SCIENTIFIC INVESTIGATIONS

A National Survey of the Effect of Sleep Medicine Specialists and American Academy of Sleep Medicine Accreditation on Management of Obstructive Sleep Apnea
Sairam Parthasarathy, M.D.1,2; Patricia L. Haynes, Ph.D.2; Rohit Budhiraja, M.D.1,2; Michael P. Habib, M.D.1,2; Stuart F. Quan, M.D.2
1

Southern Arizona Veterans Administration Health Care System, Tucson, AZ; 2University of Arizona, Tuscon, AZ

Study Objectives: To study the effect of American Academy of Sleep Medicine accreditation of sleep centers and sleep-medicine certication of physicians on the management of patients with obstructive sleep apnea (OSA). Design: Cross-sectional study. Setting: National web-based survey. Patients: Six hundred thirty-two patients with OSA. Interventions: None. Measurements and Results: Self-reported data on details of whether patients with OSA were using positive airway pressure (PAP) devices, timeliness of the initiation of PAP therapy, and overall satisfaction of care received from physicians and centers. After adjusting for covariates, lack of accreditation or certication status of providers was independently associated with discontinuation of PAP therapy (odds ratio [OR] 1.9, 95% condence interval [CI], 1.1-3.2; p = .03). Patient education leading to perception of risk associated with OSA (OR 0.5, 95% CI, 0.2-0.9) and medications for nasal congestion (OR 0.3, 95% CI, 0.1-0.8) protected against discontinuation of PAP therapy, whereas nasal congestion (OR 1.6, 95% CI, 1.0-2.4) increased the likelihood for discontinuation of PAP therapy. Certied physicians and accredited centers were more likely to here exists a dire need to raise and standardize the quality of healthcare delivery in many disease conditions, including obstructive sleep apnea (OSA).1 Unique to OSA are the uncertainties of disease definition,2 large variability in scoring of polysomnograms and therefore diagnosing OSA,3,4 and also multidisciplinary backgrounds and respective biases of physicians who treat OSA.5 In light of such variability, the training for physicians offered by formal sleep-medicine fellowships, and the benchmarks advocated by the American Academy of Sleep Medicine (AASM) for the workings of a sleep center, afford greater conformity and set standards of practice for individual physicians and sleep centers.6 So far, a systematic assessment of the effect of AASM center accredi-

educate their patients and received greater satisfaction ratings than noncertied physicians and nonaccredited centers (p < .05). Time delays in instituting PAP therapy were not inuenced by accreditation or certication status, but such delays diminished patient satisfaction. Conclusions: In this web-based survey, accreditation or certication status of sleep centers and physicians was associated with better indexes of clinical management in patients with OSA. Better patient education that fostered risk perception may have been partly responsible for such an association. Prospective studies designed to collect objective data regarding the effect of accreditation or certication status on outcomes in patients with OSA are still needed. Keywords: Sleep, professional competence, obstructive sleep apnea, patient satisfaction, continuous positive airway pressure, accreditation, patient compliance, treatment refusal, nasal obstruction, nasal decongestants, sleep apnea syndromes Citation: Parthasarathy S; Haynes PL; Budhiraja R et al. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine accreditation on management of obstructive sleep apnea. J Clin Sleep Med 2006;2(2):133-142.

tation and sleep-medicine certification of physicians on clinical outcomes in patients with OSA has not been reported. In order to measure the effect of AASM accreditation and sleep-medicine certification on clinical outcomes in patients with OSA, several important endpoints can be considered. Commentary Follows on Pages 143-144 One such endpoint that poses a challenge in the management of patients with OSA is patient adherence to positive airway pressure (PAP) therapy.7 While the minimum required adherencein hours of PAP therapy used per nightis unclear,8 discontinuation of PAP device is an unambiguous endpoint for treatment failure. In this study, we used such a clear definition of treatment failureproportion of patients who discontinued PAP therapyto measure the performance of physicians and sleep centers. Additionally, because patients risk perceptions of OSA and their knowledge of their disease condition are important to ensure adherence to therapy,8,9 we assessed patients perceptions of whether such information was dispensed by their physicians or sleep centers. Lastly, other important benchmarks in the management of patients with OSA, such as timely delivery of care10 (time lapse between initial sleep study and institution of PAP therapy) and patients overall satisfaction with care rendered by their physicians and centers, were also assessed.
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Disclosure Statement This was not an industry supported study. Drs. Parthasarathy, Haynes, Budhiraja, Habib, and Quan have indicated no nancial conicts of interest. Submitted for publication November 18, 2005 Accepted for publication December 14, 2005 Address correspondence to: Sairam Parthasarathy, M.D., Southern Arizona VA Health Care System, 3601, South Sixth Avenue, Mail Stop 1-111A, Tucson, AZ 85723; Tel: (520) 792-1450 ext. 15076; Fax: (520) 629-4641; E-mail: spartha@arc.arizona.edu
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S Parthasarathy, PL Haynes, R Budhiraja et al

