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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Obstructive sleep apnea &#40;OSA&#41; is one of the most common sleep disorders&#46; It is a chronic condition secondary to complete or partial upper airway obstruction that results in daytime sleepiness and fatigue that negatively affects the quality of life of patients&#46; OSA is also considered an important risk factor for cardiovascular&#44; metabolic and neurological comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">OSA is diagnosed by using different sleep tests&#44; from conventional polysomnography &#40;PSG&#41;&#44; which is actually the gold standard in diagnostic procedures&#44; to most simplified single-channel home devices&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> Despite the proven efficacy and agreement of simplified devices with PSG&#44; sometimes the clinical management of OSA can be hampered by different interpretations of the data from sleep studies&#46; This fact is critical when dealing with patients with non-severe OSA&#44; in whom the diagnosis and the subsequent therapeutic decision could be especially difficult&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are several guidelines&#44; consensus and research articles with various indications for CPAP treatment in OSA based on AHI severity&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> excessive daytime sleepiness&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">5&#44;6</span></a> or improved driving performance&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> Other recommendations also include hypertension and cardiovascular comorbidities&#44; regardless of OSA symptoms&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> impaired cognition&#44; insomnia or mood disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> In Spain the criteria for recommending CPAP are&#44; as stated in the Spanish Sleep Network guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> an AHI between 5 and 30<span class="elsevierStyleHsp" style=""></span>events&#47;h with significant symptoms or OSA associated pathologies&#44; or AHI greater than 30<span class="elsevierStyleHsp" style=""></span>events&#47;h&#44; giving less importance to symptoms or pathologies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore&#44; since different professionals may vary in interpreting the results of sleep studies&#44; CPAP indication could be particularly complex when dealing with non-severe patients and different diagnostic methodologies&#46; Thus&#44; clinical decision-making in this group of OSA patients may be discordant and affect its management&#46; This fact is also especially relevant since interpretation of results can be compromised in the context of clinical trials&#44; especially those involving several centers and&#47;or countries&#46; Due to the high number of multicenter clinical trials that are carried out at present&#44; it is worth to analyze the consistency of decision-making concerning recommendation of CPAP among different sleep physicians&#44; especially in case of patients with AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>events&#47;h&#44; when using PSG or home respiratory polygraphy &#40;RP&#41;&#44; as usually occurs in a sleep unit&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to compare the intra- and inter-observer variability in decision-making on treatment recommendation in patients with AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events&#47;h among different Spanish sleep physicians&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">To evaluate intra- and inter-observer agreement in therapeutic decision-making 6 sleep professionals&#44; were asked to carry out an online therapeutic decision to recommend or not CPAP treatment based on anonymized records from 40 patients that were displayed on an online-encrypted database&#46; These records included anthropometric data&#44; clinical questionnaires&#44; comorbidities&#44; physical examination and the sleep study results&#44; from either PSG or RP&#46; The 6 professionals involved were experienced sleep physicians&#44; working in different Sleep Units of Spanish University Hospitals&#44; aged 36&#8226;60 years-old&#46; All were recommended to follow the SEPAR guidelines for therapeutic decision making&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was carried out with the approval of the Hospitals&#8232;tm&#41; Ethics Committee&#46; All data were obtained from patients recruited from May 2015 to May 2017 in the Sleep Unit of Hospital Clinic &#40;Barcelona&#44; Spain&#41; and included in a clinical trial &#40;trial number NCT02779894 in <a href="http://www.clinicaltrials.gov/">http&#58;&#47;&#47;www&#46;clinicaltrials&#46;gov&#47;</a>&#41;&#46; Forty patients were randomly selected from those in the study database presenting AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events&#47;h&#46; All subjects were aged 18&#8226;75 years old and&#44; before their sleep test&#44; presented suspicion of OSA &#40;heavy snoring with breathing pauses during the night&#44; non-restful sleep and daytime somnolence or fatigue not explained by other pathologies&#41; and&#47;or refractory hypertension&#46; None of them presented invalidating somnolence &#40;medical criteria&#41;&#44; any unstable diseases&#44; previous use of CPAP&#44; uvulopalatopharyngoplasty&#44; or risk