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A New Direction for Sleep: New OSA guidelines fuel another evidence-based medicine debate

by Mary Beth Nierengarten •

A major criticism of the AASM practice parameters, said Dr. Wardrop, is the lack of input from otolaryngologists in the formulation of the guidelines. “Involvement of stakeholders in all relevant disciplines is a key feature in valid guideline development,” she said.

Dr. Harwick was one of two otolaryngologists who reviewed the published data used to generate the AASM practice parameters and was a co-author on a meta-analysis published as a companion piece with the parameters (SLEEP. 2010;33(10):1396-1407). He noted that both the meta-analysis and the parameters highlight the “paucity” of evidence on which the parameters were developed.

He also emphasized that he was not told that the meta-analysis he was involved in was going to be used as the basis to create the practice parameters and that his expertise was not solicited for the final analysis and publication.

It may be that this lack of expert input is at the hub of the response to the AASM guidelines; the authors of the guidelines themselves state that “the paucity and low quality of evidence concerning the surgical treatment of the upper airway for OSA [obstructive sleep apnea] in adults is conspicuous (p. 1412),” and conclude that more sound clinical research is needed in order to better understand the indication for surgical treatment of the upper airway for OSA in adults.

“As a specialty, it is very important that we work on developing a way of measuring outcomes that can be applied universally so we can work toward studies that will help us detemine best practices.”—John Harwick, MD

Another aspect contested by otolaryngologists: the evidence chosen by the AASM panel.

“The lack of experience among the AASM authors has raised concerns,” said Edward M. Weaver, MD, MPH, associate professor of otolaryngology and chief of sleep surgery at the University of Washington in Seattle, who also participated in a panel discussion on guidelines at the AAO-HNS meeting. He added that important studies were excluded from the review, and emphasis was directed away from clinical outcomes. “The conclusions were drawn primarily from the limited data on apnea-hypopnea index outcome, and the more important studies on clinical outcomes were not included,” he said.

Dr. Harwick also challenged the relevancy of data used to generate the parameters. “From my perspective, I don’t think the practice parameters are of great value in addressing the issues needing to be addressed in terms of looking at things associated with successful outcomes, such as improvement in the saturation index,” he said. He also emphasized the fact that the apnea-hypopnea index does not necessarily reflect important outcomes such as improvement in cardiovascular risk and patient daytime functioning.