title: Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial.
abstract: OBJECTIVE
  Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment.
  
  
  OBJECTIVE
  To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers.
  
  
  METHODS
  A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010.
  
  
  METHODS
  Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only.
  
  
  METHODS
  The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was -2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs.
  
  
  RESULTS
  There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P < .001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (P < .001). Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 (adjusted difference, -0.13; lower bound of 1-sided 95% CI, -1.5; P = .43). There were no differences in secondary outcome measures between groups. Seventeen patients (21%) withdrew from the study in the primary care group vs 6 patients (8%) in the specialist group.
  
  
  CONCLUSIONS
  Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000514303.
authors.affiliation: Adelaide Institute for Sleep Health, Repatriation General Hospital, Department of Medicine, Flinders University, Adelaide, South Australia. chingli.chai-coetzer@health.sa.gov.au
authors.forename: Ching Li
authors.initials: CL
authors.lastname: Chai-Coetzer
authors.forename: Nick A
authors.initials: NA
authors.lastname: Antic
authors.forename: L Sharn
authors.initials: LS
authors.lastname: Rowland
authors.forename: Richard L
authors.initials: RL
authors.lastname: Reed
authors.forename: Adrian
authors.initials: A
authors.lastname: Esterman
authors.forename: Peter G
authors.initials: PG
authors.lastname: Catcheside
authors.forename: Simon
authors.initials: S
authors.lastname: Eckermann
authors.forename: Norman
authors.initials: N
authors.lastname: Vowles
authors.forename: Helena
authors.initials: H
authors.lastname: Williams
authors.forename: Sandra
authors.initials: S
authors.lastname: Dunn
authors.forename: R Doug
authors.initials: RD
authors.lastname: McEvoy
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities; D001315:Australia; D045422:Continuous Positive Airway Pressure; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008511:Medicine; D008875:Middle Aged; D011320:Primary Health Care; D011788:Quality of Life; D012424:Rural Population; D012720:Severity of Illness Index; D020181:Sleep Apnea, Obstructive / Q000503:physiopathology / Q000628:therapy*; D016896:Treatment Outcome