Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives

STUDY OBJECTIVES

Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed.

METHODS

We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.

RESULTS

Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options.

CONCLUSIONS

Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated.

CITATION

Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.

452 Patient Factors and Preferences in Decision for Sleep Surgery: A Qualitative Analysis

Introduction

Patients with obstructive sleep apnea (OSA) are offered many treatment options spanning the spectrum of lifestyle modification, device therapy, and surgery. Sleep surgery, while often effective, results in moderate morbidity and has variable effectiveness on OSA improvement. Little is known about what patients consider when choosing treatment. We aim to identify factors that influenced the decision for sleep surgery among adults with OSA.

Methods

We conducted semi-structured virtual interviews with patients (≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep) who underwent sleep surgery at a tertiary academic center, querying patients about factors in their decision for OSA treatment. Interviews were audio-recorded, transcribed, and analyzed for thematic content. We anticipate enrolling 10–18 total participants based on previously reported sample size in specialty groups for thematic saturation in specialty groups (ie, when no new concepts or factors emerge from interviews). Here we report pilot qualitative analysis results.

Results

Of nine eligible patients, eight enrolled (mean +/- standard deviation age 45.8 +/- 13.4 years, 2 female/6 males). Four patients underwent nasal surgery only, two patients underwent staged procedures, one underwent pharyngeal surgery only, and the last underwent nasal surgery with tori removal. Patients reported decision making duration of days to years for scheduling surgery. Reasons for pursuing sleep surgery included fatigue, quality of life, work performance, and safety. Overarching thematic domains related to decision for surgery were (1) major concerns, (2) external factors influencing decision, and (3) retrospective satisfaction/regret with decision. Major concerns involved factors beyond surgeon’s control, such as anesthesia and postoperative pain management, not surgery itself. Family and friends were reported to be highly influential in the process, both in favor and against surgery. Social media features and celebrity patients with OSA heightened awareness of sleep surgery and set preconceived expectations. Patients were mostly satisfied with outcomes, despite unanticipated acute recovery challenges.

Conclusion

This pilot qualitative analysis identifies factors influencing patients’ OSA treatment decisions. Understanding patients’ major concerns and sources of information may help to guide physician counseling, set realistic expectations, offer peri-operative support, and better engage parents in shared decision-making for sleep surgery.

Support (if any)

None.

Nasal angiosarcoma metastatic to the larynx: Case report and systematic review of the literature

BACKGROUND

Laryngeal angiosarcoma is rare and the prognosis is poor. The purpose of this study was to describe the first case of cutaneous angiosarcoma metastatic to the larynx and systematically review all cases of laryngeal angiosarcoma.

METHODS

A 61-year-old man presented with an alar lesion diagnosed as angiosarcoma and was treated with wide local resection and radiation. Six years later, he presented with a laryngeal mass histologically similar to the initial tumor. A systematic review of reported cases of angiosarcoma of the larynx was performed.

RESULTS

Eighteen cases were identified. Mean age of presentation was 64.3 years. Men represented 66.7%. Mean follow-up was 34.1 months. Forty-seven percent died with disseminated disease at a mean of 18.4 months. Our patient did well with serial resection.

CONCLUSION

To the best of our knowledge, this case represents the first documented case of cutaneous angiosarcoma metastatic to the larynx and suggests that serial resection with long-term surveillance may be of benefit in some cases.

Reliable short-term memory in the trion model: toward a cortical language and grammar

It has previously been shown that Hebb learning in a single column in the trion model of cortical organization occurs by selection. Motivated by von Neumann's solution for obtaining reliability and by models of circulating cortical activity, we introduce Hebb intercolumnar couplings to achieve dramatic enhancements in reliability in the firing of connected columns. In order for these enhancements to occur, specific temporal phase differences must exist between the same inherent spatial-temporal memory patterns in connected columns. We then generalize the criteria of large enhancements in the global firing of the entire connected columnar network to investigate the case when different inherent memory patterns are in the columns. The spatial rotations as well as the temporal phases now are crucial. Only certain combinations of inherent memory patterns meet these criteria with the symmetry properties playing a major role. The columnar order of these memory patterns not in the same symmetry family can be extremely important. This yields the first higher-level architecture of a cortical language and grammar within the trion model. The implications of this result with regard to an innate human language and grammar are discussed.