Congratulations to Hetasvi Saraiya, OMS-III, third place winner of the 2026 Namey/Burnett Award. Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.

Introduction

Obstructive Sleep Apnea (OSA) is a highly prevalent yet frequently overlooked chronic condition characterized by upper airway collapse during sleep, leading to intermittent hypoxia and sleep fragmentation.¹ These repeated physiologic disturbances trigger sympathetic activation, oxidative stress, and systemic inflammation, contributing to substantial cardiovascular and metabolic morbidity. OSA has been strongly associated with hypertension, coronary artery disease, stroke, pulmonary hypertension, and type 2 diabetes.²

Despite its clinical significance, OSA is not routinely screened for during primary care visits. Unlike conditions such as hypertension or diabetes, where screening and documentation are embedded into standard workflows, OSA risk assessment is often absent from routine preventive care. In many outpatient practices, sleep-related symptoms are only addressed if explicitly raised by the patient, documentation is inconsistent, and screening tools are not integrated into visit structure, chart preparation or quality tabs. As a result, OSA risk frequently goes unrecognized, particularly in patients with obesity or hypertension who are already at elevated risk.

This lack of standardized screening represents a missed opportunity for prevention. Primary care settings, especially family medicine clinics, serve as the longitudinal medical home for patients managing multiple chronic conditions. Incorporating OSA screening into routine workflows allows for early identification, counseling on modifiable risk factors, and timely referral, interventions that may reduce long-term complications.

OSA develops through a combination of anatomic and functional factors, including upper airway anatomy, obesity, male sex, advancing age, and neuromuscular control of the airway.¹ When left untreated, OSA not only worsens existing chronic disease but also increases risks of motor vehicle accidents, impaired cognitive function, and reduced quality of life. Treatment options range from lifestyle modification to continuous positive airway pressure (CPAP), with evidence supporting meaningful reductions in morbidity when therapy is initiated early.

The STOP-BANG questionnaire is an easy-to-administer screening tool designed for use in outpatient settings. It assesses eight factors: snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender.³ Scores allow patients to be stratified into low, intermediate, or high-risk categories, enabling clinicians to apply targeted counseling and referral strategies. Its simplicity and reliance on readily available clinical information make STOP-BANG particularly well suited for primary care.

Objective

The primary objective of this quality improvement study was to increase OSA screening to at least 80% of eligible patients and to integrate screening as a standardized preventive measure during routine primary care visits. Eligible patients were adults with a diagnosis of hypertension and/or a body mass index (BMI) greater than 30. Secondary objectives included appropriate risk stratification into low, intermediate, or high-risk categories and facilitating timely referral to sleep medicine for patients at increased risk.

Methods

This study was designed using the Plan-Do-Study-Act (PDSA) quality improvement framework. It was conducted at a resident-driven continuity clinic at Capital Health East Trenton Clinic (ETC) in Trenton, New Jersey, between July 2024 and May 2025. The project spanned nine clinic cycles, each lasting five weeks, and involved the patient panels of seven internal medicine residents.

Patients were eligible for screening if they had a documented history of hypertension and/or a BMI greater than 30. The STOP-BANG questionnaire was integrated into chart preparation to ensure identification of eligible patients before visits. During clinical encounters, residents administered the questionnaire and provided counseling based on the risk category.

Patients were categorized as follows:

• Low risk (STOP-BANG 0-2): sleep hygiene education and preventive counseling
• Intermediate risk (STOP-BANG 3-4): referral to sleep medicine and counseling
• High risk (STOP-BANG 5-8): referral to sleep medicine and counseling

Additional interventions included resident and staff education sessions, workflow reminders, and emphasis on follow-up and documentation. Screening rates were tracked across clinic cycles, and referrals to sleep medicine were recorded.

Results

Implementation of STOP-BANG screening led to meaningful improvement in the standardization of OSA risk assessment at ETC. Baseline screening rates during Cycles 0-2 were 0%, reflecting the absence of a structured screening process. Following workflow integration and staff education, screening increased to 10% in Cycle 3 and continued to rise over subsequent cycles.

Screening rates reached 62% in Cycle 4, stabilized between 52-53% in Cycles 5-6, and peaked at 72% in Cycle 7 and 77% by Cycle 9, approaching the project’s target of 80%. Over the study period, 42 referrals to sleep medicine were generated for patients identified as intermediate or high risk.

An additional benefit of standardized screening was improved documentation. Several patients were found to have previously diagnosed OSA and were already using CPAP or BiPAP therapy, yet this information was not documented in their medical record. Incorporating STOP-BANG prompted reconciliation of sleep-related history, resulting in more comprehensive and accurate patient charts.

Discussion

Integrating STOP-BANG screening into routine primary care visits created a consistent and effective approach for identifying patients at risk for OSA. By embedding screening into clinic workflow, this initiative shifted OSA risk assessment from an optional or symptom-driven activity to a structured component of preventive care.

This approach aligns closely with osteopathic family medicine principles, which emphasize prevention, whole-person care, and the interrelationship between structure, function, and health. Early identification of OSA allows osteopathic physicians to address not only sleep disordered breathing, but also contributing lifestyle factors such as weight, alcohol use, sleep position, and management of comorbid conditions.⁴ Even when specialty referral is delayed, counseling on modifiable behaviors can begin immediately, supporting prevention and patient empowerment.⁵

Barriers encountered during implementation reflected real world challenges in primary care. Patient level barriers included low health literacy, language barriers, and patient declination of referrals. Provider level barriers included competing acute concerns and occasional omission of screening. System level challenges included long wait times for sleep medicine appointments and referral delays. These findings highlight the importance of sustainable screening improvements.

Study limitations include a small sample size and a localized clinic population, which may limit generalizability.

Conclusion

Standardizing OSA screening using the STOP-BANG questionnaire significantly improved screening rates and referral patterns in a primary care setting. This preventive medicine initiative demonstrates that integrating sleep apnea screening into routine clinical workflows is both feasible and sustainable, while aligning closely with the core principles of osteopathic family medicine.

Additional opportunities for further standardization include embedding STOP-BANG within electronic health record quality tabs or administering it alongside routine mood disorder screenings during annual physical examinations. By normalizing OSA risk assessment as a component of preventive care, family physicians can intervene earlier, promote holistic, patient-centered management, and potentially reduce long-term cardiovascular and metabolic disease burden.

References

1. Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet. 2014;383(9918):736-747. doi:10.1016/S0140-6736(13)60734-5
2. Arnaud C, Bochaton T, Pépin J-L, Belaidi E. Obstructive sleep apnoea and cardiovascular consequences: Pathophysiological mechanisms. Arch Cardiovasc Dis. 2020;113(5):350-358. doi:10.1016/j.acvd.2020.01.003.
3. STOP-BANG Score for Obstructive Sleep Apnea. MDCalc. Updated 2025. Accessed January 9, 2026. https://www.mdcalc.com/calc/3992/stop-bang-score-obstructive-sleep-apnea
4. Mokhlesi B, Grimaldi D, Van Cauter E, et al. Obstructive Sleep Apnea and Metabolic Disease: Evidence and Underlying Mechanisms. Lancet Diabetes Endocrinol. 2024;12(1):29-42. doi:10.1016/S2213-8587(23)00231-X.
5. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013;177(9):1006-1014. doi:10.1093/aje/kws342.
6. US Preventive Services Task Force; Mangione CM, Barry MJ, Nicholson WK, Cabana M, Chelmow D, Rucker Coker T, Davidson KW, Davis EM, Donahue KE, Jaén CR, Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Stevermer J, Wong JB. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(19):1945-1950. doi:10.1001/jama.2022.20304