IFM | From hypertension to hypopneas: Bringing obstructive sleep apnea management into primary care practice

Welcome to a special sponsored episode of Inside Family Medicine. I'm your host, Darren Sextro. I'm a member of Team AAFP.

Today we're joined by family physician James Bigham, MD, MPH. We're going to discuss why obstructive sleep apnea, or OSA, is more than a sleep issue. It's a cardiometabolic and whole person health concern that can be addressed in primary care. Dr. Bigham will share how he integrated sleep health and OSA management into his practice, the link between OSA and hypertension, common barriers like role uncertainty and patient hesitation, and practical ways to make OSA care more feasible in primary care.

This episode is brought to you by Resmed, the global leader in health technology focused on sleep, breathing and care delivered at home. Dr. Bigham is clinical professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. He provides primary care for patients of all ages in his practice, and he focuses on creating treatment plans tailored to each patient's needs and goals. He provides primary care for patients of all ages in his practice, and he focuses on creating treatment plans tailored to each patient's needs and goals.

In addition to his clinical and teaching roles, Dr. Bigham is involved in various community health initiatives, including educating people about vaccinations and firearm injury prevention.

Thanks for joining us again, Dr. Bigham.

Thanks for having me. It's great to be here.

So you know this. We like to begin each interview that includes a family physician like you with the same question.

So Dr. Bigham, could you share how you discovered family medicine?

Yeah. When I was in medical school, I initially wanted to do global health with a focus on HIV outreach, and when I spent some time working with a NGO in Kenya, I actually began to realize the incredible need there is for primary care and really longitudinal care, including obstetrics and just care for the whole family.

And so when I came back from one of many trips that I took doing HIV outreach, I sought out folks in family medicine at my medical school, and I found my people. I found the folks who were really focused on taking care of our patients, not just inside of clinical spaces, but also with a community health lens.

And it's made a huge difference because I have a chance to, to really lean in, and I love what we do be - the chance to care for families and to care for folks at all stages of life.

Thank you for that. Let's shift to the topic today, obstructive sleep apnea management. It affects many people. It's become a significant part of your practice. Can you tell us how your viewpoint about OSA management has changed over the years?

Obstructive sleep apnea is a really common condition in primary care populations, and we know, and we've learned more how it impacts other health conditions. I think sometimes patients will normalize their fatigue or they'll maybe minimize certain things when they come to see us.

And so what they might perceive as being, "Oh, I'm just tired because of my career or because of this stage of life with my children," may actually be that there's something more to the picture. And in primary care, we recognize the interplay between many of these conditions, and so when I'm seeing my patients with hypertension or atrial fibrillation or even individuals who are having a more challenging time with things like their mental health, I've learned I need to lean in and kind of cue in to see if there's something I'm missing.

And sleep apnea sometimes can be that missing piece of the treatment plan. And early on in my residency training in, in medical school, I really thought of obstructive sleep apnea as this really specific sleep condition, and I don't think it was that I had a bad education. I think it was maybe just the way that it was presented, as very specialty-driven and unique.

And the more I've been in practice, I realize in family medicine, we care for so many different conditions, and so many that are interconnected, and sleep apnea is one of those. And so I've had a chance to really kind of move from thinking, "Oh, this is a referral," to, "Hey, this is something that's really in line with the things that I'm doing with my patients."

And I have to say it was early in my career that there was a really big change, and it's we moved screening into our clinical spaces in primary care, and we actually had access to home sleep studies, and that was a game changer because suddenly I could go from screening right to actually doing the test, and patients could leave the clinic same day sometimes with their home sleep study.

And it's amazing how the barriers kind of fall down when it's that swift. And I also think I saw that I had a blind spot because many of those sleep studies came back positive, and then I suddenly began treating these patients, and we saw the benefits. And there's something about that in medicine that the positive feedback we get when we're actually diagnosing and treating and seeing the positive outcomes, that sometimes can help affirm that we're getting things right.

So just a moment ago, you mentioned some barriers early on. Can you tell us about some of those unexpected, perhaps real-world barriers that you faced when first integrating OSA management into your practice? What did you learn?

Yeah. I don't want to date myself here, but I would say when I was coming up through medical school and my residency training, this didn't feel like it was an integrated part of what we were doing in primary care, and so I had limited training on this, and maybe it was just not quite having as much experience managing this.

That was probably my initial issue, and one of my mentors when I was in medical school would often say, "Conditions are seeing you. Are you seeing them?" And the longer I've been in practice, I realize sometimes I have to make sure that I'm paying attention to really broaden my differential diagnosis so I'm not missing things.

