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Majority of OSA Patients Opt for Home Sleep Test

October 1, 2009 - Provided by IDS

After having tested thousands of OSA patients through its nationwide Home Sleep Testing program, Instant Diagnostic Systems (IDS) has compiled survey results revealing that  an overwhelming majority of patients preferred a Home Sleep Test (HST) to an in-lab facility study.   98% of patients responded that they preferred the Home Sleep Test, which clearly indicates that patient preference will drive the market toward more home testing.

17 Shocking Physical Effects of Sleep Deprivation

Sleep studies are uncovering something shocking: physical effects of sleep deprivation appear to have their tentacles in at least 17 different health conditions.

It's scary.

That's why sleep should never be looked on as a nuisance or waste of time. It's an absolute necessity for human health and longevity. For example, you wouldn't say, "Gee, stopping to put gas in my car is a waste of time. I think I'll skip it." Or, "I never change the oil in my car. It takes too much time."

Your car will break down. Just as you will break down if you do not get enough sleep. Yet, in an attempt to get more done every day, millions of people cut back on sleep. They seem to take sleep for granted, almost like it's an afterthought.

Bad idea.

Sleep doctors have been sounding the alarm. Sleep must become a priority, an urgency in your life, just as much as the urgency you feel when your car is almost out of gas and you're driving on a dark, lonely stretch of road.

So if you need an incentive to get some sleep, take a look at this list of physical effects of sleep deprivation.

See Yourself On this List Anywhere?

This list of the physical effects of sleep deprivation is so important, I've decided to take the time to track down the best natural remedies for many of these sleep and health topics.

I hope that will help you out so you can zero in on your own health condition and work to improve it.

Anyway, here's the list...

Effects of Sleep Deprivation

1. Sleep deprivation—alarming new studies on heart disease.
   Cardiovascular disease is the number one killer in the United States. And to think that sleep deprivation plays some part in it boggles the mind.
    
2. Sleep deprivation and anger.
   Research has shown a correlation between hostility and increased sleep disturbance. So don't blow your stack...sleep on it instead!
    
3. Sleep deprivation and fatigue.
   Consider this—well over 100,000 car accidents in North America occur every year due to sleep deprivation. Over 6,000 dead people. Sad, tragic, and unnecessary. For more information on why this happens, see my article below called Beware These Dangerous Symptoms of Sleep Deprivation.
    
4. Physical effects of sleep deprivation and weight gain.
   Sleep deprivation research shows a link between lack of sleep, weight gain, and obesity. So if you're trying to lose some weight, be sure to check out my articles below on weight loss.
   
   Depression, stress, and anxiety
    
5. Sleep deprivation and anxiety.
   Recent research suggests that sleep deprivation can cause anxiety, fear, and worry.
    
6. Physical effects of sleep deprivation on stress.
   Stress is an ongoing part of life in our world today. And it can have a huge negative effect on your body and brain.
    
7. Sleep deprivation and depression.
   Not getting enough sleep can actually cause depression in some people. And almost all people with depression have problems sleeping. 
   
   Important note: If your mood, stress, and worries are what causes insomnia and sleep deprivation for you, natural help is available. Click here for valuable information about nutritional support for depression, stress, and anxiety. (Link opens in new window.) 
   
   After you click that link above, be sure to also look for the tab that says health concerns. You'll then see where to click for even more information on depression, stress, and anxiety...as well as insomnia.
   
   That website has great information that may help you immensely. One of the top biochemists in the world is involved with the research. Explore it.
   
   Diabetes and high blood pressure
    
8. Sleep deprivation and blood sugar.
   Researchers have discovered a connection between sleep deprivation and diabetes, in particular, type 2 diabetes.
   
   Fortunately, one company has worked hard to create a formula that helps support the health of people with diabetes. Click here to help balance insulin and glucose levels naturally. (Link opens in a new window.)
    
9. Sleep deprivation effects on high blood pressure.
   Studies have shown that people who sleep less than five to six hours a night have a significantly higher risk for high blood pressure.
   
