Primary versus Specialist Care for Obstructive Sleep Apnea: A Systematic Review and Individual-Participant Data-Level Meta-Analysis
Emer Van Ryswyk, Iván D. Benítez, Alexander Sweetman, Núria Nadal, Ching Li Chai‐Coetzer, Juan F. Masa, F.J. Gómez de Terreros, Robert Adams, Manuel Sánchez‐de‐la‐Torre, Nigel Stocks, Billingsley Kaambwa, R. Doug McEvoy, Ferrán Barbé
Abstract
Abstract Rationale Primary care clinicians may be well placed to play a greater role in obstructive sleep apnea (OSA) management. Objectives To 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, sex, severity of OSA, and daytime sleepiness impacted outcomes. Methods Data sources were the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP, Scopus, ProQuest, U.S. National Institutes of Health Ongoing Trials Register, and 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 2 units) at baseline and follow-up. Results The 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 mm Hg), with similar findings in the per-protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (−$448.51 U.S.), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for subgroups in both management settings. Conclusions Similar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea.