Management of Obstructive Sleep Apnea

8/6/2019 Management of Obstructive Sleep Apnea

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There exists a dire need to raise and standardize the quality of

healthcare delivery in many disease conditions, including ob-

structive sleep apnea (OSA).1 Unique to OSA are the uncertainties

of disease definition,2 large variability in scoring of polysomno-

grams and therefore diagnosing OSA,3,4 and also multidisciplinary

backgrounds and respective biases of physicians who treat OSA.5

In light of such variability, the training for physicians offered by

formal sleep-medicine fellowships, and the benchmarks advocat-

ed by the American Academy of Sleep Medicine (AASM) for the

workings of a sleep center, afford greater conformity and set stan-

dards of practice for individual physicians and sleep centers.6 So

far, a systematic assessment of the effect of AASM center accredi-

tation and sleep-medicine certification of physicians on clinical

outcomes in patients with OSA has not been reported. In order

to measure the effect of AASM accreditation and sleep-medicine

certification on clinical outcomes in patients with OSA, several

important endpoints can be considered.

One such endpoint that poses a challenge in the management

of patients with OSA is patient adherence to positive airway pres-

sure (PAP) therapy.7 While the minimum required adherence—in

hours of PAP therapy used per night—is unclear,8 discontinuation

of PAP device is an unambiguous endpoint for treatment failure

In this study, we used such a clear definition of treatment fail-

ure—proportion of patients who discontinued PAP therapy—to

measure the performance of physicians and sleep centers. Ad-

ditionally, because patients’ risk perceptions of OSA and their

knowledge of their disease condition are important to ensure ad-

herence to therapy,8,9 we assessed patients’ perceptions of whether

such information was dispensed by their physicians or sleep cen-

ters. Lastly, other important benchmarks in the management of

patients with OSA, such as timely delivery of care10 (time lapse

between initial sleep study and institution of PAP therapy) and pa-

tients’ overall satisfaction with care rendered by their physicians

and centers, were also assessed.

A National Survey of the Effect of Sleep Medicine Specialists and American Academyof Sleep Medicine Accreditation on Management of Obstructive Sleep Apnea

Sairam Parthasarathy, M.D.1,2; Patricia L. Haynes, Ph.D.2; Rohit Budhiraja, M.D.1,2; Michael P. Habib, M.D.1,2; Stuart F. Quan, M.D.2

1Southern Arizona Veterans Administration Health Care System, Tucson, AZ; 2University of Arizona, Tuscon, AZ

Disclosure Statement

This was not an industry supported study. Drs. Parthasarathy, Haynes, Bud-

hiraja, Habib, and Quan have indicated no financial conflicts of interest.

Submitted for publication November 18, 2005

Accepted for publication December 14, 2005

Address correspondence to: Sairam Parthasarathy, M.D., Southern Arizona

VA Health Care System, 3601, South Sixth Avenue, Mail Stop 1-111A, Tuc-

son, AZ 85723; Tel: (520) 792-1450 ext. 15076; Fax: (520) 629-4641; E-mail:

[email protected]

SCIENTIFIC INVESTIGATIONS

133

Study Objectives: To study the effect of American Academy of Sleep

Medicine accreditation of sleep centers and sleep-medicine certification

of physicians on the management of patients with obstructive sleep ap-

nea (OSA).

Design: Cross-sectional study.

Setting: National web-based survey.Patients: Six hundred thirty-two patients with OSA.

Interventions: None.Measurements and Results: Self-reported data on details of whether

patients with OSA were using positive airway pressure (PAP) devices,

timeliness of the initiation of PAP therapy, and overall satisfaction of care

received from physicians and centers. After adjusting for covariates, lack

of accreditation or certification status of providers was independently as-

sociated with discontinuation of PAP therapy (odds ratio [OR] 1.9, 95%

confidence interval [CI], 1.1-3.2; p = .03). Patient education leading to

perception of risk associated with OSA (OR 0.5, 95% CI, 0.2-0.9) and

medications for nasal congestion (OR 0.3, 95% CI, 0.1-0.8) “protected”

against discontinuation of PAP therapy, whereas nasal congestion (OR

1.6, 95% CI, 1.0-2.4) increased the likelihood for discontinuation of PAP

therapy. Certified physicians and accredited centers were more likely to

educate their patients and received greater satisfaction ratings than non-

certified physicians and nonaccredited centers (p < .05). Time delays in

instituting PAP therapy were not influenced by accreditation or certifica-

tion status, but such delays diminished patient satisfaction.

Conclusions: In this web-based survey, accreditation or certification

status of sleep centers and physicians was associated with better index-

es of clinical management in patients with OSA. Better patient education

that fostered risk perception may have been partly responsible for such

an association. Prospective studies designed to collect objective data

regarding the effect of accreditation or certification status on outcomes

in patients with OSA are still needed.

