Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance

Abstract

Obstructive sleep apnea (OSA) remains a highly prevalent disorder that can lead to multiple adverse outcomes when undiagnosed and/or when left untreated. There continue to be gaps and variations in the provision of care for the adult patient population with OSA, which emphasizes the importance of the measure maintenance initiative for The Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea (originally developed in 2015). The American Academy of Sleep Medicine (AASM) convened the Quality Measures Task Force in 2018 to review the current medical literature, other existing quality measures focused on the same patient population, and any performance data or data in the medical literature that show gaps or variations in care, to inform potential revisions to the quality measure set. These revised quality measures will be implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous improvement in outcomes associated with diagnosing and managing OSA in the adult population.

Citation:

Lloyd R, Morgenthaler TI, Donald R, et al. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673–2680.

INTRODUCTION

In a 2013 population-based study, obstructive sleep apnea (OSA) was estimated to impact 14% of men and 5% of women, using an apnea-hypopnea index (AHI) cutoff of ≥ 5 events/h, along with clinical symptoms to define OSA.¹ More recent publications, including the American Academy of Sleep Medicine (AASM) clinical practice guideline on diagnostic testing for OSA, highlight the varying prevalence of OSA based on the population being studied and how OSA is defined. These estimates demonstrate the continued high impact of OSA on the US population and the importance of continuing to ensure the provision of high-quality care for this patient population, through the continuous development and maintenance of evidence-based clinical practice guidelines and quality measures.

The original Obstructive Sleep Apnea Physician Performance Measurement Set was developed in 2008, by the AASM, in collaboration with the American Medical Association, the National Committee on Quality Assurance, and several other medical specialty societies.² The 2008 quality measure set was approved by the Centers for Medicare and Medicaid Services (CMS) for inclusion in the Physician Quality Reporting System (PQRS). The Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea were developed in 2015, as an extension to the original measure set, to emphasize public safety and to improve quality of life and outcomes for adult patients with OSA.³ Two of the measures are currently included in the Merit-based Incentive Payment System (MIPS) program, which replaced the PQRS program, as a part of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). These revised measures are also currently available for reporting via the AASM Sleep Clinical Data Registry (Sleep CDR), which was established as the first sleep-specific registry.

The AASM quality measure maintenance initiative was launched in 2018, as the Quality Measures Task Force was convened to review the entire AASM quality measure portfolio. The reviews were initiated to ensure that all quality measures are consistent with current evidence, as defined by clinical practice guideline recommendations, systematic literature reviews, and other published studies within the medical literature. Updating the measure set also required a review of existing quality measures, for the purposes of quality measure harmonization, which ensures that measures are not repetitive or competing. Last, the reviews include a review of performance data, where available, for measures implemented via clinical data registries and national quality reporting programs, coupled with identifications of variations in care for adult patients with OSA.

METHODS

Literature review

An updated comprehensive literature search was conducted to identify current publications that addressed sleep apnea in terms of the quality measures within this quality measure set. The literature review included clinical practice guidelines, systematic literature reviews, and individual studies (ie, randomized controlled trials). Searches were limited to articles published between 2015 and 2019, specific to humans, and in the English language, within the PubMed database. Publication types such as news, letters, editorials, and case reports were excluded. A total of 508 abstracts and 92 full articles were retrieved for review.

Performance data

In addition to a review of the medical literature, the task force reviewed performance data, which demonstrated gaps and variations in care. Data were identified within the American Academy of Neurology (AAN) AXON Registry for Process Measure #1: Baseline Assessment of OSA Symptoms. This measure was implemented in the registry and data were shared for 1 performance year. No other performance data were identified, as the AASM had not yet developed an implementation vehicle for quality measures or quality measure data collection. While several of the sleep apnea measures were included in the PQRS for 2016, no data were reported on the measures in the 2016 PQRS Experience Report, published by the CMS.⁴ All PQRS Experience Reports were historically published 2 years after the performance year, so these were the data available when the Task Force convened in 2018.

Existing quality measures

As a part of the measure maintenance process, the Task Force also reviewed existing quality measures and determined that there were no existing adult OSA measures that required measure harmonization. The CMS defines measure harmonization as standardizing quality measure specifications for related measures when they have the following⁵:

1. The same measure focus (ie, numerator criteria)

2. The same target population (ie, denominator criteria)

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

Unintended consequences

There were no known unintended consequences identified as a result of reporting the adult OSA quality measures.

