Skip to main content


Log in

The economic burden of (obstructive) sleep apnea. Costs and implications for Germany based on the results of an international systematic review

  • Review Article
  • Published:
Journal of Public Health Aims and scope Submit manuscript



(Obstructive) sleep apnea ((O)SA) is a prevalent sleep disorder in many countries, including Germany. The aim of this review is to evaluate the economic impact of OSA on the adult population by analysing cost determinants. Research questions are what are the direct and indirect costs associated with (O)SA before and after diagnosis and in different sectors, and can costs be reduced through diagnosis and treatment? The findings will inform potential implications for the German healthcare system.

Subject and methods

In July 2023, we conducted a systematic review using PubMed, EMBASE and Web of Science to identify relevant publications. We manually searched reference lists for additional sources. Our inclusion criteria were: (1) adult population (> 18 years) with SA, OSA or SBD; (2) observational study design with a cost of illness or economic modelling element; and (3) primary or secondary data sources used to determine the monetary values of cost items. Exclusion criteria for the study were as follows: (1) target population other than the one specified, (2) focus solely on cost-effectiveness, cost–benefit, cost-consequence or cost-minimization analyses without reporting original costs, (3) publication in a language other than British or American English, (4) availability only as abstracts or (5) classification as grey literature or non-academic studies. Additionally, publications published before 2010 were excluded.

The Consensus Health Economic Criteria (CHEC) list was used for quality assessment and the Joanna Briggs Institute Critical Appraisal Checklist for economic evaluations was used to perform a risk of bias assessment.

A predefined template in Microsoft Excel was used to record the details of each study, including article characteristics, study characteristics, participant information and outcome measures. The costs from the publications were adjusted for inflation in Germany until 2022, utilising the Organisation for Economic Co-operation and Development (OECD) Purchasing Power Parities (PPP) for gross domestic product (GDP) in the respective reference years.


In total, seven publications from five countries, including one from Germany, that were published between 2010 and 2021 were included. Each utilizing different research methodologies. The study population ranged from 95 to 30.278 diagnosed patients. The reporting quality of the included publications is largely satisfactory as well as the risk of bias assessment. No study was excluded based on this result.

In most studies, direct costs (€1714 to €4777) are more significant than indirect costs (€2832 to €3069), with the inpatient sector incurring most of the costs. In Germany, indirect costs of €5854 were reported for baseline examination in the sleep laboratory in one quarter. Moreover, e.g. in Denmark, direct costs in the 12 years leading up to their diagnosis are €2525 (€1404 for healthy controls), with indirect costs amounting to €1652. Furthermore, the spouses of patients incur higher costs compared to the spouses of healthy controls. The cost in the inpatient sector varies from €531 in Taiwan to €2314 in Denmark per case, while in the outpatient sector it ranges from €337 in Denmark to €1176 in Taiwan. Also, e.g. in the USA after treatment, the average cost of a healthcare plan decreases by €5894 over two years. Additionally, there is a total saving of €535 in short-term disability costs over two years.


Research indicates that (O)SA primarily incurs direct healthcare costs. If left untreated, these costs can increase even before diagnosis. Additionally, indirect costs are linked to absenteeism and presenteeism, particularly in cases where comorbidities such as depression are present. The literature suggests that inadequate diagnosis of OSA can result in significant clinical and financial costs due to limitations in screening procedures. In the USA, Denmark and Germany, inpatient costs are typically higher than outpatient costs. However, it is important to note that the high costs in Germany are primarily due to specialized treatment provided by medical specialists and in addition due to CPAP devices. The findings highlight the significance of timely detection and adherent treatment of (O)SA in reducing healthcare expenses, also in Germany. The impact of mandibular advancement devices as a second-line therapy on treatment costs in Germany is yet to be determined.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1

Similar content being viewed by others

Data availability

Relevant material is within this manuscript.

Code availability

ot applicable.


  • American Academy of Sleep Medicine (2008) Obstructive sleep apnea. American Academy of Sleep Medicine, Darien,

  • Alnemri A, Sussman S, Estephan L, Hamilton C, Stewart M, Zhan T, Thaler A, Ananth A, Boon M, Huntley C, Hunt P (2022) Cost of total intravenous anesthesia versus inhalation anesthesia in obstructive sleep apnea surgery. Laryngoscope 132:1487–1494

    Article  PubMed  Google Scholar 

  • Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morrell MJ, Nunez CM, Patel SR, Penzel T, Pépin JL, Peppard PE, Sinha S, Tufik S, Valentine K, Malhotra A (2019) Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lanset Respir Med 7(687):698

    Google Scholar 

  • Borsoi L, Armeni P, Donin G, Costa F, Ferini-Strambi L (2022) The invisible costs of obstructive sleep apnea (OSA): systematic review and cost-of-illness analysis. PLoS ONE 17:e0268677

