Among patients who were identified as likely having moderate to severe obstructive sleep apnea, treatment based in primary care was not clinically inferior to treatment at a specialist sleep center for improvement in daytime sleepiness scores, according to a study appearing in the March 13 issue of JAMA.
"Obstructive sleep apnea with accompanying daytime sleepiness was estimated during the early 1990s to affect between 2 percent and 4 percent of middle-aged adults. With growing awareness of the public health implications of untreated disease and rising obesity rates that have increased the prevalence of obstructive sleep apnea, there has been a steady demand for sleep service provision in specialist centers and growing waiting lists for sleep physician consultation and laboratory-based polysomnography (PSG)," according to background information in the article. "One-third of primary care patients report symptoms suggestive of obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians and practice nurses might be ideally positioned to take on a greater role in diagnosis and management." However, whether an ambulatory approach would be noninferior (outcome not worse than treatment compared to) in a primary care setting is unknown.
Ching Li Chai-Coetzer, M.B.B.S., Ph.D., of the Adelaide Institute for Sleep Health, Repatriation General Hospital, Daw Park, South Australia, and colleagues conducted a study to compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. The randomized, controlled, noninferiority study included 155 patients with obstructive sleep apnea who were treated at primary care practices (n = 81) in metropolitan Adelaide, three rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. Both interventions (primary care management vs. usual care in a specialist sleep center) included continuous positive airway pressure, mandibular (lower jaw) advancement splints, or conservative measures only. The primary outcome measure was 6-month change in scores on the Epworth Sleepiness Scale (ESS). Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using