Primary care management of obstructive sleep apnea (OSA) is as effective and more cost-effective than in-laboratory diagnosis, according to a study published online April 17 in the American Journal of Respiratory and Critical Care Medicine.
General practitioners play a passive role in obstructive sleep apnea (OSA) management. Simplification of the diagnosis and use of a semi-automatic algorithm for treatment can facilitate the integration of general practitioners, which has cost advantages.
The objective of the study was to determine differences in effectiveness between primary health care area (PHA) and in-hospital specialized management protocols during six months of follow-up.
A multicenter, non-inferiority, randomized, controlled trial with two open parallel arms and a cost-effectiveness analysis was performed in six tertiary hospitals in Spain.
Sequentially screened patients with suspected OSA were randomized to PHA or in-hospital management. The PHA arm received a portable monitor (PM) with automatic scoring and semi-automatic therapeutic decision-making.
The in-hospital arm underwent polysomnography (PSG) and specialized therapeutic decision-making. Both arms received continuous positive airway pressure (CPAP) treatment or only sleep hygiene and dietary treatment.
The primary outcome measure was the Epworth sleepiness scale (ESS). Secondary outcomes were the health-related quality of life, blood pressure, incidence of cardiovascular events, hospital resource utilization, CPAP adherence and within-trial costs.
M. Ángeles Sánchez-Quiroga, M.D., from Virgen del Puerto Hospital in Madrid, and colleagues randomized 303 sequentially screened patients with an intermediate-to-high probability of OSA to primary care management or in-laboratory management. All patients received continuous positive airway pressure treatment or sleep hygiene and dietary treatment alone.
The researchers found that the primary care protocol was noninferior to the in-laboratory protocol based on the use of the Epworth sleepiness scale. Furthermore, primary health care management was more cost-effective, with a lower cost of €537.8 per patient.
"Primary health care area management may be an alternative to in-laboratory management for patients with an intermediate to high OSA probability," the authors noted. "Given the clear economic advantage of outpatient management, this finding could change established clinical practice."
In total, 307 patients were randomized, and 303 were included in the intention-to-treat analysis. Based on the ESS, the PHA protocol was non-inferior to the in-hospital protocol. Secondary outcome variables were similar between protocols. The cost-effectiveness relationship favored the PHA arm, with a lower cost of 537.8€ per patient.
In-hospital management is not necessary for approximately half of patients with a low to high OSA suspicion. Given the clear economic advantage of outpatient management, this finding could change established clinical practice.