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Bramer WM, Rethlefsen ML, Kleijnen J, Franco OH (2017) Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Syst Rev 6:245

    Article  PubMed  PubMed Central  Google Scholar 

  • De Vries GE, Hoekema A, Vermeulen KM, Claessen J, Jacobs W, van der Maten J, van der Hoeven JH, Stegenga B, Kerstjens HAM, Wijkstra PJ (2019) Clinical- and cost-effectiveness of a mandibular advancement device versus continuous positive airway pressure in moderate obstructive sleep apnea. J Clin Sleep Med 15:1477–1485

    Article  PubMed  PubMed Central  Google Scholar 

  • Diaz K, Faverio P, Hospenthal A, Restrepo MI, Amuan ME, Pugh MJ (2014) Obstructive sleep apnea is associated with higher healthcare utilization in elderly patients. Ann Thorac Med 9:92–98

    Article  PubMed  PubMed Central  Google Scholar 

  • Evers S, Goossens M, de vet H, van Tulder M & Ament A, (2005) Criteria list for assessment of methodological quality of economic evaluations: consensus on health economic criteria. Int J Technol Assess Health Care 21:240–245

    Article  PubMed  Google Scholar 

  • Fietze I, Laharnar N, Obst A, Ewert R, Felix SB, Garcia C, Gläser S, Glos M, Schmidt CO, Stubbe B, Völzke H, Zimmermann S, Penzel T (2019) Prevalence and association analysis of obstructive sleep apnea with gender and age differences - results of SHIP-trend. J Sleep Res 28:e12770

    Article  PubMed  Google Scholar 

  • Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J (2004) Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 169:668–672

    Article  PubMed  Google Scholar 

  • Franklin KA, Lindberg E (2015) Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis 7:1311–1322

    PubMed  PubMed Central  Google Scholar 

  • Gharsalli H, Harizi C, Zaouche R, Sahnoun I, Saffar F, Maalej S, Douik EL, Gharbi L (2022) Prevalence of depression and anxiety in obstructive sleep apnea. Tunis Med 100:525–533

    PubMed  PubMed Central  Google Scholar 

  • Gomersall JS, Jadotte YT, Xue Y, Lockwood S, Riddle D, Preda A (2015) Conducting systematic reviews of economic evaluations. Int J Evid Based Healthc 13:170–178

    Article  PubMed  Google Scholar 

  • Guo J, Xiao Y (2023) New metrics from polysomnography: precision medicine for OSA interventions. Nat Sci Sleep 15:69–77

    Article  PubMed  PubMed Central  Google Scholar 

  • Hillman DR, Murphy AS, Pezzullo L (2006) The economic cost of sleep disorders. Sleep 29:299–305

    Article  PubMed  Google Scholar 

  • Hoffman B, Wingenbach DD, Kagey AN, Schaneman JL, Kasper D (2010) The long-term health plan and disability cost benefit of obstructive sleep apnea treatment in a commercial motor vehicle driver population. J Occup Environ Med 52:473–477

    Article  PubMed  Google Scholar 

  • Jennum P, Kjellberg J (2011) Health, social and economical consequences of sleep-disordered breathing: a controlled national study. Thorax 66:560–566

    Article  PubMed  Google Scholar 

  • Jennum P, Ibsen R, Kjellberg J (2014) Social consequences of sleep disordered breathing on patients and their partners: a controlled national study. Eur Respir J 43:134–144

    Article  PubMed  Google Scholar 

  • Jones TA, Roddis J, Stores R (2024) The use of telemedicine in the management of continuous positive airway pressure for the treatment of obstructive sleep apnoea: a randomised controlled trial. Telemed J E Health 30:157–165

    PubMed  Google Scholar 

  • Kao LT, Lee HC, Lin HC, Tsai MC, Chung SD (2015) Healthcare service utilization by patients with obstructive sleep apnea: a population-based study. PLoS ONE 10:e0137459

    Article  PubMed  PubMed Central  Google Scholar 

  • Knauert M, Naik S, Gillespie MB, Kryger M (2015) Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg 1:17–27

    Article  PubMed  PubMed Central  Google Scholar 

  • Koehler J, Hildebrandt O, Cassel W, Conradt R, Mayr P, Alter P, Viniol C (2022) Therapieadhärenz drei Monate nach Einleitung einer nichtinvasiven CPAP-Therapie bei 1078 Patienten mit obstruktiver Schlafapnoe (OSA). Laryngo-Rhino-Otologie 102

  • Koh HE, van Vliet S, Cao C, Patterson BW, Reeds DN, Laforest R, Gropler RJ, Ju YS, Mittendorfer B (2022) Effect of obstructive sleep apnea on glucose metabolism. Eur J Endocrinol 186:457–467

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Kosky C, Madeira N, Boulton K, Hunter MT, Ling I, Reynor A, Sturdy G, Walsh J, Dhaliwal S, Singh B, Eastwood PR, McArdle N (2022) Telemedicine compared to standard face-to-face care for continuous positive airway pressure treatment: real-world Australian experience. Sleep 45(10):zsac157.

