The Use of Computer Decision Support for Pediatric Obstructive Sleep Apnea Detection in Primary Care

Abstract

Study objectives: To (1) describe outcomes from a computer decision support system (CDSS) for pediatric obstructive sleep apnea (OSA) detection in primary care; and (2) identity the prevalence of children meeting criteria for an OSA referral.

Methods: A CDSS for OSA was implemented in two urban primary care clinics. Parents of children (age 2 to 11 years) presenting to the clinic were asked if their child snored regularly, with a positive response resulting in six additional OSA screening items. Primary care providers (PCPs) received a prompt for all snoring children, listing applicable OSA signs and symptoms and recommending further evaluation and referral for OSA.

Results: A total of 2,535 children were screened for snoring, identifying 475 snoring children (18.7%). Among snoring children, PCPs referred 40 (15.4%) for further evaluation. The prevalence of additional OSA signs and symptoms ranged from 3.5% for underweight to 43.7% for overweight. A total of 74.7% of snoring children had at least one additional sign or symptom and thus met American Academy of Pediatrics guidelines criteria for an OSA referral.

Conclusions: A CDSS can be used to support PCPs in identifying children at risk for OSA. Most snoring children met criteria for further evaluation. It will be important to further evaluate this referral threshold as well as the readiness of the sleep medicine field to meet this need.

Clinical trials registration: Registry: ClinicalTrials.gov, Title: Evidence-based Diagnosis and Management of Pediatric Obstructive Sleep Apnea in Primary Care, Identifier: NCT02781376, URL: https://ichgcp.net/clinical-trials-registry/NCT02781376.

Keywords: computer decision support; obstructive sleep apnea; pediatrics; primary care; sleep disorders; snoring.

© 2019 American Academy of Sleep Medicine.

Figures

Figure 1. CHICA OSA detection algorithm.

In CHICA OSA, children are screened for snoring every 18 months. Snoring children receive 6 additional OSA screening items, and the CHICA system assesses whether other signs (ie, overweight; ADHD) are known. The PCP then receives a prompt at that visit indicating that the child snores and listing applicable signs and patient-reported symptoms. If the child does not have any additional signs or symptoms, the PCP receives a prompt indicating that the child snores and asking the PCP to do a physical examination to assess for OSA signs such as tonsillar hypertrophy. If the PCP does not respond to a prompt, the prompt presents at the next visit. Once the PCP responds to a prompt, the detection module stops, though the child is screened again for snoring after 18 months. ADHD = attention deficit hyperactivity disorder, CHICA = Child Health Improvement through Computer Automation, OSA = obstructive sleep apnea, PCP = primary care physician, PE = physical examination

Figure 2. Sample provider alerts.

(A) PCPs receive this prompt for snoring children who have one or more additional OSA symptoms. Symptoms that apply to that child are listed in the prompt. (B) Providers receive this prompt for snoring children who do not have additional identified OSA symptoms. AAP = American Academy of Pediatrics, ENT = ear, nose and throat specialist, OSA = obstructive sleep apnea, PCP = primary care physician, PSG = polysomnography.

Figure 3. Study flow diagram.

Superscript letters indicate: a = sample for analyses of prevalence of OSA signs and symptoms, b = sample for analyses of PCP response to prompt. OSA = obstructive sleep apnea, PCP = primary care provider.

Figure 4. Frequency of OSA signs and symptoms in snoring children (n = 475).

ADHD = attention deficit hyperactivity disorder, OSA = obstructive sleep apnea.

Figure 5. Number of additional OSA signs and symptoms in snoring children (n = 475, range = 0–8).

OSA = obstructive sleep apnea.