And there also can be a bit of, in medicine, we have a bit of whose role is it? There can be a little bit of we're siloed in medicine because of our specialties, and I think early on I thought, "Oh, I think there's a sleep issue here, whether it's sleep apnea or otherwise. I now need to make a referral." And I think the more I've gotten confident in what I can do and what we can do as family physicians, I've recognized I'm able to lean in and help my patients get timely screening and the treatment they need, and absolutely have colleagues I can lean into if need be in sleep medicine, which is good.

The last thing I would say, which is a big one, is initially patients have been very resistant to being screened for sleep apnea because they weren't sure if they would want treatment for sleep apnea, and it may have been there was some stigma around using CPAP, or it may have been that they heard horror stories or had their own vision of what this might be like.

I would say over the course of time, this has become more normalized. As more people have been diagnosed with sleep apnea, and more individuals are being treated, folks talk about it. I was just on a trip with a friend recently, and he brought his CPAP with him as a carry-on with our flight, and he thought nothing of just mentioning, "Oh, yep, I have sleep apnea."

I think historically in the past that might have been more of an embarrassment for folks. And then the last thing is the technology's come so far that what we're doing for PAP therapy is so much more comfortable than the old school, like, Darth Vader mask where people would feel like they had their head out a window driving down the highway sort of at night when they're going to sleep.

So, Dr. Bigham, a slightly different perspective on that barriers question. When you discuss issues about incorporating OSA screening and management into primary care with your colleagues, what barriers do they share to integrating OSA management into their practices?

I think the biggest one is time, and in primary care, we do so many things, often squeezed into a 15- or a 20-minute visit.

And so many of my colleagues recognize the importance of screening for and treating sleep apnea, but they may ask, "How am I going to carve out the time, or how can I prioritize the many things the patient wants to talk about when they come in?" Because that feels like that might kind of take over the visit.

And what I try to gently share, and what I've actually employed myself, is I try just to hold space for screening around sleep apnea when it really feels like it may pertain to the patient. And so if the patient presents and has a cardiac issue, like poorly controlled hypertension, or having some difficulty with their atrial fibrillation, or they are describing some fatigue, I might just take a moment to pan back and ask a couple more screening questions just to see if it's possible that...

Can I say it again? So what I would say is sometimes I'll take a moment, and I'll try to pan back and ask a couple more questions to the patient to see if it's possible that sleep apnea could be contributing in some way to the symptoms they're describing or the condition I'm working on treating. And so it's not about doing one more thing.

I think it's about trying to take the amount of time we need to address these chronic conditions so that we can actually adequately treat them and get patients to goal. And I would say there's a big upside when we are successful in screening and treating patients because we get that positive feedback of the blood pressures get better, the atrial fibrillation is better controlled, patients are describing less fatigue, and in many ways, that's important for us just to assure we're doing the complete care, the whole person care that we're called to do in family medicine.

Nice. So having gone through this process of integrating sleep health and OSA management into your daily work, what are some practical solutions and integration strategies that would be important for our listeners, other family physicians to know?

I think because of the amount of things that we're seeing daily in clinic, it's always important to have this question, which is, what might I be missing?

And it's really a mental check and it's ensuring that I'm not too quick to draw a conclusion about the diagnosis I'm making or what I think the treatment plan should be. It's really sort of a quality assurance piece. And, and so sometimes when I'm seeing conditions that have suboptimal control, so if that hypertension isn't responding the way I would hope it would, despite the patient being on a couple of medications, I might just take a minute and ask a couple of curious questions about whether sleep apnea could be contributing.

And it, it could be something as simple as checking in with the patient to ask, "Do you feel fatigued? Do you snore or have you been told you snore?" Because a lot of people don't know because they're asleep. "Or do you ever gasp awake or have you ever gasped awake at night?" If someone has a partner, sometimes their partner will tell them, "Hey, you stopped breathing."

And so if those things are being reported back to me, then I begin to wonder should we move towards something like a sleep study? And I, I think this is the thing as we get back to the busy schedules we have and my colleagues who feel pressed for time, I actually think the deeper dive to explore whether sleep apnea could be a contributor is something that we should embrace as part of what we're doing in the comprehensive care that we're providing.

And I think we do this in many ways. It's how we've been trained to make sure we're not missing things and it shouldn't feel like a burden. Hopefully, it just feels like a chance to circle back and just really make sure we're being as complete as possible for our patients.

You mentioned that patients sometimes express hesitancy to completing a sleep study or using PAP for OSA management.What are some approaches you employ to help improve patient engagement for both evaluation of suspected OSA and treatment when the diagnosis is made?

I think a lot of times for our patients, we use medical terms or jargon, and it's sort of a black box for them. And so taking a moment to educate the patient about what obstructive sleep apnea is and why it actually matters for the patient is important, and so connecting it with what may matter most for the patient.

