0530 Rural and Urban Differences in Obstructive Sleep Apnea Referrals in Primary Care

Abstract Introduction Limited access to obstructive sleep apnea (OSA) evaluation has increased interest in primary care–based care models, yet structural and geographic factors may influence referral patterns. We hypothesized that OSA referral rates within primary care differ by patients’ geographic location after accounting for individual and neighborhood socioeconomic factors. Methods A retrospective cohort study was conducted using our electronic medical record to identify adult patients at risk for OSA who were seen in primary care at the Cleveland Clinic Health System (Ohio and Florida) from 2017 to 2024. We included patients who received either a sleep medicine consultation or a polysomnogram or type III order within 12 months of the primary care visit. High-risk patients for OSA were defined by the presence of at least one of these comorbidities: obesity(>30 kg/m2), heart failure, atrial fibrillation, hypertension, diabetes, cardiac arrhythmias, stroke, pulmonary hypertension, or coronary artery disease; a BMI greater than 35 kg/m2; and a STOP score≥2. Rural-Urban Community Area codes were used to identify patients residing in rural and urban areas. Multivariable logistic regression was performed to examine the association between rural vs. urban residence and OSA referral, adjusting for age, sex, race, BMI, insurance, State, and Area Deprivation Index. Continuous variables were centered to mitigate multicollinearity. Results Of 25,917 patients at high risk for OSA, 3,874 were rural, and 22,043 were urban patients. Only 15% of rural patients were referred for OSA evaluation compared to 20% of urban patients (p< 0.001). Among those referred, rural patients had a higher BMI(41.5 kg/m2[IQR37.8–46.4]vs40.4 kg/m2[IQR 37.4–45.4]; p=0.003), were less likely to be referred while on government insurance (29.3%vs42.2 %,p< 0.001) and lived in neighborhoods with higher socioeconomic disadvantage (ADI, 70[58–85]vs67[45–88];p< 0.001) compared with referred urban patients. After the adjusted model, rural patients had lower odds of receiving an OSA referral compared to patients in urban areas (OR=0.75,95%CI:0.66,0.82). Conclusion Patients at high risk for OSA in rural primary care settings are less likely to be referred for evaluation than those in urban areas. These findings highlight the need to understand geographic-specific barriers to obtaining OSA evaluation to reduce inequities among rural populations. Support (if any)