Part 2: Sweden pilots new primary-specialty care pathways

Q: You’ve begun collaborating with general practitioners (GPs), focusing on involving them in the diagnostic phase to reduce patient waiting times. Can you tell us more about this project?

Professor Grote: There are ongoing discussions to involve GPs earlier in the diagnostic pathway to help cut waiting times and improve access for patients.

Back in the 1980s and early ’90s, some primary healthcare centers and GPs in Sweden were deeply interested in sleep apnea and even had diagnostic devices in their practices. In areas where travel to diagnostic centers was difficult, GPs or nurses were trained and supported to conduct sleep tests locally. But when those individuals left, the programs usually ended. My impression was that they weren’t systematic, and there was no proper reimbursement structure in place.

Today, things are more organized. Our national guidelines now define an obstructive sleep apnea (OSA) diagnosis and care pathway that often starts at the GP level. Some regional working groups, including GPs, are piloting workflows where GPs can manage major aspects of diagnosis. For example, the GP refers the patient to a neurophysiology department for sleep recording, and once results are returned, the GP is trained, or at least expected, to discuss the findings with the patients and plan treatment, or refer them to a CPAP unit, ENT doctor or dentist.

In the Gothenburg area, OSA care is still mostly specialist-driven, but we’re now discussing pilot programs to explore what greater GP involvement could look like. This approach requires clear algorithms to determine patient suitability for primary care management or referral, practical solutions around reimbursement codes and device costs, as well as resource reallocation.

Q: How much responsibility will general practitioners have compared to sleep specialists in the pathway you're developing? Should GPs refer directly to sleep specialists?

Professor Grote: The pathways still need to be developed in more detail. We need consensus on what’s feasible. But we could go back to more traditional AHI criteria: if a GP identifies a patient with an AHI above 30 and/or significant nocturnal hypoxia, along with significant symptoms or uncontrolled hypertension, then yes, they could refer directly to a CPAP center or a dentist and cut down waiting times.

Take an example of a patient with obesity and snoring that’s referred to a sleep specialist and waits 100–150 days for an evaluation. The diagnosis, OSA with an AHI of 25 or 30, is eventually verified. But treatment (CPAP or oral device) often takes another 100–200 days to start. That’s a total delay of up to 250 days from suspicion to treatment.

In contrast, a primary care facility could provide an OSA diagnosis within a month, allowing the GP to start weight reduction therapy immediately after. The referral to the sleep specialist will lead to a second sleep test, but this time as a 3- to 6-month control after weight loss therapy. This kind of modified, integrated model between GPs and specialists could offer faster, more holistic care — a clear win for the patient.

Q: How will you measure and track the outcomes of these collaborations with GPSs and dentists?

Professor Grote: We can follow patients through our national quality registry, SESAR, to see how well things are working.

There’s already good evidence from our Spanish colleagues that OSA management pathways involving primary care are successful. Papers published between 2013 and 2018 show that home sleep testing is equally effective as in-lab diagnosis of sleep apnea and OSA management involving strong collaboration with primary care can be successful. These studies also included health economic evaluation showing significant savings with primary care involvement.^1-3

Similar research from the U.S. evaluated home sleep apnea testing and have shown that outcomes in CPAP acceptance and adherence, and blood pressure are comparable between traditional and simplified pathways.

With structured support and close contact with specialists, primary care can help offload the diagnostic burden. There’s a clear case for a stratified, step-care model — similar to those used in diabetes, hypertension and COPD.

It’s not a revolutionary idea; others have attempted this. But it requires the right infrastructure, technical support platforms and reimbursement structures for both primary and specialist care. In Sweden, we now have national guidelines and regional working groups trying to implement these changes. I can’t promise success, but the effort is underway in several regions of Sweden.

Q: As drugs like glucagon-like peptide-1 (GLP-1) agonists gain traction for weight loss and even sleep apnea treatment in other countries, how do you see primary care’s role evolving in managing OSA pharmacologically in Sweden?

These drugs are very interesting as novel therapeutic agents, and they are primarily approved for obesity. However, they carry secondary indications, like for patients with a BMI starting at 27 who also have comorbidities like hyperlipidemia, hypertension or sleep apnea.

From a clinical standpoint, the evidence supporting GLP-1s has been quite strong for 5 to 6 years now. There are still questions around treatment duration and response, but I believe management of overweight and obesity, including pharmacotherapy like the GLP-1 drug class, will open new doors for sleep apnea treatment. For many patients, losing 10–20 kilograms may be even more important for long-term survival than any single intervention for sleep apnea. Of course, the ideal scenario is combining weight loss with PAP therapy or oral device therapy to achieve the best outcomes.

Having these drug treatment options available at the GP level, where suspected sleep apnea is often first identified, would be a huge advantage. But that also means we’d need to equip primary care with simplified diagnostic tools and clear guidance. If GPs could initiate treatment earlier, as I mentioned earlier, then follow-up care would also need to evolve. Whether that follow-up can be initiated in primary care using simplified devices, or if most cases still require input from sleep specialists, is something that still needs to be evaluated.

Another important aspect is future reimbursement of this new drug class. Currently, GLP-1 agonists payments are covered mainly by patients, which raises concerns about care inequity.

Looking ahead, I believe OSA care will become much more diversified. But that doesn’t mean PAP therapy centers will have less work, it just means care will be spread across more hands.

Q: If you could speak directly to Swedish politicians or payers, what message would you want to share about future sleep healthcare needs?

Professor Grote: I would emphasize treating sleep health as an essential part of both mental and physical wellbeing. That concept is gaining recognition in specialties like cardiology.

In Sweden, we’re currently developing national guidelines that go beyond OSA and cover all sleep disorders, with a strong focus on supporting initial diagnosis and treatment on the primary care level.

To policymakers specifically, I’d say: support the systematic transfer of knowledge and tools to primary caregivers. Ensure GPs have clear guidance, structured referral criteria and access to diagnostic tools. And don’t stop at OSA. All of this applies to insomnia, circadian rhythm disorders, parasomnias and more.

Ensure both primary care and sleep specialists are adequately funded too, as collaboration between these levels is crucial for delivering high-quality care.

Lastly, there’s an urgent need to make sleep medicine more appealing as a specialty. We simply don’t have enough trained sleep experts to handle the more severe and complex cases.