Keywords: Sleep, professional competence, obstructive sleep apnea,

patient satisfaction, continuous positive airway pressure, accreditation,

patient compliance, treatment refusal, nasal obstruction, nasal decon-

gestants, sleep apnea syndromesCitation: Parthasarathy S; Haynes PL; Budhiraja R et al. A national sur-

vey of the effect of sleep medicine specialists and American Academy

of Sleep Medicine accreditation on management of obstructive sleep

apnea. J Clin Sleep Med 2006;2(2):133-142.

Commentary Follows on Pages 143-144


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Journal of Clinical Sleep Medicine, Vol. 2, No. 2, 2006

We designed a survey that asked patients about the care they

received from their physicians and sleep centers for their OSA

condition. The overall purpose of the study was to study the ef-

fect of AASM accreditation of sleep centers and sleep-medicine

certification of physicians on the clinical management of patients

with OSA through a web-based survey. We hypothesized that pa-

tients with OSA who are cared for by sleep-certified physicians

or AASM-accredited centers are less likely to discontinue PAP

therapy than are patients cared for by noncertified physicians and

nonaccredited centers. We also hypothesized that patient educa-tion regarding OSA and associated risks are provided by a greater

proportion of sleep-certified physicians and AASM-accredited

centers than by noncertified physicians and nonaccredited cen-

ters. Lastly, we hypothesized that sleep-certified physicians and

AASM-accredited centers provide more timely care and achieve

greater patient-satisfaction ratings than do noncertified physicians

and nonaccredited centers.

METHODS

Patients

We conducted a cross-sectional study of 632 patients with OSA

across the country using a web-based survey. Of the 842 “hits”to the web site containing the questionnaire, 632 patients took

the time to respond to the questionnaire. Patients were naïve to

the exact purposes of the study. Patients older than 20 years of

age with a diagnosis of OSA were solicited to take the anony-

mous web-based survey (see Appendix). Such solicitations to

participate were placed on web sites frequented by patients

with OSA: sleep apnea support groups (American Sleep Apnea

Association, Washington, DC), other educational web sites

(such as apneanet.org, Glen Ellyn, IL), vendors of PAP therapy

devices (such as cpapstore.com, Kennewick, Wash, and cpaptalk.

com, Missouri City, TX), and Internet chat groups (such as the

one sponsored by the AASM, sleepeducation.com, Westchester,

IL). The Institutional Review Board of the University of Arizonaapproved the study and waived the need for documentation of

written informed consent.

Questionnaire Tool

Patients were asked to respond yes, no, or don’t know to the

following questions: (1) whether the physician managing their

sleep-apnea condition is a sleep expert (an Internet link to the

AASM web site with a state-wise list of certified sleep physicians

was provided); (2) whether the sleep center that they received ser-

vice from was accredited (an Internet link to the AASM web site

with state-wise list of AASM-accredited centers was provided);

(3) whether they received adequate education from the health-care provider in any form—verbal, audiovisual, or pamphlets;

(4) whether such education improved their understanding of their

disease condition; (5) whether such education helped them realize

the risks associated with OSA; and (6) whether they were satis-

fied with their physician’s management of their sleep-apnea con-

dition on a 5-point Likert scale that ranged from very dissatisfied

(score of 1) to very satisfied (score of 5).11 Also, they were asked

to evaluate the sleep center on a 5-point satisfaction scale.11 Pa-

tients were asked whether they were continuing to use the PAP

device or whether they had stopped using such therapy. Patients

were also asked to report when they received their PAP device in

relation to their first sleep study and the duration of time that they

have had the PAP device.

Potential confounders that may affect acceptance of PAP de-

vice were also measured: PAP pressure level, device type (auto-

matic PAP, bilevel PAP, or continuous PAP), presence and sever-

ity of nasal congestion, age, sex, height, weight (for calculations

of body mass index), and highest education (did not finish high

school, finished high school, college, masters, or doctorate). Po-

tential confounders for timeliness in healthcare delivery such as

type of health insurance (HMO, PPO, POS, Medicare, or lackof any insurance) were also requested. Also, subjective improve-

ment in sleepiness after the initiation of PAP therapy was mea-

sured using a 5-point Likert scale,12 and self-reported hours of

PAP-device use was sought. Patient responses were saved in the

file server and analyzed in aggregate.

Questionnaire Validation

We measured nasal congestion using a 5-point Likert scale that

was previously administered to patients with sleep-disordered

breathing.13 Nasal-congestion severity was scored in the following

manner: 0 for never congested, 1 for rarely, 2 for sometimes, 3 for

most of the time, and 4 for always. Additionally, we revalidated

this 5-point Likert scale against a well-validated nasal symptom

scale.14,15 We performed such validation in a separate cohort of

54 patients with OSA by correlating nasal-congestion scores

obtained by our single question versus the previously well-

validated, multiple-question nasal symptom scale. There was

good consistency between the 2 measures (Cronbach α coefficient

of 0.79).

Initial construction of questions relating to patient satisfaction

was based on patient interviews. Subsequently, an initial data set

of 50 patient responses and input from sleep-medicine experts

was used to identify questions that made the largest contribution

to variation in satisfaction scores and to shorten and edit the

questionnaire. Internal consistency for the patient education-related questions was excellent (Cronbach α coefficient of

0.93; questions 3, 4, and 5 in Appendix) and good for patient-

satisfaction questions (Cronbach α coefficient of 0.75; questions

7 and 8 in Appendix).

