Obstructive sleep apnea, or OSA, is halfway through its sixth decade of being mentioned in medical journals, according to a report in the World Journal of Otorhinolaryngology of Head and Neck Surgery.
Yet, the condition is often omitted from discussions primary care physicians have with their patients, Jennifer N. Miller, PhD, and Ann M. Berger, PhD, sleep specialists at the University of Nebraska Medical Center, wrote in Sleep Medicine Reviews.
“The current practice model of screening and assessment for OSA in primary care is fragmented and ineffective. Primary care providers encounter patients with OSA symptoms but do not routinely screen, assess, or refer to a sleep specialist,” they wrote.
The lack of coordinated care contributes to an estimated 80% to 90% of adult cases of OSA going undiagnosed, according to a recent report from The American Academy of Sleep Medicine.
Healio Primary Care reviewed abstracts from this year’s SLEEP meeting to find methods PCPs can use to help detect OSA or assess its severity.
Prompt increases snoring documentation
A computer prompt “significantly improved” PCP documentation of snoring, one of the signs of OSA, according to researchers.
“Snoring is an important initial step on the path towards OSA detection and treatment,” Sarah M. Honaker, PhD, assistant professor of pediatrics, Indiana University School of Medicine, and colleagues wrote.
They developed Child Health Improvement through Computer Automation for Snoring (CHICA-Snore). The tool asks parents via an electronic tablet while they are in the waiting room if their child snores. If parents answer affirmatively, the PCP is electronically prompted to evaluate the child for OSA.
Researchers reviewed outcomes from 194 visits that occurred 1 year before the parents indicated snoring and the visit where the parent noted the snoring. They found that with CHICA-Snore, PCPs noting of snoring went from 18.8% at baseline to 64% (P <.01).
“Next steps are to evaluate the impact of CHICA-Snore and other decision support tools on OSA referrals and other more downstream effects,” Honaker and colleagues concluded.
Throat test helpful in detecting OSA severity
A tool dubbed the Gupta Score that assessed the oropharyngeal airway enhanced clinicians’ ability to determine the severity of patients’ OSA, according to researchers.
“Modified Mallampati classification is not a useful tool in clinical assessment to predict severity of OSA,” Nilesh I. Gupta, MD, of Aurora HealthCare in Menomonee Falls, Wisconsin, wrote.
He retrospectively reviewed 198 consecutive patients who underwent a diagnostic polysomnogram. Patient data, including Epworth Sleepiness Scale and Modified Mallampati Class, were recorded at the first visit and compared with the patient’s apnea-hypopnea index. Patients then took a single breath through their nose. Any difference between the Modified Mallampati Class score and the single breath score was recorded as the Gupta Score (eg, I, II, III, IV).
Gupta found that 19 patients (mean apnea-hypopnea, 25.98 indices) had a Gupta Score of I, 65 patients had a Gupta Score of II (mean apnea-hypopnea, 36.43 indices), 17 patients had a Gupta Score of III (mean apnea-hypopnea, 46 indices) and two patients had a Gupta Score of IV (mean apnea-hypopnea, 41.2 indices).
The American Academy of Sleep Medicine defines mild OSA as five to 15 apnea-hypopnea indices per hour of sleep; moderate as between 15 and 30 apnea-hypopnea indices for each hour of sleep; and severe as 30 or more apnea-hypopnea indices per hour of sleep.
“The Gupta Score increases the probability of diagnosing a patient with OSA and its severity as indicated by this study,” Gupta wrote. “Incorporating the Gupta score in the routine clinical exam across various medical specialties may result in a greater number of patients being diagnosed and treated for OSA.”
Existing OSA screening tools may have poor specificity
Presently used pre-test probability tools for OSA performed with poor specificity, positive predictive value and diagnostic odds ratios in recent tests, according to study authors.
“OSA is a frequent cause of morbidity associated with hospitalization,” Bradley Williams, MD, of San Antonio Military Health, San Antonio, and colleagues wrote.
