Psychometric Performance and Responsiveness of the Functional Outcomes of Sleep Questionnaire and Sleep Apnea Quality of Life Index in a Randomized Trial: The HomePAP Study
Open accessAbstract
STUDY OBJECTIVES: Measures of health-related quality of life (HRQL) specific for sleep disorders have had limited psychometric evaluation in the context of randomized controlled trials (RCTs). We investigated the psychometric properties of the Functional Outcomes of Sleep Questionnaire (FOSQ) and Sleep Apnea Quality of Life Instrument (SAQLI). We evaluated the FOSQ and SAQLI construct and criterion validity, determined a minimally important difference, and assessed for associations of responsiveness to baseline subject characteristics and continuous positive airway pressure (CPAP) adherence in a RCT population. DESIGN: Secondary analysis of data collected in a multisite RCT of home versus laboratory-based diagnosis and treatment of obstructive sleep apnea (HomePAP trial). PARTICIPANTS: Individuals enrolled in the HomePAP trial (n = 335). INTERVENTIONS: N/A. MEASUREMENT AND RESULTS: The FOSQ and SAQLI subscores demonstrated high reliability and criterion validity, correlating with Medical Outcomes Study 36-Item Short Form Survey domains. Correlations were weaker with the Epworth Sleepiness Scale (ESS). Both the FOSQ and SAQLI scores improved after 3 mo with CPAP therapy. Averaging 4 h or more of CPAP use was associated with an increase in the FOSQ beyond the minimally important difference. Baseline depressive symptoms and sleepiness predicted FOSQ and SAQLI responsiveness; demographic, objective obstructive sleep apnea (OSA) severity and sleep habits were not predictive in linear regression. CONCLUSIONS: The FOSQ and SAQLI are responsive to CPAP intervention, with the FOSQ being more sensitive to differences in CPAP adherence than the SAQLI. These instruments provide unique information about health outcomes beyond that provided by changes in physiological measures of OSA severity (apnea-hypopnea index). CLINICAL TRIAL INFORMATION: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) URL: http://clinicaltrials.gov/show/NCT00642486. NIH clinical trials registry number: NCT00642486.
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Validated functional status and quality-of-life measures most used in clinical and research settings include the ESS, SAQLI, FOSQ, and PSQI.
“Validated functional status and QOL measures most used in the clinical and research settings include the ESS,436 Sleep Apnea Quality of Life Index (SAQLI),437–441 Functional Outcomes of Sleep Questionnaire (FOSQ),437,441,442 and the Pittsburgh Sleep Quality Index (PSQI).443”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The Discussion (page unavailable) supports the validity of the FOSQ and SAQLI as patient-reported measures for obstructive sleep apnea, and the paper identifies both instruments. An introductory passage says the FOSQ is widely used in sleep research but the SAQLI is less widely used; it therefore does not establish that both are among the measures most used in clinical and research settings. This citation is attached to the SAQLI and FOSQ, not the ESS or PSQI. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe SAQLI showed moderate correlations (0.3 ≤ r < 0.7) with related domains of general health-status questionnaires such as SF-36 and the Global QOL Scale.
“The SAQLI showed moderate correlations (0.3 ≤ r < 0.7) with related domains of general health-status questionnaires such as the 36-item Short Form (SF-36) and the Global QOL Scale.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The Criterion Validity section (page unavailable) reports moderate correlations between SAQLI subscales and the SF-36 social functioning and vitality domains (r = 0.40–0.58). Table 4 also reports some SF-36 correlations below 0.3, and our copy does not report a correlation with the Global QOL Scale (searched: “Global QOL Scale”). (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe SAQLI includes 35 questions across four domains: daily functioning, social interactions, emotional functioning, and symptoms, and can be combined with a fifth domain assessing negative treatment impacts.
“The SAQLI includes 35 questions across four domains: daily functioning, social interactions, emotional functioning, and symptoms and can be combined with a fifth domain that assesses negative impacts of treatment.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The Instruments section identifies the four claimed domains and says an additional subscale covers treatment-related symptoms for people receiving OSA treatment. But Internal Reliability reports 56 SAQLI items across the four domains, not 35; the first three domains alone account for 35 items, while symptoms accounts for 21. Page numbers are unavailable in our copy. (LLM, conf=0.90)
Experimental — accuracy not yet measuredThe FOSQ showed moderate correlations with related domains of the SF-36 and the Sickness Impact Profile.
