The environmental impact of diagnosis and therapy in obstructive sleep Apnea: A systematic review.

A randomized controlled trial of sleep study surveillance with targeted autoregulated positive airway pressure therapy for obstructive sleep apnea in pregnancy

Sociodemographic disparities and healthcare utilization in pediatric obstructive sleep apnea management

Chinese guideline for the diagnosis and treatment of childhood obstructive sleep apnea (2020).

: BackgroundWest Virginia (WV) has the highest rates of obesity and cardiopulmonary disease in the United States (U.S.). Recent work has identified a significant care gap in WV for obstructive sleep apnea (OSA). This OSA care gap likely has significant health implications for the region given the high rates of obesity and cardiopulmonary disease. The purpose of this mix methods study was to identify barriers that contribute to the rural OSA care disparity previously identified in WV. Methods: This study used mixed methods to evaluate the barriers and facilitators to management of OSA at Federally Qualified Health Centers serving communities in southern WV. Focus groups were conducted at federally qualified health centers with providers serving Appalachian communities. Participants also completed the validated Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire to gain insight into provider knowledge and beliefs regarding OSA. EMR analysis using diagnostic codes was completed at the sites to assess OSA prevalence rates. The same individual served as the interviewer in all focus group sessions to minimize interviewer variability/bias. Our team checked to ensure that the professional transcriptions were correct and matched the audio via spot checks. Results: Themes identified from the focus groups fell into three broad categories: (1) barriers to OSA care delivery, (2) facilitators to OSA care delivery, and (3) community-based care needs to optimize management of OSA in the targeted rural areas. Questionnaire data demonstrated rural providers feel OSA is an important condition to identify but lack confidence to identify and treat OSA. Evaluation of the electronic medical record demonstrates an even larger OSA care gap in these rural communities than previously described. Conclusion: This study found a lack of provider confidence in the ability to diagnose and treat OSA effectively and identified specific themes that limit OSA care in the communities studied. Training directed toward the identified knowledge gaps and on new technologies would likely give rural primary care providers the confidence to take a more active role in OSA diagnosis and management. An integrated model of care that incorporates primary care providers, specialists and effective use of modern technologies will be essential to address the identified OSA care disparities in rural WV and similar communities across the U.S. Community engaged research such as the current study will be essential to the creation of feasible, practical, relevant and culturally competent care pathways for providers serving rural communities with OSA and other respiratory disease to achieve health equity.

To determine the incremental increases in health care utilization and expenditures associated with sleep disorders. Adults with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) within the medical conditions file of the 2018 Medical Expenditure Panel Survey medical conditions file were identified. This dataset was then linked to the consolidated expenditures file and comparisons in health care utilization and expenditures were made between those with and without sleep disorders. Multivariate analyses, adjusted for demographics and comorbidities, were conducted for these comparisons. Overall, 5.6% ± 0.2% of the study population had been diagnosed with a sleep disorder, representing approximately 13.6 ± 0.6 million adults in the United States. Those with sleep disorders were more likely to be non-Hispanic, White, and female, with a higher proportion with public insurance and higher Charlson Comorbidity Scores. Adults with sleep disorders were found to have increased utilization of office visits (16.3 ± 0.8 vs 8.7 ± 0.3, P < .001), emergency room visits (0.52 ± 0.03 vs 0.37 ± 0.02, P < .001), and prescriptions (39.7 ± 1.2 vs 21.9 ± 0.4, P < .001) vs those without sleep disorders. The additional incremental health care expenses for those with sleep disorders were increased in all examined measures: total health care expense ($6,975 ± $800, P < .001), total office-based expenditures ($1,694 ± $277, P < .001), total prescription expenditures ($2,574 ± $364, P < .001), and total self-expenditures for prescriptions ($195 ± $32, P < .001). Sleep disorders are associated with significantly higher rates of health care utilization and expenditures. By using the conservative prevalence estimate found in this study, the overall incremental health care costs of sleep disorders in the United States represents approximately $94.9 billion. Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021;17(10):1981-1986.