   Below, you can read more about the effects of sleep deprivation on high blood pressure in another article I wrote. The article also contains a link to some great information on a hypertension diet, including a fantastic free, 64-page guide you will find invaluable
   
   More Sleep Deprivation Effects
   
   Physical effects of sleep deprivation also encompass all of the following:
    
10. Infections and weaker immune system
     
11. Frustration with life. Perhaps this is why alcohol and drug abuse are signs of sleep deprivation.
     
12. Irritability
     
13. Sleep deprivation and memory (includes reduced cognitive function, decreased mental sharpness, lack of focus and drive).
     
14. Blurred vision
     
15. Increased pain
     
16. May lead to a shortened life expectancy
     
17. Inflammation (a factor in numerous diseases, including certain types of cancer)

So there you have a quick overview of the physical effects of sleep deprivation. Who knew these things about sleep and health? Now think sleep is something you can skimp on?

By the way, it's interesting to note that studies are also showing that for adults, consistently sleeping more than nine hours a day may also lead to poor health. The magic target zone for health seems to be to consistently get seven to nine hours sleep daily for most adults.

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The burden of obstructive sleep apnea and associated excessive sleepiness

James F. Pagel, MS, MD, FAAFP, DABSM

Associate Clinical Professor of Family Practice, University of Colorado Medical School, Pueblo, Colorado

Obstructive sleep apnea (OSA) is a sleep disorder that is caused by repetitive, short-duration blockages of the upper airway, resulting in episodic cessation of breathing (apnea) or reduction in airflow (hypopnea), both of which may lead to arousal from sleep. The consequences of sleep apnea are manifold and in many cases are serious, yet the condition remains largely under-diagnosed. Early recognition and treatment are essential to alleviate the symptoms and sequelae of OSA, and the primary care provider (PCP) is ideally positioned to perform the initial appraisal of patients who may have this disorder. This supplement reviews the impact and management of OSA and its most common symptom, excessive sleepiness (ES), from the perspective of the PCP with patients at risk for OSA.

TABLE

Consequences of OSA and OSA-associated ES

The first 2 articles describe the extent of the problem, highlighting the urgent need for greater recognition of OSA. This article reviews the prevalence of OSA and OSA-associated ES and examines the significant detrimental impact they have on the daily lives of patients, as well as the economic consequences (TABLE). In addition to their societal consequences, OSA and the accompanying ES are associated with a number of well-documented comorbidities—including obesity, hypertension, cardiovascular disease, cerebrovascular events, and diabetes.¹ In the second article, Dr Max Hirshkowitz reviews the current understanding of the possible relationships between long-term comorbidities and OSA and explains how addressing OSA can also help alleviate these conditions.

Diagnosing OSA can be challenging and requires the PCP to have a high level of clinical suspicion based on patient history and risk factors. Ultimately, diagnosis of OSA usually requires referral to a sleep laboratory, where the patient may be assessed further using polysomnography. However, preliminary identification of at-risk patients relies on PCP perspicacity, especially because many patients with OSA are unaware that they have the condition. In the third article, Dr Paul Doghramji provides direction in recognizing and assessing patients with OSA in the primary care setting.

Patients who experience ≥5 apnea and hypopnea events per hour—as measured using the Apnea–Hypopnea Index (AHI)—have confirmed OSA and should be prescribed appropriate treatment. In the final article, Dr Robert Ballard reviews the current treatment options for patients with OSA and for those patients who experience residual daytime sleepiness despite optimal therapy for OSA.

  PREVALENCE OF OSA AND DAYTIME ES ASSOCIATED WITH OSA

In the United States, an estimated 9% and 24% of women and men, respectively, aged 30 to 60 years have at least mild OSA.² The overall prevalence of mild and moderate OSA is estimated at 20% and 7%, respectively, in Western countries.³ OSA and ES have a significant impact on daily functioning and quality of life. However, the condition is underrecognized. A retrospective chart review of patients referred for polysomnography by PCPs has shown that preliminary diagnosis of OSA was correct in 96% of referrals for patients with classic symptoms, including obesity, observed apneas, ES, and loud snoring.⁴However, the majority of patients with OSA do not present clinically with such symptoms and, furthermore, many patients with OSA are unaware that they have a sleeping disorder and fail to report any such symptoms to their PCP. Patients referred to sleep centers in the above study made up only 0.13% of the total patient population of the PCPs surveyed⁴; this figure is considerably lower than the prevalence rate of 26% to 32% of patients within the primary care population who are thought to currently suffer from OSA.^5,6 These findings indicate that PCPs make accurate diagnoses of OSA in those patients with prominent symptoms and physical characteristics.

