Primary care-based management can reduce burden of OSA

Patients with moderate-to-severe obstructive sleep apnea (OSA) can be successfully managed in a primary care setting by appropriately trained primary care physicians (PCPs) and community-based nurses, according to Australian researchers.

"With the rise in demand and growing waiting lists for sleep physician consultation and laboratory-based sleep services, there has been increasing interest in development of ambulatory strategies for the diagnosis and management of OSA involving home sleep monitoring and auto-titrating continuous positive airway pressure (CPAP)," said lead author Ching Li Chai-Coetzer, MBBS, of the Adelaide Institute for Sleep Health at Repatriation General Hospital in Australia. "While previous studies have demonstrated that ambulatory models of care for OSA in specialist settings can produce patient outcomes which are comparable to laboratory-based management, this is the first randomised controlled study to be conducted in primary care."

The results will be presented at the ATS 2012 International Conference in San Francisco.

"We randomized 155 patients to either primary care-based management or usual care in a specialist sleep center," said Dr. Chai-Coetzer. "At six months, mean change in Epworth sleepiness scale (ESS) scores, the primary outcome measure of the study, was similar in the two groups (4.9 in the primary care group vs. 5.1 in the specialist group)."

PCPs identified patients with symptomatic, moderate-to-severe OSA using a four-item screening tool, the ESS, and home oximetry. Primary care-based management was led by the patient's PCP and a community-based nurse and involved use of home auto-titrating continuous positive airway pressure (CPAP). Usual care in a specialist sleep center involved management by a sleep physician and laboratory-based testing.

In addition to similar changes in ESS scores at six months, mean change in Functional Outcomes of Sleep Questionnaire (FOSQ) score was similar in the two groups (2.3 in the primary care group vs. 2.7 in the specialist group), as was compliance with CPAP. Mean daily use of CPAP was 4.8 (±2.1) hours in the primary care group and 5.4 (±1.8) hours in the specialist group.

Furthermore, within-study costs for primary care management were lower than those for specialist care, with significant savings of AUD$2157 (95% CI: $1293 to $3114) per patient.

"Our results show that using a simplified, ambulatory approach for the treatment of OSA in primary care is not clinically inferior to management of these patients in a specialist sleep center," concluded Dr. Chai-Coetzer. "This approach also offers a lower cost alternative to usual care. In addition, waiting lists for specialist sleep centers are long, and home care may be preferred by patients.

"With adequate training of PCPs and their practice nurses and appropriate funding models to support an ambulatory strategy, primary care management of OSA has the potential to reduce the burden of disease in the community by improving patient access to sleep services. This would be particularly beneficial for rural and remote regions, as well as developing nations, where access to specialist services may be limited."