Researchers conducted pre-test probabilities on STOPBANG, Berlin, NAMES2, Four Variable and, collectively, OSA symptoms of high BP, snoring and elevated neck circumference on 141 patients aged 18 to 39 years (mean apnea-hypopnea, 8.1 indices). They found that 56 patients had OSA, with 63% of the cases considered mild-to-moderate. In addition, the pre-test probability for the collective symptoms of OSA showed a 13% sensitivity and 99% specificity, positive predictive value was 88%, diagnostic odds ratio was 12 and area under receiver-operator characteristic curve was 0.557. The other tools’ sensitivities varied from 85.2% to 94.6%, specificities from 23.5% to 32.9%, positive predictive value from 44.2% to 46.4%, diagnostic ORs from 2.6 to 5.4 and area under receiver-operator characteristic curves from 0.59 to 0.61.
“The combined symptom set of snoring, hypertension and elevated neck circumference, suggests high specificity and an improved diagnostic odds ratio for OSA in the young adult population,” they concluded.
Two-question survey improves recognition of sleep disorders
A two-item questionnaire effectively screened for sleep disorders, according to researchers.
Jessica Arguelles , a research associate at Kaiser Permanente in California, and colleagues asked consecutive patients “How many days a week are you not satisfied with your sleep?”, “How many days a week is sleepiness a problem?” and questions on other validated questionnaires. Some patients were not asked any questions. They then compared the patients with sleep disorders scores on existing tools vs. their two-question survey.
Arguelles and colleagues found such comparisons between the Epworth Sleepiness Scale, Insomnia Severity Index and Functional Outcomes of Sleep Questionnaire led to P scores of < .001, while the STOP-BANG had a P score of = .03.
“A sleep vital sign, based on a 2-question survey, is a simple method of screening for sleep disorders in a primary care clinic. Corresponding trends in [sleep vital sign] scores and various validated sleep surveys were observed, supporting its potential utility as a general sleep disorder screening tool,” Arguelles and colleagues wrote.
Detecting and assessing OSA is becoming increasingly important in primary care. A report in Sleep Medicine Reviews found that mild OSA may impact more than one in every three people worldwide and the moderate form of the sleep disorder affects one in 20 people across the globe.
These occurrence rates will likely go higher in the future, researchers wrote in Breathe.
“Over the past 2 decades, with the increasing prevalence of obesity, the most important risk factor in sleep breathing disorders, the number of patients diagnosed as suffering from obstructive sleep apnea ... will increase over the coming years,” Monique Suárez of the Unitat del Son in Spain, and colleagues wrote.
“There is a pressing need to improve management of this disease by new strategies where definitely primary care medicine has to be involved,” they added. – by Janel Miller
Arguelles J, et al. Introducing a sleep vital sign based on a simple 2-question survey for utilization in a primary care clinic.
Gupta NI. Gupta score of the oropharyngeal airway to predict the severity of obstructive sleep apnea – an original research study
Honaker SM, et al. Efficacy of an automated system to screen for snoring in pediatric primary care.
William B, et al. Screening for obstructive sleep apnea in the young adult population.
All presented at: Sleep 2019; June 8-12, San Antonio.
American Academy of Sleep Medicine Fact Sheet on Obstructive Sleep Apnea. https://aasm.org/resources/factsheets/sleepapnea.pdf. Accessed June 14, 2019.
Araslanova R, et al. World J Otorhinolaryngol Head Neck Surg. 2017;doi:10.1016/j.wjorl.2017.05.012
Miller JN and Berger AM. Sleep Med Rev. 2015;doi:10.1016/j.smrv.2015.09.005.
Senaratna CV, et al. Sleep Med Rev. 2017;doi: 10.1016/j.smrv.2016.07.002.
Suarez M, et al. Breathe (Sheff). 2016;doi:10.1183/20734735.011216.
Disclosures: Healio Primary Care was unable to determine the abstracts’ authors relevant financial disclosures prior to publication. Please see the individual studies cited for those authors’ relevant financial disclosures.