Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand

Exercise and motivational text messaging to support physical activity behaviour change in a population with obstructive sleep apnoea: a feasibility study

Introduction Patients with obstructive sleep apnoea (OSA) commonly present in primary care. Increasing physical activity reduces symptoms and severity of OSA. Low motivation is a barrier to physical activity in adults with OSA. Aim To investigate the feasibility and acceptability of an exercise and personalised text messaging programme to enhance motivation and support physical activity behaviour change in adults with OSA. Methods Participants were recruited from the local Sleep Clinic. Exclusion criteria were unstable angina, and/or poorly controlled hypertension. The intervention comprised three groups, who received either individual exercise prescription, personalised text messages or both over a 24-week period. Participants were allocated to one of the three groups. The primary outcome was feasibility of study design including participant recruitment and retention. Secondary outcomes were a change in 6-min walk distance and exercise self-efficacy over time. Results Thirty participants were recruited, 17 male and 13 female, with a mean age of 54.6 years. The study design appears feasible and the outcome measures used were acceptable to participants. Recruitment and retention rates were lower than anticipated. A trend towards increased functional exercise capacity was identified in all three groups, along with a corresponding increase in exercise self-efficacy over time. Discussion Exercise and personalised text messaging both appear to offer an acceptable and feasible means to increase physical activity in adults with OSA. A larger scale trial may provide justification for physiotherapist input to support patients with OSA to address physical inactivity.

Impact and outcome evaluation of HealthPathways: a scoping review of published methodologies

INTRODUCTION The HealthPathways programme is an online health information system used mainly in primary health care to promote a consistent and integrated approach to patient care. AIM The aim of this study is to perform a scoping review of the methodologies used in published impact and outcomes evaluations of HealthPathways programmes. METHODS The review included qualitative, quantitative or mixed-methods evaluations of the impact or outcome of HealthPathways. MEDLINE, Embase, CINAHL and Web of Science databases were searched. Seven programme aims were identified in the impact and outcome evaluation: (1) increased awareness and use of HealthPathways; (2) general practitioners are supported to adopt best practice, patient-centred care; (3) increased appropriate use of resources and services; (4) improved quality of referrals; (5) enhanced consistent care and management of health conditions; (6) improved patient journeys through the local health system; and (7) reduction in health-care cost and increased value for money. RESULTS Twenty-one studies were included in the final review; 15 were research papers and six were reports. 'Increased awareness and use of HealthPathways' was the most frequent programme aim evaluated (n = 12). Quantitative and qualitative research methodologies, as well as prospective and retrospective data collections, have been adopted to evaluate the impact and outcome of HealthPathways. DISCUSSION Assessing the impacts and outcomes of HealthPathways may be challenging due to limitations in primary data and the interconnectedness of change across the measured aims. Each aim may therefore require specific methodologies sensitive enough to capture the impact that HealthPathways are making over time.

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence: Unraveling the Puzzle of Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

Usefulness of Home Overnight Pulse Oximetry in Patients with Suspected Sleep-Disordered Breathing

Methods

Prospective study conducted in a university hospital. Subjects with a clinical suspicion of SAHS were included. All of them underwent home polygraphy and oximetry on the same night. A correlation was made between the apnea-hypopnea index (AHI) and the oximetry variables. The variable with the highest diagnostic value was calculated using the area under the curve (AUC), and the best cut-off point for discriminating between patients with SAHS and severe SAHS was identified.

Results

One hundred and four subjects were included; 73 were men (70%); mean age was 52 ± 10.1 years; body mass index was 30 ± 4.1, and AHI = 29 ± 23.2/h. A correlation was observed between the AHI and oximetry variables, particularly ODI3 (r = 0.850; P < 0.001) and ODI4 (r = 0.912; P < 0.001). For an AHI ≥ 10/h, the ODI3 had an AUC = 0.941 (95% confidence interval (CI) = 0.899–0.982) and the ODI4, an AUC = 0.984 (95% CI = 0.964–1), with the ODI4 having the best cut-off point (5.4/h). Similarly, for an AHI ≥ 30/h, the ODI4 had an AUC = 0.922 (95% CI = 0.859–0.986), with the best cut-off point being 10.5/h.

