Letter to the Editor
Telematic Multi-physician Decision-making for Improving CPAP Prescription in Sleep Apnoea
Toma de decisiones compartida por vía telemática para mejorar la prescripción de la CPAP en la apnea del sueño
Ramon Farréa,b,c,
, Daniel Navajasa,b,d, David Gozale, Josep M. Montserratb,c,f
Corresponding author
a Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
b CIBER de Enfermedades Respiratorias, Madrid, Spain
c Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain
d Institut for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain
e Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA
f Sleep Lab, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
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In case of unanimous (0–6 or 6–0) or draw (3–3) recommendations there is no statistical advantage when the decision is taken from 3 or 1 physicians. In the other cases, 3-physician decision is advantageous as compared with 1-physician decision. (B) Left: Distribution of 6-physician recommendations for the 40 patients with mild–moderate OSA (AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events/h). Gray: recommendations resulting in no statistical advantage when the decision is made by 3 or 1 physicians; Black: recommendations for which decision-making by 3 instead of 1 physician increases correct decision probability. Right: Expected error in CPAP prescription when the decision is taken by 3 physicians (green column) instead 1 physician (brown column). 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Montserrat" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Ramon" "apellidos" => "Farré" "email" => array:1 [ 0 => "rfarre@ub.edu" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Daniel" "apellidos" => "Navajas" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 2 => array:3 [ "nombre" => "David" "apellidos" => "Gozal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "Josep M." "apellidos" => "Montserrat" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Unitat de Biofísica i Bioenginyeria, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER de Enfermedades Respiratorias, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Institut Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Institut for Bioengineering of Catalonia, The Barcelona Institute of Science and Technology, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Department of Child Health, University of Missouri School of Medicine, Columbia, MO 65201, USA" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Sleep Lab, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Toma de decisiones compartida por vía telemática para mejorar la prescripción de la CPAP en la apnea del sueño" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2995 "Ancho" => 1194 "Tamanyo" => 233102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Probability of correct CPAP prescription when the decision is taken by 1 physician (brown columns) or by a 3-physician group (green columns), for the different 7 possible (‘yes’–‘no’) recommendations from 6 physicians (0–6, 1–5, 2–4, 3–3, 4–2, 5–1 and 6–0). In case of unanimous (0–6 or 6–0) or draw (3–3) recommendations there is no statistical advantage when the decision is taken from 3 or 1 physicians. In the other cases, 3-physician decision is advantageous as compared with 1-physician decision. (B) Left: Distribution of 6-physician recommendations for the 40 patients with mild–moderate OSA (AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events/h). Gray: recommendations resulting in no statistical advantage when the decision is made by 3 or 1 physicians; Black: recommendations for which decision-making by 3 instead of 1 physician increases correct decision probability. Right: Expected error in CPAP prescription when the decision is taken by 3 physicians (green column) instead 1 physician (brown column). (C) Same as in (B) but only for moderate OSA patients (15<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40 events/h).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Continuous positive airway pressure (CPAP) is the most common therapeutic modality for obstructive sleep apnoea (OSA). However, deciding whether a patient should be treated with CPAP is not a simple process, in light that a large number of complex clinical variables need to be considered in the decision process.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> This difficulty is particularly apparent among mild–moderate OSA patients, since quality of life is scarcely affected, CPAP compliance is relatively low, and treatment effectiveness is unclear.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–4</span></a> Although setting a threshold in the apnea–hypopnea index (AHI) is the most usual criterion for CPAP prescription in OSA, current clinical guidelines do not provide the treating physician with unambiguous rules. Consequently, virtually universal disagreement in decision making about implementation of CPAP therapy<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> has been considered as inevitable. In fact, a conventional consultation process among physicians evaluating OSA patients is viewed as impractical and not routinely implementable considering the high prevalence of OSA,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> therefore resulting in a considerable number of patients being then referred for initiation of CPAP therapy.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> However, consultation among colleagues can be markedly facilitated and become cost-effective using telematics.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Nevertheless, this approach has not been used until now to improve decision-making in CPAP prescription.