Impact of Educational Resources for Primary Care OSA Management on Referral Patterns

Background/ObjectiveBarriers in access to care have prompted development of innovative care delivery models for patients with obstructive sleep apnea (OSA). One such innovation is management of uncomplicated OSA by primary care providers (PCPs), which reserves specialist capacity for more complex patients. We developed a clinical guideline and subsequently, an online clinical pathway to support PCPs in OSA management. We aimed to evaluate the impact of these initiatives on PCP behaviour by assessing changes in the complexity of newly referred patients. MethodsWe compared data for new OSA referrals to the Foothills Medical Centre Sleep Centre in Calgary, Canada, received during three distinct referral periods: prior to the clinical guideline (November 2016 - March 2017; Period 1), after implementation of the clinical guideline (April 2017 - November 2018; Period 2), and after publication of the online primary care pathway (December 2018 - November 2019; Period 3). The primary outcome was OSA severity as defined by the oxygen desaturation index (ODI) on home sleep apnea testing performed at the time of referral. Secondary outcomes included severity of daytime sleepiness and proportion of patients with severe OSA or severe daytime sleepiness at the time of referral. Multivariable linear and logistic regression models were constructed to quantify the associations between study outcomes and Period after adjustment for baseline covariates. ResultsAmong the 2489 patients with sleep study data available, patients referred in Period 3 had more severe OSA (ODI, mean nocturnal oxygen saturation, proportion with severe OSA) compared to patients referred in earlier Periods. Severity of sleepiness did not increase across Periods. In multivariable analysis adjusting for demographics and comorbidities, ODI was significantly associated with Period (regression coefficient 1.70 (0.39, 3), p = 0.011) but severe OSA was not (odds ratio 1.17 (0.99, 1.39), p = 0.069). ConclusionsOSA severity increased following implementation of educational resources to support primary care OSA management. These findings suggest that with appropriate supports, PCPs may be more comfortable managing less severe OSA patients independently and only refer more severe cases for specialist consultation.