A Multilevel Intervention to Reduce Disparities in Obstructive Sleep Apnea and Related Cardiometabolic Outcomes

摘要 此应用程序是对RFA-MD-21-007，多慢性病中心的响应 健康差距：预防、治疗和管理。此应用程序的项目2将实现 多层次干预减少阻塞性睡眠呼吸暂停的诊断和治疗差异 改善心脏代谢结果。具体地说，该项目将实施随机临床试验，以测试 阻塞性睡眠呼吸暂停(OSA)的正压(PAP)和激励治疗假说 黑人和西班牙裔患者的增强疗法(MET)提高了对PAP疗法的依从性，并 下游后遗症包括血压、血糖和生活质量。阻塞性睡眠呼吸暂停综合征相关间歇 低氧血症和睡眠碎片激活交感神经系统，增加氧化应激，以及 加重全身炎症。这些扰动会增加血压，降低胰岛素敏感性 损害β细胞功能，影响生活质量。对PAP疗法依从性差在少数族裔中最为明显 人口，反映了多个个人和卫生系统层面的挑战。在过去的十年里，各种各样的 人们一直在严格寻求提高对PAP治疗依从性的策略。一种成功的方法是 根据激励性访谈的原则，设计了MET用于提高对MET的依从性 提高自我效能感，最大限度地改变行为。解决在以下方面实施MET的可行性 联邦合格的健康中心(FQHC)，在那里获得亚专业睡眠护理的可能性较小，我们 建议使用电子健康记录、家庭睡眠呼吸暂停测试来筛查和诊断OSA，以及 培训社区卫生工作者(CHW)以实施MET。这一应用的中心科学前提是 由CHW在激励性访谈中接受培训后实施的MET可以提高PAP的忠诚度。我们的方法 使用CHW将提供一种可行的、可推广的和可扩展的方法来解决以下常见问题 在服务不足的人中，人民行动党的遵从性很差。我们的具体目标如下。目标1：比较 特别注意社会、物质、心理和环境障碍(社会决定因素 健康)，由文化上一致的CHW与注意力匹配的比较器(包括 相同数量的电话讨论一般睡眠卫生)：(A)坚持PAP，(B)血压，(C) 24小时血糖曲线，(D)白天嗜睡，和(E)90天的生活质量。目标2：比较3、6、 以及每个研究组12个月的OSA患者的医疗利用模式和护理成本。考虑到高价 少数族裔人群中阻塞性睡眠呼吸暂停和医学合并症的患病率，这项试验的结果将有 对临床实践和公共健康的重大影响，证明OSA的早期病例识别和治疗是合理的 在服务不足的人群中。

ABSTRACT This application is in response to the RFA-MD-21-007, Centers for Multiple Chronic Diseases Associated with Health Disparities: Prevention, Treatment, and Management. Project 2 of this application will implement a multilevel intervention to reduce disparities in the diagnosis and management of obstructive sleep apnea to improve cardiometabolic outcomes. Specifically, this project will implement a randomized clinical trial to test the hypothesis that treatment of obstructive sleep apnea (OSA) with positive airway pressure (PAP) and motivational enhancement therapy (MET) therapy in Black and Hispanic patients improves adherence to PAP therapy and downstream sequelae including blood pressure, glycemic profiles, and quality of life. OSA-related Intermittent hypoxemia and sleep fragmentation activate the sympathetic nervous system, increase oxidative stress, and heighten systemic inflammation. These perturbations can increase blood pressure, decrease insulin sensitivity and impair β-cell function, and impact quality of life. Poor adherence to PAP therapy is most notable in minority populations, reflecting multiple individual, and health system level challenges. Over the last decade various strategies to augment adherence to PAP therapy have been rigorously sought. One successful approach is the use of MET to improve adherence MET, which is based on the principles of motivational interviewing, is designed to promote self-efficacy and maximize behavioral change. To address feasibility of implementing MET in Federally Qualified Health Centers (FQHC), where access to sub-specialized sleep care is less likely, we propose screening for and diagnosing OSA using the electronic health record, at home sleep apnea tests, and training community health workers (CHW) to implement MET. The central scientific premise of this application is that MET, implemented by CHW trained in motivational interviewing, can improve PAP adherence. Our approach of using CHWs will provide a feasible, generalizable, and scalable approach to tackling the common problem of poor PAP adherence in the underserved. Our Specific Aims are as follows. Aim 1: To compare the impact of MET, with specific attention to social, physical, psychological and environmental barriers (social determinants of health), delivered by culturally congruent CHWs versus an attention-matched comparator (consisting of comparable number of calls to discuss general sleep hygiene) on: (a) PAP adherence, (b) blood pressure, (c) 24-hr glycemic profiles, (d) daytime sleepiness, and (e) quality of life at 90 days. Aim 2: To compare the 3, 6, and 12 month healthcare utilization patterns and costs of care of OSA patients in each study arm. Given the high prevalence of OSA and medical comorbidities in the minority populations, findings from this trial would have a major impact on both clinical practice and public health, justifying early case identification and treatment of OSA in underserved populations.