Writing Committee. Amir Qaseem, MD, PhD, MHA; Laurel Borowski, MPH; Robert A. Gluckman, MD; Nasseer A. Masoodi, MD; and David W.

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1 PERFORMANCE MEASURE REVIEW Diagnosis and Management of Obstructive Sleep Apnea: Review of the Performance Measures by the Performance Measurement Committee of the American College of Physicians Writing Committee Amir Qaseem, MD, PhD, MHA; Laurel Borowski, MPH; Robert A. Gluckman, MD; Nasseer A. Masoodi, MD; and David W. Baker, MD, MPH Members of the ACP Performance Measurement Committee* David W. Baker, MD, MPH (chair); Robert M. Centor, MD; Andrew Dunn, MD; Mary Ann Forciea, MD; Sandra Adamson Fryhofer, MD; Robert A. Gluckman, MD; Robert H. Hopkins, MD; Catherine MacLean, MD, PhD; and Nasseer A. Masoodi, MD *Individuals who served on the Performance Measurement Committee from initiation of the project until its approval.

2 Introduction Obstructive sleep apnea (OSA) is a common disorder that affects people in all age groups. Based on the considerable mortality and morbidity associated with OSA and its comorbidities, OSA is an important public health issue. The goal of OSA treatment is to alleviate airway obstruction during sleep. However, there is a degree of uncertainty that exists regarding the condition, what characteristics of respiratory abnormality should be used to define OSA, and considerable differences in patient adherence to treatment. The American College of Physicians (ACP) published a clinical practice guideline on the diagnosis and management of OSA based on an evidence report sponsored by the Agency for Healthcare Research and Quality (AHRQ) (1, 2). The purpose of the guideline is to assess the benefits and harms of the latest clinical evidence to provide clinicians with recommendation, inform clinicians when there is no evidence, and to help clinicians deliver the best care possible. In order to encourage alignment between clinical guidelines and performance measures, the ACP Performance Measurement Committee (PMC) reviewed performance measures developed in the United States related to OSA based on the evidence presented in the ACP guideline and clinical recommendations. The goal of the PMC is to review performance measures to ensure they are evidencebased, methodologically sound, and clinically meaningful. The purpose of this paper is to provide a review of measures related to the diagnosis and management of OSA. Methods We performed a search to identify relevant performance measures that were endorsed by the National Quality Forum (NQF), or used in the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting System (PQRS) or CMS Electronic Health Record (EHR) Incentive Programs. At the time of this publication, no measures related to OSA were endorsed by NQF. The search identified four measures used in the 2013 PQRS program and developed by the Physician Consortium for Performance Improvement (PCPI). The PMC reviewed the measures based on the clinical evidence presented in the ACP guideline using a formal review instrument with standardized criteria. Conclusion ACP does not support the PCPI measure on assessment of sleep symptoms. This measure addresses patients with a prior diagnosis of OSA. Current evidence does not support the benefit of assessment of symptoms at every patient visit. In addition, there is no evidence describing an appropriate time interval for assessment of symptoms. The goal of assessment of the symptoms of OSA is to determine whether to refer patients for a sleep study or sleep consult. The PMC is not aware of a gap in the assessment of sleep symptoms, but the issue is a gap in care for the assessment of sleep symptoms before referral to a sleep study or sleep consult. The PMC suggests the need to develop an overuse measure to ensure the assessment of symptoms is performed before the initiation of a sleep study. The measure is not feasible for use in the general population as it is currently written because it is administratively burdensome to collect data on every patient with OSA at every physician visit. For example, it is unclear how the measure would be applied to a primary care physician who is caring for patients with OSA, but often sees these patients for other health issues where it is not necessary to assess OSA.

