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IIR 04-021 – HSR Study

IIR 04-021
Cost Effective Strategy to Evaluate Veterans with Sleep Apnea
Samuel T. Kuna, MD
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
Philadelphia, PA
Funding Period: February 2006 - September 2010
Portable monitors are commercially available to diagnose veterans with suspected obstructive sleep apnea (OSA). However, their application to home testing is not widely accepted because it is not known whether home testing, when compared to conventional in-laboratory testing, is cost effective and produces similar clinical outcomes.

The specific goals of the proposed research were to compare the functional impact, cost, and cost-effectiveness of evaluating veterans with suspected OSA using home versus in-laboratory testing.

296 veterans with suspected OSA were randomized to management using either home testing or standard in-laboratory testing. Home testing consisted of an overnight recording with a type 3 portable monitor (Embla) followed by at least 3 nights using an autoCPAP apparatus (Philips). Participants diagnosed with OSA were treated with continuous positive airway pressure (CPAP). Aim 1 was to determine if veterans with suspected OSA who receive home testing have the same functional outcomes and the same adherence to subsequent CPAP treatment as veterans receiving in-laboratory testing. The primary outcome measure was the global score on the Functional Outcomes of Sleep Questionnaire (FOSQ), a disease-specific quality of life questionnaire. Hypothesis 1: Following 3 months of CPAP treatment, there would be no clinically significant reduction in functional outcomes, with an a priori non-inferiority delta of -1 point, and no clinically significant decline in mean CPAP adherence, with an a priori non-inferiority delta of -0.75 hr/day, in veterans receiving home versus in-laboratory testing. Aim 2 was to compare the differences in cost and quality-adjusted life years saved (QALYS) between home versus in-lab testing to estimate a cost-effectiveness ratio. Veteran preference was assessed with the EuroQol (EQ-5D) and Health Utilities Index 2 (HUI). Hypothesis 2a: Average total health-care delivery cost would be lower for veterans receiving home testing relative to those receiving in-lab testing. Hypothesis 2b: Because we believe that at-home testing will have lower costs and equivalent outcomes, we were 90% confident that the cost per QALY ratio comparing at-home testing with in-lab testing would be less than $100,000.

The mean functional outcome score improved 1.74 +/- 2.81 in the home group (p<0.001) and 1.85 +/- 2.46 in the in-lab group (p<0.0001). The lower bound of the one-sided 95% non-inferiority confidence interval was -0.54. The mean hours of daily positive airway pressure adherence over the 3-month intervention was 3.5 +/- 2.5 hr/day in the home group and 2.9 +/- 2.3 hr/day in the in-lab group (p=0.08). The lower bound of the one-sided 95% non-inferiority confidence interval was 0.03. Improvements in the scores on the mental health component of the SF-12, the Epworth Sleepiness Scale, and a depression questionnaire (CES-D) following 3 months of CPAP treatment were significant within both groups but similar between groups.

The finding that veterans receiving home versus in-laboratory testing have similar outcomes will lead to wider acceptance of home portable monitor testing and increase veterans access to care.

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None at this time.

DRA: Health Systems
DRE: Diagnosis
Keywords: Assessment, Cost effectiveness, Sleep disorders
MeSH Terms: none

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