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Or had been diagnosed, with narcolepsy, sleep apnea, or other non-insomnia related sleep difficulties in the past 12 months; (2) experienced symptoms or self-reported a diagnosis of another serious medical condition (any type of cancer, chronic liver disease, cirrhosis, epilepsy, multiple sclerosis, muscular dystrophy, or Parkinson’s disease); or (3) were pregnant at the time of survey completion. 2.3. Insomnia Cohort IdentificationParticipants were identified based on responses to two standard assessment items within the NHWS: ‘Which of the following conditions have you experienced in the last 12 months?’ and ‘Which of your conditions have been diagnosed by a physician?’. Participants who reported experiencing insomnia in the previous 12 months, with or without receipt of a physician-assigned diagnosis of insomnia, completed the Insomnia Severity Index (ISI; see below). Insomnia severity was then determined based on responses to the validated ISI. 2.4. Insomnia SeverityInsomnia severity was assessed using the ISI, a well-established measure of insomnia symptoms that occur during both nighttime and daytime, albeit in broad categories [16]. The ISI is a 7-item self-report questionnaire assessing the nature, severity, and impact of insomnia [16,17,18,19]. Seven items are scored from 0 (indicating little/no insomnia) to 4 (indicating problems with insomnia), and total scores range from 0 to 28. Based on this summary score, insomnia severity is categorized as follows: severe insomnia (22–28), moderate insomnia (15–21), ‘subthreshold’ (mild) insomnia (8–14), and ‘no clinically significant’ insomnia (0–7) [16]. 2.5. Outcomes 2.5.1. Health-Related Quality of LifeTo provide insight into the burden of insomnia from the patient perspective, HRQoL was assessed using the Medical Outcomes Study 36-Item Version 2 Short Form Survey Instrument (SF-36v2) (RAND, Santa Monica, CA, USA) [20]. SF-36v2 is a measure of general HRQoL that comprises 36 items that map onto 8 health domains: physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. These individual domains are summarized in two component summary scores, the physical component summary (PCS) and mental component summary (MCS). PCS and MCS scores range from 0 to 100, each based on a population norm with a midpoint of 50, with higher scores indicating better HRQoL. Differences greater than 3.0 on the norm-based scoring algorithm were considered to be minimal clinically important differences (MCID) for scores on both scales [21]. 2.5.2. Health Utility StatusHealth utilities were assessed using two established measures: the Short Form-6 Dimensions (SF-6D) and the EuroQoL-5 Dimensions (EQ-5D-5L). SF-6D health utility index scores were derived from responses on the SF-36v2 [22]. EuroQol-5D (EQ-5D) health utility index scores were derived from the EQ-5D-5L, a self-report measure of health for clinical and economic appraisal that is comprised of five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression [20]. Both SF-6D and EQ-5D health utility index scores range from 0.00 (a health state equivalent to death) to 1.00 (a health state equivalent to perfect health), with higher scores indicating better health status. Consistent with previous studies, differences greater than 0.04 and 0.07 were considered to be MCID for SF-6D and EQ-5D, respectively [22,23].

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