We designed a survey that asked patients about the care they received from their physicians and sleep centers for their OSA condition. The overall purpose of the study was to study the effect of AASM accreditation of sleep centers and sleep-medicine certification of physicians on the clinical management of patients with OSA through a web-based survey. We hypothesized that patients with OSA who are cared for by sleep-certified physicians or AASM-accredited centers are less likely to discontinue PAP therapy than are patients cared for by noncertified physicians and nonaccredited centers. We also hypothesized that patient education regarding OSA and associated risks are provided by a greater proportion of sleep-certified physicians and AASM-accredited centers than by noncertified physicians and nonaccredited centers. Lastly, we hypothesized that sleep-certified physicians and AASM-accredited centers provide more timely care and achieve greater patient-satisfaction ratings than do noncertified physicians and nonaccredited centers. METHODS Patients We conducted a cross-sectional study of 632 patients with OSA across the country using a web-based survey. Of the 842 hits to the web site containing the questionnaire, 632 patients took the time to respond to the questionnaire. Patients were nave to the exact purposes of the study. Patients older than 20 years of age with a diagnosis of OSA were solicited to take the anonymous web-based survey (see Appendix). Such solicitations to participate were placed on web sites frequented by patients with OSA: sleep apnea support groups (American Sleep Apnea Association, Washington, DC), other educational web sites (such as apneanet.org, Glen Ellyn, IL), vendors of PAP therapy devices (such as cpapstore.com, Kennewick, Wash, and cpaptalk. com, Missouri City, TX), and Internet chat groups (such as the one sponsored by the AASM, sleepeducation.com, Westchester, IL). The Institutional Review Board of the University of Arizona approved the study and waived the need for documentation of written informed consent. Questionnaire Tool Patients were asked to respond yes, no, or dont know to the following questions: (1) whether the physician managing their sleep-apnea condition is a sleep expert (an Internet link to the AASM web site with a state-wise list of certified sleep physicians was provided); (2) whether the sleep center that they received service from was accredited (an Internet link to the AASM web site with state-wise list of AASM-accredited centers was provided); (3) whether they received adequate education from the healthcare provider in any formverbal, audiovisual, or pamphlets; (4) whether such education improved their understanding of their disease condition; (5) whether such education helped them realize the risks associated with OSA; and (6) whether they were satisfied with their physicians management of their sleep-apnea condition on a 5-point Likert scale that ranged from very dissatisfied (score of 1) to very satisfied (score of 5).11 Also, they were asked to evaluate the sleep center on a 5-point satisfaction scale.11 Patients were asked whether they were continuing to use the PAP device or whether they had stopped using such therapy. Patients were also asked to report when they received their PAP device in
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relation to their first sleep study and the duration of time that they have had the PAP device. Potential confounders that may affect acceptance of PAP device were also measured: PAP pressure level, device type (automatic PAP, bilevel PAP, or continuous PAP), presence and severity of nasal congestion, age, sex, height, weight (for calculations of body mass index), and highest education (did not finish high school, finished high school, college, masters, or doctorate). Potential confounders for timeliness in healthcare delivery such as type of health insurance (HMO, PPO, POS, Medicare, or lack of any insurance) were also requested. Also, subjective improvement in sleepiness after the initiation of PAP therapy was measured using a 5-point Likert scale,12 and self-reported hours of PAP-device use was sought. Patient responses were saved in the file server and analyzed in aggregate. Questionnaire Validation We measured nasal congestion using a 5-point Likert scale that was previously administered to patients with sleep-disordered breathing.13 Nasal-congestion severity was scored in the following manner: 0 for never congested, 1 for rarely, 2 for sometimes, 3 for most of the time, and 4 for always. Additionally, we revalidated this 5-point Likert scale against a well-validated nasal symptom scale.14,15 We performed such validation in a separate cohort of 54 patients with OSA by correlating nasal-congestion scores obtained by our single question versus the previously wellvalidated, multiple-question nasal symptom scale. There was good consistency between the 2 measures (Cronbach coefficient of 0.79). Initial construction of questions relating to patient satisfaction was based on patient interviews. Subsequently, an initial data set of 50 patient responses and input from sleep-medicine experts was used to identify questions that made the largest contribution to variation in satisfaction scores and to shorten and edit the questionnaire. Internal consistency for the patient educationrelated questions was excellent (Cronbach coefficient of 0.93; questions 3, 4, and 5 in Appendix) and good for patientsatisfaction questions (Cronbach coefficient of 0.75; questions 7 and 8 in Appendix). Data Analysis ENDPOINTS The primary endpoint for analysis was discontinuation of PAP therapy. Secondary endpoints were (1) patients perceptions of education they received regarding OSA and risks associated with OSA, (2) time delay in instituting PAP therapy, and (3) overall patient satisfaction of the care delivered by the physician and center, measured separately. PREDICTORS AND COVARIATES In order to assess the combined dose-effect of sleep certification of physicians and AASM accreditation of the centers on patient outcomes, we assigned patients to 1 of 3 groups: (1) the physician was certified and the center was accredited, (2) either the physician was certified or the center was accredited, and (3) neither was the physician certified nor was the center accredited. From the list of predictors and potential confounders, simple logistic-regression analysis was performed to identify significant