Review and approval

The measures were initially revised and approved for public comment by the AASM Board of Directors. The measures were posted on the AASM website for a 30-day public comment period and were simultaneously emailed to other medical specialty societies for an additional peer review, to ensure that all relevant stakeholders had an opportunity to review and provide feedback. The task force reviewed all stakeholder feedback and made additional revisions, where deemed appropriate. The final revised measures were approved for publication and implementation by the AASM Executive Committee. A driver diagram is shown in Figure 1.

Figure 1. Revised adult OSA quality measures driver diagram.

OSA = obstructive sleep apnea.

REVISED QUALITY MEASURES

Process measure 1—Baseline assessment of OSA symptoms

2015. Measure description

Proportion of patients aged 18 years and older with a diagnosis of OSA that have documentation of assessment of OSA symptoms at initial evaluation, including the presence of snoring and daytime sleepiness.

Revised measure description

Proportion of patients aged 18 years and older with a diagnosis of OSA that have documentation of assessment of OSA symptoms and/or the use of a validated instrument at the initial evaluation.

Exceptions and exception justifications

• Medical reasons: None

• Patient reasons: Patients who decline or are unable to respond to assessment

• System reasons: Patients who had initial evaluation for OSA completed by another health care provider within the past 6 months

Supporting evidence and rationale for revisions

OSA continues to be an underdiagnosed illness, leading to poor health outcomes and significant economic burden.⁶ The Task Force reviewed this measure and considered performance data shared from the AXON Registry. The original measure was implemented into the AXON Registry and data were shared for the performance year of July 1, 2017, through June 30, 2018. The performance rate for this measure was 46%, with 651 eligible clinicians reporting the measure. The AXON Registry performance rate for this measure reportedly dropped significantly from 80.91%, the previous year, when using the previous measure specification, which required either snoring or daytime sleepiness be assessed for the measure, rather than both.

The Task Force considered requiring use of a validated instrument to perform the initial assessment, although there is no current evidence that highlights 1 instrument as the single gold standard for apnea assessment. However, Task Force members and public comments emphasized that, in some instances, it is best to simply document the patient symptoms as reported during the comprehensive sleep evaluation. Additionally, the AASM clinical practice guideline on diagnostic testing for OSA specifically recommends that diagnostic testing for OSA should be performed in conjunction with a comprehensive sleep evaluation, and strongly recommends that a diagnosis not be based solely on clinical tools, questionnaires, and prediction algorithms.⁷ Therefore, the Task Force thought it would be best to allow both the documented details of the comprehensive sleep evaluation and the validated instruments to capture the baseline symptoms for this patient population and meet the measure criteria.

The Task Force also decided to modify the measure exceptions. The patient exceptions were modified to make the measure more practical, so providers are not penalized if the initial assessment is unable to be completed by the patient. The system reason was made more specific, as the Task Force modified the exception to include a 6-month timeframe. The Task Force thought that if a patient had been evaluated by another sleep medicine professional within the last 6 months, it would not be necessary to reassess baseline symptoms unless the patient had not received adequate follow-up, as noted in the clinical practice guideline.

Process measure 2—Severity assessment at initial diagnosis

2015 Measure description

Proportion of patients aged 18 years and older with a diagnosis of OSA that had an apnea-hypopnea index (AHI; defined as total apneas + hypopneas per hour of sleep), a respiratory disturbance index (RDI; defined as total apneas + hypopneas + respiratory-effort-related-arousals per hour of sleep), or respiratory event index (REI; a measure of respiratory events per unit of time for home sleep apnea test) documented or measured within 2 months of initial evaluation for suspected obstructive sleep apnea.⁸

Exceptions and exception justifications

• Medical reasons: Patients with a medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study; patients in whom a sleep study would present a bigger risk than benefit or pose an undue burden should not be included in the eligible population.

• Patient reasons: Patients who declined AHI/RDI/REI measurement; patient had financial reason for not completing testing.

• System reasons: Test was ordered but not completed; patients who decline because their insurance (payer) does not cover the expense.

