Elsevier

Academic Pediatrics

Volume 18, Issue 4, May–June 2018, Pages 418-424
Academic Pediatrics

Original Article
Unexplained Practice Variation in Primary Care Providers' Concern for Pediatric Obstructive Sleep Apnea

https://doi.org/10.1016/j.acap.2018.01.011Get rights and content

Abstract

Objective

To examine primary care provider (PCP) screening practice for obstructive sleep apnea (OSA) and predictive factors for screening habits. A secondary objective was to describe the polysomnography completion proportion and outcome. We hypothesized that both provider and child health factors would predict PCP suspicion of OSA.

Methods

A computer decision support system that automated screening for snoring was implemented in 5 urban primary care clinics in Indianapolis, Indiana. We studied 1086 snoring children aged 1 to 11 years seen by 26 PCPs. We used logistic regression to examine the association between PCP suspicion of OSA and child demographics, child health characteristics, provider characteristics, and clinic site.

Results

PCPs suspected OSA in 20% of snoring children. Factors predicting PCP concern for OSA included clinic site (P < .01; odds ratio [OR] = 0.13), Spanish language (P < .01; OR = 0.53), provider training (P = .01; OR = 10.19), number of training years (P = .01; OR = 4.26) and child age (P < .01), with the youngest children least likely to elicit PCP concern for OSA (OR = 0.20). No patient health factors (eg, obesity) were significantly predictive. Proportions of OSA suspicion were variable between clinic sites (range, 6–28%) and between specific providers (range, 0–63%). Of children referred for polysomnography (n = 100), 61% completed the study. Of these, 67% had OSA.

Conclusions

Results suggest unexplained small area practice variation in PCP concern for OSA among snoring children. It is likely that many children at risk for OSA remain unidentified. An important next step is to evaluate interventions to support PCPs in evidence-based OSA identification.

Section snippets

CHICA System

CHICA, an innovative computer decision support system that has been operating in primary care clinics at our institution since 2004, is described elsewhere in detail.12, 13, 14 Briefly, parents receive a prescreening form in the waiting room via an electronic tablet at both sick- and well-child visits. The prescreening form consists of 20 health-risk items tailored to the child according to age and medical history. With this information, CHICA generates up to 6 prompts for the PCP on a

Patient Flow

Patient flow is summarized in Figure 1. Across the 5 clinic sites, caregivers of 8256 eligible children were presented with a snoring item. A total of 8135 caregivers responded, for an overall response of 99%. Of those who responded, 2320 caregivers (29%) reported that their children snored 3 or more days per week.

During the study time frame, no prompt was generated for 7 snoring children because other health issues were prioritized for those children by the CHICA prioritization scheme.14

Discussion

This study demonstrates the feasibility of using an automated system to screen patients for snoring in busy primary care clinics. Caregiver response to the screening item was high (99%), resulting in the identification of more than 2000 snoring children. PCPs subsequently noted that approximately 21% of snoring children in fact did not snore, which may have been related to parental misinterpretation of the screening question or parental response based on the child's current status (ie, child

Acknowledgments

We thank the dedicated providers and staff at the 5 participating Eskenazi Health System clinic sites, as well as all of the participating children and families. We further acknowledge the technical expertise and efforts of the individual members of the Child Health Informatics and Research Development Lab (CHIRDL) team, which provides programming and technical support for CHICA, and the Pediatric Research Network (PReSNet) at Indiana University School of Medicine for regulatory support.

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    Conflict of interest: Dr Downs is the coinventor of CHICA and the president of Digital Health Solutions LLC, a company created to license the CHICA software. Ms Dugan is the chief technology officer of Digital Health Solutions LLC. The other authors have no conflicts of interest to disclose.

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