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covariates that influenced discontinuation of PAP therapy. Subsequently, we built multivariate logistic-regression models with continued use of PAP device as the dependent variable using significant covariates identified by simple logistic-regression analysis (p < .05). Also, general linear models were constructed to identify determinants of timely delivery of care and self-reported adherence to PAP therapy (expressed as hours per week). Multicollinearity among independent variables was verified, and, in the event of collinearity, the strongest predictor variable alone was included. Nonparametrically distributed variablessuch as time delay were log transformed to meet assumptions of normality required for multiple regression. All analyses used a list-wise deletion strategy for missing values. Results are presented as mean and standard deviation unless otherwise specified. All tests for significance and resulting p values were 2-sided, with a significance level of .05. All analyses were performed using SPSS v12.0 (SPSS Inc., Chicago, IL). Unadjusted proportions were compared using Pearson 2 test with Bonferroni correction applied when appropriate. POWER ANALYSIS Acceptance of PAP-device therapy has been reported to range from 75% to 80% of patients who were prescribed such therapy.16,17 We assumed a PAP-acceptance proportion of 70% in patients cared for by nonaccredited centers or physicians and 80% in the AASM-accredited centers or physiciansa difference of 10%. Based upon such assumptions, we estimated that we would need 412 patients per groupa total of 824 responses (assuming also that is .05, 2-sided, power of 90% using 2). We report significant results from the planned midpoint interim analysis 444 responses with accreditation or certification status. RESULTS Description of Respondents Of the 842 hits to the web site containing the questionnaire, 632 responded to the survey (overall response rate of 75%). The mean age of patients was 51 10 years (range from 20-89 years) with 35% comprising women. Average body mass index was 35.7 8.9 kg/m2, and average continuous PAP pressure was 11.5 3.6 cm h2o, with 78% of patients having been prescribed continuous PAP devices. A minority of patients were prescribed automatic PAP (10%) and bilevel PAP devices (12%). Of the 632 responses, 444 patients had responded as knowing both their physicians certification status and their sleep centers accreditation status, while 188 patients were unaware of the accreditation status of their physician, the certification status of their sleep center, or both. Discontinuation of PAP Therapy and Adherence Of the 444 patients who identified physician-accreditation status and center-certification status, 16 (5%) of 307 patients who were cared for by certified physicians and accredited centers had stopped using their PAP devices. In contrast, 7 (7%) of 99 patients cared for by either certified physicians or accredited centers had stopped using their PAP devices, and 8 (21%) of 38 patients who were cared for by noncertified physicians and nonaccredited centers had stopped using their PAP device (2; p = .001)(Table 1). Besides accreditation or certification status, Table 2 shows the relationship between other significant covariates (derived from
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Table 1Proportion of Patients Who Discontinued PAP Therapya Certication status of physician/ Using PAP deviceb Total, n accreditation status of center No Yes Both 16 (5) 291 (95) 307 One 7 (7) 92 (93) 99 None 8 (21) 30 (79) 38 Total 31 (7) 413 (93) 444 Unadjusted proportions Data are presented as number (percentage). Pearson 2 test for association (p = .001) PAP refers to positive airway pressure; Both, both the physician was certied and the center was accredited; One, either the physician was certied or the center was accredited; None, neither the physician was certied nor was the center accredited; n= number of patients.
a b

Table 2Unadjusted Odds tion of PAP Therapy Variable Certication of physician Accreditation of center Lack of accreditation or certication Education regarding OSA Risk perception and education Severity of OSA Nasal congestion score Prescription for nasal congestion Age Sex Body mass index Continuous PAP pressure level Automatic PAP Health insuranced Highest education received

Ratios of Determinants of DiscontinuaB (SE) p value -0.82 (0.33) 0.015b -1.14 (0.39) 0.004b 0.73 (0.24) 0.003b -0.6 (0.32) -0.69 (0.32) 0.22 (0.38) 0.35 (0.16) - 0.83 (0.38) -0.04 (0.02) -0.59 (0.31) - 0.05 (0.02) -0.10 (0.07) 1.5 (1.0) -1.53 (0.54) -0.18 (0.46) OR (95% CI)a 0.44 (0.23-0.85) 0.32 (0.15-0.70) 2.07 (1.29-3.33)

0.036b 0.53 (0.24-0.95) 0.03b 0.5 (0.27-0.94) 0.56c 1.24 (0.59-2.6) 0.027b 1.42 (1.04-1.93) 0.03b 0.45 (0.21-0.92) 0.014b 0.06c 0.028b 0.14 0.96 (0.93-0.99) 0.55 (0.30-1.02) 0.96 (0.92-0.99) 0.89 (0.78-1.03)

0.14 4.5(0.6-33.2) 0.005b 0.22(0.08-0.62) 0.88 1.01(0.34-2.05)

PAP refers to positive airway pressure; estimated coefcient; SE, standard error; CI, condence intervals. a Unadjusted odds ratio (OR) b p < .05 c p < .10 d Compared to no insurance

