Assessing the prioritization of primary care referrals for polysomnograms

EVIDENCE CONTINUES TO EMERGE IDENTIFYING THE NUMEROUS HEALTH EFFECTS ASSOCIATED WITH UNTREATED OBSTRUCTIVE SLEEP APNEA (OSA).1–7 With recent epidemiologic studies suggesting an at-risk prevalence as high as 26% of the US adult population,8,9 and a mortality as high as 20 deaths per 1,000 person-years,10 the nationwide impact of untreated OSA is significant.11 Fortunately, continuous positive airway pressure (CPAP) is a cost-effective treatment for the majority of moderately affected patients.12,13 However, proper OSA treatment requires appropriate and expensive diagnosis in the form of polysomnography (PSG).14 Primary care physicians have a unique opportunity to intervene in this disease, given the high percentage of symptomatic patients presenting to their practices.15–20 However, studies suggest that primary care physicians may not be aware of the adverse outcomes associated with untreated OSA.17 As a result, they may be less likely to address OSA during health maintenance visits.21,22 We sought to examine the frequency of and factors associated with polysomnogram referrals for patients at high risk for OSA attending primary care clinics at an inner-city public hospital. Because of the expense associated with polysomnography, we were interested in the role insurance status played in polysomnogram referrals. We were also interested in knowing if such patients underwent referral for polysomnograms at the same rate as they underwent referral for 2 other common screening tests: mammograms for breast cancer, and fecal occult blood testing (FOBT), colonoscopies, or flexible sigmoidoscopies for colon cancer. Breast and colon cancer were chosen as comparative diseases because their mortality rates are similar to that of OSA.10,23