A large majority of patients with OSA remain undiagnosed. It has been estimated that the actual prevalence of OSA and associated ES is approximately 3 times higher than the number of patients diagnosed with this sleep disorder.⁷ Up to 93% of women and 82% of men with moderate to severe OSA and ES are not clinically diagnosed.⁸ The prevalence of undiagnosed OSA within the community suggests a requirement for greater awareness among PCPs regarding prevalence and associated comorbidities for this diagnosis as well as increased vigilance for the less obvious sequelae of this condition.⁴

In addition to obesity or overweight, other risk factors are associated with the development of OSA, including male sex, increasing age, hypertension, smoking, and use of alcohol or sedatives (see“Recognition of obstructive sleep apnea” on page S17 of this supplement). OSA may also have a genetic basis: a number of studies have indicated that due to the hereditary nature of anatomic characteristics (overweight or craniofacial architecture) and traits such as ventilatory control abnormalities, individuals in a family with these traits may be at particular risk for developing this sleep disorder.⁹ Of the 18 million individuals with OSA in the United States, the majority are overweight, male, and hypertensive.^1,3,10 The World Health Organization predicts that by 2015 there will be >700 million obese adults (body mass index [BMI] ≥30 kg/m²) worldwide,¹¹ and this, given the growing proportion of elderly individuals within the global population, will lead to an exponential increase in the number of people with OSA.

Weight change, obesity, diabetes, cardiovascular disease, and increasing age are important determinants in the progression of OSA.^3,12 In a 4-year longitudinal study, a 10% increase in weight was associated with a 32% increase in AHI score and a 6-fold higher risk of developing moderate or severe OSA. Conversely, patients who reduced their weight by 10% experienced a 26% decrease in AHI score.¹³ The effect of weight gain on the progression of OSA is more pronounced in men than in women.¹⁴

Frustratingly, there is a lack of data concerning the prevalence of OSA in populations other than middle-aged or elderly white men. However, a small number of studies have indicated that the occurrence and etiology of OSA may differ with ethnicity. For example, Li and colleagues have reported that Asian patients with OSA tend to be less obese and have more severe symptoms than white patients.¹⁵Furthermore, the odds of having an AHI of ≥30 are 2.5 times higher in African Americans relative to white Americans when BMI and other confounding factors are taken into account.¹⁶

Although generally considered to be “the subjective state of sleep need,” ES is often referred to as sleepiness, drowsiness, languor, inertness, tiredness, fatigue, or sluggishness.^17,18 ES associated with OSA is estimated to occur in 22.6% of women with OSA (2% of women) and 15.5% of men with OSA (4% of men).² Undiagnosed OSA with associated ES is thought to occur in up to 5% of the population.³Estimating the true prevalence of ES associated with OSA is problematic, as this symptom has multiple causes. In addition to ES associated with OSA, ES can also occur as a result of central nervous system disorders such as narcolepsy and secondary to a variety of other sleep and medical disorders, including circadian misalignment (eg, that due to shift-work disorder or jet lag); behavioral sleep deprivation; use of sedating drugs and alcohol; and general poor health.¹⁹ The etiology of ES is not always clearly defined in epidemiologic studies.

It is unclear whether the ES associated with OSA is secondary to OSA-related sleep fragmentation or to the chronic intermittent hypoxemia associated with obstructive events occurring during sleep.^20-22Patients with more severe OSA tend to have higher levels of both subjectively and objectively defined ES.^22-24 The subjective complaint of ES may not correlate with the results of physiologic tests for this symptom,²⁵ foremost among which are the Multiple Sleep Latency Test (MSLT) and the Maintenance of Wakefulness Test (MWT). Both of these tests use modified polysomnography to assess sleep onset latency during a series of daytime nap periods. The effects of ES on performance during the day can also be assessed using tests of complex reaction and coordination, or by tests that assess the patient’s ability to complete complex behavioral tasks (eg, driving performance).²⁶ Many of these tests (and particularly driving simulators) have shown sensitivity to low-level sedation, have highly reproducible results, and can correlate performance with a real-life analog (eg, driving).²⁷ However, given that performance measures are susceptible to non–task-related influences (eg, motivation, distraction, and comprehension of instructions), the results of performance and questionnaire rating tests do not always correlate with results obtained from the MSLT and MWT.¹⁷

