Knowledge and attitudes of primary care physicians toward sleep and sleep disorders

Primary Care Clinic Approaches to Facilitating Patient Health Behavior Change in Alabama

Background  Non-communicable chronic diseases (NCCDs), such as cardiovascular disease, diabetes, and cancer, are the leading cause of death and disability and the leading driver of healthcare costs in the U.S. It is estimated that 80% of chronic diseases and premature deaths are attributable to modifiable lifestyle factors related to smoking and alcohol intake, poor eating patterns, and physical inactivity. Inadequate sleep also plays a significant role. Among other directives, primary care providers (PCPs) have the opportunity to contribute to preventing and treating NCCD in their patients. Comprehensive, evidence-based behavioral counseling interventions are recommended to PCPs as a first-line approach to improving outcomes. However, presumably due to a lack of PCP time, training or resources, most patients report not receiving such services. Currently, the extent to which PCPs in Alabama offer or refer patients to health behavior change (HBC) services is unknown.  Objectives  This study aims to assess the following: (1) Alabama PCPs' current approaches in facilitating patient HBC in the domains of eating patterns, physical activity, sleep, and stress and (2) the likelihood of the Alabama PCPs referring patients to virtual HBC programs, once developed by an osteopathic medical school in the state.  Methods  Data were collected from clinic personnel who were knowledgeable regarding the clinic's approach to facilitating patient HBC via scripted telephone interviews and online surveys sent via email. The clinic list utilized for the study was derived from a list of VCOM-Auburn clinical preceptors. Primary care and specialty clinics were included. Data were analyzed descriptively to determine the number of clinics that (1) provide, recommend, or refer programs, services, or resources to patients to facilitate HBC related to eating patterns, physical activity, sleep, and stress management and (2) are likely to refer patients to free virtual HBC programs, once developed by an osteopathic medical school in the state. Results  Of the 198 clinics that were contacted, 75 were excluded, 46 were "no response," 53 agreed to participate, and 50 completed the survey. Of the 50 clinics that completed the survey, 33 indicated offering resources or referrals for diet, 29 stated they offered resources or referral services for physical activity, 33 indicated offering resources or referrals for sleep, and 28 indicated offering or recommending resources for stress management to patients. Most of the clinics (29/50) felt that their patients would benefit most from a program that facilitates improvement in eating patterns, and 41/50 clinics said that they are either "somewhat" or "extremely" likely to refer patients to a free VCOM-Auburn HBC program, once available.  Conclusions Findings indicate that a significant percentage of PCP clinics are not offering HBC resources to patients and that most PCP clinics would consider referring patients to free VCOM-Auburn HBC programs, once available. Phone data were significantly different from email data. The primary limitations were a low response rate and potential response bias.

Mapping the insomnia patient journey in Europe and Canada

Introduction

Insomnia affects daily functioning and overall health, and is thus associated with significant individual, societal, and economic burden. The experience of patients living with insomnia, their perception of the condition, and its impact on their quality of life is not well documented. The objective of this study was to map the patient journey in insomnia and identify unmet needs.

Methods

Participants were individuals with insomnia, and healthcare professionals (HCPs) who treat insomnia, in the United Kingdom, France, Germany, Italy, and Canada. Qualitative interviews (50 patients, 70 HCPs) and a quantitative survey (700 patients, 723 HCPs) were conducted to inform the patient-journey mapping and obtain information on the emotions, perceptions, and experiences of patients and HCPs.

Results

The patient journey comprises seven phases. The first defines the onset of insomnia symptoms. Phase 2 represents self-initiated behavior change to improve sleep (e.g., sleep hygiene, reducing caffeine, exercise). The next phase is characterized by use of over-the-counter (OTC) treatments, which generally fail to provide lasting relief. Phase 4 describes the first HCP consultation (occurring several months to several years after onset) and typically occurs at a crisis point for the patient; patients may be looking for an immediate solution (e.g., medication), which may not align with their HCP's recommendation. The following stage comprises sleep hygiene/behavioral changes (±OTC treatment) under HCP guidance for many patients, although offering prescription treatments without a sleep hygiene stage under supervision is more common in some countries. Phase 6 describes prescription medication initiation, where patients fluctuate between relief/hopefulness and a sense of failure, while HCPs try to balance the need to provide relief for the patient while maintaining best medical practice and minimizing adverse effects. The final phase (living with long-term insomnia) represents an indefinite period during which sleep issues remain unresolved for many patients, with most of them continuing to use prescription treatments for longer than indicated and creating their own variable, self-managed regimens combining multiple modalities.

Conclusion

This patient journey analysis for insomnia revealed seven distinct phases, highlighting different touchpoints where insomnia management could be optimized.

Joint Prevalence of Influenza Preventive Behaviors Among Adults-United States, 2020

INTRODUCTION/OBJECTIVES

The Centers for Disease Control and Prevention recognizes routine vaccination, sufficient sleep, and adequate physical activity as behavioral approaches to reduce the incidence of influenza. We aimed to determine the joint national prevalence of these health behaviors among U.S. adults, which has not been reported.

METHODS

We used the 2020 National Health Interview Survey to assess prevalence of receiving influenza vaccination in the past 12 months, obtaining sufficient sleep, and achieving adequate physical activity among U.S. adults (n = 30,312). We calculated the joint prevalence overall and by sociodemographic and health-related variables.

