Quality measure for screening for adult obstructive sleep apnea by primary care providers: 2024 update after measure maintenance

Abstract

Obstructive sleep apnea (OSA) is a prevalent respiratory sleep disorder that, when left undiagnosed or untreated, can lead to adverse outcomes. There continue to be gaps and variations in screening adults who are high risk for OSA in the primary care setting, leading to many adults in the United States going undiagnosed. As a part of the ongoing American Academy of Sleep Medicine quality measure maintenance initiative, the American Academy of Sleep Medicine Quality Measures Task Force reviewed the original screening for adult OSA by primary care physicians quality measure. The measure was updated to further address the adult populations who are at high risk for OSA to ensure that the measure is consistent with the most current medical literature, increasing the likelihood that patients at high risk for OSA are properly screened for the sleep disorder.

Citation:

Lloyd RM, Crawford T, Donald R, et al. Quality measure for screening for adult obstructive sleep apnea by primary care providers: 2024 update after measure maintenance. J Clin Sleep Med. 2024;20(11):1819–1822.

INTRODUCTION

In 2016, the quality measure for screening for adult obstructive sleep apnea (OSA) by primary care physicians¹ was developed as part of the National Healthy Sleep Awareness Project.² A key objective of the National Healthy Sleep Awareness Project was to create a quality measure that would increase the number of patients experiencing OSA symptoms who seek medical assessment. Screening for adult OSA by primary care providers (PCPs) plays a crucial role in identifying and managing this prevalent sleep disorder. In a population-based study using an apnea-hypopnea index cutoff of ≥ 5 events/h (hypopneas associated with 4% oxygen desaturations) along with clinical symptoms to define OSA, the estimated prevalence of OSA was 14% in males and 5% in females.³ As OSA can have significant health implications if left undiagnosed and untreated, early detection allows for timely interventions and improved patient outcomes. This measure highlights the importance of PCPs taking an active role in screening for OSA to ensure the well-being and overall health of their adult patients. Typically, PCPs do not screen at-risk patients for OSA despite existing clinical practice guidelines recommending early and accurate diagnosis of OSA for this population.⁴ Some of the challenges PCPs may face with incorporating screening for OSA during an office visit include insufficient training, limited access to resources, and lack of time needed to screen, assess, and make a diagnosis. Nevertheless, the initial evaluation for OSA should begin in the PCP’s office where the PCP may see patients with the following diagnoses or symptoms that put them at high risk for OSA: obesity, heart failure, atrial fibrillation or other arrhythmias, coronary artery disease, hypertension, stroke, pulmonary hypertension, prediabetes or diabetes, craniofacial anomalies, sleep complaints, sleepiness, pregnancy, patients undergoing evaluation for bariatric or other applicable surgical procedures, and/or those with other high-risk conditions. In this paradigm of care, the PCP may screen the patients with a validated OSA instrument and recommend an evidence-based action plan. In most cases, this plan would include referring patients to a sleep specialist or for home or sleep lab testing. However, this measure includes flexibility for other action plans when clinically appropriate, including lifestyle modifications or surgical management or referral to an otolaryngologist, dentist, or other specialist experienced in the evaluation and management of OSA. PCPs may also either refer patients for diagnostic testing or may simply refer patients to a sleep specialist, otolaryngologist, dentist, or other specialist experienced in the evaluation and management of OSA. Although an evaluation by a sleep specialist is typically more detailed, including a sleepiness assessment and a comprehensive physical exam, an initial screening by a PCP can assist in lower health care-related costs and quicker diagnosis and treatment.⁵ This care pathway, the specific patient populations that would benefit from screening for OSA, and updated literature were all considered during discussions about updates to this quality measure.

METHODS

Literature review

An updated, comprehensive literature search was conducted to identify current publications that addressed screening for adult OSA in the primary care setting. The literature review included clinical practice guidelines, systematic literature reviews, and individual studies (ie, randomized controlled trials). Searches were limited to articles published between 2017 and 2022, specific to humans, English language, and age criteria within the PubMed database. Publication types such as news, letters, editorials, and case reports were excluded. A total of 192 abstracts and 51 full articles were retrieved for review.

Performance data

In addition to a review of the medical literature, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force (Task Force) searched for performance data, which may demonstrate performance gaps and/or variations in care. In 2021, the AASM developed an implementation vehicle for quality measures (Sleep Clinical Data Registry), which at the time of publication is only available for AASM-accredited facilities and affiliated clinicians. This measure was also designated a Qualified Clinical Data Registry measure for the Merit-based Incentive Payment System program from 2021–2023. To our knowledge, this measure has not yet been implemented in any other clinical data registry and the Task Force found no performance data.

Gaps in care

As a part of the measure maintenance process and literature review, the Task Force also searched for gaps in care for the screening for adult OSA by PCPs measure. These gaps represent potential inconsistencies between the care provided to patients and the recommended best practices.

