Management of Obstructive Sleep Apnea by Primary Care Clinicians

8/7/2019 Management of Obstructive Sleep Apnea by Primary Care Clinicians

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ManagementofObstructiveSleepApneabyPrimaryCareClinicians

Practice-BasedResearchNetworksTaskOrder

OKPRNTaskOrder3-HHSA290200710009

TaskOrderOfficer:EliseBerliner

Contractor:TheUniversityofOklahomaHealthSciencesCenterandtheOklahomaPhysicians

Resource/ResearchNetwork(OKPRN)

ProjectPeriod:9/1/200812/31/2009

NetworksInvolved:

TheOklahomaPhysiciansResource/ResearchNetwork(OKPRN)

TheAlabamaPractice-BasedResearchNetwork(APBRN)

TheLosAngelesResearchNetwork(LANet)

TheProHealthNetwork(ProHealth)inConnecticut

TheSouthFloridaPractice-BasedResearchNetwork(SoFlaPBRN)

PrincipalInvestigator:

JamesW.Mold,M.D.,M.P.H.

DepartmentofFamilyandPreventiveMedicine

UniversityofOklahomaHealthSciencesCenter

900NE10thStreet

OklahomaCity,OK73104


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Summary:

Interview,chartabstraction,andpatientsurveydatawereobtainedfromfivedifferent

regionalpractice-basedresearchnetworksinanefforttobetterunderstandhowprimarycare

cliniciansrecognize,evaluate,andmanageadultpatientswithobstructivesleepapnea(OSA).

Wespecificallysoughtinformationwithwhichtoanswerasetof19questions,whichwere

subsequentlyreorderedandexpandedto24.Wewereabletoanswer,withsomedegreeof

confidence,15ofthese.Becausesofewhomesleeptests(HSTs)werereportedbyclinicians

andpatients,wecouldnotprovidespecificinformationabouttheiruse.Medicalrecord

documentationofCPAPfollow-upwastooinconsistenttoprovideusefulinformationabout

impactoftreatment.

Baseduponananalysisofthesedata,thefollowingconclusionswerereached:

1. Ninetypercent(90%)ofadultpatientsbeingseenbyprimarycareproviders(PCPs)have

sleeprelatedsymptoms.Onlyabout15%haveeverdiscussedthesesymptomswith

theirPCP.Onaverage,sleepsymptomsaredocumentedinonly30%ofthemedical

recordsofpatient65yearsofageandolder.Documentationrateswerehigherinsome

networksthaninothers.

2. BasedupontheBerlinSleepQuestionnaire,nearly40%ofyoungeradultsandnearly30%ofolderadults,notknowntohaveOSA,waitingtobeseenbytheirPCP,areathigh

riskforhavingOSA.

3. Fewerthan5%ofadultpatientswithsleepsymptomsbeingseeninprimarycare

settingsandfewerthan10%ofpatientsover65yearsofagewithsleepsymptoms

recordedintheirmedicalrecordshavebeenreferredforovernightsleeptesting.

4. Two-thirdsofovernightsleepstudiesareorderedbyPCPs.Tenpercentaredonevia

self-orfamily-referral.Therestareorderedbysub-specialists.5. Morethanone-thirdofadultpatientswithOSAwerediagnosedpriortoseeingtheir

currentPCP.

6. WhenpatientsarereferredforovernightsleeptestingforsuspicionofOSA,morethan

60%oftestsdoneonolderadultsandmorethan70%oftestsdoneonyoungeradults


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arepositive.Theratesofpositivetestsmaybehigherwhenpatientsarereferredby

theirprimarycareprovider.

7. Onlyasmallminorityofpatientsaresenttoasleepexpertforaconsultationpriorto

overnightsleeptesting.Mostarereferreddirectlyfortesting.

8. Mostprimarycarecliniciansarestillunfamiliarwithhomesleeptests(HSTs),andvery

fewsleepconsultantsappeartobedoingthem.Sixpercent(6%)ofprimarycare

patientswhohavebeendiagnosedwithOSAreporthavinghadanHST.However,itis

possiblethatsomeofthemmayhavehadanovernightpulseoximetrytest,atestthatis

orderedfairlyoftenbyPCPs.

9. Theaveragewaittimeforapolysomnography(PSG)is2weekswitharangeof2daysto

5weeks.

10.About50%ofpatientswhoundergoPSGhavesplitnighttesting.Thedecisiontodo

splitnighttestingdependsuponavarietyoffactors,andtheproportionofpatients

receivingsplitnighttestingvarieswidely(40-100%)betweensleepconsultants.

11.ThedegreeofinvolvementofPCPsintheprescriptionofCPAPandinitialmanagement

variesgreatlybetweencliniciansandbyregionofthecountry.InOklahoma,mostof

thisworkisdonebyPCs,whileintheotherfournetworks,sleepconsultantsappearto

playalargerrole,atleastinitially.12.MeetingMedicarereportingrequirementsrequiressomedegreeofcoordination

betweenthePCP,sleepconsultant,andtheDMEcompany.Exceptincaseswherethe

sleepconsultantmanagesthepatientinitiallyandworkscloselywithoneorafewDME

companies,thisstepisoftenhandledpoorly.

13.Approximatelytwo-thirdsofyoungeradultswithOSAandapproximatelyhalfofolder

adultswithOSAbeingseenbyPCPscontinuetousetheirCPAPdeviceslongterm.


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Numbersofcliniciansandpatientsfromwhomdatawasobtained,totalsand

bynetwork

Network OKPRN APBRN LANet ProHealth SoFlaPBRN Total

Primary

Care

Clinician

Interviews

9 9 9 9 8 44

Sleep

Consultant

Interviews

6 9 1 1 1 18

Sleep

ApneaPatient

Chart

Abstractio

ns

128 217 32 191 121 689

65+Year-

OldChart

Abstractio

ns

226 223 165 208 140 962

30-64Year-OldPatient

Surveys

316 316 327 169 0 1,128

65+yo

Patient

Surveys

255 62 65 131 0 513


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TypesofData

PrimaryCareClinicianInterviews:

Practicemembershiplistsfromeachnetworkwereobtainedandrandomizedusing

computer-generatedrandomnumbertables.Eligibleclinicianswithineachpracticewerethenrandomizedinthesameway.Onlyprimarycarepracticesandcliniciansthatcarefor

adultpatientswereincluded.Eachnetworkattemptedtoenrolloneclinicianfromeach

practiceinorderofrandomizationuntil9cliniciansfrom9differentpracticeswereenrolled.

Noneofthenetworkshadtogobeyondthe15thpracticetoenrolltheir9clinicians.

Interviewswereconductedwitheachclinicianusingsemi-structuredinterviewscripts.

Eachclinicianwaspaid$150tocompensatethemfortheirtime.Thecliniciansresponses

wererecordedandtranscribed.Eachnetworkusedaslightlydifferentinterviewguide

coveringthesamematerial.TheOKPRNinterviewquestionsareattached.

SleepConsultantInterviews:

Attheconclusionoftheinterview,theclinicianswereaskedforthenamesofthe

sleepconsultantstowhomtheyreferpatientsfordiagnostictesting.Thenetworksthen

attemptedtoconductsemi-structuredinterviewswithasmanyoftheseconsultantsas

possible.Eachsleepconsultantinterviewedwaspaid$150.Eachnetworkusedaslightly

differentinterviewguidecoveringthesamematerial.TheOKPRNinterviewguideis

attached.

