Improving Access to Sleep Apnea Care: A Pragmatic Study of New Consultation Models

项目背景：阻塞性睡眠呼吸暂停（OSA）是最常见的睡眠障碍之一 在美国退伍军人中。不幸的是，大多数退伍军人管理局的睡眠计划都不能保持 随着退伍军人对OSA评估和治疗的需求不断增加。 项目目标：本提案的目标是比较医疗保健提供模式，直接转诊 呼吸暂停监测（DREAM），为有OSA风险的退伍军人提供首次面对面（IP）接触。中央 拟议研究的假设是，梦想临床路径可以改善退伍军人获得 通过减少家庭睡眠呼吸暂停测试（HSAT）和OSA治疗的等待时间， 保持与IP评估相当的预后准确性。我们将测试我们的中心假设， 通过实现以下具体目标实现本提案的目标： 目标1。比较从转诊到睡眠测试和治疗OSA的时间， 传统的临床路径，其中包括与护理提供者的初次接触。 目标二。比较退伍军人的气道正压通气（PAP）依从性和患者报告的临床结局 不管有没有第一次的睡眠服务 目标3：确定家庭睡眠呼吸暂停测试的阴性预测值 拟议研究的意义和与退伍军人健康的相关性：OSA与 高血压、中风、心血管疾病、糖尿病和早产儿的风险增加 死亡改善退伍军人获得OSA评估和治疗的机会将提高 他们的睡眠和生活质量。 HSR&D优先领域：1）通过实施远程医疗改善退伍军人的医疗保健服务; 2）测试 新的护理模式，以改善可及性、成本和/或结果; 3）实施的设计和测试 提高有效做法和护理质量的战略。 创新：该方法具有创新性，因为：（a）使用DREAM临床模型代替初始IP OSA评估的咨询是新颖的;（B）使用电子病历数据直接对退伍军人进行分类， 睡眠研究是这项技术的一个新应用。 项目方法：本研究是一项务实的，前瞻性的，观察性研究，比较了医疗保健 基于存储在患者电子病历（EMR）中的数据的交付模型（DREAM）， 为有阻塞性睡眠呼吸暂停（OSA）风险的退伍军人提供首次现场（IP）门诊。转介的病人 参与睡眠医学诊所的OSA将酌情进行HSAT，随后在实验室内进行 睡眠测试，如果家庭研究是负面的。将在基线和第3- 4天测量患者报告的结局。 个月将在3个月时收集治疗依从性和使用数据。 预期结果：与初始IP途径相比，DREAM将显著缩短等待时间， 退伍军人接受评估和治疗OSA。此外，睡眠呼吸暂停研究的阳性诊断率 分配到DREAM的退伍军人与参加初始面对面培训的退伍军人相比， 约会.在DREAM条件下坚持OSA治疗不会劣于最初的亲自治疗 咨询;患者的结局和满意度在DREAM中不会劣于面对面组。 下一步：如果DREAM模型证明了减少退伍军人等待OSA诊断时间的有效性 和治疗，将采取措施在整个医疗中心和诊所实施该程序。 VHA系统。

Project Background: Obstructive sleep apnea (OSA) is one of the most common sleep disorders among U.S. military Veterans. Unfortunately, most VA sleep programs have not been able to keep up with Veterans’ ever-increasing demand for OSA assessment and treatment. Project Objectives: The objective of this proposal is to compare a health care delivery model, Direct Referral for Apnea Monitoring (DREAM), with initial in-person (IP) encounters for Veterans at risk for OSA. The central hypothesis of the proposed research is that the DREAM clinical pathway can improve Veterans’ access to sleep services by reducing wait times for home sleep apnea testing (HSAT) and OSA treatment while maintaining prognostic accuracy that is comparable to IP assessments. We will test our central hypothesis and accomplish the objective of this proposal by pursuing the following specific aims: Aim 1. Compare the time from referral to sleep testing and treatment of OSA in Veterans in the DREAM vs. the traditional clinical pathway, which includes an initial encounter with a care provider. Aim 2. Compare positive airway pressure (PAP) adherence and patient-reported clinical outcomes in Veterans with and without an initial sleep provider encounter. Aim 3. Determine the negative predictive value of home sleep apnea testing Significance of the Proposed Research and Relevance to Veterans’ Health: OSA is associated with increased risk for hypertension, stroke, cardiovascular disease, diabetes mellitus, and premature death. Improving Veterans’ access to OSA assessment and treatment will improve the quality of their sleep and the quality of their lives. HSR&D Priority Areas: 1) Improving Veterans’ healthcare access via telehealth implementation; 2) Testing new models of care to improve access, cost, and/or outcomes; 3) Design and testing of implementation strategies to improve uptake of effective practices and quality of care. Innovation: This approach is innovative because, (a) the use of the DREAM clinical model in lieu of initial IP consultation for OSA evaluations is novel; (b) using electronic medical record data to triage Veterans directly to sleep studies is a new application of this technology. Project Methods: This study is a pragmatic, prospective, observational study that compares a health care delivery model (DREAM) which is based on data stored in patients’ electronic medical records (EMRs), with initial in-person (IP) clinic encounters for Veterans at risk for obstructive sleep apnea (OSA). Patients referred to the participating sleep medicine clinics for OSA will undergo HSAT as appropriate, with subsequent in-lab sleep testing if the home study is negative. Patient-reported outcomes will be measured at baseline and 3- months. Adherence with treatment and utilization data will be collected at 3-months. Expected Results: Compared to the initial IP pathway, DREAM will result in significantly shorter wait times for Veterans to receive assessment and treatment for OSA. Also, rates of positive diagnostic sleep apnea studies will be statistically equivalent in Veterans assigned to DREAM compared to those who attend initial in-person appointments. Adherence to OSA treatment in the DREAM condition will not be inferior to initial in-person consultation; patient outcomes and satisfaction will not be inferior in the DREAM versus the in-person arm. Next Steps: If the DREAM model demonstrates efficacy for reducing Veterans’ wait times for OSA diagnosis and treatment, steps will be taken to implement the procedure in medical centers and clinics throughout the VHA system.