Obstructive sleep apnea (OSA) is the most common sleep disorder affecting Americans; approximately 80% of patients who report poor sleep have undiagnosed OSA.1 Sleep apnea is consistently described as the collapse of the upper airway during sleep, which causes hypoxemia. When hypoxemia ensues, the individual awakens and sleep is fragmented.2-4 This cycle continues through the night and causes numerous problems such as daytime sleepiness from poor sleep quality, depression, motor vehicle accidents, workplace errors, and chronic conditions such as cardiovascular disease.1,3,5,6 Because of the harmful effects of untreated OSA, it is imperative that patients be diagnosed and effectively treated to prevent adverse outcomes.

Patients with untreated OSA are at a 3-fold increased risk for motor vehicle accidents when driving compared with the general population.5 According to Knauert et al, if patients with OSA were diagnosed and treated with at least a 70% adherence rate, approximately 500,000 collisions could be prevented.2 This would result in approximately 1000 lives saved with a cost savings of approximately $11.1 billion. In a study by Sassani et al, more than 800,000 drivers were involved in accidents related to undiagnosed or untreated OSA in 2000.7 These collisions cost $15.9 billion, and 1400 lives were lost.7 Untreated OSA costs as much as $3.4 billion in additional medical costs each year.8 The number of physician visits, medication use, and unemployment rates were significantly higher in patients with undiagnosed OSA vs patients without OSA or those successfully treated for it.8 Thus, OSA is a major public health problem for which treatment could benefit both the patient and the community.

Patients with untreated OSA have been shown to have numerous cognitive disturbances, which can lead to poor work performance and quality of life.1 This is particularly important in safety-sensitive jobs, such as healthcare providers, public transportation drivers, and over-the-road truckers.9 In a study by Soylu et al, the number of incidents involving nurses — including medication errors, selection of incorrect surgical instruments, and needlestick injuries — was significantly increased among those with daytime sleepiness.10 Daytime sleepiness is one of the most important indicators of OSA.4

Sleep apnea also has an effect on chronic diseases. According to Maeder et al, OSA can cause sympathetic activation, oxidative stress, and systemic inflammation.3 These effects can have detrimental consequences on the cardiovascular system, including hypertension, diabetes, coronary artery disease, cardiac arrhythmias (including atrial fibrillation and sudden cardiac death), and heart failure. Other studies have found links between OSA and stroke, depression, and all-cause mortality.6,11,12 Although many studies have demonstrated the value of diagnosing and treating patients with OSA, there is a paucity of studies that address screening for OSA in all patients.

Identification of individuals with symptoms of OSA can be easily captured with a screening questionnaire. This is frequently done with the Epworth Sleepiness Scale (ESS), which has been validated as a clinical indicator for excessive daytime sleepiness and can be used to determine whether referral for a sleep study is indicated.13 It is important to determine an ESS score for all patients, as OSA may be clinically unsuspected and left undiagnosed for some time, largely because symptoms of snoring and daytime sleepiness are often considered normal and frequent complaints of individuals in society today.14

Quality Improvement Project

The purpose of this undertaking was to evaluate the use of the ESS before and after the tool was added to an EMR to screen all patients in an internal medicine office for daytime sleepiness. Questions explored were: What is the baseline rate of screening using the ESS, and how does it compare with rates after adding the ESS to the EMR? Will use of the ESS to screen all patients, not only those with reported symptoms, increase the number of patients who are referred for polysomnography?