MedicalRecordsAbstractions:

Structuredmedicalrecordsabstractionswerecompletedfortwodifferentsetsof

patientscaredforbyenrolledcliniciansineachnetwork.Thevariablescollectedare

attached.

Thefirstsetofpatientsincludedalloftheadultpatientsineachenrolledclinicians

practicethatwasknowntohaveobstructivesleepapnea(OSA)uptoamaximumof25

patientsperclinician.Thesepatientswereidentifiedusingbillingrecords,electronicmedical

records,clinicianandstaffrecall,andprospectivelogsofpatientswhocameinduringthe


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study.WaitingroomposterswereusedtoencouragepatientstobesuretheirPCPwas

awareoftheirOSAdiagnosis.

Thesecondwasarandomsampleof25ofrecordsofeachenrolledcliniciansolder

patients(>65yearsofageandolder)whohadbeenseenwithintheprioryear.These

patientswereidentifiedfrombillingrecords.

PatientSurveys:

Ineachoftheenrolledclinicianspractices,researchassistantsattemptedtoenroll25

consecutiveadultpatientsaged30to64and25consecutivepatients65yearsofageand

older.EnrolledpatientswereaskedtocompleteaquestionnairethatincludedtheBerlin

SleepQuestionnaireplussocio-demographicquestionsandquestionsaboutpriorsleepapnea

evaluationanddiagnosis.Onenetworkwasunabletoobtainpatientsurveydatasothreeof

theothernetworkssurveyedadditionalpatients.InOKPRN,thisinvolvedgoingto4

additionalpracticesnotoriginallyenrolledinthestudy.Thesurveyinstrumentisattached.


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PrimaryCareCliniciansInterviewed

Discipline:

FamilyMedicine41(95.0%)

InternalMedicine3(5%)Allopathic/Osteopathic:M.D.42(95%)D.O.2(5%)

LocationofPractice:

Rural8(18.2%)

Suburban23(52.3%)

Urban13(29.5%)

PercentageofTimeSeeingPatients:

0-50%2(5%)

51-74%0(0%)

75-100%42(95%)

NumberofPatientsSeen/Week(Note:WedonthavethisinformationforSoFlaPBRN):

0-501(2.7%)

51-747(19.4%)

75-10016(44.4%)

>10012(33.3%)

MedicalRecordsAbstractionPatients

SleepApneaPatients

Age:Mean52.8S.D.13.9Range21-91

Gender:Female298(43.3%)Male391(56.7%)

PrimaryHealthInsuranceType:

Medicare171(24.8%)

Medicaid28(4.1%)

Private454(65.9%)

Uninsured34(4.9%)

CantTell1(0.1%)


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Selfpay1(0.1%)

AgeWhenSleepApneaDiagnosed:


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CongestiveHeartFailure42(4.4%)

CardiacArrhythmias42(4.4%)

GERD155(16.1%)

DiabetesMellitus251(26.1%)

MetabolicSyndrome22(2.3%)

CoronaryArteryDisease130(13.5%)

CorPulmonale(RightHeartFailure)7(0.7%)

PatientsSurveyed

Age:Mean:55.8S.D.:15.3Range:30-96

Gender:Female:1002(61.6%)Male:625(38.4%)

BodyMassIndex:Mean:29.6S.D.:7.4Range:13-77

Race:

White1069(68.2%)

Black214(13.6%)

AmericanIndian27(1.7%)

Asian34(2.2%)

Other220(14.0%)

Unknown4(0.3%)

Diagnoses:

Hypertension(HighBloodPressure)755(47.5%)

SleepApnea124(7.8%)


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Note:Whenthedatafromallnetworkswerevirtuallyidentical,onlysummativedatafromall

networksisreported.Whensummativedatawasnotfelttoaddanything,onlynetworklevel

dataisreported.

Question1:Howfrequentlydopatientscomplainofsymptomsofsleepapnea

duringprimarycareofficevisits?

a.Whatproportionofprimarycarepatientshassleep-relatedsymptoms?

b. HowoftendopatientsreportthemtotheirPCP?

c. Howoftenaresleep-relatedsymptomsrecordedinthemedicalrecords?

ProspectivePatientSurveys

AllNetworks:Patients30-64(N=1128):

89.7%(1012/1128)reportedatleastonesleepsymptom.

Thefollowingsymptomswerereported:

Snoring59.4%(670/1128)

Breathingcessation18.5%(209/1128)Noddingoffatthewheel17.2%(194/1128)

Daytimefatigue79.3%(895/1128)

19.5%(220/1128)reportedhavingdiscussedtheirsleepsymptomswiththeirPCP.

58.3%(658/1128)reportednotdiscussingtheirsleepsymptomswiththeirPCP.

6.6%(75/1128)couldntrecallwhethertheydiscussedthesymptomswiththeirPCP.

5.3%(60/1128)providedinsufficientinformation.

AllNetworks:Patients30-64withoutsleepapnea(N=960):

89.9%(863/960)reportedexperiencingatleastonesleepsymptom.


Snoring56.6%(543/960)


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Breathingcessation13.3%(125/960)

Noddingoffatthewheel15.5%(149/960)



64.4%(618/960)reportednotdiscussingtheirsleepsymptomswiththeirPCP



AllNetworks:Patients30-64withsleepapnea(N=94):



Snoring87.2%(82/94)






9.6%(9/94)couldntrecallwhethertheydiscussedthesymptomswiththeirPCP.2.1%(2/94)providedinsufficientinformation.

AllNetworks:FemalePatients30-64withoutsleepapnea(N=602):



Snoring51.5%(310/602)

Breathingcessation10.0%(61/602)Noddingoffatthewheel13.8%(83/602)





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Snoring69.3%(244/352)








AllNetworks:AllPatients65+(N=513):

82.5%(423/513)reportedatleastonesleepsymptom.

Snoring46.4%(238/513)




17.5%(90/513)reportedhavingdiscussedtheirsleepsymptomswiththeirPCP.59.3%(304/513)reportednotdiscussingtheirsleepsymptomswiththeirPCP



AllNetworks:Patients>65withoutsleepapnea(N=450):


Thefollowingsymptomswerereported:Snoring45.3%(204/450)





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AllNetworks:MalePatients>65withoutsleepapnea(N=168):



Snoring48.8%(82/168)








AllNetworks:Non-obese(BMI65withoutsleepapnea(N=303):



Snoring43.2%(131/303)


Noddingoffatthewheel8.3%(25/303)Daytimefatigue71.9%(218/303)





AllNetworks:Obese(BMI>30)Patients>65withoutsleepapnea(N=118):83.9%(99/118)reportedexperiencingatleastonesleepsymptom.


