ORIGINAL ARTICLE

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AN EXAMINATION OF AUSTRALIAN GENERAL PRACTITIONERS' KNOWLEDGE, ATTITUDES AND PRACTICES IN RELATION TO SLEEP DISORDERS

One GP stated that drug companies have no interest in funding education relating to OSA as there is no financial gain.

GPs agreed that sleep disorders causes significant impediments to individuals, nonetheless, two-thirds of the GPs reported they did not routinely initiate discussions about sleep during the consultation. Some stated that enquiries would be made during a general health check; most indicated that sleep would be addressed if sleep was the presenting problem, if triggered by symptoms, or if sleep disorders had been identified in past consultations:

“...the theoretical answer is ‘I’m sure it’s quite important’; the practical answer is ‘I don’t do it routinely’. I would ask it whenever there’s any question in my head about those other issues, about snoring, about sleep apnoea, about depression, about using HRT for hot flushes. If they come in with a sore shoulder, I certainly don’t ask.”

Most GPs agreed that many sleep problems were underpinned by mental health issues such as depression, and life stressors such as family, bereavement, and work:

“…very rarely is it just a sleep problem. Often it would be psychiatric symptoms of one kind or another. So, there may be a degree of mood disorder, anxiety, life stresses, not necessarily diagnosable as a syndrome.”

2. Clinical practices in managing sleep disorders

2.1 Presentation and assessment

The majority reported having between one and ten cases presenting with sleep problems each week. Patients were generally middle-aged or elderly, but children, shift workers and teens were also represented.

When patients present with a sleep related disorder, GPs agreed that a combination of presenting symptoms, the order of symptom presentation and a sleep history would influence whether they thought insomnia was the primary or secondary problem:

“...as far as I’m aware, mainly use history as a guide as to when their symptoms arise, try and get some feeling as to what came first, the insomnia or depression, seeing what the sleep pattern has been from childhood, et cetera. So again, get a gauge as to whether the insomnia appears to be fairly short term, or more like a secondary reaction to an underlying cause.”

Generally, the assessment of OSA was based on signs such as obesity, hypertension, snoring, excessive daytime sleepiness as well as risk assessment in some cases:

“(falling asleep at inappropriate times during the day) people do that, you have to wake them up in the waiting room.”

2.2 Management

GPs preferred behavioural interventions including sleep hygiene and lifestyle advice to manage sleep symptoms. A few GPs used specific psychological techniques, and others mentioned pharmacological therapies. When treating sleep disorders associated with depression, some preferred prescribing anti-depressants rather than hypnotics. However, patient’s expectations influenced several when deciding management interventions:

“...some patients don't want drugs, other patients want drugs or other patients particularly don't want psychological therapy. This means they are a little bit more restricted and we try and work (with) them.”

In acute cases such as bereavement, GPs may prescribe hypnotics as a one-off:

“…well, that would be sleep hygiene and also asking about caffeine use and alcohol use as well in the younger age group because that can be a thing that can be a cause of a sleep disturbance, and assess mood and check it’s not depression. Then the sleeping tablets would be a last resort.”

Most were conservative in prescribing for new and/or younger patients and in most cases, preferred behavioural interventions, for both young and elderly patients:

“…well, I always try the behavioural first.”

When managing elderly patients, GPs provided advice about risks associated with benzodiazepines, however, most expressed leniency regarding writing repeats as withdrawal symptoms may cause suffering and impact on quality of life:

“(so you feel well there’s no point in taking them off it)…we always talk about the side effects of them (prescribing medication) and as long as there hasn’t been an increased use and they’re not depressed and not drinking and it’s not going to interact with any of their medications.”

“…at the end of the day, the elderly, I find, are more interested in the quality of life rather than the quantity and therefore I tend to be a bit; I am very careful with giving Benzos but on the other hand, you sort of tend to be a bit more; the attitude is to make them comfortable. A bit more lenient yeah.”

