A Minor Matter of Delay . . .
© Kerrin Leon White
It raises concern about the risk of accidents and other untoward events resulting from untreated obstructive sleep apnea (OSA) during the few weeks' wait usual between first clinical evaluation by the sleep specialist and first laboratory sleep study for definitive diagnosis of OSA. The study makes an important point, which may have far wider implications than the abstract indicates.
Researchers at the University of Texas in Houston asked 124 patients referred to a sleep disorders center, to complete questionnaires concerning adverse events related to excessive daytime sleepiness since the time of first referral to the sleep center.
Of these 124, 111 turned out to have sleep apnea, defined as having an Apnea Hypopnea Index greater than 10 apneas+hypopneas per hour of sleep. The remaining 13 turned out to have no evidence of sleep disorder; neither did they report any adverse experiences during their wait. Men outnumbered women by 3 to 1.
Half of the 111 patients with proven sleep apnea did report major adverse events during their wait for a laboratory study, which averaged 36 days. These events included falling asleep at work (34%) or at the wheel of the car (18%), automobile accidents (6%) or near-misses (18%), and others (11%) including demotion or firing at work.
The investigators commented that the procedure for patient referral, insurance approval, and scheduling for lab tests should be streamlined.
The brief summary available leaves it unclear whether the investigators thought further about the implications of their findings.
I did so, and realized that the single month of delay between referral and first sleep study represents only one of many and much longer delays between the first onset of sleep apnea symptoms and its first definitive treatment. I refer to delays between first symptoms and first suspicion on the part of patient or spouse that these symptoms may represent a serious disease needing evaluation. Also, there is sometimes a delay between first suspicions and first taking action in the form of bringing these symptoms to a doctor's attention. Often, if the doctor to whose attention these are brought does not have any knowledge about sleep disorders, further delay will take place before referral to a sleep specialist. Even then, resort of mediocre or ineffective "alternative" strategies to control sleep apnea, allowed as reasonable by the sleep clinician, may further delay first trial of CPAP. Combined, all these delays probably take up years, or even decades!