Snoring50.8%(60/118)



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RetrospectiveRecordAbstraction

OKPRN:Patients>65withoutsleepapnea(N=226):

21.2%(48/226)reportedatleastonesleeprelatedsymptom.

o

NoneDocumented78.8%(178/226)

o Troublegettingtosleep2.7%(6/226)

o Daytimesleepiness0.4%(1/226)

o Unintentionalsleepepisodes0.4%(1/226)

o Restlesssleep3.5%(8/226)

o Unrefresingsleep0.4%(1/226)

o Fatigue14.2(32/226)

o

TroubleConcentrating0%(0/226)o Wakesholdingbreath,choking,orgasping0%(0/226)

o Bedpartnerreportsloudsnoring0.4%(1/226)

o Bedpartnerreportsapneicepisodes0.4%(1/226)

o Nocturnalangina0%(0/226)

o Morningheadache0%(0/226)

o Snoring0%(0/226)

APBRN:Patients>65withoutasleepapneadiagnosis(N=223):


o NoneDocumented63.2%(141/223)



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o Unrefreshingsleep4.0%(9/223)

o Fatigue17.5%(39/223)

o TroubleConcentrating1.8%(4/223)

o Wakesholdingbreath,choking,orgasping0.4%(1/223)



o Nocturnalangina0.4%(1/223)

o

Morningheadache0.9%(2/223)

o Snoring6.3%(14/223)

SoFlaPBRN:Patients>65withoutasleepapneadiagnosis(N=140):




o

Daytimesleepiness0%(0/140)o Unintentionalsleepepisodes0%(0/140)

o Restlesssleep0%(0/140)

o Unrefresingsleep0%(0/140)

o Fatigue5.7%(8/140)


o Wakesholdingbreath,choking,orgasping0%(0/140)

o

Bedpartnerreportsloudsnoring0%(0/140)o Bedpartnerreportsapneicepisodes0%(0/140)


o Morningheadache0.7%(1/140)

o Snoring0.7%(1/140)


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ProHealth:Patients>65withoutasleepapneadiagnosis(N=208):

44.7%(93/208)reportedatleastonesleeprelatedsymptoms







o Fatigue28.4%(59/208)

o

TroubleConcentrating1.0%(2/208)







LANet:Patients>65withoutasleepapneadiagnosis(N=165):





o Unintentionalsleepepisodes0%(0/165)

o

Restlesssleep1.2%(2/165)o Unrefresingsleep1.2%(2/165)

o Fatigue2.4%(4/165)

o TroubleConcentrating0%(0/165)



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o Bedpartnerreportsloudsnoring0%(0/165)

o Bedpartnerreportsapneicepisodes0%(0/165)




AllNetworks:Patients>65withoutasleepapneadiagnosis(N=962):




o

Daytimesleepiness2.7%(26/962)




o Fatigue14.8%(142/962)



o

Bedpartnerreportsloudsnoring1.5%(14/962)o Bedpartnerreportsapneicepisodes0.6%(6/962)



o Snoring2.7%(26/962)

AllNetworks:FemalePatients>65withoutdiagnosisofsleepapnea(N=584):

30.3%(177/584)reportedatleastonesleeprelatedsymptom.o NoneDocumented69.7%(407/584)





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o Fatigue17.1%(100/584)








AllNetworks:MalePatients>65withoutdiagnosisofsleepapnea(N=378):






o

Restlesssleep3.7%(14/378)o Unrefresingsleep1.3%(5/378)

o Fatigue11.1%(42/378)





o

Nocturnalangina0%(0/378)o Morningheadache0%(0/378)

o Snoring4.8%(18/378)

OKPRN:Patientswithsleepapnea(N=128):


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o Unrefresingsleep1.6%(/128)

o Fatigue28.1%(36/128)



o

Bedpartnerreportsloudsnoring3.1%(4/128)




o Snoring43.0%(55/128)

APBRN:Patientswithapneadiagnosis(N=217):

93.5%(203/217)reportedatleastonesleeprelatedsymptom.o NoneDocumented6.5%(14/217)





o Unrefreshingsleep14.3%(31/217)

o

Fatigue60.8%(132/217)o TroubleConcentrating9.2%(20/217)





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o Snoring49.3%(107/217)

SoFlaPBRN:Patientswithsleepapneadiagnosis(N=121):






o

Restlesssleep11.6%(14/121)


o Fatigue24.0%(29/121)





o

Nocturnalangina0%(0/121)o Morningheadache5.8%(7/121)

o Snoring32.2%(39/121)

ProHealth:Patientswithsleepapneadiagnosis(N=191):

92.7%(177/191)reportedatleastonesleeprelatedsymptoms


o

Troublegettingtosleep13.1%(25/191)o Daytimesleepiness55.5%(106/191)





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o Fatigue25.1%(48/191)







o Snoring55.0%(105/191)

LANet:Patientswithsleepapneadiagnosis(N=32):








o

Fatigue34.4%(11/32)o TroubleConcentrating3.1%(1/32)



o Bedpartnerreportsapneicepisodes0%(0/32)



o

Snoring37.5%(12/32)

AllNetworks:Patientswithsleepapnea(N=689):




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o Fatigue37.2%(256/689)





o

Nocturnalangina0%(0/689)


o Snoring46.2%(318/689)

AllNetworks:FemalePatientswithsleepapnea(N=298):



o

Troublegettingtosleep15.8%(47/298)o Daytimesleepiness40.3%(120/298)




o Fatigue41.3%(123/298)


o

Wakesholdingbreath,choking,orgasping0%(0/298)o Bedpartnerreportsloudsnoring6.7%(20/298)





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o Snoring46.0%(137/298)

AllNetworks:MalePatientswithsleepapnea(N=391):








o

Fatigue34.0%(133/391)







o

Snoring46.3%(181/391)

Question2:Whatproportionofconsecutivepatientsbeingseeninaprimary

caredoctorsofficeisathighriskforsleepapneabasedupontheBerlin

Questionnaire?


AllPatients30-64(N=1128):

49.2%(555/1128)ofpatientsareathighriskforsleepapnea

Patients30-64withoutsleepapnea(N=960):



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AllPatients65+(N=513):


Patients>65withoutsleepapnea(N=450):


Question3:Doprimarycarecliniciansroutinelyscreenforsleepapnea?Ifso,

whatmethodsdotheyuse?

ClinicianInterviews

OKPRN(N=9):

Noneofthecliniciansroutinelyscreenforsleepapnea.

22%(2/9)cliniciansreportedusingastandardizedsleepquestionnairewhensymptoms

arereportedbythepatient.OneusestheBerlinSleepQuestionnaireandtheotheruses

theEpworthsleepinessscale.

APBRN(N=9):

55.6%(5/9)ofclinicianssaidtheyroutinelyscreenforsleepapnea.

Onlyonereportedusingastandardizedscreeningtool(Epworth).Theothersrelyupon

ReviewofSystemsdonewithannualexams.Thepercentageofadultsroutinely

receivingannualexamswasnotestimated.

SoFlaPBRN(N=8):

Noneofthecliniciansroutinelyscreenforsleepapnea.

Nonereportedusingastandardizedsleepquestionnairewhensymptomsarereported

bythepatient.


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ProHealth(N=9):

44.4%(4/9)ofcliniciansroutinelyscreenforsleepapnea.


bythepatient.

LANet(N=9):



bythepatient.

AllNetworks(N=44)


6.8%(3/44)cliniciansreportedusingastandardizedsleepquestionnaire(Berlinor

Epworth)whensymptomsarereportedbythepatient.

Question4:Howfrequentlydopatientspresenttoprimarycarepracticeshaving

alreadyreceiveddiagnostictestingortreatmentforsleepapnea?