When managing OSA, all GPs stated they would give lifestyle advice such as losing weight or reducing alcohol intake, but mainly management strategies are guided by specialists:

”Generally, people would get managed primarily by the sleep physician who’s running their sleep study. So, most of the steering I think comes from them and we just facilitate it.”

Referral practices varied amongst GPs with some indicating they would rarely refer the patient to psychologists without a suspicion of mental health issues:

“As for insomnia, I find that I don't ever need to refer to a specialist. I somehow manage, like you look for secondary causes and you manage the secondary causes, because a secondary cause could be mental health problems and then you will have to refer for those problems, rather than for insomnia, per say.”

Others indicated that they would refer to a psychologist to address sleep problems:

“I might be considering referring someone to a psychologist (for insomnia), rarely to a psychiatrist; it would be more commonly a psychologist and it would often be for a behavioural type program.”

Most participating GPs agreed that patients exhibiting signs of OSA would be referred to a sleep clinic for a sleep study:

“If I believe it is sleep apnoea, I don’t do any other investigation. I refer them on.”

3. Factors influencing GPs’ clinical practice

GPs identified a number of factors which influenced their clinical practice behaviours; GP-related factors, patient-related factors and system-related factors.

3.1 GP-related factors

Participating GPs stated their knowledge about sleep physiology and sleep disorders was lacking.

“I think my skills are poor. Apart from being able to provide them with some hypnotics, the other suggestions I’ve got are pretty minimal.”

A few felt their knowledge could be improved if succinct assessment material was available. Journal articles and publications targeted at GPs were the main source of information for most; others had attended seminars and a few used written feedbacks from sleep physicians. Several expressed the desire to engage in further education; however, the limited availability of education activities was also noted.

Personal experience enhanced clinical practice; having personal experience with sleep problems provided insight into the patients’ experiences, altered management and added validity to advice:

“…I suppose it’s innate isn’t it? It probably does. One’s own experience in every medical scenario has an influence over how you manage things.”

3.2 Patient-related factors

Patients’ preparedness to commit to the GP’s advice and not anticipate a ‘quick fix’ was associated with positive treatment outcomes:

“Critically would be their preparedness to say, ‘This is not something which has a quick fix, and so I will do some of these long term or difficult things’, psychological strategies and so on.”

Illiteracy, in older patients was a barrier for some as these patients do not respond well to written material:

“Some of my patients tell me, ’Twenty years painting, no reading’.”

Some GPs felt that many patients lacked awareness of sleep problems which in turn, meant that patients do not specifically present with a sleep problem, complicating identification:

“A patient’s lack of education, lack of awareness of the issues, and I am unaware of it, then certainly, the general public is aware, so they are not going to present and say I have got restless legs or I have got delayed sleep syndrome or I have got REM abnormal behaviour. So, it is just a lack of general information.”

Concern was also expressed for patients who depend on the public health system, as they may not be able to pursue referrals to non-bulk-billing clinical psychologists:

“I would prefer more of these chronic patients to be assessed by clinical psychologists but the patients I send there, reckon they can’t afford it. This may or may not be true. But in any case, the clinical psychologist does not bulk-bill. Although it is potentially possible that they could, but yet they don't.”

Patients may also struggle to have a sleep study conducted within a reasonable timeframe in the public system, and may not be able to afford to pay for a sleep study in a private facility:

“The patient is still is out of pocket one hundred bucks for a home-study (sleep study), so again, that might exclude some patients.”

“Public hospitals, they’ve got sleep studies but it is a couple of years wait to get in. So, you are a bit restricted.”

3.3 System related factors

Time constraints of the standard consultation influences clinical practice behaviours as GPs are renumerated for short consultations and penalised for engaging in longer, more in-depth consultations:

“You’re much better off to see six or eight people in an hour for short consults than three for a higher bidding of long consults. We have a bizarre system which pays you much less than doing the job well.”