Data Analysis

ENDPOINTS

The primary endpoint for analysis was discontinuation of PAP

therapy. Secondary endpoints were (1) patients’ perceptions of

education they received regarding OSA and risks associated with

OSA, (2) time delay in instituting PAP therapy, and (3) overall

patient satisfaction of the care delivered by the physician andcenter, measured separately.

PREDICTORS AND COVARIATES

In order to assess the combined “dose-effect” of sleep certifi-

cation of physicians and AASM accreditation of the centers on

patient outcomes, we assigned patients to 1 of 3 groups: (1) the

physician was certified and the center was accredited, (2) either

the physician was certified or the center was accredited, and (3)

neither was the physician certified nor was the center accredited

From the list of predictors and potential confounders, simple lo-

gistic-regression analysis was performed to identify significant

134

S Parthasarathy, PL Haynes, R Budhiraja et al




covariates that influenced discontinuation of PAP therapy. Sub-

sequently, we built multivariate logistic-regression models with

continued use of PAP device as the dependent variable using sig-

nificant covariates identified by simple logistic-regression analy-

sis (p < .05).

Also, general linear models were constructed to identify

determinants of timely delivery of care and self-reported adherence

to PAP therapy (expressed as hours per week). Multicollinearity

among independent variables was verified, and, in the event of

collinearity, the strongest predictor variable alone was included. Nonparametrically distributed variables—such as time delay—

were log transformed to meet assumptions of normality required for

multiple regression. All analyses used a list-wise deletion strategy

for missing values. Results are presented as mean and standard

deviation unless otherwise specified. All tests for significance and

resulting p values were 2-sided, with a significance level of .05. All

analyses were performed using SPSS v12.0 (SPSS Inc., Chicago,

IL). Unadjusted proportions were compared using Pearson χ 2 test

with Bonferroni correction applied when appropriate.

POWER ANALYSIS

Acceptance of PAP-device therapy has been reported to

range from 75% to 80% of patients who were prescribed such

therapy.16,17 We assumed a PAP-acceptance proportion of 70% in

patients cared for by nonaccredited centers or physicians and 80%

in the AASM-accredited centers or physicians—a difference of

10%. Based upon such assumptions, we estimated that we would

need 412 patients per group—a total of 824 responses (assuming

also that α is .05, 2-sided, power of 90% using χ 2). We report

significant results from the planned midpoint interim analysis—

444 responses with accreditation or certification status.

RESULTS

Description of Respondents

Of the 842 “hits” to the web site containing the questionnaire,

632 responded to the survey (overall response rate of 75%). The

mean age of patients was 51 ± 10 years (range from 20-89 years)

with 35% comprising women. Average body mass index was 35.7

± 8.9 kg/m2, and average continuous PAP pressure was 11.5 ± 3.6

cm h2o, with 78% of patients having been prescribed continuous

PAP devices. A minority of patients were prescribed automatic

PAP (10%) and bilevel PAP devices (12%). Of the 632 responses,

444 patients had responded as knowing both their physician’s cer-

tification status and their sleep center’s accreditation status, while

188 patients were unaware of the accreditation status of their phy-

sician, the certification status of their sleep center, or both.

Discontinuation of PAP Therapy and Adherence

Of the 444 patients who identified physician-accreditation sta-

tus and center-certification status, 16 (5%) of 307 patients who

were cared for by certified physicians and accredited centers had

stopped using their PAP devices. In contrast, 7 (7%) of 99 pa-

tients cared for by either certified physicians or accredited centers

had stopped using their PAP devices, and 8 (21%) of 38 patients

who were cared for by noncertified physicians and nonaccredited

centers had stopped using their PAP device (χ 2; p = .001)(Table

1). Besides accreditation or certification status, Table 2 shows the

relationship between other significant covariates (derived from

Table 1) and discontinuation of PAP therapy. The odds ratios are

hazard ratios for discontinuation of PAP therapy (Table 2). From

Table 2, covariates were entered into a forward-regression model

(Table 3). Block 1 consisted of covariates that are known to in-

fluence acceptance of PAP therapy (age, body mass index, and

health insurance), block 2 consisted of covariates of interest (na-

sal-congestion score and medications for nasal congestion), and

block 3 consisted of predictors (lack of accreditation or certifica-

tion status or risk perception due to patient education).

Multivariate logistic-regression analysis (Table 3) revealed that

lack of accreditation of physician or certification of center and

severity of nasal congestion score were independently associated

with discontinuation of PAP therapy (Table 3). In contrast, patient

education leading to enhanced perception of risk associated with

OSA, having health insurance, and medications for nasal conges-

tion “protected” against discontinuation of PAP therapy (Table 3).