“The FOSQ showed moderate correlations with related domains of the SF-36 and the Sickness Impact Profile.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The Criterion Validity section reports moderate correlations between FOSQ activity level and SF-36 domains, except bodily pain; the Discussion also describes moderate correlations with SF-36 social and physical role domains. Our copy does not report a correlation between the FOSQ and the Sickness Impact Profile (searched: “Sickness Impact Profile” and “SIP”). Page numbers were not available in the indexed passages. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPSG measures (AHI, minimum O2 saturation) were either poorly or not significantly correlated with any of the questionnaires.
“PSG measures (AHI, minimum O2 saturation) were either poorly or not significantly correlated with any of the questionnaires.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The Relation with AHI section reports no correlation between AHI and FOSQ or SAQLI scores, except a weak correlation with SAQLI emotional functioning (r = 0.134). Our copy does not report correlations between minimum O2 saturation and the questionnaires, or establish the claim for every questionnaire used in the study. (LLM, conf=0.86)
Experimental — accuracy not yet measured
In one study, the FOSQ showed a larger improvement in scores in patients who used >4h of CPAP nightly, while there was no difference in scores for the SAQLI.
“In one study, the FOSQ showed a larger improvement in scores in patients who used >4h of CPAP nightly while there was no difference in scores for the SAQLI.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
Experimental — accuracy not yet measuredThe SAQLI and FOSQ both demonstrated the ability to detect change over time after treatment initiation.
“The SAQLI and FOSQ both demonstrated the ability to detect change over time after treatment initiation.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The FOSQ has 30 questions in five domains: activity, vigilance, intimacy and sex, general productivity, and social outcome.
“The FOSQ has 30 questions in five domains: activity, vigilance, intimacy and sex, general productivity, and social outcome.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
Both the SAQLI and FOSQ showed large effect sizes (d ≥ 0.8) after CPAP treatment in patients with OSA.
“Both showed large effect sizes (d ≥ 0.8) after CPAP treatment in patients with OSA.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The SAQLI is a disease-specific health-related quality-of-life questionnaire that evaluates functioning across daily aspects of life affected by poor sleep.
“The SAQLI is a health-related QOL questionnaire that is diseasespecific and includes questions focused on evaluating functioning across daily aspects of life affected by poor sleep.”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
The FOSQ and SAQLI demonstrated excellent internal consistency (α ≥ 0.9).
“while the FOSQ and SAQLI demonstrated excellent internal consistency (α ≥ 0.9).437,438,440,442”
From International Consensus Statement on Obstructive Sleep Apnea (2023) · cites this paper as [437]
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- Authors
- Billings, M. E., Rosen, C. L., Auckley, D., Benca, R., Foldvary-Schaefer, N., Iber, C., Zee, P. C., Redline, S., & Kapur, V. K.
- Affiliations
- University of Washington (US)
- University Hospitals Cleveland Medical Center (US)
- MetroHealth Medical Center (US)
- University of Wisconsin–Madison (US)
- Case Western Reserve University, School of Medicine, Cleveland, OH
- University of Minnesota (US)
- Northwestern University (US)
- Beth Israel Deaconess Medical Center (US)
- Corresponding author
- Billings, Martha E.
- ORCID
- Venue
- Sleep
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-12-01
- Volume
- 37
- Issue
- 12
- Pages
- 2017-2024
- ISSN
- 0161-8105 (ISSN-L)
- 1550-9109
- PMC
- PMC4548522
- OpenAlex
- W2115289881
- Cited by
- 67
- References
- 36
- Citations by year
- 2026: 1 · 2025: 5 · 2024: 7 · 2023: 8 · 2022: 8 · 2021: 5 · 2020: 8 · 2019: 7 · 2018: 8 · 2017: 4 · 2016: 5 · 2015: 1
- FWCI
- 2.22
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- SLEEP (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- American Sleep Medicine Foundation
- ResMed Foundation
- Sanofi
- Teva Pharmaceutical Industries
- Purdue University
- Jazz Pharmaceuticals
- ResMed
- Topics
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Keywords
- Functional Outcomes of Sleep Questionnaire, obstructive sleep apnea, health-related quality of life, psychometric properties, construct validity, criterion validity, minimally important difference, responsiveness, CPAP adherence, continuous positive airway pressure, home sleep monitoring, depressive symptoms, daytime sleepiness
- MeSH terms
- Female, Humans, Male, Middle Aged, Patient Compliance, Psychometrics, Quality of Life, Surveys and Questionnaires, Sleep, Reproducibility of Results, Treatment Outcome, Sleep Apnea, Obstructive, Continuous Positive Airway Pressure
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