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We herein describe a novel model of telematic physician consultation (TPC) in the context of decision making regarding the need for CPAP therapy, and use real-world data to provide a proof of concept of its feasibility and potential benefits. In TPC, the physician who treats a patient has the external support of 2 independent specialists to decide on CPAP treatment. While this approach seems straightforward and reasonable, whether it is feasible and improves decision-making in routine OSA patients has not been assessed. To this effect, we randomly selected 40 patients with mild–moderate OSA (AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events/h) from the database of a clinical trial (NCT02779894; ClinicalTrials.gov) that included a general population of patients with OSA.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> All the clinical and sleep study variables (≈60) of each patient were placed anonymously on a specially designed website that was only accessible to 6 experienced sleep physicians from different Spanish hospitals, who were then asked to provide their recommendations about CPAP prescription: ‘yes’ or ‘no’ (‘no’ could be both a clear negative to CPAP or no prescription until additional patient evaluation). For each possible combination of ‘yes’–‘no’ recommendations we first theoretically calculated the probability of correct decision when the latter was made by 1 or 3 physicians; second, we experimentally determined how the ‘yes’–‘no’ recommendations were distributed among the patients, and finally we computed the expected value of correct decision corresponding to 1- or 3-physician decision on CPAP initiation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As the correct decision for each patient is unknown, we assumed that it was better estimated by the majority of the recommendations of the 6 physicians. Consequently, among the 7 possible ‘yes’–‘no’ recommendations (0–6, 1–5, 2–4, 3–3, 4–2, 5–1 and 6–0), the decision on CPAP treatment was considered correct only for recommendations 4–2, 5–1 and 6–0. For each of the 7 combinations ‘yes’–‘no’, the probability that a single physician would recommend the correct decision is 6/6, 5/6, 4/6, 3/6, 4/6, 5/6 and 6/6 (i.e. 100%, 83.3%, 66.7%, 50%, 66.7%, 83.3% and 100%), respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). To calculate the probability of a correct CPAP prescription decision when taken by the majority of 3 physicians, we considered that among the 20 different possible combinations of 3 recommendations from 6 physicians (C(6,3)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6!/(3!(6<span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>3)!), the number of combinations that yields a positive result (2 or 3 physicians recommending CPAP) are 0, 0, 4, 10, 16, 20 and 20 for the above 7 ‘yes’–‘no’ recommendations, respectively. Therefore, the probability of correct decision is: 100%, 100%, 80%, 50%, 80%, 100% and 100%, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). As expected, only when the 6-physician recommendation is unanimous (0–6 or 6–0) or when it is a tie (3–3) there is no statistical advantage when the decision is made by 3 or 1 physicians. Otherwise, decision-making by 3 physicians instead of 1 physician alone increases the correct decision probability (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">To calculate the real-life impact in the decision-making of 1 or 3 physicians, the theoretical probability analysis in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A was combined with the actual distribution of the spectrum of real-data recommendations of the 6 external physicians on the 40 mild–moderate OSA patients (a total of 240 decisions), shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B. The left panel in this figure reflects the variability in physician agreement as regards therapeutic decision on CPAP.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> In 42.5% of the patients, the 6-physician recommendation was one for which using the 3-physician decision approach reduces the prescription error versus the 1-physician approach (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). When considering the actual distribution of the recommendations (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) and the corresponding probability of correct decisions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), the error frequency in CPAP prescription decision would be considerably reduced from 12.9% to 6.2% of the patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Interestingly, when the analysis was limited to the 24 patients with moderate OSA (15<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events/h), the decision-making error when switching from 1-physician to 3-physician prescription was also reduced by ≈50%: from 16.7% to 8.7% of patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C).