Obstructive Sleep Apnea Care Research Articles

Strategies to address common sleep disorders among middle-aged and older adults

Abstract Obstructive sleep apnea (OSA) is an underdiagnosed and prevalent condition in middle-aged and older adults, with a disproportionate burden of OSA in marginalized populations. Lack of appropriate and timely treatment puts many at risk of poor quality of life, comorbidity, motor vehicle crashes and increased health care utilization. Furthermore, social and environmental disparities were acknowledged as contributing to sleep health disparities, OSA health literacy and adherence to OSA treatment. This presentation will overview the social and environmental determinants of OSA prevalence and management. The presenter will also cover strategies to improve access and waiting time for OSA diagnosis and treatment in middle-aged and older adults, such as screening for OSA in general and marginalized populations, alternative at-home OSA detection solutions, involvement of alternative care providers in OSA care, alternative OSA targeted therapies, including accessible self-administered interventions, health equity interventions targeting OSA, and promotion of sleep-centered lifestyle approaches, including weight loss, diet and exercise.

Morphological Prediction of CPAP Associated Acute Respiratory Instability.

Multiple mechanisms are involved in the pathogenesis of obstructive sleep apnea (OSA). Elevated loop gain is a key target for precision OSA care and may be associated with treatment intolerance when the upper airway is the sole therapeutic target. Morphological or computational estimation of LG is not yet widely available or fully validated - there is a need for improved phenotyping/endotyping of apnea to advance its therapy and prognosis. This study proposes a new algorithm to assess self-similarity as a signature of elevated loop gain using respiratory effort signals and presents its use to predict the probability of acute failure (high residual event counts) of continuous positive airway pressure (CPAP) therapy. Effort signals from 2145 split-night polysomnography studies from the Massachusetts General Hospital were analyzed for SS and used to predict acute CPAP therapy effectiveness. Logistic regression models were trained and evaluated using 5-fold cross-validation. Receiver operating characteristic (ROC) and precision-recall (PR) curves with AUC values of 0.82 and 0.84, respectively, were obtained. Self-similarity combined with the central apnea index (CAI) and hypoxic burden outperformed CAI alone. Even in those with a low CAI by conventional scoring criteria or only mild desaturation, SS was related to poor therapy outcomes. The proposed algorithm for assessing SS as a measure of expressed high loop gain is accurate, non-invasive, and has the potential to improve phenotyping/endotyping of apnea, leading to more precise sleep apnea treatment strategies.

Discrepancies in pediatric OSA surgery hospital stay length across regions

ObjectiveTo investigate regional disparities in the length of hospital stay (LOS) for pediatric patients undergoing tonsillectomy for obstructive sleep apnea (OSA) in the United States. MethodsWe utilized the Healthcare Cost and Utilization Project (HCUP) Kid Inpatient Database (KID) for 2016, analyzing data on pediatric OSA patients aged 0–20. We compared LOS in different U.S. regions and employed statistical tests to assess significance. ResultsRegional variation in LOS was observed among pediatric OSA patients. The Midwest and South regions showed longer LOS compared to the West and Northeast. Notably, standard deviations for LOS in the Midwest and South were substantial, signifying significant variability. ConclusionOur findings emphasize the importance of addressing regional differences in pediatric OSA care. Prolonged hospital stays can impose significant burdens on children and families. Identifying and mitigating factors driving these disparities is crucial for enhancing the quality and efficiency of care, ultimately striving for more equitable healthcare for pediatric OSA patients nationwide.

Decisional Needs of Veterans With Mild Traumatic Brain Injury Initiating Treatment for Insomnia Disorder and Obstructive Sleep Apnea.

