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: 35.29). 03/2013; 309(10):997-1004. DOI: 10.1001/jama.2013.1823
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.
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ABSTRACT: Recently, portable sleep recording devices became an accepted alternative to polysomnography (PSG) for obstructive sleep apnoea (OSA) diagnosis in patients with a high pre-test probability of moderate to severe OSA but home polysomnography (H-PSG) was not recommended because there was insufficient data. The present review has analysed six prospective randomiszed cross-over studies comparing H-PSG to in-lab PSG. These studies convincingly showed that H-PSG allows complete sleep evaluation. The quality of patient's sleep tends to be better at home. H-PSG is accurate for OSA diagnosis and the failure rate is low despite the absence of supervision. In addition, it could offer a final and comprehensive diagnosis for many other sleep disorders. It is also likely that H-PSG can reduce PSG-related costs but complete cost-effectiveness analyses are not yet available. Recently, remotely attended H-PSG via telemonitoring has been tested and may reduce H-PSG failure rate. In conclusion, H-PSG can be used to rule-in and rule out OSA in suspected patients, even in the presence of co-morbidities and is an alternative when type 3 recording is negative. Future developments should target simplification of technical aspects of H-PSG, together with remote monitoring, in order to obtain good quality H-PSG performed in adequate conditions.
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ABSTRACT: The high prevalence of obstructive sleep apnea (OSA) and increasing awareness of its potential health consequences has placed significant pressure on laboratory-based sleep services leading to growing waiting lists and delays in diagnosis and treatment. Consequently, there has been increasing interest in the use of simplified, ambulatory models of care involving clinical prediction tools, portable sleep monitoring and home auto-titrating continuous positive airway pressure (CPAP). Researchers are also exploring the potential role for a wider range of health care providers including trained nurses and general practitioners in the primary management of OSA. Recent randomised controlled studies evaluating the clinical effectiveness of ambulatory management strategies versus traditional laboratory-based care for patients with OSA have consistently demonstrated that comparable patient outcomes can be achieved. The cost-effectiveness of these strategies is currently being debated, and further research examining the long term economic implications of ambulatory models of care is needed.
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