If both risk perception and lack of accreditation or certification

135

AASM and OSA Managemen

Table 1 —Proportion of Patients Who Discontinued PAP Therapya

Certification status of physician/ Using PAP deviceb Total, n

accreditation status of center No Yes

Both 16 (5) 291 (95) 307

One 7 (7) 92 (93) 99

None 8 (21) 30 (79)

Total 31 (7) 413 (93) 444

aUnadjusted proportions b

Data are presented as number (percentage). Pearson χ 2

test for as-sociation (p = .001)

PAP refers to positive airway pressure; Both, both the physician was

certified and the center was accredited; One, either the physician was

certified or the center was accredited; None, neither the physician

was certified nor was the center accredited; n= number of patients.

Table 2 —Unadjusted Odds Ratios of Determinants of Discontinua-

tion of PAP Therapy

Variable B (SE) p value OR (95% CI)a

Certification of physician -0.82 (0.33) 0.015 b 0.44 (0.23-0.85)

Accreditation of center -1.14 (0.39) 0.004 b 0.32 (0.15-0.70)

Lack of accreditation or 0.73 (0.24) 0.003 b 2.07 (1.29-3.33)

certification

Education regarding OSA -0.6 (0.32) 0.036 b 0.53 (0.24-0.95)

Risk perception and -0.69 (0.32) 0.03 b 0.5 (0.27-0.94)

education

Severity of OSA 0.22 (0.38) 0.56c 1.24 (0.59-2.6)

Nasal congestion score 0.35 (0.16) 0.027 b 1.42 (1.04-1.93)

Prescription for nasal - 0.83 (0.38) 0.03 b 0.45 (0.21-0.92)

congestion

Age -0.04 (0.02) 0.014 b 0.96 (0.93-0.99)

Sex -0.59 (0.31) 0.06c 0.55 (0.30-1.02)

Body mass index - 0.05 (0.02) 0.028 b 0.96 (0.92-0.99)

Continuous PAP pressure -0.10 (0.07) 0.14 0.89 (0.78-1.03)

level

Automatic PAP 1.5 (1.0) 0.14 4.5(0.6-33.2)

Health insuranced -1.53 (0.54) 0.005 b 0.22(0.08-0.62)

Highest education received -0.18 (0.46) 0.88 1.01(0.34-2.05)

PAP refers to positive airway pressure; β estimated coefficient; SE,

standard error; CI, confidence intervals.aUnadjusted odds ratio (OR)

b p < .05c p < .10dCompared to no insurance




status were entered into the model for Step 4 (not shown in Table

3), accreditation or certification status was no longer significant

(B = -0.46; SE = 0.30; p = .12). This is likely due to significant

collinearity between these 2 variables (r = -0.27, p < .001). These

findings suggest that risk perception and education may mediate

the relationship between accreditation or certification status and

PAP discontinuation.

Self-reported usage of PAP device was higher for patients cared

for by accredited versus nonaccredited centers: 44.2 ± 14.4 versus39.6 ± 19.8 hours per week, respectively (p = .017). Similarly,

patients cared for by certified physicians tended to use their PAP

device for longer durations than did patients cared for by noncer-

tified physicians: 44.3 ± 14.4 versus 41.3 ± 18.6 hours per week,

respectively (p = .057). General linear models built to adjust for

confounders revealed that the self-reported usage of PAP device

was explained by variables, similar to those in the logistic-regres-

sion models reported for discontinuation of PAP therapy (Table

3). While the combined “dose-effect” of certification or accredi-

tation status, risk perception, prescription of nasal medications,

and body mass index were directly related to self-reported adher-

ence to PAP therapy, nasal congestion score was inversely related

to self-reported adherence to PAP therapy (p < .05).

Degree of improvement in subjective sleepiness was mea-sured by a 5-point Likert scale that ranged from -1 (sleepiness is

worse), 0 (no change), +1 (slightly improved), +2 (substantially

improved), and +3 (completely resolved). As expected, the Likert

scores for improvement in sleepiness were greater in patients who

were continuing to use PAP therapy (1.76 ± 0.78) than in patients

who had discontinued such therapy (0.53 ± 1.23; p < .0001)(ques-

tion 27; Appendix). Moreover, the degree of improvement in

sleepiness was directly correlated with the hours of self-reported

adherence to PAP therapy (R = 0.44; p < .0001).

Patient Education

Certified physicians and accredited centers were more likely

to provide adequate education to patients regarding OSA. Physi-

cian certification and center accreditation were associated with

a greater proportion of patients receiving adequate education re-

garding OSA (Table 4). Seventy-seven percent of patients cared

for by certified physicians and accredited centers reported receiv-

ing adequate education regarding OSA. In contrast, only 43% of

patients cared for by noncertified physicians and nonaccredited

centers reported receiving adequate education regarding OSA (p

< .0001; Table 4). Similarly, the accreditation status of the caring

physician and the certification status of the center were also di-

rectly related to the proportion of patients who received education

that led them to perceive the risks associated with OSA (Table

4). Patients who were cared for by noncertified physicians andnonaccredited centers were more likely to seek information re-

garding OSA elsewhere than were those patients who were cared

for by certified physicians and accredited centers (Table 4). Simi-

lar findings were noted when such educational endpoints were

136


Table 3 —Hierarchical Logistic Regression Estimating Discontinua-

tion of PAP Therapy

Variable B (SE) Adjusted OR Δχ 2

(95% CI)

