How to assess, diagnose, refer and treat adult obstructive sleep apnoea: a commentary on the choices

Sleep health management in community pharmacy: Where are we and where should we be heading?

BACKGROUND

Poor sleep health is now recognised as a significant risk factor for chronic diseases and is associated with considerable comorbidity and mortality. Community pharmacists are primary care clinicians with an integral role in sleep health promotion and chronic sleep disorder management; however, it is unclear to what extent this is currently being undertaken or what the perspectives of Australian community pharmacists regarding their role in sleep health are.

OBJECTIVES

To explore community pharmacists' current sleep health practice and perspectives on the potential future of sleep health care in community pharmacy.

METHODS

Qualitative semi-structured interviews were carried out with a maximally varied, convenience-based purposive sample of community pharmacists. Interviews were audio-recorded, transcribed verbatim and subjected to, in sequence; an inductive analysis followed by a deductive approach where the inductively derived thematic structure was used as a framework.

RESULTS

Twenty-five community pharmacists from two Australian states were interviewed. Insomnia and obstructive sleep apnea (OSA) were the most frequently encountered sleep disorders in community pharmacy presentations. Four key themes were derived from the data: 1) Preparedness, 2) Approach, 3) Capabilities and 4) What needs to change? All participants reported that their sleep health knowledge was insufficient and emphasized the need for more education and training. Although some were engaged in providing OSA services, none of the participants offered services for insomnia or other sleep disorders. Time/task pressures, low health system/health care professional sleep health recognition/awareness and the lack of standardised pharmacy-specific sleep health management guidelines were commonly cited barriers for sleep health service provision.

CONCLUSION

Community pharmacists commonly manage day-to-day sleep health; however, most expressed a need for increased sleep health recognition/awareness by the health system, targeted education/training for pharmacists and support for the future provision of community pharmacy-delivered sleep health services. With the appropriate implementation strategies, community pharmacists could utilise their availability and accessibility to improve the future of primary care sleep health management.

A Cost-Effective Novel Innovative Box (C-Box) to Prevent Cockroach Infestation of Continuous Positive Airway Pressure Equipment: A Unique Problem in Northern Tropical Australia

Cockroaches and other pests infestation of continuous positive airway pressure (CPAP) equipment has been rarely reported in the medical literature. In this report, we describe a box (C-Box) designed to prevent pest infestation of the CPAP equipment. Over experience, using this C-Box has demonstrated that it can prevent pest infestation and reduce the cost of replacing pest-infested CPAP machines.

Cost-effectiveness strategies in OSAS management: a short review

Obstructive sleep apnoea (OSAS) is an underdiagnosed chronic disease with a high prevalence in adults. It is becoming a significant social problem, since it is associated with a worsening in quality of life and increase in mortality. The cost-effectiveness ratio of diagnostic and therapeutic management of OSAS is a strategic issue to counteract the expected increasing demand of objective testing. OSAS patients with any clinical evidence of comorbidities must be studied using simplified and less expensive systems such as Home Sleep Testing (HST). On the other hand, Sleep Laboratory Polysomnography (PSG) is the gold standard to manage OSAS patients with comorbidities. It should be pointed out that the use of HST can lead to incorrect diagnosis in poorly selected OSAS subjects. This short review discusses various topics for the proper diagnosis and treatment of OSAS in view of epidemiological factors and results in terms of costs and social benefit of the disease. Whatever the strategy chosen and/or the organisational model adopted for managing OSAS, it cannot and should not take into account only cost-effectiveness. Long-term prospective studies evaluating cost-effectiveness ratios and outcomes of OSAS treatment of hospital management models versus home care models are needed.

Diagnostic accuracy of a two-stage model for detecting obstructive sleep apnoea in chronic tetraplegia

BACKGROUND

Obstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia.

METHODS

An existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units.

RESULTS

Injury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87-0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66-93) and 88% (75-94) in the development group, and 77% (65-87) and 81% (68-90) in the validation group. Similar results were demonstrated with the original model.

CONCLUSION

Implementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments.

TRIAL REGISTRATION NUMBER

Results, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

How Do Sleep-Related Health Problems Affect Functional Status According to Sex?