We sought to elicit key informant (KI) perspectives regarding decisional needs of Veterans with mild traumatic brain injury (mTBI) who are initiating insomnia disorder and obstructive sleep apnea (OSA) treatment within the Veterans Health Administration (VHA) Polytrauma/TBI System of Care (PSC). Specifically, we sought to understand: (1) information regarding treatment options that Veterans with mTBI require in order to make an informed decision; and (2) values used to guide decision-making (ie, personally meaningful aspects of the decision used to compare treatment options). Nationwide VHA PSC sites. Clinicians included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders in the VHA PSC (n =29). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year (n =20). Semi-structured interviews with the 49 KIs were recorded and transcribed verbatim. Themes were identified using a descriptive and interpretive approach to qualitative analysis. Not applicable. Informational needs identified by both KI groups included information regarding outcomes and downsides of treatment, accessible delivery, treatment candidates, description of diagnosis, and level of commitment. Values used to guide decision-making for both insomnia disorder and OSA treatment included benefits, downsides, and availability of treatments. Values used to decide on insomnia treatments alone included time commitment, intrinsic management of sleep, beliefs regarding mental health treatment, and time course of benefit. Values used to decide on OSA treatment alone included intrusiveness of the treatment, appearance, and impact on bed partners. The current study revealed the decisional needs of Veterans with mTBI who are initiating sleep disorder treatment. Findings can inform the development of decision aids and other efforts aimed at promoting patient-centered management of comorbid mTBI and sleep disorders, thereby improving care quality and clinical outcomes.

Racial Disparity in Obstructive Sleep Apnea Care and its Impact on Cardiovascular Health.

Racial disparities in sleep health as well as the diagnosis and treatment of sleep disorders have emerged as a key driver of cardiovascular outcomes. Obstructive sleep apnea (OSA), is characterized by repeated airway obstructions during sleep and is associated with an increased risk of cardiovascular disease. While racial and ethnic minorities have disproportionately high OSA prevalence rates, diagnosis rates remain low. One explanation behind this phenomenon are structural environmental and lifestyle barriers that prevent access to OSA care. Additionally, there remains significantly limited understanding of OSA and its causes and symptoms within communities. In general, minorities have poorer sleep health due to systemic and environmental racism, which also causes an increased in conditions such as obesity that increases OSA risk. Disparities also persist within various types of OSA treatment. The most common form of treatment, continuous positive airway pressure (CPAP) has lower adherence among African Americans, as well as those living in areas with low socioeconomic status (SES), primarily minorities. There have been a small number of studies that have shown some initial success of educational campaigns about OSA within minority communities in increasing screenings and diagnoses. Peer based education has been an effective technique, and there is a need for such programs to be expanded. Disparities persist, with minority groups having worse sleep health and lower rates of adherence to OSA treatment. Some grassroots, peer-led educational campaigns show promise in increasing adherence. In light of these disparities, there remains a need for the field of sleep medicine to continue addressing the systemic barriers that hinder the timely evaluation and treatment in racial minorities.

Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation.

Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA. The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them. A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation. Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022. This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

A real-world observational study assessing relationships between excessive daytime sleepiness and patient satisfaction in obstructive sleep apnea

Objectives/BackgroundTo estimate prevalence and severity of excessive daytime sleepiness among patients with obstructive sleep apnea (OSA) who were prescribed treatment; assess perception and satisfaction of OSA-related care; describe relationships between excessive daytime sleepiness, treatment adherence, and patient satisfaction. Patients/methodsA national population-based cross-sectional sample of US adults with clinician-diagnosed OSA was surveyed in January 2021 via Evidation Health's Achievement App. Patients completed the Epworth Sleepiness Scale, rated satisfaction with healthcare provider and overall OSA care, and reported treatment adherence. Covariates affecting excessive daytime sleepiness (average weekly sleep duration, treatment adherence, sleepiness-inducing medications, age, sex, body mass index, nasal congestion, smoking status, and comorbidities) were adjusted in multivariate regression models. ResultsIn 2289 participants (50.3 % women; 44.8 ± 11.1 years), EDS was highly prevalent (42 %), and was experienced by 36 % of patients with high positive airway pressure (PAP) therapy adherence. Each additional hour of nightly PAP use was associated with improved sleepiness (a 0.28-point lower Epworth score; p < 0.001). Excessive daytime sleepiness was associated with lower patient satisfaction with healthcare providers and overall care (OR [95 % CI] 0.62 [0.48–0.80] and 0.50 [0.39–0.64], respectively; p < 0.0001), whereas PAP adherence was associated with higher patient satisfaction (OR [95 % CI] 2.37 [1.64–3.43] and 2.91 [2.03–4.17]; p < 0.0001), after adjusting for confounders. ConclusionsIn a real-world population-based study of patients with OSA, excessive daytime sleepiness was highly prevalent and associated with poor patient satisfaction ratings. Better patient-centered care among patients with OSA may require interventions aimed at addressing excessive daytime sleepiness and treatment adherence.

