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

Parental experiences in navigating health services for paediatric residual obstructive sleep apnoea: An exploratory qualitative descriptive study

OBJECTIVES

To explore parents' experiences and perceptions regarding engagement in health services for managing residual paediatric obstructive sleep apnoea (OSA) across levels of care.

METHODS

Qualitative description guided study design. Data were collected through semi-structured interviews with parents of children diagnosed with residual OSA at a university-based sleep clinic. The relevant literature informed the interview guide and was piloted before data collection. Inductive, manifest content analysis was used to describe parents' perceptions and experiences using data-driven categories and sub-categories. Several strategies were employed to ensure rigour in this study.

RESULTS

Eight interviews were conducted. Parents' views were organized into five categories: awareness of the sleep issue, interaction with non-sleep specialists, interaction with sleep specialists, interaction with dental professionals, and further actions and support. Parents reported several engagement issues due to their interactions with different care providers. These issues included having to personally identify and raise the sleep problem, feeling that care providers did not take this problem seriously, waiting for an extended period to be referred for sleep services, and receiving conflicting or insufficient treatment recommendations. Overall, parents perceived that their actions and the services received across levels of care were not effective enough to address paediatric OSA.

CONCLUSION

Based on this exploratory qualitative descriptive research, along with developing evidence-based clinical guidelines for paediatric OSA screening and management tailored to different levels of care, strategies intended to improve the engagement of patients and care providers in addressing paediatric OSA should be developed and empirically tested.

Temporal and Regional Trends in Obstructive Sleep Apnea Using Administrative Health Data in Alberta, Canada

Rationale: Obstructive sleep apnea (OSA) is a common treatable condition with important health and societal consequences. Objectives: We aimed to assess the annual incidence and prevalence of clinically recognized and geographic clustering of OSA in Alberta, Canada, using administrative health data case definitions. Methods: We used two administrative health databases in Alberta to identify ICD-9 and ICD-10 (International Classification of Diseases, Ninth and 10th Revisions, respectively) diagnostic codes for adults and children at least 2 years old diagnosed with OSA between 2003 and 2020. We defined OSA using an algorithm developed and validated in Alberta: at least three claims or one hospitalization within 2 years. We mapped residential postal codes to 70 subregional health authorities (SRHAs). Crude, age group- and sex-specific incidence and prevalence, and age group- and sex-standardized rates were calculated for Alberta and SRHAs. Spatial scan statistics identified clusters of SRHAs in which OSA cases were higher (hot spots) or lower (cold spots) than expected. Results: Between 2003 and 2020, OSA prevalence increased from 0.14% to 4.59%. The annual incidence of OSA increased after 2013. Incidence and prevalence were higher in older adults and children aged 2-11 years compared with 12-17 years. Cluster analysis revealed regional variation in OSA incidence and prevalence over time with no consistent pattern except for cold spots in one large metropolitan center (Calgary). Conclusions: From 2003 to 2020, the incidence and prevalence of clinically recognized OSA increased but varied by geography. Administrative health data can be used to guide interventions aimed at improving health service delivery and the quality of OSA care.

Knowledge and attitudes about obstructive sleep apnea among otorhinolaryngology trainee residents in Saudi Arabia: A survey-based cross-sectional study

BACKGROUND

Obstructive sleep apnea is a common disorder frequently encountered in otorhinolaryngology practice. This study was conducted to assess the knowledge and attitudes toward obstructive sleep apnea among otorhinolaryngology trainees in Saudi Arabia.  Methods: This was a survey-based cross-sectional study. An online questionnaire was sent in July 2020 via email and WhatsApp instant messaging to all otorhinolaryngology trainee residents in Saudi Arabia. We utilized the previously validated obstructive sleep apnea knowledge and attitudes questionnaire (OSAKA).  Results: 32.4% of all email recipients completed the questionnaire and met the inclusion criteria. 66.7% were males, thirty-two participants (53.3%) were at the junior level (R2-R3), and twenty-eight (46.7%) were at the senior level (R4-R5). The mean total knowledge score was 13.98/18. Senior residents had a higher mean total knowledge score than junior residents. Senior residents had a higher mean total attitude score than junior residents. Age, gender, residency program area, and years of previous otorhinolaryngology practice showed no significant differences in terms of knowledge levels and attitudes toward obstructive sleep apnea. Exposure to obstructive sleep apnea surgery and awareness of sleep disorders other than sleep apnea were found to be associated with an increased level of confidence in identifying patients at risk of obstructive sleep apnea and in the ability to manage them.  Conclusions: This study describes the current condition of obstructive sleep apnea knowledge and attitudes among otorhinolaryngology residents in Saudi Arabia. Addressing studied elements may improve training outcomes.

Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is an under-recognized condition that results in morbidity and mortality. Postoperative complications, including medical emergency team activation (META), are disproportionally increased among surgical patients at risk for OSA. A systematic approach is needed to improve provider recognition and treatment, but protocols that demonstrate improvement in META are lacking. As part of a multidisciplinary quality improvement project, DOISNORE50 (DIS), a sleep apnea questionnaire and proactive safety measure, was algorithmically applied to all perioperative patients.

METHODS

Consecutive sleep screening was conducted among perioperative patients. Of the 49,567 surgical navigation center patients, 11,932 had previous diagnosis of OSA. Of the 37,572 (96%) patients screened with DIS, 25,171 (66.9%) were Low Risk (DIS < 4), 9,211 (24.5%) were At Risk (DIS ≥ 4), and 3,190 (8.5%) were High Risk (DIS ≥ 6) for OSA, respectively. High Risk patients received same-day sleep consultation. On the day of surgery, patients with Known OSA, At Risk, and High Risk for OSA received an "OSA Precaution Band." An electronic chart reminder alerted admission providers to order postoperative continuous positive airway pressure (CPAP) machine and sleep consult for patients High Risk for OSA.

RESULTS

Implementation of a comprehensive program was associated with increased sleep consultation, sleep testing, and inpatient CPAP use (P < .001). For every 1,000 surgical patients screened, 30 fewer META, including rapid responses, reintubation, code blues, and code strokes, were observed. However, inpatient sleep consultation and inpatient CPAP use were not independently associated with reduced META. In the subgroup of patients hospitalized longer than 3 days, inpatient CPAP use was independently associated with reduced META.

CONCLUSIONS

In this single-center, institution-wide, multidisciplinary-approach, quality improvement project, a comprehensive OSA screening process and treatment algorithm with appropriate postoperative inpatient CPAP therapy and inpatient sleep consultations was associated with increased CPAP use and reduced META. Further prospective studies are needed to assess cost, feasibility, and generalizability of these findings.

CITATION

Namen AM, Forest D, Saha AK, et al. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):1953-1965.

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.

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).

Empathy, better patient care, and how interprofessional education can help

Interprofessional education (IPE) has been promoted as one way to prepare healthcare students for interprofessional encounters they might experience in the workplace. However, the link between IPE, interprofessional care in the workforce, and better patient outcomes is tenuous, perhaps in part due to the inability of IPE programs to adequately address barriers associated with interprofessional care (e.g., power differentials, role disputes). Empathy, or understanding the experiences of others, has emerged as a critical tool to breaking down barriers inherent to working in teams. Given the evidence connecting empathy to stronger team collaboration and better patient care, researchers significantly revamped programming from a prior training called Interprofessional Education for Complex Neurological Cases (IPE Neuro) to enhance empathy, foster stronger team collaboration, and improve information integration among participants. In this improved three-session program, participants from seven different professions were grouped into teams, assessed a patient volunteer with neurological disorder, and created and presented an integrated, patient-centric treatment plan. Students (N = 31) were asked to report general empathy levels, as well as attitudes, team skills, and readiness toward interprofessional care, before and after the program. We conducted paired samples t-tests and thematic analysis to analyze the data. Results showed that participants reported higher empathy levels, more positive attitudes, and greater team skills pre- to posttest with moderate to large effects. Results bolster IPE Neuro programming as one approach to prepare students for interprofessional care while underscoring the potential implications of IPE to improve empathy levels of healthcare professionals.

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.