profession&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The sleep studies corresponded to in-hospital PSG&#44; in-hospital RP or home RP&#46; In in-hospital PSG &#40;Grael&#47;Somt&#232;c&#41; PSG&#44; Compumedics Limited 2006&#44; Abbotsford&#44; Victoria&#44; Australia&#41; the signals of electroencephalogram &#40;EEG- leads F4-M1&#44; C4-M1 and O2-M1&#41;&#44; electrooculogram &#40;EOG&#41; chin and leg electromyogram &#40;EMG&#41;&#44; and electrocardiogram &#40;ECG&#41; were recorded&#44; as well as nasal and oronasal flow &#40;cannula and thermistor&#41;&#44; respiratory effort&#44; and oxygen saturation &#40;SpO<span class="elsevierStyleInf">2</span>&#41;&#44; body position&#44; snoring &#40;tracheal microphone&#41;&#46; All patients were also video monitored&#46; In-hospital PR &#40;Somt&#232; PSG&#44; Compumedics Limited 2006&#44; Abbotsford&#44; Victoria&#44; Australia&#41; consisted in recording nasal flow &#40;cannula&#41;&#44; snoring&#44; respiratory effort&#44; SpO<span class="elsevierStyleInf">2</span> and body position&#44; as well as video monitoring&#46; In home RP &#40;Portable type 3 ApneaLink air&#44; ResMed&#44; Australia&#41; the registered variables were nasal flow &#40;cannula&#41;&#44; snoring&#44; respiratory effort&#44; SpO<span class="elsevierStyleInf">2</span>&#44; pulse frequency&#44; and body position&#46; Sleep scoring was performed using the standardized AASM criteria<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">11</span></a>&#58; apnea was defined as an absence of flow for more than 10<span class="elsevierStyleHsp" style=""></span>s&#46; Hypopnea was defined as a discernible reduction in the amplitude of the airflow signal from the pre-event baseline for at least 10<span class="elsevierStyleHsp" style=""></span>s&#44; associated with an oxygen desaturation &#8805;3&#37; in both PSG and PR and also associated with arousal in PSG&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Online procedure</span><p id="par0045" class="elsevierStylePara elsevierViewall">To carry out the therapeutic decision&#44; all professionals logged-in into a especially designed website with individual username and password&#46; Professionals could see a list of patients identified by an anonymous alphanumeric code&#46; To evaluate the intra-individual agreement&#44; each of the patients was visualized 3 independent times&#44; with a different code each&#44; at random order and without knowledge of the evaluators&#46; Therefore&#44; each professional evaluated 120 cases&#46; In order to avoid fatigue&#44; each evaluator was allowed to analyze a maximum of 15 cases per day along a 3-month period&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">When entering into each case evaluation&#44; the data provided for therapeutic decision-making were displayed&#46; They included anthropometric features &#40;age&#44; gender&#44; body mass index &#40;BMI&#41;&#44; and systolic and diastolic blood pressure&#41;&#44; clinical questionnaires &#40;Epworth sleepiness scale &#40;ESS&#41;&#44; EuroQol-5D and EuroQol-VAS&#41;&#44; comorbidities &#40;high blood pressure&#44; cardiac disease&#44; neurological or respiratory diseases&#44; diabetes&#44; dyslipidemia&#44; depression&#44; anxiety or neoplasms&#41;&#44; and physical examination data &#40;micrognathia&#44; retrognathia&#44; amygdala and palatine Friedman class&#44; nasal obstruction or ORL surgery&#41;&#46; To help in analyzing the sleep history of the case&#44; the following data were also displayed&#58; ASDA sleepiness scale&#44; daily amount of sleep hours&#44; presence of snoring&#44; choking attacks&#44; nicturia&#44; witnessed apneas&#44; morning headache&#44; restless sleep&#44; daytime sleepiness&#44; restless legs syndrome&#44; aggressive behavior during sleep&#44; and muscle weakness associated to intense emotions or sleepwalking&#46; The results of the sleep studies included recorded time&#44; AHI&#44; central apneas&#44; total respiratory events&#44; Cheyne&#8226;Stokes breathing&#44; postural predominance&#44; basal and mean SpO<span class="elsevierStyleInf">2</span>&#44; ODI 3&#37;&#44; and CT90 for all tests&#46; In case of PSG sleep efficiency&#44; sleep staging&#44; arousal index&#44; and postural ODI were included&#46; Based on all the information provided&#44; sleep professionals were asked to choose a therapeutic decision &#40;CPAP&#47;non-CPAP&#41; if an OSA diagnosis was attributed to the case&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">To assess observer reliability on the therapeutic decision-making &#40;CPAP treatment or not&#41; between the same and the different physicians &#40;intra- and inter-individual agreement&#41;&#44; the Fleiss&#8232;tm&#41; Kappa &#40;Kappa&#41; statistics for categorical variables<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a> was calculated&#46; Data are presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation for the variables measured in numerical scale and in percentage for the measurement in nominal scale&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Percentage of CPAP indication of the three therapeutic decisions for each actual patient made by each evaluator &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; was also analyzed by 2-way ANOVA&#44; taking &#8220;time of therapeutic decision&#8221; and &#8220;sleep physician&#8221; as factors&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the patients&#8232;tm&#41; demographics and comorbidities of the sleep