O bstructive sleep apnea (OSA) is characterized by recurring episodes of cessation (apnea) or reduction (hypopnea) in airflow during sleep caused by obstruction of the upper airway. In recent population-based studies, the estimated prevalence of moderate to severe sleep-disordered breathing ranges from 3% to nearly 50% depending on age group and sex. 1,2 A survey conducted by the Public Health Agency of Canada in 2009 found that 26% of Canadian adults reported symptoms and risk factors that are associated with a high risk of OSA; 3 however, prevalence data in Canada are limited by the absence of studies using objective sleep testing. Obstructive sleep apnea may be underdiagnosed; only 3% of Canadians aged 18 years or older reported a formal diagnosis despite high rates of symptom reporting; 3 yet, high-quality prospective studies have shown clear benefit of treatment for patients with sleepiness, cognitive or psychological dysfunction, or poor quality of life owing to obstructive sleep apnea. 4-6 Large population-based studies have shown that untreated moderate or severe OSA is associated with serious complications. 7-9 We review signs, symptoms and morbidity associated with OSA, along with diagnostic options, treatments and considerations for long-term follow-up, based on evidence and recommendations from clinical guidelines, systematic reviews and primary studies (Box 1). What signs, symptoms and risk factors should prompt consideration of obstructive sleep apnea? About 25% of patients with OSA report daytime sleepiness; a greater proportion report unrefreshing sleep or fatigue. 10 Other symptoms include frequent nocturnal waking due to choking or gasping, nocturia, morning headaches, poor concentration, irritability and erectile dysfunction. 11-13 Bed partners may report snoring or witnessed apneas. Atypical symptoms, which are more frequently reported by women, include insomnia, impaired memory, mood disturbance, reflux and nocturnal enuresis. 14 However, the correlation of symptoms with disease severity is poor, 15 which is why it is important for physicians to be alert to milder symptoms. There are many underlying risk factors, predisposing conditions and associated comorbidities for OSA; they are summarized in Appendix 1, available at www.cmaj.ca/ lookup/suppl/
Background:Increased demand and escalating costs necessitate innovation in health care. The challenge is to implement complex innovations—those that require coordinated use across the adopting organization to have the intended benefits.Purpose:We wanted to understand why and how two of five similar hospitals associated with the same health care authority made more progress with implementing a complex inpatient discharge innovation whereas the other three experienced more difficulties in doing so.Methodology:We conducted a qualitative comparative case study of the implementation process at five comparable urban hospitals adopting the same inpatient discharge innovation mandated by their health care authority. We analyzed documents and conducted 39 interviews of the health care authority and hospital executives and frontline managers across the five sites over a 1-year period while the implementation was ongoing.Findings:In two and a half years, two of the participating hospitals had made significant progress with implementing the innovation and had begun to realize benefits; they exemplified an integrated implementation mode. Three sites had made minimal progress, following a fragmented implementation mode. In the former mode, a semiautonomous health care organization developed a clear overall purpose and chose one umbrella initiative to implement it. The integrative initiative subsumed the rest and guided resource allocation and the practices of hospital executives, frontline managers, and staff who had bought into it. In contrast, in the fragmented implementation mode, the health care authority had several overlapping, competing innovations that overwhelmed the sites and impeded their implementation.Practice Implications:Implementing a complex innovation across hospital sites required (a) early prioritization of one initiative as integrative, (b) the commitment of additional (traded off or new) human resources, (c) deliberate upfront planning and continual support for and evaluation of implementation, and (d) allowance for local customization within the general principles of standardization.
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