Clinical pathways and wait times for OSA care in Ontario, Canada: A population cohort study

Abstract

RATIONALE: Lengthy wait times for obstructive sleep apnea (OSA) in Canada remain a concern.

OBJECTIVES: To describe the clinical pathway for OSA and determine wait times from assessment of OSA until continuous positive airway pressure (CPAP) treatment in Ontario.

METHODS: We conducted a population-based cohort study from 2006 to 2013. We used billing information to identify clinic visits for sleep complaints and polysomnography (PSG). We calculated the time from primary care visits until diagnostic PSG (diagnostic time) and from PSG until CPAP initiation (treatment time) for each year. We used logistic regression to identify factors associated with diagnostic and treatment time >6 months.

RESULTS: A total of 216 514 CPAP users were included. Most (52%) had a diagnostic PSG without a sleep assessment and 52% underwent a titration PSG. The median diagnostic wait for hospital and community-based facilities were 260 (IQR 87–869) days and 203 (36–838) days, respectively, with less than 50% of patients undergoing PSG within 6 months of PC assessment. The median treatment wait was 108 days (57–193) at hospital and 82 days (45–143) at community-based facilities; less than 70% started on CPAP within 6 months. Female sex, recent hospitalization and having diagnostic PSG at a hospital were associated with longer diagnostic and treatment times.

CONCLUSIONS: The clinical pathway for assessment and treatment of OSA in Ontario is highly variable and current wait times in Ontario remain lengthy. Interventions to improve physician education, redistribute sleep medicine resources and adopting new technologies should be considered.

RÉSUMÉ

JUSTIFICATION: Les longues périodes d’attente pour l’apnée obstructive du sommeil (APS) au Canada continuent d’être préoccupantes.

OBJECTIFS: Décrire le parcours clinique pour l’AOS et déterminer les temps d’attente à partir de l’évaluation de l’AOS jusqu’au traitement par aération par pression positive continue (CPAP) en Ontario.

MÉTHODES: Nous avons mené une étude de cohorte populationnelle de 2006 à 2013. Nous avons utilisé l’information relative à la facturation pour recenser les consultations médicales pour des problèmes liés au sommeil et pour une polysomnographie. Nous avons calculé le temps d’attente entre les consultations dans des établissements de soins primaires jusqu’au diagnostic par polysomnographie (temps d’attente pour le diagnostic) et de la polysomnographie jusqu’au début du traitement par CPAP (temps d’attente pour le traitement) pour chaque année. Nous avons utilisé une régression logistique pour cerner les facteurs associés aux périodes d’attente de plus de six mois pour le diagnostic et le traitement.

RÉSULTATS: Au total, 216 514 utilisateurs de CPAP ont été inclus dans l’étude. La plupart d’entre eux (52 %) s’étaient soumis à une polysomnographie et 52 % s’étaient soumis à une polysomnographie avec titration. Le temps d’attente médian pour obtenir un diagnostic en ce qui concerne les hôpitaux et les établissements communautaires était de 260 (IIQ 87-869) jours et 203 (36-838) jours respectivement, et moins de 50% des patients avaient passé une polysomnographie dans les six mois suivant l’évaluation. Le temps d’attente médian pour le traitement était de 108 jours (57-193) à l’hôpital et 82 jours (45 -143) dans les établissements communautaires; moins de 70 % avaient commencé la CPAP en moins de six mois. Le fait d’être de sexe féminin, d’avoir été hospitalisé récemment et d’avoir eu une polysomnographie à l’hôpital était associé avec de plus longues périodes d’attente pour le diagnostic et le traitement.

CONCLUSIONS: Le parcours clinique pour l’évaluation et le traitement de l’apnée obstructive du sommeil est très variable et les temps d’attente en Ontario demeurent longs. Des interventions pour améliorer l’éducation des médecins, redistribuer les ressources en matière de médecine du sommeil et adopter de nouvelles technologies devraient être envisagées.

Keywords:

• Obstructive sleep apnea
• wait times
• health administrative data

Acknowledgments

Thanks to Pat Hanly for comments on the initial plan for this manuscript.

Declaration of interest

The opinions, results and conclusions are those of the authors and are independent from the funding sources. No endorsement by ICES, AMOSO, SSMD, LHRI or the MOHLTC is intended or should be inferred. Parts of this material are based on data and information compiled and provided by CIHI. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI.

Additional information

Funding

This study was supported by the Institute for Clinical Evaluative Sciences (ICES) Western site. ICES is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Core funding for ICES Western is provided by the Academic Medical Organization of Southwestern Ontario (AMOSO), the Schulich School of Medicine and Dentistry (SSMD), Western University, and the Lawson Health Research Institute (LHRI). M. Povitz was supported by the Opportunities Fund of the Academic Health Sciences Centre Alternative Funding Plan of the Academic Medical Organization of Southwestern Ontario (AMOSO) grant number S16-004.

Notes on contributors

Marcus Povitz

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Krista Bray Jenkyn

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Tetyana Kendzerska

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Britney Allen

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Sachin R. Pendharkar

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Alexandra Ouedraogo

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Charles F.P. George

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.

Salimah Z. Shariff

B. Allen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Acquisition, analysis, or interpretation of data: M. Povitz, K.B. Jenkyn, S.Z. Shariff, B. Allen; Drafting of the manuscript: M. Povitz; Critical revision of the manuscript: All; Statistical analysis: B. Allen; Geospatial analysis: A. Ouedraogo; Study supervision: S.Z. Shariff.