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Hello and welcome to Global OSA Institute Insights. This episode, navigating social barriers and diagnostic attrition, explores how primary care teams can help patients complete the obstructive sleep apnea pathway when practical barriers make every next step harder. In this podcast, we will use an illustrative patient scenario to explore not simply what care is indicated, but how systems and teams can help patients access and complete that care. Before we begin, please review the faculty information, disclosure statements, and learning objectives using the link in the episode description. And remember to claim your CME credit by completing the evaluation linked there as well. This podcast is a continuing education activity, managed and accredited by Partners for advancing clinical Education in collaboration with Medall and supported by an independent medical education grant from Lily. I am your Medal host, and joining me is Doctor Azizi Seishas, professor of psychiatry and behavioral sciences director, the Media and Innovation Lab, associate director, Center for Translational Sleep and Circadian Sciences, and interim chair, Department of Informatics and Health Data Science. Thank you for having me. Let's start with our first case. A clinical need, an uncertain pathway. A 52-year-old adult has obesity, BMI 37 kg per square meter, type 2 diabetes and hypertension that remains elevated despite treatment with three agents, including a diuretic. They report fatigue and morning headaches, and their stop bang assessment suggests high OSA risk. The clinical team believes further diagnostic evaluation is warranted. The patient is covered by Medicaid, works variable shifts, provides care for a family member, and has limited access to reliable transportation. Local sleep services and participating durable medical equipment, DME suppliers, are difficult to reach. Before arranging testing, the clinician learns that time away from work and uncertainty about coverage have already delayed other healthcare appointments. The question for today is not to make an individualized diagnostic decision, but to consider how a clinically appropriate pathway can be made accessible and completed. Doctor Seishas, when a primary care team has only a short visit with someone at high risk of OSA, what can research and implementation experience tell us about identifying risk without placing another burden on patients? Well, thank you for that really very rich question and case because oftentimes my clinical friends and provider friends would say they wish they had that amount of information because if they had that amount of information ahead of time, then it would lead to, you know, um, you know, much better, um, action in the healthcare system. Um, and, and so most people who are listening now will say that that level. Of characterization, um, you, we don't usually get that, you know, on an everyday basis. So, in a perfect world, the case study that you just have highlighted is really ideal. So, I think the first thing we need to do is to recognize is that identifying risk and completing care are two very different challenges. So, in this particular case, you know, there are several clinical features that should really heighten suspicion for um obstructive sleep apnea. We have obesity, we have type 2 diabetes, we have hypertension. That remains elevated despite multiple medications, um, especially a diuretic. Um, so we also have fatigue and morning headaches. Now, none of those findings independently, um, can be used to establish a diagnosis of sleep apnea and even a high stop bang score. Is a screening result, not a diagnostic test, but collectively when you put the entire just thought together, they tell us that this is someone whose sleep health deserves some attention. So the question really is how do we identify that risk without making an already complicated healthcare experience even more burdensome for all parties. So the answer is integrated case finding rather than creating a separate screening enterprise or workflow. So if a patient is already being seen for hypertension and diabetes or obesity, we should use that existing encounter to ask a few targeted questions. For example, Are you snoring? Has anyone noticed that you stop breathing during sleep? Do you have, you know, you know, issues, you know, with feeling refreshed when you're awake? Are you excessively sleepy during the day? And importantly, how is sleep affecting your daily functioning? So we can use validated screening instruments and tools like a stop band to structure risk recognition, but we must understand their limitations. Screening tools, let me just be clear, and I think most of our audience knows this, screening tools are designed to help us identify who may need further evaluation. They are not substitutes for clinical assessment or appropriate diagnostic testing, which is why in 2017, the American Academy of Sleep Medicine, which I am a member, they laid out very clear diagnostic guidelines and made this distinction very clear. Now, from a population health perspective, which is the work that I do as well. I would add another step. So before the patient leaves, you know, we should really ask whether they can realistically complete whatever diagnostic pathway the treatment team determines as appropriate. So because a referral that cannot be completed is not the same thing as access to care. So I would encourage primary care teams, any teams, whether it be a federally qualified community hospital or a large academic health center. To adopt a simple approach I call RAP, RAP. First, recognize risk. Second, access the clinical and practical pathway. And then lastly, plan the next step with the patient. This is what we've been able to establish here at the University of Miami, and we did this very well as well when we were at NYU School of Medicine. And that plan should include more than just a referral order. It should include an explanation, a named contact that a patient or, you know, can focus on, and some understanding of whether work schedules, transportation, cost, or caregiving could interfere with them fulfilling that referral order. The goal is not simply to identify more patients at risk. The goal is to ensure That identification leads somewhere clinically meaningful, and that is really the goal of what we need to do to move things further beyond the screening and risk identification to diagnosis, and if the person actually does have sleep apnea, how do we move them forward seamlessly in a way that they will necessarily get the right Um, intervention at the right time and provide as much wraparound support for them to be able to manage their condition well. Doctor Seishas, through sleep health disparities research and community engagement, what have you learned about the barriers people may face after being told they need a sleep test? I think one of the most important lessons from sleep health disparities, research that we have done that have identified barriers to care, I think, you know, oftentimes begin after we've made the correct clinical decisions. And, and, and, and they are, uh, don't get me wrong, I think the, the steps toward identification and screening and assessment. And diagnosis is replete with many barriers and challenges as well, from individual to provider to system level barriers and, and, and our work focuses entirely on that. But notwithstanding that, you know, let's say you've done everything as a provider extremely well or as best as you can, right? One of the things that I would strongly encourage is that we may identify a patient appropriately, um, we may recommend testing appropriately, we may even place the order correctly, but none of those actions guarantees that the patient will complete the test. And I think this is where we have to change the way we interpret what happens next. So when a patient misses an appointment or doesn't complete testing, The health care system may describe that person as noncompliant. We try not to do that, but that because that label often tells us very little about why care did not happen. So I would say consider the patient in this scenario. They work variable shifts, they may have caregiving responsibilities. They might be having transportation issues where it's unreliable, um, coverage may be uncertain, and we've gotten many of those concerns as well. And so participating sleep service.