Provider Perspectives on Sleep Apnea from Appalachia: A Mixed Methods Study

Abstract

West Virginia (WV) has the highest rates of obesity and cardiopulmonary disease in the United States (U.S.). Recent work has identified a significant care gap in WV for obstructive sleep apnea (OSA). This OSA care gap likely has significant health implications for the region given the high rates of obesity and cardiopulmonary disease. The purpose of this mix methods study was to identify barriers that contribute to the rural OSA care disparity previously identified in WV. Methods: This study used mixed methods to evaluate the barriers and facilitators to management of OSA at Federally Qualified Health Centers serving communities in southern WV. Focus groups were conducted at federally qualified health centers with providers serving Appalachian communities. Participants also completed the validated Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire to gain insight into provider knowledge and beliefs regarding OSA. EMR analysis using diagnostic codes was completed at the sites to assess OSA prevalence rates. The same individual served as the interviewer in all focus group sessions to minimize interviewer variability/bias. Our team checked to ensure that the professional transcriptions were correct and matched the audio via spot checks. Results: Themes identified from the focus groups fell into three broad categories: (1) barriers to OSA care delivery, (2) facilitators to OSA care delivery, and (3) community-based care needs to optimize management of OSA in the targeted rural areas. Questionnaire data demonstrated rural providers feel OSA is an important condition to identify but lack confidence to identify and treat OSA. Evaluation of the electronic medical record demonstrates an even larger OSA care gap in these rural communities than previously described. Conclusion: This study found a lack of provider confidence in the ability to diagnose and treat OSA effectively and identified specific themes that limit OSA care in the communities studied. Training directed toward the identified knowledge gaps and on new technologies would likely give rural primary care providers the confidence to take a more active role in OSA diagnosis and management. An integrated model of care that incorporates primary care providers, specialists and effective use of modern technologies will be essential to address the identified OSA care disparities in rural WV and similar communities across the U.S. Community engaged research such as the current study will be essential to the creation of feasible, practical, relevant and culturally competent care pathways for providers serving rural communities with OSA and other respiratory disease to achieve health equity.

Comparison of ocular surface assessment outcomes between healthy controls and patients with obstructive sleep apnea–hypopnea syndrome: a meta-analysis of the literature

“…The most prominent feature of this condition is chronic intermittent hypoxia, which stimulates chronic inflammatory processes, attenuates antioxidant mechanisms, and increases the production of reactive oxygen products during the reoxygenation phase (Vaccaro et al, 1992;Vakil et al, 2018;Ma et al, 2019). Patients with OSAHS have an increased risk of cardiovascular diseases (CVDs), like hypertension, heart failure, and coronary heart disease (Kohler, 2015;Stansbury and Strollo, 2015). Oxidative stress, sympathetic activity, and systemic inflammatory reactions are linked to chronic intermittent hypoxia that might impact the ocular vasculature (Kohler and Stradling, 2010).…”

Exploring Nurse Practitioner Students’ Perceptions of a Sleep e-Learning Program

“…NP students in our study reported having minimal exposure to sleep education prior to engaging in our modules and previously felt unequipped to address or discuss sleep issues with their patients in a primary care setting. Prior studies also highlighted lack of sleep education preparation (Meaklim et al, 2020) and lack of confidence to manage and discuss sleep with patients (Chang et al, 2020; Mindell & Owens, 2003; Stansbury et al, 2022). Exposure to sleep education increases providers’ intentions to discuss sleep with patients (Valerio & Heaton, 2014).…”

“…Studies indicate that primary care practitioners, inclusive of NPs, identify sleep disorders as important but feel less confident in the management and treatment of sleep disorders, such as obstructive sleep apnea (OSA; Chang et al, 2020; Mindell & Owens, 2003; Stansbury et al, 2022). Focus groups with 14 rural practitioners (five NPs) in West Virginia identified that providers feel OSA is an important disease to consider and had a reasonable knowledge of the condition; they desired more education regarding screening, diagnosis, and management to supplement lack of confidence in identifying and managing OSA and treatments such as positive airway pressure (Stansbury et al, 2022). This sentiment has been similarly echoed in studies of primary care physicians.…”

The Current Landscape of Ohio Otolaryngologists and Associated Conditions: A State- Level Analysis

“…12,13 Oral cancer, sleep apnea, and hearing loss are more prevalent in Appalachia-conditions all treated by otolaryngologists. [14][15][16] Healthcare workers can help mitigate the high prevalence of health conditions, yet Appalachian Ohio has 12% fewer primary care physicians, 28% fewer physician specialists, and 35% fewer mental health providers per 100,000 people. 17 To our knowledge, no previous research studies have been conducted on the distribution of otolaryngologists and corresponding conditions in Ohio.…”