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA. Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance. Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home. T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA. Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

RATIONALE: Geography is an increasingly recognized barrier to the diagnosis and treatment of chronic diseases, yet no prior studies have investigated its influence on the patient-borne burden of obstructive sleep apnea (OSA) care. OBJECTIVE: We aimed to determine if wait times and costs of OSA care differ between rural and urban adults. METHODS: We conducted a secondary analysis of data from a prospective cohort study comparing OSA treatment outcomes among urban and rural adults. Participants were recruited at the time of continuous positive airway pressure (CPAP) initiation for uncomplicated OSA. Residential postal codes were translated into geographic census areas to classify participants as urban (community size > 100,000) or rural. Participants were administered a questionnaire exploring wait times and costs of OSA care at baseline and three months. RESULTS: We enrolled 242 participants (100 rural). Twenty-six percent of respondents waited at least six months to seek medical attention for possible OSA, with no difference between groups. Wait times for diagnosis and treatment were three months or less for 91 and 93% of respondents, respectively. However, rural respondents experienced longer delays from first assessment to diagnosis and from diagnosis to treatment. Fewer individuals with rural residence were supported by government funding for diagnostic testing or CPAP. Rural participants more commonly reported additional appointment-related costs and greater total costs of care. CONCLUSION: Rural patients experience longer wait times and a greater financial burden for OSA care. The findings of this study will inform the development of novel models of OSA care sensitive to the needs of unique populations.

Refining the diagnosis of obstructive sleep apnoea

A REAL-WORLD STUDY ASSESSING THE RELATIONSHIP BETWEEN POSITIVE AIRWAY PRESSURE TREATMENT, EXCESSIVE DAYTIME SLEEPINESS, AND PATIENT SATISFACTION IN OSA

The Lung Centre, Vancouver, British Columbia Correspondence: Dr John A Fleetham, The Lung Centre, 7th Floor, 2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5653, fax 604-875-5587, e-mail john.fleetham@vch.ca In the current issue of the Canadian Respiratory Journal, Rotenberg et al (1) (pages 170-174) report data from a crosssectional survey sent to otolaryngologists, respirologists and family physicians in Ontario, to characterize wait times for obstructive sleep apnea (OSA) care. The major finding was that patients with suspected OSA in Ontario waited a mean of 11.6 months to initiate continuous positive airway pressure (CPAP) treatment and 16.2 months to initiate surgical therapy. This is much longer than the wait time in the Canadian Thoracic Society (CTS) guidelines, which recommend a maximum wait time of two to four weeks for urgent patients with comorbid disease or daytime sleepiness and a critical safety occupation, and six months for all patients with suspected OSA (2,3). Excessive diagnostic wait times frequently lead to inappropriate or incorrect therapy. Wait times for the diagnosis of sleep apnea in Canada have not improved much since Flemons et al (4) reviewed wait times for the diagnosis of OSA in five countries, including Canada, 16 years previously. To paraphrase what Pack (5) wrote in an associated editorial: “It seems inconceivable that we should tell a patient the following: You are highly likely to have severe sleep apnea, a disorder associated with an increased risk of car crashes, high blood pressure, and probably heart attack and stroke. We have an effective treatment for this disorder. We will arrange a study for you in 11.6 months’ time to assess this”. The even longer wait time for surgical treatment of OSA reported by Rotenberg et al also merits comment. The role of corrective upper airway surgery in the treatment of OSA is controversial. The current CTS guidelines conclude that laser-assisted uvulopalatoplasty is not recommended for the treatment of OSA, but that uvulopalatopharyngoplasty may be considered in selected patients with OSA who have failed CPAP and/or oral appliance therapy. The delay in the diagnosis and treatment of OSA in Ontario needs to be put in the context of the rest of Canada, where the diagnosis and treatment of sleep apnea is provided in a very different manner. Ontario has the highest number of sleep laboratories in Canada and most other parts of the world apart from the United States (4). Moreover, Ontario is one of the few provinces, along with Manitoba and Saskatchewan, in which the provincial medical plan funds CPAP treatment. The majority of centres in Canada outside of Ontario use ambulatory sleep monitoring – in addition to polysomnography – to diagnose OSA. After OSA has been diagnosed, there is no additional delay in the provision of CPAP therapy because this is funded by the patient and does not require approval by a funding agency. The majority of respondents to the survey in the article by Rotenberg et al (1) identified ‘not enough sleep laboratories’ as the reason for long wait times. Many would argue that more sleep laboratories are not what is required – what is necessary is a more appropriate diagnostic strategy that uses clinical prediction equations and ambulatory sleep monitoring (6) in conjunction with polysomnography for patients with comorbid disease or who fail to improve with CPAP treatment. Furthermore, if resources for the management of OSA are to be rationed, a higher priority should be given to treatment than to diagnosis. Patients with OSA use health care services at approximately twice the rate of control subjects for up to 10 years before the diagnosis of OSA (7). CPAP treatment has an incremental cost-effectiveness ratio of $2,618 per quality-adjusted life year over no treatment (8). A ratio of less than $10,000 per qualityadjusted life year is generally considered to be extremely cost effective. While CPAP treatment for OSA is funded in many other countries including the United Kingdom (9) and the United States (10), it is not funded in the majority of Canadian provinces. In 2008, The Lung Association and the CTS jointly recommended funding of CPAP treatment under all provincial and federal health insurance plans for adults and children appropriately diagnosed with OSA; however, little progress has been made over the past two years. It is now time to end the postal code differences that currently exist in Canada with regard to access to the diagnosis and treatment of OSA. editorial