  • Marchi NA, Solelhac G, Berger M, Haba-Rubio J, Gosselin N, Vollenweider P, Marques-Vidal P, Popp J, von Gunten A, Preisig M, Draganski B, Heinzer R (2023) Obstructive sleep apnoea and 5-year cognitive decline in the elderly. Eur Respir J

  • Masa JF, Corral J, Sanchez de Cos J, Duran-Cantolla J, Cabello M, Hernández-Blasco L, Monasterio C, Alonso A, Chiner E, Aizpuru F, Vázquez-Polo FJ, Zamorano J, Montserrat JM, Garcia-Ledesma E, Pereira R, Cancelo L, Martinez A, Sacristan L, Salord N, Carrera M, Sancho-Chust JN, Negrín MA, Embid C (2013) Effectiveness of three sleep apnea management alternatives. Sleep 36:1799–1807

    Article  PubMed  PubMed Central  Google Scholar 

  • Matthew JP, David M, Patrick MB, Isabelle B, Tammy CH, Cynthia DM, Larissa S, Jennifer MT, Elie AA, Sue EB, Roger C, Julie G, Jeremy MG, Asbjørn H, Manoj ML, Tianjing L, Elizabeth WL, Evan M-W, Steve M, Luke AM, Lesley AS, James T, Andrea CT, Vivian AW, Penny W, Joanne EM (2021) Prisma 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 372:n160

    Google Scholar 

  • Mayer G, Apelt S, Hessmann P, Reese JP, Dodel R, Heitmann J (2015) Sleep apnea patient care in Hessen. Somnologie 19:145–153

    Article  Google Scholar 

  • Mayer G, Arzt M, Braumann B, Ficker JH, Fietze I, Frohnhofen H, Galetke W, Maurer JT, Orth M, Penzel T, Pistner H, Randerath W, Rösslein M, Sitter H, Stuck BA (2017) German S3 guideline nonrestorative sleep/sleep disorders, chapter “sleep-related breathing disorders in adults”, short version: German sleep society (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM). Somnologie 21:290–301

    Article  PubMed  PubMed Central  Google Scholar 

  • Morsy NE, Farrag NS, Zaki NFW, Badawy AY, Abdelhafez SA, EL-Gilany AH, EL Shafey MM, Pandi-Perumal SR, Spence DW, Bahammam AS (2019) Obstructive sleep apnea: personal, societal, public health, and legal implications. Rev Environ Health 34:153–169

    Article  PubMed  Google Scholar 

  • Mulgrew AT, Ryan CF, Fleetham JA, Cheema R, Fox N, Koehoorn M, Fitzgerald JM, Marra C, Ayas NT (2007) The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med 9:42–53

    Article  CAS  PubMed  Google Scholar 

  • OECD (2022) Purchasing power parities (PPP) (indicator) [Online]. Available: [Accessed 2023]

  • Ohayon MM (2002) Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 6:97–111

    Article  PubMed  Google Scholar 

  • Omachi TA, Claman DM, Blanc PD, Eisner MD (2009) Obstructive sleep apnea: a risk factor for work disability. Sleep 32:791–798

    Article  PubMed  PubMed Central  Google Scholar 

  • Pachito DV, Bagattini ÂM, Drager LF, Eckeli AL, Rocha A (2022) Economic evaluation of CPAP therapy for obstructive sleep apnea: a scoping review and evidence map. Sleep Breath 26:17–30

    Article  PubMed  Google Scholar 

  • Parish JM, Lyng PJ (2003) Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure. Chest 124:942–947

    Article  PubMed  Google Scholar 

  • Pelletier-Fleury N, Meslier N, Gagnadoux F, Person C, Rakotonanahary D, Ouksel H, Fleury B, Racineux JL (2004) Economic arguments for the immediate management of moderate-to-severe obstructive sleep apnoea syndrome. Eur Respir J 23:53–60

    Article  CAS  PubMed  Google Scholar 

  • Ronald J, Delaive K, Roos L, Manfreda J, Bahammam A, Kryger MH (1999) Health care utilization in the 10 years prior to diagnosis in obstructive sleep apnea syndrome patients. Sleep 22:225–229