An easy maneuver to screen for moderate-to-severe obstructive sleep spnea: the Simmons Chin Press and Tongue Curl

OBJECTIVES

To demonstrate that the Simmons chin press and tongue curl (SCPTC) correlates with diagnosis of moderate-to-severe obstructive sleep apnea (msOSA) by itself as well as irrespective of the presence of other associated features.

MATERIAL AND METHODS

A consecutive sample of 1,911 sleep studies performed on adult patients from 2/8/2017 to 3/5/2019 was analyzed. The SCPTC exam maneuver was performed on each patient, followed by home sleep apnea testing or in-laboratory polysomnography. The AASM hypopnea 1B 4% desaturation criteria were utilized for scoring to correlate results to existing literature on morbidity and mortality. A chi-squared using low and high SCPTC score was performed for the outcome of msOSA. Known significant predictors of OSA were dichotomized for comparison and a multiple logistic regression was performed.

RESULTS

1,708 patients qualified for inclusion: 902 males (52.8%) and 806 females (47.2%) with a mean age of 49.4 and a mean body mass index (BMI) of 28.6. A high SCPTC score correlated with an odds ratio (OR) of 2.49 (95% CI: 2.03-3.04, p<0.001) for msOSA. A multiple logistic regression analysis including other risk factors for msOSA demonstrated that high SCPTC scores had an odds ratio for msOSA of 1.77 (95% CI: 1.40-2.23; p<0.001).

CONCLUSION

The SCPTC is a reproducible physical exam feature that can be utilized by healthcare providers to screen for patients with msOSA.

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence: Unraveling the Puzzle of Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

Competencies to promote collaboration between primary and secondary care doctors: an integrative review

Background

In a society where ageing of the population and the increasing prevalence of long-term conditions are major issues, collaboration between primary and secondary care is essential to provide continuous, patient-centred care. Doctors play an essential role at the primary-secondary care interface in realising ‘seamless’ care. Therefore, they should possess collaborative competencies. However, knowledge about these collaborative competencies is scarce. In this review we explore what competencies doctors need to promote collaboration between doctors at the primary-secondary care interface.

Methods

We conducted an integrative literature review. After a systematic search 44 articles were included in the review. They were analysed using a thematic analysis approach.

Results

We identified six themes regarding collaborative competencies: ‘patient-centred care: a common concern’, ‘roles and responsibilities’, ‘mutual knowledge and understanding’, ‘collaborative attitude and respect’, ‘communication’ and ‘leadership’. In every theme we specified components of knowledge, skills and attitudes as found in the reviewed literature. The results show that doctors play an important role, not only in the way they collaborate in individual patient care, but also in how they help shaping organisational preconditions for collaboration.

Conclusions

This review provides an integrative view on competencies necessary for collaborative practice at the primary-secondary care interface. They are part of several domains, showing the complexity of collaboration. The information gathered in this review can support doctors to enhance and learn collaboration in daily practice and can be used in educational programmes in all stages of medical education.

The Impact of Telehealth on the Organization of the Health System and Integrated Care

Sleep medicine is a rapidly developing field of medicine that is well-suited to initiatives such as Telehealth to provide safe, effective clinical care to an expanding group of patients. The increasing prevalence of sleep disorders has resulted in long waiting lists and lack of specialist availability. Telemedicine has potential to facilitate a move toward an integrated care model, which involves professionals from different disciplines and different organizations working together in a team-oriented way toward a shared goal of delivering all of a person's care requirements. Issues around consumer health technology and nonphysician sleep providers are discussed further in the article.

Understanding the burden of illness of excessive daytime sleepiness associated with obstructive sleep apnea: a qualitative study

BACKGROUND

Obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness (EDS), which may go undiagnosed and can significantly impair a patient's health-related quality of life (HRQOL). This qualitative research examined timing and reasons patients sought medical care for their EDS and OSA symptoms, and the impact of EDS on HRQOL.

METHODS

Focus groups were conducted in 3 US cities with 42 participants currently experiencing EDS with OSA. Transcripts were coded and analyzed using an adapted grounded theory approach common to qualitative research.

