Anne Marie Morse, DO, pediatric neurologist and sleep medicine specialist, Geisinger, discusses factors contributing to insufficient screening of obstructive sleep apnea (OSA) in patients with stroke and how a team-based approach fared in expediting diagnosis.
Using a multidisciplinary approach to screen and treat patients with stroke who have obstructive sleep apnea (OSA) may contribute to significant financial savings, as well as risk mitigation for these patient populations, said Anne Marie Morse, DO, pediatric neurologist and sleep medicine specialist, Geisinger.
Can you discuss present barriers to screening for OSA? Is education on the condition mostly to blame or are there other factors that contribute to insufficient screening?
Insufficient screening in obstructive sleep apnea is definitely multifactorial. When you ask about whether or not education is one of the leading causes, yeah, it's a big culprit. We recognized that part of the reason that we did this program was because we found that less than 10% of patients who had a stroke were referred by the neurology or stroke team to get a polysomnography or sleep evaluation. So, that's barrier number one.
Of those 10% who were actually referred, it was almost a year between the time of referral to the time that they actually were screened by a sleep specialist, and then many times it was another 3 to 4 months before they had the polysomnography and CPAP [continuous positive airway pressure]. So, leading to many patients not getting the appropriate screening and intervention in a timely fashion.
Can you discuss the inpatient diagnostic and treatment strategy presented at SLEEP 2021 on OSA assessment in patients with stroke?
The reason we implemented an inpatient strategy was several fold. As I mentioned earlier, when we look at a lack of education, it was a method of trying to get improved buy-in from the peers who have a major role in the treatment of patients who have strokes. So, our neurology colleagues, nursing, or respiratory therapists, etc.
Secondly, when we look at the fact that OSA is considered an independent risk factor for stroke, it's important to treat that the same as we would treat hypertension. We're not going to wait a year, or even several months or weeks, before we decide that we're going to implement a strategy to diagnose it and treat it.
We thought that we would be able to help get ahead of the curve by getting the patient to the diagnosis sooner. So, really trying to put it on the same level as what we would put an echocardiogram or an MRI to better understand the etiology and the therapeutic interventions that would best alleviate further risk for recurrent stroke.
What lessons were learned from the study findings? How does the strategy compare with current methods of screening for OSA?
Based on the study, some of the things that we identified was that the prevalence of OSA was quite high. So, demonstrating the value just there. The other pieces that we've identified is that it was a strategy that did require multiple personnel to have buy-in.
So, we needed the stroke team or the vascular team to put in the orders for the polysomnography. We needed our respiratory therapist in nursing in order to be able to apply the home sleep testing on the patient and to monitor them overnight, making sure that we get a good quality of study. And then obviously, we need the sleep team in order to interpret it. So, it was a team approach that I think would be very reasonable to maintain going forward past a research evaluation, and one that I think would allow for significant financial savings, as well as risk mitigation.
What implications may these findings have for clinicians, and what are some next steps?
I think what these findings demonstrate are similar to some other studies that have looked at similar strategies, which is getting to the diagnosis sooner may benefit our patients. Some of the next steps are going to be really understanding how we scale this so that we can spread it across all of our health care system. So, we're a large health care system that covers 47 counties with multiple hospital systems, and so making sure that we are able to replicate this successfully at other institutions.
The other piece is going to be the part that really has been the crux of OSA management irrespective, which is ensuring that patients not only get the CPAP, but keep the CPAP, and that we ensure that there's continued adherence to use.
Naik S, Zand R, Andary NE, Morse AM. Sleep and stroke: improved OSA time to diagnosis for stroke patients using an inpatient diagnostic and treatment strategy. Sleep. 2021;44(suppl 2):A163. doi:10.1093/sleep/zsab072.409