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Table 2 Summary of relevant TDF domains, belief statements and representative quotes about screening for OSA in tetraplegia

From: Understanding the clinical management of obstructive sleep apnoea in tetraplegia: a qualitative study using the theoretical domains framework

Domain Belief statements Representative quotes Frequency of belief out of 20
Knowledge I don’t know of any clinical practice guidelines recommending management of OSA in tetraplegia. “No I don’t know or aware of any existing clinical guidelines.” 10
Regarding clinical practice guidelines: “I assume they [clinical practice guidelines] exist. But I wouldn’t go hunting for them because I don’t disagree with the concept that they should be screened.”
I know that the prevalence of OSA is very high in tetraplegia and that OSA causes negative outcomes. “So the paper that I usually refer to…where they followed acute spinal cord injuries, so it was within the first year, and they test for sleep apnoea and it was up to like 80%. And then most other papers say, you know, up to 60% of spinal cord injury will have sleep apnoea.” 14
“Yes. I’m aware it is high. It is definitely high in the first 2-3 months, but I can see a lot of the studies from one year post injury, that’s quite variable, it’s varies from 40-70%.”
Social/Professional Role and Identity As the doctor managing the patients’ rehabilitation and spinal cord injury needs, screening for OSA is my clinical responsibility. “I think it should be the physician’s role. I think that’s the most appropriate person because if the symptoms come back positive, it does have to be a medical referral onto the respiratory clinic.” 17
“I think it is our responsibility as their spinal cord injury doctor to understand sleep apnoea and understand respiratory; it falls under the umbrella of respiratory management, right. Especially somebody with a cervical injury, like you have to know what MIPS and MEPS are, vital capacities are, what their PFTs are. And sleep apnoea is just another component of that.”
Beliefs about Capabilities I am confident/not confident that I am identifying OSA in most of my patients. “I think we get everything, we get all patients we need, well we catch all the patients who are in need of ventilation, yes.” 8
“I’d say I’m pretty confident, yeah I don’t miss it in many patients.”
“I wouldn’t be very confident [to identify OSA symptoms]. The symptoms, there are so many other contributors to the symptoms that are described, I wouldn’t be very confident.” 8
“In the acute phase, I think I’m probably missing a good proportion. Just ballparking, maybe 30%, 30 to 40%, I might be missing. In the community phase, of those that I follow regularly, probably missing less, but I’m sure I'm still missing some. Maybe 10%, 10–20%.”
Beliefs about Consequences Routine screening may identify non-symptomatic OSA that does not need to be treated. “Okay, but even if you screen symptoms, and they have some symptoms, people can be affected by their symptoms in a different way. Did he have a problem? If he didn’t have a problem, why suddenly I found a problem with him and I start him to sleep with a machine on. The problem is blanket screening and blanket investigation we’ll end up having more people on a treatment that otherwise may not need to be. That is my worry.” 3
“From my point of view, in the clinic, I’d probably be most interested in following up patients who had symptoms that were relevant to them. I guess a disincentive for me is to be actively pursuing investigation results of patients who don’t seem to have symptoms of that. Because what’s the point? I mean, like, with any test or referral, there’s a saying in medicine, don’t do it if it’s not going to change the treatment. Yeah, well it would be a waste of resources, but also it’s inconvenient for the patient.”
Routine screening helps prevent patients who are poor at recognizing their symptoms from being missed. “Yeah because patients do not complain about that, that you have to measure it before you know that they have it, so sometimes they have the complaints of tiredness and that kind of stuff and then you have a trigger but if they don’t have that complaint then the screening might disappear.” 3
I am/I am not sure that the benefits of routine screening would outweigh the costs. “No question about it, yes. Because most patients, when they’re eventually getting ventilation during the night, they feel a lot better and they can have more… what do you call it, they can do much better during the day, so I think most patients will benefit from it (screening).” 13
“Have to do it. Yeah, of course. The only long run if you ignore something which is there and you don’t treat it, you don’t manage it, of course at the end of the day that will cost you even more. And also you have to respect the patient’s wellbeing and their needs.”
“I wouldn’t be convinced. I’m not convinced of that at the moment, no. Should I just screen them all? I don’t know if that would be cost-effective, I don’t think so.” 5
“I think it’s probably only worthwhile when the patient initiates the concern about fatigue and sleepiness because, otherwise, my experience is that if they’re really not troubled by symptoms in the day, they do not tolerate CPAP.”
Memory, Attention and Decision Processes A checklist/form is helpful/would be helpful to prompt me to screen for OSA in the inpatient unit and outpatient clinic. “With our clinics we do have a template, we always get prompted to ask these questions about sleep, excessive snoring, does your partner notice you are not breathing for a while, and then we check the risk factors. So as long as the template is there we usually – I usually, you get prompted to ask it and I would.” 14
“Inpatients definitely, so we have some standing orders ... And on there it was just immediate, everyone gets overnight oximetry and pulmonary function tests, and then in outpatient I do have like a template I use when I see patients, so there’s a respiratory heading which usually prompts me to ask about that.”
“And I often think, “Oh, gosh, I should remember to ask the patients about their breathing but I never seem to. So, I think that if there was a box, like, are you having sleep-disordered breathing symptoms, I mean, most doctors have an idea what those symptoms are, you could just quickly ask the patient four or five questions.”
“I think it will be nice if we can come up with a routine screen that we will screen everybody on admission, like an admission ASIA, something like that, we could do an admission and a discharge. If it’s a very short questionnaire that we can do. I think it would be worthwhile.”
Environmental Context and Resources I don't have enough time in outpatients to screen for OSA symptoms. “I think it’s, for us like, probably the time that I am allotted with patients, so there’s a lot of things to cover. 6
“In our current setup we don’t have time. We still allocate an hour for the patient, there are so many things to discuss, especially if they come once a year. And we don’t have any allied health clinic.”
Patients often have more important medical issues to discuss in their outpatient appointment than OSA. “So they're having a very hard time with bladder, with bowel, with pain, spasticity, and then unfortunately the respiratory system does fall on the wayside a little bit. And if you – if they are really worried about their bladder, and you finish talking about their bladder, and they're thinking about their bladder, and start talking about sleep apnoea, they tend not to take it – it's hard to then take on so much information.” 6
“Usually I’ll have the patient kind of lead the discussion as to what their most important thing they want to talk about that day is and I’ll kind of ask them prompting questions just to see a more general review of systems, but in that appointment, like, yeah I think that might be why things are getting missed because they may just want to talk about pain that day or they may just want to talk about their bladder or their pressure ulcer; we don’t get around to discussing sleep apnoea as well as we should.”