Should a sleep doctor get referrals for Inspire therapy from ENT (Ear, Nose, and Throat) specialists or primary care physicians?

Referral Pathways for Inspire Therapy in Sleep Medicine

Sleep medicine specialists should accept referrals for Inspire therapy from both ENT specialists and primary care physicians, with ENT specialists being particularly valuable for pre-screening anatomical suitability. 1

Optimal Referral Pathway

The referral pathway for Inspire therapy (hypoglossal nerve stimulation) should follow a collaborative approach involving multiple specialties:

Primary Care Physician Role

• Can serve as initial screeners for OSA symptoms using validated tools like STOP questionnaire 1
• Should refer patients with suspected sleep apnea to sleep specialists for proper diagnosis 1
• May identify patients who have failed or are intolerant to CPAP therapy

ENT Specialist Role

• Particularly valuable for evaluating upper airway anatomy that affects Inspire candidacy
• Can assess for anatomical contraindications to Inspire therapy
• Brings specialized expertise in surgical considerations for implantation 1
• Can perform drug-induced sleep endoscopy (DISE) to evaluate collapse patterns

Sleep Specialist Role

• Responsible for confirming OSA diagnosis through polysomnography 1
• Evaluates CPAP failure/intolerance documentation
• Makes final determination of Inspire therapy candidacy
• Coordinates the multidisciplinary approach to treatment 1
• Provides long-term follow-up and device titration

Evidence Supporting This Approach

The VA/DOD Clinical Practice Guidelines highlight the importance of a "working group composed of diverse providers to include primary care physicians, sleep specialists, dentists, otolaryngologists, psychologists, nurses, and pharmacologists" in the management of sleep disorders 1. This underscores the value of a collaborative approach.

The American Academy of Sleep Medicine (AASM) position paper on telemedicine emphasizes that "sleep diagnostics should be performed in a manner that is in accordance with standards, clinical practice guidelines, and practice parameters established by the AASM," reinforcing the central role of sleep specialists in diagnosis and treatment planning 1.

Challenges in Referral Patterns

Research has identified several barriers in the referral process that should be addressed:

• 66% of generalists and 68% of specialists report lack of coordination as a barrier to effective collaboration 2
• Generalists often lack confidence in managing sleep disorders and may not recognize the value of specialist consultation 2
• Primary care physicians tend to prioritize ease of communication and shared medical record systems when choosing specialists for referrals 3

Best Practices for Inspire Therapy Referrals

1. Establish clear referral criteria: Sleep specialists should provide referring physicians with specific criteria for potential Inspire candidates

2. Create standardized referral forms: Include essential information like CPAP compliance data, comorbidities, and BMI

3. Implement bidirectional communication: Ensure referring physicians receive feedback about patient outcomes

4. Consider potential complications: Be aware that Inspire therapy has reported adverse events including infection (34.2%), neuropraxia (15.1%), and hematoma/seroma (11.6%) 4

5. Develop collaborative relationships: Foster relationships with both ENT specialists and primary care physicians to optimize patient care

Conclusion

While both ENT specialists and primary care physicians can appropriately refer patients for Inspire therapy, the optimal approach involves a collaborative pathway where primary care identifies potential candidates, ENT specialists evaluate anatomical considerations, and sleep specialists make the final determination of candidacy and manage long-term care. This collaborative approach aligns with current clinical practice guidelines and optimizes patient outcomes.