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  • Measure Summary
  • NQMC:010358
  • Mar 2015

Adult obstructive sleep apnea (OSA): proportion of patients aged 18 years and older diagnosed with OSA who were prescribed an evidence-based therapy after initial diagnosis.

Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015 Mar 15;11(3):357-83. PubMed External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: American Academy of Sleep Medicine (AASM), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Sep 26. 21 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the proportion of patients aged 18 years and older diagnosed with obstructive sleep apnea (OSA) who were prescribed an evidence-based therapy after initial diagnosis.

Rationale

In order to improve quality of life for patients who have obstructive sleep apnea (OSA), clinicians should employ an evidence-based therapy for OSA. No one treatment modality is universally accepted or used by all patients, and several treatment modalities are supported by evidence demonstrating improved alertness and quality of life in OSA patients. Thus, the clinician may consider various treatment options and match the modality appropriately to the patient's features and wishes.

Multiple treatment modalities are supported by evidence demonstrating improved alertness and quality of life in OSA patients. Evidence-based treatments include positive airway pressure (PAP) therapy (including continuous positive airway pressure [CPAP], bilevel positive airway pressure [BPAP], and auto-titrating positive airway pressure [APAP]), oral appliances, upper airway surgery, and positional therapy. While weight loss may be beneficial for many OSA patients, it was not included as it was considered a useful adjunctive treatment, rather than an active modality of therapy.

Randomized controlled and observational studies support positive airway pressure therapy for improved alertness and quality of life in patients with severe OSA and sleepy patients with mild to moderate OSA (Weaver et al., 2012; Doff et al., 2013). The AASM practice parameters recommend CPAP for improving self-reported sleepiness in patients with OSA (Standard) and for improving quality of life in patients with OSA (Kushida et al., 2006).

For oral appliance therapy, there are randomized trials, placebo controlled or in parallel cohort with CPAP for improved alertness and quality of life (Doff et al., 2013; Petri et al., 2008; Gotsopoulos et al., 2002; Naismith et al., 2005). The benefits were demonstrated for some patients with severe OSA as well (Doff et al., 2013).

Surgical airway reconstruction is evidence-based (Caples et al., 2010), largely supported by cohort, case-series studies and a randomized control study for quality of life and alertness effects (Woodson et al., 2003; Holty & Guilleminault, 2010; Robinson et al., 2009; Vicini et al., 2010).

Positional therapies for avoidance of supine sleep position in OSA patients selected for supine position dependency of the AHI are also evidence-based for improving quality of life and function, but evidence is from a few small case series and randomized studies (Jokic et al., 1999; Oksenberg et al., 2006; Skinner et al., 2008).

This process measure of prescribing evidence-based therapies may familiarize some clinicians with additional treatment modalities not previously considered and may provide support for some treatment modalities not considered a covered service by some insurance carriers.

Evidence for Rationale

Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015 Mar 15;11(3):357-83. PubMed External Web Site Policy

Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1396-407. PubMed External Web Site Policy

Doff MH, Hoekema A, Wijkstra PJ, van der Hoeven JH, Huddleston Slater JJ, de Bont LG, Stegenga B. Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep. 2013 Sep;36(9):1289-96. PubMed External Web Site Policy

Gotsopoulos H, Chen C, Qian J, Cistulli PA. Oral appliance therapy improves symptoms in obstructive sleep apnea: a randomized, controlled trial. Am J Respir Crit Care Med. 2002;166(5):743-8.

Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010 Oct;14(5):287-97. PubMed External Web Site Policy

Jokic R, Klimaszewski A, Crossley M, Sridhar G, Fitzpatrick MF. Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea syndrome. Chest. 1999 Mar;115(3):771-81. PubMed External Web Site Policy

Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J Jr, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS, American Academy of Sleep Medicine. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006 Mar 1;29(3):375-80. [94 references] PubMed External Web Site Policy

Naismith SL, Winter VR, Hickie IB, Cistulli PA. Effect of oral appliance therapy on neurobehavioral functioning in obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med. 2005 Oct 15;1(4):374-80.

