Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment

IN RESPONSE: Dr. Parthasarathy and colleagues suggest that several aspects of our systematic review limit our conclusions. We disagree. First, we noted the limitations in, and low strength of, the evidence indicating that care by NSSs and SSPs resulted in similar outcomes in adults with known or suspected obstructive sleep apnea. Second, we did not provide pooled results, because of the paucity and heterogeneity of studies reporting quality of life, adherence, and Epworth Sleepiness Scale (ESS) scores, a decision suggested by the journal's editors. We noted that none of the 5 randomized controlled trials reporting adherence found a statistically or clinically significant difference between the NSS and SSP groups. The pooled adherence results provided by Dr. Parthasarathy and colleagues were not statistically significant, and their reported mean difference did not achieve the clinically important threshold defined by a consensus of selected sleep experts and adopted by the American Academy of Sleep Medicine (1). We also described that care provided by both NSSs and SSPs resulted in clinically significant mean reductions in daytime sleepiness from baseline as measured by ESS scores but that there were no between-group differences when comparing NSS with SSP care. Care provided by both NSSs and SSPs resulted in clinically significant mean reductions in daytime sleepiness from baseline as defined by a consensus-based, 2-point improvement in the ESS score. There were no between-group differences in ESS score improvement when comparing NSS with SSP care. Third, our explicitly stated focus was the comparison of outcomes associated with care provided by SSPs versus that offered by providers with different qualifications. Nurses were therefore classified as NSSs even if they were highly experienced in sleep medicine. We noted the high level of experience of NSSs in these studies, raised caution about widespread implementation, and encouraged research in settings with less experienced NSSs. We excluded from our analysis the 2 studies referenced by Dr. Parthasarathy and colleagues (2, 3) because they compared board-certified SSPs or accredited facilities with nonboard-certified SSPs or nonaccredited facilities rather than NSSs with SSPs. We cited these studies and their results in the Discussion section. Finally, we strongly disagree with Dr. Parthasarathy and colleagues' suggestion that our review was biased and excluded inconvenient data. We adhered to the PRISMA checklist (4) and used standard methods for literature searching, study selection, data synthesis, and assessment of risk of bias and strength of evidence. Our review underwent extensive peer review and revisions. In summary, given the limited supply of SSPs and the high prevalence of obstructive sleep apnea, our systematic review indicates that some initial diagnosis and management of suspected obstructive sleep apnea might be feasible by NSSs with subspecialty support for more complex cases. However, further studies are needed to determine whether NSSs can achieve similar outcomes to SSPs in nonacademic centers and among primary care providers without extensive sleep medicine experience.