IntroductionCovid-19-related public health control measures have necessitated a rapid transition in healthcare delivery. We qualitatively explored clinicians’ and patients’ experiences of the pandemic’s impact on the delivery and receipt of obstructive sleep apnea (OSA) care.MethodsBetween September and December 2020, we conducted ten 90-minute virtual focus groups with sleep clinicians (n=19) and English and Spanish-speaking patients with OSA (n= 30) recruited through an urban academic sleep clinic, national organizations, social media, and snowball sampling. An interdisciplinary team conducted a rapid qualitative analysis that included prefigured and emergent domains. The team developed a comprehensive analytic matrix, identifying key themes within and between groups and triangulating them across participant types.ResultsClinicians and patients across all groups confirmed a rapid shift to the adoption of telemedicine. Clinicians reported telemedicine enhanced evaluations by enabling direct observation of the home environment, providing opportunities to guide patients on medical equipment used in the home, and cultivating meaningful social connections for patients. Perceived benefits varied across patient subgroups (age, language, technological self-efficacy). The majority of clinicians reported that telemedicine’s initial uptake resulted in delays in care and revenue loss, but sustained use was thought to be feasible over time. Patients reported delays in care related to the pandemic’s disruption on healthcare and their personal safety concerns. Additionally, telemedicine’s adoption directly altered other elements of care, including the delivery of patient education materials and loss of tacit information gained during the in-person visit. All groups reported adequate mask fitting as a central challenge for patients using positive airway pressure therapy. Spanish-speaking patients noted concerns of increased difficulty accessing care and navigating the OSA care system due to limited English proficiency, in addition to the limited availability of OSA resources in Spanish.ConclusionDuring the Covid-19 pandemic, the rapid adoption of telemedicine largely facilitated OSA care but altered patient-clinician interactions, delivery of patient education materials, and mask fitting success. Given that telemedicine will likely be sustained post-pandemic, there are needs for targeted efforts aimed at addressing disparities in telemedicine, enhancing practitioner telepresence and education, and new approaches for mask fitting to ensure successful OSA care.Support (if any)Patient-Centered Outcomes Research Institute EADI-16493

