Sleep-Disordered Breathing in the Active-Duty Military Population and Its Civilian Care Cost
Results
A total of 197,183 service members were diagnosed with SDB from FY 2009 to FY 2013. Both the annual incidence and prevalence of SDB for the active-duty military population showed upward trends for each of the years evaluated (Figure 1). 
Notably, 72% of service members seen for SDB ranged in age from 25 to 44 years (Table). 
Discussion
This study shows that the prevalence and incidence of SDB in the active-duty population are less than those reported for the civilian populace as a whole but are still greater than expected for an otherwise healthy and young population. Furthermore, the burden of disease and the cost to diagnose and treat have steadily increased for each of the past 5 fiscal years that were assessed.
The data show an upward trend in the incidence and prevalence of SDB in the military from FY 2009 to FY 2013 for reasons that are not clear but likely with many confounding contributions. As the spectrum of SDB has become better defined and the detrimental sequelae are better understood, it is likely that both service members and health care providers are more aware of the symptoms and more importantly, the potential for interventions that improve quality of life. It is also important to note that the U.S. military is a very transient organization with a nearly constant turnover between new enlistees/officers and those leaving the service or retiring after 20 years of service. Thus, despite an annual incidence of nearly 3% throughout the years evaluated, the annual increase in prevalence is not necessarily commensurate.
The FY 2013 prevalence (4.2%) and civilian care costs ($98,259,519) present traditional indications of the disease burden. Both metrics represent a sizable and increasing disease burden for the military. It is also important to note that these costs reflect only the short-term expenses for initial diagnosis and therapy. These costs in no way reflect the care for the long-term medical sequelae that have been recently linked to uncontrolled SDB/OSA, such as heart and vascular diseases, hypertension, and increased stroke risk. Additional costs will continue to grow.
Perhaps the most validated predictive factor for diagnosis of SDB or OSA is body habitus as measured by body mass index (BMI). In particular, nearly 60% to 90% of patients with OSA are obese.2 Weight gain seems to increase the OSA severity, whereas losing weight decreases it.14-16 Although the U.S. military employs height and weight standards that preclude those with persistently overweight or obese BMIs from continued service, these standards often are not rigid, and there are overweight or even obese active-duty members. Interestingly, despite a population that essentially controls for the most predictive risk factor, the prevalence of SDB is still approximately 1 in 20 (4.9%) in FY 2013.
Given the significant burden of disease represented by the incidence, prevalence, and cost data determined in this study and the growing recognition of long-term complications from poorly controlled SDB, it has become evident that more efficacious interventions are needed. Modern treatments for SDB can be classified as surgical or nonsurgical but with no single modality fitting the need for all patients secondary to poor adherence and/or limited efficacy.17-20 However, to mitigate the impact on military readiness and taxpayer-funded health care costs, it may be appropriate to begin exploring therapeutic options beyond the current standard of care. For example, an invasive and costly onetime surgical intervention using an implantable device to stimulate the hypoglossal nerve to open a person’s airway during inspiration is being investigated in a younger, nonobese cohort of patients.21 Further research is warranted into this specific model of therapeutic intervention and others for service members.
