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National strategy on the integration of sleep and circadian rhythms into public health research and policies: Report from the Canadian Sleep and Circadian Network

Published:August 10, 2022DOI:https://doi.org/10.1016/j.sleh.2022.06.005

      Abstract

      Scientists in sleep and circadian rhythms, public health experts, healthcare providers, partners, and stakeholders convened in 2020 for a 2-day meeting organized by the Canadian Sleep and Circadian Network to develop a national strategy for integrating sleep and circadian rhythms into public health and policies in Canada. The objective of this paper is to present the national strategy that emerged from this meeting of 60 participants from across Canada. The meeting focused on 4 key target priorities: (1) atypical working schedules, (2) sleep and circadian rhythms of children and adolescents, (3) insomnia, and (4) impact of sleep apnea on health. Following constructive discussions, it was decided that the following 4 strategic objectives should be prioritized to accelerate the integration of sleep and circadian rhythms into public health policies in Canada: (1) increase public health sleep and circadian rhythm research, (2) increase public health education and knowledge mobilization on sleep, (3) inform and support public health sleep interventions and policies, and (4) promote sleep health training. Participants recommended that research and public health efforts address needs along the continuum of sleep health. The committee noted that strategies and interventions could differ across contexts, settings, sectors, and jurisdictions. The national strategy also identified high-priority research questions in public health and recommended mechanisms to build research capacity, providing a path forward for the integration of sleep and circadian rhythms into public health research and policies.

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      References

        • Cirelli C
        • Tononi G
        Is sleep essential?.
        PLoS Biol. 2008; 6: e216
        • Duffy JF
        • Czeisler CA
        Effect of light on human circadian physiology.
        Sleep Med Clin. 2009; 4: 165-177
        • James SM
        • Honn KA
        • Gaddameedhi S
        • Van Dongen HPA
        Shift work: disrupted circadian rhythms and sleep—implications for health and well-being.
        Curr Sleep Med Rep. 2017; 3: 104-112
        • Chaput J-P
        • Dutil C
        • Featherstone R
        • et al.
        Sleep duration and health in adults: an overview of systematic reviews.
        Appl Physiol Nutr Metab. 2020; 45: S218-S231
        • Chaput J-P
        • Dutil C
        • Featherstone R
        • et al.
        Sleep timing, sleep consistency, and health in adults: a systematic review.
        Appl Physiol Nutr Metab. 2020; 45: S232-S247
        • Buysse DJ.
        Sleep health: can we define it? Does it matter?.
        Sleep. 2014; 37: 9-17
        • Hillman DR
        • Lack LC.
        Public health implications of sleep loss: the community burden.
        Med J Aust. 2013; 199: 7-10
        • Chaput J-P
        • Wong SL
        • Michaud I.
        Duration and quality of sleep among Canadians aged 18 to 79.
        Health Rep. 2017; 28: 28-33
      1. Hurst M. Who gets any sleep these days?: Sleep patterns of Canadians. Canadian Social Trends. Ottawa: Statistics Canada; 2008.

      2. Williams C. You snooze, you lose? – Sleep patterns in Canada. Canadian Social Trends. Ottawa: Statistics Canada; 2001.

        • Thompson C
        • Legault J
        • Moullec G
        • et al.
        A portrait of obstructive sleep apnea risk factors in 27,210 middle-aged and older adults in the Canadian Longitudinal Study on Aging.
        Sci Rep. 2022; 12: 1-11
        • Horne J
        • Reyner L.
        Vehicle accidents related to sleep: a review.
        Occup Environ Med. 1999; 56: 289-294
        • Dingus TA
        • Klauer SG
        • Neale VL
        • et al.
        The 100-Car Naturalistic Driving Study, Phase II – Results of the 100-Car Field Experiment.
        Department of Transportation. National Highway Traffic Safety, United States2006 (ed)
      3. Safety recommendation. In: National Transportation Safety Board, ed. Washington, DC; 1995. https://www.ntsb.gov/safety/safety-studies/Documents/SS9501.pdf

