected]
of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(3):
479–504.
8. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research DISCLOSURE STATEMENT
electronic data capture (REDCap)—a metadata-driven methodology and workflow
process for providing translational research informatics support. J Biomed Inform. All authors approved the final manuscript. Work for this study was performed at the
2009;42(2):377–381. Heart Institute (InCor), University of Sao Paulo Medical School, Brazil. This study
9. Instituto Brasileiro de Geografia e Estatıstica (IBGE). Previa da populaç~ao was funded by the ResMed Foundation and Brazilian Sleep Association. L.F.D.
calculada com base nos resultados do Censo Demografico 2022 ate 25 de serves as a consultant to ResMed. D.P. and A.L.E. acted as consultants to
dezembro de 2022. Available from: https://www.ibge.gov.br/estatisticas/sociais/ ResMed during the development of this program and data collection. R.B.S. and
populacao/22827-censo-demografico-2022.html?edicao=35938&t=resultados. C.S.A. were employees of ResMed at the time of the data collection and writing up
Acessed December 15, 2022. of the manuscript. F.H.S.K. is a current employee of ResMed.
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