PUPC Conference Coverage

Improving Diagnosis and Referral of Obstructive Sleep Apnea in Primary Care

Miranda Manier, BA

Key Highlights

  • Obstructive sleep apnea (OSA) affects roughly one-third of men and nearly one-fifth of women in the US, but up to 80% of moderate to severe cases remain undiagnosed.
  • OSA is strongly associated with increased cardiovascular and cerebrovascular risk, including atrial fibrillation, stroke, and heart failure.
  • Appropriate use of home sleep apnea testing (HSAT) and polysomnography (PSG) depends on comorbidities, clinical suspicion, and insurance policies.
  • CPAP therapy is the mainstay of treatment, while alternative therapies—such as oral appliances, airway stimulation devices, and GLP-1 agonists—are expanding options for patients.

Obstructive sleep apnea (OSA) remains a common yet underrecognized condition with profound implications for patient health. During a presentation on May 8 at the Practical Updates in Primary Care Virtual Meeting, Julianne Blythe, MPA, PA-C, RPSGT, discussed the clinical burden of OSA and provided practical guidance on testing and referral strategies.

Dr Blythe highlighted that although 33.9% of men and 17.4% of women in the United States are affected, 80% of moderate-to-severe OSA cases are still undiagnosed. Symptoms such as snoring, daytime fatigue, and insomnia are often overlooked, particularly in non-obese and female patients, leading to delays in diagnosis and management.

OSA is associated with a spectrum of comorbid conditions, including obesity, treatment-resistant hypertension, atrial fibrillation, stroke, and type 2 diabetes. OSA is present in up to 65% of patients with coronary artery disease and 55% of those with a history of stroke. The condition contributes to endocrine dysfunction, such as lowered testosterone levels in men, and increased risk for sleep-disordered breathing in women with polycystic ovary syndrome. OSA may also exacerbate depression, cognitive decline, and has been linked to increased cancer risk due to intermittent hypoxia.

To facilitate diagnosis, clinicians are encouraged to use tools like the Epworth Sleepiness Scale (ESS) and the STOP-Bang questionnaire, which measures Snoring loudly, Tiredness during the day, Observed apnea, Pressure (high blood pressure), BMI, Age, Neck circumference, and Gender. Physical examination findings such as Mallampati class II-IV, macroglossia, crowded dentition, and increased neck circumference are suggestive of OSA.

For diagnostic evaluation, Dr Blythe explained that polysomnography (PSG, Type I) remains the gold standard due to its comprehensive data capture, but home sleep apnea testing (HSAT, Types III and IV) is suitable for many patients, particularly those with a high pre-test probability and no significant cardiopulmonary disease.

HSAT is generally preferred by insurance carriers, and in some states, coverage of in-lab PSG is contingent upon a prior HSAT or documented failure of HSAT. Medicare requires documentation of symptoms like snoring or witnessed apneas for approval. PSG is indicated when parasomnias, neuromuscular disorders, or other complex conditions are suspected.

Treatment of OSA typically begins with CPAP, which is effective in 90% to 100% of patients. However, adherence varies, and Dr Blythe discussed that alternative options are available. These include auto-adjusting continuous positive airway pressure, bilevel positive airway pressure, mandibular repositioning devices, and surgically implanted upper airway stimulation systems. Additionally, the glucagon-like peptide-1 receptor agonist tirzepatide was recently approved for the treatment of moderate to severe obstructive sleep apnea (OSA) in patients with obesity, reflecting a growing role for pharmacologic intervention.

Dr Blythe concluded her presentation by emphasizing the efficiency of tiered diagnostic approaches for appropriate patient populations.

“If the HSAT confirms diagnosis of OSA, there is no further need to confirm with in-lab PSG,” she said.

Reference

Blythe J. Obstructive Sleep Apnea: Testing and Referring Guidelines. Practical Updates in Primary Care. May 8, 2025. https://www.hmpglobalevents.com/pupc