Rural Patients at High Risk for Sleep Apnea Less Likely to Be Referred for Evaluation: SLEEP 2026

Rural individuals at high risk for obstructive sleep apnea (OSA) were less likely than urban individuals to be referred for sleep apnea evaluation after a primary care visit, according to findings presented at SLEEP 2026 in Baltimore, Maryland.¹

In a retrospective cohort study of 25 917 participants at high risk for OSA, 15% of rural participants were referred for evaluation compared with 20% of urban participants (P<.001). After adjustment for age, sex, race, body mass index (BMI), insurance, state, and Area Deprivation Index, rural participants had 25% lower odds of receiving an OSA referral compared with urban participants (OR, 0.75; 95% CI, 0.66-0.82).¹

The findings highlight a potential access gap in sleep apnea evaluation at a time when limited access to specialty sleep care has increased interest in primary care–based OSA models. OSA is associated with cardiometabolic comorbidities that are frequently managed in primary care, including hypertension, cardiovascular disease, stroke, and type 2 diabetes.¹

“These findings highlight that geographic location is an independent factor in whether high-risk patients are referred for obstructive sleep apnea evaluation in primary care,” principal investigator Joscilin Mathew, MD, sleep medicine fellow at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, said in a SLEEP 2026 announcement.² “Understanding the barriers specific to rural settings will be important for reducing these disparities.”

Investigators used electronic medical record data from the Cleveland Clinic Health System in Ohio and Florida to identify adults at high risk for OSA who were seen in primary care from 2017 to 2024. Researchers included individuals who received either a sleep medicine consultation or an order for polysomnography or type III sleep testing within 12 months of the primary care visit.¹

High-risk participants were identified using clinical factors including obesity, cardiovascular and metabolic comorbidities, BMI greater than 35 kg/m², and STOP Questionnaire score of 2 or higher. Rural or urban residence was determined using Rural-Urban Community Area codes.¹

Of the full cohort, 3874 participants lived in rural areas and 22 043 lived in urban areas. Among those referred for OSA evaluation, rural participants had a higher median BMI than urban participants, at 41.5 kg/m² vs 40.4 kg/m² (P=.003). Rural participants who were referred also lived in neighborhoods with greater socioeconomic disadvantage, with a median Area Deprivation Index of 70 compared with 67 among referred urban patients (P<.001).¹

Rural participants who were referred were less likely than referred urban participants to be on government insurance, at 29.3% vs 42.2%, respectively (P<.001).¹

For primary care clinicians, the findings suggest that OSA risk recognition alone may not be sufficient to ensure evaluation, particularly for rural participants. Barriers may include distance to sleep centers, limited sleep medicine availability, insurance or cost concerns, transportation, digital access, and competing clinical priorities during primary care visits.¹

The authors concluded that participants at high risk for OSA in rural primary care settings are less likely to be referred for evaluation than participants in urban areas. They noted that additional work is needed to identify geography-specific barriers and develop strategies to reduce inequities in OSA evaluation.¹

“Patients in rural areas may face unique structural barriers to accessing sleep medicine care, and primary care-based models for obstructive sleep apnea evaluation may be one avenue for addressing these gaps,” senior author Cinthya Peña Orbea, MD, assistant professor of medicine at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, said in the announcement.²

References

1. Mathew J, Sancheti H, Lapin B, McGinley M, Thornton J, Peña-Orbea C. Rural and urban differences in obstructive sleep apnea referrals in primary care. Abstract 0530. Presented at: SLEEP 2026; June 15, 2026; Baltimore, MD. Sleep. 2026;49(suppl 1). doi:10.1093/sleep/zsag091.0529
2. Associated Professional Sleep Societies. Rural patients at high risk for obstructive sleep apnea are less likely to be referred for evaluation than urban patients. Published June 8, 2026. Accessed June 15, 2026. https://www.sleepmeeting.org/rural-patients-at-high-risk-for-obstructive-sleep-apnea-are-less-likely-to-be-referred-for-evaluation-than-urban-patients/