Table 1) and discontinuation of PAP therapy. The odds ratios are hazard ratios for discontinuation of PAP therapy (Table 2). From Table 2, covariates were entered into a forward-regression model (Table 3). Block 1 consisted of covariates that are known to influence acceptance of PAP therapy (age, body mass index, and health insurance), block 2 consisted of covariates of interest (nasal-congestion score and medications for nasal congestion), and block 3 consisted of predictors (lack of accreditation or certification status or risk perception due to patient education). Multivariate logistic-regression analysis (Table 3) revealed that lack of accreditation of physician or certification of center and severity of nasal congestion score were independently associated with discontinuation of PAP therapy (Table 3). In contrast, patient education leading to enhanced perception of risk associated with OSA, having health insurance, and medications for nasal congestion protected against discontinuation of PAP therapy (Table 3). If both risk perception and lack of accreditation or certification

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Table 3Hierarchical Logistic Regression Estimating Discontinuation of PAP Therapy Variable B (SE) Adjusted OR 2 (95% CI) Step 1 7.66a Age 0.01 (0.02) 1.01 (0.97-1.05) BMI 0.05 (0.03)b 1.05 (0.99-1.11) Health insurance -1.64 (0.71)a 0.19 (0.05-0.77) Step 2 8.19a Nasal congestion 0.45 (0.22)a 1.57 (1.03-2.41) score 0.28 (0.10-0.81) Medications for nasal -1.27 (0.54)a congestion Step 3c 4.64a a Lack of accreditation or 0.62 (0.28) 1.86 (1.08-3.20) certication Step 3c Risk perception and - 0.77 (0.36)a 0.47 (0.23-0.93) education PAP refers to positive airway pressure; BMI, body mass index; estimated coefcient; SE, standard error; CI, condence intervals; 2 = change in 2. a p < .05 b p < .10 c Risk perception and lack of accreditation or certication were collinear; therefore they are inserted separately.

respectively (p = .057). General linear models built to adjust for confounders revealed that the self-reported usage of PAP device was explained by variables, similar to those in the logistic-regression models reported for discontinuation of PAP therapy (Table 3). While the combined dose-effect of certification or accreditation status, risk perception, prescription of nasal medications, and body mass index were directly related to self-reported adherence to PAP therapy, nasal congestion score was inversely related to self-reported adherence to PAP therapy (p < .05). Degree of improvement in subjective sleepiness was measured by a 5-point Likert scale that ranged from -1 (sleepiness is worse), 0 (no change), +1 (slightly improved), +2 (substantially improved), and +3 (completely resolved). As expected, the Likert scores for improvement in sleepiness were greater in patients who were continuing to use PAP therapy (1.76 0.78) than in patients who had discontinued such therapy (0.53 1.23; p < .0001)(question 27; Appendix). Moreover, the degree of improvement in sleepiness was directly correlated with the hours of self-reported adherence to PAP therapy (R = 0.44; p < .0001). Patient Education Certified physicians and accredited centers were more likely to provide adequate education to patients regarding OSA. Physician certification and center accreditation were associated with a greater proportion of patients receiving adequate education regarding OSA (Table 4). Seventy-seven percent of patients cared for by certified physicians and accredited centers reported receiving adequate education regarding OSA. In contrast, only 43% of patients cared for by noncertified physicians and nonaccredited centers reported receiving adequate education regarding OSA (p < .0001; Table 4). Similarly, the accreditation status of the caring physician and the certification status of the center were also directly related to the proportion of patients who received education that led them to perceive the risks associated with OSA (Table 4). Patients who were cared for by noncertified physicians and nonaccredited centers were more likely to seek information regarding OSA elsewhere than were those patients who were cared for by certified physicians and accredited centers (Table 4). Similar findings were noted when such educational endpoints were

status were entered into the model for Step 4 (not shown in Table 3), accreditation or certification status was no longer significant (B = -0.46; SE = 0.30; p = .12). This is likely due to significant collinearity between these 2 variables (r = -0.27, p < .001). These findings suggest that risk perception and education may mediate the relationship between accreditation or certification status and PAP discontinuation. Self-reported usage of PAP device was higher for patients cared for by accredited versus nonaccredited centers: 44.2 14.4 versus 39.6 19.8 hours per week, respectively (p = .017). Similarly, patients cared for by certified physicians tended to use their PAP device for longer durations than did patients cared for by noncertified physicians: 44.3 14.4 versus 41.3 18.6 hours per week,

Table 4Proportion of Patients Receiving Education Based on Physician-Certication and Center-Accreditation Status Education about OSA Risk perception Sought education elsewhere Yes No Yes No Yes No Physician certication statusa Certied 304 (73) 98 (24) 309 (75) 65 (16) 155 (50) 154 (50) Not certied 62 (44) 77 (24) 94 (48) 71 (36) 73 (63) 43 (37) p Valueb < .001 < .001 .02 Center accreditation statusa Accredited 290 (72) 98 (24) 284 (72) 102 (26) 148 (50) 146 (49) Not accredited 35 (47) 39 (52) 40 (53) 34 (45) 40 (65) 22 (35) < .001 .004 .056 p Valueb Accreditation-certication status (n=444)a Physician certied and center accredited 237 (77) 62 (20) 238 (78) 60 (20) 109 (49) 115 (51) Either physician certied or center accredited 57 (57) 42 (42) 51 (51) 48 (48) 49 (64) 28 (36) Neither physician certied nor center accredited 13 (33) 25 (64) 19 (49) 19 (49) 21 (62) 13 (38) < .001 < .001 .04 p Valueb Data are presented as number (percentage). OSA refers to obstructive sleep apnea. Patients responding as Dont know to receiving education or accreditation of certication status are not shown. b 2 test with Bonferroni correction.
a

