Evidence-based Diagnosis and Management of Pediatric Obstructive Sleep Apnea in Primary Care

Study Design: This study will use a cluster randomized control trial (RCT) over a two-year period in four pediatric community clinics affiliated with our institution. To minimize contamination, randomization will occur by clinic, with the individual patient as the unit of analysis. Four clinics are already matched in pairs to facilitate a balance of patient numbers and demographics, and a coin flip will determine which clinic pair will receive CHICA-OSA and which will serve as control clinics. The two control clinics also have the CHICA system in place but the only intervention pertaining to sleep will be a simple module that identifies snoring children. While receiving automated prompts to help identify snoring children, PCPs in control clinics will evaluate and manage OSA using their standard methods (i.e., treatment-as-usual).

Participants: Participants will include all children between the ages of 1 and 11 years presenting to their PCP to one of four pediatric community clinics located in Indianapolis, Indiana.

CHICA System: CHICA is comprised of: (1) a knowledge base of pediatric guideline rules; (2) a repository of patient data; (3) a tablet user interface; and (4) an interface to the existing electronic medical record system. The result is a system that both delivers "just-in-time" patient-relevant guidelines to PCPs during the clinical encounter and captures accurate structured data from all who interact with it. In the waiting room caregivers complete a prescreening form (PSF), available in English and Spanish, consisting of a series of twenty surveillance questions tailored to the child's age and past history. A positive response to a question may trigger additional follow-up questions. During the clinic visit, relevant feedback from caregiver responses and information about clinical guidelines are displayed prominently on a provider worksheet (PWS) in the electronic health record.

Visit 1. While in the waiting room, caregivers for all eligible children will respond to an item on the PSF as follows: "Does your child consistently snore 3 or more nights per week?" For caregivers in CHICA-OSA clinics, a "yes" response will trigger additional questions about signs and symptoms of OSA. Specific items corresponding to the symptoms will be taken from the Pediatric Sleep Questionnaire (PSQ19) and include observed apnea, snorts, gasps, daytime sleepiness, and other signs and symptoms listed in the AAP guideline paper. The PCP will then receive a PWS prompt listing signs and symptoms that apply to the child, based on either existing data in the electronic record (e.g., current ADHD diagnosis; overweight) or on caregiver responses to items assessed in the waiting room (e.g., observed apnea; daytime sleepiness). When evidence-based criteria are met, according to the 2012 American Academy of Pediatrics (AAP) guidelines, the PCP will be encouraged to refer the child (for a PSG, to a sleep specialist, or to an ENT).

In the control clinics, parents will complete a surveillance question about snoring, and PCPs will receive a generic prompt but will not receive any additional information about signs and symptoms or guidance on how to further evaluate or manage. For children in both the CHICA-OSA and control clinics, if a caregiver does not report snoring the item about snoring will be repeated one year later.

Subsequent Visits: At the next visit (sick or WCC), snoring will again be assessed as one of the health surveillance questions for all eligible children. However, children from the CHICA-OSA clinics who were referred for PSG at the previous visit will receive an additional item asking whether or not the child has had an adenotonsillectomy in the past year. If the child has not had this surgery the PCP will receive a prompt to assess the outcome of the original referral (e.g., PSG did not suggest OSA; PSG suggested OSA and surgery scheduled; PSG scheduled; adenotonsillectomy scheduled; family does not have appointment) and re-refer if appropriate. If a caregiver reports that a child has had a T\&A and no longer snores, the PCP will not receive any additional prompts and snoring will be reassessed in two years. However, if a caregiver reports residual snoring after surgery, the provider will receive a prompt to refer for possible residual OSA.

Collaborators on this study include: Stephen Downs, MD, Indiana University School of Medicine; Ameet Daftary, MD, Indiana University School of Medicine; and Tamara Dugan, MS, Indiana University School of Medicine