        • Kripke DF
        • Garfinkel L
        • Wingard DL
        • Klauber MR
        • Marler MR.
        Mortality associated with sleep duration and insomnia.
        Arch Gen Psychiatry. 2002; 59: 131-136
        • Committee on Sleep Medicine and Research
        Sleep Disorders and Sleep Deprivation: an Unmet Public Health Problem.
        Institute of Medicine of the National Academies, Washington, D.C.2006
        • Kling RN
        • McLeod CB
        • Koehoorn M.
        Sleep problems and workplace injuries in Canada.
        Sleep. 2010; 33: 611-618
        • Reynolds AC
        • Appleton SL
        • Gill TK
        • et al.
        Sickness absenteeism is associated with sleep problems independent of sleep disorders: results of the 2016 Sleep Health Foundation National Survey.
        Sleep Health. 2017; 3: 357-361
        • Chaput JP
        • Janssen I.
        Sleep duration estimates of Canadian children and adolescents.
        J Sleep Res. 2016; 25: 541-548
        • Gibson ES
        • Powles AC
        • Thabane L
        • et al.
        Sleepiness" is serious in adolescence: two surveys of 3235 Canadian students.
        BMC Public Health. 2006; 6: 116
        • Gariepy G
        • Danna S
        • Gobiņa I
        • et al.
        How are adolescents sleeping? Adolescent sleep patterns and sociodemographic differences in 24 European and North American countries.
        J Adolesc Health. 2020; 66: S81-S88
        • Michaud I
        • Chaput J.
        Are Canadian children and adolescents sleep deprived.
        Public Health. 2016; 141: 126-129
        • Matricciani L
        • Paquet C
        • Galland B
        • Short M
        • Olds T.
        Children's sleep and health: a meta-review.
        Sleep Med Rev. 2019; 46: 136-150
        • Hafner M
        • Stepanek M
        • Taylor J
        • Troxel WM
        • van Stolk C.
        Why sleep matters—the economic costs of insufficient sleep.
        Rand Health Q. 2017; 6
        • Daley M
        • Morin CM
        • LeBlanc M
        • Gregoire JP
        • Savard J.
        The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers.
        Sleep. 2009; 32: 55-64
        • Jackson CL
        • Walker JR
        • Brown MK
        • Das R
        • Jones NL.
        A workshop report on the causes and consequences of sleep health disparities.
        Sleep. 2020; 43: zsaa037
        • Bartel KA
        • Gradisar M
        • Williamson P.
        Protective and risk factors for adolescent sleep: a meta-analytic review.
        Sleep Med Rev. 2015; 21: 72-85
        • Roenneberg T.
        Chronobiology: the human sleep project.
        Nature. 2013; 498: 427-428
        • Grandner MA
        • Jackson NJ
        • Izci-Balserak B
        • et al.
        Social and behavioral determinants of perceived insufficient sleep.
        Front Neurol. 2015; 6: 112
        • Leger D
        • Beck F
        • Richard JB.
        Sleep loss in the homeless—an additional factor of precariousness: survey in a group of homeless people.
        JAMA Intern Med. 2017; 177: 278-279
        • Bambra C
        • Gibson M
        • Sowden A
        • Wright K
        • Whitehead M
        • Petticrew M.
        Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews.
        J Epidemiol Community Health. 2010; 64: 284-291
      4. The 2030 agenda for sustainable development. Government of Canada. Available at: https://www.international.gc.ca/world-monde/issues_development-enjeux_developpement/priorities-priorites/agenda-programme.aspx?lang=eng, 2022.

        • Khubchandani J
        • Price JH.
        Short sleep duration in working American adults, 2010–2018.
        J Community Health. 2020; 45: 219-227
        • Anbazhagan S
        • Ramesh N
        • Nisha C
        • Joseph B
        Shift work disorder and related health problems among nurses working in a tertiary care hospital, Bangalore, South India.
        Indian J Occup Environ Med. 2016; 20
        • Di Milia L
        • Waage S
        • Pallesen S
        • Bjorvatn B.
        Shift work disorder in a random population sample–prevalence and comorbidities.
        PLoS One. 2013; 8: e55306
        • Drake CL
        • Roehrs T
        • Richardson G
        • Walsh JK
        • Roth T.
        Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers.
        Sleep. 2004; 27: 1453-1462
        • Flo E
        • Pallesen S
        • Mageroy N
        • et al.
        Shift work disorder in nurses–assessment, prevalence and related health problems.
        PLoS One. 2012; 7: e33981
        • Vanttola P
        • Puttonen S
        • Karhula K
        • Oksanen T
        • Härmä M.
        Prevalence of shift work disorder among hospital personnel: a cross-sectional study using objective working hour data.
        J Sleep Res. 2020; 29: e12906
        • Waage S
        • Moen BE
        • Pallesen S
        • et al.
        Shift work disorder among oil rig workers in the North Sea.
        Sleep. 2009; 32: 558-565
        • Ferri P
        • Guadi M
        • Marcheselli L
        • Balduzzi S
        • Magnani D
        • Di Lorenzo R.
        The impact of shift work on the psychological and physical health of nurses in a general hospital: a comparison between rotating night shifts and day shifts.
        Risk Manag Healthc Policy. 2016; 9: 203-211
        • Oyane NM
        • Pallesen S
        • Moen BE
        • Akerstedt T
        • Bjorvatn B.
        Associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of Norwegian nurses.
        PLoS One. 2013; 8: e70228
        • Kaliyaperumal D
        • Elango Y
        • Alagesan M
        • Santhanakrishanan I.
        Effects of sleep deprivation on the cognitive performance of nurses working in shift.
        J Clin Diagn Res. 2017; 11: CC01-CC03
        • Gurubhagavatula I
        • Barger LK
        • Barnes CM
        • et al.
        Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health: guidance from the American Academy of Sleep Medicine and the Sleep Research Society.
        Sleep. 2021; 44: zsab161
      5. International Civil Aviation Organization (ICAO). Fatigue risk management systems implementation guide for operators: International Air Transport Association; 2011. https://www.icao.int/safety/fatiguemanagement/FRMS%20Tools/FMG%20for%20Airline%20Operators%202nd%20Ed%20%28Final%29%20EN.pdf

        • Sprajcer M
        • Thomas MJW
        • Sargent C
        • et al.
        How effective are Fatigue Risk Management Systems (FRMS)? A review.
        Accid Anal Prev. 2022; 165106398
        • Tremblay MS
        • Carson V
        • Chaput J-P
        • et al.
        Canadian 24-hour movement guidelines for children and youth: an integration of physical activity, sedentary behaviour, and sleep.
        Appl Physiol Nutr Metab. 2016; 41: S311-S327
        • Gradisar M
        • Gardner G
        • Dohnt H.
        Recent worldwide sleep patterns and problems during adolescence: a review and meta-analysis of age, region, and sleep.
        Sleep Med. 2011; 12: 110-118
        • Kann L
        • McManus T
        • Harris WA
        • et al.
        Youth risk behavior surveillance-United States, 2015.
        MMWR Surveill Summ. 2016; 65: 1-174
        • Patte KA
        • Qian W
        • Leatherdale ST
        Sleep duration trends and trajectories among youth in the COMPASS study.
        Sleep Health. 2017; 3: 309-316
        • Gruber R
        • Carrey N
        • Weiss SK
        • et al.
        Position statement on pediatric sleep for psychiatrists.
        J Can Acad Child Adolesc Psychiatry. 2014; 23: 174-195
        • Chaput J-P
        • Dutil C
        • Sampasa-Kanyinga H.
        Sleeping hours: what is the ideal number and how does age impact this?.
        Nat Sci Sleep. 2018; 10: 421
        • Randler C
        • Faßl C
        • Kalb N.
        From Lark to Owl: developmental changes in morningness-eveningness from new-borns to early adulthood.
        Sci Rep. 2017; 7: 45874
        • Sampasa-Kanyinga H
        • Hamilton HA
        • Chaput JP.
        Use of social media is associated with short sleep duration in a dose–response manner in students aged 11 to 20 years.
        Acta Paediatr. 2018; 107: 694-700
        • LeBourgeois MK
        • Hale L
        • Chang A-M
        • Akacem LD
        • Montgomery-Downs HE
        • Buxton OM.
        Digital media and sleep in childhood and adolescence.
        Pediatrics. 2017; 140: S92-S96
        • Cabré-Riera A
        • Torrent M
        • Donaire-Gonzalez D
        • Vrijheid M
        • Cardis E
        • Guxens M.
        Telecommunication devices use, screen time and sleep in adolescents.
        Environ Res. 2019; 171: 341-347
        • Cain N
        • Gradisar M.
        Electronic media use and sleep in school-aged children and adolescents: a review.
        Sleep Med. 2010; 11: 735-742
        • Chaput JP
        • Tremblay MS
        • Katzmarzyk PT
        • et al.
        Sleep patterns and sugar-sweetened beverage consumption among children from around the world.
        Public Health Nutr. 2018; 21: 2385-2393
        • Lin Y
        • Tremblay MS
        • Katzmarzyk PT
        • et al.
        Temporal and bi-directional associations between sleep duration and physical activity/sedentary time in children: an international comparison.
        Prev Med. 2018; 111: 436-441
        • Bonuck KA
        • Schwartz B
        • Schechter C.
        Sleep health literacy in head start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep.
        Sleep Health. 2016; 2: 19-24
        • Buxton OM
        • Chang A-M
        • Spilsbury JC
        • Bos T
        • Emsellem H
        • Knutson KL.
        Sleep in the modern family: protective family routines for child and adolescent sleep.
        Sleep Health. 2015; 1: 15-27
        • Lumeng JC
        • Chervin RD.
        Epidemiology of pediatric obstructive sleep apnea.
        Proc Am Thorac Soc. 2008; 5: 242-252
        • Devolin M
        • Phelps D
        • Duhaney T
        • et al.
        Information and support needs among parents of young children in a region of Canada: a cross-sectional survey.
        Public Health Nurs. 2013; 30: 193-201
        • Nicholls H.
        Let teenagers sleep.
        NY Times. 2018;
        • Alvaro C
        • Jackson LA
        • Kirk S
        • et al.
        Moving Canadian governmental policies beyond a focus on individual lifestyle: some insights from complexity and critical theories.
        Health Promot Int. 2011; 26: 91-99
        • Wold B
        • Mittelmark MB.
        Health-promotion research over three decades: The social-ecological model and challenges in implementation of interventions.
        Scand J Public Health. 2018; 46: 20-26
        • Gruber R
        • Somerville G
        • Finn C.
        School-based sleep health education in Canada.
        Sleep Med. 2019; 56: 9-15
        • Faught EL
        • Qian W
        • Carson VL
        • et al.
        The longitudinal impact of diet, physical activity, sleep, and screen time on Canadian adolescents' academic achievement: an analysis from the COMPASS study.
        Prev Med. 2019; 125: 24-31
        • Veugelers PJ
        • Schwartz ME.
        Comprehensive school health in Canada.
        Can J Public Health. 2010; (https://pubmed.ncbi.nlm.nih.gov/21133195/): S5-S8
      6. World Health Organization. What is a health promoting school? World Health Organization. Available at: https://www.who.int/school_youth_health/gshi/hps/en/. Accessed Feb, 2022.