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600 500

Time delay, days

150

100

50

0 0 50 100 150 200 250 300

Duration since issuance of PAP device, months

Figure 1Time delay for institution of positive airway pressure (PAP) therapy is regressed against patient-reported duration of time lapsed since issuance of PAP device (n = 569). Note that there has been a progressive lengthening of time delays in instituting PAP therapy (r = -0.22; p < .0001).

Table 5Determinants of Patient Satisfaction Score Evaluating Physicians and Centers Variable B (SE) p Value Satised with physician (dependent variable)a Model 1 (R2= 0.09) Log of time delay - 0.44 (0.10) < .0001b Discontinuation of PAP therapy -1.01 (0.32) .001b Non-certied physician -0.46 (0.13) < .0001b Model 2 (R2 = 0.21) Log of time delay -0.31 (0.09) .001b Discontinuation of PAP therapy -0.74 (0.23) .001 Risk perception 1.02 (0.10) < .0001 Satised with center (dependent variable)a Model 1 (R2= 0.15) Log of time delay -0.29 (0.09) .001b Discontinuation of PAP therapy - 0.75 (0.22) .001b Risk perception 0.72 (0.1) < .0001b Model 2 (R2= 0.08) Log of time delay -0.34 (0.12) < .0001b Discontinuation of PAP therapy -0.97 (0.29) .001b Nonaccredited center -0.49 (0.15) .001b PAP refers to positive airway pressure; B estimated coefcient; SE, standard error; CI, condence intervals. a Risk perception and lack of accreditation or certication were collinear; therefore they are inserted separately. b p < .05

analyzed after patients were grouped by physician-certification or center-accreditation status alone (Table 4). Timeliness of Care Timeliness of caretime delay between the first sleep study and when the patient received the PAP devicewas a median of 27 days (interquartile range; 7 to 30). Timeliness of care was not related to physician-certification or center-accreditation status, either individually or when considered together (P>.2). Timeliness of care was inversely related to the duration of therapy (R= - 0.22; p < .0001; Figure 1). Notably, the insurance status (insured versus not), type of insurance carrier, and issuance of an automatic PAP device were not associated with speedier service (p > .4). Patient Satisfaction Patient-satisfaction scores for care rendered by the physician with a highest score of 5 signifying greatest satisfactionwas higher in patients cared for by certified physicians (3.78 1.18) than noncertified physicians (3.19 1.27; p < .0001). After univariate regressions identified significant explanatory variables, general linear models revealed that the following were independently associated with lower patient-satisfaction scores: not perceiving the risk of OSA through education received, discontinuation of PAP therapy, noncertified physicians, and longer time delays (log of time delay) in instituting PAP therapy (Table 5). Patient-satisfaction scores for care rendered by the center with a score closer to 5 signifying greater satisfactionwas higher in patients cared for by accredited centers (4.11 0.98) than those cared for by nonaccredited centers (3.58 1.24; p < .0001). After univariate regressions identified significant explanatory variables, general linear models revealed that the following were independently associated with lower patient-satisfaction scores: time delays in instituting PAP therapy (log of time delay), nonaccredited centers, not perceiving the risk of OSA through education received, and discontinuation of PAP therapy (Table 5).
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Internal and External Validity Besides the good-to-excellent internal consistency between components of the questionnaire (Cronbach coefficient of 0.75 to 0.93; Methods section), we further checked the data for internal and external validity. First, for external validity, the demographics of our patient population (age, height, weight, and sex) and continuous PAP pressure level are very similar to those reported in other large series of patients with OSA.18-21 Moreover, the proportion of patients who received continuous, automatic, and bilevel PAP devices78%, 10%, and 12%is similar to prior reports22 (external validity). In order to further assess the internal validity, we correlated self-reported pressure level of the continuous PAP therapy versus self-reported body mass index. In our study, selfreported pressure level prescribed for continuous PAP therapy was positively correlated with body mass index (R = 0.41; p < .0001). DISCUSSION To our knowledge, this is the first study to show an effect of physician sleep certification and sleep center accreditation on discontinuation of PAP therapy and self-reported adherence to PAP therapy in patients with OSA. Moreover, in comparison with patients cared for by nonaccredited centers and noncertified physicians, patients cared for by accredited centers and certified physicians were more likely to have perceived the risks of OSA through education and were more satisfied with their care. Time delays in instituting therapy for patients with OSA were not influenced by accreditation-certification status of physicians and centers but unfavorably impacted patient satisfaction. In patients with OSA, worsening nasal congestion and lack of medications for nasal congestion are independent risk factors for discontinuing PAP therapy and low hours of device use.