Cost-Utility Analysis of Continuous Positive Airway Pressure Therapy Compared With Usual Care for Obstructive Sleep Apnea in the Public Health System in Brazil

ObjectivesThis study aimed to conduct a cost-utility analysis of continuous positive airway pressure (CPAP) therapy compared with usual care as treatment of moderate to severe cases of obstructive sleep apnea (OSA) in Brazil, where decentralized policies of CPAP provision are in place. MethodsMarkov cohort model comparing CPAP therapy with usual care, that is, no specific treatment for OSA, for moderate to severe cases was used. The payer perspective from the Unified Health System, Brazil, was adopted. Effectiveness parameters and costs related to health states were informed by literature review. Resource use related to CPAP therapy was defined by specialists and costs informed by recent purchase and leasing contracts. Incremental cost-effectiveness ratios were generated for purchase and leasing contracts to reflect current practices. A conservative willingness-to-pay threshold was set at 1 gross domestic product per capita per quality-adjusted life-year (QALY) (Brazilian reais [BRL] 40 712/QALY). Uncertainties were explored in deterministic and probabilistic sensitivity analyses. ResultsIncremental cost-effectiveness ratio for the purchase modality was 8303 BRL/QALY and for leasing 45 192 BRL/QALY. Considering the adopted willingness-to-pay threshold, provision of CPAP by the purchase modality was considered cost-effective but not the leasing modality. The parameter related to the greatest uncertainty was the reduction in the risk of having a stroke attributable to CPAP. Probabilistic analysis confirmed the robustness of results. ConclusionsCPAP therapy is a cost-effective alternative compared with usual care for moderate to severe OSA for the purchase modality. These results should help underpinning the decision making related to a uniform policy of CPAP provision across the country.

The OSA patient journey: pathways for diagnosis and treatment among commercially insured individuals in the United States.

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.

Health disparities in the detection and prevalence of pediatric obstructive sleep apnea

IntroductionPediatric Obstructive Sleep Apnea (OSA) is associated with negative health outcomes, behavior problems, and poor academic performance when left untreated. Prior research has shown that children from racial and ethnic minority backgrounds and those living in lower socioeconomic status (SES) homes or neighborhoods have higher prevalence of OSA but lower likelihood of receiving evidence-based care for OSA. Disparities in pediatric OSA detection (e.g., timely assessment and diagnosis) likely contribute to this observed inequity in receiving treatment. A polysomnogram (PSG) is the gold standard for diagnosing OSA but completing PSG can be challenging. Study aims were to examine racial, ethnic, and SES differences in (1) OSA prevalence and severity and (2) OSA detection, specifically PSG completion rates, timing since referral, and age of diagnosis.MethodsChildren (aged 1–18, N = 1,860, 56% male) were referred for PSG during a 6-month period. Participants' racial/ethnic background were as follows: 64.8% White non-Hispanic, 23.5% Black non-Hispanic, 9.4% White Hispanic, and 2.4% other. Children predominantly had Medicaid insurance (64.5%). SES was measured by insurance type and neighborhood SES using the Distressed Communities Index (DCI) for each participant's zip code (Economic Innovations Group; https://eig.org/dc). Covariates included child age and sex, BMI, premature birth status, and smoke exposure in the home.ResultsWe replicated previous research by showing that children from minority racial/ethnic backgrounds and lower SES backgrounds had higher prevalence rates of OSA and worse disease severity. Across racial, ethnic, and socioeconomic backgrounds, only 31.6% of the children referred successfully completed PSG. Insurance coverage (Medicaid or private vs. self-pay), was an important factor in predicting earlier timing and better completion rates of PSG, which is essential for successful diagnosis and treatment of pediatric OSA.