  SOCIETAL CONSEQUENCES OF OSA

Motor vehicle accidents among patients with OSA

Driver sleepiness is estimated to cause 20% of all motor vehicle accidents.²⁸ In 2000, more than 800,000 US drivers were involved in OSA-related motor vehicle accidents, at a cost of 1400 lives.²⁹ This is perhaps not surprising, given that several studies of patient driving records indicate motor vehicle accidents are more common among patients with OSA compared with the general population.^30-34 A study that assessed patients with OSA using a driving simulator demonstrated a correlation between collisions with obstacles during the simulation and a higher rate of real-world motor vehicle accidents. Compared with control subjects, patients with OSA consistently hit a significantly higher percentage of obstacles (1.4% vs 4.3%, respectively; P <.05) and had a significantly higher automobile accident rate (P<.01).³⁵ Drivers with OSA have an increased risk of crashing due to impaired vigilance and general detriments to cognitive function,^36,37 and up to one-quarter of patients with untreated OSA report frequently falling asleep while driving.³⁸ Sleep deprivation associated with shift work, as well as the use of medications with side effects such as ES, are known to negatively affect driving performance and may further aggravate ES in individuals with OSA.^39,40

Treatment with continuous positive airway pressure (CPAP) has been demonstrated to significantly (P<.05) reduce accident frequency and concentration faults in driving simulator studies in patients with OSA and in surveys of driver records.^41-43 This recovery in driving performance has been attributed to significant (P <.05) improvements in cognitive performance—including tracking error and reaction time—in patients who receive CPAP.⁴³

Commercial drivers are a particularly well-characterized population in studies of OSA because of the risk factors associated with this group (male sex and middle age) and interest in the effects—sometimes extreme and dangerous—that this disorder has on their professional lives.^32,44-46 Howard and colleagues have reported a prevalence of 16% for ES associated with OSA in a cohort of 2342 Australian commercial vehicle drivers.³² This was much higher than the prevalence of 4% recorded in working males in the general Australian population.⁴⁴ In addition, an AHI score of ≥30/hour has been associated with marked sleepiness and impaired task performance in commercial drivers.⁴⁶

Standardization of driver workloads, enforcement of breaks and minimum sleep requirements, and adherence to guidelines for the assessment of commercial drivers could result in improved road safety.⁴⁷In accordance with these guidelines, PCPs need to be particularly vigilant in recognizing and referring commercial drivers who may have OSA for specialist assessment. Continued collaboration between the PCP and the sleep specialist is also important in order to manage patient symptoms, monitor patient compliance with the recommended treatment, and ensure that therapy is effective so that the risk of accidents is reduced to the point where the patient can return to work.

Effects of OSA-induced ES in the workplace

Patients with OSA have difficulty with attention, task learning, and performing monotonous duties at work compared with the general population.⁴⁸ As a consequence of their reduced wakefulness, poor vigilance, and inattention, people with OSA are at higher risk of being involved in an occupational accident compared with the general population or with colleagues without sleep-disordered breathing.^39,49 As mentioned previously, cognitive dysfunction may be an important factor in the increased risk of road accidents in patients with OSA. However, cognitive impairment can also affect a patient’s ability to gain or maintain employment because their behavior may be misinterpreted as laziness or a lack of motivation. OSA-related problems have also been characterized in children. Chronically sleepy children, some of whom have OSA, do not perform as well in school as do students without sleep complaints, a situation that can have potential repercussions in terms of these individuals’ achievements in later life.^50,51

In addition to work performance difficulties, ES associated with OSA is also responsible for industrial and workplace accidents. A study by Lindberg and colleagues showed that blue-collar workers with snoring and ES associated with OSA had a significantly greater number of accidents at work (P =.01) than colleagues who did not have these symptoms of OSA.³⁹ White-collar workers also showed a trend in this respect, although the difference in the number of accidents in the white-collar group did not reach signifcance.³⁹ A retrospective and prospective study of daytime non-shift workers in 8 industrial plants reported a 2-fold higher risk of occupational injury among patients with ES, although the proportion of these workers with ES associated with OSA was not recorded.⁴⁹