</p><p id="par0025" class="elsevierStylePara elsevierViewall">This study provides a solid proof of concept on the feasibility and potential improvements achieved by our novel proposal of telematic multi-physician decision-making approaches for improving CPAP treatment decision in OSA. If the attending physician is supported by the opinion of 2 independent colleagues, unnecessary CPAP prescription may be avoided in ≈8% of mild–moderate OSA patients. Such changes in clinical decision would have a considerable impact both in cases in which CPAP was prescribed to patients not requiring the treatment (patient inconvenience and unnecessary treatment costs (≈320<span class="elsevierStyleHsp" style=""></span>US$/year<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a>) and in cases where patients requiring CPAP would not be treated (reducing adverse health consequences of untreated OSA and associated opportunity costs (2700–5200<span class="elsevierStyleHsp" style=""></span>US$/year<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a>). Considering that the incidence of new CPAP prescriptions is ≈25 per 10,000 inhabitants per year,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> and that in ≈70% of OSA patients the disease is mild–moderate,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> it can be estimated that TPC, if implemented as proposed here, would avoid prescription errors in ≈175,000 patients per year in the OCED countries (1.25 billion inhabitants), likely resulting in beneficial reductions in healthcare costs, even after TPC implementation. Indeed, the increases in the effectiveness of CPAP prescription would entail only very modest cost increments per patient, corresponding to ≈15<span class="elsevierStyleHsp" style=""></span>min of off-line telematic assessment by 2 sleep specialists.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, the implementation of an updated telematic version of the consultation among physicians could provide considerable cost-effective improvements in the prescription of CPAP in OSA, a proposal that we believe should be substantiated in the future by specifically designed clinical trials including a wide-spectrum population to provide statistically powered conclusions. Notably, the approach described here can be readily transposed to other unresolved issues in OSA diagnosis and treatment,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> in which complex decision-making could benefit from a straightforward approach of inter-physician consultation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial</span><p id="par0035" class="elsevierStylePara elsevierViewall">Supported in part by the <span class="elsevierStyleGrantSponsor" id="gs1">Spanish Ministry of Economy and Competitiveness</span> (SAF2017-85574-R, DPI2017-83721-P; AEI/FEDER, UE), and the <span class="elsevierStyleGrantSponsor" id="gs2">CERCA Program of Generalitat de Catalunya</span>. D.G. is supported by <span class="elsevierStyleGrantSponsor" id="gs3">NIH</span> grant <span class="elsevierStyleGrantNumber" refid="gs3">HL130984</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2995 "Ancho" => 1194 "Tamanyo" => 233102 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Probability of correct CPAP prescription when the decision is taken by 1 physician (brown columns) or by a 3-physician group (green columns), for the different 7 possible (‘yes’–‘no’) recommendations from 6 physicians (0–6, 1–5, 2–4, 3–3, 4–2, 5–1 and 6–0). In case of unanimous (0–6 or 6–0) or draw (3–3) recommendations there is no statistical advantage when the decision is taken from 3 or 1 physicians. In the other cases, 3-physician decision is advantageous as compared with 1-physician decision. (B) Left: Distribution of 6-physician recommendations for the 40 patients with mild–moderate OSA (AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events/h). Gray: recommendations resulting in no statistical advantage when the decision is made by 3 or 1 physicians; Black: recommendations for which decision-making by 3 instead of 1 physician increases correct decision probability. Right: Expected error in CPAP prescription when the decision is taken by 3 physicians (green column) instead 1 physician (brown column). (C) Same as in (B) but only for moderate OSA patients (15<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>AHI<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>40 events/h).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.J. Epstein" 1 => "D. Kristo" 2 => "P.J. Strollo Jr." 3 => "N. Friedman" 4 => "A. Malhotra" 5 => "S.P. Patil" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Clin Sleep Med" "fecha" => "2009" "volumen" => "5" "paginaInicial" => "263" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19960649" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0070" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What characterizes patients who are unable to tolerate continuous positive airway pressure (CPAP) treatment?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Janson" 1 => "E. Nöges" 2 => "S. Svedberg-Randt" 3 => "E. Lindberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/rmed.1999.0703" "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "2000" "volumen" => "94" "paginaInicial" => "145" "paginaFinal" => "149" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10714420" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0075" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Moderate sleep apnoea: a “silent” disorder, or not a disorder at all?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E.O. Bixler" 1 => "A.N. Vgontzas" 2 => "J. Gaines" 3 => "J. Fernandez-Mendoza" 4 => "S.L. Calhoun" 5 => "D. Liao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01955-2015" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2016" "volumen" => "47" "paginaInicial" => "23" "paginaFinal" => "26" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26721959" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0080" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Obstructive sleep apnoea of mild severity: should it be treated?