RESULTS AND CONCLUSIONS

The overall joint prevalence was 8.5% (95% CI, 8.0-9.0). Prevalence was lower among older persons (vs younger); Hispanic and non-Hispanic Black persons (vs non-Hispanic White); current and former smokers (vs never smokers); postpartum women (vs neither pregnant nor postpartum); and those with a history of coronary heart disease, hypertension, stroke, diabetes, and chronic obstructive pulmonary disease (vs not having those respective condition). In addition to recommending annual vaccination, primary care providers might encourage sufficient sleep and adequate physical activity-especially among patients who have increased risk for influenza complications and are less likely to achieve these behaviors.

Precision Medicine in Adult Obstructive Sleep Apnea and Home Diagnostic Testing: Caution in Interpretation of Home Studies Without Clinician Input Is Necessary

Purpose

To assess the validity of home sleep apnea test directed diagnosis and treatment of obstructive sleep apnea (OSA) in a real-life clinical setting and establish the extent to which clinical evaluation alters diagnosis and therapeutic intervention, in the context of the evolving realm of precision medicine.

Methods

Retrospective consecutive cohort study of 505 patients referred to a single center between 15th September 2015 to 14th September 2016, multidisciplinary specialist sleep clinic presenting with a home sleep apnea test prior to referral. We evaluated the effect of sleep medicine practitioner (SMP) and ear, nose, and throat surgeon (ENTS) review on patient diagnoses, disease severity, and management options in OSA.

Results

Hundred and fifteen patients were included. Repeat evaluation with in-lab polysomnogram (PSG) was required in 46/115 (40.0%) of patients, of which 20/46 (43.5%) had OSA severity changed. Sleep medicine practitioner review decreased the need for repeat testing with formal in-lab PSG (p < 0.05) and increased patient acceptance of continuous positive airway pressure (CPAP) as a long-term management option for OSA. Sleep medicine practitioner/ENTS review resulted in discovery of a non-OSA related sleep disorder or change in OSA severity in 47.8% (55/115). Ear, nose, and throat surgeon review resulted in additional or changed diagnosis in 75.7% (87/115) of patients.

Conclusion

In the clinical assessment and diagnosis of OSA, patients should be reviewed by medical practitioners with an interest in sleep disorders to better navigate the complexities of assessment, as well as the identification of co-morbid conditions.

Sleep disorders in a sample of Lebanese children: the role of parental mental health and child nutrition and activity

BACKGROUND

Sleep habits are an important component of a child's health and it is affected by parent-child relationship. Also, child's diet and nutrition appear to be an important factor affecting sleep health. Few studies have addressed the effect of parental emotional disturbance that can leave on children's sleep. Therefore, the objective of our study was to assess the prevalence of sleep disorders in pre- and school-aged children and evaluate its relation with parental mental health and child's nutrition and activity.

METHODS

A cross-sectional study, conducted between October 2020 and January 2021, which enrolled 402 Lebanese parents from all over Lebanon. The questionnaire was distributed online using the snowball technique. The Pediatric Sleep Questionnaire (PSQ) was used to assess pediatric sleep behaviors and the Family Nutrition and physical activity questionnaire was used to assess parental behaviors that might predispose children for obesity.

RESULTS

A total of 76 (19%) children had sleep disorders (PSQ scores of 8 or more). The multivariable analysis showed that higher paternal depression (Beta = 0.079, p = 0.010), maternal depression (Beta = 0.089, p = 0.001) and higher anxiety in the father (Beta = 0.064, p = 0.021) were significantly associated with higher PSQ scores (worse sleep) in the child. Higher Family Nutrition and Physical Activity Screening Tool scores in the child (Beta = -0.161, p < 0.001) was significantly associated with lower PSQ scores (better sleep).

CONCLUSION

Paternal anxiety and depression, as well as maternal depression, were factors associated with children's sleeping disorders. Future studies are needed to assess parental influence on child's development.

Perspectives on primary care management of obstructive sleep apnea: a qualitative study of patients and health care providers

STUDY OBJECTIVES

Difficulties in providing timely access to care have prompted interest in primary care delivery models for obstructive sleep apnea (OSA). Sustainable implementation of such models requires codesign with input from key stakeholders. The purpose of this study was to identify patient and provider perspectives on barriers and facilitators to optimal, patient-centered management of OSA in a primary care setting.

METHODS

This study was conducted in Alberta, Canada. Data from key stakeholders were collected through an online survey of primary care providers (n = 119), focus groups and interviews with patients living with OSA (n = 28), and workshops with primary care and sleep providers (n = 36). Quantitative survey data were reported using descriptive statistics, and qualitative data were analyzed using an inductive thematic approach.

RESULTS

Several barriers were identified, including poor specialist access, variable primary care providers knowledge of OSA, and lack of clarity about provider roles for OSA management. Barriers contributed to patients being poorly informed about OSA, leading them to separate OSA from their overall health and eroding trust in the system. Suggestions for improvement included integration of care providers in a comprehensive model of care, facilitated by improved system navigation and more effective use of technology. Themes were consistent across data collection methods and between stakeholder groups.

CONCLUSIONS

Although primary care delivery models may improve access to OSA management, stakeholders identified important challenges in the current system. Innovative models of care, developed with input from patients and providers, may mitigate barriers and support optimal primary care management of OSA.

Knowledge of Sleep Disorders Among Physicians at a Tertiary Care Hospital in Qatar: Cross-sectional Study

Background

Sleep disorders constitute a major health problem because of their relatively high and rising prevalence. Several studies worldwide have analyzed health care providers’ knowledge of sleep disorders.