RESULTS

Over three-fifths of study participants (n = 26, 62%) were currently using a positive airway pressure (PAP) or dental device; one-third (n = 14, 33%) had previously used a positive airway pressure (PAP) or dental device, and the remainder had either used another treatment (n = 1, 2%) or were treatment naïve (n = 1, 2%). Twenty-two participants (52%) reported experiencing OSA symptoms for ≥1 year, with an average duration of 11.4 (median 8.0, range 1-37) years before seeking medical attention. Several (n = 7, 32%) considered their symptoms to be "normal," rather than signaling a serious medical condition. Thirty participants (71%) discussed their reasons for ultimately seeking medical attention, which included: input from spouse/partner, another family member, or friend (n = 20, 67%); their own concern about particular symptoms (n = 7, 23%); and/or falling asleep while driving (n = 5, 17%). For all 42 participants, HRQOL domains impacted by EDS included: physical health and functioning (n = 40, 95%); work productivity (n = 38, 90%); daily life functioning (n = 39, 93%); cognition (n = 38, 90%); social life/relationships (n = 37, 88%); and emotions (n = 30, 71%).

CONCLUSIONS

Findings suggest that patients may be unaware that their symptoms could indicate OSA requiring evaluation and treatment. Even following diagnosis, EDS associated with OSA can continue to substantially affect HRQOL and daily functioning. Further research is needed to address diagnostic delays and unmet treatment needs for patients with EDS associated with OSA.

Sleep breathing disorders: have we reached the tipping point?

Sleep medicine: a new approach http://ow.ly/qzVh30iVkWL.

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.

Obstructive sleep apnea knowledge and attitudes among recent medical graduates training in Ecuador

Background

We aimed to assess recent Latin American medical school graduates' knowledge and attitudes about OSA and examine whether their knowledge and attitudes about OSA differed from practicing physicians.

Methods

Recent medical graduates completed the Spanish translation of the OSA Knowledge and Attitudes (OSAKA) questionnaire at the 2013 national primary-care residency-placement meeting in Ecuador. The OSAKA includes 18 knowledge and five attitudinal items about OSA. We compared recent graduates' data with data collected in 2010-2011 from practicing physicians using chi-square tests of associations among categorical variables and analysis of variance of differences in mean knowledge and attitude scores. Unadjusted logistic regression models tested the odds that recent graduates (vs. practicing physicians) answered each item correctly.

Results

Of 265 recent graduates, 138 (52.1%) were male, and mean age was 25.9 years. Although mean knowledge was low overall, scores were lower for recent graduates than for the 367 practicing physicians (53.5% vs. 60.4%; p < 0.001). Practicing physicians were significantly more likely to answer specific items correctly with one exception-recent graduates were more likely to know that < 5 apneas-hypopneas/h is normal (OR 1.47, 1.03-2.07). Physicians in practice attributed greater importance to OSA as clinical disorder and the need for identifying patients with OSA; but recent graduates reported greater confidence in managing patients with OSA and CPAP.

Conclusions

OSA-focused educational interventions during medical school should help to improve recent medical graduates' abilities to diagnose and treat OSA. We recommend a greater number of hours of medical students' exposure to sleep education.

An investigation into the association between demographic and morbidity factors, and sleep disturbance

BACKGROUND

The recognition of sleep disorders is important because in the long term, they are associated with numerous deleterious health outcomes. Despite the high prevalence of sleep disorders, they are widely under-diagnosed at general practice level.

AIM

This study aims to investigate the association between demographic and morbidity factors, and self-reported sleep disturbance symptoms.

METHODS

A quantitative cross-sectional study design was used. The data collection tool was an anonymous questionnaire consisting of 22 sleep symptoms categorised into four subscales: 1. Insomnia, 2. Daytime Distress, 3. Sleep Disorder, 4. Psychological Distress. Participants were adults ≥18 years of age attending their general practitioner.