      7. Public Health Agency of Canada. School Health. Available at: http://cbpp-pcpe.phac-aspc.gc.ca/public-health-topics/school-health/. Accessed Feb, 2022.

      8. Organization WH. Health for the world's adolescents: a second chance in the second decade: summary: World Health Organization; 2014. https://apps.who.int/iris/handle/10665/112750

        • Gruber R
        • Somerville G
        • Bergmame L
        • Fontil L
        • Paquin S.
        School-based sleep education program improves sleep and academic performance of school-age children.
        Sleep Med. 2016; 21: 93-100
        • Corkum P
        • Weiss S
        • Hall W
        • et al.
        Assessment and treatment of pediatric behavioral sleep disorders in Canada.
        Sleep Med. 2019; 56: 29-37
        • Katz SL
        • Witmans M
        • Barrowman N
        • et al.
        Paediatric sleep resources in Canada: the scope of the problem.
        Paediatr Child Health. 2014; 19: 367-372
        • Bock DE
        • Roach-Fox E
        • Seabrook JA
        • Rieder MJ
        • Matsui D.
        Sleep-promoting medications in children: physician prescribing habits in Southwestern Ontario, Canada.
        Sleep Med. 2016; 17: 52-56
        • Janjua I
        • Goldman RD.
        Sleep-related melatonin use in healthy children.
        Can Fam Physician. 2016; 62: 315-317
        • Au R
        • Carskadon M
        • Millman R
        • et al.
        School start times for adolescents.
        Pediatrics. 2014; 134: 642-649
        • Chaput J-P.
        The integration of pediatric sleep health into public health in Canada.
        Sleep Med. 2019; 56: 4-8
        • Wheaton AG
        • Chapman DP
        • Croft JB.
        School start times, sleep, behavioral, health, and academic outcomes: a review of the literature.
        J Sch Health. 2016; 86: 363-381
        • Marx R
        • Tanner-Smith EE
        • Davison CM
        • et al.
        Later school start times for supporting the education, health, and well-being of high school students.
        Cochrane Database Syst Rev. 2017; 7Cd009467
        • Gariepy G
        • Janssen I
        • Sentenac M
        • Elgar FJ.
        School start time and sleep in Canadian adolescents.
        J Sleep Res. 2017; 26: 195-201
        • Clara MI
        • Allen Gomes A.
        An epidemiological study of sleep−wake timings in school children from 4 to 11 years old: insights on the sleep phase shift and implications for the school starting times' debate.
        Sleep Med. 2020; 66: 51-60
        • Troxel WM
        • Wolfson AR.
        The intersection between sleep science and policy: introduction to the special issue on school start times.
        Sleep Health. 2017; 3: 419-422
        • Mcquigge M.
        Canadian high schools resisting calls for later class start times.
        The Globe and Mail. 2017;
        • Kirby M
        • Maggi S
        • D'Angiulli A
        School start times and the sleep–wake cycle of adolescents: a review and critical evaluation of available evidence.
        Educ Res. 2011; 40: 56-61
        • Association AP
        Diagnostic and Statistical Manual of Mental Disorders. 2013; (DSM-5)
        • Sateia MJ.
        International classification of sleep disorders.
        Chest. 2014; 146: 1387-1394
        • Morin CM
        • LeBlanc M
        • Belanger L
        • Ivers H
        • Merette C
        • Savard J.
        Prevalence of insomnia and its treatment in Canada.
        Can J Psychiatry. 2011; 56: 540-548
        • Morin CM
        • Drake CL
        • Harvey AG
        • et al.
        Insomnia disorder.
        Nat Rev Dis Primers. 2015; 1: 15026
        • Baglioni C
        • Battagliese G