So if someone comes in and is describing feeling fatigued and I explain, "I'd like to screen for sleep apnea because it's possible the issue here is you're not getting adequate sleep at night because you keep gasping awake at night. We can give you a therapy you use at night, and you're going to feel rested possibly for the first time in a decade," that gets a lot of buy-in from patients because they actually see them trying to meet a need.

I'm not just checking a box. I'm really trying to make sure that we're addressing the thing they've come in with. For other patients who maybe don't have more of those fatigue-predominant symptoms, but more of an issue with a cardiac condition we're trying to manage, I just try to explain to them that we're both on the same team, which is optimize their heart health. If they are awakening at night hundreds of times, they’re putting strain on their heart, and they're lowering their oxygen levels which can potentially cause harm.

And so what I want to do is make sure we've addressed that so that that isn't an ongoing strain. And often when I explain we're doing all these other things for your heart, diet, exercise, your blood pressure medications, maybe a statin for lipid lowering. All of those things may actually not be as effective as we want them to be if we aren't addressing this other foundational thing.

And in many ways for patients, when they have it explained to them in a way where it really hits, and they can see how it matters to their overall health, they're really open to testing. One question they often ask is, "How am I going to get tested?" Because many people think they're going to have to go into some dark room that feels strange, and have people watch them sleep, and sometimes people do have to go to the sleep lab.

But really, one of the things that's so helpful for patients is if we can do a home sleep study, where someone can actually do the test right in their own bed. It's probably a more accurate test anyway, because it really shows us what the conditions are when they're in their own home, in the comfort of their own bed.

When we were doing this from our clinic, the handing out the home sleep study kits, I volunteered actually to trial the home study kit, just so I could have the lived experience, and encourage my patients that if I could do it, it was idiot-proof. That anybody could do it. And there's something about that.

It wasn't about manipulation. It was about just having a shared connection and saying, "I've had a chance to do this. I'm not asking you to do something that is overly cumbersome." And my patients, I think, appreciate the fact that they can have a forecast of what it's going to be like, because so much of this is an uncertainty and unclear for them, and they may actually have a reservation even just about the testing, let alone the treatment down the road.

Dr. Bigham, you're obviously very far along in your OSA management intelligence, even on a personal level, but how would you describe the connection with the sleep medicine experts in your practice now?

It's important for us as family physicians to lean into the role we have as the medical home for our patients, and in many ways, we want to be the health coach, the health guide, maybe the quarterback of the team, if you will.

And so in so many ways, what I want to do for patients is make sure that they feel they've got a connection with me, and when we need sleep medicine, we can lean into them. There are many times where I can do a home sleep study which reports out that the patient does have sleep apnea, and there's a need for PAP therapy, and I may not even need to get in touch with sleep medicine because I can manage all of the initial settings right out of the gate.

When there is a concern about added complexity or if we need to be doing things to, to modify pressures and things like that, then absolutely I'll lean into my sleep medicine colleagues. I think my colleagues appreciate I'm taking many of the maybe low-hanging fruit off of their plate because they have access concerns, and many times there can be a delay to getting in to be seen.

And so if primary care is able to, as we're seeing patients, manage some of these things, it may actually enhance care for the folks and access for the folks who really need the, the more specified care that sleep medicine can offer. I also think one way that I connect on this frequently is with my colleagues in cardiology.

It's very common when my patients are seeing the cardiologist because we're having concerns about how things are going with their cardiac care. The cardiologist will often also place an order for a home sleep study, and then I'll connect with the cardiologist on the result of the sleep study, and we'll decide how we're going to move forward as far as if there was a diagnosis of sleep apnea. Should I be prescribing the PAP therapy, or is there something more going on that seems concerning that would require more subspecialty care? And I appreciate that role that we have to play as family physicians, and many times the patients looking to me, or patients look to us because we have that trust. We've cultivated those connections, and so I want to be a guide for my patients through this process.

So you've been on a long, and it sounds like quite a successful journey in OSA management within your practice. What kind of impact have these changes had on your patients, on your practice? And definitely worth saying for family physicians and care teams listening, what might they expect if they take a similar approach?

As I've moved towards recognizing the need to screen for and treat sleep apnea in my patient panel, I've seen a lot more success treating the whole patient.

I'm hearing a lot of stories back from patients, often portal messages, or the next time I see them in clinic, they'll say, "Hey, that PAP therapy works." Or they'll say, "Oh, my gosh, is this what it feels like to actually sleep at night? I feel so much better." And we'll notice that things like their blood pressure improves or other markers of their overall cardiac health may improve.

Sometimes we'll see mood improve, and mental fogginess and, and things like that. And so there's this beauty of being able to come together with my patients and partner with them towards their health, and actually help them understand what's going on that's causing symptoms, and then actually help them feel better.