Time constraints also led to discrepancies in clinical practice; some GPs indicated that clinical practice behaviours were guided by time constraints rather than best practice:

“Sometimes I might give them just a one-off supply (of benzodiazepines) depending on time factors, and if I haven’t got enough time to deal with it on that first occasion and send them away with some tablets first and then if they need repeats, to then come back and discuss it further.”

DISCUSSION

Results from this study are similar to those reported elsewhere;¹³ the majority of GPs rated their knowledge of sleep disorders as fair to poor. The results of the DSKQ and qualitative reports suggest that participating GPs appear reasonably confident in identifying and managing typical OSA patients, whereas GPs reported a lack of understanding of the physiological underpinnings for sleep disorders and limited knowledge of less common sleep disorders; results supported by the outcomes of DSKQ. This is not surprising as one barrier identified was a lack available educational material specifically tailored to meet the needs of GPs. In this study, GPs stated that they would welcome educational interventions and materials to improve detection and management. Educational interventions, diagnostic materials and expert support have been shown to increase diagnosis and referrals for OSA.²¹

While GPs acknowledged that sleep problems can cause significant impediments to patients’ lives, but would rarely enquire about patients sleep during standard consultations. Sleep disturbances were regularly encountered by the GPs in this study (one to ten encounters per week), yet it has been estimated that up to 60.6 % of primary care patients may experience sleep disturbances, hence, many may remain undiagnosed.^8,22,23

GPs’ time constraints were similarly identified²² as a barrier which could be overcome by longer consultations.

Patients’ health literacy is a factor which could impact of clinical practice behaviours as patients may not recognise the sleep problem, lack the language or communication skills to express symptoms appropriately. Management of insomnia may involve sleep diaries, logs and the use of actigraphy devices and the complexity of appropriately using this material require a reasonable level of literacy. Therefore, improving health literacy has been advocated as one avenue to improve the detection and diagnosis of sleep disorders.²⁴

In this study, GPs indicated a reluctance to prescribe pharmacological interventions and expressed preference for non-pharmacological interventions for dyssomnias such as insomnia, with the exception of many elderly patients who have developed a dependency from long term use. Some discrepancies were noted in the results suggesting that, although GPs would prefer to appropriately assess and manage sleep disorders, they are faced with significant system related factors that do not support the GPs. Participating GPs’ clinical management of insomnia appear to be in sharp contrast with the reported national prescribing practices of 95.2% of insomnia sufferers being treated with pharmacological interventions; in this study  conservative prescribing behaviour was reported.¹² These differences may be attributed to the study’s small sample size; further research is required to assess this. GPs would welcome educational interventions and materials to improve the detection and management of patients with sleep disorders.²¹

Some limitations should be noted; the sample size was small and comprised GPs from metropolitan Melbourne only, subsequently, group comparisons could not be made. The DSKQ has not been validated for use with GPs, but no primary care validated instrument was available. Nevertheless, this pilot study aimed at indicating future directions for a more definitive study and potential interventions.

CONCLUSION

The outcomes of this study highlight the need for educational opportunities relating to sleep disorders and potentially further integration of sleep medicine into undergraduate curricular. Such educational opportunities could provide GPs with a deeper understanding of sleep and sleep disorders. However, in order to empower GPs to utilise their skills, it is crucial to consider all factors which impact on clinical practice behaviours, in particular system constraints that are difficult to manipulate. If GPs were empowered to detect, identify and manage sleep disorders, this, in turn, may improve patient health outcomes, increase referral rates and decrease the risks of misdiagnosis.

ACKNOWLEDGEMENT

The researchers would like to acknowledge the contributions of the GPs who participated in the focus group and interviews. We thank them all for their assistance and kind cooperation.

We also thank the Royal Australian College of General Practice for funding this project through the 2008/2009 RACGP/CONROD Research Fellowship awarded to Dr Craig Hassed.

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