Primary vs. Specialist Care for Obstructive Sleep Apnea: A Systematic Review and Individual Participant Data Level Meta-Analysis.

Abstract

RATIONALE\nPrimary care clinicians may be well placed to play a greater role in obstructive sleep apnea management.\n\n\nOBJECTIVES\nTo evaluate the outcomes and cost-effectiveness of sleep apnea management in primary versus specialist care, using an individual-participant data meta-analysis to determine whether age, gender, severity of OSA and daytime sleepiness impacted outcomes.\n\n\nMETHODS\nData sources were CINAHL, CENTRAL, MEDLINE Ovid SP, Scopus, ProQuest, US NIH Ongoing Trials Register, ISRCTN registry [inception until 09-25-2019]. Hand-searching was undertaken. Two authors independently assessed articles and included trials that randomized adults with a suspected diagnosis of sleep apnea to primary versus specialist management within the same study and reported daytime sleepiness using the Epworth Sleepiness Scale (range 0-24; >10 indicates pathological sleepiness; minimum clinically important difference two units) at baseline and follow-up.\n\n\nRESULTS\nThe primary analysis combined data from 970 (100%) participants (four trials). Risk of bias was assessed (Cochrane Tool). One-stage intention-to-treat analysis showed a slightly smaller decrease in daytime sleepiness (0.8; 0.2 to 1.4), but greater reduction in diastolic blood pressure in primary care (-1.9; -3.2 to -0.6 mmHg), with similar findings in the per protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (-$448.51 USD), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for sub-groups in both management settings.\n\n\nCONCLUSIONS\nSimilar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea. Registration: PROSPERO (CRD42020154688).