Identifying OSA Risk in the General Adult Primary Care Population

Purpose: The purpose of this project is to illustrate the need for the implementation of a novel screening tool for obstructive sleep apnea (OSA) in the primary care setting. Background: OSA has been associated with numerous comorbidities including hypertension, Diabetes Mellitus and stroke. Despite these associations, the condition continues to be widely underdiagnosed in the general adult population. Methods: Using the seven-step process outlined in the Knowledge to Action framework, a research translation project implementing the NAMES OSA screening tool in a community-based primary care setting was conducted. Implications: Implementation of a novel screening tool in the primary care setting consisting of patient history, symptoms and physical exam findings in the form of a paper questionnaire may increase the detection rate of OSA. Conclusions: The implementation of the NAMES2 assessment tool resulted in increased awareness of OSA risk presentation as evidenced by a 5% increase in OSA screening rates in the involved primary care practice site. Consequently, increased detection of OSA risk in the adult primary care setting can potentially increase treatment in those affected with this condition thereby decreasing the incidence of existing or developing comorbidities in this population

Psychometric Properties of Obstructive Sleep Apnea Screening Measures in Patients Referred to a Sleep Clinic

Background: Obstructive Sleep Apnea (OSA) contributes to all-cause and cardiac mortality. There are no current guidelines for OSA screening in outpatient settings. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis of the disorder. The purpose of this study was to identify the psychometric properties of three self-report OSA screening measures (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and an objective portable sleep monitor (PSM) compared to apnea-hypopnea index (AHI) levels (≥5, ≥ 15, and ≥ 30) from polysomnogram (PSG). Methods: A methodological design was used. Patients referred to a sleep specialist for an OSA consultation were recruited and enrolled at initial sleep evaluation. Participants completed the three OSA self-report screening measures and those participants who met inclusion criteria were sent home with a PSM for one night measurement. Automatic scoring was used. PSGs were ordered by the physician and AHI results were obtained from the medical record. Results: Participants (N=170) were enrolled (88 male, 82 female; age 54.5, SD 5.0 years). Almost all participants completed the self-report OSA screening measures, approximately half completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability level. The PSM measure had the highest positive predictive value (PPV). The PSM measure had the strongest psychometric properties of the screening measures. Conclusions: The STOP Bang was the preferred self-report OSA screening measure because of high sensitivity levels. A positive STOP Bang warrants assessment for OSA. The ESS is the least desirable screening measure. If a patient qualifies, further screening with a PSM is indicated. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥ 30. PSM results can guide the referral process from primary or specialty clinicians to sleep specialist

Obstructive Sleep Apnea and the Effects of Co-Existing Factors on PACU Stay Time

Significance/Background: Obstructive Sleep Apnea (OSA) is the most common disturbance during sleep affecting 30% of the population. The occurrence of moderate/severe OSA is 11.4% in men and 4.7% in women. OSA is caused by repetitive partial or complete obstruction of the upper airway with apnea episodes. OSA is prevalent in western society, yet is frequently undiagnosed due to lack of knowledge of the disorder. This population presents a challenge during the peri-operative period due to increased risk for several complications. Of particular interest to Nurse Anesthetists, are respiratory complications that result in delayed emergence from anesthesia, delayed post-operative recovery, increased apneic episodes, hypoxemia, and death. Examining duration of recovery periods between the two OSA groups will help determine if patients with additional cofactors benefit from longer post-operative monitoring or modification of anesthetic technique. Methods: An observational correlation design to include a non-randomized convenience sample of two groups. Comparisons were made between groups regarding cofactors, complications and duration of postoperative recovery times. Patients having elective abdominal surgery under general anesthesia were identified. OSA status was determined based upon Sleep Studies, or STOP-BANG tool criteria. Medical, surgical, and anesthesia data was reviewed. Total recovery times and pre-existing disease documented. Multiple Logistic and Regression testing compared effects of cofactors on postoperative recovery times. Chi square analysis evaluated relationship of individual cofactors with OSA and Non-OSA patients. T-test analysis compared demographic information. P score of \u3c .05 was considered significant. Results: This study indicated significant correlation with higher number of cofactors amongst patients diagnosed with OSA (p\u3c 0.012). Increased incidence of higher ASA classification in OSA diagnosed patients; (p\u3c .017) extended PACU stay time in OSA diagnosed patients; (p= 0.05) and unplanned admissions in OSA patients; (p=. 007). Patients with OSA use higher number of prescribed medications compared to non-OSA patients have a 3.36 greater chance of hypertension as an additional cofactor (p\u3c .05) and were 8.75 times more likely to experience airway difficulties or complications with general anesthesia when compared to non-OSA patients (p\u3c .05). Multiple logistic regression testing demonstrated increased incidence for both airway difficulties (p= .003) and Hypertension (p=. 054). Multiple linear regression results indicate one cofactor HTN as a significant predictor for PACU stay time. (R2= .179, R2adj= .136, F (1)) Implications: Findings will lead to optimum monitoring, management; recovery measures and anesthesia techniques that will prevent extended postoperative periods and reduce or eliminate postoperative complications of OSA