  OSA AND ES ARE DETRIMENTAL TO QUALITY OF LIFE

Patients with OSA may experience cognitive dysfunction, irritability, moodiness, depression, decreased libido, impotence, cardiovascular disease, and diabetes, all of which may affect quality of life (see “The clinical consequences of obstructive sleep apnea” on page S9).^20,52 Vitality and social functioning are frequently reported to be the most affected domains in assessments of quality of life in patients with OSA (FIGURE).^20,53 ES associated with OSA is fundamental to this impairment because it affects patients’ perceptions of their own emotional and physical health, can mar their ability to interact socially^54,55 and has been found to contribute more significantly to impairment in all domains of the Medical Outcomes Study Short-Form (36-item) Health Survey (SF-36) than did sleep-disordered breathing (including OSA).⁵⁶

Depression associated with OSA has also been reported to have profoundly detrimental effects on quality of life, more so even than ES associated with OSA in some studies.^20,57 In a study of patients with OSA and depression, depression was found to correlate with impairment in 5 of the 8 domains of the SF-36, including general health perceptions and vitality.²⁰ Furthermore, patients with OSA and depression report poorer sleep quality independent of the actual quality of their sleep, as assessed using polysomnography, indicating the substantial effects that these comorbid conditions can have on patient quality of life.⁵⁷

  OSA TAKES AN ECONOMIC TOLL

In 1988, motor vehicle accidents caused by sleepiness in the United States were estimated to cost $43 billion to $56 billion, although the proportion of these accidents caused by OSA is unknown.⁵⁸ In 2000, the cost of road collisions that were directly attributable to OSA was $15.9 billion.²⁹ OSA and associated ES are responsible not only for economic costs associated with workplace and motor vehicle accidents, but also for loss of productivity due to days of from work and physician visits.

A study in a Canadian population estimated that for the 10 years before diagnosis of OSA, physician claims for individuals with OSA were C$3,972 per patient—twice that of age-matched controls (C$1,969 per patient; based on data for 1984–1995, not adjusted for inflation).⁵⁹ Therapy for OSA is an extremely efficient use of health care resources⁶⁰ and compares favorably with other commonly funded medical treatments.⁶¹ Hospital stays are reduced from 1.27 days/year before diagnosis of OSA to 0.54 days/year 1 year after diagnosis.⁶² Current data on the economic burden of OSA and ES associated with OSA are scant and further studies would help clarify the societal impact of this disorder.

  SUMMARY

ES associated with OSA has far-reaching consequences for both the individual, in terms of morbidity, mortality, and impaired quality of life, and for society as a whole, due to the economic burden and impact of this disorder on motor vehicle and occupational accidents. OSA is estimated to be present in 9% to 24% of the adult population and, of great concern, will continue to grow in prevalence with global increases in age and obesity. Appropriate diagnosis and treatment are essential in order to alleviate the morbidity and mortality associated with this disorder.

Study confirms not enough sleep raises diabetes, obesity risks

By 

RYAN JASLOW / 

CBS NEWS/ April 12, 2012, 9:58 AM

CBS News) It's no secret our bodies need sleep to function at their best. For shift workers who vary their work and sleep schedules, they especially risk not getting enough shut-eye.

Worked to death? 10 jobs that may hurt your heart
Study: Sleeping less may mean you'll eat more

A new study confirms those workers, and anyone who doesn't get enough sleep, can harm their health by raising their risk for diabetes and obesity.

Previous studies of shift workers and similar groups suggest sleep patterns that are inconsistent with our body's "internal clock " could lead to health problems. For this new study, researchers instead looked at 21 healthy participants, and put them through experiments that mimicked the sleep patterns of shift workers or those of people with recurring jet lag.

In the six-week study that's published in the April 11 issue of Science Translational Medicine, 21 men and women started out by getting an "optimal" 10 hours of sleep per night, and followed that with three weeks of about 5.5 hours of sleep that varied between day or night, such as a shift worker may experience. The study ended by participants getting nine nights of "recovery sleep" at their usual slumber time. Participants ranged in age from their 20s to their 60s, and lived in dimly lit rooms without windows to prevent their bodies from adjusting to day and night.