studies analyzed&#46; Out of 40 sleep studies&#44; 57&#46;5&#37; were from male patients&#44; mean aged 51&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;70 years and 28&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;04<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46; Mean AHI was 18&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;32<span class="elsevierStyleHsp" style=""></span>events&#47;h&#44; ranging 0&#8226;40&#46; Concerning diurnal somnolence&#44; patients presented a mean ESS of 8&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;56&#44; ranging 0&#8226;22&#46; Quality of life questionnaires showed mean EuroQol-5D of 0&#46;84<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;21 and EuroQol-VAS of 71&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;18&#44; ranging 0&#46;17&#8226;1 and 10&#8226;100&#44; respectively&#46; Therefore&#44; the sleep studies analyzed corresponded to a population of patients with wide ranges of sleepiness and quality of life&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">As every actual sleep study was blindly analyzed 3 times by the 6 physicians&#44; each case was analyzed 18 times&#44; and a total of 720 medical decisions were made for assessing the concordance among health professionals&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the diagnosis and medical decisions chosen by all the health professionals that participated in the study&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Fleiss&#8232;tm&#41; Kappa agreement for intra-observer decision-making is represented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; Overall intra-observer evaluation reliability of sleep professionals was found to be good&#44; showing almost perfect agreement &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;83&#44; 95&#37; CI&#58; 0&#46;75&#8226;0&#46;90&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Concordance was also assessed considering two different categories of AHI&#46; For AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>events&#47;h sleep physicians showed again an almost perfect agreement &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;81&#44; 95&#37; CI&#58; 0&#46;70&#8226;0&#46;93&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; while for AHI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>events&#47;h the agreement was found to be substantial &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;78&#44; 95&#37; CI&#58; 0&#46;68&#8226;0&#46;87&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">As indicated in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#44; Fleiss&#8232;tm&#41; Kappa agreement clearly decreased when assessing inter-observer agreement&#46; Considering all AHI&#44; inter-observer evaluation reliability was found to be moderate &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;46&#44; 95&#37; CI&#58; 0&#46;42&#8226;0&#46;51&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; For AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>events&#47;h the worst values of concordance were found&#58; agreement could be not demonstrated between sleep physicians &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#44; 95&#37; CI&#58; &#8743;0&#46;01 to 0&#46;14&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;095&#41;&#46; When analyzing AHI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>15&#44; inter-observer agreement slightly increased&#44; and was found to be fair &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#44; 95&#37; CI&#58; 0&#46;31&#8226;0&#46;43&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the percentage of CPAP indication of the 3 therapeutic decisions for each actual patient made by each evaluator&#46; The results of 2-way ANOVA were consequent with intra- and inter-observer agreement analysis&#46; Whereas the time of analysis factor was not significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;346&#41;&#44; a significant effect of physician was observed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study analyzed intra- and inter-observer agreement in the therapeutic decision-making among Spanish sleep physicians treating patients with AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40<span class="elsevierStyleHsp" style=""></span>events&#47;h&#46; The results&#44; obtained from more than seven hundred evaluations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>720&#41; demonstrated a good intra-observer concordance&#46; However&#44; regarding to inter-individual agreement this study revealed lower concordance&#58; overall concordance was found to be moderate but in case of less severe patients &#40;AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>events&#47;h&#41; the inter-subject concordance considerably worsened&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Despite the existence of a number of clinical guidelines and consensus for the management of OSA&#44; these results show a level of concordance below it is desirable&#46; The majority of available reports have not analyzed the concordance of therapeutic decision-making between different sleep physicians&#44; but between different diagnostic procedures&#44; usually comparing simplified devices versus the gold standard in-hospital PSG&#46; Indeed&#44; Masa et al&#46; <a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> analyzed the therapeutic decision-making agreement between home RP and in-hospital PSG