Objective

In this study, we aimed to assess the knowledge of sleep disorders among physicians in Qatar.

Methods

A total of 250 physicians were surveyed regarding their knowledge of sleep medicine by using the validated 30-item Assessment of Sleep Knowledge in Medical Education (ASKME) Survey. The participants included residents, fellows, and consultants in medicine and allied subspecialties. A high score was defined as ≥60% of correctly answered questions, implying the respondent has adequate knowledge of sleep disorders.

Results

Responses were received from 158 of the 250 physicians, with a response rate of 63.2%. This included responses from 34 residents, 74 clinical fellows, and 50 consultants. The overall mean score was 15.53 (SD 4.42), with the highest possible score of 30. Only 57 of 158 (36.1%) respondents were able to answer ≥60% of the questions correctly. No statistically significant difference was found in the scores of participants with regard to their ranks (ie, residents, fellows, or consultants) or years of medical training.

Conclusions

This study demonstrates that health care providers in Qatar have decreased awareness and knowledge about sleep medicine, which may reflect reduced emphasis on sleep disorders during medical school and training. Increasing awareness regarding sleep medicine among nonspecialist physicians will allow early detection and treatment of sleep disorders, thereby reducing the morbidity associated with these disorders.

Outpatient health care utilization for sleep disorders in the Cerner Health Facts database

STUDY OBJECTIVES

Sleep disorders are common in the general population. This study aimed to identify direct health care utilization for sleep disorders using big data through the Cerner Health Facts database.

METHODS

The Cerner Health Facts database has 68.7 million patients in the data warehouse, documenting approximately 506.9 million encounters from 100 nonaffiliated health care systems. To identify sleep-related health care utilization, we examined the frequency of outpatient encounters related to sleep disorders between the years 2000 and 2017. Sleep disorders were grouped-based on the International Classification of Sleep Disorders-Third Edition.

RESULTS

Approximately 20.5 million patients were identified with a total of 127.4 million outpatient encounters. In pediatric patients (ages 0-18 years), health care utilization for major sleep diagnoses was measured per 100,000 encounters. Sleep-related breathing disorders ranked first among common sleep disorders for pediatric patients followed by parasomnia, insomnia, sleep movement disorders, hypersomnolence, then circadian rhythm disorders (820.1, 258.1, 181.6, 68.3, 48.1, and 16.2 per 100,000 encounters, respectively). However, in adult patients, the ranking was slightly different, with sleep-related breathing disorders ranked first, followed by insomnia, sleep-related movement disorders, hypersomnolence, parasomnia, then circadian rhythm disorders (1352.6, 511.6, 166.3, 79.1, 25.7, and 4.2 per 100,000 encounters, respectively). In general, there was a bimodal pattern with a clear dip in sleep-related health care utilization in young adults age (age 19-29 years), with the exception of insomnia.

CONCLUSIONS

Patients with sleep disorders show relatively low health care utilization despite a known high prevalence of sleep disorders in the general population. This finding may highlight under-recognition of sleep problems or decreased access to health care for sleep disorders. In addition, this study highlights the effect of age-based variation on different sleep disorders, which may have an impact on allocating resources.

Why Treat Insomnia?

"Why treat insomnia?" This question grows out of the perspective that insomnia is a symptom that should only receive targeted treatment when temporary relief is needed or until more comprehensive gains may be achieved with therapy for the parent or precipitating medical or psychiatric disorders. This perspective, however, is untenable given recent data regarding the prevalence, course, consequences, and costs of insomnia. Further, the emerging data that the treatment of insomnia may promote better medical and mental health (alone or in combination with other therapies) strongly suggests that the question is no longer "why treat insomnia," but rather "when isn't insomnia treatment indicated?" This perspective was recently catalyzed with the American College of Physicians' recommendation that chronic insomnia should be treated and that the first line treatment should be cognitive-behavioral therapy for insomnia (CBT-I).

Feasibility of text message sleep assessment in African American and Latino patients with type 2 diabetes

STUDY OBJECTIVES

Text messaging (TM) may provide an inexpensive and convenient method for self-reported sleep assessment. This pilot study evaluated the feasibility of a TM sleep diary among a racial/ethnic minority population with uncontrolled type 2 diabetes.

METHODS

A convenience sample of 40 participants with uncontrolled type 2 diabetes was recruited. Participants wore an Actiwatch (Philips Spectrum Plus, Philips Respironics, Murrysville, Pennsylvania) for 7 consecutive days during both wake and sleep intervals and completed a daily TM sleep diary including 10 questions adapted from the Consensus Sleep Diary. The relationships between sleep measures from TMs and actigraphy were explored through Bland-Altman plots and correlations.

RESULTS

Of the 40 participants enrolled, 34 were African American and 6 were Latino. The mean age was 52.2 years (standard deviation = 8.2), and the mean hemoglobin A1c was 9.0% (standard deviation = 1.5). All but 1 participant attempted to complete the TM sleep diary. With a maximum of 70 TM replies possible, the median number of responses per participant was 66 (interquartile range = 59.5-69). Actigraphy and TM measures were related for total sleep time (median = 382 vs 393 min, respectively [r = .71; P < .01]), sleep onset latency (median = 31.4 vs 27.5 min [r = .61; P < .01]), time in bed (433.3 vs 489.3 min [r = .74; P < .01]), and sleep efficiency (77% vs 86% [r = .45; P = .005]). The measure of wake after sleep onset was higher from actigraphy than from TM, with a weak relationship between the 2 measures (median 47.9 vs 6.0 min [r = .31; P = .05]).