        • Feige B
        • et al.
        Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies.
        J Affect Disord. 2011; 135: 10-19
        • Sivertsen B
        • Overland S
        • Neckelmann D
        • et al.
        The long-term effect of insomnia on work disability: the HUNT-2 historical cohort study.
        Am J Epidemiol. 2006; 163: 1018-1024
        • Morin CM
        • LeBlanc M
        • Daley M
        • Gregoire JP
        • Merette C.
        Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors.
        Sleep Med. 2006; 7: 123-130
        • Qaseem A
        • Kansagara D
        • Forciea MA
        • Cooke M
        • Denberg TD
        • Clinical Guidelines Committee of the American College of P
        Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2016; 165: 125-133
        • Riemann D
        • Baglioni C
        • Bassetti C
        • et al.
        European guideline for the diagnosis and treatment of insomnia.
        J Sleep Res. 2017; 26: 675-700
        • Edinger JD
        • Arnedt JT
        • Bertisch SM
        • et al.
        Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline.
        J Clin Sleep Med. 2021; 17: 255-262
        • Hirshkowitz M
        • Whiton K
        • Albert SM
        • et al.
        National Sleep Foundation's sleep time duration recommendations: methodology and results summary.
        Sleep Health. 2015; 1: 40-43
        • Ross R
        • Chaput JP
        • Giangregorio LM
        • et al.
        Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep.
        Appl Physiol Nutr Metab. 2020; 45: S57-S102
        • van Straten A
        • van der Zweerde T
        • Kleiboer A
        • Cuijpers P
        • Morin CM
        • Lancee J.
        Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis.
        Sleep Med Rev. 2018; 38: 3-16
        • Morin CM
        • Edinger JD
        • Beaulieu-Bonneau S
        • et al.
        Effectiveness of sequential psychological and medication therapies for insomnia disorder: a randomized clinical trial.
        JAMA Psychiatry. 2020; 77: 1107-1115
        • Lancee J
        • van Straten A
        • Morina N
        • Kaldo V
        • Kamphuis JH.
        Guided online or face-to-face cognitive behavioral treatment for insomnia: a randomized wait-list controlled trial.
        Sleep. 2016; 39: 183-191
        • Wickwire EM
        • Shaya FT
        • Scharf SM.
        Health economics of insomnia treatments: the return on investment for a good night's sleep.
        Sleep Med Rev. 2016; 30: 72-82
        • Peppard PE
        • Young T
        • Barnet JH
        • Palta M
        • Hagen EW
        • Hla KM.
        Increased prevalence of sleep-disordered breathing in adults.
        Am J Epidemiol. 2013; 177: 1006-1014
        • Laratta CR
        • Ayas NT
        • Povitz M
        • Pendharkar SR.
        Diagnosis and treatment of obstructive sleep apnea in adults.
        Can Med Assoc J. 2017; 189: 8
        • Lozo T
        • Komnenov D
        • Badr MS
        • Mateika JH.
        Sex differences in sleep disordered breathing in adults.
        Respir Physiol Neurobiol. 2017; 245: 65-75
      9. Berry RB, Albertario CL, Harding SM, et al. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, Version 2.5; 2018. https://aasm.org/clinical-resources/scoring-manual/

        • Benjafield AV
        • Ayas NT
        • Eastwood PR
        • et al.
        Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis.
        Lancet Respir Med. 2019; 7: 687-698
      10. Statistics Canada. Sleep apnea in Canada, 2016 and 2017. Available at: https://www150.statcan.gc.ca/n1/pub/82-625-x/2018001/article/54979-eng.htm. Accessed May 15, 2022.