3 Measure Specifications PCPI Measure #1: Assessment of sleep symptoms (3) Obstructive sleep apnea: percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness. Description: This measure is used to assess the percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness. Clinical Topic: Obstructive sleep apnea; assessment of sleep symptoms (snoring, daytime sleepiness) Numerator Patient visits with an assessment of sleep symptoms documented, including Statement: presence or absence of snoring and daytime sleepiness Denominator All visits for patients aged 18 years and older with a diagnosis of obstructive sleep Statement: apnea. Refer to the original measure documentation for administrative codes. Exclusions: Documentation of a medical reason(s) for not documenting an assessment of sleep symptoms (e.g., patient didn't have initial daytime sleepiness, patient visits between initial testing and initiation of therapy) Level of Physicians Analysis: Data Source: Administrative clinical data Electronic health/medical record 2012 PQRS Pulmonary Measure Group (CMS #276) Measure American Academy of Sleep Medicine (AASM), Physician Consortium for Steward: Performance Improvement, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA); ACP does not support the PCPI measure on severity assessment at initial diagnosis. This measure aligns with the ACP guidelines recommending a sleep study to diagnose OSA. However, the PMC is not aware of a gap in care. Both the apnea hypopnea index (AHI) and the respiratory disturbance index (RDI) are standard tests routinely reported during a sleep study. Without a threshold level of abnormality for AHI and RDI the measure currently lacks the specification to be a useful measure. Both the American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicaid Services (CMS) consider AHI 15 events/hr or AHI 5 events/hr with symptoms (such as daytime somnolence and fatigue) as criteria for OSA diagnosis (1). The PMC suggests that the measure should include a threshold of AHI to determine OSA diagnosis that aligns with clinical guidelines.

4 Measure Specifications PCPI Measure #2: Severity assessment at initial diagnosis (3) Obstructive sleep apnea: percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis. Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis. Clinical Topic: Obstructive sleep apnea; apnea hypopnea index (AHI); respiratory disturbance index (RDI) Numerator Patients who had an apnea hypopnea index (AHI) or a respiratory disturbance Statement: index (RDI) measured at the time of initial diagnosis: *AHI for polysomnography performed in a sleep lab is defined as (Total Apneas + Hypopneas per hour of sleep); AHI for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring). **RDI is defined as (Total Apneas + Hypopneas + Respiratory-Effort- Related-Arousals per hour of sleep). Denominator All patients aged 18 years and older with a diagnosis of obstructive sleep Statement: apnea. Refer to the original measure documentation for administrative codes. Exclusions: Documentation of medical reason for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis (e.g., psychiatric disease, dementia) Documentation of patient reason for not measuring an AHI or a RDI at the time of initial diagnosis (e.g., patient declined) Documentation of system reason for not measuring an AHI or a RDI at the time of initial diagnosis (e.g., financial, insurance coverage, test ordered but not yet completed Level of Analysis: Physicians Data Source: Administrative clinical data Electronic health/medical record 2012 PQRS Pulmonary Measure Group (CMS 277) Measure Steward: American Academy of Sleep Medicine (AASM), Physician Consortium for Performance Improvement, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA); ACP supports the PCPI measure on prescription of positive airway pressure therapy. The PMC supports this measure because it aligns with the ACP guideline. The ACP Guideline recommends that continuous positive airway pressure should be used as therapy for patients diagnosed with OSA (Grade: strong recommendation, moderate-quality evidence) (2). However, ACP recommends

5 mandibular advancement devices (MAD) as an alternative therapy to continuous positive airway pressure for patients diagnosed with OSA who prefer MAD or in those with adverse effects associated with CPAP (Grade: weak recommendation, low-quality evidence) (2). While this clinical situation will fall into the measure exclusion criteria, the PMC suggests it would be more clinically useful if this measure included an option for physicians to satisfy the measure if patients use MAD as a second-line therapy. Measure Specifications PCPI Measure #3: Positive airway pressure therapy prescribed (3) Obstructive sleep apnea: percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy. Description: This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy. Clinical Topic: Obstructive sleep apnea; positive airway pressure therapy Numerator Patients who were prescribed positive airway pressure therapy Statement: Denominator All patients aged 18 years and older with a diagnosis of moderate or severe Statement: obstructive sleep apnea* *Moderate or severe sleep apnea is defined as apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) greater than or equal to 15 episodes per hour of sleep. Refer to the original measure documentation for administrative codes. Exclusions: Medical reason (s) for not prescribing positive airway pressure therapy (e.g., patient unable to tolerate, alternative therapies used) Patient reason(s) for not prescribing positive airway pressure therapy (e.g., patient declined) System reason(s) for not prescribing positive airway pressure therapy (e.g., financial, insurance coverage) Level of Analysis: Physicians Data Source: Administrative clinical data Electronic health/medical record 2012 PQRS Pulmonary Measure Group (CMS 278) Measure Steward: American Academy of Sleep Medicine (AASM), Physician Consortium for Performance Improvement, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA); ACP supports the PCPI measure on the assessment of adherence to positive airway pressure therapy. The ACP guideline states that compliance with therapies, especially CPAP, is an important issue related to the effective treatment of OSA. Clinicians should keep patient preferences and adherence, specific

