The diagnosis and treatment of sleep disordered breathing in patients with cardiovascular disease in England: current pathways and barriers to optimal care

Abstract

Cardiovascular disease (CVD) is a major health burden accounting for more than 30% of deaths worldwide, but there have been significant advances in its management in recent years. These have been adopted into clinical practice guidelines, however, there is a mismatch between the widely perceived ‘best practice’ and how patients are actually managed in clinical practice. In most healthcare systems, the delivery of care is not standardised. Sleep disordered breathing (SDB) is highly prevalent in patients with CVD and can further potentiate their cardiovascular risk and lead to adverse cardiovascular mortality. A literature review of the association between cardiovascular disease and SDB will be evaluated in relation to pathophysiology, screening, diagnosis and treatment in this thesis. The current evidence for the management of SDB in CVD will also be reviewed. SDB has been traditionally considered as a discipline in respiratory medicine, therefore there are diagnosis and treatment challenges and most patients with SDB are undiagnosed and untreated. Patients with both CVD and SDB are likely to have multiple comorbidities requiring complex management strategies. Thus, the main aim of this thesis is to identify these practice barriers to diagnosis and treatment in patients with SDB and CVD, using both quantitative and qualitative methodology. Publicly available data sources related to SDB (such as Hospital Episode Statistics [HES data] and NHS RightCare), were used help understand the variation in service provision and diagnostic rates. To identify the barriers to diagnosis and treatment of patients with SDB and CVD, mixed-methods were used (i.e. both quantitative and qualitative methodology). For primary care, previously conducted GP and patient surveys were analysed and semi-structured interviews of healthcare professionals were carried out to identify barriers in secondary and tertiary care. In the past two decades, large number of QI tools have been widely in the management of cardiovascular disease with aim of overcoming barriers, however, we do not know whether they change cardiovascular outcome. Thus, a secondary aim of this thesis is to identify effective QI methodology and utilise them to improve and redesign local practice. A systematic review (of randomised/cluster controlled trials) was also carried out with the aim of exploring the impact of QI methodology on CVD outcome. Although the current evidence suggests that treating patients with SDB using PAP therapy may not have strong benefits as previously thought, the diagnosis of SDB is still important in patients with CVD because it reflects a group with higher CV risk. There are a variety of barriers that could delay the diagnosis and treatment of SDB, such as the lack of local access to sleep studies, lack of guidelines and hard outcome data, patient perceptions and cultural barriers between HPs. QI methods can be used to potentially overcome these barriers and care pathways seems to be the most effective.Open Acces