A notable prevalence of OSA is observed among patients with chronic conditions such as type 2 diabetes, severe obesity, resistant hypertension, heart failure,⁶ ischemic stroke,⁷ and atrial fibrillation.⁸ This observation has been substantiated by studies, which revealed a high incidence of undiagnosed moderate-to-severe sleep apnea in high-risk cardiovascular cohorts, amounting from 35–57% for patients with chronic stroke.^6,7 The availability of screening tools becomes significantly crucial to ascertain whether these high-risk individuals necessitate further assessment for an OSA diagnosis. While the instances of patients with chronic conditions remaining undiagnosed with OSA at a notable frequency are evident, there is a lack of research that explicitly addresses the disparities within primary care settings.

Existing quality measures

As part of the measure maintenance process, the Task Force also reviewed existing quality measures and determined that there were no identified competing or related screening for adult OSA by PCPs measures that required measure harmonization. Center for Medicare and Medicaid Services defines measure harmonization as standardizing quality measure specifications for related measures when they have⁹:

• The same measure focus (ie, numerator criteria)

• The same target population (ie, denominator criteria)

• Elements that apply to many measures (eg, age designation for children)

Unintended consequences

Although screening and treating OSA in primary care settings is clearly an important goal, unintended consequences were identified as a result of releasing the screening for adult OSA by PCPs quality measure for public comment in the summer of 2023. The following concerns were raised regarding the potential increase in administrative and financial burdens for clinicians when reporting on this measure:

1. The measure includes a chart review, which could be time-consuming and labor-intensive.

2. Primary care clinics would be required to additionally capture apnea-related symptoms, validated screenings, and provision of an evidence-based care plan recommendation.

3. Implementation would require additional information technology build specific for this measure in each PCP’s electronic medical record system, potentially consuming valuable limited personnel and financial resources.

4. Some insurance plans do not currently cover recommended treatments, posing additional challenges for patients and their PCPs.

The Task Force extensively discussed the unintended consequences of this measure. While this measure may increase the administrative and financial burden on providers, enhancing screening rates for the high-risk populations and recommending treatment may reduce the time to OSA diagnosis and treatment, before serious adverse OSA-related consequences occur. It is important to highlight that the screening for adult OSA by PCPs measure is a quality measure that can be optionally reported as a Qualified Clinical Data Registry measure for Center for Medicare and Medicaid Services Merit-based Incentive Payment System submission by PCPs.

Review and approval

Revisions to this measure were initially reviewed and approved for public comment by the AASM Executive Committee. The measure was then posted on the AASM website for a 30-day public comment period and was simultaneously shared with several medical specialty societies for an additional peer review, to ensure that all relevant stakeholders had an opportunity to provide feedback. The Task Force reviewed all stakeholder feedback and made additional revisions, where deemed appropriate. The final revised measure was approved for publication and implementation by the AASM Executive Committee.

REVISED QUALITY MEASURE

The following are descriptions of the quality measure and any exceptions, as well as the supporting rationale for revising the measure to better align with current evidence and clinical practice. The full technical description of the measure can be found in the supplemental material.

2016 Measure description

All patients aged 18 years and older at high risk for OSA with documentation of screening for OSA using an appropriate standardized tool at least every 12 months AND in whom a recommended follow-up plan is documented based upon the result of the screening. Patients at high risk for OSA are defined as follows: obesity (body mass index ≥ 30 kg/m²), congestive heart failure, atrial fibrillation, treatment resistant hypertension (blood pressure above goal despite adherence to antihypertensive regimen of 3 medications, or hypertension controlled by at least 4 medications), impaired glucose tolerance or type 2 diabetes, nocturnal dysrhythmias, stroke, pulmonary hypertension, preoperative for bariatric surgery, coronary artery disease.

2024 Revised measure description

All patients aged 18 years and older at high risk for OSA, as identified by a PCP, with documentation of screening for OSA symptoms and/or the use of a validated OSA instrument and for whom an evidence-based action plan is recommended

• Note: OSA symptoms include, but are not limited to, snoring and daytime sleepiness

• Definition: For the purposes of this measure, patients considered at high risk for OSA may include, but are not limited to, patients with obesity, heart failure, atrial fibrillation or other arrhythmias, coronary artery disease, hypertension, stroke, pulmonary hypertension, prediabetes or diabetes, craniofacial anomalies, sleep complaints, sleepiness, pregnancy, patients undergoing evaluation for bariatric or other applicable surgical procedures

• Definition: For the purposes of this measure, an evidence-based action plan may include lifestyle modifications, surgical management, referral for home or in-lab sleep apnea testing; or referral to a sleep specialist, otolaryngologist, dentist or other specialist experienced in evaluation and management of OSA

Exceptions and exception justifications

The following are exceptions and justifications for excluding a patient from inclusion in reporting on this quality measure.

