Barriers and enablers to the diagnosis and treatment of obstructive sleep apnoea in chronic heart failure from patients' and clinicians' perspectives.
Authors: Bernhardt L , Squire I , Robertson N 
Published: July 2022

Abstract

Funding Acknowledgements
Type of funding sources: Other. Main funding source(s): This study was co-funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM), now recommissioned as NIHR Applied Research Collaboration East Midlands (ARC EM) and Leicestershire Partnership NHS Trust - Raising Health Charitable Funds Award and supported by the NIHR Leicester Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Background
Chronic Heart Failure (CHF) is associated with a considerable burden of disability. Despite the impact of evidence-based therapies on CHF related deaths and disability, many patients continue to experience persistent symptoms and will die from progressive CHF. This may be exacerbated by the presence of co-morbidities that contribute to both the development and progression of CHF. The identification and management of co-morbidities, such as obstructive sleep apnoea (OSA), may provide an additional strategy for the management of CHF, leading to improved survival, symptoms, and health care cost. OSA remains largely under diagnosed and under treated with a negative impact on the patient and health care systems as complications develop. To bridge this gap and to develop targeted interventions, the identification of possible barriers to, and enablers of, the diagnosis and treatment of OSA in CHF, is essential.

Purpose
To investigate the barriers to, and enablers of, the diagnosis and treatment of OSA from CHF patients’ and clinicians’ perspectives.

Methods
A qualitative study design was utilised to elicit and describe perceived barriers and enablers associated with the diagnosis and treatment of OSA in CHF. CHF patients (n=10) and clinicians (n=20) took part in semi-structured interviews that were analysed using thematic analysis.

Results
Findings from both patients’ and clinicians’ interviews reported barriers and enablers at all stages of the diagnostic pathway. Patient-reported barriers comprised poor recognition of symptoms, lack of understanding, insufficient information provided by health care professionals, poorly tolerated treatment, and poor access to sleep services. Patient enablers were partner-reported symptoms, awareness of others with OSA, confidence in their heart failure clinician, outcome expectancy, and support from a partner and the sleep disorders service.
Clinician-reported barriers were that patients perceived OSA as a low priority compared to their diagnosis of CHF, lack of awareness, knowledge, and skills in the assessment of OSA, variable levels of confidence and low clinical priority of OSA, variable access to sleep services and poor patient uptake and adherence to OSA treatment. Key enablers were perceived outcomes expectancy, education, high confidence, and prompts built into their assessment template.

Conclusion
Findings identified several key barriers and enablers across the OSA diagnostic pathway and associated with both CHF patients and clinicians. Targeted interventions based on the study findings are likely to significantly influence the OSA diagnostic pathway, effective clinical recognition, diagnosis of OSA and treatment of OSA. Development of co-designed and co-produced targeted interventions for clinician upskilling is essential.