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Now we will shift to the 3rd objective of our program. So this is really implementing simplified diagnostic algorithms and integrated cardio metabolic obstructive sleep apnea care pathways. So the polling question 5. In your setting, what usually happens when a high-risk patient is suspected of moderate to severe obstructive sleep apnea, but in laboratory polysomnography access is delayed? A. The patient waits for in laboratory polysomnography. B. The patient is referred to a sleep specialist. C. Home sleep apnea testing is arranged. D. Cardiometabolic care is continued without obstructive sleep apnea testing. E. The next steps vary by sight, hair, or availability. So I'll give you some time to answer. So we'll move on to our third patient case. So we have a 50-year-old male with obesity resistant hypertension and diabetes, body mass index of 37, BP elevated at 156/94, hemoglobin A1C elevated at 8.2. He has loud snoring, witness apneas, morning headaches, and daytime sleepiness. Upwards sleepiness scale score is 14, and there's a high suspicion for moderate to severe obstructive sleep apnea. The in laboratory polysomnogram wait time, however, several months, and there's no home sleep apnea testing pathway or sleep specialist triage, um, that's initiated. So we have obesity and the cardiovascular disease risk and suspected sleep apnea that are being managed uh separately in this case. So sleep apnea remains underdiagnosed. We reviewed that, but in particular, it remains underdiagnosed in high risk populations in the United States. So the high rates of elevated OSA risk and there's low rates of diagnosis in the US, uh, in middle-aged adults. So in a recent survey, a US based survey on sleep apnea that included Approximately 1000 adults that were representative of the US population, 81% of respondents had never been tested or diagnosed, and of those 11% suspected that they had sleep apnea, which is equivalent to 29 million United States adults. So when assessing for sleep apnea risk, 26% overall were categorized as intermediate and 12% as high risk. And we know that they're underrepresented minorities, um, African Americans have a higher prevalence of sleep apnea and more severe sleep apnea versus non-Hispanic whites. There are some data to to show that risk factors may also be different across. Race and ethnicity, um, in terms of differences in body fat distribution and higher prevalence of comorbidities. And in terms of the higher rates of sleep apnea, and yet this underdiagnosis in African Americans, um, prevalence is estimated to be about 24%, uh, with a moderate to severe degree of sleep apnea, and 95% of those with moderate to severe sleep apnea are undiagnosed. So overall there's an underdiagnosis, but in particular, this is a problem in our underrepresented minorities, and the risk factors in African Americans um include age, male sex, body mass index, hypertension, neck circumference, and habitual snoring, uh, more so than some of those other listed risk factors. So the guidance really supports targeted primary care physician initiated obstructive sleep apnea screening in high-risk adults. In the US, you know, primary care physicians have a lot on their plate when they're doing the intake for patients, and sometimes just don't have the bandwidth to screen for. obstructive sleep apnea or it's not built into their um their care path. So the American Academy of Sleep Medicine Quality Measures task force really highlighted the importance of primary care physicians taking an active role in screening for sleep apnea, recommending that the initial evaluation for sleep apnea begin in the office of the primary care physician and They can be patients can be screened with validated obstructive sleep apnea instruments and recommended an evidence-based action plan which may include referral to a specialist. Starting with the primary care physician identifying adults at high risk for sleep apnea. Um, in terms of, uh, symptoms related to sleep apnea, cardio metabolic risk factors, and then documenting the screening for sleep apnea, uh, using validated tools as we've reviewed, and then developing an action plan as we talked about lifestyle modification, a referral for diagnostic testing, or referral to a sleep medicine specialist. So, This kind of comprises of a pathway for a faster, um, and more efficient diagnosis and treatment for sleep apnea. The home sleep apnea testing first pathways can really simplify the route to diagnosis in those patients who are uncomplicated. Um, so when there's clinical suspicion for sleep apnea, There's high pretest probability for sleep apnea based on signs and symptoms and increased risk based upon screening, um, and There's factors that allow for home sleep apnea testing acquisition and interpretation, then, you know, don't coincide with any issues in terms of home sleep apnea testing, in terms of comorbidities or um mobility issues or such as that, then you can proceed with home sleep apnea testing. It's administered by a sleep center, supervised by a sleep physician, so that we can really ensure, given the limitations of home sleep apnea testing, that the results are being interpreted appropriately given the clinical context. And, um, then making the diagnosis of obstructive sleep apnea. Now, if there's excess comorbidities such as um cardiopulmonary disease that's severe, severe heart failure, um, neuromuscular disease can common in sleep disorders such as insomnia, uh, suspected hyperventilation, stroke history, or other, you know, other sleep disorders that we feel that A home sleep apnea test would not suffice. Then, uh, proceeding to polysomnography, um, supervised by a sleep physician and then, um, leading to the sleep apnea diagnosis. So this is kind of a, um, a pathway by which we can consider, uh, the route to diagnosis in In our patients. Although the primary care physician sleep specialist collaboration has challenges, um, really having a good collaboration can reduce delays in the sleep apnea care path. So, um, collaboration across primary care physicians and sleep specialists is recommended, um, and sleep apnea guidance, um, advocating really advocates for a multidisciplinary team care. Um, however, both primary care physicians and sleep specialists report barriers to achieving this coordination of the care of sleep disorders in terms of lack of role clarity, lack of coordination. So those, those kind of be the primary drivers of what's standing in the way. And despite these challenges, um, we know that this effective collaboration can reduce delays in the sleep apnea care path. Um, within a study of 100 patients with sleep apnea who had home sleep apnea testing ordered, initially managed by primary care physician or sleep medicine specialist, um, the primary care. Physician managed patients waited just one additional day after home sleep apnea testing interpretation to be offered treatment. Um, in sleep medicine specialist managed pathways, they spent 113 days in the sleep apnea care path. Um, in primary care physician managed, uh, patients spent 28 days in the sleep apnea care path. And um in sleep medicine specialists managed patients, they had about a one hour longer use of nightly positive airway pressure. So, Overall, we can surmise that primary care physicians can aid timely sleep apnea diagnosis testing and allow patients to bypass the lengthy specialty care wait times. However, enhanced education and support is really needed to address the variation in patient outcomes. The sleep apnea diagnosis should also trigger treatment initiation and early adherence support. So building in that early adherence, as we know, optimal early adherence uh will affect later adherence and impact later adherence.