Supporting evidence and rationale for revisions

OSA treatment selection and implementation are still dependent on the severity of the disease. Therefore, the Task Force felt strongly that this measure remain in the quality measure set. Although there were no performance data to review, a review of the medical literature determined that, while patients are receiving polysomnography or home sleep apnea tests in most instances, there are discrepancies in how severity should be determined. Not only are there varying hypopnea definitions but recent literature suggests that AHI may not be the optimal measure of OSA severity.^9,10 However, at present, there is not a more consistently accepted standard for assessing severity, and present guidelines still suggest use of the rate of respiratory events as a guide to disease severity. No edits were made to the measure denominator or numerator language, as these are still consistent with the AASM Scoring Manual rules.⁸ Several public comments suggested that an additional exception should be added for patients who had their initial comprehensive sleep evaluation at another practice. However, the Task Force decided this modification was not necessary as all new patients should receive a comprehensive sleep evaluation by their treating provider.

Outcome measure 2—Improve quality of life

2015 Measure description

Proportion of patients aged 18 years and older diagnosed with OSA that showed any improvement in their quality of life (QoL) from baseline within 1 year of starting treatment.

Exceptions and exception justifications

• Medical reasons: Patients who have been diagnosed with a terminal or advanced disease with an expected lifespan of less than 6 months; patients with an unstable or poorly controlled medical disease; patients who have been diagnosed with severe psychiatric disorders (ie, severe depression, schizophrenia).

• Patient reasons: Patients who change treatment modalities within 1 year of starting their initial treatment; patients who do not return for a follow-up appointment within 1 year of initiating treatment; patients who decline or unable to complete the QoL assessment instrument; patients who do not have an impaired QoL at baseline.

• System reasons: None.

Supporting evidence and rationale for revisions

It is well documented in the medical literature that OSA is associated with decreased health-related QoL (HRQoL) using a wide variety of HRQoL instruments, and an increase in comorbid illnesses including cardiovascular disease and metabolic disorders.¹¹ The Task Force reviewed this measure and agreed that, although there is not yet convergence on exactly which HRQoL instrument should be used, this is an important outcome to measure and document, as it will speak to the effectiveness of the assessments and treatment captured in the process measures. No changes were made to the measure description, components, or exceptions, as the measure language is still appropriate and captures the intended information.

Process measure 3—Evidence-based therapy prescribed

2015. Measure description

Proportion of patients aged 18 years and older diagnosed with OSA that were prescribed an evidence-based therapy after initial diagnosis.

Revised measure description

Proportion of patients aged 18 years and older diagnosed with moderate to severe OSA or symptomatic mild OSA that were prescribed an evidence-based therapy after initial diagnosis.

Definition: For the purposes of this measure, evidence-based therapies include positive airway pressure, oral appliances (custom, titratable, Food and Drug Administration [FDA]–cleared appliances), positional therapies, upper airway surgeries, hypoglossal nerve stimulation.

Exceptions and exception justifications

• Medical reasons: None.

• Patient reasons: Patients who do not wish to be prescribed therapy; patients who do not return for follow-up after initial diagnosis.

• System reasons: Patient’s insurance (payer) does not cover the expense.

Supporting evidence and rationale for revisions

OSA treatment is determined based on severity of the disease, a collaborative decision between the provider and patient across evidence-based treatment options, and how well patients are able to tolerate therapy. Although first-line treatment is positive airway pressure (PAP) therapy, there are other treatment options if PAP is not effective or is not well tolerated by patients. Given the variations in care provided to patients with OSA, the Task Force thought this measure should remain in the quality measure set, with several updates. The Task Force discussed several potential revisions for this measure, given the importance of treatment for adult OSA. Initially, a numerator definition was added, to simplify the measure language so data are easier to capture, therefore improving measure implementation. Additionally, upon review of the therapies listed in the measure and a review of the medical literature, hypoglossal nerve stimulation was added to the definition, as an additional treatment for OSA. The Task Force also discussed the oral appliances language, included in the numerator definition, due to several public comments suggesting that the measure exclude oral devices prescribed for snoring that do not effectively treat OSA. Ultimately, the decision was made to add “custom, titratable, and FDA cleared appliances,” to address this concern.

The Task Force also discussed whether to add more specificity regarding OSA severity within the denominator statement. Initially, the discussion led to the addition of moderate to severe OSA, since moderate to severe OSA requires treatment. However, the Task Force also decided to include symptomatic mild OSA since patients experiencing symptoms should receive some form of treatment.