STUDY OBJECTIVES

To measure differences in functional status between men and women presenting with sleep-related health problems.

METHODS

A retrospective clinical audit of 744 Australian patients across 7 private general practices between April 2013 and January 2015 was conducted. Patients completed an electronic survey as part of their routine consultation, which included the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire 10 (FOSQ-10), and other questions relating to the effect of their sleep problem. The proportion of males and females with ESS and FOSQ-10 scores associated with disorders of daytime sleepiness and burden of symptoms due to sleepiness, respectively, were compared, as well as reported differences between the sexes in memory, concentration, issues with relationships, feeling depressed, and trouble sleeping.

RESULTS

On presentation, females were more likely to have sleeping disorders associated with daytime sleepiness (median ESS score of 9 for females versus 8 for males, P = .038; proportion ESS > 9 was 49.0% for females versus 36.9% for males, P = .003). Women were also more likely to report an increased burden of symptoms due to sleepiness compared to men, as shown by lower FOSQ-10 scores (P < .001). Secondary outcome measures showed that females were more likely to feel excessively tired and depressed, have difficulties with memory and concentration, and have trouble sleeping at night. Snoring kept partners awake in roughly the same proportion of males and females, and a larger proportion of the partners of males were forced out of the room.

CONCLUSIONS

Sleep-related health issues both manifest in and affect the lives of males and females differently. Sleep health professionals should recognize these differences on all levels of disease prevention and health promotion from patient education, to diagnosis and management to improve quality of life for those with sleep-related health problems.

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

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist.

SLEEP DISORDERS

MORE ASSESSMENTS, SHORTER WAITS WITH COMMUNITY SLEEP SERVICE: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.

Trends in maxillofacial imaging

Maxillofacial imaging encompasses radiology of the teeth and jaws, including the temporomandibular joints. Modalities used include intra-oral radiographs, panoramic tomography, cephalograms, cone-beam computed tomography, computed tomography, magnetic resonance imaging, ultrasound, and radionuclide imaging. Common indications for imaging are impacted and supernumerary teeth, dental implants, inflammatory dental disease, and fibro-osseous lesions, cysts, and masses of the jaws. Osteonecrosis of the jaws may follow radiotherapy or the use of bisphosphonates and other drugs. Imaging of the temporomandibular joints and the potential role of imaging in obstructive sleep apnoea are also discussed.

Should the diagnosis and management of OSA move into general practice?

Sleep apnoea is a common disease that for accurate management requires the participation of primary care medicine http://ow.ly/G6Mq301zcaM.

Diagnostic pathways for obstructive sleep apnoea in the Australian community: observations from pharmacy-based CPAP providers

PURPOSE

Models for the diagnosis of obstructive sleep apnoea (OSA) are evolving in many countries to meet public demand. In Australia, the unregulated sleep industry does not provide a framework to govern or review emerging pathways in the community. The objectives of this study were to (1) describe current diagnostic pathways for OSA in Australia as reported by continuous positive airway pressure (CPAP) providers in community pharmacies and (2) obtain stakeholder feedback on pathways and identify potential areas for practice improvement.

METHODS

Semi-structured telephone interviews were conducted with pharmacy-based CPAP practitioners. Participants described diagnostic pathways used in their setting. Subsequently, an expert forum of stakeholders provided feedback on identified pathways during a focus group.

RESULTS

Twenty-two telephone interviews were conducted, identifying six key diagnostic pathways. Pathways varied in terms of the diagnostic test used, the practitioner who initiated or interpreted the test and who discussed results with the patient and made treatment recommendations. A nine-member stakeholder group raised medical, ethical and organisational concerns over certain pathways. Concerns included diagnostic tests initiated or interpreted in the absence of an appropriately trained medical practitioner and potential conflicts of interest for CPAP providers offering both diagnostic and treatment services. A best practice framework was proposed to guide practice and translate study findings. Preliminary practice recommendations were subsequently developed.

CONCLUSIONS

Diagnostic models have evolved in Australia that raise stakeholder concerns. It is important to address these concerns while still facilitating patient access to services. Development of a practice framework could promote medically appropriate, patient-centred care.