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Performance of Sleep Histories in an Ambulatory Medicine Clinic^*

Impact of Simple Chart Reminders

^* From the Department of Medicine, Sections of Pulmonary/Critical Care (Drs. Namen and Haponik) and General Internal Medicine (Dr. Wymer), and the Department of Public Health Science (Dr. Case), Wake Forest University School of Medicine, Winston-Salem, NC.

Correspondence to: Andrew M. Namen, MD, Section of Pulmonary/Critical Care Medicine, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157

Background: The sleep history is essential to recognizing clinically important sleep disorders, but little is documented about its performance in the primary care setting.

Study objectives: To estimate the frequency of documented sleep histories by medical house officers (HOs) in an ambulatory medicine clinic and to assess whether a chart reminder influences their performance.

Design: We reviewed the performance of medical HOs after introduction of a medical record form that included a simple sleep history prompt among reminders relating to health promotion. For each of 108 HOs, we randomly selected a chart with a sleep history prompt and one without.

Results: Any sleep history was documented in only 37 of 216 medical records (17%), including 21 of 122 patients (17%) with risk factors for obstructive sleep apnea (OSA). Use of chart reminders was associated with nearly a fivefold increase of sleep histories (29% vs 6%, p < 0.001), and charts with prompts had more notations about specific sleep complaints (2.6 ± 0.9 vs 1.0 ± 0.0 notes per patient, p < 0.0001). Sleep histories were recorded less often (p < 0.001) than histories of cigarette smoking or alcohol use. Although 24% of physicians appeared to be influenced by the prompt, sleep problems were included on problem lists of only six patients (3%). Overall, the frequencies of diagnostic studies (1% of all patients, 6% of those with sleep histories) or documented therapeutic recommendations (0%) relating to sleep were low, whether or not chart reminders were used, with sleep testing obtained in only one patient. Sleep interventions were documented less often than smoking cessation or weight loss (p < 0.002).

Conclusions: Sleep histories are seldom documented by medical HOs, even in patients at risk for OSA. Use of a simple chart reminder was associated with an increased frequency of recorded sleep histories, but had no clear impact on diagnosis or treatment. If sleep problems and their management are to be prioritized appropriately, then the obstacles to obtaining sleep histories and to following up cues to sleep disorders must be clarified and overcome.

Key Words: ambulatory clinic • chart reminders • sleep apnea • sleep histories

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