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

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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.