National patterns of physician management of sleep apnea and treatment among patients with hypertension

PLOS ONE, Nov 2019

Study objectives Sleep apnea is associated with hypertension, and treatment may improve outcomes. We examine national burden of sleep apnea, rates of sleep apnea treatment, and whether racial/ethnic disparities exist among patients with hypertension. Methods Data from the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey (NAMCS/NHAMCS), 2005–2012, were analyzed (N = 417,950). We identified hypertension patient visits where sleep apnea diagnosis or complaint was recorded. Primary outcome measures were sleep study, medication, or behavioral therapy (diet, weight loss, or exercise counseling). We used multivariate logistic regression to examine treatment by demographic/clinical factors. Results Among patients with hypertension, sleep apnea was identified in 11.2-per-1,000 visits. Overall, patients with hypertension and a sleep disorder were referred for sleep study in 14.4% of visits, prescribed sleep medication in 11.2% of visits, and offered behavioral therapy in 34.8% of visits. Adjusted analyses show behavioral therapy more likely to be provided to obese patients than normal/overweight (OR = 4.96, 95%CI[2.93–8.38]), but less likely to be provided to smokers than nonsmokers (OR = 0.54, 95%CI[0.32–0.93]). Non-Hispanic blacks were less likely to receive medications than non-Hispanic whites (OR = 0.19, 95% CI[0.06–0.65]). Conclusions In the U.S., sleep apnea were observed in a small proportion of hypertension visits, a population at high-risk for the disorder. One explanation for the low prevalence of sleep apnea observed in this patient population at high risk for the disorder is under-diagnosis of sleep related breathing disorders. Behavioral therapy was underutilized, and non-Hispanic Blacks were less likely to receive medications than non-Hispanic Whites.

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National patterns of physician management of sleep apnea and treatment among patients with hypertension

N = National patterns of physician management of sleep apnea and treatment among patients with hypertension Rebecca Robbins 0 2 3 Azizi Seixas 0 2 3 Girardin Jean-Louis 0 2 3 Sairam Parthasarathy 0 1 2 David M. Rapoport 0 2 Gbenga Ogedegbe 0 2 3 Joseph A. Ladapo 0 2 0 Funding: Funded by National Heart, Lung, and Blood Institute R25HL116378 Girardin Jean-Louis National Heart, Lung, and Blood Institute K23 HL116787 Joseph A Ladapo, National Institutes of Health R01 MD011544 Joseph A Ladapo , Robert 1 Department of Medicine, University of Arizona, Tuscon, Arizona, United States of America, 3 Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America, 4 Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA , Los Angeles, California , United States of America 2 Editor: Andrea Romigi, University of Rome Tor Vergata , ITALY 3 Department of Population Health, NYU School of Medicine , New York, New York , United States of America Study objectives - Data Availability Statement: All data files are available from publicly available websites accessible through the CDC website: https://www. cdc.gov/nchs/ahcd/datasets_documentation_ related.htm. Methods Results Wood Johnson Foundation 72426 Joseph A Ladapo. Competing interests: The authors have declared that no competing interests exist. Conclusions In the U.S., sleep apnea were observed in a small proportion of hypertension visits, a population at high-risk for the disorder. One explanation for the low prevalence of sleep apnea observed in this patient population at high risk for the disorder is under-diagnosis of sleep related breathing disorders. Behavioral therapy was underutilized, and non-Hispanic Blacks were less likely to receive medications than non-Hispanic Whites. Introduction Sleep apnea is common among patients with cardiovascular disease (CVD),[ 1 ] particularly hypertension.[2±8] [ 9 ] This can be explained in part by the observation that hypertension and sleep apnea share common pathophysiological risk factors that exacerbate both conditions. [ 10 ] Sleep apnea is a treatable sleep disorder.[ 11 ] Unfortunately, while others have called for increased attention to diagnosing and treating sleep apnea among hypertension patients,[ 12 ] we know little about physician management of hypertensive patients presenting with sleep apnea in national samples. There is growing epidemiological evidence supporting a relationship between sleep apnea and hypertension. Sleep apnea is associated with increased mortality and both hypertension and pulmonary hypertension, in addition to coronary artery disease (CAD), cardiac arrhythmias, congestive heart failure (CHF), and stroke.[ 11 ] Previous analysis utilizing the National Ambulatory Medical Care Survey has examined characteristics of sleep-related medical visits in the general population (e.g., prevalence of sleep difficulty, and physician management),[ 13 ] yet we know little about trends pertaining to sleep apnea prevalence or treatment among higher-risk patients with hypertension. In addition to the link between hypertension and sleep, evidence suggests sleep apnea is undertreated in the general population.[ 14 ] According to some estimates, sleep apnea affects between 9 and 24 percent of adults in the US,[ 10,15 ] but only 2 percent report a diagnosis.[16] Particularly concerning are even lower rates of diagnosis among minority populations who suffer a disproportionately higher burden of hypertension[ 17 ] and sleep apnea.[ 18,19 ] Blacks in particular are at greater risk of hypertension,[17] disrupted sleep,[ 19 ] and sleep apnea[ 18 ] than other racial or ethnic groups. We know little about how sleep apnea diagnosis or physician management approaches differ across racial or ethnic groups with cardiovascular risk factors. Clinical guidelines for the treatment of sleep apnea most often includes a sleep study, and treatment using continuous positive airway pressure (CPAP).[ 20 ] Meta-analysis shows an association between use of CPAP in the treatment of OSA and a modest reduction in blood pressure.[ 21 ] Other, behavioral and lifestyle treatments that have been explored for the treatment of OSA. Meta-analysis has found behavioral therapy, such as weight loss, to be effective for reduction in OSA parameters.[ 22 ] We examine sleep apnea, as reported by patients or diagnosed by physicians, and physician management of sleep apnea, specifically, provision of a sleep study and behavioral treatment and therapy (e.g., weight loss, exercise) among individuals with hypertension. We also examine physician provision of medication to patients with sleep apnea, because some physicians may use sedative agents as a short-term strategy to improve compliance with CPAP[23±25] or prescribe them to patients with comorbid psychiatric illness,[ 26 ] though the (...truncated)


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Rebecca Robbins, Azizi Seixas, Girardin Jean-Louis, Sairam Parthasarathy, David M. Rapoport, Gbenga Ogedegbe, Joseph A. Ladapo. National patterns of physician management of sleep apnea and treatment among patients with hypertension, PLOS ONE, 2018, Volume 13, Issue 5, DOI: 10.1371/journal.pone.0196981