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients

The aim was to determine the feasibility of using an unattended 2-channel device to screen for obstructive sleep apnea in a population of high-risk patients using a targeted, case-finding strategy. The case finding was based on the presence of risk factors not symptoms in the studied population. The study took place from June 2007 to May 2008 in rural and metropolitan Queensland and New South Wales. Family doctors were asked to identify patients with any of the following: BMI > 30, type 2 diabetes, treated hypertension, ischemic heart disease. Participants applied the ApneaLink+O2 at home for a single night. The device recorded nasal flow and pulse oximetry. Data were analyzed by proprietary software, then checked and reported by either of two sleep physicians. 1,157 patients were recruited; mean age 53 ± 14.6, M/F% = 62/38, mean BMI = 31.8, obesity = 35%, diabetes = 16%, hypertension = 39%, IHD = 5%, Mean Epworth Sleepiness Scale score (ESS) = 8.3. The prevalence of unrecognized OSA was very high: 71% had an AHI > 5/h, 33% had an AHI > 15/h, and 16% had an AHI > 30/h. The ApneaLink+O2 device yielded technically adequate studies in 93% of cases. The study shows that a "real world" simple low cost case finding and management program, based on unattended home monitoring for OSA, can work well in a population with risk factors and comorbidities associated with OSA, independent of the presence of symptoms. The prevalence of unrecognized OSA was very high.

Obstructive sleep apnea (OSA) is a prevalent and debilitating condition that is significantly underdiagnosed. The majority of adults sleep with someone-a partner. Partners can play a significant role in the patient's OSA diagnosis. The goal of this work is to describe facilitators and barriers to OSA diagnosis as discussed by patients with OSA and their partners. This was a qualitative secondary analysis with results drawn from 20 dyadic interviews, conducted 1 couple at a time, in 20 newly diagnosed adult patients with OSA and their partners. Qualitative interview data were analyzed using conventional content analysis. Facilitators of OSA diagnosis were partners pushing patients to seek care, patients actively seeking care, and care providers identifying the patient's risk of OSA. Barriers to OSA diagnosis were patients' lack of serious attention to symptoms, patients' negative perceptual framing of diagnosis and treatment of OSA, and poor coordination of health care services. We recommend engaging partners in the OSA diagnosis and developing educational and behavioral interventions to raise public awareness about OSA. It is important to educate clinicians on atypical presentations of OSA. Further investigation is needed to evaluate the impact of health care services on OSA diagnosis. Ye L, Li W, Willis DG. Facilitators and barriers to getting obstructive sleep apnea diagnosed: perspectives from patients and their partners. J Clin Sleep Med. 2022;18(3):835-841.

The aims of this study were to characterize obstructive sleep apnea (OSA) care pathways among commercially insured individuals in the United States and to investigate between-groups differences in population, care delivery, and economic aspects. We identified adults with OSA using a large, national administrative claims database (January 1, 2016-February 28, 2020). Inclusion criteria included a diagnostic sleep test on or within ≤ 12 months of OSA diagnosis (index date) and 12 months of continuous enrollment before and after the index date. Exclusion criteria included prior OSA treatment or central sleep apnea. OSA care pathways were identified using sleep testing health care procedural health care common procedure coding system/current procedural terminology codes then selected for analysis if they were experienced by ≥ 3% of the population and assessed for baseline demographic/clinical characteristics that were also used for model adjustment. Primary outcome was positive airway pressure initiation rate; secondary outcomes were time from first sleep test to initiation of positive airway pressure, sleep test costs, and health care resource utilization. Associations between pathway type and time to treatment initiation were assessed using generalized linear models. Of 86,827 adults with OSA, 92.1% received care in 1 of 5 care pathways that met criteria: home sleep apnea testing (HSAT; 30.8%), polysomnography (PSG; 23.6%), PSG-Titration (19.8%), Split-night (14.8%), and HSAT-Titration (3.2%). Pathways had significantly different demographic and clinical characteristics. HSAT-Titration had the highest positive airway pressure initiation rate (84.6%) and PSG the lowest (34.4%). After adjustments, time to treatment initiation was significantly associated with pathway (P < .0001); Split-night had shortest duration (median, 28 days), followed by HSAT (36), PSG (37), PSG-Titration (58), and HSAT-Titration (75). HSAT had the lowest sleep test costs and health care resource utilization. Distinct OSA care pathways exist and are associated with differences in population, care delivery, and economic aspects. Wickwire EM, Zhang X, Munson SH, etal. The OSA patient journey: pathways for diagnosis and treatment among commercially insured individuals in the United States. J Clin Sleep Med. 2024;20(4):505-514.