CONCLUSIONS

TM is a novel and feasible method for sleep assessment in racial/ethnic minority adults with uncontrolled type 2 diabetes.

Sleep health practices and sleep knowledge among healthcare professionals in Dutch paediatric rehabilitation

BACKGROUND

Sleep disorders are highly prevalent in children with neurodisabilities, yet they seem under-recognized in paediatric rehabilitation settings. The aim of this study was to assess among two groups of healthcare professionals (HCPs) working in paediatric rehabilitation: (1) sleep health practices and (2) knowledge about sleep physiology, sleep disorders and sleep hygiene.

METHODS

We performed a cross-sectional sleep survey among medical and non-medical HCPs and the general population. Participants (30 rehabilitation physicians [RPs], 54 allied health professionals [AHPs] and 63 controls) received an anonymous 30-item survey consisting of three domains: (1) general information, (2) application of sleep health practices and (3) sleep knowledge.

RESULTS

RPs address sleep issues more frequently in clinical practice than AHPs. Sleep interventions mostly consist of giving advice about healthy sleep practices and are given by the majority of HCPs. While RPs demonstrated the highest scores on all knowledge domains, total sleep knowledge scores did not exceed 50% correct across groups, with AHPs and controls showing equal scores. Sleep hygiene rules closest to bedtime and related to the sleep environment were best known, whereas those related to daytime practices were rarely mentioned across all groups. A small minority of HCPs (RPs 20%; AHPs 15%) believed to possess sufficient sleep knowledge to address sleep in clinical practice. No association was found between self-perceived knowledge and sleep knowledge scores among HCPs.

CONCLUSIONS

Sleep should become a standard item for review during routine health assessments in paediatric rehabilitation settings. HCPs' limited exposure to sleep education may result in feelings of incompetence and inadequate sleep knowledge levels, affecting their sleep health practices. Appropriate sleep training programs should be implemented to empower HCPs with knowledge, skills and confidence, needed to recognize and treat sleep disorders in children with neurodisabilities, as well as to be able to guide parents.

Clinician and patient barriers to the recognition of insomnia in family practice: a narrative summary of reported literature analysed using the theoretical domains framework

BACKGROUND

Insomnia is a common sleep complaint, with 10% of adults in the general population experiencing insomnia disorder, defined as lasting longer than three months in DSM-5. Up to 50% of patients attending family practice experience insomnia, however despite this, symptoms of insomnia are not often screened for, or discussed within this setting. We aimed to examine barriers to the assessment and diagnosis of insomnia in family practice from both the clinician and patient perspective.

METHODS

The present article identified research that has examined barriers to assessing insomnia from the clinician's and the client's perspectives following MEDLINE and Google Scholar searches, and then classified these barriers using the theoretical domains framework.

RESULTS

The most common barriers from the clinician's perspective were related to Knowledge, Skills, and the Environmental Context. From the patient perspective, barriers identified included their Beliefs about the consequences of Insomnia, Social Influences, and Behavioural Regulation of Symptoms.

CONCLUSIONS

Utilising this theoretical framework, we discuss options for bridging the gap between the identification and subsequent management of insomnia within the family practice setting. To assist clinicians and those in community health care to overcome the Knowledge and Skills barriers identified, this article provides existing relevant clinical criteria that can be utilised to make a valid diagnosis of insomnia.

Primary care physicians' knowledge of sleep medicine and barriers to transfer of patients with sleep disorders. A cross-sectional study

OBJECTIVES

To assess primary care physicians' (PCPs) knowledge and attitudes toward sleep disorders.  Methods: In this cross-sectional quantitative study, we surveyed 88 primary care centers under the Ministry of Health during 2015 in Riyadh, Saudi Arabia, using a combination of pre-designed validated questionnaires. Knowledge was assessed using the Assessment of Sleep Knowledge in Medical Education (ASKME) questionnaire, and attitude was assessed using a pre-designed survey. For numerical variables, t-test was used, and for categorical variables, Chi-square test was used. Results: Data from 223 PCPs (males 50.2%) were analyzed. Among the participants, 44 (19.9%) did not know that sleep medicine is a distinct medical specialty, and 24 (10.9%) felt that sleep disorders are uncommon medical problems based on their daily practice. Only 87 (39%) of physicians stated that they referred patients with sleep disorders to specialized medical centers for further management. The mean score of the ASKME questionnaire was 14.4 ± 4 out of 30 (48%). The majority of physicians (78.5%) obtained a score between 11 and 20. Score results were not related to gender or years of practice. Conclusion: Primary care physicians' have a low level of awareness and poor knowledge of sleep medicine and sleep disorders.

Training, knowledge, attitudes and practices of Canadian health care providers regarding sleep and sleep disorders in children

Background

Sleep disorders are prevalent in children and are associated with significant comorbidity.

Objective

To assess the training, knowledge, attitudes and practices of Canadian health care providers (HCPs) regarding sleep disorders in children.

Method

A 42-item survey, designed to collect information on frequency of paediatric sleep disorders-related screening and diagnosis, implementation of evidence-based interventions and related knowledge base, was completed by HCPs.

