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Kim J, Tran K, Seal K, et al. Interventions for the Treatment of Obstructive Sleep Apnea in Adults: A Health Technology Assessment [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Mar. (CADTH Optimal Use Report, No. 6.1b.)

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Interventions for the Treatment of Obstructive Sleep Apnea in Adults: A Health Technology Assessment [Internet].

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Implementation Issues

This section addressed Research Question 5: What are some of the implementation issues associated with PAP devices, EPAP valves, OAs, surgical interventions, and lifestyle for the treatment of OSA in adults?

Methods

Study Design

A narrative literature review was conducted to identify some of the implementation issues associated with different interventions for the treatment of OSA in adults.

Screening and Selection of Studies

Citations arising from the literature searches conducted to address Research Questions 1 to 4 were screened independently in duplicate for information related to implementation issues at the same time as reviewers of those respective sections screened citations for their sections. Articles addressing any of the following domains, as defined by INTEGRATE-HTA,298 were considered to be potentially relevant to implementation: setting, provider, geographical issues, epidemiology, socioeconomic issues of individuals and their communities, sociocultural issues, political considerations, legal issues, ethical issues, and funding issues. In addition, two relevant CADTH Rapid Response reports299,300 were identified and reviewed as well. From each relevant article, the bibliographic details (i.e., authors, year of publication, and country of origin), population and intervention information, and implementation issues identified were captured by one reviewer.

Descriptive Analysis and Synthesis Strategy

Issues identified from relevant studies are organized by OSA intervention (i.e., PAP devices, EPAP valves, OAs, surgical interventions, and lifestyle modifications) and further categorized by the level where the issue arises: individual, team, organization, or system or policy. This information was summarized narratively.

Results

Quantity of Research Available

From the included and excluded studies found through the literature search for Research Questions 1 through 4, 27 articles were identified that included information on potential supports and barriers to implementing the various interventions for the treatment of OSA. Of these, 14 plus one Rapid Response report pertained to PAP devices,183,236,268,270,300-310 four discussed OAs,311-314 one article focused on surgery for OSA,315 no articles focused on lifestyle interventions or EPAP valves, and eight studies plus one Rapid Response report covered either more than one intervention, diagnosis of OSA, or specific populations.285,299,316-321 Following peer review, an additional two articles were added to further clarify identified implementation issues,322,323 bringing the final tally of included studies to 29.

Diagnosing OSA

One overarching issue was identified, which pertains to all OSA interventions and affects all levels of the health care system: the issue of getting diagnosed.306,319,321 If OSA is not diagnosed, it cannot be effectively treated.

Barriers:

One of the biggest barriers to diagnosis, as reported in the literature, is the difficulties encountered by family physicians and their patients and families when trying to confirm a diagnosis of suspected OSA. Lack of access to sleep specialists and specialized sleep labs was recognized as a barrier to the diagnosis and subsequent treatment of OSA.319 This can be even more of a barrier in Canada for our rural populations306 and for those living in northern and remote areas far from a specialized sleep lab.320

Supports:

The literature suggests that one way to overcome this barrier and improve accessibility to OSA diagnosis is to use home-based portable diagnostic testing devices and treatment titration options when access to sleep labs is limited or difficult.306,319 These could be used together with telehealth-based support.321

A Rapid Response of the evidence on the diagnostic accuracy, clinical effectiveness, cost-effectiveness, and evidence-based guidelines of home-based sleep studies versus lab-based sleep studies for the diagnosis of OSA was undertaken to supplement the information found in the clinical literature for Research Questions 1 to 4. Overall, the summary of abstracts appears to indicate that home-based testing is accurate, feasible, and acceptable to patients.299 Making home-based devices available to patients who cannot readily access sleep labs and specialists may then help to overcome this barrier to the effective treatment of OSA.

Positive Airway Pressure Devices

Much of the literature on implementation issues for OSA interventions focuses on CPAP devices. Although the effectiveness of these devices depends on their constant use, there are a number of barriers and supports at multiple levels that can affect their use.236,302-307,310,316,317,317 Estimates of non-adherence with CPAP in the first year of therapy vary from one-third to more than 50% of patients.183,303,309

Barriers:

At a health care system and policy level, funding of CPAP devices remains a barrier for patients, particularly for those who already face significant socioeconomic challenges.285,310 An approach to overcoming this barrier with adequate funding that minimizes patient costs for CPAP therapy has been recommended in the literature.285,310 Currently, coverage for CPAP devices and therapy varies greatly across Canada.