Conclusion

Nocturnal oximetry is useful for diagnosing and evaluating the severity of SAHS. The ODI4 variable was most closely correlated with AHI for both diagnosis.

Review of methods and study designs of evaluations related to clinical pathways

Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.

Oximetry use in obstructive sleep apnea

INTRODUCTION

Overnight oximetry has been proposed as an accessible, simple, and reliable technique for obstructive sleep apnea syndrome (OSAS) diagnosis. From visual inspection to advanced signal processing, several studies have demonstrated the usefulness of oximetry as a screening tool. However, there is still controversy regarding the general application of oximetry as a single screening methodology for OSAS. Areas covered: Currently, high-resolution portable devices combined with pattern recognition-based applications are able to achieve high performance in the detection of this disease. In this review, recent studies involving automated analysis of oximetry by means of advanced signal processing and machine learning algorithms are analyzed. Advantages and limitations are highlighted and novel research lines aimed at improving the screening ability of oximetry are proposed. Expert commentary: Oximetry is a cost-effective tool for OSAS screening in patients showing high pretest probability for the disease. Nevertheless, exhaustive analyses are still needed to further assess unattended oximetry monitoring as a single diagnostic test for sleep apnea, particularly in the pediatric population and in populations with significant comorbidities. In the following years, communication technologies and big data analyses will overcome current limitations of simplified sleep testing approaches, changing the detection and management of OSAS.

[Diagnostic accuracy of STOP-Bang questionnaire on moderate sleep apnoea in primary care]

OBJECTIVE

We aimed to compare the diagnostic utility of the STOP-Bang questionnaire for moderate apnoea against the gold standard (type I polysomnography) in a primary care setting.

METHOD

Study of diagnostic utility in primary care. Estimated sample: 85 cases and 85 healthy controls. In convenience sampling, 203 patients were recruited by their physicians at six health centres. Twenty-five were excluded, and 57 women and 121 men, of whom 74 had apnoea-hypopnoea index (AHI) ≥15, were analyzed. STOP-Bang was validated by comparing scores in the same patient with the apnoea-hypopnoea index observed in polysomnography, as a gold standard. Sample size, ROC curve analysis and optimal cut-off points were identified with the easyROC, pROC, and OptimalCutpoints packages.

RESULTS

The area under the curve in moderate apnoea (AHI ≥15) of the STOP-Bang was 0.777 (0.667-0.808), with optimal cut-off points different by sex (4 in women and 6 in men). In the cross-validation with k=10, the area under the curve for the STOP-Bang was 0.678.

CONCLUSIONS

The STOP-Bang presents a diagnostic moderate utility for AHI≥15, but superior to other scales, in a community population. Its performance is more appropriate in women.

Clinical Reproducibility of the Epworth Sleepiness Scale for Patients With Suspected Sleep Apnea

STUDY OBJECTIVES

To determine the reproducibility of the Epworth Sleepiness Scale (ESS) score in a clinical population referred for diagnostic testing with suspected obstructive sleep apnea.

METHODS

A retrospective audit of patients referred for a diagnostic sleep study with suspected sleep apnea was undertaken. Data collection was two 3-month time periods from January to March in 2012 and 2014. To evaluate reproducibility, the ESS score at primary care referral was compared to the ESS score at first specialist assessment/sleep assessment. The proportion of scores changing by more than 2, 3, 5, or 7 points was determined. Data were analyzed using Bland-Altman plots and paired t tests.

RESULTS

A total of 154 patients (68% male) with a mean ± standard deviation age of 51 ± 13 years, body mass index 36 ± 10 kg/m², and apnea-hypopnea index 43 ± 40 events/h were included. The average ESS score change was -0.2 with a standard deviation of 3.9 reflecting a wide scatter. A difference between the sequential ESS scores of 5 or more was seen in 21% of subjects.

CONCLUSIONS

In a clinical obstructive sleep apnea referral population, the ESS score was variable when administered sequentially. Given this variability the ESS should not be used as the sole tool to prioritize patients for obstructive sleep apnea assessment.

COMMENTARY

A commentary on this article appears in this issue on page 711.