Oksenberg A, Silverberg D, Offenbach D, Arons E. Positional therapy for obstructive sleep apnea patients: A 6-month follow-up study. Laryngoscope. 2006 Nov;116(11):1995-2000.

Petri N, Svanholt P, Solow B, Wildschiødtz G, Winkel P. Mandibular advancement appliance for obstructive sleep apnoea: results of a randomised placebo controlled trial using parallel group design. J Sleep Res. 2008 Jun;17(2):221-9. PubMed External Web Site Policy

Robinson S, Chia M, Carney AS, Chawla S, Harris P, Esterman A. Upper airway reconstructive surgery long-term quality-of-life outcomes compared with CPAP for adult obstructive sleep apnea. Otolaryngol Head Neck Surg. 2009 Aug;141(2):257-263. PubMed External Web Site Policy

Skinner MA, Kingshott RN, Filsell S, Taylor DR. Efficacy of the 'tennis ball technique' versus nCPAP in the management of position-dependent obstructive sleep apnoea syndrome. Respirology. 2008 Sep;13(5):708-15. PubMed External Web Site Policy

Vicini C, Dallan I, Campanini A, De Vito A, Barbanti F, Giorgiomarrano G, Bosi M, Plazzi G, Provini F, Lugaresi E. Surgery vs ventilation in adult severe obstructive sleep apnea syndrome. Am J Otolaryngol. 2010 Jan-Feb;31(1):14-20. PubMed External Web Site Policy

Weaver TE, Mancini C, Maislin G, Cater J, Staley B, Landis JR, Ferguson KA, George CF, Schulman DA, Greenberg H, Rapoport DM, Walsleben JA, Lee-Chiong T, Gurubhagavatula I, Kuna ST. Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. Am J Respir Crit Care Med. 2012 Oct 1;186(7):677-83. PubMed External Web Site Policy

Woodson BT, Steward DL, Weaver EM, Javaheri S. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2003 Jun;128(6):848-61.

Primary Health Components

Obstructive sleep apnea (OSA); therapy; positive airway pressure; oral appliances; positional therapy; upper airway surgery

Denominator Description

All patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients who were prescribed evidence-based therapies (such as positive airway pressure, oral appliances, positional therapies, upper airway surgeries) after initial diagnosis (see related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Obstructive sleep apnea (OSA) is one of the most prevalent sleep disorders, affecting approximately to 3% to 7% of men and 2% to 5% of women in the general population (Punjabi, 2008; Stradling & Davies, 2004; Young et al., 1993; Young, Peppard, & Gottlieb, 2002). When polysomnographic criteria alone are considered, the prevalence rate increases dramatically to 24% in men and 9% in women (Young et al., 1993). Despite the fact that OSA is a common disease, it remains considerably underdiagnosed, with 75% to 80% of cases remaining unidentified (Kapur et al., 2002; Young, Skatrud, & Peppard, 2004).
  • The implications of untreated OSA are significant from the individual patient, healthcare, and economic perspectives. For the affected individual, OSA is associated with a number of nocturnal symptoms, as well as with difficulty in daytime functioning secondary to daytime sleepiness, irritability, fatigue, and decreased cognitive functioning (Punjabi, 2008). In fact, untreated OSA has been shown to significantly reduce quality of life (Baldwin et al., 2001; Lopes et al., 2008). Furthermore, untreated OSA (especially severe OSA) is associated with a multitude of adverse health outcomes including cardiovascular disease (Lurie, 2011), disorders of glucose metabolism including insulin resistance and diabetes (Aurora & Punjabi, 2013; Gharibeh & Mehra, 2010), stroke (Redline et al., 2010), and an increased risk of death (Punjabi et al., 2009). Another compelling motivation for early case identification and treatment of OSA is the higher prevalence of traffic accidents noted in persons with untreated OSA (Horstmann et al., 2000; Sassani et al., 2004; Teran-Santos, Jimenez-Gomez, & Cordero-Guevara, 1999). From an economic perspective, the healthcare costs and resource utilization of undiagnosed OSA is staggering, running into billions of dollars per year (Alghanim et al., 2008; The Harvard Medical School Division of Sleep Medicine, 2010), similar to other chronic disorders. The financial burden of OSA-related motor vehicle crashes alone is enormous. Furthermore, therapy for OSA seems to reduce comorbidities associated with OSA as well as healthcare costs and utilization (Albarrak et al., 2005; Banno et al., 2006).

