Can primary care providers manage obstructive sleep apnea?

INTRODUCTION

Obstructive sleep apnea (OSA) is a highly prevalent condition, with recent estimates indicating that close to 1 billion individuals aged between 30 and 69 years are affected by OSA worldwide, including 425 million who have moderate–severe disease (apnea-hypopnea index ≥15 events/h).¹ Despite the availability of effective therapies and overwhelming evidence of the adverse health consequences associated with untreated OSA, the condition remains largely undiagnosed and poses a substantial burden for the global community. In highly populated, poorly resourced regions, such as Africa and Asia, specialist sleep services remain scarce or are nonexistent. Even in highly developed, well-resourced countries, long waiting times for sleep physician consultations or to access laboratory polysomnography testing are commonly reported,^2–4 contributing to substantial delays in OSA diagnosis and treatment initiation, particularly for patients living in rural or remote locations.

To address the escalating societal and economic burden of disease, there has been growing interest in the development of innovative management models for OSA that utilize ambulatory diagnostic techniques and/or involve health care professionals other than sleep physicians as principal providers of care, including primary care physicians and community-based nurses.⁵ Researchers in Australia and Spain have consistently shown in 4 recently published, randomized controlled trials that outcomes for patients with OSA who are managed by primary care physicians and nurses in primary care are comparable to those managed in specialist settings, and with significant cost savings.^6–9 It could be argued that these trials involved a limited number of interested and highly motivated primary care providers (PCPs), so questions remain unanswered as to whether PCPs more generally are willing and ready to assume greater responsibility for OSA diagnosis and care and whether patients would be in favor of management models for sleep disorders that are centered within primary care.

The study by Pendharkar et al¹⁰ in this issue of the Journal of Clinical Sleep Medicine helps to address this important knowledge gap by exploring the perspectives of key stakeholders on primary care management of OSA. Both qualitative and quantitative methods were used to survey PCPs, sleep specialists, and patients, enabling identification of important barriers and facilitators to potential practice change. A number of challenges with existing OSA care pathways were highlighted by this study, including the following: significant delays in sleep specialist access; variable knowledge about OSA among PCPs; a lack of clarity regarding provider roles in management; patients being poorly informed about their diagnosis and treatment plans, leading to a disconnection of OSA from other health issues; an erosion of trust in community homecare providers due to conflict-of-interest concerns; and a desire for greater primary care or specialist physician involvement in patient care. Potential solutions to the issues identified by the study authors included better integration of providers into multidisciplinary models of care, development of clear clinical pathways and defined roles to improve system navigation, and use of technology to facilitate communication and sharing of information.

Our experience in Australia supports the findings of Pendharkar et al and suggests the need for a systemic approach to ensure that all those with sleep disorders have access to appropriate care. We anticipate that models of care will differ between countries and between regions within the same country but all will need to consider patient and community preferences, the range of appropriate providers in primary care (and their associated training needs), and the integration with specialist sleep services and available funding models. These questions are currently being addressed by a consortium of Australian investigators via research projects funded by the National Health and Medical Research Council.

There will likely be a need to test different approaches. For example, while there is some evidence that nurse-led models of care for OSA in sleep clinics are at least as effective and are less expensive than physician care,¹¹ and an expanded role for nurses in primary care is being actively promoted in chronic disease management,^12,13 the role of practice nurses in delivering OSA management in primary care has not been investigated. Likewise, the extent to which primary care physicians with a special interest in sleep can add value to the management of OSA is unknown, although special-interest PCPs have been shown to improve outcomes in other disorders.¹⁴ Whichever model of OSA service delivery in primary care best suits a country or region, its successful adoption will require the strong support of existing specialist sleep physicians and services.

DISCLOSURE STATEMENT

All authors have seen and approved the manuscript. The authors report no conflicts of interest.

REFERENCES