In a randomized, multi-center study that compared the results of two obstructive sleep apnea diagnostic and treatment protocols, “simplified” and traditional, as well as their respective costs, researchers found that the simplified model of care was not inferior to the usual physician-led, more expensive hospital-based model.
Obstructive sleep apnea, which may affect as many as 20 to 30 million adult Americans and a growing number of people worldwide, is independently linked to cardiovascular problems, hypertension and other co-morbidities, as well as an increased risk of motor vehicle accidents.
According to national health statistics, nearly 38,000 cardiovascular deaths annually are in some way related to sleep apnea. As obesity continues to be a growing problem in Western and developing countries, the prevalence of sleep apnea is almost certainly rising with it.
The serious complications of sleep apnea, together with its increasing prevalence, make its diagnosis a pressing public health issue. However, traditional diagnosis and treatment of sleep apnea can be expensive and time-consuming.
Diagnosis and treatment are also limited by the availability and accessibility of the sleep centers and specialist doctors required. “In Western countries, the waiting lists for sleep medicine service are often very long. In developing countries, there may be no sleep medicine services at all in many areas,” said Dr. Antic, study author.
To determine whether diagnosis and subsequent treatment could be simplified without health costs to the patient, the researchers developed a simplified sleep apnea treatment program using experienced nurses, home ambulatory diagnosis and auto-titrating continuous positive airway pressure (CPAP).
They compared the results of patients thus diagnosed and treated to those who underwent traditional sleep apnea treatment that relies on specialist physicians and sleep studies.
They assessed the patients’ sleepiness on the validated Epworth Sleepiness Scale (ESS) and set the minimal clinically significant change at +/- 2 points. They also assessed other outcomes of sleep, including quality of life measures, executive neurocognitive function on maze tasks and maintenance of wakefulness tests and CPAP adherence. In all, the study assessed almost 200 patients with moderate to severe sleep apnea who were randomly assigned to the simplified or traditional model.
The patients in the nurse-led group spent about 50 minutes longer with the nurse than the patients in the physician-led groups, but were seen by physicians 12 percent of the time. Patients in the physician-led group, meanwhile, had an average of 2.36 consultations with physicians, as opposed to 0.18 for patients in the nurse-led group.
Despite these obvious differences, none of the secondary outcomes measured showed significant differences between the groups, and differences in ESS scores between groups were lower than the pre-determined minimum for clinical significance.
Notably, the patients in the nurse-led group were diagnosed and treated for $722 U.S. dollars less per patient than those in the physician-led group, but did not suffer from inferior care or outcomes.
“While we were not surprised at this finding, we were very pleased, as it indicates a robust new avenue for providing better access to sleep services for those with moderate-severe obstructive sleep apnea in a timely yet cost effective fashion without sacrificing patient outcomes,” said Dr. Antic.
Edward Grandi, Executive Director of the American Sleep Apnea Association welcomes the results of the study saying, “This approach could benefit a significant number of the less complicated apnea cases that are currently untreated due to cost constraints.”