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Primary Care vs Specialist Sleep Center Management of Obstructive Sleep Apnea and Daytime Sleepiness and Quality of Life: A Randomized Trial
Study Questions:
How does a primary care model compare with a specialized sleep center relative in the diagnosis and care of obstructive sleep apnea (OSA)?
Methods:
This was a randomized, controlled, noninferiority study involving 155 patients with OSA treated at primary care practices (n = 81) or a University Sleep Center in Australia (n = 74), between September 2008 and June 2010. Exclusion criteria were: 1) morbid obesity, 2) neuromuscular disease, 3) unstable psychiatric disease or cognitive impairment, 4) hospitalization in the previous 3 months for serious heart or vascular symptoms, or 5) severe lung disease. Subjects were screened for OSA using a validated questionnaire which, if positive, was followed by overnight oximetry. Primary care management of OSA versus usual care at a University Sleep Center included continuous positive airway pressure (CPAP), mandibular advancement splints, or conservative measures only. Quality-of-life measures and Epworth Sleepiness scores (ESS) were measured and compared in both groups before and after treatment.
Results:
In all, 402 patients were referred, 301 agreed to participate, and 155 were eligible for randomization. Patients in primary care and specialist practices were more likely to be male (85% vs. 77%), obese (mean body mass index 33.1 vs. 33.7 kg/m2), and middle-aged (57.2 vs. 54.5 years of age). In the specialist group, 73 of 74 patients had a polysomnogram (PSG). Three patients in the primary care group crossed over to the sleep specialist group, one of whom had a laboratory full-night diagnostic PSG. At baseline, 90% of patients in the primary care group initiated CPAP, whereas 70% in the specialist group initiated CPAP, with a higher proportion of patients being managed with conservative measures only. After 6 months’ follow-up, the proportion of patients using CPAP were similar in both cohorts (63% in the primary care group; 61% in the specialist group). In the primary care group, the mean baseline ESS score of 12.8 decreased to 7.0 at 6 months (p < 0.001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (p < 0.001). Primary care management was noninferior to specialist management, with a mean change in ESS score of 5.8 vs. 5.4 (p = 0.43). There were no differences in quality-of-life measures between groups.
Conclusions:
Among patients with OSA, the authors concluded that treatment under a primary care model compared with a specialist model did not result in worse ESS, and shared similar proportions of patients compliant with CPAP. The authors suggested that their primary care and specialist treatment models may be comparable.
Perspective:
One attraction to this simplified treatment model could be delivery of care at lower cost; however, this has yet to be proven. Before adapting this model to widespread practice, larger studies with cardiovascular endpoints would be ideal, as well as validation of OSA by PSG in the primary care group. It is important to acknowledge that these results cannot be generalized to all populations, including those with morbid obesity and central apneas, which are not identified by screening oximetry and common among cardiology patients. Last, the higher number of withdrawals from the primary care group may have biased the results by excluding patients with the worse outcomes.
Keywords: Neuromuscular Diseases, Follow-Up Studies, Sleep Apnea Syndromes, Body Mass Index, Polysomnography, Obesity, Morbid, Continuous Positive Airway Pressure, Sleep Apnea, Central, Australia, Cardiovascular Diseases, Sleep Apnea, Obstructive, Primary Health Care, Lung Diseases
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