Detecting Obstructive Sleep Apnea in an Adult Primary Care Population

Obstructive sleep apnea (OSA) is a sleep-related disorder that pauses or decreases air flow during sleep as a result of an obstructed upper airway. About 25 million people in the United States are affected by OSA. OSA has low identification and referral rates, especially in primary care facilities as indicated by the lack of patients\u27 sleep histories. Screening tools such as questionnaires ensure an effective detection of OSA. The practice-focused question examined whether implementing the Epworth sleepiness scale (ESS) in an outpatient primary care setting would increase the number of referrals of high-risk patients. The purpose of the project was to improve the referral rates of high-risk patients for OSA evaluation through ESS in a primary care clinic. The plan-do-study-act model was used to guide and evaluate the intervention and analysis of outcomes to determine the success and failure rates of the intervention in relation to the project goal. The data were collected from an outpatient primary care clinic. Measures of central tendency were used to summarize the data, and a 2-proportion z test was employed to analyze the efficiency of the education procedure. The findings showed that the implementation of the ESS increased the number of referrals for high-risk patients (z = 4.140, p = 0.000), indicating that the ESS is an effective tool in facilitating the management of OSA. The findings of this project could be used to increase awareness of the positive benefits of the ESS, which can encourage the implementation of the tool in other clinical facilities and further education about the ESS. The project might contribute to positive social change and nursing practice through the increase of referrals for OSA, which improves the quality of life of patients

Implementing a Screening Pathway for Identifying Patients at Risk for Obstructive Sleep Apnea in Primary Care

Obstructive sleep apnea (OSA) is emerging as a significant health problem largely underrecognized by health care providers in the primary care setting (Pagel, 2008). The intent of this practice innovation project was to change and reduce the variation in practice for OSA screening that did not follow what is known about best practices. In this study, a preexperimental one-group pretest-posttest design was carried out to evaluate the outcomes associated with implementing an evidence-based screening pathway into practice for OSA based on the recommendations set forth in a clinical practice guideline recently published by the American Academy of Sleep Medicine (Epstein et al., 2009). The intervention consisted of providing education and training to primary care providers and staff for accurately identifying and screening eligible patients according to the pathway. Those individuals who were identified as having symptoms of OSA were referred on for a sleep study. Comparison data consisted of sleep study referral rates over a two month period prior to the intervention and were compared to sleep study referral rates over a two month period after the intervention was implemented into practice. The analysis indicates that there is not a statistically significant difference between the two groups (X2 = 1.091, p = 0.148). However, among the sub-group of patients identified as eligible for screening through chart review, significantly more patients were referred on for a sleep study during the post-intervention period compared to the pre-intervention period (X2 = 7.815, p = 0.003). Of the 227 patients identified as eligible for screening post-intervention, six were referred on for a sleep study. This result suggests with 95% certainty that the intervention (education and training for the implementation of a screening pathway) led to a statistically significant increase in the number of patients referred on for a sleep study. The majority of patients who were categorized as eligible for screening were White, male, age 50 years or younger, and indicated for screening due to their body mass index (\u3e35 kg/m2). Results of this study demonstrate a small but clinically significant increase in the number of sleep study referrals after the pathway was implemented into practice. Despite the relatively few successful screenings that were performed in this study, there is still a need for ongoing screening in the primary care setting due to the increasing prevalence and debilitating conditions associated with OSA (Chai-Coetzer et al., 2013a). High patient volumes, time restraints, and neglecting to offer screening to every adult patient were identified as the major barriers to successfully implementing this project. Continued efforts are needed in educating providers about the importance of screening for OSA in the primary care setting. With the increasing prevalence of OSA, there is hope for earlier detection and prompter treatment with the advent of routine screening in the primary care setting

Improving Identification of High-Risk Obstructive Sleep Apnea Patients in Primary Care: An Integrative Review

Obstructive sleep apnea continues to be an area that is underdiagnosed and therefore undertreated. Left untreated, the condition is associated with increased morbidity and mortality as it can amplify the risk of multiple health conditions. Due to the negative impact of obstructive sleep apnea it is necessary for healthcare providers to provide timely detection. Primary care providers are in a position to identify high-risk individuals and refer them for further follow up testing. High-risk identification can be accomplished by integrating validated screening tools into patient assessments. This integrative review provides an overview of current screening tools for use in the primary care setting, barriers to screening adoption, and successful practices

Obstructive sleep apnea syndrome in end stage renal disease patients undergoing hemodialysis

Obstructive Sleep Apnea Syndrome (OSAS) is very prevalent among End Stage Renal Disease (ESRD) patients. The syndrome is considered to be an important cardiovascular risk factor for the general population and for Chronic Kidney Disease (CKD) patients, as well. The augmented cardiovascular morbidity and mortality in ESRD patients makes the early diagnosis and treatment of the syndrome in this population a necessity. The present review focuses on the clinical presentation and the signs and symptoms of the syndrome in ESRD patients that in many cases differ from the ones on the general population. Furthermore, it attempts to explain the special conditions and mechanisms related to CKD that lead to the pathogenesis of the syndrome and explain its augmented relation to cardiovascular risk. It aims to help nephrologists understand the syndrome, be aware of its high prevalence and impact on this population, achieve an early referral and accurate diagnosis of the syndrome and consider the therapeutic options suitable for this population

Effects of an Obstructive Sleep Apnea Screening Program on Providers\u27 Adherence

Obstructive sleep apnea (OSA) is a widely prevalent chronic disease estimated to affect 22 million Americans, with 80 percent of moderate to severe cases undiagnosed (American Sleep Apnea Association [ASAA], 2017). Unmanaged OSA has been associated with numerous detrimental health outcomes including hypertension, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular conditions (ASAA, 2017). The purpose of this evidence-based practice project was to determine if the implementation of a screening protocol would affect providers’ adherence to screening for OSA. The Theory of Planned Change was used as a guide to optimize providers’ adherence to the protocol at a family medicine clinic in Northwest Indiana. Following an extensive review of the literature, the screening protocol was designed instructing providers’ which patients needed to be screened for OSA and the preferred method. To determine if the screening protocol had an effect on providers’ adherence to screening, a two-group comparison design was utilized. Pre-intervention group data were manually collected from medical records of at-risk patients at the clinic prior to protocol implementation. Post intervention group data were collected from medical records of patients managed after protocol implementation. In the pre-intervention group, 1 (0.7%) patient at-risk for OSA were screened compared to the post-intervention group 44 (34.9%). Using chi-square test, a significant association was found between providers’ adherence to screening at-risk patients between the groups (X2(1)=56.67, p\u3c0.001). A significant association was found between providers’ adherence to using the STOP-Bang Questionnaire between the two groups (X2(1)=60.61, p\u3c0.001). No significant relationship was found between the number of patients referred for OSA diagnostic testing between the two groups (X2(1)=.488, p=.485). Although the intervention significantly improved providers’ adherence to screening for OSA, clinical significance is limited since there was no significant relationship found in the number of patients referred for diagnostic testing or incidence of patients with a new diagnosis of OSA