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "W.T. McNicholas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MCP.0000000000000420" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Pulm Med" "fecha" => "2017" "volumen" => "23" "paginaInicial" => "506" "paginaFinal" => "511" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28858969" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0085" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Therapeutic decision-making for sleep apnea and hypopnea syndrome using home respiratory polygraphy: a large multicentric study" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Spanish Sleep Network" "etal" => true "autores" => array:6 [ 0 => "J.F. Masa" 1 => "J. Corral" 2 => "R. Pereira" 3 => "J. Duran-Cantolla" 4 => "M. Cabello" 5 => "L. Hernández-Blasco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201103-0428OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2011" "volumen" => "184" "paginaInicial" => "964" "paginaFinal" => "971" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21737584" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0090" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Heinzer" 1 => "S. Vat" 2 => "P. Marques-Vidal" 3 => "H. Marti-Soler" 4 => "D. Andries" 5 => "N. Tobback" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S2213-2600(15)00043-0" "Revista" => array:6 [ "tituloSerie" => "Lancet Respir Med" "fecha" => "2015" "volumen" => "3" "paginaInicial" => "310" "paginaFinal" => "318" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25682233" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0095" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Profile of CPAP treated patients in Ontario, Canada, 2006–2013: a population-based cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Povitz" 1 => "T. Kendzerska" 2 => "P.J. Hanly" 3 => "K. Bray Jenkyn" 4 => "B. Allen" 5 => "C.F.P. George" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.sleep.2018.06.005" "Revista" => array:6 [ "tituloSerie" => "Sleep Med" "fecha" => "2018" "volumen" => "51" "paginaInicial" => "22" "paginaFinal" => "28" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30081383" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0100" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Web-based versus usual care and other formats of decision aids to support prostate cancer screening decisions: systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Baptista" 1 => "E. Teles Sampaio" 2 => "B. Heleno" 3 => "L.F. Azevedo" 4 => "C. Martins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2196/jmir.9070" "Revista" => array:6 [ "tituloSerie" => "J Med Internet Res" "fecha" => "2018" "volumen" => "20" "paginaInicial" => "e228" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29945857" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0033350615001584" "estado" => "S300" "issn" => "00333506" ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0105" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Concordancia intra e inter-especialista en la decisión terapèutica para el Síndrome de Apneas del Sueño. Intra- and inter-physician agreement in Therapeutic Decision for Sleep Apnea Syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.M. Lugo" 1 => "M. Torres" 2 => "O. Garmendia" 3 => "M.C. Suarez-Giron" 4 => "C. Ruiz" 5 => "C. Carmona" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2019.04.013" "Revista" => array:4 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2019 Apr 4" "volumen" => "pii: S0300-2896" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31171411" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0110" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cost-effectiveness of continuous positive airway pressure treatment in moderate-severe obstructive sleep apnea syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Català" 1 => "R. Villoro" 2 => "M. Merino" 3 => "S. Sangenís" 4 => "L. Colomés" 5 => "S. Hernández Flix" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2016.02.005" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2016" "volumen" => "52" "paginaInicial" => "461" "paginaFinal" => "469" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26993090" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0115" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical consequences and economic costs of untreated obstructive sleep apnea syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Knauert" 1 => "S. Naik" 2 => "M.B. Gillespie" 3 => "M. Kryger" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.wjorl.2015.08.001" "Revista" => array:6 [ "tituloSerie" => "World J Otorhinolaryngol Head Neck Surg" "fecha" => "2015" "volumen" => "1" "paginaInicial" => "17" "paginaFinal" => "27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29204536" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0120" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Challenges and perspectives in obstructive sleep apnoea: report by an ad hoc working group of the Sleep Disordered Breathing Group of the European Respiratory Society and the European Sleep Research Society" "etal" => true "autores" => array:6 [ 0 => "W. Randerath" 1 => "C.L. Bassetti" 2 => "M.R. Bonsignore" 3 => "R. Farre" 4 => "L. Ferini-Strambi" 5 => "L. Grote" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01675-2018" "Revista" => array:4 [ "tituloSerie" => "Eur Respir J" "fecha" => "2018" "volumen" => "52" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30385603" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005500000011/v1_201911020900/S1579212919303027/v1_201911020900/en/main.assets" "Apartado" => array:4 [ "identificador" => "45358" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005500000011/v1_201911020900/S1579212919303027/v1_201911020900/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212919303027?idApp=UINPBA00003Z" ]
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