    Article  CAS  PubMed  Google Scholar 

  • Schöbel C, Zentgraf C, Strassburg S, Grosse Sundrup M, Konsortium SW (2022) Sleep Well. Zeitschrift Für Pneumologie 19:191–200

    Article  Google Scholar 

  • Scholz S, Biermann-Stallwitz J, Brettschneider C, Damm O, Freytag A, Greiner W, Icks A, König H-H, Krauth C, Kuhlmann A, Kunigkeit C, Montalbo J, Mostardt S, Mühlbacher A, Neumann A, Neusser S, Plagemann T, Schwalm A, Ultsch B, Wasem J, Witte J (2020) Standardisierte Kostenberechnungen im deutschen Gesundheitswesen: Bericht der Arbeitsgruppe „Standardkosten“ des Ausschusses „ökonomische Evaluation“ der dggö. Gesundheitsökonomie & Qualitätsmanagement 25:52–59

    Article  Google Scholar 

  • Schweitzer PK, Taranto-Montemurro L, Ojile JM, Thein SG, Drake CL, Rosenberg R, Corser B, Abaluck B, Sangal RB, Maynard J (2023) The combination of aroxybutynin and atomoxetine in the treatment of obstructive sleep apnea (MARIPOSA): a randomized controlled trial. Am J Respir Crit Care Med 208:1316–1327

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Sherman B (2013) Obstructive sleep apnea and health benefits purchasing: an employer perspective. J Clin Sleep Med 9:187–189

    Article  PubMed  PubMed Central  Google Scholar 

  • Sia C-H, Hong Y, Tan LWL, van Dam RM, Lee C-H, Tan A (2017) Awareness and knowledge of obstructive sleep apnea among the general population. Sleep Med 36:10–17

    Article  PubMed  Google Scholar 

  • Siccoli MM, Pepperell JC, Kohler M, Craig SE, Davies RJ, Stradling JR (2008) Effects of continuous positive airway pressure on quality of life in patients with moderate to severe obstructive sleep apnea: data from a randomized controlled trial. Sleep 31:1551–1558

    Article  PubMed  PubMed Central  Google Scholar 

  • Sjösten N, Vahtera J, Salo P, Oksanen T, Saaresranta T, Virtanen M, Pentti J, Kivimäki M (2009) Increased risk of lost workdays prior to the diagnosis of sleep apnea. Chest 136:130–136

    Article  PubMed  Google Scholar 

  • Sterling KL, Alpert N, Cistulli PA, Pépin JL, More S, Cole KV, Malhotra A (2023) Healthcare resource utilisation and costs in patients with treated obstructive sleep apnea. J Sleep Res e14099

  • Streatfeild J, Smith J, Mansfield D, Pezzullo L, Hillman D (2021) The social and economic cost of sleep disorders. Sleep 44

  • Veasey SC, Rosen IM (2019) Obstructive sleep apnea in adults. N Engl J Med 380:1442–1449

    Article  PubMed  Google Scholar 

  • Vennelle M, Engleman HM, Douglas NJ (2010) Sleepiness and sleep-related accidents in commercial bus drivers. Sleep Breathing 14:39–42

    Article  PubMed  Google Scholar 

  • Vo TN, Kats AM, Langsetmo L, Taylor BC, Schousboe JT, Redline S, Kunisaki KM, Stone KL, Ensrud KE (2020) Association of sleep-disordered breathing with total healthcare costs and utilization in older men: the outcomes of sleep disorders in older men (MrOS sleep) study. Sleep 4

  • Wickwire EM (2021) Value-based sleep and breathing: health economic aspects of obstructive sleep apnea. Fac Rev 10:40

    Article  PubMed  PubMed Central  Google Scholar 

  • Wickwire EM, Albrecht JS, Towe MM, Abariga SA, Diaz-Abad M, Shipper AG, Cooper LM, Assefa SZ, Tom SE, Scharf SM (2019) The impact of treatments for OSA on monetized health economic outcomes: a systematic review. Chest 155:947–961

    Article  PubMed  Google Scholar 

  • Wickwire EM, Tom SE, Vadlamani A, Diaz-Abad M, Cooper LM, Johnson AM, Scharf SM, Albrecht JS (2020) Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients. J Clin Sleep Med 16:81–89

    Article  PubMed  PubMed Central  Google Scholar 

Download references


The author would like to thank Anna Bludau for her assistance in screening the literature and reviewing the manuscript.


No funding was received for conducting this study.

Author information

Authors and Affiliations



Not applicable.

Corresponding author

Correspondence to Pauline Birte zur Nieden.

Ethics declarations

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflict of interest

The author declares no conflict of interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 27 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nieden, P.B.z. The economic burden of (obstructive) sleep apnea. Costs and implications for Germany based on the results of an international systematic review. J Public Health (Berl.) (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: