Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial. Chai-Coetzer CL, et al JAMA. 2013 Mar 13;309(10):997-1004. doi: 10.1001/jama.2013.1823.
Abstract: Primary Care vs Specialist Sleep Center Management of OSA
IMPORTANCE: Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients withobstructive 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 inspecialist 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 specialistmodel did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable.
COMMENT: Primary Care vs Specialist Sleep Center Management of OSA and daytime sleepiness and quality of life: a randomized trial.
This paper confirms once more that GPs who have some basic understanding of the pathogenesis and consequences of Obstructive Sleep Apnoea, are in an ideal position to screen and treat this extremely common condition. Hospital services are stretched beyond their limits. Sleep Apnoea, and burden of consequences of this condition, could be effectively managed in General Practice. Bottom line: Some extra training would be necessary, but there is an inevitable move towards more simple and effective evaluation of this prevalent condition. (Dr Alex Bartle)
The Wisconsin cohort is most widely quoted – it gives a prevalence of SDB of 2-4% for middle-aged adults. This was prior to the obesity epidemic. In addition, evidence for treatment benefits for patients with less severe illness is increasing. It is unlikely that a specialist-based service will cope with the demand. The Adelaide group has been combining four-item sleep questionnaire and overnight oximetry to allocate CPAP treatment. The service was facilitated by nurse specialists and also delivered to three ruaral areas. Bottom line: treatment for sleep apnoea was equally effective and less expensive when delivered in a primary-care setting. (Associate Professor Lutz Beckert - Respiratory Research Review)