Sociodemographic disparities and healthcare utilization in pediatric obstructive sleep apnea management

ObjectivesWe examined (1) disparities in obstructive sleep apnea (OSA) care by insurance coverage, and by child race and ethnicity among Medicaid-insured children (MIC), and (2) healthcare utilization changes after OSA care. MethodsIBM MarketScan insurance claims were used to index OSA care 1-year before and after initial OSA diagnosis in 2017 among 2-17-year-old children (n = 31,787, MIC: 59%). OSA care and healthcare utilization analyses adjusted for child age, sex, obesity, and complex chronic conditions. ResultsWe identified 8 OSA care pathways, including no care, which occurred in 34.4% of the overall sample. MIC had 13% higher odds of no OSA care compared to commercially-insured children (CIC). MIC had 32–48% lower odds of any treatment pathway involving specialty care, but a 13–46% higher likelihood of receiving surgical care without polysomnogram (PSG) and PSG only. In MIC, non-Latinx Black/African American (Black) and Hispanic/Latinx children were 1.3–2.2 times more likely than White children to receive treatment involving specialty care and/or PSG, while Black children were 31% less likely than White youth to undergo surgery. In the full sample, surgical care was associated with less outpatient and emergency healthcare utilization compared to those untreated or not surgically treated. ConclusionsVaried OSA management by insurance coverage suggests disparities in access to and engagement in care and potentially greater disease burden among MIC. Surgical care is associated with reduced healthcare utilization. The lower odds of surgery in Black MIC should be further evaluated in the context of OSA severity, healthcare biases, and family preferences.

730-P: Effects of Obstructive Sleep Apnea Treatment on Whole-Body and Adipose Tissue Insulin Sensitivity—Role of Senescence and Mitigation by Adjuvant Metformin Therapy

Introduction: Obstructive sleep apnea (OSA) is a prevalent sleep disorder linked to high type 2 diabetes risk. Positive airway pressure (PAP) therapy is the standard of care for OSA, but it inconsistently improves glucose homeostasis. Senescent cells are common in adipose tissue (AT) of patients with OSA and may impair insulin signaling. However, the effects of PAP therapy on AT senescence are not known. Addition of metformin, an insulin-sensitizer with anti-senescent effects, may be a good adjuvant therapeutic strategy to improve glycemic control in patients with OSA. Methods: We randomly assigned 16 nondiabetic participants with OSA (Mean± SD; age: 50.9 ± 6.7 y, BMI: 36.5 ± 2.9 kg/m2) in a 1:1 ratio to receive either 2g metformin or placebo daily along with PAP therapy for 3 months in a double-blind pilot study. Whole body and AT insulin sensitivity was determined by 2h oral glucose tolerance test (OGTT). AT biopsy was obtained to estimate tissue insulin signaling and senescence. Results: The metformin and placebo groups had comparable age, BMI and OSA severity at baseline. PAP compliance was 38% and 75% in the metformin and placebo groups, respectively. Matsuda Index, glucose area under the curve (2h AUC), and free-fatty acid suppression at baseline and follow-up were not different in metformin or placebo treated groups. Compared to baseline, insulin AUC and insulin to glucose AUC ratio during OGTT was unchanged in the metformin but increased in the placebo group. Metformin, but not placebo, was associated with increased insulin mediated AKT phosphorylation and decreased senescence biomarkers (p21 and MCP1) in AT during the follow-up visit. Conclusion: Metformin, as adjunct to PAP therapy, attenuated insulin rises during OGTT, improved AT insulin signaling, and lowered senescence biomarkers in OSA patients. Larger trials of longer treatment duration are needed to determine if metformin can prevent diabetes in OSA patients. Disclosure S. Rodrigues: None. W.S. Dantas: None. R.A. Beyl: None. R.C. Hebert: None. I. Griffith: None. M. Tanksley: None. E.C. Mader: None. J.P. Kirwan: None. C.L. Axelrod: None. E. Ravussin: Research Support; Eli Lilly and Company, Novartis AG. Advisory Panel; Novartis. P. Singh: None. Funding National Institutes of Health (P30DK072476, U54GM104940); CAPES (88887.470405/2019-00 to S.R.)