        • Hirsch Allen AJM
        • Bansback N
        • Ayas NT.
        The effect of OSA on work disability and work-related injuries.
        Chest. 2015; 147: 1422-1428
        • Mulgrew AT
        • Nasvadi G
        • Butt A
        • et al.
        Risk and severity of motor vehicle crashes in patients with obstructive sleep apnoea/hypopnoea.
        Thorax. 2008; 63: 536-541
        • Marrone O
        • Bonsignore MR.
        Obstructive sleep apnea and cancer: a complex relationship.
        Curr Opin Pulm Med. 2020; 26: 657-667
        • Abuyassin B
        • Sharma K
        • Ayas NT
        • Laher I.
        Obstructive sleep apnea and kidney disease: a potential bidirectional relationship?.
        J Clin Sleep Med. 2015; 11: 915-924
        • Liguori C
        • Maestri M
        • Spanetta M
        • et al.
        Sleep-disordered breathing and the risk of Alzheimer's disease.
        Sleep Med Rev. 2020; 55101375
        • Badran M
        • Yassin BA
        • Fox N
        • Laher I
        • Ayas N.
        Epidemiology of sleep disturbances and cardiovascular consequences.
        Can J Cardiol. 2015; 31: 873-879
        • Golbidi S
        • Badran M
        • Ayas N
        • Laher I.
        Cardiovascular consequences of sleep apnea.
        Lung. 2012; 190: 113-132
        • Albarrak M
        • Banno K
        • Sabbagh AA
        • et al.
        Utilization of healthcare resources in obstructive sleep apnea syndrome: a 5-year follow-up study in men using CPAP.
        Sleep. 2005; 28: 1306-1311
        • Banno K
        • Ramsey C
        • Walld R
        • Kryger MH.
        Expenditure on health care in obese women with and without sleep apnea.
        Sleep. 2009; 32: 247-252
        • Bjornsdottir E
        • Keenan BT
        • Eysteinsdottir B
        • et al.
        Quality of life among untreated sleep apnea patients compared with the general population and changes after treatment with positive airway pressure.
        J Sleep Res. 2015; 24: 328-338
        • Hla KM
        • Young T
        • Hagen EW
        • et al.
        Coronary heart disease incidence in sleep disordered breathing: the Wisconsin Sleep Cohort Study.
        Sleep. 2015; 38: 677-684
        • Moyer CA
        • Sonnad SS
        • Garetz SL
        • Helman JI
        • Chervin RD.
        Quality of life in obstructive sleep apnea: a systematic review of the literature.
        Sleep Med. 2001; 2: 477-491
        • Redline S
        • Yenokyan G
        • Gottlieb DJ
        • et al.
        Obstructive sleep apnea-hypopnea and incident stroke: the Sleep Heart Health Study.
        Am J Respir Crit Care Med. 2010; 182: 269-277
        • Jennum P
        • Ibsen R
        • Kjellberg J.
        Morbidity and mortality in children with obstructive sleep apnoea: a controlled national study.
        Thorax. 2013; 68: 949-954
      11. American Academy of Sleep Medicine. Hidden health crisis costing America billions: underdiagnosing and undertreating obstructive sleep apnea draining healthcare system: Frost and Sullivan; 2016. https://aasm.org/resources/pdf/sleep-apnea-economic-crisis.pdf

        • Hillman D
        • Mitchell S
        • Streatfeild J
        • Burns C
        • Bruck D
        • Pezzullo L.
        The economic cost of inadequate sleep.
        Sleep. 2018; 41
      12. Interventions for the treatment of obstructive sleep apnea in adults: a health technology assessment. Ottawa 2017. https://www.ncbi.nlm.nih.gov/books/NBK535532

