Implementation of an obstructive sleep apnea screening tool with hypertensive patients in the primary care clinic

Abstract

Background and Purpose: Patients with severe obstructive sleep apnea (OSA) have an almost 4-fold higher odds of resistant hypertension than those with less severe OSA. Obstructive sleep apnea screening practices in primary care are deficient. Additional study is needed regarding the value of OSA screening in hypertensive adults who present to the primary care clinic. Methods: This was a convenience sample of adults with hypertension from a rural primary care clinic in Iowa. Staff identified patients who met the inclusion criteria for the project. The STOP-Bang Questionnaire was used to screen the patients for OSA. Providers subsequently used discretion as to ordering polysomnography (PSG). Conclusions: Thirty-two patients were screened over a 3-month time period. All of the men included in the study scored either high or intermediate risk for OSA. Forty percent of the study participants scored high risk for OSA, with 33% of those participants referred for PSG. At project conclusion, three participants had undergone PSG testing, and all were diagnosed with sleep apnea. Implications for Practice: To ensure timely diagnosis and treatment of OSA, primary care providers should consider screening all hypertensive adults for OSA. With compulsory screening and subsequent identification and treatment of patients with OSA, nurse practitioner providers can pave the way in reducing mortality and morbidity associated with OSA, as well as resistant hypertension.

Improving the screening process for obstructive sleep apnea in the primary care setting

“…The literature review suggests a high prevalence of underdiagnosed and undertreated OSA in 75–80% of the population with limitations in the current evidence supporting annual screenings (Aurora et al, 2015). This quality-improvement project aimed to support routine OSA screenings for asymptomatic high-risk patients, providing early evaluations, referrals, and treatment measures in the primary stages of OSA (Bakhai et al, 2017; Ononye et al, 2019; Showalter & O'Keefe, 2019).…”

“…Similarly, findings of Showalter and O’Keefe (2019) showed that 40% of hypertensive and obese patients were at high-risk for OSA, with 7.5% diagnosed with OSA (Showalter & O’Keefe, 2019). Findings of all three studies supported the implementation of screening measures such as the STOP-Bang Questionnaire to identify low, intermediate, or high levels of risk for OSA in asymptomatic patients with risk factors of hypertension and obesity (Bakhai et al, 2017; Ononye et al, 2019; Showalter & O’Keefe, 2019). They also recommended routine screening protocols to increase screenings and facilitate referrals for diagnostic testing in primary care (Bakhai et al, 2017; Ononye et al, 2019; Showalter & O'Keefe, 2019).…”

“…The lack in clinical guidelines for screening protocols contributes to the percentage of undiagnosed patients and consequences of untreated OSA. However, supportive research has suggested that annual screening protocols for all high-risk and asymptomatic patient populations can increase the detection of the disease, confirmatory testing, treatment plans, and prevent cardiovascular mortality (Bakhai et al, 2017; Jonas et al, 2017; Miller & Berger, 2016; Ononye et al, 2019; Showalter & O'Keefe, 2019).…”

“…Bakhai et al (2017), Ononye et al (2019), and Showalter and O'Keefe (2019) conducted quality-improvement projects to perform OSA screenings for high-risk patient populations in the primary care setting to assess improvements in screening and referral rates. Specifically, Bakhai et al (2017) found a 3.3% improvement in diagnosis rate and estimated that only 1% of hypertensive patients were screened, leading to underdiagnosis and necessitating standards for OSA screenings (Bakhai et al, 2017).…”

Integration of implementation science in cardiovascular behavioral medicine.

“…OSA is highly and increasingly prevalent in adults, largely tracking with the obesity epidemic in developed countries (Peppard & Hagen, 2018). OSA is associated with a two- to threefold higher risk of cardiovascular and metabolic disease, with multiple studies linking OSA to the development of stroke, cardiac arrhythmias, and abnormalities in glucose metabolism (Tobaldini et al, 2019), and patients with severe OSA had an almost fourfold higher risk of resistant hypertension (Showalter & O’Keefe, 2019). As OSA is linked to a wide range of adverse health outcomes and mortality, it is critical to develop acceptable, feasible, and sustainable methods for identifying and treating patients with OSA.…”