Evidence for Additional Information Supporting Need for the Measure

Albarrak M, Banno K, Sabbagh AA, Delaive K, Walld R, Manfreda J, Kryger MH. Utilization of healthcare resources in obstructive sleep apnea syndrome: a 5-year follow-up study in men using CPAP. Sleep. 2005 Oct;28(10):1306-11. PubMed External Web Site Policy

Alghanim N, Comondore VR, Fleetham J, Marra CA, Ayas NT. The economic impact of obstructive sleep apnea. Lung. February 2008;186(1):7-12. [49 references]

Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015 Mar 15;11(3):357-83. PubMed External Web Site Policy

Aurora RN, Punjabi NM. Obstructive sleep apnoea and type 2 diabetes mellitus: a bidirectional association. Lancet Respir Med. 2013 Jun;1(4):329-38. PubMed External Web Site Policy

Baldwin CM, Griffith KA, Nieto FJ, O'Connor GT, Walsleben JA, Redline S. The association of sleep-disordered breathing and sleep symptoms with quality of life in the Sleep Heart Health Study. Sleep. 2001 Feb 1;24(1):96-105. PubMed External Web Site Policy

Banno K, Manfreda J, Walld R, Delaive K, Kryger MH. Healthcare utilization in women with obstructive sleep apnea syndrome 2 years after diagnosis and treatment. Sleep. 2006 Oct;29(10):1307-11. PubMed External Web Site Policy

Gharibeh T, Mehra R. Obstructive sleep apnea syndrome: natural history, diagnosis, and emerging treatment options. Nat Sci Sleep. 2010;2:233-55. PubMed External Web Site Policy

Horstmann S, Hess CW, Bassetti C, Gugger M, Mathis J. Sleepiness-related accidents in sleep apnea patients. Sleep. 2000 May 1;23(3):383-9. PubMed External Web Site Policy

Kapur V, Strohl KP, Redline S, Iber C, O'Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath. 2002 Jun;6(2):49-54. PubMed External Web Site Policy

Lopes C, Esteves AM, Bittencourt LR, Tufik S, Mello MT. Relationship between the quality of life and the severity of obstructive sleep apnea syndrome. Braz J Med Biol Res. 2008 Oct;41(10):908-13. PubMed External Web Site Policy

Lurie A. Cardiovascular disorders associated with obstructive sleep apnea. Adv Cardiol. 2011;46:197-266. PubMed External Web Site Policy

Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O'Connor GT, Rapoport DM, Redline S, Resnick HE, Robbins JA, Shahar E, Unruh ML, Samet JM. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009 Aug;6(8):e1000132. PubMed External Web Site Policy

Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb 15;5(2):136-43. PubMed External Web Site Policy

Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O'Connor GT, Resnick HE, Diener-West M, Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med. 2010 Jul 15;182(2):269-77. PubMed External Web Site Policy

Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep. 2004 May 1;27(3):453-8. PubMed External Web Site Policy

Stradling JR, Davies RJ. Sleep. 1: Obstructive sleep apnoea/hypopnoea syndrome: definitions, epidemiology, and natural history. Thorax. 2004 Jan;59(1):73-8. PubMed External Web Site Policy

Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. Cooperative Group Burgos-Santander. N Engl J Med. 1999 Mar 18;340(11):847-51. PubMed External Web Site Policy

The Harvard Medical School Division of Sleep Medicine. The price of fatigue: the surprising economic costs of unmanaged sleep apnea. [internet]. 2010 [accessed 2014 Aug 08].

Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993 Apr 29;328(17):1230-5. PubMed External Web Site Policy

Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002 May 1;165(9):1217-39.

Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004 Apr 28;291(16):2013-6. PubMed External Web Site Policy

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA)

Note: Refer to the original measure documentation for administrative codes.

Exclusions
Unspecified

Exceptions

  • Patient Reasons: Patients who do not wish to be prescribed therapy; patients who do not return for follow-up after initial diagnosis.
  • System Reasons: Patients whose insurance (payer) does not cover the expense.

Exclusions/Exceptions

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

Inclusions
Number of patients who were prescribed evidence-based therapies (such as positive airway pressure, oral appliances, positional therapies, upper airway surgeries) after initial diagnosis

Note: Weight loss is considered adjunctive therapy.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Process measure #3: evidenced-based therapy prescribed.

Measure Collection Name

Adult Obstructive Sleep Apnea

Submitter

American Academy of Sleep Medicine - Medical Specialty Society

Developer

American Academy of Sleep Medicine - Medical Specialty Society

Funding Source(s)

American Academy of Sleep Medicine

Composition of the Group that Developed the Measure

R. Nisha Aurora, MD (Johns Hopkins University, School of Medicine, Baltimore, MD); Nancy A. Collop, MD (Emory Sleep Center, Atlanta, GA); Ofer Jacobowitz, MD, PhD (ENT and Allergy Associates and Mount Sinai Hospital, New York, NY); Sherene M. Thomas, PhD (American Academy of Sleep Medicine, Darien, IL); Stuart F. Quan, MD (Division of Sleep Medicine, Harvard Medical School, Boston, MA; Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Arizona Respiratory Center, University of Arizona College of Medicine, Tucson, AZ); Amy J. Aronsky, DO (CareCentrix, Hartford, CT)

Financial Disclosures/Other Potential Conflicts of Interest

This was not an industry supported study. Dr. Collop is Editor-In-Chief of the Journal of Clinical Sleep Medicine and has received royalties from UpToDate. Dr. Jacobowitz has received research support from ImThera Medical Research. Dr. Thomas is an employee of the American Academy of Sleep Medicine. Dr. Quan is Editor Emeritus of the Journal of Clinical Sleep Medicine and has consulted for GCC (Global Corporate Challenge). Dr. Aronsky is employed by CareCentrix, Inc., a benefit management company and is a past member of the American Academy of Sleep Medicine Board of Directors. The other authors have indicated no financial conflicts of interest.

Measure Initiative(s)

Physician Quality Reporting System

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Mar

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: American Academy of Sleep Medicine (AASM), Physician Consortium for Performance Improvement®, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2008 Sep 26. 21 p.

Source(s)

Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015 Mar 15;11(3):357-83. PubMed External Web Site Policy

Measure Availability

Source not available electronically.

For more information, contact the American Academy of Sleep Medicine (AASM) at 2510 North Frontage Road, Darien, IL 60561; Phone: 630-737-9700; Fax: 630-737-9790; E-mail: webmaster@aasmnet.org; Web site: www.aasmnet.org/ External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 13, 2009. The information was verified by the measure developer on April 1, 2010.

This NQMC summary was retrofitted into the new template on June 7, 2011.

Stewardship for this measure was transferred from the PCPI to the American Academy of Sleep Medicine. The American Academy of Sleep Medicine informed NQMC that this measure was updated. This NQMC summary was updated by ECRI Institute on October 26, 2015. The information was verified by the measure developer on November 13, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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