        • Bratton DJ
        • Gaisl T
        • Wons AM
        • Kohler M.
        CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis.
        JAMA. 2015; 314: 2280-2293
        • Campos-Rodriguez F
        • Queipo-Corona C
        • Carmona-Bernal C
        • et al.
        Continuous positive airway pressure improves quality of life in women with obstructive sleep apnea: a randomized controlled trial.
        Am J Respir Crit Care Med. 2016; 194: 1286-1294
        • Marin JM
        • Agusti A
        • Villar I
        • et al.
        Association between treated and untreated obstructive sleep apnea and risk of hypertension.
        JAMA. 2012; 307: 2169-2176
        • Povitz M
        • Hanly PJ
        • Pendharkar SR
        • James MT
        • Tsai WH.
        Treatment of sleep disordered breathing liberates obese hypoxemic patients from oxygen.
        PLoS One. 2015; 10e0140135
        • Rizzi CF
        • Ferraz MB
        • Poyares D
        • Tufik S.
        Quality-adjusted life-years gain and health status in patients with OSAS after one year of continuous positive airway pressure use.
        Sleep. 2014; 37: 1963-1968
        • Eckert DJ
        • Malhotra A.
        Pathophysiology of adult obstructive sleep apnea.
        Proc Am Thorac Soc. 2008; 5: 144-153
        • Finnsson E
        • Ólafsdóttir GH
        • Loftsdóttir DL
        • et al.
        A scalable method of determining physiological endotypes of sleep apnea from a polysomnographic sleep study.
        Sleep. 2020; (https://pubmed.ncbi.nlm.nih.gov/32929467/)
        • Mazzotti DR
        • Keenan BT
        • Lim DC
        • Gottlieb DJ
        • Kim J
        • Pack AI
        Symptom subtypes of obstructive sleep apnea predict incidence of cardiovascular outcomes.
        Am J Respir Crit Care Med. 2019; 200: 493-506
        • Edwards BA
        • Redline S
        • Sands SA
        • Owens RL.
        More than the sum of the respiratory events: personalized medicine approaches for obstructive sleep apnea.
        Am J Respir Crit Care Med. 2019; 200: 691-703
        • Azarbarzin A
        • Sands SA
        • Stone KL
        • et al.
        The hypoxic burden of sleep apnoea predicts cardiovascular disease-related mortality: the Osteoporotic Fractures in Men Study and the Sleep Heart Health Study.
        Eur Heart J. 2019; 40: 1149-1157
        • Younes M
        • Ostrowski M
        • Soiferman M
        • et al.
        Odds ratio product of sleep EEG as a continuous measure of sleep state.
        Sleep. 2015; 38: 641-654
        • Peres BU
        • Hirsch Allen AJ
        • Fox N
        • et al.
        Circulating biomarkers to identify cardiometabolic complications in patients with obstructive sleep apnea: a systematic review.
        Sleep Med Rev. 2019; 44: 48-57
        • Garvey JF
        • Taylor CT
        • McNicholas WT.
        Cardiovascular disease in obstructive sleep apnoea syndrome: the role of intermittent hypoxia and inflammation.
        Eur Respir J. 2009; 33: 1195-1205
        • Lavie L.
        Oxidative stress—a unifying paradigm in obstructive sleep apnea and comorbidities.
        Prog Cardiovasc Dis. 2009; 51: 303-312
        • Ayas NT
        • Foster GE
        • Shah N
        • Floras J
        • Laher I.
        Could adjunctive pharmacology mitigate cardiovascular consequences of obstructive sleep apnea?.
        Am J Respir Crit Care Med. 2019; 200: 551-555
        • Flemons WW
        • Douglas NJ
        • Kuna ST
        • Rodenstein DO
        • Wheatley J.
        Access to diagnosis and treatment of patients with suspected sleep apnea.
        Am J Respir Crit Care Med. 2004; 169: 668-672
        • Pendharkar SR
        • Bischak DP
        • Rogers P.
        Evaluating healthcare systems with insufficient capacity to meet demand.
        Proc Winter Simul Conf. 2012; 77: 1-13
        • Phillips B
        • Gozal D
        • Malhotra A.
        What is the future of sleep medicine in the United States?.
        Am J Respir Crit Care Med. 2015; 192: 915-917
        • Povitz M
        • Bray Jenkyn K
        • Kendzerska T
        • et al.
        Clinical pathways and wait times for OSA care in Ontario, Canada: a population cohort study.
        Can J Respir Crit Care Sleep Med. 2019; 3: 91-99
        • Rotenberg B
        • George C
        • Sullivan K
        • Wong E.
        Wait times for sleep apnea care in Ontario: a multidisciplinary assessment.
        Can Respir J. 2010; 17: 170-174
        • Allen AJMH
        • Amram O
        • Tavakoli H
        • Almeida FR
        • Hamoda M
        • Ayas NT.