Results

Ninety-seven HCPs completed the survey. One per cent obtained training in paediatric sleep during undergraduate training and 3% obtained such training during their residencies, yet 34.9% estimated that 25 to 50% of their patients suffered from sleep disorders. Most HCPs thought that sleep disorders significantly impacted children's health and daytime function. Most HCPs screened for developmental sleep issues, but not consistently for sleep disorders. Most recommended evidence-based behavioural interventions for behavioural sleep disorders, but some also reported behavioural interventions that were not first-line or recommended. Inadequate knowledge regarding melatonin use was evident. Most participants reported rarely/never ordering a sleep study for a child with suspected obstructive sleep apnea (OSA). Most were familiar with surgical and weight loss management options for OSA; many were unfamiliar with benefits of continuous positive airway pressure. Participants' knowledge scores were highest on developmental and behavioural aspects of sleep, and lowest on sleep disorders.

Conclusions

HCPs exhibit significant gaps in their knowledge, screening, evaluation and treatment practices for paediatric sleep disorders. Training at the undergraduate, graduate and postgraduate levels, as well as Continuing Medical Education are needed to optimize recognition, treatment and follow-up of paediatric sleep disorders.

Describing knowledge encounters in healthcare: a mixed studies systematic review and development of a classification

Background

Implementation science seeks to promote the uptake of research and other evidence-based findings into practice, but for healthcare professionals, this is complex as practice draws on, in addition to scientific principles, rules of thumb and a store of practical wisdom acquired from a range of informational and experiential sources. The aims of this review were to identify sources of information and professional experiences encountered by healthcare workers and from this to build a classification system, for use in future observational studies, that describes influences on how healthcare professionals acquire and use information in their clinical practice.

Methods

This was a mixed studies systematic review of observational studies. DATA SOURCES: OVID MEDLINE and Embase and Google Scholar were searched using terms around information, knowledge or evidence and sharing, searching and utilisation combined with terms relating to healthcare groups. ELIGIBILITY: Studies were eligible if one of the intentions was to identify information or experiential encounters by healthcare workers. DATA EXTRACTION: Data was extracted by one author after piloting with another. STUDY APPRAISAL: Studies were assessed using the Mixed Methods Appraisal Tool (MMAT). PRIMARY OUTCOME: The primary outcome extracted was the information source or professional experience encounter. ANALYSIS: Similar encounters were grouped together as single constructs. Our synthesis involved a mixed approach using the top-down logic of the Bliss Bibliographic Classification System (BC2) to generate classification categories and a bottom-up approach to develop descriptive codes (or “facets”) for each category, from the data. The generic terms of BC2 were customised by an iterative process of thematic content analysis. Facets were developed by using available theory and keeping in mind the pragmatic end use of the classification.

Results

Eighty studies were included from which 178 discreet knowledge encounters were extracted. Six classification categories were developed: what information or experience was encountered; how was the information or experience encountered; what was the mode of encounter; from whom did the information originate or with whom was the experience; how many participants were there; and where did the encounter take place. For each of these categories, relevant descriptive facets were identified.

Conclusions

We have sought to identify and classify all knowledge encounters, and we have developed a faceted description of key categories which will support richer descriptions and interrogations of knowledge encounters in healthcare research.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0564-1) contains supplementary material, which is available to authorized users.

Examining uptake of online education on obstructive sleep apnoea in general practitioners: a randomised trial

Background

Obstructive sleep apnoea (OSA) affects up to 28 % of the adult population in Western countries. The detection and management of OSA by general practitioners (GPs) can be poor. The study aimed to examine what influence enhanced invitations had on uptake of on-line learning modules for OSA by GPs, and whether recent referrals of patients to sleep specialists influenced uptake.

Methods

Practicing GPs in regional Australia were identified and randomised to receive either an enhanced or standard invitation letter to a new on-line education module for OSA. The enhanced letter included indication that the module was eligible for professional accreditation and described the prevalence and burden of sleep disorders. Some included extra emphasis if the GP had recently referred a patient for diagnostic investigation of OSA. Two reminder letters were sent.

Results

Of 796 eligible GPs who received the letters, sixteen (2 %) accessed the website and four completed the modules over the four-month study period. GPs who received an enhanced invitation letter were not significantly more likely to access the website compared to GPs who received the standard invitation letter. Recent referral of a patient for diagnostic investigation was also not a significant factor in influencing use of the module.

Conclusion

GP interest in on-line education about OSA appears low, and emphasis of relevant recent past patient(s) and the opportunity for professional education points was not successful in increasing engagement. There is a need to identify effective approaches to improving the detection and management of OSA in general practice.

Health promotion in obstructive sleep apnea syndrome

Introduction Obstructive sleep apnea syndrome (OSAS), which is commonly underdiagnosed, has a high occurrence in the world population. Health education concerning sleep disorders and OSAS should be implemented. Objectives The objective was to identify studies related to preventive actions on sleep disorders, with emphasis on OSAS. Data Synthesis A literature review was conducted using Lilacs, Medline, PubMed, and Scopus by combining the following keywords: "Health Promotion," "Sleep Disorders," "Primary Prevention," "Health Education," and "Obstructive Sleep Apnea Syndromes." Initially, 1,055 papers, from 1968 to 2013, were located, with the majority from the Scopus database. The inclusion criteria were applied, and four articles published between 2006 and 2012 were included in the present study. Conclusions The studies on preventive actions in sleep disorders, with emphasis on OSAS, involved the general population and professionals and students in the health field and led to increased knowledge on sleep disorders and more appropriate practices.

