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Obstructive sleep apnea (OSA) affects up to 26% of US adults, is often undiagnosed, and increases perioperative morbidity. We hypothesized that patients screened on the day of surgery as moderate/high risk for OSA (S-OSA) present similar perioperative respiratory complications, hospital use, and mortality than patients with previously diagnosed OSA (D-OSA). Second, we hypothesized that both OSA groups have more respiratory complications than No-OSA patients.The electronic medical database from 1 academic and 2 community hospitals was retrospectively queried to identify adults undergoing nonemergent inpatient surgery (January 1, 2012, to December 31, 2014). Based on the day-of-surgery preoperative assessment and STOP-BANG (Snoring, Tiredness, Observed apnea during sleep, high blood Pressure, Body mass index >35, Age >50 years, thick Neck, Gender male) score, they were classified as D-OSA, S-OSA, or No-OSA. Perioperative respiratory events and interventions, hospital use, and mortality were measured. The primary outcome composite (adverse respiratory events [AREs]) included perioperative hypoxemic events and difficult airway management. Hypoxemic event was defined as peripheral saturation of oxygen (SpO2) <90% by continuous pulse oximetry for ≥3 minutes, or if validated and/or manually entered into the medical chart. Hypoxemia was classified as mild (lowest SpO2 86%–89%) or moderate/severe (lowest SpO2 ≤85%). Secondary outcomes included postoperative respiratory interventions, intensive care unit admission, hospital length of stay, and 30-day and 1-year all-cause mortality. Outcomes were compared using linear and logistic regression analyses.A total of 28,912 patients were assessed: 3432 (11.9%) D-OSA; 1546 (5.3%) S-OSA; and 23,934 (82.8%) No-OSA patients. At least 1 ARE was present in 68.0% of S-OSA; 71.0% of D-OSA; and 52.1% of No-OSA patients (unadjusted P < .001), primarily ≥1 moderate/severe hypoxemic event after discharge from the postanesthesia care unit (PACU; 39.9% in S-OSA; 39.5% in D-OSA; and 27.1% in No-OSA patients). S-OSA patients compared to D-OSA patients presented lower rates of moderate/severe hypoxemia in the PACU but similar intraoperatively and postoperatively, higher difficult mask ventilation rates, and similar difficult intubation reports. After adjusting for demographic, health, and surgical differences and hospital type, the likelihood of ≥1 ARE was not different in S-OSA and D-OSA patients (adjusted odds ratio 0.90 [99% confidence interval, 0.75–1.09]; P = .15). S-OSA patients compared to D-OSA patients had significantly increased postoperative reintubation, mechanical ventilation, direct intensive care unit admission after surgery, hospital length of stay, and 30-day all-cause mortality.Patients classified as S-OSA have similar rates of AREs to D-OSA patients, but increased postoperative respiratory interventions, hospital use, and 30-day all-cause mortality. These worse postoperative outcomes in S-OSA patients than D-OSA patients could reflect the lack of awareness and appropriate management of this bedside S-OSA diagnosis after PACU discharge. Multidisciplinary interventions are needed for these high-risk patients.