Sleep-disordered breathing: A survey of otolaryngologic practice at military hospitals.

Abstract

We conducted a survey of otolaryngologists at all Veterans Administration and Department of Defense hospitals in the United States to ascertain the nature and scope of their treatment of sleep-disordered breathing. Questionnaire responses indicated that head and neck surgeons in military hospitals have a strong interest in the management of patients with snoring and sleep apnea. Because of the difficulty in obtaining timely sleep test results and the low number of referrals from physicians who perform such testing, many otolaryngologists expressed a desire to be able to perform their own sleep testing.

Introduction

Personal experience has shown us that sleep test results are difficult to obtain at the Veterans Administration (VA) Healthcare System in San Diego. Anecdotal evidence derived from communication with colleagues indicates that the same is true at other military facilities. To ascertain the nature of the problem nationwide, we surveyed otolaryngologists at all VA and Department of Defense (DOD) hospitals in the United States in an attempt to quantify and understand their experiences.

Methods

Questionnaires were mailed to otolaryngologists at all VA and DOD hospitals in the United States. According to the Federal Practitioner's 1999 Directory of VA and DOD Healthcare Facilities, there are 167 VA hospitals and healthcare centers and 112 DOD hospitals in the U.S. [1]

We sorted the returned questionnaires according to the type of hospital (VA or DOD), and we calculated arithmetic means with standard deviations for each subgroup as well as for the total number of respondents. In cases where respondents provided a numerical range instead of a specific number, we calculated the mean of the range to facilitate statistical analysis. We also noted instances where respondents failed to give numerical answers and instead used a checkmark.

Results

Of the 167 VA and 112 DOD questionnaires that we mailed, we received 77 usable responses (50 VA and 27 DOD). Respondents at 66 facilities (43 VA and 23 DOD) indicated that they see patients who have sleep-disordered breathing (SDB)--that is, snoring or sleep apnea. The 43 VA respondents saw a mean of 14 ([+ or -]17) SDB patients per month at each facility, while the DOD respondents saw an average of 16 ([+ or -]11) per month.

The VA respondents reported that 24% ([+ or -]26%) of patients who came to the otolaryngology department for evaluation of snoring or sleep apnea brought sleep test results with them, as did 19% ([+ or -]22%) of the SDB patients seen at the DOD hospitals. VA hospitals ordered an average of 7 ([+ or -]7) sleep tests per month, and needed an average of 12 ([+ or -]12) weeks to schedule the tests and receive the results. DOD hospitals ordered an average of 9 ([+ or -]7) tests per month and needed 6 ([+ or -]4) weeks to schedule the tests and receive the results.

Thirty-three of the 66 respondents (50%) who saw SDB patients said they would be interested in performing sleep tests for diagnostic purposes if such testing were readily available. But only 17 of the 66 (26%) said they would dispense continuous positive-airway pressure (CPAP) if it were available.

For the treatment of snoring, uvulopalatopharyngoplasty (UPPP) was the preferred procedure, followed in descending order by uvulectomy, laser-assisted uvulopalatoplasty (LAUP), cautery-assisted palatal stiffening, and somnoplasty (table 1).

Sleep apnea patients who fail CPAP were treated primarily with nasal surgery and UPPP (table 2). Some of these patients underwent genioglossus advancement and/or hyoid suspension. Although all respondents said they perform tracheostomy for sleep apnea, the number of these procedures is low--typically one tracheostomy per facility every 2 to 4 months. Very few patients with sleep apnea were treated with LAUP.

Discussion

The results of our survey suggest that there is substantial interest in sleep medicine in military hospitals across the country. The perception that sleep test results are difficult to obtain was validated by our finding that the mean waiting period was 10 weeks. Presumably, this time lag--along with the respondents' observations that referrals from sleep-medicine physicians are few--prompted 50% of the respondents to express an interest in performing sleep testing, although only 26% expressed an interest in dispensing CPAP.

Acknowledgment

Acknowledgment is extended to Barbara Stribling, Dr. Davidson's assistant, for her outstanding effort in preparing and finalizing the manuscript.

From the Division of OtolaryngologyuHead and Neck Surgery, University of California, San Diego, School of Medicine.

Reprint requests: Terence M. Davidson, MD, VA San Diego Healthcare System, Head and Neck Surgery (112C), 3350 La Jolla Village Dr., San Diego, CA 92161. Phone: [phone], ext. 3405; fax: [phone]; e-mail: [e-mail]

This article was supported by a grant from the Peter Farrell Foundation.

Reference

(1.) Maher MB. Federal Practitioner Directory of VA and DOD Healthcare Facilities. Chatham, N.J.: Quadrant Healthcom, 1999.