From the 2022 HVPA National Conference
Zonair Khan MD (Cleveland Clinic Foundation), Jenna Carson MD, Michael Delicce MD, Abel Joseph MD, Jiafei Niu DO, Tarek Taha MD, Adeola Ishola MD, Everly Ramos MD, Rohan Vishwanath DO, Pena Noticewala MD, Jessica Donato MD
Obstructive Sleep Apnea (OSA) is associated with multiple co-morbidities, increased mortality, and economic burden.1 No consensus for OSA screening exists; the US Preventive Services Task Force (USPSTF) offers no formal recommendations, and the American Academy of Sleep Medicine (AASM) recommends annual screening in specific populations such as patients with hypertension, diabetes, and obesity. 2,3
Use of the validated STOP-BANG questionnaire represents a practical opportunity for screening and subsequent diagnosis of OSA.
Our QI project sought to increase the percentage of patients in resident primary care panels with hypertension, diabetes mellitus type II, and/or obesity screened for OSA with STOP-BANG by 20% in 9 months.
Patients and Methods
In our large academic internal medicine program involving multiple resident clinic sites, baseline data established the percentage of eligible patients screened for OSA. Exclusion criteria consisted of prior OSA diagnosis, sleep testing within the past year, and hospital follow-up or acute visit encounters. Investigation of the current state through process mapping and use of a fishbone diagram revealed that the lack of trigger in clinic workflow was one of the root causes. The first intervention incorporated use of a “Badge Backer,” a laminated card that listed indications for screening and exclusion criteria and was attached behind residents’ ID badges used to access the EMR. A second PDSA cycle utilized standardized pre-charting with the addition of columns in the EPIC schedule template for BMI, blood pressure, and HbA1c, which visually displayed the indications for screening upon entering the schedule as a trigger to enter a widely available STOP-BANG dot phrase into the note template.
At baseline, 20% of eligible patients were screened. Following PDSA Cycle 1, 26.8% (11/41) of patients were screened. Following PDSA Cycle 2, 53.9% (34/63) of patients were screened. All participating residents added the “Badge Backer” to their ID badges; however, only 67% found that it triggered screening. 100% of participating residents incorporated the EPIC columns into their schedule templates, and residents referred to these columns during pre-charting for 98% of their visits with patients eligible for screening.
This resident-led QI initiative demonstrated that a lack of trigger within the clinic workflow was a primary driver of inadequate OSA screening. Two attempts to address this were implemented with the standardization of pre-charting being the more successful intervention by more than doubling the number of patients screened. This intervention will be sustained with these columns remaining a consistent part of the EPIC schedule template. Plans for spread include an oral presentation of this intervention to the entire internal medicine residency program.
Screening is a cornerstone of effective primary care but can be challenging among innumerable health maintenance topics to address. By incorporating an effective trigger to increase the number of high-risk patients screened for OSA, there is opportunity for increased diagnosis and treatment of OSA. This will improve patient outcomes, thereby, reducing the associated economic burden of delayed and missed diagnoses and fostering higher value care.
1. Knauert M, et. al. Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg. 2015;1(1):17-27. Published 2015 Sep 8.2. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(4):407–414. 3. American Academy of Sleep Medicine Health Advisory: Obstructive Sleep Apnea Screening. August 18, 2017