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Obstructive Sleep Apnea (OSA) in the Primary Care Setting

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Obstructive Sleep Apnea (OSA) in the Primary Care Setting Care Process Model (CPM) MAY 2013 MANAGEMENT OF Obstructive Sleep Apnea (OSA) in the Primary Care Setting This care process model (CPM) was developed by a multidisciplinary Sleep Apnea Development Team, in collaboration with Intermountain Healthcare’s Primary Care Clinical Program. The CPM promotes a model of care for screening, testing, diagnosis, treatment, and long-term management for patients with — or at risk for — obstructive sleep apnea (OSA). The model is derived from national guidelines and practice parameters from the American Academy of Sleep Medicine (AASM), along with other evidence-based literature and local expert consensus. Why Focus ON OBSTRUCTIVE SLEEP APNEA? WHAT’S INSIDE • OSA is common, and recognition by clinicians is low. Based on probability ALGORITHMS AND NOTES. .2 studies with in-lab polysomnography, 1 in 5 adults have at least mild OSA, and Screening and referral ............ 2 1 in 15 have OSA of moderate or worse severity. An estimated 75% to 80% of Testing, diagnosis, and treatment. ... 4 YOU3 cases that could benefit from treatment remain undiagnosed. OVERVIEW. ..................6 • OSA can have serious health consequences. OSA is associated with increased AASM recommendations ........... 6 incidence of hypertension, heart disease, atrial fibrillation, stroke, glucose intolerance, and impotence. Untreated OSA can cause daytime sleepiness, Sleep medicine specialists .......... 6 cognitive impairment, loss in work productivity, and increased risk of SCREENING AND REFERRAL . 7 automobile crashes — and can significantly reduce quality of life. Severe, Signs and symptoms .............. 7 HIR untreated OSA may increase cardiovascular mortality. Risk factors and associated • OSA is costly to the economy. One study showed an increased risk of lost conditions ..................... 8 workdays before OSA diagnosis and treatment — 1.8 times more days for Sleep apnea questionnaires ....... 10 SJS women and 1.6 times more days for men than controls. Screening CMV operators .......... 11 • OSA is costly to public health. At least 1 million police-reported crashes (1,550 SLEEP STUDIES . .. 12 deaths, $12.5 billion in losses) are caused by driver fatigue each year. It has been In-lab sleep studies .............. 12 projected that, if all U.S. drivers with OSA were treated with CPAP at a cost of TEN Home sleep studies .............. 13 $3.18 billion, the U.S. would save $11.1 billion in collision costs and 980 lives. • Primary care practitioners can make a significant difference. PCPs are in an TREATMENT . 14 ideal position to recognize and manage OSA by incorporating recommended Treatment options ............... 14 screening, evaluation, and referral processes into daily practices. Improved Treatment benefits .............. 14 diagnosis and treatment of OSA reduces morbidity and mortality, improves Positive airway pressure (PAP) ..... 15 PAG1 comorbid disease processes, and improves patient quality of life. Behavioral therapies ............. 16 Alternative and adjunctive GOALS therapies ...................... 17 • Increase recognition of potential obstructive sleep apnea (OSA) and other sleep FOLLOW-UP AND LONG-TERM disorders in the primary care setting. MANAGEMENT . 18 • Guide appropriate referral for sleep consultations and/or sleep lab studies. RESOURCES AND REFERENCES .19 . • Reduce variation in approach to screening, diagnosis, treatment, and long-term management of OSA — not only in the primary care community, but also INTERMOUNTAIN SLEEP LABS . 20 within and between sleep centers. • Facilitate improved coordination of care between PCPs and sleep specialists. • Provide education tools to support implementation. WHAT’S NEW? • Home sleep testing (HST) exclusions and indicators (pages 3(f), 5(d), and 13) • HST follow-up indications (page 18) MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA (OSA) MAY 2013 ALGORITHM: SCREENING AND REFERRAL PATIENT VISIT Patient concern and/or clinical suspicion of possible sleep disorder and/or part of routine health maintenance evaluation EVALUATE patient and administer STOP-BANG OSA screening questionnaire (a, b) o Snoring: Do you snore loudly (louder than talking or o Body mass index (BMI) greater than 35? loud enough to be heard through closed doors)? o Age older than 50 years? o Tired: Do you often feel tired, fatigued, or sleepy o Neck circumference greater than 17 inches during the daytime, even after a “good” night’s sleep? (men) or 16 inches (women)? o Observed: Has anyone observed you stop breathing o ender = male? during your sleep? G See page 19 for information on accessing and o Pressure: Do you have or are you being treated for ordering Intermountain’s STOP-BANG clinical high blood pressure? form and patient questionnaire . 