No changes were made to the measure exceptions.

Process measure 4—Assessment of adherence to OSA therapy

2015. Measure description

Proportion of patients aged 18 years and older with OSA that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually.

Revised measure description

Proportion of patients aged 18 years and older with OSA that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually preferably using an objective informatics system, if available, but adherence may be self-reported, if objective reporting is not available.

Exceptions and exception justifications

• Medical reasons: Patients who have been diagnosed with a terminal or advanced disease with an expected lifespan of less than 6 months.

• Patient reasons: Patients who decline therapy; patients who do not return for follow-up at least annually; patients unable to access/afford therapy.

• System reasons: Patient’s insurance will not cover therapy.

Supporting evidence and rationale for revisions

Therapy adherence is extremely important for patients with OSA to experience improvement in signs and symptoms of OSA. Despite the clear efficacy of PAP therapy, adherence continues to be highly variable in patients with OSA.¹² There were no performance data available for this measure in the 2016 PQRS Experience Report, despite an earlier version of this measure being included in the then PQRS program. However, much of the feedback received during the public comment period included recommendations to modify the numerator language to require the assessment of adherence to occur at least annually, although sleep medicine professionals may monitor therapy adherence more frequently remotely or in person. Additional edits to the numerator language include modifications that allow for self-reported assessments if objective assessments are not available. In some instances, patients may not have access to objective informatics systems for adherence tracking. In these instances, the Task Force felt it was important to allow for self-reported assessments, so providers are not penalized via the measure.

Modifications to the denominator were made to simplify measure implementation, by capturing the list of evidence-based therapies in a denominator definition. No other changes were made to the denominator statement. The measure exceptions have been modified significantly. The Task Force discussed the medical reason exceptions and thought there are instances in which a patient who receives surgical treatment (ie, upper airway stimulation) would continue to be monitored. Patients who receive surgical treatment may continue to require additional OSA therapy management and the Task Force decided they should be assessed at least annually as standard therapy follow-up. The patient reason exceptions were reviewed and modified slightly to make the exceptions clearer. The patient decline reason seemed to be captured twice, so the latter exception was removed. Patients who do not return for follow-up at least annually were specified to further align the patient exceptions with the language in the revised numerator.

Process measure 5—Assessment of sleepiness

2015. Measure description

Proportion of patients aged 18 years and older diagnosed and treated for OSA that had sleepiness assessed annually.

Revised measure description

Proportion of patients aged 18 years and older diagnosed and treated for OSA that had documentation of assessment of sleepiness and/or the use of a validated instrument at least annually.

Exceptions and exception justifications

• Medical reasons: Patients diagnosed with a terminal or advanced disease with an expected lifespan of less than 6 months.

• Patient reasons: Patients who do not return for follow-up; patients who decline or are unable to respond to the assessment; patients who decline therapy; patients who are unable to access or afford therapy.

• System reasons: Patients who decline because their insurance (payer) does not cover the expense.

Supporting evidence and rationale for revisions

Excessive daytime sleepiness is one of the most common symptoms of OSA, which can have a significant impact on the lives of patients with OSA. The reductions in QoL associated with excessive sleepiness may be substantial, involving compromised cognitive performance and work productivity as well as possible harm to the individual and the public.¹³ There are many ways to assess sleepiness, including through a comprehensive sleep evaluation and/or through the use of validated instruments. Although sleepiness assessments are commonly performed at a patient’s initial visit, this measure focuses on capturing ongoing assessments, to ensure that the patient’s treatment is improving this symptom. Some patients report ongoing excessive daytime sleepiness, despite PAP therapy and/or other therapies, making this an important measure to report. Similar to process measure 1, the measure was originally revised to require the use of a validated instrument to assess sleepiness. Public comments again suggested that there is lack of convergence on a standard, validated instrument for this assessment and strongly urged that this language be reconsidered. The Task Force agreed that the assessment may be documented as a part of the comprehensive sleep evaluation and, therefore, decided to include both as options for assessment of sleepiness. The denominator statement was revised, to move the list of evidence-based therapies into a denominator definition, to reduce any potential challenges to measure implementation, simplifying the denominator language. The measure exceptions for this measure were updated so patients who received surgical treatment were not included in the medical reason exceptions, as these patients should continue to receive assessments after surgery or other apnea device therapies, to monitor potential improvements or changes in sleepiness or OSA symptoms.