Factors associated with referrals for obstructive sleep apnea evaluation among community physicians

STUDY OBJECTIVES

This study assessed knowledge and attitudes toward obstructive sleep apnea (OSA) among community physicians and explored factors that are associated with referrals for OSA evaluation.

METHODS

Medical students and residents collected data from a convenience sample of 105 physicians practicing at community-based clinics in a large metropolitan area. Average age was 48 ± 14 years; 68% were male, 70% black, 24% white, and 6% identified as "other." Physicians completed the Obstructive Sleep Apnea Knowledge and Attitudes questionnaire.

RESULTS

The average year in physician practice was 18 ± 19 years. Of the sample, 90% reported providing care to black patients. The overall OSA referral rate made by physicians was 75%. OSA knowledge and attitudes scores ranged from 5 to 18 (mean = 14 ± 2) and from 7 to 20 (mean = 13 ± 3), respectively. OSA knowledge was associated with white race/ ethnicity (rp = 0.26, p < 0.05), fewer years in practice (rp = -0.38, p < 0.01), patients inquiring about OSA (rp = 0.31, p < 0.01), and number of OSA referrals made for OSA evaluation (rp = 0.30, p < 0.01). Positive attitude toward OSA was associated with patients inquiring about OSA (rp = 0.20, p < 0.05). Adjusting for OSA knowledge and attitudes showed that physicians whose patients inquired about OSA were nearly 10 times as likely to make a referral for OSA evaluation (OR = 9.38, 95% CI: 2.32-38.01, p < 0.01).

CONCLUSION

Independent of physicians' knowledge and attitudes toward obstructive sleep apnea, the likelihood of making a referral for obstructive sleep apnea evaluation was influenced by whether patients inquired about the condition.

Linking emotional distress to unhealthy sleep duration: analysis of the 2009 National Health Interview Survey

OBJECTIVE

The objective of the study was to examine the independent association of emotional distress with unhealthy sleep duration (defined as <7 or >8 hours).

METHODS

Data from the 2009 National Health Interview Survey (NHIS), a cross-sectional household survey, were analyzed to investigate the associations of emotional distress with unhealthy sleep durations, adjusting for sociodemographic factors, health risks, and chronic diseases through hierarchical multiple logistic regression analysis.

PARTICIPANTS

A total of 27,731 participants (age range 18-85 years) from the NHIS 2009 dataset were interviewed.

MEASURES

Unhealthy sleep duration is defined as sleep duration <7 or >8 hours, whereas healthy sleep is defined as sleep duration lasting for 7-8 hours. Emotional distress is based on the Kessler 6 Non-Specific Distress Battery, which assesses the frequency of feeling sad, nervous, restless, hopeless, worthless, and burdened, over a 30-day period.

RESULTS

Of the sample, 51.7% were female; 83.1% were white and 16.9% were black. Eleven percent experienced emotional distress and 37.6% reported unhealthy sleep. Adjusted logistic regression analysis revealed that individuals with emotional distress had 55% greater odds of reporting unhealthy sleep (odds ratio [OR] =1.55, 95% confidence interval [CI] =1.42, 1.68, P<0.001).

CONCLUSION

Emotional distress, an important proxy for poor psychological health, was a significant predictor of unhealthy sleep, independent of the influences of several factors including demographic (age, education, sex, race/ethnicity, and family income), health risks (alcohol consumption and smoking status), and chronic diseases/conditions (diabetes, obesity, hypertension, heart disease, cancer, and arthritis).

Risk of sleep apnea in hospitalized older patients

BACKGROUND/OBJECTIVES

To assess the prevalence of undiagnosed obstructive sleep apnea (OSA) among general medical inpatients and to investigate whether OSA risk is associated with in-hospital sleep quantity and quality.

DESIGN

Prospective cohort study.

SETTING

General medicine ward in academic medical center.

PARTICIPANTS

424 hospitalized adult patients ≥ 50 years old without a sleep disorder diagnosis (mean age 65 years, 57% female, 72% African American).

MAIN MEASURES

The Berlin questionnaire, a validated screen for determining risk of OSA, was administered to hospitalized medical patients. Sleep duration and efficiency were measured via wrist actigraphy. Self-reported sleep quality was evaluated using Karolinska Sleep Quality Index (KSQI).

KEY RESULTS

Two of every 5 inpatients ≥ 50 years old (39.5%, n = 168) were found to be at high risk for OSA. Mean in-hospital sleep duration was ∼ 5 h and mean sleep efficiency was 70%. Using random effects linear regression models, we found that patients who screened at high risk for OSA obtained ∼ 40 min less sleep per night (-39.6 min [-66.5, -12.8], p = 0.004). These findings remained significant after controlling for African American race, sex, and age quartiles. In similar models, those patients who screened at high risk had ∼ 5.5% less sleep efficiency per night (-5.50 [-9.96, -1.05], p = 0.015). In multivariate analysis, patients at high risk for OSA also had lower self-reported sleep quality on KSQI (-0.101 [-0.164, -0.037], p = 0.002).

CONCLUSION

Two of every 5 inpatients older than 50 years screened at high risk for OSA. Those screening at high risk have worse in-hospital sleep quantity and quality.

COMMENTARY

A commentary on this article appears in this issue on page 1067.

(Mis) perceptions and interactions of sleep specialists and generalists: obstacles to referrals to sleep specialists and the multidisciplinary team management of sleep disorders

STUDY OBJECTIVES

This study assessed generalists' perceptions and challenges in providing care to sleep disorders patients and the role of sleep specialists in improving gaps in care.

