Study data showed that 43% of patients with obstructive sleep apnea were referred to sleep specialist physicians for ongoing management by a primary care provider.
A qualitative study that combined patients and provider perspectives on barriers and facilitators to optimize patient-centered management of obstructive sleep apnea (OSA) revealed important challenges in the current system and highlighted the need to develop innovative models of care with input from both parties.
Led by Sachin Pendharkar, MD, MSc, respirologist and sleep physician, University of Calgary, the study identified multiple barriers in providing timely access to care for patients with OSA in primary care delivery models, including poor specialist access, variable primary care providers (PCP) knowledge of OSA, and lack of clarity about provider roles for OSA management.
The study collected data from surveyed PCPs (n = 119), focus groups and interviews with patients living with OSA (n = 28), and workshops with primary care and sleep providers (n = 36). Pendharkar and colleagues reported quantitative survey data using descriptive statistics, while qualitative data was analyzed using an inductive thematic approach.
When evaluating provider confidence in the management of OSA, PCPs reported moderate confidence in their knowledge about the diagnosis and management, although results were highly variable. Using a Likert scale, researchers found that while physicians understood their role in diagnosing OSA, they lacked confidence in their role with respect to treatment.
In comparison to physicians, respiratory therapists reported greater knowledge about OSA, while nurses reported poorer knowledge. Notably, both of these non-physician providers lacked clarity about their role in OSA management. The data also showed that 43% of patients (standard deviation [SD], 42%) with OSA were referred to sleep specialist physicians for ongoing management by a PCP.
Barriers and facilitators to optimal OSA care delivery, adverse impacts of the current model on patients, and potential solutions to improve care delivery were among the 3 broad themes identified from survey, focus group, interview and workshop data.
Providing timely sleep specialist access for patients with suspected OSA was a major concern for patients and PCPs, noting that delays in care were unacceptable to these patients. These issues were magnified within rural communities, where specialty OSA care was less readily available. This led to problems with the quality of clinical care and patient-born costs.
Respiratory home care companies, which helped mitigate these delays and improved access to quality care, were both valued by patients and PCPs. Stakeholders also saw these providers as filling an important gap resulting from long wait times for sleep specialist physician care of OSA.
As for the variable provider knowledge about OSA, deficiencies spanned the care continuum from selection of diagnostic tests to initiation of treatment to follow-up. Despite this, patients accepted the variability on the condition that a sleep specialist or respiratory homecare company was involved in their care.
One patient was quoted saying, “I think he’s an excellent doctor but he’s not a specialist on this, so he’s a little bit reluctant to say more than what the [homecare company] has said.”
A poor understanding of OSA care was common for patients, who felt unclear about the diagnosis or severity of OSA or the treatment plan. Overall, patients were unsure of what to expect and perceived a lack of an overall care plan.
Disconnection of OSA and medical health was also a main concern brought up by patients. The fragmented system of care led patients to separate OSA from their other health problems, and perceived respiratory homecare companies to be technical providers for OSA treatment, whereas PCPs oversaw all other medical issues.
Lastly, patients and providers described a perception of conflict of interest among community homecare providers, who both perform home sleep apnea testing and dispense positive airway pressure (PAP) machines. This perception led to an erosion of trust, with patients expressing a desire for greater physician involvement.
The first potential solution to improve care delivery was an integrated model of care. Due to the complexities of patients with OSA, several providers claimed that using integrated care delivery models using multidisciplinary teams can help.
One PCP was quoted saying, “Why don’t we have a team, a multi-disciplinary team, so there’s a sleep apnea nurse that educates patients, that does…follow up and stuff like that, why don’t we use the most appropriate provider to [provide] service, [be]cause that’s not always the physician.”
The second suggestion was an improved system navigation. Stakeholders highlighted the value of standardizing roles and care delivery processes to promote success of integrated models. PCPs were in support of this change but called for navigation guides and clinical pathways to bridge knowledge gaps and improve care coordination.
Technology as a facilitator was among the more notable solutions suggested, which has already been implemented in rural communities to address geographic disparities in sleep specialist capacity. Stakeholders also noted that controlled PAP (CPAP) machine downloads as a facilitator for communication between homecare providers and PCPs could support integration strategies.