Process measure 6—Assessment for drowsy driving (previously titled: Assessment of Motor Vehicle Crashes or Near-Miss Crashes)

2015. Measure description

Proportion of patients aged 18 years and older diagnosed with OSA that were questioned about motor vehicle crashes (or near-miss crashes) associated with drowsiness/excessive sleepiness at initial evaluation.

Revised measure description

Proportion of patients aged 18 years and older diagnosed with OSA that were questioned about drowsy driving at initial evaluation and at least annually.

Exceptions and exception justifications

• Medical reasons: None.

• Patient reasons: Patients who do not drive; patients who decline to respond; patient does not return for follow-up at least annually.

• System reasons: None.

Supporting evidence and rationale for revisions

Although performance data are not available for this measure, it is one that is largely supported by the medical literature. Sleepiness at the wheel, or drowsy driving, continues to increase the risk of motor vehicle accidents.¹⁴ Each year, drowsy driving accounts for about 100,000 crashes, 71,000 injuries, and 1,550 fatalities.¹⁵ The AASM released a statement in 2019, Confronting Drowsy Driving: The American Academy of Sleep Medicine Perspective, calling upon institutions and policy makers to increase public awareness and improve education on the issue.¹⁶ Therefore, there was a change made to the title and numerator language to align with existing drowsy-driving initiatives and campaigns on a national level and to ensure that the quality measure aligns more with the symptom of drowsy driving rather than the intermediate outcome, which, for the purposes of this measure, would be motor vehicle crashes. An additional change to the numerator was also finalized so this assessment would be performed at the initial evaluation and at least annually to assess whether there has been an improvement or change in this symptom year over year. Despite no changes to the denominator, the Task Force thought it important to add a patient reason exception for those patients who do not return for follow-up at least annually.

Process measure 7—Assessment of weight (retired; see Process measure 8) Process measure 8—Weight-management discussion

2015. Measure description

Proportion of overweight or obese (BMI [body mass index] ≥ 25 kg/m²) patients aged 18 years and older diagnosed with OSA who had a discussion at least annually with the health care provider on the patient’s weight status, or who were referred to a specialist for their weight management.

Revised measure description

Proportion of overweight or obese (BMI ≥ 25 kg/m²) patients aged 18 years and older diagnosed with OSA that had their visit weight documented and were provided with education by the health care provider at initial evaluation and at least annually or who were referred to a specialist for weight management.

Definition: Weight-management discussion includes discussion of how being overweight or obese may worsen sleep apnea and increase cardiovascular risks

Exceptions and exception justifications

• Medical reasons: Patients who have been diagnosed with a terminal or advanced disease with an expected lifespan of less than 6 months; patients who are pregnant.

• Patient reasons: Patients who report they are currently in a weight-management program.

• System reasons: Weight management has been discussed by another provider within 6 months.

Supporting evidence and rationale for revisions

While there are no performance data available for this quality measure, the medical literature continues to demonstrate that weight-loss interventions can improve OSA severity, cardiometabolic comorbidities, and QoL for patients with OSA.¹⁷ Therefore, the Task Force decided to retain the measure with several modifications. First is the addition of the weight assessment, which had previously been captured by a separate measure. The Task Force initially discussed retiring the weight assessment measure and acknowledged that there is no evidence of a performance gap, as patients are weighed on almost every visit. However, the Task Force ultimately decided to add the weight assessment as an additional data element to this measure to ensure documentation. The Task Force also added several additional data elements to the measure to ensure that patients receive weight-management education from the initial provider at their initial visit and at least annually or are referred to a specialist for weight management. The referral to a specialist was added as the medical literature indicates that physician beliefs about their own competency in managing obesity may lead them to refer patients to weight-management programs instead of providing the weight-management education.¹⁸ For these physicians, the Task Force wanted to ensure that the measure would be met if an action was taken to provide a resource for the patient to receive weight-management education. The Task Force also added a definition to clarify what a weight-management discussion may include, which focuses on the potential impact of patients remaining overweight or obese. Although no changes were made to the denominator language, the system reason exception was modified to capture patients who discussed weight management with another provider within 6 months.

