Diagnosis and Management of Patients with Obstructive Sleep Apnea in Primary Care. Ready or Not?

A new tool to screen patients with severe obstructive sleep apnea in the primary care setting: a prospective multicenter study

Background

The coordination between different levels of care is essential for the management of obstructive sleep apnea (OSA). The objective of this multicenter project was to develop a screening model for OSA in the primary care setting.

Methods

Anthropometric data, clinical history, and symptoms of OSA were recorded in randomly selected primary care patients, who also underwent a home sleep apnea test (HSAT). Respiratory polygraphy or polysomnography were performed at the sleep unit to establish definite indication for continuous positive airway pressure (CPAP). By means of cross-validation, a logistic regression model (CPAP yes/no) was designed, and with the clinical variables included in the model, a scoring system was established using the β coefficients (PASHOS Test). In a second stage, results of HSAT were added, and the final accuracy of the model was assessed.

Results

194 patients completed the study. The clinical test included the body mass index, neck circumference and observed apneas during sleep (AUC 0.824, 95% CI 0.763–0.886, P < 0.001). In a second stage, the oxygen desaturation index (ODI) of 3% (ODI3% ≥ 15%) from the HSAT was added (AUC 0.911, 95% CI 0.863–0.960, P < 0.001), with a sensitivity of 85.5% (95% CI 74.7–92.1) and specificity of 67.8% (95% CI 55.1–78.3).

Conclusions

The use of this model would prevent referral to the sleep unit for 55.1% of the patients. The two-stage PASHOS model is a useful and practical screening tool for OSA in primary care for detecting candidates for CPAP treatment.

Clinical Trial Registration Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979; Identifier: NCT02591979. Date of registration: October 30, 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01827-0.

Primary vs. Specialist Care for Obstructive Sleep Apnea: A Systematic Review and Individual Participant Data Level Meta-Analysis

RATIONALE

Primary care clinicians may be well placed to play a greater role in obstructive sleep apnea management.

OBJECTIVES

To evaluate the outcomes and cost-effectiveness of sleep apnea management in primary versus specialist care, using an individual-participant data meta-analysis to determine whether age, gender, severity of OSA and daytime sleepiness impacted outcomes.

METHODS

Data sources were CINAHL, CENTRAL, MEDLINE Ovid SP, Scopus, ProQuest, US NIH Ongoing Trials Register, ISRCTN registry [inception until 09-25-2019]. Hand-searching was undertaken. Two authors independently assessed articles and included trials that randomized adults with a suspected diagnosis of sleep apnea to primary versus specialist management within the same study and reported daytime sleepiness using the Epworth Sleepiness Scale (range 0-24; >10 indicates pathological sleepiness; minimum clinically important difference two units) at baseline and follow-up.

RESULTS

The primary analysis combined data from 970 (100%) participants (four trials). Risk of bias was assessed (Cochrane Tool). One-stage intention-to-treat analysis showed a slightly smaller decrease in daytime sleepiness (0.8; 0.2 to 1.4), but greater reduction in diastolic blood pressure in primary care (-1.9; -3.2 to -0.6 mmHg), with similar findings in the per protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (-$448.51 USD), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for sub-groups in both management settings.

CONCLUSIONS

Similar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea. Registration: PROSPERO (CRD42020154688).

Primary care and sleep unit agreement in management decisions for sleep apnea: a prospective study in Spain

STUDY OBJECTIVES

Involvement of primary care teams in the care of patients with OSA is a focus of interest. The study objective was to compare diagnostic and therapeutic agreement between decisions taken by primary care professionals and sleep unit specialists.

METHODS

This was a prospective multicenter study conducted at primary care and specialized care centers in the urban area of Barcelona, Spain. Men and women aged 18-75 years who visited the participating primary care centers for any reason were recruited. Both primary care physicians and sleep specialists made a diagnostic and therapeutic decision with clinical data and results of a home sleep apnea test. All patients were finally assessed with respiratory polygraphy or polysomnography as a gold-standard test.

RESULTS

A total of 229 patients underwent a home sleep apnea test and were evaluated at the primary care centers and the sleep units. Diagnostic agreement using the same tools and excluding indeterminate decisions was 69.8% (Cohen's kappa = 0.64; 95% confidence interval, 0.56-0.72). Agreement for therapeutic decisions (PAP vs conservative treatment) was obtained in 82.5% of patients (Cohen's kappa = 0.62; 95% confidence interval, 0.51-0.73), increasing to 92.5% (Cohen's kappa = 0.49, 95% confidence interval, 0.40-0.58) when indeterminate options were excluded. As compared with the final therapeutic decisions made at the sleep unit with respiratory polygraphy/polysomnography, primary care physicians agreed regarding 83.3% (Cohen's kappa = 0.62; 95% confidence interval, 0.49-0.74) of patients.