among 348 patients&#44; describing that home RP was adequate for high AHI&#44; but insufficient for mild or moderate AHI and concluded that this diagnostic method was effective only in patients with high pretest of OSA&#46; Similar results have been obtained in a clinical study carried out in a pediatric population using in-lab RP versus PSG&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> and the authors concluded that clinical decision-making in children with mild and moderate OSA may be difficult&#46; Studying an adult population&#44; Guerrero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> tried to go a step further and analyzed the agreement of therapeutic decision making after three consecutive nights with home RP versus PSG in patients with mild to moderate pretest of OSA or with associated comorbidities that could mask OSA symptoms&#46; In this study&#44; the authors also assessed the concordance between different specialists&#44; comparing the therapeutic decisions made by sleep physicians and respiratory physicians&#46; The authors demonstrated that this particular diagnostic method is useful to manage patients without high pretest probability of OSA or with comorbidities only when evaluated by a qualified sleep specialist&#46; It is important to bear in mind that these and other clinical studies have also shown that these diagnostic approaches&#44; in addition to effectively enabling a correct decision making to prescribe therapy for OSA in certain patient population&#44; also reduced costs&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a> A different study<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> assessed both diagnosis and therapeutic decision agreement between personnel from sleep reference centers with PSG and from non-reference centers employing a simplified device&#46; The authors found a substantial level of concordance between different professionals&#44; but each group of professionals employed a different diagnostic method&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Our study is unique since&#44; as far as we know&#44; there are no published studies addressed to analyze the performance of CPAP therapeutic decision-making in OSA among sleep specialists in case that all of them analyze the same patient cases&#44; using different real-life diagnostic methods&#46; In fact&#44; the available data are focused on comparing how respiratory events or sleep stage are scored&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">18&#8226;21</span></a> The causes that could explain the lack of concordance we found are not well known&#46; However&#44; we could speculate that&#44; although it was recommended to follow the SEPAR regulations&#44; it is possible that each evaluator has also used their own criteria by taking into account other circumstances &#40;gender&#44; quality of life&#44; different pathologies&#44; or only sleepiness&#41;&#46; In addition&#44; the lack of a clinical face-to-face interview could have conditioned the therapeutic decision proposed by the 6 professionals involved in the study&#46; Moreover&#44; it is remarkable that current consensuses are global and have little impact on defining the management of mild&#47;moderate cases&#46; In order to simplify the study and to focus on the most relevant therapeutic decision &#40;CPAP prescription&#41; other aspects usual in clinical practice&#44; such as decision to refer patients to other specialty doctors &#40;e&#46;g&#46; otorhinolaryngologist or neurologist&#41;&#44; have not been analyzed&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">By showing the striking and worrying results we have found&#44; especially taking into account that our 6 sleep physicians had solid experience in the field&#44; we intend to draw the attention of the sleep community&#46; There are several possible consequences of this relatively poor agreement between sleep professionals&#46; On the one hand&#44; OSA management could differ especially of those patients with low AHI&#46; On the other hand&#44; the interpretation of the many multicentre studies that are currently on-going may be hampered by the lack of agreement we report here&#46; The results found in different decision-making in other medical specialties regarding the agreement between specialist physicians have also revealed the need to seek strategies to improve inter-observer reliability&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">22&#8226;25</span></a> Thus&#44; it seems advisable that clinical guidelines for the management of OSA need revision&#44; in particular concerning recommendations to manage OSA patients with low AHI&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Financial</span><p id="par0110" class="elsevierStylePara elsevierViewall">The Spanish Ministry of Economy and Competitiveness &#40;PI14&#47;00416 and PI17&#47;01068&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Background</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea &#40;OSA&#41; and also compromise correct interpretation of the results of multicenter clinical trials&#44; especially in subjects with non-severe OSA&#46; The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI&#60;40<span class="elsevierStyleHsp" style=""></span>events&#47;h&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision &#40;CPAP treatment&#41; based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study&#46; The clinical data was shown in an online