Screening for sleep disorders lacking in primary care

ByErin Michael

Survey data showed that most primary care physicians view sleep health as an important aspect of patient care, but they often feel uncomfortable diagnosing and treating sleep disorders.

“Sleep disorders, as diagnosable diseases in and of themselves, can lead to poor quality of life and premature death if untreated,” Karen J. Klingman, PhD, RN, associate dean and associate professor in the college of nursing at Upstate Medical University at the State University of New York, told Healio Primary Care. “In addition, untreated sleep disorders adversely affect outcomes of other diseases such as obesity, diabetes, depression and cardiovascular disease — to name a few — by interacting to make it harder to maintain healthy weight, control blood glucose, maintain non-depressed mood, or maintain healthy blood pressure, for example.”

PCPs with lower comfort levels towards sleep disorders — Reference: Klingman KJ, et al. Sleep. 2020;10.1093/sleep/zsaa056.1168.

Survey results

Klingman and colleagues conducted two surveys evaluating sleep disorder screening practices in primary care offices.

The first survey included 99 clinicians at two centers. Among them, 56% were MDs, 21% were DOs, 17% were physician assistants and 6% were nurse practitioners.

Karen J. Klingman

Most clinicians rated sleep as highly important for cardiopulmonary health (85%), mental health (84%) and general health (83%). There were no differences based on provider or physician characteristics, according to the researchers.

Klingman and colleagues also found that knowledge of sleep disorders was considered highly important by 88% of participants, and that 82% considered diagnosing these disorders highly important.

However, many participants also reported lower comfort levels with discussions about sleep disorders (78%), overseeing and monitoring these disorders (62%), diagnosing the disorders (60%) and treating patients with the disorders (48%).

Klingman said the lack of comfort regarding sleep health among PCPs may be due to the limited amount of sleep health training during medical school. According to the researchers, 80% of participants said it would be useful to have an efficient sleep disorder screener. The respondents also said that time constraints limited their ability to address sleep disorders.

For the second survey, Klingman and colleagues collected EMR data from 2014 to 2018 to determine how often sleep disorders were detected and treated in primary care settings.

A total of 1,021 PCPs were included in the study. The proportion of those who diagnosed sleep disorders varied from 58% to 89% and those who treated sleep disorders varied from 50% to 91% during the study period.

The average percentage of patients who were diagnosed and treated for sleep disorders accounted for just 2.5% of each PCP’s entire caseload.

“It is not clear if the small percentage of primary care patients being routinely assessed for sleep health is because only a few providers are assessing most of the time, or most providers are assessing only a few patients with obvious sleep problems,” Klingman said, adding that there may be issues in the process or systems that PCPs use to perform or document sleep health assessments in a way that is easily accessible later.

“We need to make it easy for PCPs to assess for sleep disorders and to ensure good follow-up occurs if they find something,” Klingman said. “We also need to provide convincing data that if sleep disorders are attended to, then managing many other chronic conditions will also become easier as well. And, of course, process and system issues should be identified and addressed.”

Education intervention

A study presented at the virtual SLEEP 2020 meeting evaluated the benefits of phone-based education modules on sleep medicine that, when completed, can be exchanged for free CME/CNE credits.

“We developed an app-based, asynchronous curriculum in sleep medicine relevant to primary care in an attempt to broaden the workforce of providers who can diagnose and treat sleep disorders,” Ilene M. Rosen, MD, MSCE, associate professor of medicine at the Hospital of the University of Pennsylvania, said during the presentation.

Rosen and colleagues used a training evaluation model to assess three application modules, which were case-based and fully autonomous. The modules included topics such as health sleep basics, jet lag, insomnia and obstructive sleep apnea. Providers who used the app had access to discussion boards moderated by a board-certified sleep physician.

A total of 19 providers — 12 PCPs and nine advanced practice nurses — completed all three core modules.

Of the participants, 94.4% said they would recommend the curriculum to colleagues, and of those who had previously been exposed to online courses, 93.3% said the modules provided them with a similar or better experience.

Rosen and colleagues reported that 77.8% of participants said the program would either greatly or completely contribute to any improvement in patient health outcomes.

All participants met the score requirement upon completion to receive one CME/CNE credit per module completed.

In the 4 months following the program, the number of sleep consultation or sleep study orders rose by 24.2% among participants compared with the 4 months prior to the program.

The researchers noted that the findings were limited by the small sample size — although just 19 participants completed the modules, a total of 118 providers were invited to participate.

“Interestingly, many providers cited a lack of time when they declined participation, which was consistent with our prior experience in primary care,” Rosen said.

In addition to larger studies, she said that “consideration should also be given to the appropriate provider group to engage in this type of education — that is, primary care vs. other specialties. Also, we believe that engagement of physician learners as compared to advanced practice provider learners requires fuller investigation.”

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