0266 An mHealth intervention to deliver personalized messages to increase adherence to OSA care among transportation workers

Abstract Introduction Transportation workers are at risk for obstructive sleep apnea (OSA), yet OSA is commonly undiagnosed in this population. In a two-phase study, we design and evaluate a tailored, mobile health (mHealth) intervention aimed at achieving OSA awareness, including changes in OSA beliefs, among operators of large highway maintenance vehicles. Methods In Phase 1, we recruited highway maintenance vehicle operators employed at worksites in the US northeast for focus groups to examine OSA beliefs and barriers. Results of the Phase 1 focus groups were used to inform the tailored intervention. In Phase 2, we evaluated the tailored approach, “Sleep Strong, Live Long,” in a mini-RCT. Worksites were randomized to intervention (Sleep Strong, Live Long) or control. Employees at both worksites completed baseline questionnaires and follow-up questionnaires 2-months post-baseline. Employees at the intervention worksite received a 30 minute in-person education session, access to an interactive website including video success stories, then follow-up text messages over 2 months as part of the Sleep Strong, Live Long program. The control condition received the intervention after completing follow-up surveys. We compared responses on the follow-up surveys between intervention and control conditions using linear regression with baseline responses as covariates. Results Phase 1 themes included common sleep complaints, inconsistent work schedules, and misconceptions about OSA (n=45). 75% of Phase 1 participants reported resistance to OSA behavior change. Phase 2 mini-RCT participants (n= 38) were on average 43.4 (sd=12.1) years old. Participants were 86.8% male and 67.6% reported an annual household income of $50,000 or more. Exposure to the intervention was associated with an improvement in OSA literacy (b=0.14, p=0.037), but not OSA self-efficacy (b=0.12, p=0.330) or OSA readiness to change (b=0.76, p=0.336). Conclusion We provide preliminary support for improving OSA literacy among a sample of transportation workers. Future research may evaluate the tailored program in a larger sample of workers and with a longer follow-up period to consider whether OSA literacy and self-efficacy mediate actual OSA behaviors, such as changes in OSA evaluation and treatment. Support (if any) This work was supported by the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health (NIH, Grant # K01HL150339).

Online information on mandibular advancement device for the treatment of obstructive sleep apnea: a content, quality and readability analysis.

Despite increasing scientific interest in the effectiveness of mandibular advancement device (MAD) for the treatment of obstructive sleep apnea (OSA), laypeople lack knowledge about this treatment option. To investigate content, quality and readability of the online information regarding MAD. Google, Yahoo and Bing were searched for "sleep apnea", "mandibular advancement device" and "oral appliance". Websites were analyzed for content (multidisciplinary care team, qualified dentist, treatment contraindications and side effects), as well as for quality (DISCERN instrument, HONcode) and readability scores (Flesch Reading Ease, FRE, and Flesch-Kincaid Reading Grade, FKG). 155 websites were included: 53% from health professionals, 20% commercial, 17% academic, 10% from non-health professionals. Content was incomplete, especially for commercial ones. 71.61% websites failed to acknowledge treatment contraindications, approximately 40.00% did not mention side effects and the need for a multidisciplinary care team, while 22.58% did not address the need to consult a qualified dentist. Quality and reliability were poor. Mean DISCERN score was 39.93 (95% CI 37.90-41.96), with lower scores for commercial websites compared with others. Only nine websites displayed HONcode certification. Readability was quite difficult, with mean FRE score of 59.50 (95% CI 57.58-61.42) and mean FKG level of 6.92 (95% CI 6.64-7.21). Health care professionals should be aware that currently available online information do not fulfill the most important aspects of MAD therapy and may be difficult to understand by laypeople. This could contribute to cause delays in appropriate OSA care and unrealistic treatment expectations, increasing the risk of treatment discontinuation.

Exploring patient-borne costs and wait times for obstructive sleep apnea (OSA) care among rural and urban adults

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.

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.

