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So applying for OSA screening tools and what is the role of home sleep studies and how we can support these diagnostic pathways. So this is another question, so primary care physicians, in your primary care pathway, what most often drives escalation from suspected OSA to testing or referrals? Symptoms alone, valet to OSA questionnaire, it with sleepiness score, cardiomyelabot risk profile and local pathway of specialist requirements. So give you time to answer this. So I guess there's no right or wrong answer here and I think it really depends on what your uh preference is and I think all these answers could be correct. So let's go to patient case three to illustrate our learning point. 61 year old man with obesity, hypertension, diabetes and dyslipidemia, moderate moderate severe obesity BMI of 37, hypertensive despite anti-hypertensive medication, diabetic and hyperlipidemia, reports fatigue, unrefreshing sleep, loud snoring, but no witness apneas. It was scores 9, but no validated OSA questionnaire was completed. Sleep referral was deferred because referral thresholds were unclear, and cardio metabolic therapy was intensified, but no referral for sleep studies were made. So primary care physicians can play a key role in timely assessment and care of patients with RSA. With the increasing prevalence of RSA waiting times for assessment care with specialized services has simply increased, and we know that. So interest in the role of primary care and RSA care has grown because this is the majority of patients see you, not us. Primary care are actively involved in management of many chronic diseases and play and can play a greater role in timely assessment and care of OSA. Shorter waitlists for assessment, care leads to better adherence to CPAP therapy and reduced daytime sleepiness. In some healthcare systems, primary healthcare are required to assess those, they suspect of having sleep apnea prior to a sleep study. And we know the questionnaires can be very useful, stop bang OSA 50, Berlin questionnaire which I've shown before, and sleep with sleep with sleepiness scores to assess whether OSA patients are symptomatic. So the landscape for primary care management is shifting. And I guess it's analogy, like when insulin came out with diabetes, it was a specialist only. But you guys look after diabetes now and I think with sleep apnea it's you guys as well. So I think it's important that you're aware of OSA, the screening pathways, the different questionnaires, the it was sleepiness score and when to refer for sleep studies. And we know in patients that are managed by GPs who are aware of OSA. Diagnosis, treatment options, versus a specialized sleep unit, that there's actually no difference in outcomes. But the caveat here is that the GPs who were involved with OSA care were educated in terms of OSA assessment and management, but they had non-inferior outcomes to the typical specialist led pathways. The also caveat with this study was that the patients that were, Included in the study were generally speaking not complicated. These were not patients that had dementia and OSA, heart failure and OSA, severe COPD and OSA. So in patients with uncomitated OSA, I think primary care can work just as well as specialist sleep units in terms of management and outcomes. So the screening questionnaires are important, the stop bang, the OSA 50, and the Berlin questionnaire. I think the stop bang and OSA 50 tend to be the easier ones to use. I find the Berlin a bit harder. The important thing about these questionnaires is they have high sensitivity but low specificity. So there's a high false positive rate. Because of the high false positive rate, even though they're very sensitive tests, we still have to do a sleep study. So you need something objective to confirm the diagnosis. As mentioned, you can't make a diagnosis based on the questionnaire by itself. So the it was sleepiness score is important. This measures subjective daytime sleepiness, and this will guide you in terms of how you screen for patients with sleep apnea and also response to treatment as well. So it was sleepiness score has been around for a number of decades. There was some controversial. with the it was sleepiness score, but some of the questions now are not relevant to 2026. You know, sitting quietly after lunch without alcohol. I don't know how many people work and have alcohol at lunchtime nowadays when they're working. But that's a different uh research question. So positive RSA screened by a primary health care physician prompts varying levels of sleep study testing. So level one testing, the gold standard polysommography, the problem with this test is long waitless, um, expensive, um, and I think in patients that are uncomplicated. Who do not have significant comorbidities, you're not suspecting another sleep disorder, I don't think you need a level 1 sleep study. I think a level 2 unattended full PSG or even a level 3 study, which is a limited channel sleep study that focused more on cardio respiratory end points like oximetry and respiratory bands, even level 4 study may be satisfactory. But they have to be they have to be supervised and they have to be reported by a practitioner who's experienced in sleep medicine. So, level one sleep study is the gold standard, it's limited by access, and it's important for people that have complex sleep apnea, significant comorbidities. Or there's other steep conditions going on. Or level 234, which are more simplified tests that you can do at home. These are satisfactory and probably fine in patients with uncomplicated possible obstructive sleep apnea based on the screening questionnaires and the it was sleeping score. As long as the reports have been reported by sleep physicians who have access to the raw data, which I think is important. You have obviously high pre-test probability for sleep apnea. So, primary care physicians can use a structured diagnostic pathway to support the timely assessment and care with sleep apnea. So patients with symptoms suggestive I will say you do the questionnaires if they've got a high sleepiness score, you can refer for a sleep study, be it level 1 or level 2, based on your assessment. It doesn't have to be specialist. But I think a specialist should be involved if there are complex presentations, certificate comorbidities, if there are, Driving issues or work related issues, or if you're worried about uh other sleep disorder out there. So let's go to polling question 6. The patient had a slight bang of 5 at a score of 9, obesity, hypertension, diabetes, but no major complexity markers. What is the best next step? A reassuring review of symptoms worsen. They've got a posture questionnaire, 2 repeat questionnaires in 12 months' time, 3, intensify hypertension diabetes treatment only. D, arrange for sleep testing referral now. A, wait for witness apneas to occur. So I'll give you a little bit of time to answer this. So I think the correct answer is D here guys. I think we need to refer for a sleep study. This patient has obesity, comorbidities, symptoms, he's got a positive screening questionnaire in terms of a stop bang and it was sleep with a score of 9. I think he needs a sleep study to confirm obstructive sleep apnea. Stratification, cause you want to know the degree of sleep apnea they have. And I think a home sleep study or level two would suffice, uh, particularly in the base of this patient does not have any other major complexity markers such as heart failure, dementia, previous stroke, poor mobility, etc. So back to our patients, stop banger 5 was applied, 5 out of 8, sleepiness, EPA score of 9, consistent with mild sleepiness, no complexity markers identified, so you don't really need to do an in-lab sleep study. This patient had a level 3 sleep study which mainly focused on cardio metabolic bands, and as per primary care pathway, the sleep study confirmed moderate to severe sleep apnea. Their respiratory event index was 28 events per hour with an auction ID of 84%, and OSA treatment referral initiated promptly after results were reviewed, and the follow-up is obviously the baseline sleepiness, symptoms, BP, hemoglobin AC, weight and treatment outcomes.