METHODS

A mixed-method approach included qualitative (semi-structured interviews, discussion groups) and quantitative (online surveys) data collection techniques regarding care of patients with obstructive sleep apnea (OSA) and shift work disorder (SWD).

RESULTS

PARTICIPANTS

OSA: generalists n = 165, specialists (internists, neurologists, psychiatrists, pulmonologists) n = 12; SWD: generalists n = 216, specialists n = 108. Generalists reported challenges in assessing sleep disorders and diagnosing patients with sleep complaints. Generalists lacked confidence (selected ≤ 3 on a 5-pt Likert scale) in managing polypharmacy and drug interactions (OSA: 54.2%; SWD: 62.6%), addiction (OSA: 61.8%), and continuous positive airway pressure (OSA: 66.5%). Generalists in both studies reported deficits in knowledge of monitoring sleep disorders (OSA: 57.7%; SWD: 78.7%), rather relying on patients' subjective reports; 23% of SWD generalists did not identify SWD as a medical condition. Challenges to generalist-specialist collaboration were reported, with 66% of generalists and 68% of specialists in the SWD study reporting lack of coordination as a barrier. Generalists reported lack of consistency in sleep medicine and a perceived lack of value in consulting with sleep specialists.

CONCLUSIONS

Knowledge and attitudinal challenges were found in primary care of patients with sleep disorders. Sleep specialists need to clarify and educate practitioners regarding primary care's approach.

Sleep medicine knowledge, attitudes, and practices among medical students in Guangzhou, China

PURPOSE

This study aimed to describe the knowledge, attitudes, and practices of Chinese medical students towards sleep medicine.

METHODS

The authors surveyed medical students at Southern Medical University in 2009. Students completed a questionnaire before and after attending a 3-h sleep disorders course.

RESULTS

All 324 questionnaires were returned. Less than one half of the students were aware that restless legs syndrome, somniloquy, and teeth grinding are sleep disorders. Only a small percentage of students knew that sleep disorders are related to diabetes, anemia, hyperlipidemia, and attention deficit syndrome. After the 3-h sleep disorders course, the percentage of students who regarded snoring, restless legs syndrome, nightmares, and somniloquy as sleep disorders increased from 64.9 to 92.7 %, 40.8 to 64.4 %, 48.0 to 60.3 %, and 33.5 to 59.9 % (P < 0.001), respectively. Sleep problems were considered to be a significant issue by 93.8 % of the students. The students thought that people with sleep disorders should seek treatment. Of the students, 81.3 % were interested in sleep medicine. The students considered that it is necessary to set up specialized sleep medicine departments to manage sleep disorders. Of the students, 76.8 % thought they or their friends had sleep problems, and 44.8 % consulted physicians about sleep problems. Greater than two thirds of the students (67.1 %) did not have formal education about sleep medicine. Few students were aware of medical schools offering a course in sleep medicine. Most of the students liked learning in the form of elective courses, lectures, or online course. The students also realized that having sleep medicine knowledge is needed as a physician.

CONCLUSIONS

Chinese medical students attached importance to sleep disorders, but knew little about sleep disorders. Knowledge of sleep medicine can be improved with a short training course.

A brief primer on sleep for pediatric and child clinical neuropsychologists

Sleep problems are common in the children seen by pediatric and child clinical neuropsychologists, and these problems have the potential to significantly impact the child and his or her family. All are treatable to some degree, and some respond extremely well to existing treatments. This article provides a brief overview of the impact, nature, screening, and treatment for childhood sleep problems, with a particular emphasis on issues relevant to practicing neuropsychologists.

Education in sleep disorders in US dental schools DDS programs

INTRODUCTION

Medical school surveys of pre-doctoral curriculum hours in the somnology, the study of sleep, and its application in sleep medicine/sleep disorders (SM) show slow progress. Limited information is available regarding dentist training. This study assessed current pre-doctoral dental education in the field of somnology with the hypothesis that increased curriculum hours are being devoted to SM but that competencies are still lacking.

MATERIALS AND METHODS

The 58 US dental schools were surveyed for curriculum offered in SM in the 2008/2009 academic year using an eight-topic, 52-item questionnaire mailed to the deans. Two new dental schools with interim accreditation had not graduated a class and were not included. Responses were received from 49 of 56 (87.5%) of the remaining schools.

RESULTS AND CONCLUSIONS

Results showed 75.5% of responding US dental schools reported some teaching time in SM in their pre-doctoral dental program with curriculum hours ranging from 0 to 15 h: 12 schools spent 0 h (24.5%), 26 schools 1-3 h, 5 schools 4-6 h, 3 schools 7-10 h, and 3 schools >10 h. The average number of educational hours was 3.92 h for the schools with curriculum time in SM, (2.96 across all 49 responding schools). The most frequently covered topics included sleep-related breathing disorders (32 schools) and sleep bruxism (31 schools). Although 3.92 h is an improvement from the mean 2.5 h last reported, the absolute number of curriculum hours given the epidemic scope of sleep problems still appears insufficient in most schools to achieve any competency in screening for SRBD, or sufficient foundation for future involvement in treatment.

Patients' and clinicians' experiences of consultations in primary care for sleep problems and insomnia: a focus group study

BACKGROUND

Insomnia affects around one-third of adults in the UK. Many sufferers seek help from primary care.

AIM

To explore patients' and primary care practitioners' expectations, experiences, and outcomes of consultations for sleep difficulties, as a basis for improving the treatment of insomnia in primary care.