At the individual patient level, discomfort or problems that result from CPAP use can lead to patients choosing not to continue with CPAP therapy. These are covered in depth in the Patient Experience section of this report. However, many of these issues may arise from a lack of patient education and training on use of the CPAP device, as there are no generally accepted guidelines for CPAP education for patients.236

While not well documented, Indigenous peoples in Canada may have a higher prevalence of OSA than nonIndigenous peoples, and more severe OSA.318 At the same time, Indigenous peoples may be less likely to seek and receive an OSA diagnosis,320 and may be less likely to adhere to their CPAP, if prescribed.318 This could, in part, be explained by an environmental scan that found no strategies, projects, programs, or initiatives targeting sleep apnea in this population.323

Supports:

Supports that have been suggested in the literature to overcome these various barriers often target the team or organization level of the health care continuum and their interactions with patients (and their family members). These include close monitoring and retesting,300,301,306 evaluation for anatomical abnormalities or functional abnormalities that may be increasing nasal resistance and treating these if found.301 and patient education about the risks of OSA and the benefits of CPAP therapy.236,305,307,316 These interventions could include structured telehealth and/or teleconsultation and telemonitoring,270,305,306,321 or an interactive website or audio intervention to support CPAP users.308,309

One study found that patients do better with their CPAP therapy if the sleep centre and the health care providers involved in their care are accredited for the treatment of OSA.316

Efforts at the manufacturer level have also been recognized as significant to improving CPAP adherence and these include using air humidification to help prevent dry mouth and throat, heated humidification, quieter machines, mask interface and pressure modalities, flexible (C-flex, A-flex) air pressure; using telehealth to detect any CPAP issues; and providing access to technical assistance.270,321,322

Oral Appliances

A number of implementation issues are identified in the literature for OAs in the treatment of OSA.

Barriers:

Even once diagnosed with OSA, access to therapy with an OA can be difficult. Physicians may not consider OAs for OSA because they are unfamiliar with them or are unsure how to access them for their patients.313 Another concern of physicians may be how well OAs work in the treatment of OSA and physicians are uncertain how to evaluate their effectiveness.313 To be suitable candidates, patients must meet specific anatomical requirements, and have healthy teeth and alveolar ridges.311,313 Problematic dental fillings or dentures may be contraindications to oral appliance therapy for OSA and dental rehabilitation may be a necessary, and often expensive, first step.311 In the economic review, the first-year costs of OA were twice that of PAP therapy (based on Ontario costs), making cost another barrier to OA therapy. Even once therapy with an oral appliance has been established, regular re-evaluations to prevent and treat side effects, such as changes to the condyle, are necessary, and access to dental professionals including orthodontists is essential.311

Supports:

To address these challenges with implementation of OA therapy for OSA, an organized multidisciplinary approach has been recommended, perhaps in the form of a dental sleep clinic.314 Respirologists, sleep specialists, dentists, dental surgeons, orthodontists, and other health professionals may be required as part of the multidisciplinary team.

Surgery

Little information from the literature on implementation issues for surgery in the treatment of OSA was found. No studies on implementation issues for OSA surgeries performed by dental specialists (i.e., oral and maxillofacial surgeons) were found, and only one study on OSA surgery performed by non-dental surgeons was identified. The Australian paper identified the issue that many surgeons have little or no exposure to performing surgery for OSA and that there is little consistency for training of surgical residents in this type of surgery.315 The paper does indicate that surgery for OSA is a “developing multidisciplinary field.”315

Lifestyle Interventions

Little information was identified in the clinical literature related to implementation issues with lifestyle interventions for the treatment of OSA. Although one paper recognized weight control and bariatric surgery as possible treatments for OSA, it also acknowledged that weight-loss programs may be likely to fail because of the metabolic changes that can occur with OSA.317 The same paper also stated the importance of patient education by physicians regarding the contribution of obesity to OSA and to provide advice about maintaining an optimal weight.

This section addressed Research Question 6: What are some potential environmental impacts associated with PAP devices, EPAP valves, OAs, surgical interventions, and lifestyle modifications for the treatment of OSA in adults?

Copyright © 2017 Canadian Agency for Drugs and Technologies in Health.

The copyright and other intellectual property rights in this document are owned by CADTH and its licensors. These rights are protected by the Canadian Copyright Act and other national and international laws and agreements. Users are permitted to make copies of this document for non-commercial purposes only, provided it is not modified when reproduced and appropriate credit is given to CADTH and its licensors.

Except where otherwise noted, this work is distributed under the terms of a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence (CC BY-NC-ND), a copy of which is available at http://creativecommons.org/licenses/by-nc-nd/4.0/

Bookshelf ID: NBK535538

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