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Risk Perception and Education Reports cite that between 25% and 50% of patients with OSA may abandon treatment during the first 2 to 4 weeks of treatment.23-26 Although physical factors such as poor mask fit, nasal congestion, and high pressure contribute to such nonadherence, psychological factors may play a major role as well.7,9 Using the social cognitive model,27 Weaver and colleagues developed a questionnaire-based instrument involving 3 major cognitions that play a role in adherence to PAP therapypatients perception of health risk associated with OSA, patients expectations of outcomes, and patients perceived ability to use the PAP device.7 In this instrument, perception of risk was an additional, and important component, believed to determine and predict patient behavior in response to therapy and considered an improvement over a prior model.9 Such perception of risk is usually imparted by educating the patient regarding disease-specific outcomes and health risks.27,28 In our study, education leading to a patients perception of risk due to OSA was associated with decreased odds for discontinuing PAP therapy (adjusted odds ratio [OR] 0.5, p = .03; step 3, Table 3). This is in agreement with other investigations showing the beneficial effect of intensive education on adherence to PAP therapy.29 Certification-Accreditation Status In our study, successful education of the patient regarding the health risks of OSA was performed more often by certified physicians and accredited centers than by noncertified physicians and nonaccredited centers (Table 4). Such education leading to risk perception may underlie the lower likelihood for discontinuation of PAP therapy in patients cared for by certified physicians and accredited centers than in patients cared for by noncertified physicians and nonaccredited centers. This is further supported by the collinearity between risk perception and accreditation or certification status in our regression model (Table 3). Besides promoting adherence to PAP therapy through education, physicians may favorably influence adherence to PAP therapy by other means: prescription of medications to relieve nasal congestion, heated humidifier,30 or choice of mask interfaces.31 We have previously reported differences in prescription practices among physicians of various specialties.32 Physicians who specialized in the parent fields for sleep medicinepulmonary medicine, neurology, and psychiatrywere less likely to prescribe sedatives to patients with as yet undiagnosed OSA.32 Conversely, a survey by Chervin and colleagues appears to indicate that there is wide variability in practice patterns of physicians managing patients with sleep problemsregardless of their certification status.33 In the present study, while prescription of medications for nasal congestion protected against discontinuing PAP therapy (OR 0.3, 95% CI 0.10.8; p = .02; Table 3), certified physicians were no more likely than noncertified physicians to prescribe medications for nasal congestion (p = .5; not shown). Therefore, such a mechanism is unlikely to be responsible for the effect of accreditation or certification status on discontinuation of PAP therapy. We chose discontinuation of PAP therapy as the primary endpoint because, currently, it is unclear as to what threshold of hourly PAP-therapy use is acceptable and what, if any, are the benefits associated with an extra hour of nightly usage.8 In keeping with this line of reasoning, we had originally powered the study based on continuation or discontinuation of PAP therapy and not hourly
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usage. Nevertheless, we did collect information regarding selfreported hourly PAP use, and the effects of accreditation or certification status on hour-based adherence to PAP therapy was no different than the effect of such status on discontinuation of PAP therapy. Moreover, while self-reporting of PAP-therapy usage is not as accurate as monitoring device compliance using microchip technology,26 we do not believe that a systematic bias would have occurred across the patient groups compared in our study. Nasal Congestion and Therapy Previous studies have identified nasal congestion and symptoms as important reasons for abandoning PAP therapy or poor adherence.7,34 However, a systematic measurement of nasal symptoms using validated questionnaires in patients using PAP therapy has not been performed. Often, such nasal symptoms are attributed to PAP therapy.35,36 In our study, however, patients who had already discontinued PAP therapy reported higher nasal-congestion scores than did patients who were continuing to use their PAP devices. This would suggest that nasal congestion might play an important role in acceptance of PAP therapy, and, conceivably, such a role may be independent of the effect of PAP therapy on nasal symptoms. Additionally, the importance of nasal congestion on discontinuation of PAP therapy is further emphasized by our finding that prescription of medications for nasal congestion protected against discontinuation of PAP therapy (OR 0.3, 95% CI 0.1-0.8; p = .02; Table 3). Satisfaction Rates Certified physicians and accredited centers achieved greater satisfaction ratings from patients than did noncertified physicians and nonaccredited centers. Other factors determining patient satisfaction were receiving education leading to perception of health risks associated with OSA and outcome of treatmentwhether they continued to use the PAP device or not and timeliness of care. This is consistent with other reports that have identified access to care and physician communication as important determinants of patient satisfaction.37,38 In light of this information, the sleep community and healthcare systems need to address the rising wait times (Figure). Wait Times We chose the time lapse between first sleep study and delivery of PAP device because these are points in time that the patient is more likely to remember. Our data are consistent with recent reports of time delays for sleep evaluation in the United States,10 but the magnitude of our wait times is lower than that reported by Flemons and colleagues.10 Such a difference is probably due to the fact that the 2 studies measured different timeframes along the timeline of care delivered to patients with OSA. Our data, however, allow relating the wait times to patient satisfaction and also provide trends that allow extrapolation. Limitations There are several limitations to this study. First, this is an observational study, making it difficult to attribute cause-and-effect relationships. Second, self-selection of patients agreeing to participate in this study may not be representative of the average patient. Third, although response rate was good, it is unknown

