pii: jc- 00275 -16http://dx.doi.org/10.5664/jcsm.6038

CO MMEN TA RY

Primary Care is Waking Up to the Importance of Sleep Disorders

Commentary on Cross et al. Management of snoring and sleep apnea in Australian primary care: the BEACH study (2000–2014). J Clin Sleep Med 2016;12(8):1167–1173. Richard D. Simon Jr., MD, FAASM Kathryn Severyns Dement Sleep Disorders Center, Providence St. Mary Medical Center, Walla Walla, WA; University of Washington, Seattle, WA

The identification and treatment of most illness starts in Primary Care Offices, Walk-In Centers, or Emergency rooms. Over 20 years ago, sleep specialists warned of the seriousness of sleep disorders, which for the most part were undiagnosed and thus untreated. This was attributed to the facts that sleep disordered patients did not report symptoms to physicians and physicians, being largely unaware of the seriousness of sleep disorders, did not ask.1 In 1992, The Walla Walla Project was started to bring the diagnosis and treatment of sleep disorders into primary care medicine. With appropriate training, the diagnosis and treatment of obstructive sleep apnea (OSA) increased 100-fold for patients at the Walla Walla Clinic, and continuous positive airway pressure (CPAP) compliance rates were similar to those in established sleep centers.2 The project was originally designed to enable interested primary care physicians to diagnose and treat the majority of sleep disorders but for a variety of reasons (lack of interest in or difficulty in managing CPAP, difficulty and time commitment in learning the basics of sleep medicine, lack of significant sleep medicine training in medical school or residencies3), a fully accredited sleep center was started instead. Since then, care has been provided for over 11,000 sleep-disordered patients. Attempts to duplicate the Walla Walla Project over the next several years in other communities (Moscow, Idaho; The Dalles, Oregon; Tacoma, WA) all resulted in the establishment of fully certified sleep centers. These experiences suggested that primary care providers (PCP) did not wish to learn to diagnose and manage sleep disorders but preferred the expertise of a sleep center to refer patients for diagnosis and treatment (personal experience). During these projects, we were able to survey patients in two family medicine practices in Moscow, Idaho, where we found that 32% had insomnia, 23.6% had obstructive sleep apnea, and that 29.3% had restless legs syndrome4 confirming that a sea of sleep disorders was flowing through primary care. The study by Cross et al. in this month’s journal is a very satisfying report that the management rate of patients with adult obstructive sleep apnea has risen from 94 to 296 per 100,000 PCP encounters in Australia from 2000–2014.5 They also observed that the management rate for snoring remained steady at around 15–25 per 100,000 encounters. Unfortunately, the study was not able to define how PCPs differentiated sleep apnea from 1081

snoring. Referral rates were high for both OSA (59 per 100 problems managed) and snoring (69 per 100 problems managed) with medical referrals (to a sleep clinic or respiratory physician) higher for patients managed with OSA than for snoring, in which surgical referrals were higher. It would have been more satisfying if the type of “management” had been described in more detail. But the study clearly shows that more patients with sleep related breathing disorders are being identified and that the majority referred for further specialty care. This is consistent with the hypothesis that PCPs prefer to use the expertise of a sleep center rather than to diagnose and treat patients independently, which is very similar to what we have observed in Walla Walla. It is also of interest that the male-to-female ratio was noted to be 2:1, suggesting that primary care providers may not share the same gender biases probably present in previous studies which suggested a much higher male to female ratio. The authors also commented that the growth of sleep apnea management (tripled from 2000–2014; 94–296 per 100,000 encounters) has increased more rapidly than the growth of diabetes management (1.5 increase from 2000–2014, 2800–4200 per 100,000 encounters). The reasons for this increase in sleep apnea management are not clear, but I suspect they are secondary to the increased attention given to sleep disorders in print media, television, social media, self-help media, as well as increased exposure to sleep medicine in training programs (perhaps more so than was the case 14 years ago). One might expect management rates of sleep apnea perhaps somewhat higher because the prevalence of diabetes in the USA is estimated at 12% to 14%,6 which is similar to that of obstructive sleep apnea,7 suggesting that there is still more to be done. This study adds significantly to the clinical sleep medicine literature by demonstrating that the management rates for adult sleep apnea in primary care is rising rapidly. Because of the very large number of patients with sleep apnea (not to mention other sleep disorders) and because of the relatively low number of sleep specialists, alternative methods of identifying and treating patients are clearly needed. The best remedy, in my opinion, will focus on education and in particular the introduction of comprehensive sleep physiology and sleep medicine curricula in all health professional schools and training programs. I’m hopeful that this will occur in the not so distant future. Journal of Clinical Sleep Medicine, Vol. 12, No. 8, 2016

RD Simon Jr. Commentary 6. Menke A, Casagrande S, Geiss L, Cowie CC. Prevalence of and trends in diabetes among adults in the United States 1988–2012. JAMA 2015;314:2021–9. 7. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Am J Epidemiol 2013;177:1006–14.

C I TAT I O N Simon Jr RD. Primary care is waking up to the importance of sleep disorders. J Clin Sleep Med 2016;12(8):1081–1082.

SUBM I SSI O N & CO R R ESPO NDENCE I NFO R M ATI O N

R E FE R E N CES

Submitted for publication July, 2016 Accepted for publication July, 2016 Address correspondence to: Richard D. Simon Jr., MD, FAASM, Medical Director, Kathryn Severyns Dement Sleep Disorders Center, Providence St. Mary Medical Center, Walla Walla, WA and Clinical Associate Professor of Medicine, University of Washington, Seattle, WA; Email: [email protected]

1. Dement WC, Mitler MM. It’s time to wake up to the importance of sleep disorders. JAMA 1993;299:1549–50. 2. Ball EM, Simon RD Jr, Tall AA, Banks MB, Nino-Murcia G, Dement WC. Diagnosis and treatment of sleep apnea within the community. The Walla Walla Project. Arch Intern Med 1997:157:419–24. 3. Rosen RC, Rosekind M, Rosevear C, Cole WE, Dement WC. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep 1993;16:249–54. 4. Kushida CA, Nichols DA, Simon RD, et al. Symptom-based prevalence of sleep disorders in an adult primary care population. Sleep Breath 2000;4:11–6. 5. Cross NE, Harrison CM, Yee BJ, et al. Management of snoring and sleep apnea in Australian primary care: the BEACH study (2000–2014). J Clin Sleep Med 2016;12:1167–73.

Journal of Clinical Sleep Medicine, Vol. 12, No. 8, 2016

D I SCLO S U R E S TAT E M E N T Dr. Simon has indicated no financial conflicts of interest.

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Primary Care is Waking Up to the Importance of Sleep Disorders.

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