RESULTS

A total of 281 questionnaires were analysed (70.3% response rate). Participants with a diagnosis of depression and those who experienced low mood 'very frequently' had significantly higher median scores on all four subscales. Those with a body mass index (BMI) >30 kg/m² had a higher median score on subscale 3, compared to those with lower BMIs. Smokers had higher median scores on subscales 1-3 compared to non-smokers. Participants >65 years of age had lower median scores on all subscales compared to younger participants. Married participants had lower median scores on subscales 1-3 compared to unmarried participants. A total of 37% reported that they would be willing to participate in an overnight sleep study, and 5.3% had been formally diagnosed with a sleep disorder.

CONCLUSIONS

A number of factors are significantly associated with sleep disturbance, particularly depression, low mood, elevated BMI and smoking. General practitioners should consider these factors to increase recognition of patients who would benefit from sleep disorder investigation.

A Survey of Sleep Medicine Physician Perceptions on the Surgical Treatment of Obstructive Sleep Apnea

PURPOSE

Surgical treatment for obstructive sleep apnea (OSA) varies by specialty. Our survey sought to answer 3 principal questions: 1) To which surgical specialists are sleep physicians referring patients for upper airway surgery? 2) Which surgical treatment do sleep specialists find to be most effective in treating OSA? 3) Do sleep medicine physicians believe that maxillomandibular advancement (MMA) is worthwhile to patients who are surgical candidates?

MATERIALS AND METHODS

We formulated a cross-sectional survey. The study sample was obtained by identifying all practices that advertised as sleep medicine specialists in Houston, Texas, by using Internet searches. Physicians who treated children were excluded. Seventy-nine surveys were hand delivered to offices in the greater Houston area; the survey included 6 questions to determine referral and surgical preferences for OSA. Variable responses included years in practice, specialty, and a comments section. A 10-point Likert scale was used to assess sleep medicine physicians' referral patterns and perceptions regarding surgical treatment of OSA. Numerical data were analyzed by calculating mean values and by dividing responses into "disagree" (<5), "neutral" (5), and "agree" (>5).

RESULTS

Twenty-six surveys were returned. More sleep medicine physicians referred patients to ear, nose, and throat surgeons (52%) than to oral and maxillofacial surgeons (20%). MMA was viewed as the most effective surgery (72%), followed by "none" (16%), "other" (8%), and uvulopalatopharyngoplasty (4%). More respondents viewed the benefits versus risks as favorable for MMA (44%) than for uvulopalatopharyngoplasty (29%).

CONCLUSIONS

The results of this survey show that sleep medicine physicians in the greater Houston area view MMA as the most favorable and effective surgical option for treating OSA. Although MMA was most often referred for, more respondents refer patients to ear, nose, and throat surgeons than to oral and maxillofacial surgeons for surgical management of OSA. Years in practice displayed no correlation in referral patterns or preference for type of OSA surgery.

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.

Major care gaps in asthma, sleep and chronic obstructive pulmonary disease: a road map for knowledge translation

Large gaps between best evidence-based care and actual clinical practice exist in respiratory medicine, and carry a significant health burden. The authors reviewed two key care gaps in each of asthma, chronic obstructive pulmonary disease and obstructive sleep apnea. Using the 'Knowledge-to-Action Framework', the nature of each gap, its magnitude, the barriers that cause and perpetuate it, and past and future strategies that might address the problem were considered. In asthma: disease control is ascertained inadequately, leading to a prevalence of poor asthma control of approximately 50%; and asthma action plans, a key component of asthma management, are provided by only 22% of physicians. In obstructive sleep apnea: disease is under-recognized, with sleep histories ascertained in only 10% of patients; and Canadian polysomnography wait times remain longer than recommended, leading to unnecessary morbidity and societal cost. In chronic obstructive pulmonary disease: a large proportion of patients seen in primary care remain undiagnosed, mainly due to underuse of spirometry; and <10% of patients are referred for pulmonary rehabilitation, despite strong evidence demonstrating its cost effectiveness. Given the prevalence of these chronic conditions and the size and nature of these gaps, the latter exact an important toll on patients, the health care system and society. In turn, complex barriers at the patient, provider and health care system levels contribute to each gap. There have been few previous attempts to bridge these gaps. Innovative and multifaceted implementation approaches are needed and have the potential to make a large impact on Canadian respiratory health.