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as to how the nonrespondents may have influenced the results. Fourth, this Internet-based survey does not include patients without Internet access and may have discounted patients belonging to lower socioeconomic strata or patients with disabilities. Fifth, race demographic was not sought, but we do not believe that this would have significantly affected the sampling because our patients age, sex, height, and weight information are very similar to those in previous reports. Lastly, patients were asked to rely on their memoryespecially with regard to time delaysand such information may be prone to recall bias. ACKNOWLEDGEMENTS The authors are indebted to all the organizations that helped advertise the survey. The authors thank Mr. Joe Guilford (of cpapstore.com) and Mr. David Hargett (Chairman, American Sleep Apnea Association) for helpful suggestions and advertisement. Funded by SAVAHCS Research Award and American Sleep Medicine Foundation of the American Academy of Sleep Medicine. REFERENCES
1. 2. 3. 4. 5. 6. 7. Grant opportunities. American Academy of Sleep Medicine Bulletin. 2004.11;16. Nieto FJ, Young TB, Lind BK, et al. Association of sleep-disordered breathing, sleep apnea, and hypertension in a large communitybased study. Sleep Heart Health Study. JAMA 2000;283:1829-36. Drinnan MJ, Murray A, Griffiths CJ, Gibson GJ. Interobserver variability in recognizing arousal in respiratory sleep disorders. Am J Respir Crit Care Med 1998;158:358-62. Tsai WH, Flemons WW, Whitelaw WA, Remmers JE. A comparison of apnea-hypopnea indices derived from different definitions of hypopnea. Am J Respir Crit Care Med 1999;159:43-8. Tachibana N, Ayas NT, White DP. A quantitative assessment of sleep laboratory activity in the United States. J Clin Sleep Med 2005;1:2326. American Academy of Sleep Medicine. Professional Standards. Clinical Practice Parameters. Available at:http://www.aasmnet.org/ PracticeParam.aspx. Accessed June 26, 2005 Weaver TE, Maislin G, Dinges DF, et al. Self-efficacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure. Sleep 2003;26:727-32. Weaver T, Maislin G, Dinges D, Pack A, Multisite Study Group. CPAP dose duration for effective response. Am J Respir Crit Care Med 2003;167:A155. Stepnowsky CJ Jr, Marler MR, Ancoli-Israel S. Determinants of nasal CPAP compliance. Sleep Med 2002;3:239-47. Flemons WW, Douglas NJ, Kuna ST, Rodenstein DO, Wheatley J. Access to diagnosis and treatment of patients with suspected sleep apnea. Am J Respir Crit Care Med 2004;169:668-72. Otani K, Harris LE, Tierney WM. A paradigm shift in patient satisfaction assessment. Med Care Res Rev 2003;60:347-65. Weaver TE. Outcome measurement in sleep medicine practice and research. Part 1: assessment of symptoms, subjective and objective daytime sleepiness, health-related quality of life and functional status. Sleep Med Rev 2001;5:103-28. Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleepdisordered breathing. The University of Wisconsin Sleep and Respiratory Research Group. J Allergy Clin Immunol 1997;99:S757-62. Craig TJ, Teets S, Lehman EB, Chinchilli VM, Zwillich C. Nasal congestion secondary to allergic rhinitis as a cause of sleep disturbance and daytime fatigue and the response to topical nasal corticosteroids. J Allergy Clin Immunol 1998;101:633-7. Golden S, Teets SJ, Lehman EB, et al. Effect of topical nasal azelastine on the symptoms of rhinitis, sleep, and daytime somnolence in perennial allergic rhinitis. Ann Allergy Asthma Immunol 2000;85:53-7. 139