• Medical reasons: patients with unstable medical, neurological, or psychiatric condition; patient is being treated for OSA

• Patient reasons: patient declines OSA screening or evidence-based plan

• System reasons: none

Supporting evidence and rationale for revisions

The Task Force discussed in depth how frequently OSA may be undiagnosed and untreated, and the importance that PCPs play in diagnosing OSA in high-risk populations. The screening for adult OSA by PCPs measure captures whether high-risk patients are being screened and/or referred for diagnostic testing or a more in-depth evaluation for OSA when being seen by their PCP.¹⁰

While the original intent of the measure was to focus on screening in the primary care setting, this was not specified in the measure language or the measure title. The Task Force agreed that the measure language should specify PCPs, which may include advanced practice providers such as nurse practitioners and physician assistants. The measure title was also revised to screening for adult OSA by PCPs, to align with the true intent of the measure.

During the public comment period, the Task Force was presented with feedback concerning the 2022 United States Preventive Service Task Force recommendation,¹¹ which asserts the insufficiency of evidence supporting OSA screening in the general adult population. However, both the 2016 quality measure and this revised measure are specifically targeting adults at high risk for OSA, rather than the general population as a whole.

A review of the medical literature provided confirmation that adults with chronic conditions, such as type 2 diabetes, hypertension, heart failure,⁶ etc., should be considered high risk for OSA and further evaluated to confirm a diagnosis. To specify which adults would be considered high risk, a definition was included in the denominator. This definition was added to offer a more concise list of high-risk conditions that should be considered when screening and evaluating for OSA. It is also important to note that this list is not exhaustive, and PCPs should use their discretion and ongoing information in determining if a patient should be considered high risk for OSA.

The numerator language for this measure was modified to define an evidence-based action plan and provide examples of what that may entail. It is important to highlight that an evidence-based action plan must be recommended to the patient and documented in the patient record. The Task Force made changes to the numerator to allow providers more freedom in choosing a validated OSA instrument and evidence-based action plan that best suits their patients’ needs. Additionally, a notation was added to the numerator to offer examples of symptoms related to OSA for better understanding of the measure.

The medical and patient exception language for the measure was also refined to clarify the measure’s intent. The exception for patients with a tracheostomy was removed, as appropriate care should be provided and documented for patients who have undergone this procedure unless they have an unstable medical, neurological, or psychiatric condition, which has been added as a medical exception.

IMPLEMENTATION STRATEGIES

The revised quality measure set will be implemented into the AASM Sleep Clinical Data Registry, Sleep Clinical Data Registry. The clinical data registry was established by the AASM in May of 2021 and contains the entire AASM sleep-specific quality measure portfolio. The registry was previously approved by Center for Medicare and Medicaid Services as a Qualified Clinical Data Registry for reporting quality measures as a part of the Quality Payment Program, a national quality reporting initiative that includes Merit-based Incentive Payment System. The registry is a measure implementation vehicle that can also be used for AASM accreditation, quality measure validation, and to collect data for scientific acceptability, benchmarking, quality improvement, and research. Sleep Clinical Data Registry is currently available to all AASM-accredited facilities and affiliated clinicians.

FUTURE DIRECTIONS

Given that PCPs frequently are the first point of direct medical care for most high-risk patients, there is value in screening them for OSA in the primary care setting. The Task Force recommends incorporating additional process and outcome measures, specifically designed to improve OSA screening by PCPs, in future iterations of this measure. During the 30-day public comment period, another medical society stressed the importance of accounting for the timeliness for OSA management and follow-up by PCPs. Underscoring the significance of prompt intervention and ongoing monitoring in OSA cases, the medical society emphasized the need to incorporate measures that assess the timeliness of diagnosis, treatment initiation, and follow-up care by PCPs. This detailed approach ensures that patients with OSA receive timely and appropriate interventions in the primary care setting, leading to improved health outcomes and enhanced quality of care. The Task Force plans to develop a new, treatment follow-up measure, in the future. Lastly, this measure should be tested for feasibility and outcomes. Long-term tracking and analyses are necessary to validate that expected outcomes are, in fact, being achieved.

DISCLOSURE STATEMENT

Dr. Revana is currently the principal investigator of a phase 2 clinical trial at Harmony Biosciences, LCC, and a consultant at Trend, LLC. Dr. Donald holds stock in the following entities: Becton, Dickinson and Company, Medtronic, Pfizer, and Zimmer Biomet Holdings, Inc. Dr. Junna is Secretary of the Minnesota Sleep Society Board of Directors. Ms. Crawford and Ms. Gray are employed by the American Academy of Sleep Medicine. The other authors report no conflicts of interest.

ABBREVIATIONS

AASM

American Academy of Sleep Medicine

OSA

obstructive sleep apnea

PCP

primary care provider

Task Force

Quality Measures Task Force