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Although sleep habits have long been recognized as a promoter of health, the World Health Organization 2014 report on non-communicable diseases (NCDs) only listed smoking, alcohol intake, diet and physical activity (PA) as key modifiable risk factors that could enhance health and prevent NCDs. Cross-sectional data on 4385 surveys from the 2015 Catalan Health Survey, representative of the 2015 non-institutionalized Catalan population over age 14, were used to assess and compare the independent associations of low PA (International Physical Activity Questionnaire (IPAQ): low activity); poor diet (PREvención con DIeta MEDiterránea questionnaire (PREDIMED): low-adherent); poor sleep health (Satisfaction, Alertness, Timing, Efficiency and Duration scale (SATED)

BACKGROUND Obstructive sleep apnea syndrome (OSA) is a chronic sleep disorder characterized by repeated episodes of upper airway collapse during sleep. This leads to arterial hypoxemia and sleep disruption and causes daytime sleepiness and several associated dysfunctions, including cardiovascular, respiratory, metabolic, inflammatory, cognitive, and behavioral disorders.(1) OSA is a relevant public health issue, with epidemiological studies showing a prevalence of 10% in middle-aged men and 3% in middle-aged women.(2) Moreover, OSA has been associated with the development of cardiovascular events(3,4) and resistant hypertension,(5) has a negative impact on quality of life,(6) and has even been shown to have a causative role in traffic accidents.(7) The application of continuous positive airway pressure (CPAP) is a highly effective treatment for OSA that can improve symptoms and quality of life, decrease traffic accidents and potentially lessen cardiovascular morbidity.(8,9) Furthermore, CPAP is cost-effective.(10) However, only approximately 10% of individuals with OSA are diagnosed and treated. This scarcity in diagnosis has direct public health consequences due to the above-mentioned health implications and the high economic costs associated with untreated OSA. Currently, the diagnosis and management of OSA are performed in highly specialized hospital-based sleep units (SUs), where full sleep studies (polysomnography (PSG)) or respiratory poligraphy (RP) can be conducted. However, this management approach has proven to be insufficient in identifying most OSA cases in the population, in addition to being cost-ineffective and generating long waiting lists.(11) Given that OSA is a common chronic disorder, we believe that all levels of a healthcare system, especially primary care (PC), should be included in its management.(12-14) The first trials assessing the management of OSA at the PC level reported satisfactory results.(15-19) Moreover, our group showed that CPAP compliance did not differ between the PC and SU setting and was more cost-effective in the PC setting. 19 However, in the above studies, although OSA management occurred at the PC level, diagnosis had always occurred in a SU. Therefore, in the current study, we aimed to determine the efficacy and cost-effectiveness of implementing a program for the diagnosis and management of OSA that can be conducted by PC personnel, and we compared these outcomes to those generated using the standard diagnosis and management protocols that are practiced in SUs. AIMS The main objectives of the GESAP study are to assess the efficacies of PC and SU programs for OSA management. These assessments will be made using the Epworth sleepiness scale (ESS) before and for 6 months after initiating the program to assess its cost-effectiveness based on both ESS and quality of life (EuroQol-5D). Secondary objectives include assessments of patient satisfaction, treatment compliance, and the number, severity, and evolution of the treatment's side effects. Fondo de Investigación Sanitaria (PI 13/02004), Fondo Europeo de Desarrollo Regional (FEDER), Una manera de hacer Europa; the Spanish Respiratory Society (SEPAR); and Esteve-Teijin (Spain). Cofunded by Ministerio de Economía y Competitividad [COFUND2014-51501]. The authors would like to thank all PC personnel involved in the study, as well as the kind support from Maricel Arbonés, Olga Mínguez and Lídia Pascual (Group of Translational Research in Respiratory Medicine, IRB Lleida, Spain).

Over the last few years, the epidemics of noncommunicable diseases and the need for cost-containment1 are triggering factors for a profound transformation of the way we approach delivery of care for chronic patients. In this new scenario, conventional disease-oriented approaches, centered on the management of clinical episodes, are being replaced by patient-centered integrated care services,2 as promoted by the World Health Organization. Lessons learnt from deployment experiences4, 5 following patient-centered approaches are being disseminated as good practices.6 However, there are several factors that need further attention, such as the need for further assessment of implementation strategies in real-world scenarios and the lack of transferability from progress achieved in disease-oriented integrated care to management of complex chronic patients (CCP).5, 7 Likewise, efficacy achieved in integrated care interventions, assessed through randomized controlled trials, may not translate into effectiveness at health system level. In addition, poor comparability among experiences on management of multimorbidity emerges as an important hurdle for the adoption of integrated care. In this regard, the lack of an operational definition for CCP is not a negligible factor, as it clearly limits an appropriate service workflow design, which, in turn, precludes both evaluation and comparability of reported experiences.