And really, at the level of my practice, that makes things more streamlined, because I'm able to optimize things. I'm no longer running into, kind of banging my head against a wall of, "Why won't things change? Why aren't they better?" Because I've actually now found one of the culprits for why. There may have been an underlying condition in the form of sleep apnea that if I don't address it, I'm not going to be able to have success optimizing things like the cardiac health or optimizing mental health and wellbeing.

And so as I've been able to get individuals screened and on treatment pretty swiftly, what we see is often then fewer visits too. Because when we address the issue, and the patient is doing well, they get time off for good behavior. They don't have to keep coming back to clinic. When things are optimized, I might be seeing a patient with chronic conditions once every six or every 12 months, versus when they're actually feeling the effects of their condition. They may be sending portal messages or they may be requesting ongoing appointments, which is appropriate because they want to see their condition being addressed.

And then really the, the last thing I would say is there's a lot of satisfaction in this job in family medicine when we have a chance to, to help our patients. This is why I went to medical school, and I think it's why a lot of us went to medical school and went into family medicine. We show up at work every day because we want to help people who are in a place where they're experiencing some condition that's impacting their health in a negative way.

And I want to move the needle and help them feel better. I want to do the thing I can to help them understand what's going on and be empowered about how their body works and what they're experiencing. And then I want to take steps with them to encourage them to do the very thing that may help them feel better.

I think there's something about the beauty of helping a patient feel better, and in many ways, when a patient has a chance to, to feel better, they're going to experience overall wellbeing and health, and that's the goal of what we're doing. It's not always perfect. Not every patient has an instantaneous improvement in symptoms.

Sometimes we do have to do some work making sure we get the exact right mask or the exact right settings. Often I'll lean into the DME team, or I'll lean into the sleep medicine colleagues I have to make sure that we get that exactly right for the patient. I'd say for the vast majority of my patients, as I've moved towards addressing sleep apnea, making sure that I'm in a timely way screening and then treating sleep apnea, I'd say they're getting expedited care, and they're getting on the path to, to wellness much quicker than earlier in my career when I think I was missing it.

What are ultimately a few things that family physicians and their teams can do right now to start this process? Perhaps some good first steps I think one thing that's helpful is just to take a moment and reflect a bit on your practice. Reflect a bit on how you approach sleep apnea screening and how you're approaching the treatment of sleep apnea.

In no way am I saying you need to add in more or be burdened with one more thing. It's actually the opposite. It's how might you make getting to optimal treatment swifter and easier for patients. And so it may be that you take some time when you're seeing a patient who has a condition that's not where it should be, whether it's blood pressure, their blood sugar, their mental health or even if they're describing fatigue, then maybe it's beginning just to ask a couple of curious questions.

Maybe it's introducing a STOP-BANG or a different clinical tool to screen just briefly into those encounters. And if you get a positive screen, then finding a way to swiftly get the patient moved on to screening for sleep apnea. If it's possible in your health system, home sleep studies make a big difference.

Patients are very fond of this because they don't have to carve out a night to be away from home or their family for the test. When I'm caring for patients who have young children who couldn't be left alone at night, the home sleep study gives them the chance to, in the comfort of their own bed, do the screening.

And I explain to them, those tests are read by the same individuals who read our in-lab studies, and we know they have good accuracy. And so it's not a step down or a worse form of screening, and it may be the very thing we need to offer patients so they can get around a bit of a barrier they feel.

And then it's also important to think about if you need more training. Many of us maybe didn't get this training when we were in residency or in medical school. And so trying to pursue either additional CME resources or checking things out on the AAFP toolkits and those sorts of resources may be helpful so that we can brush up.

Because at some level, our patients want us to be confident in what we're doing, and sometimes our confidence lags if we don't feel like we've got the clinical acumen we need. So I think moving towards it is important, and then I hope you begin doing this. I hope you begin finding success as you screen patients, they are positive for sleep apnea, and then you have a chance to treat them.

Because at the end of the day, when the patient comes back and says, "Hey, thank you so much. I feel so much better. You're helping me live a better life, a more fulfilling life, a healthier and more whole life," I mean, that's what it's all about. That's why we show up at clinic each day, every day. That's why we do family medicine.

Thank you. Thank you so much for joining us, Dr. Bigham, and for sharing your expertise with us today, and thank you to Resmed for sponsoring today's conversation. To our listeners, if you'd like more resources, as Dr. Bigham just referenced, related to sleep health and OSA management, including resources from the AAFP, see the links in the show notes.

If you enjoyed today's episode, let us know by dropping a line to aafpnews@aafp.org. Be sure to share the episode with your followers on social media and tag the AAFP.