        Relationship between travel time from home to a regional sleep apnea clinic in British Columbia, Canada, and the severity of obstructive sleep apnea.
        Ann Am Thorac Soc. 2016; 13: 719-723
        • Antic NA
        • Buchan C
        • Esterman A
        • et al.
        A randomized controlled trial of nurse-led care for symptomatic moderate–severe obstructive sleep apnea.
        Am J Respir Crit Care Med. 2009; 179: 501-508
        • Billings M
        • Pendharkar SR.
        Alternative care pathways for OSA and the impact on PAP adherence: unravelling the puzzle of adherence.
        Sleep Med Clin. 2020; (https://pubmed.ncbi.nlm.nih.gov/33485532/)
        • Pendharkar SR
        • Dechant A
        • Bischak DP
        • Tsai WH
        • Stevenson A-M
        • Hanly PJ.
        An observational study of the effectiveness of alternative care providers in the management of obstructive sleep apnea.
        J Sleep Res. 2016; 25: 234-240
        • Pendharkar SR
        • Tsai WH
        • Penz ED
        • et al.
        A randomized controlled trial of an alternate care provider clinic for severe sleep-disordered breathing.
        Ann Am Thorac Soc. 2019; 16: 1558-1566
        • Donovan LM
        • Shah A
        • Chai-Coetzer CL
        • Barbé F
        • Ayas NT
        • Kapur VK.
        Redesigning care for obstructive sleep apnea.
        Chest. 2020; 157: 966-976
        • Pendharkar SR
        • Blades K
        • Kelly JE
        • et al.
        Perspectives on primary care management of obstructive sleep apnea: a qualitative study of patients and health care providers.
        J Clin Sleep Med. 2021; 17: 89-98
        • Pepin J-L
        • Baillieul S
        • Tamisier R.
        Reshaping sleep apnea care: time for value-based strategies.
        Ann Am Thorac Soc. 2019; 16: 1501-1503
        • Camacho M
        • Ryhn MJ
        • Fukui CS
        • Bager JM.
        Multidisciplinary sleep clinic: a patient-centered approach.
        Cranio. 2017; 35: 129
        • Heatley EM
        • Harris M
        • Battersby M
        • McEvoy RD
        • Chai-Coetzer CL
        • Antic NA.
        Obstructive sleep apnoea in adults: a common chronic condition in need of a comprehensive chronic condition management approach.
        Sleep Med Rev. 2013; 17: 349-355
        • Shelgikar AV
        • Durmer JS
        • Joynt KE
        • Olson EJ
        • Riney H
        • Valentine P.
        Multidisciplinary sleep centers: strategies to improve care of sleep disorders patients.
        J Clin Sleep Med. 2014; 10: 693-697
        • Bruyneel M.
        Telemedicine in the diagnosis and treatment of sleep apnoea.
        Eur Respir Rev. 2019; 28180093
        • Pendharkar SR
        • Povitz M
        • Bansback N
        • George CFP
        • Morrison D
        • Ayas NT.
        Testing and treatment for obstructive sleep apnea in Canada: funding models must change.
        Can Med Assoc J. 2017; 189: E1524-E1528
        • Esmail L
        • Moore E
        • Rein A.
        Evaluating patient and stakeholder engagement in research: moving from theory to practice.
        J Comp Eff Res. 2015; 4: 133-145
        • Sharpe H
        • Gallant D
        • Guirguis L
        • et al.
        Respiratory research prioritization for Alberta.
        Am J Respir Crit Care Med. 2019; 199: A6243
        • Amirav I
        • Vandall-Walker V
        • Rasiah J
        • Saunders L.
        Patient and researcher engagement in health research: a parent's perspective.
        Pediatrics. 2017; 140
        • Dudley KA
        • Patel SR.
        Disparities and genetic risk factors in obstructive sleep apnea.
        Sleep Med. 2016; 18: 96-102
        • Marchildon GP
        • Katapally TR
        • Beck CA
        • et al.
        Exploring policy driven systemic inequities leading to differential access to care among indigenous populations with obstructive sleep apnea in Canada.
        Int J Equity Health. 2015; 14: 148
        • Pamidi S
        • Knutson KL
        • Ghods F
        • Mokhlesi B.
        The impact of sleep consultation prior to a diagnostic polysomnogram on continuous positive airway pressure adherence.
        Chest. 2012; 141: 51-57
        • Pandey A
        • Mereddy S
        • Combs D
        • et al.
        Socioeconomic inequities in adherence to positive airway pressure therapy in population-level analysis.
        J Clin Med. 2020; 9: 442
        • Walia HK
        • Thompson NR
        • Katzan I
        • Foldvary-Schaefer N
        • Moul DE
        • Mehra R
        Impact of sleep-disordered breathing treatment on quality of life measures in a large clinic-based cohort.
        J Clin Sleep Med. 2017; 13: 1255-1263