Step 1 7.66a

Age 0.01 (0.02) 1.01 (0.97-1.05)

BMI 0.05 (0.03) b 1.05 (0.99-1.11)

Health insurance -1.64 (0.71)a 0.19 (0.05-0.77)

Step 2 8.19a

Nasal congestion 0.45 (0.22)a 1.57 (1.03-2.41)score

Medications for nasal -1.27 (0.54)a 0.28 (0.10-0.81)

congestion

Step 3c 4.64a

Lack of accreditation or 0.62 (0.28)a 1.86 (1.08-3.20)

certification

Step 3c

Risk perception and - 0.77 (0.36)a 0.47 (0.23-0.93)

education

PAP refers to positive airway pressure; BMI, body mass index; β es-

timated coefficient; SE, standard error; CI, confidence intervals; Δχ 2

= change in χ 2.a

p < .05 b p < .10cRisk perception and lack of accreditation or certification were col-

linear; therefore they are inserted separately.

Table 4 —Proportion of Patients Receiving Education Based on Physician-Certification and Center-Accreditation Status

Education about OSA Risk perception Sought education elsewhere

Yes No Yes No Yes No

Physician certification statusa

Certified 304 (73) 98 (24) 309 (75) 65 (16) 155 (50) 154 (50)

Not certified 62 (44) 77 (24) 94 (48) 71 (36) 73 (63) 43 (37)

p Value b < .001 < .001 .02

Center accreditation statusa

Accredited 290 (72) 98 (24) 284 (72) 102 (26) 148 (50) 146 (49)

Not accredited 35 (47) 39 (52) 40 (53) 34 (45) 40 (65) 22 (35)

p Value b < .001 .004 .056

Accreditation-certification status (n=444)a

Physician certified and center accredited 237 (77) 62 (20) 238 (78) 60 (20) 109 (49) 115 (51)

Either physician certified or center accredited 57 (57) 42 (42) 51 (51) 48 (48) 49 (64) 28 (36)

Neither physician certified nor center accredited 13 (33) 25 (64) 19 (49) 19 (49) 21 (62) 13 (38)

p Value b < .001 < .001 .04

Data are presented as number (percentage). OSA refers to obstructive sleep apnea.aPatients responding as “Don’t know” to receiving education or accreditation of certification status are not shown.

bχ 2 test with Bonferroni correction.




analyzed after patients were grouped by physician-certification or

center-accreditation status alone (Table 4).

Timeliness of Care

Timeliness of care—time delay between the first sleep study

and when the patient received the PAP device—was a median of

27 days (interquartile range; 7 to 30). Timeliness of care was not

related to physician-certification or center-accreditation status, ei-

ther individually or when considered together (P>.2). Timeliness

of care was inversely related to the duration of therapy (R= - 0.22;

p < .0001; Figure 1). Notably, the insurance status (insured versus

not), type of insurance carrier, and issuance of an automatic PAPdevice were not associated with speedier service (p > .4).

Patient Satisfaction

Patient-satisfaction scores for care rendered by the physician—

with a highest score of 5 signifying greatest satisfaction—was

higher in patients cared for by certified physicians (3.78 ± 1.18)

than noncertified physicians (3.19 ± 1.27; p < .0001). After univar-

iate regressions identified significant explanatory variables, gen-

eral linear models revealed that the following were independently

associated with lower patient-satisfaction scores: not perceiving

the risk of OSA through education received, discontinuation of

PAP therapy, noncertified physicians, and longer time delays (log

of time delay) in instituting PAP therapy (Table 5).

Patient-satisfaction scores for care rendered by the center—

with a score closer to 5 signifying greater satisfaction—was high-

er in patients cared for by accredited centers (4.11 ± 0.98) than

those cared for by nonaccredited centers (3.58 ± 1.24; p < .0001).

After univariate regressions identified significant explanatory

variables, general linear models revealed that the following were

independently associated with lower patient-satisfaction scores:

time delays in instituting PAP therapy (log of time delay), nonac-

credited centers, not perceiving the risk of OSA through education

received, and discontinuation of PAP therapy (Table 5).

Internal and External Validity

Besides the good-to-excellent internal consistency between

components of the questionnaire (Cronbach α coefficient of 0.75

to 0.93; Methods section), we further checked the data for internal

and external validity. First, for external validity, the demographics

of our patient population (age, height, weight, and sex) and con-

tinuous PAP pressure level are very similar to those reported in

other large series of patients with OSA.18-21 Moreover, the propor-

tion of patients who received continuous, automatic, and bilevel

PAP devices—78%, 10%, and 12%—is similar to prior reports22

(external validity). In order to further assess the internal validity,

we correlated self-reported pressure level of the continuous PAP

therapy versus self-reported body mass index. In our study, self-

reported pressure level prescribed for continuous PAP therapy

was positively correlated with body mass index (R = 0.41; p <

.0001).

