The Missing Conversation

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Screen Shot 2014-02-27 at 11.41.12 AMBy Michael Coppola, MD

Primary care practitioners (PCPs) have the responsibility to uncover and address healthcare risks in the populations they serve. Today, PCPs have become accustomed to asking intimate questions of patients, “Do you feel unsafe at home?”  “How many drinks do you have in a day, week or month?” and “Do you have unprotected sex?” 

It appears however, that a very simple conversation is not happening in the exam room: “Do you snore regularly?” or “Has anyone told you that you stop breathing in your sleep?” – – and these are critical questions that can lead to reversing a serious health problem.  Yet patients who complain of these symptoms are often speaking to deaf ears, as they must bring their complaints to their PCPs on multiple occasions before a diagnosis of obstructive sleep apnea (OSA) is established. 

OSA is a serious medical disorder, which negatively impacts the most significant medical conditions of adult medicine.  Hypertension, highway crashes, metabolic syndrome, stroke, atrial fibrillation and excess mortality are all tied to untreated OSA. The economic burden is also significant and multiple studies have shown that each untreated person generates over $2,000 a year in excess medical expenditures.

Lost productivity, absenteeism and disability increase that number by 2.5 to 5 times. OSA is therefore no longer just a sleep disorder, but a complex medical problem whose under-recognition is creating unnecessary risk to quality of life, to the health of our patients and to our economy. Treatment has been shown to reverse many of these morbidities, resulting in immediate health care savings.

Sleep specialists have had primary responsibility for managing sleep disorders, including OSA, using complex sleep lab testing modalities evoking images of the 1931 Frankenstein movie.  Continuous positive airway pressure (CPAP) therapy, the universal OSA treatment of choice, was plagued with loud machines, patient complaints, and the requirement for a sleep lab titration to determine the “optimal” pressure. This made it difficult for primary care to engage in treatment for this condition and PCPs were forced to take a “here’s your referral” approach.  The difficulty with this approach is that it has left 75% of these patients with a serious condition undiagnosed and untreated.

Millions of Americans struggle with obesity, hypertension and diabetes, yet the connection between these disorders and OSA is not foremost in the minds of PCPs.  The care of diabetes, hypertension and obesity quite correctly falls within the realm of PCPs.  The Patient Centered Medical Home and new value based payment models have placed the responsibility for managing chronic medical conditions squarely with the primary care office.  Value based payment plans financially reward those who can efficiently improve the health of the populations they serve. The Healthcare Effectiveness Data and Information Set (HEDIS) measures, which place high value on measurable outcomes for diabetes and hypertension, drive many of these reward and rating structures. In Massachusetts, physicians are tiered according to their quality and efficiency scores for all five payers contracted with state and municipal employee plans.

It is time for PCPs to become proactive in the recognition and treatment of OSA. The American Academy of Sleep Medicine (AASM) recommends that all patients with Type II diabetes and hypertension be evaluated for sleep apnea. Although sleep specialists play a role in caring for these patients, a dramatically increased role for PCPs is critical to addressing this condition.  Simple screening tools like the STOP-BANG and Berlin questionnaires help to identify those who are at risk for the condition. Conversations during preventative care visits about habitual snoring and witnessed apneas will uncover most of the higher risk patients.

For those screened at high risk for OSA, patient centered diagnostic tests and treatments can be initiated by PCPs. Home sleep tests (HST) which measure breathing during sleep (Type III recordings) are now becoming standard care, and a recent study funded and published by the AASM found no difference patient outcomes for those randomized to HST versus a traditional sleep laboratory. Patients who test positive at home can be treated by a number of treatment options, such as newer generation CPAP devices that are often more comfortable, leading to greater compliance. And auto-titrating CPAP can be prescribed without the need for a CPAP titration study in a majority of patients.

The diagnosis and treatment of OSA is now patient centered and ideal for integration into progressive primary care practices. The improvement in quality of life for treated patients and reversal of co-morbidities will reward practices that develop OSA programs. It all begins with one simple conversation.

Michael Coppola, M.D. is Executive Vice President of Medical Affairs and Chief Compliance Officer at NovaSom (www.novasom.com), provider of the AccuSom® Home Sleep Test. He is also Past President & Chief Medical Officer of the American Sleep Apnea Association, a patient advocacy group.