database and included anthropometric features&#44; clinical questionnaires&#44; comorbidities&#44; physical examination and sleep study results&#46; Intra- and inter-observer decision-making were analyzed by the Fleiss&#8232;tm&#41; Kappa statistics &#40;Kappa&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A total of 720 medical decisions were taken to analyze the agreement between sleep professionals&#46; Overall intra-observer evaluation reliability was almost perfect &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;83&#44; 95&#37; CI&#44; 0&#46;75&#8226;0&#46;90&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; However&#44; overall inter-observer concordance decreased to moderate agreement &#40;Kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;46&#44; 95&#37; CI&#44; 0&#46;42&#8226;0&#46;51&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Nevertheless&#44; it was especially low when considering AHI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>events&#47;h&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low&#47;moderate OSA&#46; However&#44; when analyzing inter-observer agreement the results were considerably worse&#46; These findings underline the importance of developing improved consensus management protocols&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La gran variedad de procedimientos diagn&#243;sticos y recomendaciones de tratamiento puede dificultar el manejo del s&#237;ndrome de apnea obstructiva del sue&#241;o &#40;SAHS&#41;&#44; y del mismo modo comprometer la correcta interpretaci&#243;n de los resultados de ensayos cl&#237;nicos multic&#232;c&#41;ntricos&#44; especialmente en pacientes con SAHS no grave&#46; El objetivo de este estudio fue analizar la decisi&#243;n terap&#232;c&#41;utica de distintos m&#232;c&#41;dicos expertos en sue&#241;o en pacientes con el &#237;ndice de apnea hipopnea &#60;&#160;40 eventos&#47;h&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#232;c&#41;todos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se pidi&#243; a seis especialistas con amplia experiencia en sue&#241;o de diferentes centros de Espa&#241;a que tomaran una decisi&#243;n terap&#232;c&#41;utica &#40;terapia de presi&#243;n positiva continua en las v&#237;as respiratorias o CPAP&#41; basada en datos an&#243;nimos de los pacientes con sospecha de SAHS en los que previamente se hab&#237;a llevado a cabo un estudio del sue&#241;o&#46; Los datos cl&#237;nicos proced&#237;an de una base de datos online e inclu&#237;an caracter&#237;sticas antropom&#232;c&#41;tricas&#44; cuestionarios cl&#237;nicos&#44; comorbilidades&#44; examen f&#237;sico y resultados del estudio del sue&#241;o&#46; La concordancia intra- e interobservador de la toma de decisiones se analiz&#243; mediante el estad&#237;stico Fleiss&#8232;tm&#41; Kappa &#40;Kappa&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se analizaron un total de 720 decisiones m&#232;c&#41;dicas para evaluar el consenso entre profesionales del sue&#241;o&#46; De manera global&#44; la fiabilidad de la evaluaci&#243;n intraobservador fue casi perfecta &#40;Kappa&#160;&#61;&#160;0&#44;83&#59; 95&#37; CI&#59; 0&#44;75 a 0&#44;90&#44; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41;&#46; Sin embargo&#44; la concordancia global interobservador disminuy&#243; hasta alcanzar un grado moderado de consenso &#40;Kappa&#160;&#61;&#160;0&#44;46&#59; 95&#37; CI&#59; 0&#44;42 a 0&#44;51&#44; <span class="elsevierStyleItalic">p</span>&#160;&#60;&#160;0&#44;001&#41;&#44; que fue especialmente bajo cuando se tuvo en cuenta un &#237;ndice de apnea hipopnea &#60;15 eventos&#47;h&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Este estudio demuestra una buena concordancia intraobservador en la toma de decisiones terap&#232;c&#41;uticas de distintos m&#232;c&#41;dicos expertos en sue&#241;o que tratan a pacientes con SAHS leve o moderado&#46; Sin embargo&#44; los resultados relativos al acuerdo interobservador fueron notablemente peores&#46; Estos hallazgos se&#241;alan la importancia de desarrollar mejores protocolos consensuados de manejo&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Smokers</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Alcohol intake</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;52&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dislipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;57&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cardiovascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;7&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Neurological disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respiratory disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;17&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;22&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anxiety&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;20&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;32&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">CT90 &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;05<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;43&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">ODI3&#37;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">18&#46;90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">71&#46;37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">8&#46;02<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-entry\n
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