Article

Primary Care vs Specialist Sleep Center Management of Obstructive Sleep Apnea and Daytime Sleepiness and Quality of Life A Randomized Trial

JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 03/2013; 309(10):997-1004. DOI: 10.1001/jama.2013.1823
Source: PubMed

ABSTRACT IMPORTANCE Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment. OBJECTIVE To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. DESIGN, SETTING, AND PATIENTS A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. INTERVENTIONS Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only. MAIN OUTCOME AND MEASURES The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was -2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs. RESULTS There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P < .001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (P < .001). Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 (adjusted difference, -0.13; lower bound of 1-sided 95% CI, -1.5; P = .43). There were no differences in secondary outcome measures between groups. Seventeen patients (21%) withdrew from the study in the primary care group vs 6 patients (8%) in the specialist group. CONCLUSIONS AND RELEVANCE Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000514303.

2 Followers
 · 
202 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Pharmacists in Australia have pioneered an innovative role in providing obstructive sleep apnea (OSA) services in community pharmacies. A professional practice framework is yet to be established for this novel service area. Objectives To explore the practices and experiences of Australian pharmacy staff providing OSA services. Method Semi-structured telephone interviews were conducted using an interview guide to explore a priori areas of interest. Interviews were audio recorded, transcribed verbatim and thematically analyzed using a framework approach. Results Interviews were completed with 22 practitioners from demographically diverse pharmacies. Key themes emerging from the interviews included motivation for providing the service, current practice frameworks, determinants for sustaining the service and future directions for the profession. Participants reflected on the professional satisfaction they derived from providing the service and being able to contribute to an important public health area. However, numerous impediments to service provision were discussed; these were broadly conceptualized as financial, professional, societal and geographical issues. Important practitioner needs were highlighted, including professional training opportunities and support. The need for a regulatory practice framework to ensure quality and uniformity of service provision within the profession was emphasized. Broader uptake of these services in the absence of such a framework was a key area of concern. Conclusions This study showcases a novel area of pharmacy service provision. Innovative services need to be explored and defined before being consolidated into professionally recognized areas of practice. For OSA services in Australia, the next key step for the profession is to establish a professional practice framework to support current and future implementers of the service and ensure a minimum standard of care.
    Research in Social and Administrative Pharmacy 08/2014; DOI:10.1016/j.sapharm.2014.08.009 · 2.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The prevalence of obstructive sleep apnea (OSA) has been steadily rising over recent decades and patient access to laboratory-based sleep services and specialist consultations have become increasingly limited, resulting in potential delays in treatment. As a result, there has been growing interest in the use of non-sleep laboratory methods for diagnosing and managing OSA, including the use of screening questionnaires, portable sleep monitoring devices, and home autotitrating continuous positive airway pressure. There is also evidence in support of a role for alternative health care professionals, such as sleep-trained nurses and primary care physicians in the diagnosis and treatment of OSA. In this review, we compare the different types of home monitoring devices, discuss the limitations of portable monitoring compared with full laboratory polysomnography, and summarize the results from published comparative effectiveness studies which have evaluated ambulatory models of care for the management of OSA. We also consider how future models of care that may be needed to deal with the burden of disease will evolve and some of the issues that prevent the translation of such models of care in many countries.
    Seminars in Respiratory and Critical Care Medicine 10/2014; 35(5):545-51. DOI:10.1055/s-0034-1390139 · 3.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This review on breathlessness and motor neurone disease (MND) is important, as palliative care teams are increasingly becoming involved in the complex care of these patients at an earlier stage in their illness. Subtle cognitive and behavioural changes with MND may make management more challenging. Breathlessness is a distressing symptom, impacting on both patients and carers. Assessment and expectant management of breathlessness improves the quality of life (QoL) and may minimize hospital admission.
    Current Opinion in Supportive and Palliative Care 07/2014; 8(3). DOI:10.1097/SPC.0000000000000077