OKPRN:PatientswithSleepApnea(N=128):

32.0%(41/128)ofpatientswithsleepapneahadbeendiagnosedandtreatedpriorto

theirseeingtheircurrentPCP.

62.5%(80/128)ofpatientsdiagnosedwithsleepapneawerediagnosedandtreated

afterseeingthecurrentPCP.

5.5%(7/128)wereclassifiedascanttell.

APBRN:PatientswithSleepApnea(N=217):


beforeseeingtheircurrentPCP.


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13.8%(30/217)wereclassifiedasCannotTell.

SoFlaPBRN:PatientswithSleepApnea(N=121):






ProHealth:PatientswithSleepApnea(N=191):






LANet:PatientswithSleepApnea(N=32):

9.4%(3/32)ofpatientsdiagnosedwithsleepapneawerediagnosedbeforeseeingtheir

currentPCP.

56.3%(18/32)ofpatientsdiagnosedwithsleepapneawerediagnosedandafterseeing

thecurrentPCP.


AllNetworksPatientswithSleepApnea(N=689):

14.7%(101/689)ofpatientsdiagnosedwithsleepapneawerediagnosedbeforeseeing

theircurrentPCP.


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72.1%(497/689)ofpatientsdiagnosedwithsleepapneawerediagnosedandafter

seeingthecurrentPCP.


PatientSurveys

OKPRN:Patients30-64withsleepapnea(N=41):

48.8%(20/41)ofpatientsdiagnosedwithsleepapneawerediagnosedbeforeseeing

theircurrentPCP.

51.2%(21/41)ofpatientsdiagnosedwithsleepapneawerediagnosedafterseeingtheir

currentPCP.

OKPRN:Patients65+withsleepapnea(N=20):

30.0%(6/20)ofpatientsdiagnosedwithOSAwerediagnosedbeforeseeingtheir

currentPCP.

15.0%(3/20)ofpatientsdiagnosedwithOSAwerediagnosedafterseeingtheircurrent

PCP.

55%(11/20)couldntrecallorfailedtoanswerthisquestion.

APBRN:Patients30-64withsleepapnea(N=30):46.7%(14/30)ofpatientsdiagnosedwithsleepapneawerediagnosedbeforeseeing

theircurrentPCP.


currentPCP.

6.7%(2/30)couldntrecallorfailedtoanswerthisquestion.

APBRN:Patients65+withsleepapnea(N=4):

50.0%(2/4)ofpatientsdiagnosedwithOSAwerediagnosedbeforeseeingtheircurrentPCP.


PCP.


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LANet:Patients30-64withsleepapnea(N=5):


currentPCP.


currentPCP.

40%(2/5)couldntrecallorfailedtoanswerthisquestion.

LANet:Patients65+withsleepapnea(N=2):

100.0%(2/2)ofpatientsdiagnosedwithOSAwerediagnosedbeforeseeingtheir

currentPCP.

0%(0/2)ofpatientsdiagnosedwithOSAwerediagnosedafterseeingtheircurrentPCP.

ProHealth:Patients30-64withsleepapnea(N=18):


currentPCP.


currentPCP.


ProHealth:Patients65+withsleepapnea(N=6):

16.7%(1/6)ofpatientsdiagnosedwithOSAwerediagnosedbeforeseeingtheircurrent

PCP.


PCP.


SoFlaPBRN:Nodata



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Polysomnography2.4%(2/82)

Homesleeptest0%(0/82)

Nocturnalpulseoximetrytest0%(0/82)

Taperecordingofsleep0%(0/82)

Sleepdiary0%(0/82)

Other0%(0/82)

SoFlaPBRNPatients>65withoutsleepapneaandwithsleep-relatedsymptomsrecordedin

thechart(N=22):

Notestingdone100%(22/22)

Polysomnography0%(0/22)




Sleepdiary0%(0/22)

Other0%(0/22)

ProHealthPatients>65withoutsleepapneaandwithsleep-relatedsymptomsrecordedinthechart(N=93):

Notestingdone81.7%(76/93)



Nocturnalpulseoximetrytest7.5%(7/93)


Sleepdiary1.1%(1/93) Other0%(0/93)

LANetPatients>65withoutsleepapneaandwithsleep-relatedsymptomsrecordedinthe

chart(N=23):


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Sleepdiary0%(0/23)

Other4.3%(1/23)

AllNetworksPatients>65withoutsleepapneaandwithsleep-relatedsymptomsrecordedin

thechart(N=268):






Sleepdiary0.4%(1/268)

Other0.7%


AllNetworks:AllPatients30-64:(N=1128):

10.0%(113/1128)reporthavingbeentestedforsleepapneawithanovernightsleep

study.

83.4%(941/1128)reportnothavingbeentestedforsleepapneawithanovernightsleep

study.

2.7%(27/1128)ofpatientsdidnotknowwhethertheyhadhadanovernightsleepstudy.

AllNetworks:Patients30-64withoutsleepapnea:(N=960):

3.2%(31/960)reporthavingbeentestedforsleepapneawithanovernightsleepstudy.


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study.


AllNetworks:AllPatients>65:(N=513):



study.


AllNetworks:Patients>65withoutsleepapnea:(N=450):



study.


Question6:Whenpatientssuspectedofhavingsleepapneaarereferredfor

diagnostictesting,whatproportionofthetestsispositive?

ClinicianInterviews(Estimates)

OKPRN:(N=9):

89.2%(Range:50-100%)testsarepositiveforsleepapnea.

APBRN:(N=9):

85.4%(Range:50-100%)

LANet:(N=6):

80.0%(Range:70-100%)


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ProHealth:(N=9):

79.1%(Range:55-93%)

SoFlaPBRN:(N=7):

85.7%(Range:70-100%)

AllNetworks:(N=40):

84.1%(Range:50-100%)

SleepConsultantInterviews(Estimates)

OKPRN:(N=6):

83.2%(Range:70-95%)testsarepositive.

APBRN:(N=8):


LANet:(N=1):

80.0%testsarepositive.

ProHealth:(N=1):


SoFlaPBRN:(N=1):


AllNetworks:(N=17):


ProspectivePatientSurveys:Patientswhohadhadasleeptest


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OKPRN:Patients30-64(N=41):

80.5%(33/41)ofpatientswhoreceivedanovernightsleepstudywereconfirmedto

havesleepapneabyapositivetest.

OKPRN:Patients65+:(N=34):



APBRN:Patients30-64(N=38):

68.4%(26/38)ofpatientswhoreceivedanovernightsleepstudywereconfirmed

tohavesleepapneabyapositivetest.

APBRN:Patients65+:(N=5):



LANet:Patients30-64(N=12):



LANet:Patients65+:(N=2):50.0%(1/2)ofpatientswhoreceivedanovernightsleepstudywereconfirmedto


ProHealth:Patients30-64(N=22):



ProHealth:Patients65+:(N=6):100.0%(6/6)ofpatientswhoreceivedanovernightsleepstudywereconfirmed


SoFlaPBRN:Nodata


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AllNetworks:Patients30-64(N=113):

71.7%(87/113)ofpatientswhoreceivedanovernightsleepstudywere

confirmedtohavesleepapneabyapositivetest.

AllNetworks:Patients65+:(N=47):



Question7:Whoinitiatesreferralsforsleeptesting?

SleepConsultantInterviews(Estimates)

OKPRN:(N=6):

73.3%(Range:60-100%)ofpatientsarereferredbyPCPs.

23.3%(Range:0-38%)ofpatientsreferredbysub-specialists.

5%(Range:0-15%)ofpatientsareselfreferred.

APBRN:(N=8):


28.3%(Range:5-50%)ofpatientsarereferredbysub-specialists.

7.7%(Range:0-13%)ofpatientsareselfreferred.

LANet:(N=1):

60%ofpatientsarereferredbyPCPs.

35%ofpatientsarereferredbysub-specialists.

0%ofpatientsareselfreferred.

ProHealth:(N=1):




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SoFlaPBRN:(N=1):




AllNetworks:(N=17):


26.9%(Range:0-50%)ofpatientsarereferredbysub-specialists.

5.8%(Range:0-15%)ofpatientsareselfreferred.


OKPRN:Patients30-64whohadhadasleepstudy(N=41):

68.3%(28/41)ofpatientswerereferredbyaPCP

41.5%(17/41)ofpatientswerereferredbytheircurrentPCP

26.8%(11/41)ofpatientswerereferredbyanotherPCP14.6%(6/41)ofpatientswerereferredbyasub-specialist

7.3%(3/41)ofpatientswereselfreferred

4.9%(2/41)didntknowwhoreferredthemfortheirsleepstudy.

OKPRN:Patients65+whohadhadasleepstudy(N=34):



32.4%(11/34)ofpatientswerereferredbyanotherPCP23.5%(8/34)ofpatientswerereferredbyasub-specialist


5.9%(2/34)dontknowwhoreferredthemfortheirsleepstudy.


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APBRN:Patients30-64whohadhadasleepstudy(N=38):



31.6%(12/38)ofpatientswerereferredbyanotherPCP

13.2%(5/38)ofpatientswerereferredbyasub-specialist



APBRN:Patients65+whohadhadasleepstudy(N=5):



0%(0/5)ofpatientswerereferredbyanotherPCP


0%(0/5)ofpatientswereselfreferred

0%(0/5)dontknowwhoreferredthemfortheirsleepstudy.

LANet:Patients30-64whohadhadasleepstudy(N=12):

66.7%(8/12)ofpatientswerereferredbyaPCP50.0%(6/12)ofpatientswerereferredbytheircurrentPCP





LANet:Patients65+whohadhadasleepstudy(N=2):

100.0%(2/2)ofpatientswerereferredbyaPCP50.0%(1/2)ofpatientswerereferredbytheircurrentPCP


0%(0/2)ofpatientswerereferredbyasub-specialist



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ProHealth:Patients30-64whohadhadasleepstudy(N=22):






0%(0/22)didntknowwhoreferredthemfortheirsleepstudy.

ProHealth:Patients65+whohadhadasleepstudy(N=6):




0%(0/6)ofpatientswerereferredbyasub-specialist



SoFlaPBRN:Nodata

AllNetworks:Patients30-64whohadhadasleepstudy(N=113):





10.6%(12/113)ofpatientswereselfreferred3.5%(4/113)didntknowwhoreferredthemfortheirsleepstudy.

AllNetworks:Patients65+whohadhadasleepstudy(N=47):




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4.3%(2/47)dontknowwhoreferredthemfortheirsleepstudy.

Question8:Arepatientsusuallyreferredtoasleepspecialistforaninitial

consultationordirectlyforpolysomnography(PSG)orhomesleeptests(HST)?


OKPRN:(N=9):

16.7%(Range:0-100%)ofpatientsarereferredtoasleepspecialistforinitial

consultationpriortoPSGorHST

APBRN:(N=9):

Noneofthecliniciansreferpatientstoasleepspecialistforinitialconsultationbefore

PSGorHST

LANet:(N=9):


PSGorHST

ProHealth:(N=9):


PSGorHST

SoFlaPBRN:(N=8):


consultationbeforePSGorHST


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AllNetworks:(N=44):


consultationbeforePSGorHST

Question9:Whatproportionofpatientsisreferredforahomesleeptest(HST)

ratherthanPSG?

ClinicianInterviews

OKPRN:(N=9):

NoneofthecliniciansreferpatientsspecificallyforHSTs.

APBRN:(N=9):

NoneofthePCPsreferpatientsspecificallyforHSTs.

LANet:(N=9):

NoneofthePCPsreferpatientsspecificallyforHSTs.

ProHealth:(N=9):

NoneofthePCPshadorderedanHST.OnehadreceivedinformationonHSTbuthadnt

startedreferringpatientsforit.

SoFlaPBRN(N=8):

Onlyoneofthe8PCPseverreferspatientsforhomesleeptesting.Fourareunfamiliar

withHST.OnewasunsureaboutMedicaresreimbursementpolicyregardingHST.One

wasuncertainabouttheaccuracyofthetest.OnewouldreferforHSTbutdidnthavea

referraloptioncloseenough.


OKPRN:Patientswithsleepapnea(N=128):


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Sleepdiary0%(0/128)

Other10.2(13/128)

APBRN:Patientswithsleepapnea(N=217):



Homesleeptest2.8%(6/217)


Taperecordingofsleep2.3%(5/217)


Other3.7%(8/217)

LANet:Patientswithsleepapnea(N=32): Notestingdone75.0%(24/32)





Sleepdiary0%(0/32)

Other0%(0/32)

ProHealth:Patientswithsleepapnea(N=191):

Notestingdone15.2(29/191)



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Sleepdiary0%(0/191)

Other3.7%(7/191)

SoFlaPBRN:Patientswithsleepapnea(N=121):






Sleepdiary0%(0/121)

Other0.8%(1/121)

AllNetworks:Patientswithsleepapnea(N=689):


Polysomnography70.5%(486/689) Homesleeptest1.9%(13/689)




Other4.2%(29/689)

ProspectivePatientSurveysOKPRN:Patients30-64whohadbeentestedforsleepapnea(N=41):

87.8%(36/41)ofpatientstestedforOSAreceivedaPSG

9.8%(4/41)ofpatientstestedforOSAreceivedaHST

OKPRN:Patients65+whohadbeentestedforsleepapnea(N=34):


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APBRN:Patients30-64whohadbeentestedforsleepapnea(N=38):


0%(0/38)ofpatientstestedforOSAreceivedaHST

APBRN:Patients65+whohadbeentestedforsleepapnea(N=5):



LANet:Patients30-64whohadbeentestedforsleepapnea(N=12):



LANet:Patients65+whohadbeentestedforsleepapnea(N=2):



ProHealth:Patients30-64whohadbeentestedforsleepapnea(N=22):100.0%(22/22)ofpatientstestedforOSAreceivedaPSG


ProHealth:Patients65+whohadbeentestedforsleepapnea(N=6):



SoFlaPBRN:Nodata

AllNetworks:Patients30-64whohadbeentestedforsleepapnea(N=113):




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AllNetworks:Patients65+whohadbeentestedforsleepapnea(N=47):



SleepConsultantInterviews

ThefollowingquotationfromoneoftheOklahomasleepconsultantsisworthreporting:

Currentlywearereimbursedabout$550-600perPSGbyMedicare.Thisisreferredtoasa

LevelIstudy.LevelIIstudiesarenearlyascomplicated,whilelevelIVstudiesarequitesimple.

Medicarepaysthesame(mylatestinformationisabout$150,whichincludestechnicaland

interpretationbillings)forLevelsII,III,andIVstudies.Obviouslyitisnotparticularly

economicallysensibletodoaLevelIIorIIIstudywhenyoucandoafullPSG,andeventheLevel

IVtestsarenotreallyeconomicallyviableatthislowrate.Thepatientsneedtobeseentobe

setup,arrangementshavetobemadetogetthedatabacktothelab,thestudyhastobe

downloaded,scored,andinterpreted.

AndfromAlabama,baseduponinterviewswithseveraloftheirsleepconsultants:

ManyprivatepayersdonotreimburseforHSTs.Therearemanyadministrativehoopstojump

throughforMedicare.MedicarereimbursementforHSTsisverylow,somanysleeplabswontdothemforthatreason.ManytimespatientsstillneedaPSGtodetermineCPAPpressure

settings,sonowthetestingbecomesevenmoreexpensivesincepatientsgettwotestsinstead

ofone.

Question10:Inwhatproportionofpatientsissplitnighttestingperformed?


OKPRN:(N=6):

68.0%(Range:40-100%)ofpatientsundergosplit-nighttesting.

APBRN(N=9):


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LANet:(N=1):

80%ofpatientsundergosplit-nighttesting.

ProHealth:(N=1):


SoFlaPBRN(N=1):


AllNetworks(N=18):


Question11:WhatistheaveragewaittimeforPSGorHST?


OKPRN:(N=6):

1.8weeks(Range:1.0-3.0)

APBRN(N=9):

2.6weeks(Range:1.0-5.0).

LANet:(N=1):

2.1days.

ProHealth:(N=1):

2.5weeks.

SoFlaPBRN(N=1):


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1week.

AllNetworks:(N=18):

2.1weeks(Range:0.3-5.0)

Question12:ForpatientswhoreceivePSG,howmanyrequireretesting?

Ourdatawasinadequatetoanswerthisquestion.

Question13:Whatisthewaittimeforretesting?

Ourdatawasinadequatetoaddressthisquestion.

Question14:ForpatientswhoreceiveHST,whichdevices(TypeII-7channels,

TypeIII4channels,orTypeIV1or2channels)arebeingusedinwhat

proportions?


Question15:IsHSTgenerallyattendedorunattended?


Question16:WhenHSTisused,istheregenerallyfollowupwithhomeorlab

testing?

Ourdatawasinadequatetoanswerthisquestion.


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Question17:IsCPAPprescribedmorefrequentlybyasleepspecialistorprimarycare

physician?

ClinicianInterviewsOKPRN:(N=9):

88.9%(8/9)ofclinicianssaidthePCPusuallyprescribestheCPAP.

APBRN:(N=9):

Itwasdifficulttotellforsurebecauseofthewaythequestionwasasked.However,it

seemsthatallofthePCPsletthesleepconsultantprescribetheCPAP.

LANet:(N=9):

21.4%(2/9)ofclinicianssaidthePCPprescribestheCPAPabout50%ofthetime.

78.6%(7/9)ofcliniciansletthesleepconsultantprescribeit.

ProHealth:(N=9):

33.3%(3/9)ofclinicianssaidthePCPsometimesprescribestheCPAP(10%,10%,and

40%ofthetime.Theothersletthesleepconsultantprescribeit.

SoFlaPBRN:(N=8):

Itwasdifficulttotellforsurebecauseofthewaythequestionwasasked.However,it

seemsthatatleast5ofthe8PCPsletthesleepconsultantprescribetheCPAP.The

othersmayprescribeitforsomepatientsandsaytheyareveryinvolvedinthelong-

termmanagementofthesepatients.

Question18:WhatfollowupisprovidedforpatientsonCPAP,anddoesthat

occurinprimarycareorsleepspecialtycare?

ClinicianInterviews


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OKPRN:(N=9):

66.7%ofcliniciansreportedthatthePCPisresponsibleforthefollowupofCPAP

treatment.

APBRN:(N=8):

37.5%ofcliniciansreportedthatthePCPisresponsibleforfollowuponCPAP

treatment.

LANet:(N=0):

NocliniciansreportedthatthePCPisresponsibleforfollowuponCPAPtreatment.

ProHealth:(N=9):


treatment.

SoFlaPBRN:(N=6):


treatment.

Question19:Howdoestheproviderdeterminewhetherthepatientisadhering

toCPAPtherapyandwhetherthetherapyishelpingthepatient?

ClinicianInterviews

Thedatawasinadequatetoaddressthisquestionwithcertainty,butmanyofthePCPs

seemedunfamiliarwithreportingrequirements,assumingthateitherthesleep

consultantortheDMEcompanywasresponsible.

Referral(Sleep)CenterInterviews


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Thedatawasinadequatetoaddressthisquestion.Afewofthesleepconsultantstakea

veryactiveroleintheinitialmanagementofpatientswithOSAandhandleMedicare

reporting.

Question20:WhatproportionofpatientscontinuestousetheirCPAPregularly

foranextendedperiodoftime?


OKPRN:(N=8):

66.6%(Range:20-93%)ofpatientscontinuetousetheirCPAPlongterm

APBRN:(N=8):


LANet:(N=7):


ProHealth:(N=9):


SoFlaPBRN:(N=0):

Becauseofthewaythequestionwasasked,itwasdifficulttoobtainameaningful

estimate.

AllNetworks(N=32):


PatientSurveys

OKPRN:Patients30-64withsleepapnea(N=26):


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65.4%(17/36)ofpatientssaidtheyhavecontinuedtousetheirCPAPlongterm

OKPRN:Patients65+withsleepapnea(N=4):


APBRN:Patients30-64withsleepapnea(N=25):


APBRN:Patients65+withsleepapnea(N=4):

50.0%(2/4)ofpatientscontinuetousetheirCPAPlongterm

LANet:Patients30-64withsleepapnea(N=1):


LANet:Patients65+withsleepapnea(N=0)

ProHealth:Patients30-64withsleepapnea(N=14):


ProHealth:Patients65+withsleepapnea(N=4):


SoFlaPBRN:Nodata



AllNetworks:Patients65+withsleepapnea(N=12):


ChartAuditsofPatientswithSleepApnea

Medicalrecordsdocumentationofadherencewasinadequatetoaddressthisquestion.Seealsosummativedataonpatientswhosechartswereaudited.

Question21:Whatproportionofsleepapneapatientsbenefitsfromtreatment?


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Thedataavailableinthemedicalrecordswasinadequatetoaddressthisquestion.Seealso

summarydataonpatientswhosechartswereabstracted.

Question22:Whatproportionofpatientswithnegativetestingresults

continuestohavesymptoms?Whatisthemostcommonalternativediagnosis?

Whatproportionisreferredtoasleepspecialist?

Thisinformationcouldnotbedeterminedfromthechartabstractions.

Question23:Whatproportionofpatientsisreferredforfollowuptesting

and/oratrialofCPAPwithoutapositivePSG?

Thedatawasinadequatetoaddressthisquestion.Theseeventshappenonlyrarely.

Question24:WhatfollowupcareisprovidedforpatientswithnegativePSG?


SleepApnea

ClinicianInterviewSchedule

Interviewer:Thepurposeofthisinterviewistofindouthowyouapproachsleepproblems,

particularlyobstructivesleepapnea.

1. Doyouroutinelyaskadultpatientsaboutsleephabitsorsleepproblems?

FOLLOW-UP:Ifso,howdoyoudoit?


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()NOTETOINTERVIEWER:Ifcliniciannamesatool,askforacopyifpossible.Ifnot,get

specificinformationregardingname,source,cost,etc.)

2. Doyouuseanystandardizedtoolstohelpyouidentifyobstructivesleepapnea?

FOLLOW-UP:Ifso,whichone(s)?

()NOTETOINTERVIEWER:Ifcliniciannamesatool,askforacopyifpossible.Ifnot,get

specificinformationregardingname,source,cost,etc.)

3. Whenyoususpectapatienthasobstructivesleepapnea,whatisyournextstep?

Ifclinicianrefersthepatientfortesting,ASK:Towhichconsultantororganizationdo

youreferthem?(Beveryspecific,andobtaintheaddressandphonenumbers.)

FOLLOW-UP:Whatproportionofcasesofsuspectedsleepapneadoyourefer?

Ifclinicianordersaspecificdiagnostictest,ASK:Whichonedoyouusuallyorder?

FOLLOW-UPQUESTION:Whydoyoupreferthisdiagnosticapproachoverothers?

FOLLOW-UP:Inwhatproportionofcasesdoyouusethisdiagnostictest?

Ifcliniciannamesanyotherapproach,ASK:Wouldyoudescribethisstrategy?

NOTETOINTERVIEWER:Ifmorethanoneapproach,ASKforeachone.)

FOLLOW-UPQUESTION:Inwhatproportionofcasesdoyouusethisapproach?

FOLLOW-UPQUESTION:Whyorinwhatcircumstancesdoyouusethis/these

approaches?

4. Whatobstacleshaveyouencounteredtotheoptimalevaluationandtreatmentof

patientswithsuspectedobstructivesleepapnea?


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FOLLOW-UP:Wouldyouestimatehowofteneachofthesefactorsgetinthewayof

appropriatediagnosisandmanagement?Apercentforeachwouldbehelpful.

FOLLOW-UP:Howdotheyimpactevaluationandmanagement?)

5. Whenyouthinkofallthepatientsyouhavesuspectedofhavingobstructivesleepapnea

andhavereferredfordiagnostictesting,whatpercentofthetestshavebeenpositive?

(REPHRASEIFNECESSARY:Whatwewanttoknowishowgoodyouareatpredicting

thatpatientshavethiscondition?)

6. Howlikelyisitthatyouwilladdobstructivesleepapneatoapatientsproblemlistonce

thediagnosishasbeenconfirmed,giventhatdiagnostictestresultsmaycomebackbetweenvisits?(Pleaseestimateapercentage.)

FOLLOW-UP:Howlikely(percentage)isitthatobstructivesleepapneawilleventually

makeitintoyourbillingrecordsforthesepatients?(Onceadiagnosishasbeen

madebysomeoneelse,howlikelyareyoutoincludeitasoneofyourdiagnosesfor

billingonsubsequentvisits?)

7. Oncethediagnosisofobstructivesleepapneahasbeenconfirmed,whatisyourusualroleinthemanagement?Forexample,

WhenCPAPisindicatedorrecommended,doyouusuallyprescribeit,ordoesa

consultantdothat?InwhatpercentofcasesinwhichCPAPisindicateddoyou

prescribeityourself?

Whatothertreatmentmodalitieshavebeenprescribedforyourpatientswith

obstructivesleepapnea?

FOLLOW-UP:Wouldyoutellmeforeachofthese,whatpercentdidyouprescribe

themodalityyourself?


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8.Doyougenerallycontinuetomanagepatientssleepapneaordoyouleavethatto

others?

FOLLOW-UP:Ifyoudomanagethesepatients,howdoyoudeterminewhetherthey

areusingtheirCPAPdevices?

9. WhatpercentofyourpatientswithobstructivesleepapneaactuallyweartheirCPAP

deviceconsistentlylongterm?

FOLLOW-UP:Whatreasonsdoyourpatientsgivefornotwearingthedevice?

FOLLOW-UP:Whatisyourresponsetopatientswhoadmittonotwearingtheir

CPAPconsistently?

10.Thinkaboutthelastpatientyoudiagnosedwithsleepapnea.Describetheprocessof

careinvolvedfromsuspiciontodiagnosistotreatmenttofollow-up.

Thatconcludestheinterview.Thankyouverymuchforparticipating!

Paythem.


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Discussstrategiesforcontactingthesleeplabandhomesleeptestconsultants.(e.g.Seeifthe

cliniciancancallandgiveyouanintroduction.)


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ObstructiveSleepApneaSleepLabInterviews

INTERVIEWER:Thepurposeofthisinterviewistohelpusunderstandhowpatientswith

obstructivesleepapneaarediagnosedandmanagedinprimarycaresettings.

1. Whatpercentofyourpatientsarereferredbyeachofthefollowinggroups: a.

Primarycareclinicians?

b.Subspecialists?

c.Patientself-referral?

2. Fromwheredomostofyourpatientscome;thatis,whatisyourcatchmentareaor

primaryservicearea?Couldyouestimatethegeographicradiusinmiles?

3. Whenpatientsarereferredbecauseofsuspectedobstructivesleepapnea,whatdoyou

usuallydotoevaluatethem?(Listalldiagnosticsteps.)NOTETOINTERVIEWER:Ifa

diagnosticalgorithmisused,drawit.FOLLOW-UP:Arethereanysocio-demographic

factors(e.g.,age,gender,insurancecoverage)thataffecttheapproachthatyoutake?

Whatotherfactorsmightsometimesleadyoutouseadifferentdiagnosticapproach

andwhatarethedifferencesinyourapproach?

4. Whatistheaveragewaittimeforanon-urgentappointmentinyourlab?

5. Inwhatproportionofpatientsdoyoudosplitnighttesting?


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FOLLOW-UP:Whataretheindicationsfordoingsplitnighttesting?

FOLLOW-UP:Isthisdecisionmadepriortothesleepstudy?

FOLLOW-UP:Isasplitnightstudyyourusualprocedure?

6. Amongpatientsreferredbyprimarycarecliniciansbecauseofsuspectedobstructive

sleepapnea,whatpercentactuallyhaveobstructivesleepapnea?

7. Whatpercentofpatientswhoreceiveadiagnostictestinyourlabrequireretestingat

somepoint?FOLLOW-UP:Whatarethereasonsforretesting?(Listallreasons.)

8. Inyourexperience,whatpercentofpatientssuspectedofhavingobstructivesleepapneabutwithnormaltestresultscontinuetohavesymptoms?FOLLOW-UP:Doyou

everprescribeatrialofCPAPorothersimilarsleepapneatreatmentsforthese

patients?Howoftendoyoudothis?(Rarely?Occasionally?Fairlyoften?Frequently?)

9. Howdoyoucommunicateyourfindingsandrecommendationstoreferringclinicians?

FOLLOW-UP:Howdoyoucommunicatefindingstopatients?

10.DoyouorsomeoneelseinyourlabgenerallyprescribeCPAPorothertreatmentsordo

youmakearecommendationtothereferringclinicianandpatientandletthemhandle

that?FOLLOW-UP:Forwhatpercentofpatientsdoyoudoeach?