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16. Collard P, Pieters T, Aubert G, Delguste P, Rodenstein DO. Compliance with nasal CPAP in obstructive sleep apnea patients. Sleep Med Rev 1997;1:33-44. 17. Speer TK, Fayle RW. The effect of systematic desensitization and sensory awareness training on adherence to CPAP treatment. Sleep Res 1997;26:216. 18. Punjabi NM, Bandeen-Roche K, Marx JJ, Neubauer DN, Smith PL, Schwartz AR. The association between daytime sleepiness and sleep-disordered breathing in NREM and REM sleep. Sleep 2002;25:307-14. 19. Mendelson WB. The relationship of sleepiness and blood pressure to respiratory variables in obstructive sleep apnea. Chest 1995;108:966-72. 20. Chervin RD, Aldrich MS. The relation between multiple sleep latency test findings and the frequency of apneic events in REM and non-REM sleep. Chest. 1998;113:980-4. 21. Sin DD, Mayers I, Man GCW, Pawluk L. Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea. A population-based study. Chest 2002;121:430-5. 22. Parthasarathy S, Habib M, Quan SF. How are automatic positive airway pressure and related devices prescribed by sleep physicians? A web-based survey. J Clin Sleep Med 2005;1:27-34. 23. Zozula R, Rosen R Compliance with continuous positive airway pressure therapy: assessing and improving treatment outcomes. Curr Opin Pulm Med 2001;7:391-8. 24. Berthon-Jones M, Lawrence S, Sullivan CE, Grunstein R. Nasal continuous positive airway pressure treatment: current realities and future. Sleep 1996;19:S131-5. 25. Reeves-Hoche MK, Meck R, Zwillich CW. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med 1994;149:149-54. 26. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993;147:887-95. 27. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215. 28. Haynes RB. Introduction. In: Taylor DW, Sackett DL, eds. Compliance in heath care. Baltimore: Johns Hopkins University Press; 1979:1-7. 29. Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med 1999;159:1096-100. 30. Massie CA, Hart RW, Peralez K, Richards GN. Effects of humidification on nasal symptoms and compliance in sleep apnea patients using continuous positive airway pressure. Chest 1999;116:403-8. 31. Massie CA, Hart RW. Clinical outcomes related to interface type in patients with obstructive sleep apnea/hypopnea syndrome who are using continuous positive airway pressure. Chest 2003;123:1112-8. 32. Lu B, Budhiraja R, Parthasarathy S. Sedating medications and undiagnosed obstructive sleep apnea: physician determinants and patient consequences. J Clin Sleep Med 2005;1:367-71. 33. Chervin RD, Moyer CA, Palmisano J, et al. Sleep disordered breathing in Michgan: a practice pattern survey. Sleep Breath 2003;7:95-104. 34. Janson C, Noges E, Svedberg-Randt S, Lindberg E. What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment? Respir Med 2000;94:145-9. 35. Grunstein RR. Sleep-related breathing disorders. Nasal continuous positive airway pressure treatment for obstructive sleep apnoea. Thorax 1995;50:1106-13. 36. Richards GN, Cistulli PA, Ungar RG, Berthon-Jones M, Sullivan CE. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med 1996;154:182-6. 37. Hays RD, Brown JA, Spritzer KL, Dixon WJ, Brook RH. Member ratings of health care provided by 48 physicians. Arch Intern Med 1998;158:785-90. 38. Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med 1999;14:409-17.

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APPENDIX: Questionnaire This is a research survey. Participation in this survey is entirely voluntary. The purpose of this study is to determine patients' perception of the care they received for their SLEEP APNEA condition. Please respond to this questionnaire only if you have been diagnosed with OBSTRUCTIVE SLEEP APNEA and if you are at least 20 years old. Participation is anonymous, and the responses will be used only for research purposes and analyzed in aggregate. There is no remuneration for participation. 1. Was the physician who managed your sleep apnea a SLEEP EXPERT? You can check this website if your sleep physician is certified in sleep medicine. (html link to AASM web site with list of certified sleep physicians) Yes No Dont know Was the sleep center (the place where you had your sleep study or portable sleep study hooked up) certified by the American Academy of Sleep Medicine? You can check to see if your center is AASM accredited at this web site (html link to AASM web site with list of certified sleep centers) Yes No Dont know Did you receive ADEQUATE education about sleep apnea from your providers? (Verbal, audiovisual aids, pamphlets, brochures or other) Yes No Dont know Did such education improve your understanding of sleep apnea? Yes No Dont know Did such education help you realize the risks associated with sleep apnea? Yes No Dont know If you did not receive satisfactory education regarding the risks of sleep apnea from your physician and sleep center, did you receive it elsewhere? Yes No Not applicable How satisfied are you with the care you have received from your physician for your sleep apnea condition? Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied How satisfied are you with the care you received from the sleep center? Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied
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Appendix Cont. 9. Currently, are you using a CPAP, BiPAP, or auto-PAP machine? Yes No

10. During a typical night, how many hours do you use the machine? ____ hrs 11. During a typical week, how many days do you use your (CPAP, BiPAP, or auto-PAP) machine? ____ nights 12. How severe is your sleep apnea? Mild Moderate Severe Dont know 13. Do you experience nose congestion? Never Rarely (once a month) Sometimes (2 to 4 times a month) On most days (5 to 15 times a month) All the time (16 to 30 times a month) 14. If you suffer nasal congestion, were you prescribed any medications to relieve such congestion? Yes No 15. If you are on CPAP, what is your prescribed CPAP level? ____ cm H2O 16. If you are on BiPAP, what are the upper and lower levels (Example: enter as "14/6") ____ / ____ cm H2O 17. Are you using an auto-PAP (otherwise called a smart CPAP) machine? Yes No Dont know 18. What is your gender? Male Female 19. How old are you? ____ years 20. How much do you weigh? (lbs) _____ lbs 21. How tall are you? (feet and inches; example: 5'6") ___ ft ___ in 22. How long has it been since you were issued a CPAP machine (in months)? ____ months 23. How many days did it take between your FIRST sleep study and when you received the machine for treating sleep apnea? (Not applicable if you were never prescribed such a machine) ____ days
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Appendix Cont. 24. What kind of insurance did you have at the time your sleep apnea was diagnosed and treated? HMO PPO POS Medicare VA No insurance Dont know 26. What is your highest education level? Did not graduate from high school Graduated high school College Masters Doctorate 27. Have your symptoms of sleepiness improved? Completely resolved Substantially improved Slightly improved No change Worse

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