Effects of an Obstructive Sleep Apnea Screening Program on Providers\u27 Adherence

Obstructive sleep apnea (OSA) is a widely prevalent chronic disease estimated to affect 22 million Americans, with 80 percent of moderate to severe cases undiagnosed (American Sleep Apnea Association [ASAA], 2017). Unmanaged OSA has been associated with numerous detrimental health outcomes including hypertension, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular conditions (ASAA, 2017). The purpose of this evidence-based practice project was to determine if the implementation of a screening protocol would affect providers’ adherence to screening for OSA. The Theory of Planned Change was used as a guide to optimize providers’ adherence to the protocol at a family medicine clinic in Northwest Indiana. Following an extensive review of the literature, the screening protocol was designed instructing providers’ which patients needed to be screened for OSA and the preferred method. To determine if the screening protocol had an effect on providers’ adherence to screening, a two-group comparison design was utilized. Pre-intervention group data were manually collected from medical records of at-risk patients at the clinic prior to protocol implementation. Post intervention group data were collected from medical records of patients managed after protocol implementation. In the pre-intervention group, 1 (0.7%) patient at-risk for OSA were screened compared to the post-intervention group 44 (34.9%). Using chi-square test, a significant association was found between providers’ adherence to screening at-risk patients between the groups (X2(1)=56.67, p\u3c0.001). A significant association was found between providers’ adherence to using the STOP-Bang Questionnaire between the two groups (X2(1)=60.61, p\u3c0.001). No significant relationship was found between the number of patients referred for OSA diagnostic testing between the two groups (X2(1)=.488, p=.485). Although the intervention significantly improved providers’ adherence to screening for OSA, clinical significance is limited since there was no significant relationship found in the number of patients referred for diagnostic testing or incidence of patients with a new diagnosis of OSA

Screening the Commercial Motor Vehicle Driver for Sleep Apnea

Abstract The transportation industry has the third highest occupational risk for death and disability (BLS, 2010) with 7% of Commercial Motor Vehicle Drivers (CMVD) falling asleep while driving (NHTSA, 2006). One contributing factor may be undiagnosed Obstructive Sleep Apnea (OSA) (Tregear et al, 2009). In 2006, a Joint Task Force (JTF) published screening recommendations for OSA, which led to a change in the Department of Transportation screening practices within a local Occupational Medicine clinic. The purpose of this study was to: (a) determine what percentage of drivers having had a positive clinical screening examination (met two of three objective measures) tested positive for a diagnosis of OSA (b) determine what percentage of drivers diagnosed with OSA had an Apnea-Hypopnea-Index (AHI) greater than or equal to 20 abnormal breaths per hour, meeting the threshold for mandatory treatment, (c) determine the relationship between Body Mass Index (BMI), hypertension and neck circumference with a diagnosis of OSA. The electronic medical records of 182 drivers were reviewed. Of these, 143 were found eligible for the study with the following findings: 63% (n = 90) clinically screened positive and underwent confirmatory testing by Polysomnography (PSG). Of these, 92% (n = 83) were found to have OSA, and 48% (n = 43) met the threshold for mandatory treatment. The study found no correlation between a diagnosis of OSA and BMI. Hypertension was found to have an inverse relationship. Neck circumference was found to have a significant positive correlation. No drivers self-reported daytime sleepiness and would have been missed using the current recommendations. Screening the CMVD for OSA with self-reported symptoms of sleepiness is not adequate. This study shows the importance of neck circumference as the best predictor of identifying OSA