CONCLUSIONS

Primary care professionals may assume an important role in the management of OSA in coordination with sleep centers, identifying patients who require specific treatment and should be referred to specialized care.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: PASHOS Project: Advanced Platform for Sleep Apnea Syndrome Assessment; URL: https://clinicaltrials.gov/ct2/show/NCT02591979; Identifier: NCT02591979.

Which older adults receive sleep medicine specialty care? Predictors of being seen by a board-certified sleep medicine provider

STUDY OBJECTIVES

The aim of this study was to characterize older adult Medicare beneficiaries seen by board-certified sleep medicine providers (BCSMPs) and identify predictors of being seen by a BCSMP.

METHODS

Our data source was a random 5% sample of Medicare administrative claims data (2006-2013). BCSMPs were identified using a cross-matching procedure based on national provider identifiers available within the Medicare database and assigned based on the first sleep disorder diagnosis received. Sleep disorders (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome) were operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. The number of sleep disorders per beneficiary was computed and compared between BCSMPs and nonspecialists. Logistic regression was used to identify medical and demographic predictors of being seen by a BCSMP.

RESULTS

A total of 57,209 beneficiaries received one or more sleep disorder diagnoses during the study period. Of these, 1,279 (2.2%) were initially diagnosed by a BCSMP. Relative to individuals seen by nonspecialists, beneficiaries treated by a BCSMP were more likely to have two or more sleep disorders (9.0% vs 24.1%, P < .001). The most common diagnosis assigned by BCSMPs was obstructive sleep apnea (70.4% of patients seen by BCSMPs were diagnosed with obstructive sleep apnea). The most common diagnosis assigned by nonspecialists was insomnia (48.2% of patients seen by nonspecialists were diagnosed with insomnia). In a fully adjusted regression model, male sex (odds ratio [OR] 1.53; 95% confidence interval [CI] 1.36, 1.72), asthma (OR 1.50; 95% CI 1.30, 1.73), and heart failure (OR 1.24; 95% CI 1.10, 1.41) were positively associated with being treated by a BCSMP. Conversely, depression (OR 0.85, 95% CI 0.73, 1.00), anxiety (OR 0.69, 95% CI .59, .82), Alzheimer and related dementias (OR 0.80, 95% CI .65, .99), and anemia (OR .88, 95% CI .78, .99) were associated with a reduced likelihood of being seen by a BCSMP.

CONCLUSIONS

Relative to older adults seen by nonspecialists, those seen by BCSMPs are more medically but less psychiatrically complex and are diagnosed with a greater number of sleep disorders. These results suggest the possibility that medically complex patients are referred for specialty care, whereas psychiatrically complex patients might be seen at the nonspecialist level. Further, these results demonstrate the value of board certification in sleep medicine in caring for complex sleep patients.

Coordinated program between primary care and sleep unit for the management of obstructive sleep apnea

The purpose of this study is to develop and validate a work model in the primary health-care setting for identifying patients with obstructive sleep apnea–hypopnea syndrome (OSAHS) based on clinical variables and an ambulatory sleep monitoring study. After screening, patients with mild–moderate OSAHS could be managed by primary care physicians, whereas those identified with severe OSAHS would be referred to specialists from sleep units for starting specific treatment. The proposed model does not move the entire health-care process to a generally overburdened primary care level and favors the coordinated work and the necessary flexibility to adapt the model to challenges and perspectives of OSAHS.

New organisation for follow-up and assessment of treatment efficacy in sleep apnoea

Obstructive sleep apnoea (OSA) is a highly prevalent disease, and there is an increased demand for OSA diagnosis and treatment. However, resources are limited compared with the growing needs for OSA diagnosis and management, and alternative strategies need to be developed to optimise the OSA clinical pathway. In this review, we propose a management strategy for OSA, and in general for sleep-disordered breathing, to be implemented from diagnosis to follow-up. For this purpose, the best current options seem to be: 1) networking at different levels of care, from primary physicians to specialised sleep laboratories; and 2) use of telemedicine. Telemedicine can contribute to the improved cost-effectiveness of OSA management during both the diagnostic and therapeutic phases. However, although the technology is already in place and different commercial platforms are in use, it is still unclear how to use telemedicine effectively in the sleep field. Application of telemedicine for titration of positive airway pressure treatment, follow-up to improve compliance to treatment through early identification and solution of problems, and teleconsultation all appear to be promising areas for improved OSA management.

Telemedicine could improve the management of sleep apnoea and other breathing disorders during sleep.http://bit.ly/2XPoPW1