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

摘要 本申请是对RFA-MD-21-007，与糖尿病相关的多种慢性疾病中心的回应。 健康差距：预防，治疗和管理。本应用程序的项目2将实现 多层次干预，以减少阻塞性睡眠呼吸暂停的诊断和管理的差异， 改善心脏代谢结果。具体而言，该项目将实施一项随机临床试验， 气道正压通气联合激励治疗阻塞性睡眠呼吸暂停（OSA） 在黑人和西班牙裔患者中，增强治疗（MET）可提高PAP治疗的依从性， 下游后遗症包括血压、血糖谱和生活质量。OSA相关间歇性 低氧血症和睡眠片段激活交感神经系统，增加氧化应激， 增加全身炎症。这些扰动会增加血压，降低胰岛素敏感性 并损害β细胞功能，影响生活质量。PAP治疗依从性差在少数人群中最为显著 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， 人们一直在积极寻求增加PAP治疗依从性的策略。一个成功的方法是 使用MET来提高依从性MET是基于动机性访谈的原则而设计的 提高自我效能，最大限度地改变行为。探讨在下列国家实施MET的可行性： 联邦合格的健康中心（NHC），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、在家进行睡眠呼吸暂停测试来筛查和诊断OSA， 培训社区卫生工作者实施MET。这一应用的核心科学前提是 MET，由经过动机访谈培训的CHW实施，可以提高PAP依从性。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： 服务水平低下人群的PAP依从性差。我们的具体目标如下。目标1：比较 MET，特别关注社会、生理、心理和环境障碍（ 健康），由文化一致的CHW与注意力匹配的比较者（包括 讨论一般睡眠卫生的电话数量相当）：（a）PAP依从性，（B）血压，（c） 24小时血糖曲线，（d）日间嗜睡，和（e）90天时的生活质量。目的2：比较3、6、 以及每个研究组中阻塞性睡眠呼吸暂停综合症患者12个月的医疗保健利用模式和护理成本。鉴于高 在少数人群中OSA和医学合并症的患病率，本试验的结果将具有 对临床实践和公共卫生产生重大影响，证明早期发现和治疗阻塞性睡眠呼吸暂停综合症是合理的 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.