By study's end, the researchers saw that restricting sleep and disrupting the body's clock, or circadian rhythm, decreased metabolism among participants and caused a spike in their blood glucose after eating, a sign that the pancreas isn't producing enough insulin. The researchers say that could translate to an extra 10 pounds of weight gain each year and an increased risk for diabetes.

"The evidence is clear that getting enough sleep is important for health, and that sleep should be at night for best effect," study author Dr. Orfeu M. Buxton, a neuroscientist and sleep researcher at Brigham and Women's Hospital in Boston, said in a written statement.

Buxton said these effects are not limited to shift workers. As more Americans work later hours, they too are setting themselves up for health problems.

"The modern condition of excess work, excess pressure, no sleep -- all this disruption -- we can't adapt well to it metabolically," Buxton told WebMD. "This is a maladaptive response to modern life."

Dr Matthew Hobbs, head of research at the British organization Diabetes UK, cautioned that the study was rather small and the laboratory settings may not apply to the real world, telling BBC News, " For these reasons, it is not possible to conclude that the findings would translate to real conditions in the wider public."

Buxton agreed that the shifts his participants went through were brutal, tellingTIME, "Nobody would do a night 

He says that the takeaway message is that sleep is as essential as other commonly extolled healthy habits of diet and exercise, and if one of them becomes a lower priority, they'll all fall.

"So you have a ton of job demands and you're not getting a lot of sleep. That gives you less energy for exercise," Buxton told WebMD. "Similarly, your diet changes. Not only are you hungrier and having cravings for more food, and eating more," but being tired makes it tougher to resist junk food cravings.

Many shift workers are in the transportation industry. Click here for the results of a survey that named the sleepiest transportation workers.

© 2012 CBS Interactive Inc. All Rights Reserved.

The Role of the Primary Care Physician in Recognizing Obstructive Sleep Apnea

Naomi R. Kramer, MD; Thorley E. Cook, DO; Carol C. Carlisle, RN; R. William Corwin, MD; Richard P. Millman, MD

ABSTRACT

Background  Obstructive sleep apnea (OSA) is a common disorder among middle-aged adults. However, OSA is a recently described disorder for which most primary care physicians do not have formal training. The primary objectives of this article are to evaluate what percentage of patients referred by primary care physicians for sleep studies had OSA; to characterize the clinical features of these patients and compare them with our known OSA population; and to determine whether primary care physicians asked key questions contained in a work sheet to make the diagnosis of OSA.

Methods  

A retrospective chart review at a hospital-based sleep center that is accredited to evaluate all sleep disorders, not just OSA. The health maintenance organization is a staff model one.

Patients  Sixty-nine patients who were referred for a sleep study by a health maintenance organization internist or family practitioner between June 1, 1994, and May 30, 1995. Results  Ninety-six percent of the 68 patients referred for polysomnography had OSA. Most were very symptomatic and obese. These 68 patients represent 0.13% of the primary care patient panel. In addition, most of the patients were referred by a few physicians; 6 (11%) of the 55 physicians ordered 33% of the 68 studies.

Conclusions  

Primary care physicians did recognize obese patients with prominent symptoms of sleep apnea. However, only a small percentage of their patient panel was referred, suggesting that this condition is still underdiagnosed. This seems particularly true as most of the sleep studies were ordered by a small group of physicians. Future work incorporating educational interventions is necessary to improve detection and treatment of OSA.

OBSTRUCTIVE sleep apnea (OSA) is a common disorder among middle-aged adults.1- 2 It occurs in 2% to 4% of this population and is more common in the elderly. However, OSA is a recently described disorder for which most primary care physicians do not have formal training. As managed care has a growing influence on the practice of medicine, primary care physicians may play a bigger role in screening for OSA. Prior to March 1994, the largest regional staff model health maintenance organization (HMO) restricted referrals for a sleep study to subspecialists in pulmonology, otorhinolaryngology, or neurology. On March 28, 1994, the HMO changed this policy. Primary care physicians, including internal medicine and family practice physicians were sent a memo instructing them to directly order sleep studies. They were provided with a work sheet to aid them in asking the appropriate questions to identify OSA. These work sheets were also placed in the office area where the physicians worked.