DISCUSSION

To our knowledge, this is the first study to show an effect

of physician sleep certification and sleep center accreditation

on discontinuation of PAP therapy and self-reported adherence

to PAP therapy in patients with OSA. Moreover, in comparisonwith patients cared for by nonaccredited centers and noncertified

physicians, patients cared for by accredited centers and certified

physicians were more likely to have perceived the risks of OSA

through education and were more satisfied with their care. Time

delays in instituting therapy for patients with OSA were not in-

fluenced by accreditation-certification status of physicians and

centers but unfavorably impacted patient satisfaction. In patients

with OSA, worsening nasal congestion and lack of medications

for nasal congestion are independent risk factors for discontinu-

ing PAP therapy and low hours of device use.

0 50 100 150 200 250 300

0

50

100

150

500600

T i m e

d e l a y ,

d a y s

Duration since issuance of PAP device, months

Figure 1 —Time delay for institution of positive airway pressure

(PAP) therapy is regressed against patient-reported duration of time

lapsed since issuance of PAP device (n = 569). Note that there has

been a progressive lengthening of time delays in instituting PAP ther-

apy (r = -0.22; p < .0001).

137


Table 5 —Determinants of Patient Satisfaction Score Evaluating Phy-

sicians and Centers

Variable B (SE) p Value

Satisfied with physician (dependent variable)a

Model 1 (R 2= 0.09)

Log of time delay - 0.44 (0.10) < .0001 b

Discontinuation of PAP therapy -1.01 (0.32) .001 b

Non-certified physician -0.46 (0.13) < .000 b

Model 2 (R 2 = 0.21)

Log of time delay -0.31 (0.09) .001 b

Discontinuation of PAP therapy -0.74 (0.23) .001

Risk perception 1.02 (0.10) < .0001

Satisfied with center (dependent variable)a

Model 1 (R 2= 0.15)

Log of time delay -0.29 (0.09) .001 b

Discontinuation of PAP therapy - 0.75 (0.22) .001 b

Risk perception 0.72 (0.1) < .0001 b

Model 2 (R 2= 0.08)

Log of time delay -0.34 (0.12) < .0001 b

Discontinuation of PAP therapy -0.97 (0.29) .001 b

Nonaccredited center -0.49 (0.15) .00 b

PAP refers to positive airway pressure; B estimated coefficient; SE,

standard error; CI, confidence intervals.aRisk perception and lack of accreditation or certification were col-

linear; therefore they are inserted separately. b p < .05




Risk Perception and Education

Reports cite that between 25% and 50% of patients with OSA

may abandon treatment during the first 2 to 4 weeks of treat-

ment.23-26 Although physical factors such as poor mask fit, nasal

congestion, and high pressure contribute to such nonadherence,

psychological factors may play a major role as well.7,9 Using the

social cognitive model,27 Weaver and colleagues developed a

questionnaire-based instrument involving 3 major cognitions that

play a role in adherence to PAP therapy—patient’s perception of

health risk associated with OSA, patient’s expectations of out-

comes, and patient’s perceived ability to use the PAP device.7 In

this instrument, perception of risk was an additional, and impor-

tant component, believed to determine and predict patient behav-

ior in response to therapy and considered an improvement over a

prior model.9 Such perception of risk is usually imparted by edu-

cating the patient regarding disease-specific outcomes and health

risks.27,28 In our study, education leading to a patient’s perception

of risk due to OSA was associated with decreased odds for discon-

tinuing PAP therapy (adjusted odds ratio [OR] 0.5, p = .03; step 3,

Table 3). This is in agreement with other investigations showing

the beneficial effect of intensive education on adherence to PAP

therapy.29

Certification-Accreditation Status

In our study, successful education of the patient regarding the

health risks of OSA was performed more often by certified physi-

cians and accredited centers than by noncertified physicians and

nonaccredited centers (Table 4). Such education leading to risk

perception may underlie the lower likelihood for discontinua-

tion of PAP therapy in patients cared for by certified physicians

and accredited centers than in patients cared for by noncertified

physicians and nonaccredited centers. This is further supported

by the collinearity between “risk perception” and accreditation

or certification status in our regression model (Table 3). Besides

promoting adherence to PAP therapy through education, physi-

cians may favorably influence adherence to PAP therapy by other

means: prescription of medications to relieve nasal congestion,

heated humidifier,30 or choice of mask interfaces.31 We have previ-

ously reported differences in prescription practices among physi-

cians of various specialties.32 Physicians who specialized in the

“parent” fields for sleep medicine—pulmonary medicine, neurol-

ogy, and psychiatry—were less likely to prescribe sedatives to

patients with as yet undiagnosed OSA.32 Conversely, a survey by

Chervin and colleagues appears to indicate that there is wide vari-

ability in practice patterns of physicians managing patients with

sleep problems—regardless of their certification status.33 In the

present study, while prescription of medications for nasal conges-

tion protected against discontinuing PAP therapy (OR 0.3, 95%

CI 0.1–0.8; p = .02; Table 3), certified physicians were no more

likely than noncertified physicians to prescribe medications for

nasal congestion (p = .5; not shown). Therefore, such a mecha-

nism is unlikely to be responsible for the effect of accreditation or

certification status on discontinuation of PAP therapy.

