Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
Identify the recommendations made in the American College of Physicians 2014 Diagnosis of Obstructive Sleep Apnea in Adults clinical practice guideline.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwapril4. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at email@example.com.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Christopher Cole- Senior Editor
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
Between 10% and 17% of Americans have moderate to severe sleep apnea, according to recent estimates. The prevalence of the condition has been increasing in recent years, due in part to the escalating obesity rate in the United States. However, an estimated 80% of those with sleep apnea remain undiagnosed.
Addressing the Issue
“Polysomnographs are considered the reference standard for an obstructive sleep apnea (OSA) diagnosis, but it requires specialized facilities,” explains Dr. Qaseem, lead author of the recent guidelines on OSA from the American College of Physicians (ACP). “Polysomnographs are also resource intensive and expensive and require patients to stay overnight for observation. As an alternative to polysomnographs, portable monitors are increasingly being used because they are much cheaper and more convenient for patients.” Portable monitors are broken down into types II through IV, with polysomnographs being designated as type I (Table 1).
The ACP recommends that a sleep study be performed for patients with unexplained daytime sleepiness. “This is a weak recommendation based on low-quality evidence,” Dr. Qaseem says, “but we believe that there is a need to have a targeted approach to diagnosing OSA. This starts with evaluation of the risk factors and common symptoms. Patients with daytime sleepiness have been shown to be the most responsive to OSA treatment, whereas there is a lack of evidence supporting treatment benefits to improve other outcomes, such as hypertension, diabetes, or coronary disease, especially in patients without daytime sleepiness.”
To perform a sleep study in these patients, the ACP recommends polysomnographs for diagnostic testing. “If polysomnographs are available, they should be used,” adds Dr. Qaseem. “Portable sleep monitors are recommended in patients without serious comorbidities as an alternative if polysomnographs are not available. Polysomnographs, however, are considered the gold standard.” One of the issues with the portable monitors, according to Dr. Qaseem, is that they tend to have high positive likelihood ratios in general but low negative likelihood ratios for various Apnea Hypopnea Index cutoff points. Monitors with more channels perform better than those with fewer channels. Providers should ensure that patients who are unable or unwilling to undergo polysomnographs understand that portable monitors have reliability issues and that results obtained from using them should be considered carefully.
Among the portable monitors, determining the best option for diagnosing OSA is difficult because of a lack of comparative effectiveness studies. Still, portable monitors are preferable over the multiple questionnaires that are available for diagnosing OSA (Table 2). “Evidence was insufficient to determine the diagnostic accuracy of most questionnaires, whereas the evidence behind portable monitors is of moderate quality,” Dr. Qaseem says. “Questionnaires may be helpful in predicting risk for OSA, but the sensitivity and specificity had a wide range.”
A Need for More Research
Dr. Qaseem believes additional research is needed. “Preoperative screening for OSA is an important topic that has gained the interest of many healthcare providers and researchers,” he says. “However, whether it improves patient outcomes has yet to be determined. We also need to conduct more research that explores the utility of an OSA diagnosis in patients with comorbid conditions like congestive heart failure or neurologic disorders.” Dr. Qaseem adds that interest is growing in the use of phased testing—which involves a series of tests that may be done depending on the results of initial tests—in comparison with full, overnight polysomnograph testing; data are currently lacking in this area.
Evidence shows that patients with OSA have higher rates of healthcare use, more frequent and longer hospital stays, and greater healthcare costs before their diagnosis than after it. “Providers who have patients with tiredness, fatigue, and unrefreshing sleep should look for unexplained sleepiness and perform a sleep study in those who have yet to determine if they have OSA,” concludes Dr. Qaseem. “Providers can refer to the ACP guidelines to help diagnose OSA in their patients.”
Readings & Resources (click to view)
Qaseem A, Dallas P, Owens D, et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161:210-220. Available at http://annals.org/data/Journals/AIM/930624/0000605-201408050-00009.pdf.
Planès C, Leroy M, Bouach Khalil N, et al. Home diagnosis of obstructive sleep apnoea in coronary patients: validity of a simplified device automated analysis. Sleep Breath. 2010; 14:25-32.
Santos-Silva R, Sartori D, Truksinas V, et al. Validation of a portable monitoring system for the diagnosis of obstructive sleep apnea syndrome. Sleep. 2009; 32:629-636.
To K, Chan W, Chan T, et al. Validation study of a portable monitoring device for identifying OSA in a symptomatic patient population. Respirology. 2009; 14:270-275.