6 reasons for noncompliance, and costs in mind before initiating CPAP treatment. The performance measure encourages physicians to obtain objective measurements of CPAP compliance to promote shared decision making and encourage patient-centered care. However, this measure could be subjected to gaming. The exclusion criteria patient did not bring card is not appropriate. For example, if 95% of patients forget the card, the physician could achieve the perfect score (100%) on the measure if the other 5% of patients bring their card. The measure as currently written will not improve the quality of care. In addition, this measure is not under the provider s control and may not be useful for primary care physicians. The more interesting question would be whether the physician makes an effort to improve compliance or offer second line therapies for OSA given low patient compliance. Measure Specifications PCPI Measure #4: Assessment of adherence to positive airway pressure therapy (3) Obstructive sleep apnea: percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured. Description: This measure is used to assess the percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured. Clinical Topic: Obstructive sleep apnea; positive airway pressure therapy adherence Numerator Patient visits with documentation that adherence to positive airway pressure Statement: therapy was objectively measured* *Objectively measured is defined as: positive airway pressure machinegenerated measurement of hours of use. Denominator Statement: All visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy. Refer to the original measure documentation for administrative codes. Exclusions: Documentation of a patient reason(s) for not objectively measuring adherence to positive airway pressure therapy (e.g., patient didn't bring data from card) Documentation of a system reason(s) for not objectively measuring adherence to positive airway pressure therapy (e.g., therapy not yet initiated, not available on machine) Level of Analysis: Physicians Data Source: Administrative clinical data; Electronic health/medical record 2012 PQRS Pulmonary Measure Group (CMS 279) Measure Steward: American Academy of Sleep Medicine (AASM), Physician Consortium for Performance Improvement, National Committee for Quality Assurance (NCQA). Obstructive sleep apnea physician performance measurement set. Chicago (IL): American Medical Association (AMA)

7 Gaps in Performance Measurement Opportunities to Promote High-Value Care The PMC recommends the development of overuse measures in two areas. The first measure should target patients who have received a sleep study and have not had symptoms assessed (i.e. presence or absence of snoring and daytime sleepiness). There is a need to perform an appropriate risk assessment that will indicate the need for a sleep consult or sleep study in order to measure possible overuse of services. The second measure should assess whether the results obtained from a sleep study are interpreted correctly and used to make informed treatment decisions. References 1. Qaseem A, Dallas P, Owens DK, Starkey M, Holty JEC, Shekelle P, and the Clinical Guidelines Committee of the American College of Physicians. Diagnosis of Obstructive Sleep Apnea: A Clinical Practice Guideline from the Clinical Guidelines Committee of the American College of Physicians. (in review) 2. Qaseem A, Holty JEC, Owens DK, Dallas P, Starkey M, Shekelle P, and the Clinical Guidelines Committee of the American College of Physicians. Management of Obstructive Sleep Apnea: A Clinical Practice Guideline from the American College of Physicians. (in review) 3. American Academy of Sleep Medicine (AASM)/Physician Consortium for Performance Improvement (PCPI)/National Committee for Quality Assurance Obstructive Sleep Apnea Physician Performance Measurement Set, American Medical Association. Accessed 15 March Financial Support: Financial support for the Performance Measurement Committee exclusively comes from the ACP operating budget. Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC meeting and conference call and can be viewed at: Approved by the ACP Board of Regents on: April 8, 2013 Requests for Inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians, 190. N Independence Mall West, Philadelphia, PA 19106: , aqaseem@acponline.org