We chose discontinuation of PAP therapy as the primary end-

point because, currently, it is unclear as to what threshold of hour-

ly PAP-therapy use is acceptable and what, if any, are the benefits

associated with an extra hour of nightly usage.8 In keeping with

this line of reasoning, we had originally powered the study based

on continuation or discontinuation of PAP therapy and not hourly

usage. Nevertheless, we did collect information regarding self-

reported hourly PAP use, and the effects of accreditation or cer-

tification status on hour-based adherence to PAP therapy was no

different than the effect of such status on discontinuation of PAP

therapy. Moreover, while self-reporting of PAP-therapy usage is

not as accurate as monitoring device compliance using microchip

technology,26 we do not believe that a systematic bias would have

occurred across the patient groups compared in our study.

Nasal Congestion and TherapyPrevious studies have identified nasal congestion and symp-

toms as important reasons for abandoning PAP therapy or poor

adherence.7,34 However, a systematic measurement of nasal symp-

toms using validated questionnaires in patients using PAP therapy

has not been performed. Often, such nasal symptoms are attrib-

uted to PAP therapy.35,36 In our study, however, patients who had

already discontinued PAP therapy reported higher nasal-conges-

tion scores than did patients who were continuing to use their PAP

devices. This would suggest that nasal congestion might play an

important role in acceptance of PAP therapy, and, conceivably,

such a role may be independent of the effect of PAP therapy on

nasal symptoms. Additionally, the importance of nasal conges-

tion on discontinuation of PAP therapy is further emphasized by

our finding that prescription of medications for nasal congestion

protected against discontinuation of PAP therapy (OR 0.3, 95%

CI 0.1-0.8; p = .02; Table 3).

Satisfaction Rates

Certified physicians and accredited centers achieved greater

satisfaction ratings from patients than did noncertified physicians

and nonaccredited centers. Other factors determining patient sat-

isfaction were receiving education leading to perception of health

risks associated with OSA and outcome of treatment—whether

they continued to use the PAP device or not and timeliness of

care. This is consistent with other reports that have identified ac-cess to care and physician communication as important determi-

nants of patient satisfaction.37,38 In light of this information, the

sleep community and healthcare systems need to address the ris-

ing wait times (Figure).

Wait Times

We chose the time lapse between first sleep study and delivery

of PAP device because these are points in time that the patient

is more likely to remember. Our data are consistent with recent

reports of time delays for sleep evaluation in the United States,10

but the magnitude of our wait times is lower than that reported

by Flemons and colleagues.10

Such a difference is probably dueto the fact that the 2 studies measured different timeframes along

the timeline of care delivered to patients with OSA. Our data,

however, allow relating the wait times to patient satisfaction and

also provide trends that allow extrapolation.

Limitations

There are several limitations to this study. First, this is an ob-

servational study, making it difficult to attribute cause-and-effect

relationships. Second, self-selection of patients agreeing to par-

ticipate in this study may not be representative of the average

patient. Third, although response rate was good, it is unknown

138





as to how the nonrespondents may have influenced the results.

Fourth, this Internet-based survey does not include patients with-

out Internet access and may have discounted patients belonging

to lower socioeconomic strata or patients with disabilities. Fifth,

race demographic was not sought, but we do not believe that this

would have significantly affected the sampling because our pa-

tients’ age, sex, height, and weight information are very similar

to those in previous reports. Lastly, patients were asked to rely on

their memory—especially with regard to time delays—and such

information may be prone to recall bias.

ACKNOWLEDGEMENTS

The authors are indebted to all the organizations that helped

advertise the survey. The authors thank Mr. Joe Guilford (of cpap-

store.com) and Mr. David Hargett (Chairman, American Sleep

Apnea Association) for helpful suggestions and advertisement.

Funded by SAVAHCS Research Award and American Sleep Med-

icine Foundation of the American Academy of Sleep Medicine.

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3. Drinnan MJ, Murray A, Griffiths CJ, Gibson GJ. Interobserver vari-ability in recognizing arousal in respiratory sleep disorders. Am JRespir Crit Care Med 1998;158:358-62.

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7. Weaver TE, Maislin G, Dinges DF, et al. Self-efficacy in sleep apnea:instrument development and patient perceptions of obstructive sleepapnea risk, treatment benefit, and volition to use continuous positiveairway pressure. Sleep 2003;26:727-32.

8. Weaver T, Maislin G, Dinges D, Pack A, Multisite Study Group.CPAP dose duration for effective response. Am J Respir Crit CareMed 2003;167:A155.

9. Stepnowsky CJ Jr, Marler MR, Ancoli-Israel S. Determinants of na-sal CPAP compliance. Sleep Med 2002;3:239-47.

10. Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J.Access to diagnosis and treatment of patients with suspected sleepapnea. Am J Respir Crit Care Med 2004;169:668-72.

11. Otani K, Harris LE, Tierney WM. A paradigm shift in patient satis-faction assessment. Med Care Res Rev 2003;60:347-65.

