Referrals Difficult

Getting a referral for a sleep study remains challenging. While the purpose of the soon-to-be-published “Go To Sleep” study is specifically to evaluate a strategy to improve diagnosis and treatment of sleep apnea among veterans with stroke or transient ischemic attack and hypertension, researchers conducting the prospective multisite trial found that relatively few patients are referred for sleep-testing in routine care.

Henry Klar Yaggi, MD, MPH, shown in a Yale University Photo

“Many veterans with sleep apnea are not classically symptomatic. They may not be sleepy, and not all are overweight,” said lead researcher Dawn Bravata, MD, of the VA Health Services Research and Development Center of Excellence on Implementing Evidence-Based Practice at the Richard L. Roudebush VA Medical Center in Indianapolis, IN, and the Indiana University School of Medicine.

“It was shocking how many are missed,” she added in an interview with US Medicine.

Despite the issues surrounding diagnosis, the biggest problem with sleep apnea is getting patients to consistently use a CPAP. Up to 40% of patients prescribed CPAP equipment self-report low adherence to treatment guidelines. As the severity of sleep apnea decreases, the rate of noncompliance rises.

Sleep-apnea severity is measured using the apnea-hypopnea index (AHI). An AHI of fewer than five events per hour is considered normal. Five to 14 events per hour is considered mild sleep apnea. Moderate sleep apnea has an AHI of 15 to 30 events per hour, and more than 30 is considered severe.

Provent, an alternative therapy, was approved for use nationally by the VA during the past year and promises to increase treatment adherence. A disposable, one-way valve inserted just inside the nostril, Provent creates pressure on expiration that provides keeps airways open. The device “is well tolerated and typically reserved for patients with more mild or moderate sleep apnea,” Yaggi said.

The noiseless and inconspicuous valves are particularly appealing to those with less-severe sleep apnea and who often find the inconvenience of wearing the CPAP mask and its associated sounds more troublesome than the improvement in noticeable symptoms seem to warrant.