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11.OnceCPAPorasimilartreatmenthasbeenrecommendedorprescribed,doyouusually

havepatientsreturnforfollow-upvisitsordoyouleavefollow-upandongoing

managementtothereferringclinician?FOLLOW-UP:Ifyouseepatientsbackfor

ongoingcare/monitoringorforproblems,howdoyoukeepthereferringclinicianinformedaboutthis?

12.Howdoyousuggestthatreferringclinicians(orhowdoyouasthecareprovider)

determinewhetherpatientsareactuallyusingtheirCPAPdeviceasprescribed?

13.Whatdoyouchargeforthevariousservicesyouprovidetopatientssuspectedofhaving

obstructivesleepapnea?Wouldyouprovidealistofcodesandthechargesforeach?

THANKYOUFORYOURTIME!

Iwillbecontactingthesleepconsultantsthatyoumentionedtoseeiftheywouldbewillingto

beinterviewedaswell.Woulditbepossibleforyoutocontactthemfirsttoletthemknowthat

weareworkingtogetheronthisprojectandtoencouragethemtoconsiderparticipating?


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Chart Audits: Patients 65 Years Old and Older

Variable Type Range Options

Network Study Number Integer 1 through 51=OKPRN, 2=APBRN, 3=SoFlaPBRN, 4=ProH5=LANet

Practice Study Number Integer 1 through 9 In order of randomization. See list below

Patient Study Number Integer 1 through 25 In order audited for each clinician.

Patient Age (At Time of Audit) Integer21 through120 Age of patient at the time of the chart audit.

Patient Gender Integer 0,1 0=Female; 1=Male

Sleep Symptoms Integer 0 through 15 0=Asymptomatic; 1 - See list of possible sympto

Sleep-Related Diagnoses Integer 0 through 10 0=No diagnoses; 1 - See list of possible diagno

Sleep Studies Integer 0 through 6 0=No studies; 1-See list of possible studies.

Treatments for Sleep Symptoms Integer 0 through 7 0=No treatments tried;1 - See list of possible treatments

Possible Symptoms:

0. Asymptomatic

1. Trouble getting to sleep

2. Daytime sleepiness

3. Unintentional sleep episodes

4. Restless sleep

5. Unrefreshing sleep

6. Fatigue

7. Trouble concentrating

8. Wakes holding breath, choking, or gasping

9. Bed partner reports loud snoring

10. Bed partner reports apneic episodes11. Nocturnal angina

12. Morning headache

13. Snoring

14. Restless legs syndrome

15. Not documented

Sleep-Related Diagnoses

0. No diagnosis

1. Obesity

2. Hypertension

3. Pulmonary Hypertension

4. Congestive Heart Failure5. Cardiac arrhythmias

6. GERD

7. Diabetes mellitus

8. Metabolic syndrome

9. Coronary artery disease

10. Cor pulmonale (right heart failure)


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Possible Sleep Studies0. No testing done

1. Polysomnography

2. Home sleep test

3. Nocturnal pulse oximetry test

4. Tape recording of sleep sounds

5. Sleep diary

6. Other

Possible Sleep Treatments

0. No treatment

1. Sleep hygiene instructions

2. Prescription sleep medication

3. Non-prescription sleep medication

4. Herbal sleep remedy

5. Weight reduction

6. Adjustment of other medications

7. Other


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ChartAudits:SleepApneaPatients

Variable Range Options

NetworkStudyNumber 1though5 1=OKPRN,2=APBRN,3=SoFlaPBRN,

4=ProHealth,5=LANet

PracticeStudyNumber 1through9 Intheorderitappearedonthe

randomizationlistyouweregive.Seelist

below

PatientStudyNumber 1through25 Intheoderinwhichitwasaudited

PatientAge(Attimeofaudit) 21through120 Ageofpatientatthetimeofthechartaudit

PatientGender 0,1 0=Female;1=Male

PrimaryHealthInsurance

Type

1through5 1=Medicare;2=Medicaid;3=Private;

4=Uninsured;5=Canttell

SecondaryHealthInsurance

Type

1through4 1=Medicaid;2=Private;3=None;4=Canttell

AgeWhenSleepApnea

Diagnosed

1through120 Ageofpatientatthetimeofthediagnosisof

sleepapnea(bestestimate)DiagnosisofOSAmade

Before/SinceThisPCP

0,1 0=DxmadebeforepatientsawthisPCP;

1=Dxmadesincethen

SymptomsPriortoDiagnosis 0through14 0=Asymptomatic;1-Seelistofpossible

symptoms

SleepApnea-Related

Diagnoses

0through10 0=Nodiagnoses;1Seelistofpossible

diagnoses

TestusedtoDiagnoseSleep

Apnea

0through6 0=Notestingdone;1Seelistofpossible

tests

TreatmentModalitiesTried 0through18 0=Notreatmentstried;1Seelistof

possibletreatmentsCurrentTreatment 0through18 0=Nocurrenttreatment;1Seelistof

possibletreatments

ImpactofTreatmenton

Symptoms

0through2 0=Txdidnthelp;1=Txhelped;2=Canttell

AbilitytoAdhereto

Treatment

0through3 0=Stopped;1=Partiallyadherent;2=Fully

adherent;3=Canttell

EvidenceofRepeatTests 0,1 0=No;1=Yes

DiagnosisonProblemList 0,1 0=No;1=Yes

DiagnosisinNotes 0,1 0=No;1=Yes

PolysomnogramReportin

Chart

0,1 0=No;1=Yes

SleepApneaFollow-up 0through3 0=PCP;1=Sleepspecialist;2=Other;3=No

follow-up


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Possible Symptoms:

0. Asymptomatic

1. Trouble getting to sleep

2. Daytime sleepiness3. Unintentional sleep episodes

4. Restless sleep

5. Unrefreshing sleep

6. Fatigue

7. Trouble concentrating

8. Wakes holding breath, choking, or gasping

9. Bed partner reports loud snoring

10. Bed partner reports apneic episodes

11. Nocturnal angina

12. Morning headache

13. Snoring

14. Not documented

Sleep-Related Diagnoses

0. No diagnosis

1. Obesity

2. Hypertension

3. Pulmonary Hypertension

4. Congestive Heart Failure

5. Cardiac arrhythmias

6. GERD

7. Diabetes mellitus

8. Metabolic syndrome

9. Coronary artery disease10. Cor pulmonale (right heart failure)

Diagnostic Tests

0. No testing done

1. Polysomnography

2. Home sleep test

3. Nocturnal pulse oximetry test

4. Tape recording of sleep

5. Sleep diary

6. Other

Possible Sleep Apnea Treatments0. No treatment

1. Sleep positioning

2. Sleep apnea vest

3. Weight reduction

4. CPAP

5. BiPAP

6. VPAP

7. DPAP


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8. AutoPAP

9. UPPP

10. LAUP

11. Somnoplasty surgery

12. Jaw realignment surgery

13. Tracheostomy

14. Injection snorplasty15. CAPSO (pallatal stiffening)

16. Tongue base suspension

17. Palatal implants

18. Dental sleep apnea appliance

Management of Obstructive Sleep Apnea by Primary Care Clinicians

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