Process measure 9—Assessment of blood pressure (retired; see Process measure 10) Process measure 10—Elevated blood pressure discussion

2015. Measure description

Proportion of patients aged 18 years and older diagnosed with OSA with an elevated blood pressure reading (according to the most recent Joint National Committee guideline for high blood pressure) noted at the visit who have documentation of a discussion with the health care provider of this elevated blood pressure.

Revised measure description

Proportion of patients aged 18 years and older diagnosed with OSA with a visit blood pressure of 130/80 mm Hg or higher that had a discussion with the health care provider about the elevated blood pressure.

Definition: Elevated blood pressure discussion includes how inadequately treated sleep apnea may worsen hypertension, and how both may increase cardiovascular risks.

Exceptions and exception justifications

• Medical reasons: None.

• Patient reasons: None.

• System reasons: Patients who have had a discussion with another health care provider in the last 24 hours about their elevated blood pressure.

Supporting evidence and rationale for revisions

OSA continues to be associated with common cardiovascular diseases, including but not limited to hypertension, coronary and cerebrovascular diseases, heart failure, and atrial fibrillation.¹⁹ Therefore, the Task Force thought it important to retain this measure, despite retiring the previous measure, which captured blood pressure assessment. There is no known gap in care related to blood pressure assessment as patient blood pressures are generally documented on almost every office visit as standard of care. This measure, however, is more focused on the intervention which includes a discussion with the provider regarding an elevated blood pressure reading. The Task Force reviewed the updated blood pressure guidelines and decided to add the specific blood pressure reading 130/80 mm Hg to the denominator so providers know specifically when the measure requires the elevated blood pressure discussion. The 2017 Guideline for High Blood Pressure in adults defined stage 1 hypertension as ≥ 130 or ≥ 80 mm Hg.²⁰ The Task Force also thought it would be helpful to add detail regarding what should be included in an elevated blood pressure discussion by a sleep medicine professional, so a definition was added to focus on the potential cardiovascular risks associated with untreated apnea. No edits were made to the exception language.

IMPLEMENTATION STRATEGIES

The revised quality measure set will be implemented into the AASM Sleep Clinical Data Registry, Sleep CDR. 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 is approved by CMS 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 MIPS. The registry is a measure implementation vehicle that can also be used for quality measure validation, and to collect data for scientific acceptability, benchmarking, quality improvement, and research. Sleep CDR is currently available to all AASM-accredited facilities and affiliated clinicians.

FUTURE DIRECTIONS

Digitalized data collection has enhanced the ability to collect process measure data and to analyze outcomes-related data with the goal of improving patient care. These data allow practice benchmarks to be collected and analyzed for Quality Improvements (QI) and practice interventions to improve patient outcomes. Further, the aggregation of local benchmarks allows practices to recognize national quality measure benchmarks, to acknowledge and understand areas for practice QI interventions, and to continue quality measure reassessments over time. Collection of patient-reported outcomes has increased with e-questionnaires delivered through electronic health record (EHR) patient portals, and some practices have integrated testing and therapy monitoring data into the EHR. Collection and analysis of quality measure “big data” will become increasingly used in the future to direct improved personalized-care models and standards of practice. With this current set of updated measures, the Task Force attempted to recognize a standard approach that includes practices transitioning from paper to electronic quality measure documentation. The future includes understanding that quality measures will continue to require updates as rapid changes in technologies, data accuracy, and reporting are occurring for diagnostic testing, evidence-based therapeutic options, and monitoring capabilities. Additionally, the Task Force attempted to adapt measures to account for new and future technologies, as well as unforeseen workflow and practice disruptors such as those that have occurred in the past 2 years (COVID-19 [coronavirus disease 2019] pandemic, major PAP recall).

DISCLOSURE STATEMENT

Ms. Gray is employed by the American Academy of Sleep Medicine (AASM). Dr. Trotti is a member of the AASM Board of Directors. The other authors report no conflicts of interest.

ABBREVIATIONS

AASM

American Academy of Sleep Medicine

AHI

apnea-hypopnea index

CMS

Centers for Medicare and Medicaid Services

OSA

obstructive sleep apnea

PAP

positive airway pressure

PQRS

Physician Quality Reporting System

QoL

quality of life