DESIGN OF STUDY

A qualitative phenomenological approach.

METHOD

Separate focus groups for GPs and nurse prescribers and patients recruited from eight general practices that were in a quality improvement collaborative. Constant comparative analysis was used.

RESULTS

Emergent themes from 14 focus groups comparing participating patients (n = 30) and practitioners (n = 15), provided insights on presentation, beliefs, expectations, and management of sleep problems. Patients initially tried to resolve insomnia themselves; consulting was often a last resort. Patients felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted, and felt this would hamper patients' ability to take non-drug treatments seriously. Clinicians expected patients who were already on sleeping tablets to be resistant to stopping them, whereas patients were often open to alternatives.

CONCLUSION

Better management of insomnia should take into account the perceptions and interactions of patients and practitioners. Practitioners need to empathise, listen, elicit patients' beliefs and expectations, assess sleep better, and offer a range of treatments, including cognitive and behavioural therapies, tailored to individual needs. Practitioner education should incorporate understanding of patients' decision-making processes, the clinicians' role during the consultation, and how to negotiate and deliver strategies for resolving sleep problems.

Clinical psychology training in sleep and sleep disorders

There is growing evidence to suggest that clinical psychologists would benefit from more training in sleep and sleep disorders. Sleep disturbances are commonly comorbid with mental health disorders and this relationship is often bidirectional. In addition, psychologists have become integral members of multidisciplinary sleep medicine teams and there are not enough qualified psychologists to meet the clinical demand. The purpose of this study was to evaluate the current education on sleep and sleep disorders provided to clinical psychology predoctoral students and interns. Directors of graduate programs and internships (N=212) completed a brief online survey on sleep education in their program. Only 6% of programs offers formal didactic courses in sleep, with 31% of programs offering training in the treatment of sleep disorders. There are few programs with sleep faculty (16%), and most reported that their institutions were ineffective in providing sleep education. Thirty-nine percent of training directors reported they would implement a standard curriculum on sleep, if available. The findings from this study suggest that more opportunities are needed for trainees in clinical psychology to gain didactic and clinical experience with sleep and sleep disorders.

Development of a questionnaire to assess dentists' knowledge, opinion, education resources, physician cooperation, and clinical practice regarding obstructive sleep apnea (OSAQ-D)

This report describes the construction of a questionnaire to assess dentists' knowledge, opinion, education resources, clinical practice, and physician cooperation regarding obstructive sleep apnea (OSA) based on the PRECEDE-PROCEED model. The scale development included such steps as generating an item pool, expert review of initial item pool, pilot test, and final test. After the expert review, a total of 78 items made up the pilot test instrument including five demographic (age, year graduated from dental school, gender, years in practice dentistry, and membership of the Academy of Dental Sleep Medicine), 22 knowledge, 15 opinion, 11 education resources, 10 physician cooperation, and 15 clinical practice questions. The pilot test samples were third or fourth year dental school students and dentists from the University of Florida. Nineteen dentists and 26 students returned the survey. Based on the results of item analysis and content review, a total of 70 questions were remained for the final test. The final questionnaire was mailed to 450 dentists who were randomly selected from a list of 10,838 dentists with a Florida license and also delivered to 65 dental school students and postgraduates of the University of Florida. A total of 163 participants including 112 dentists and 51 students and postgraduates responded. The average age was 42.87 years, and most of them are males (77.8%). Only one dentist was a current member of the Academy of Dental Sleep Medicine. The item analysis was performed for five scales. 8 items with poor item difficulty, lower item discrimination, or having big effect on the item consistency were removed from the instrument, and 62 questions were kept for the further evaluation. The reliability coefficient alpha of knowledge, opinion, education resources, physician cooperation, and clinical practice scales was 0.77, 0.86, 0.67, 0.75, and 0.86, respectively. According to the standard from DeVellis (Scale development: theory and applications, Sage, Thousand Oaks, 2003), they were acceptable, or respectable, or even very good.

Knowledge, opinions, and clinical experience of general practice dentists toward obstructive sleep apnea and oral appliances

Undiagnosed obstructive sleep apnea (OSA) can contribute to hypertension, cardiovascular disease, stroke, and detract from overall quality of life. Dentists can play an important role in detecting, making recommendations for, and treating OSA with oral appliances (OAs). A survey of 18 questions of knowledge and opinion of, educational background for, and clinical experience with OSA and OAs was mailed to 500 general practice dentists in Indiana, United States. Two hundred survey returns produced 192 valid responses. Responders reported strong positive opinions toward OSA and OAs. However, 58% of dentists could not identify common signs and symptoms of OSA, and 55% of dentists did not know the mechanism for mandibular advance devices. Only 39% of dentists could identify snoring, mild OSA, and intolerance to continuous positive airway pressure as possible indications for OA treatment. Respondents reported a general lack of education about both OSA and OAs. Only 31 (16%) were taught about this issue in dental school; 77 (40%) knew little or nothing about OA treatment for OSA patients; 57 (30%) learned from postgraduate training. Cooperation and referrals between dentists and physicians were rated as "poor." Of the responders, 54% never consulted with physicians for a suspected OSA patient in their practice; 75% of dentists reported they have never been referred patients by physicians; and 80% of dentists never or less than five times prescribed OAs to OSA patients. Results suggest a need for increased education and training regarding OSA and OAs in dental school, as well as increased cooperation between dentists and physicians for better patient care.