In addition, there is no significant difference between both methods of care with regard to objective sleepiness, general and disease-specific quality-of-life measures, neurocognition, patient satisfaction, or adherence to continuous positive airway pressure (CPAP) after 3 months.
With the rise in obesity, the prevalence of OSA has increased throughout developed countries and will likely rise among developing countries as well because of their increasing acceptance of Western lifestyles, according to the study. Furthermore, the number of sleep centers and physician specialists is not adequate to meet the growing need.
"[Thus], more cost-effective clinical pathways of investigation and treatment are required to match the increased demand for services that is resulting from increasing public awareness of OSA," explain Nick A. Antic, PhD, MBBS, FRACP, from the Adelaide Institute for Sleep Health, Repatriation General Hospital in Daw Park, and the Department of Medicine, Flinders University in Bedford Park, South Australia, and colleagues. "The present study was designed as a randomized controlled study in which a package of care incorporating...newer management strategies including simplified home diagnosis, CPAP titration with an autoadjusting positive airway pressure device to set a fixed CPAP pressure, and overall care supervised by a specialist nurse was compared with the more traditional physician-directed, in-laboratory polysomnography (PSG), hospital-based program of care."
A total of 195 symptomatic patients with moderate to severe OSA from 3 Australian sleep medicine service centers were randomly assigned to receive either the simplified, nurse-led model of care or the traditional, physician-directed model of care. The primary endpoint of the study was the change in Epworth Sleepiness Scale (ESS) score after 3 months of CPAP therapy. The ESS score among the patients who received the nurse-led model of care was 4.02, and the ESS score among the patients who received the traditional physician-directed care was 4.15 (difference, −0.13; 95% confidence interval [CI], −1.52 to 1.25).
Nurse-Lead Management Noninferior
"We found that the mean change in ESS score for nurse-led management was not inferior to the mean change in ESS score for specialist-led service because the lower limit of the two-sided 95% confidence interval for the mean difference did not include −2, the margin of noninferiority," state Dr. Antic and colleagues.
In addition, there was no significant difference between the 2 models of care with respect to the other outcomes measured, which include the Short Form 36 Health Survey, Functional Outcomes of Sleep Questionnaire, executive neurocognitive function, objective CPAP adherence, Maintenance of Wakefulness Test after 3 months of therapy, and general patient satisfaction with investigation and treatment.
However, there was a significant decrease in the cost associated with the simplified, nurse-led model of care vs the traditional, physician-directed model of care. Specifically, nurse-led management cost $1111 Australian (A$1111) per patient less than physician-directed care (95% CI, A$1084 – A$1137). "Hence the within-study analysis suggests that a nurse-led model of care saves considerable resources without compromising effects in patients diagnosed by oximetry as having a high likelihood of moderate to severe [OSA,] and consequently is cost-effective in these patients," write the researchers.
One possible limitation of this study is the fact that the results may not be replicated without the specific combination of diagnostic and therapeutic equipment used. Moreover, several conditions contributed to the effectiveness of the simplified model of care in this study. These include awareness of the pretest probability of OSA among the patient referrals, availability of a highly experienced nursing staff in the management of OSA, access to a tertiary sleep laboratory as a back-up for the interpretation and quality control of oximetry data and autoadjusting positive airway pressure (APAP) data, and availability of input from a sleep physician.
Physician Consult Allowed
Twelve percent of the patents in the simplified model of care group received physician consults because of unsatisfactory progress. "We believed it important for the specialist nurse to be able to cross-consult under circumstances in which they were uncertain about the management of the patient," explain Dr. Antic and colleagues. "[Thus, there is] the need for this simplified model of care to be ideally conducted either within a tertiary sleep medicine service or with patient access to same. We do not recommend that the simplified management approach occur autonomously."
Nevertheless, the researchers emphasize that there is the possibility that the use of this simplified model of care could be used in existing sleep medicine clinics to reduce the PSG and physician waiting time by approximately 20% to 25%.
"This overall package of care involving simplified OSA diagnosis, APAP titration in the home, and the expansion of the sleep medicine workforce using skilled CPAP nurses working under protocol (with the backup of sleep medicine services if needed) has the potential to add significantly to the field of sleep medicine and improve access to care for those with OSA," the authors conclude.
This study was supported by the National Health and Medical Research Council of Australia. Dr. Antic has received financial support for research in terms of equipment from Respironics and ResMed and from Masimo. Another author has received grants totaling $2.5 million from the Respironics Sleep and Respiratory Foundation for an investigator-initiated multicenter trial. Equipment grants are also pending for the Respironics Foundation and ResMed for the same trials. The authors also received $20,000 from Fisher and Paykel for the same study in 2008.
Am J Respir Crit Care Med. 2009;179:501–508.
Source : http://www.medscape.com/viewarticle/589440
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