Parental experience of hypoglossal nerve stimulator implantation in adolescents with Down Syndrome and obstructive sleep apnea

PurposeThe purpose of this study is to explore the experience of parents in deciding whether to participate in a clinical trial of the insertion of the Hypoglossal Nerve Stimulator (HNS) to treat their adolescent with Down Syndrome (DS) and Obstructive Sleep Apnea (OSA). Design and methodsA qualitative descriptive design with interviews was used to gather parental experiences from those who consented to HNS for their adolescent with DS and OSA. Interviews were conducted, audiotaped, and transcribed. Basic content analysis was followed to interpret the data. Using a process of data debriefing/engagement, codes were generated, and field/reflective notes were used to assure trustworthiness of the data. ResultsParents, 13 mothers/2 fathers, participated. Three themes were identified: Parents experience desperation about acceptance of standard of care for their adolescent with DS and OSA. This desperation led parents to seek information/insights from social media and they came to rely on those sites to explore options, ultimately leading them to HNS clinical trial. Finally, parents had a desire to share experience with HNS implantation. ConclusionsParents described being desperate at acceptance of standards of care for OSA. They shifted reliance on experts and parents by searching social media pages to explore options for treatment of OSA. Parents wished to share experiences with the HNS implantation. Practice implicationsNurses play a role in preparing for the HNS by instructing/educating parents. Nurses can identify supportive social media sites for parents during the HNS decision and suggest ways to measure outcomes of HNS.

Mechanism and management of atrial fibrillation in the patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a highly prevalent disorder in patients with atrial fibrillation (AF). Although there has been an increase in the incidence of AF due to the aging population, it has been reported that OSA is still underdiagnosed because many patients remain asymptomatic or unaware of the symptoms associated with OSA, such as daytime sleepiness. Untreated OSA reduces the effectiveness of AF treatment, regardless of pharmacological or non-pharmacological modes of therapy, such as catheter ablation. Experimental and clinical studies have shown that OSA pathophysiology is multifactorial, comprising of hypoxemia, hypercapnia, autonomic dysfunction, negative intrathoracic pressure changes, and arousals of OSA, and lead to AF. Both the acute and long-term effects of obstructive apnea episodes are involved in the development of an arrhythmogenic substrate of AF. Undiagnosed OSA causes underutilized opportunities for more effective AF management. Therefore, it is important to screen for OSA in all patients being considered for rhythm control therapy. However, regardless of the growing evidence of the negative prognostic impact of OSA, there is a lack of awareness regarding this connection not only among patients but also among cardiologists and arrhythmia specialists. There is a barrier to performing a systemic screening for OSA in clinical practice. Therefore, it is important to establish a comprehensive OSA care team for the efficient diagnosis and treatment of OSA. This review provides the current understanding of OSA and its relationship to AF and the importance of the diagnosis and management of OSA in AF.

Patient-reported Differences in Obstructive Sleep Apnea Care between Jurisdictions with and without Government Funding for Continuous Positive Airway Pressure.

Rationale: Funding for obstructive sleep apnea (OSA) treatment may impact how patients access care, wait times, and costs of care. Objectives: The aim of this study was to compare differences in diagnosis and treatment of OSA between Canadian jurisdictions with and without public funding for continuous positive airway pressure (CPAP). Methods: We administered an anonymous internet survey to Canadian adults reporting a physician diagnosis of OSA. Responses were categorized on the basis of whether the respondent's province provided full or partial funding for CPAP therapy for all patients. We assessed wait times for diagnosis and treatment, patient-borne costs, and model of care delivery compared between jurisdictions with and without universal CPAP funding. Results: We received 600 responses representing all Canadian provinces and territories. The median (interquartile range) age was 59 (49-66) years; 57% were male, and 21% were from rural settings. Patients living in provinces without public CPAP funding (n = 419) were more likely to be diagnosed using home sleep apnea testing (69% vs. 20%; P = 0.00019). Wait times were similar after adjustment for demographics, disease characteristics, and model of care. Although patient-borne costs of care were similar between jurisdictions, patients from regions without CPAP funding reported that cost had a greater influence on the choice of therapy. Sleep specialists were more commonly involved in OSA care in regions with CPAP funding. There was no difference in the current use of therapy between jurisdictions with and without public funding. Conclusions: This survey study demonstrates that public funding for CPAP therapy impacts how Canadians access OSA care but is not associated with differences in wait times or costs. Future research is required to determine the impact of different funding models for OSA care on clinical outcomes.

Provider Perspectives on Sleep Apnea from Appalachia: A Mixed Methods Study.

: 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.