We completed a retrospective chart review of the patients referred by primary care physicians for all-night sleep studies in the subsequent year. We attempted to answer 4 questions: (1) What percentage of patients referred by primary care physicians had OSA? (2) What were the clinical features of these patients? (3) How did this population of patients compare with our known OSA population? (4) Did the primary care physicians ask key questions from the work sheet in making the diagnosis of OSA?

PATIENTS AND METHODS

This retrospective chart review was approved by the Institutional Review Board of the HMO, Harvard Pilgrim Community Health Care, Providence, RI. The data base at the Sleep Disorders Center was reviewed to determine the number of patients referred by primary care physicians for sleep studies. Any patient referred by an internist or family practitioner between June 1, 1994, and May 30, 1995, was included. The sleep study data and the information included in the referral letter, copied progress notes, or the work sheet the referring physician sent with the request for a sleep study were reviewed. Any missing data were then obtained from the primary care physician's office chart. Cards were sent to patients whose anthropometric data were still missing after review of the above. The patients were subsequently assigned a number so that their data could be analyzed anonymously.

The sleep study consisted of an all-night polysomnogram (PSG) that included 2 electro-oculographic leads, 2 electroencephalographic leads, a submental electromyogram, an airflow thermistor, a snoring microphone, chest and abdominal piezoelectrode bands, 1-channel electrocardiogram representing V1, and bilateral anterior tibialis leg electromyographic leads. The PSGs were completed either as a baseline (monitored for the entire night) or as a split study. For a split study, a minimum of 2 hours of sleep was recorded. If OSA was documented during this time, nasal continuous positive airway pressure was titrated during the remainder of the study. Thirty (44%) of 68 studies were performed as split studies. Obstructive sleep apnea was defined as an apnea/hypopnea index of 5 events or more per hour of sleep. However, for a split study, an apnea/hypopnea index of 10 was required to initiate therapy with nasal continuous positive airway pressure. An apnea was defined as a cessation of airflow for 10 seconds or longer. A hypopnea was defined by the presence of 2 of the following 3 criteria: greater than 2% oxygen desaturation, 50% decrease in airflow, or an arousal evident on the electroencephalogram.

Historic controls consisted of 206 previously described patients with OSA evaluated at our Sleep Disorders Center.3 This group was used only for comparison with our current group with regard to the apnea/hypopnea index; nadir oxygen saturation; age; and body mass index (BMI or Quetelet index [calculated as weight in kilograms divided by the square of the height in meters: weight (kg)/{height (m)}2]). Data were analyzed using StatView SE Plus Graphic (Abacus Concepts, Berkeley, Calif) for the Macintosh computer.

RESULTS

A questionnaire designed to identify more subjects with OSA would include mild snoring as abnormal. This would identify most subjects with apnea but would also include patients with snoring without OSA. On the other hand, if the cutoff for snoring intensity is extremely severe, approximately 60% of patients with OSA would be missed. However, very few patients without OSA would be included. Therefore, the wording of a questionnaire used to survey a patient population is very important to consider. Our work sheet included questions regarding common presenting symptoms and associated disorders. The common clinical features of OSA are as follows: chronic loud snoring, observed apneas or gasps, recurrent nocturnal awakenings, excessive daytime sleepiness, decreased memory and concentration, depression and irritability, and sexual dysfunction. The medical disorders commonly associated with OSA are listed as follows:

• Hypertension
• Upper body obesity
• Male sex
• Increasing age
• Abnormal pharyngeal anatomy
• Enlarged tonsils and adenoids
• Redundant pharyngeal tissue
• Retrognathia
• Nasal obstruction
• Excessive use of alcohol
• Untreated hypothyroidism

​

CONCLUSIONS

Primary care physicians did recognize obese patients with prominent symptoms of OSA. However, only a small percentage of their patient panel was referred, which suggests the condition is still underdiagnosed. This seems particularly true as a small group of physicians ordered most of the sleep studies. This underestimation of OSA despite access to the work sheet is most likely due to lack of formal training in this area. Education of primary care physicians and incorporation of a sleep history into the review of systems may increase detection of sleep disorders, referral for diagnosis and treatment, and thus prevention of associated complications. The Walla Walla project also suggests that easy access to consultation with a sleep specialist may also facilitate screening for OSA by primary care physicians.

Therefore, future work incorporating educational interventions and enhancing accessibility to sleep centers is necessary to improve detection and treatment of OSA.

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