12. Weaver TE. Outcome measurement in sleep medicine practice and

research. Part 1: assessment of symptoms, subjective and objectivedaytime sleepiness, health-related quality of life and functional sta-tus. Sleep Med Rev 2001;5:103-28.

13. Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respi-ratory Research Group. J Allergy Clin Immunol 1997;99:S757-62.

14. Craig TJ, Teets S, Lehman EB, Chinchilli VM, Zwillich C. Nasalcongestion secondary to allergic rhinitis as a cause of sleep distur- bance and daytime fatigue and the response to topical nasal cortico-steroids. J Allergy Clin Immunol 1998;101:633-7.

15. Golden S, Teets SJ, Lehman EB, et al. Effect of topical nasal az-elastine on the symptoms of rhinitis, sleep, and daytime somno-lence in perennial allergic rhinitis. Ann Allergy Asthma Immunol2000;85:53-7.

16. Collard P, Pieters T, Aubert G, Delguste P, Rodenstein DO. Com- pliance with nasal CPAP in obstructive sleep apnea patients. SleepMed Rev 1997;1:33-44.

17. Speer TK, Fayle RW. The effect of systematic desensitization andsensory awareness training on adherence to CPAP treatment. SleepRes 1997;26:216.

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24. Berthon-Jones M, Lawrence S, Sullivan CE, Grunstein R. Nasa

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tive evaluation of patient compliance. Am J Respir Crit Care Med1994;149:149-54.

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APPENDIX: Questionnaire

This is a research survey. Participation in this survey is entirely voluntary. The purpose of this study is to determine patients' percep-

tion of the care they received for their SLEEP APNEA condition.

Please respond to this questionnaire only if you have been diagnosed with OBSTRUCTIVE SLEEP APNEA and if you are at least 20

years old. Participation is anonymous, and the responses will be used only for research purposes and analyzed in aggregate. There is

no remuneration for participation.

1. Was the physician who managed your sleep apnea a SLEEP EXPERT?You can check this website if your sleep physician is certified in sleep medicine.

(html link to AASM web site with list of certified sleep physicians)

Yes

No

Don’t know

2. Was the sleep center (the place where you had your sleep study or portable sleep study hooked up) certified by the American

Academy of Sleep Medicine?

You can check to see if your center is AASM accredited at this web site

(html link to AASM web site with list of certified sleep centers)

Yes

No

Don’t know

3. Did you receive ADEQUATE education about sleep apnea from your providers?

(Verbal, audiovisual aids, pamphlets, brochures or other)

Yes

No

Don’t know

4. Did such education improve your understanding of sleep apnea?

Yes

No

Don’t know

5. Did such education help you realize the risks associated with sleep apnea?Yes

No

Don’t know

6. If you did not receive satisfactory education regarding the risks of sleep apnea from your physician and sleep center, did you receive

it elsewhere?

Yes

No

Not applicable

7. How satisfied are you with the care you have received from your physician for your sleep apnea condition?

Very satisfied

SatisfiedNeutral

Dissatisfied

Very dissatisfied

8. How satisfied are you with the care you received from the sleep center?

Very satisfied

Satisfied

Neutral

Dissatisfied

Very dissatisfied

140





Appendix Cont.

9. Currently, are you using a CPAP, BiPAP, or auto-PAP machine?

Yes

No

10. During a typical night, how many hours do you use the machine?

____ hrs

11. During a typical week, how many days do you use your (CPAP, BiPAP, or auto-PAP) machine?____ nights

12. How severe is your sleep apnea?

Mild

Moderate

Severe

Don’t know

13. Do you experience nose congestion?

Never

Rarely (once a month)

Sometimes (2 to 4 times a month)

On most days (5 to 15 times a month)All the time (16 to 30 times a month)

14. If you suffer nasal congestion, were you prescribed any medications to relieve such congestion?

Yes

No

15. If you are on CPAP, what is your prescribed CPAP level?

____ cm H2O

16. If you are on BiPAP, what are the upper and lower levels (Example: enter as "14/6")

____ / ____ cm H2O

17. Are you using an auto-PAP (otherwise called a smart CPAP) machine?Yes

No

Don’t know

18. What is your gender?

Male

Female

19. How old are you?

____ years

20. How much do you weigh? (lbs)

_____ lbs

21. How tall are you? (feet and inches; example: 5'6")

___ ft ___ in

22. How long has it been since you were issued a CPAP machine (in months)?

____ months

23. How many days did it take between your FIRST sleep study and when you received the machine for treating sleep apnea?

(Not applicable if you were never prescribed such a machine)

____ days

141

AASM and OSA Management



Journal of Clinical Sleep Medicine Vol 2 No 2 2006

Appendix Cont.

24. What kind of insurance did you have at the time your sleep apnea was diagnosed and treated?

HMO

PPO

POS

Medicare

VA

No insurance

Don’t know

26. What is your highest education level?

Did not graduate from high school

Graduated high school

College

Masters

Doctorate

27. Have your symptoms of sleepiness improved?

Completely resolved

Substantially improved

Slightly improved

No changeWorse

142


Documents

Management of Obstructive Sleep Apnea