Limitations of this study included the relatively small sample size of 150 patients who were studied, and limitation of the study to a single internal medicine practice. Between time 1 and time 2, the practice underwent changes in office structure, which involved moving to a direct primary care practice that includes a fee for service. Because of the changes in the practice, a new EMR was implemented, and therefore BMI data were unable to be collected at time 3 for all patients.

Implications for Practice

The implications of this project are noteworthy. The findings indicate that a simple intervention involving adding the ESS to the EMR can identify patients with OSA who would have otherwise been undiagnosed; this could lead to better patient outcomes by diagnosing and treating patients with OSA before adverse effects occur. After patients are flagged as high risk by the ESS tool (a score of ≥10), the clinician can then refer the patient for a sleep study, on the basis of which continuous positive airway pressure therapy may be initiated. According to the project findings, there exists the potential for an entirely different group of patients to be identified at risk for OSA. This project could be expanded to other offices, as well as to the hospital setting.

Recommendations for future research are to not simply add the ESS to the EMR, but to create a hard stop that requires providers to screen every patient. By implementing the ESS in the EMR with a hard-stop feature, there is a built-in system for sustainability of routine screening. In time 2, the ESS was available to the provider in the EMR; however, no ESS data were obtained or documented. Therefore, it is recommended that the ESS be used on every patient seen in the office, whether reporting symptoms of sleep-related disorders or asymptomatic.


OSA is a significant health issue that often goes undiagnosed. This project evaluated the use of screening all patients in an internal medicine office, finding that screening resulted in a 20% increase in detection of patients at high risk for OSA, as indicated by an ESS score of 10 or more. This finding is significant in that more widespread screening can result in earlier diagnosis and referral for a sleep study and potentially the addition of continuous positive airway pressure therapy. The literature supports screening as an effective tool for diagnosis of OSA. This is important, as undiagnosed OSA is associated with comorbidities such as cardiovascular disease, stroke, diabetes, and depression.3,6,11,12 Clinicians are encouraged to adopt ESS screening in their practice, and to perform screening on every patient, even those who do not report symptoms suspicious of OSA.


1. Colten HR, Altevogt BM. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: National Academy Press. 2006.

2. Knauert M, Naik S, Gillespie MB, Kryger M. Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome. World J Otorhinolaryngol Head Neck Surg. 2015;1(1):17-27.

3. Maeder MT, Schoch OD, Rickli H. A clinical approach to obstructive sleep apnea as a risk factor for cardiovascular disease. Vasc Health Risk Manag. 2016;12:85-103.

4. Tamanna S, Ullah MI. Sleep apnea and cardiovascular disease. Cardiovasc J. 2016;8(2):143-148.

5. Basoglu OK, Tasbakan MS. Elevated risk of sleepiness-related motor vehicle accidents in patients with obstructive sleep apnea syndrome: a case-control study. Traffic Inj Prev. 2014;15(5):470-476.

6. Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311-1322.

7. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM. Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep. 2004;27(3):453-458.

8. Leger D, Bayon V, Laaban JP, Philip P. Impact of sleep apnea on economics. Sleep Med Rev. 2012;16(5):455-462.

9. Perlman S. Sleep apnea and workplace safety. BCMJ. 2014;56(2):94-96.

10. Soylu O, Erboy F, Ornek T, et al. Prevalence of snoring and obstructive sleep apnea syndrome among nurses and resident doctors working in a university hospital. Eurasian J Pulmonol. 2014;16(2):105-109.

11. Maurer RE, Im K. Obstructive sleep apnea and depression: issues for psychiatrists. Psychiatric Times. 2016;33(8):1-5.

12. Wells ME, Vaughn BV. Poor sleep challenging the health of a nation. Neurodiagn J. 2012;52(3):233-249.

13. Pahwa P, Karunanayake CP, Hagel L, et al. Prevalence of high Epworth Sleepiness Scale scores in a rural population. Can Respir J. 2012;19(2):e10-e14.

14. McNicholas WT, Luo Y, Zhong N. Sleep apnoea: a major and under-recognised public health concern. J Thorac Dis. 2015;7(8):1269-1272.

15. Johns MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep. 1991;14(6):540-545.

16 Johns MW. Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth Sleepiness Scale: Failure of the MSLT as a gold standard. J Sleep Res. 2000;9(1):5-11.

17. Foldvary-Schaefer N. 5 surprising facts about sleep apnea. Published October 19, 2015. Accessed March 25, 2019.

18. Garbarino S, Guglielmi O, Campus C, et al. Screening, diagnosis, and management of obstructive sleep apnea in dangerous-goods truck drivers: to be aware or not? Sleep Med. 2016;25:98-104.

19. Grossman DC, Curry SJ, Davidson KW, et al; US Preventive Services Task Force. Screening for obstructive sleep apnea in adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(4):407-414.