2 or fewer STOP-BANG factors 3 or more STOP-BANG factors = LOW RISK for OSA = HIGH RISK for OSA Does clinical no correlation support significant risk level (b)? yes Still Other Reevaluate no concerned? no yes Refer for SLEEP CONSULTATION prn indications (c)? AND/OR SLEEP STUDIES (d) yes Any urgent no factors (e)? yes Consult / yes Schedule communicate with delay? No sleep specialist (d) ongoing AND/OR no concern Conduct nocturnal pulse oximetry (f) yes Patient reluctance? Significant Ongoing hypoxemia concerns but no noted no significant hypoxemia 1. Schedule sleep consult/studies using available Start O2 during sleep until sleep referral forms (d) . consult/study (d) 2. Provide applicable patient education and instructions (g) . See TESTING and TREATMENT Algorithm *STOP-BANG questionnaire adapted with permission from Chung F, CHU (page 4) Yegneswaran B, Liao P, et al . Anesthesiology . 2008;108(5):812-821 . 2 ©2010–2013 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. MAY 2013 MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA (OSA) (d) Referral and communication SCREENING AND REFERRAL • Many PCPs can manage patients with straightforward ALGORITHM NOTES symptoms and risk factors of OSA if they choose to do so. Complex cases should be referred to a sleep specialist to ensure appropriate test selection, education, and follow-up — all of which are (a) STOP-BANG OSA screening questionnaire critical for successful treatment outcomes . See the sidebar on page 11 for further discussion on direct referral for sleep studies versus referral Intermountain is recommending use of the STOP-BANG screening for sleep consultation . Use the algorithm on pages 4 and 5 to help questionnaire because it is concise and easy to use, and it has been guide test selection, treatment, and follow-up . validated in a pre-surgical setting . The STOP-BANG is based on the following symptoms and risks shown to be strongly associated • Communication between the PCP and sleep specialist with OSA . (See pages 8–11 for more information on OSA risk factors is important. Talk with a specialist if scheduling is delayed to and OSA screening questionnaires .) help assess urgency and/or to select a in-lab study . If a patient is referred directly for sleep studies, it’s critical to communicate • noring S required clinical information to the sleep lab . A standard • Tiredness/sleepiness/fatigue referral form is available (see page 19) . • Observed breathing cessation or gasping for air during sleep • Pressure (Hypertension) • Body mass index > 35 (e) Urgent factors • Age > 50 Patient should be seen as soon as possible if any of these factors are present: • Neck circumference > 17 inches (men) or 16 inches (women) • Known or suspected severe hypoxemia • Gender = male • Job sensitive (e g. ,. commercial driver or pilot) • Nodding off or falling asleep while driving • Severe cardiac, pulmonary, or neurological disease (b) STOP-BANG note • Refractory hypertension There is some concern that the STOP-BANG screen may be too sensitive • Recent history of TIA for the primary care setting, since such a large percentage of the general • Anticipated surgery population may be overweight, over 50, male, and/or hypertensive . Of greater • Other time-sensitive risk as determined by physician judgment concern, however, is that OSA is under-diagnosed and under-treated in the primary care setting . Using a sensitive screen helps alert providers to the possibility of OSA . Providers should weigh all these factors, along with specific (f) Nocturnal pulse oximetry and other home sleep patient characteristics, when determining next steps for referral and sleep testing (HST) as screening tests testing . This algorithm provides a guide only . Overnight pulse oximetry and other HST devices may play a role in screening for OSA, but are NOT recommended to confirm diagnosis or determine treatment (see the Testing and Treatment Algorithm on (c) Other high-risk indications pages 4 to 5 for more information) . Even as screening tools, these devices In addition to the STOP-BANG factors, the following factors have been have limitations and should not be used automatically, but rather in specific shown to be of concern and/or to have a strong association with OSA circumstances as part of the OSA screening process . and should be evaluated as part of a comprehensive sleep evaluation . • Indications. HST can be useful for the following: The presence of these symptoms or conditions may heighten your – To help stage urgency if patient can’t get in for sleep consult or study in suspicion of OSA and/or indicate the need for consultation with a a timely manner or to exclude patients with low pretest probability sleep specialist . (See pages 8 and 9 for more details on these – To help convince the reluctant patient of the importance of a sleep study
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