Insomnia is a common and complex problem among older adults and is associated with significant morbidity and mortality. Unfortunately, insomnia is often unrecognized and untreated in primary care settings, and offered treatment may be limited to medications alone rather than considering the full range of effective treatments, such as behavioral interventions, that are supported by strong evidence. Clinical practice guidelines for the treatment of insomnia are also available, including recent VHA guidelines for the treatment of insomnia among Veterans in primary care. However, available evidence (both within and outside the VHA) suggests that gaps exist between best practices and current insomnia care in primary care settings. Our research program has focused on developing and testing interventions for treating sleep problems in older people. In this study, we used the VHA HSR&D Quality Enhancement Research Initiative (QuERI) model as the framework for translating research into practice and optimizing best practices throughout VHA. This study focused on QuERI step 3, which involves defining existing practice patterns and outcomes across VHA and current variation from best practices.
The immediate study objectives included: 1) Identify potential provider, patient and organizational factors that affect current practice patterns and implementation of best practices for the assessment and treatment of insomnia in older Veterans, and 2) Develop and pilot-test a provider survey that measures practice patterns and identifies variation in primary care providers' insomnia care practices.
For survey development and testing we used a mixed methods approach. Initially, we conducted key respondent interviews with VHA primary care providers (n=5) to identify provider factors (e.g., knowledge, attitudes, behaviors) that may impact assessment and treatment of insomnia in older Veterans. We also conducted three focus group discussions with older Veterans (total n=21, mean age=69.8 years) with self-reported symptoms of insomnia to identify patient-level factors (e.g., behaviors, treatment preferences) that could impact assessment and treatment of insomnia.
Based on the key respondent interviews and Veteran focus groups, we developed a draft of a provider survey. This survey draft was evaluated for face and content validity by a technical advisory panel of local content experts during a half-day session. The survey was then refined based on the panel's recommendations and formatted for on-line administration. The on-line survey was pre-tested with five primary care providers within VHA Greater Los Angeles Healthcare System, including a cognitive interview with the provider following completion of the survey. Using an iterative approach, the survey was refined throughout the pre-test period.
The survey was pilot-tested in a sample of 123 VHA primary care providers (i.e., physicians, nurse practitioners, physician assistants) within four VISNs that represented different geographic areas. The sample was drawn from among primary care providers listed on the VHA KLF database in the identified VISNs who had a VA FTE of 50% or greater. The sample was stratified by site (hospital-based outpatient clinics versus community-based outpatient clinics (CBOCs)) and provider (physician versus nurse practitioners/physician assistants (NP/PA)) to ensure accurate representation of provider and facility types within each VISN. Providers received an email invitation to complete the anonymous on-line survey, with a reminder email sent two weeks later.
Descriptive statistics were used to summarize the data. A summary knowledge score was calculated from the four insomnia knowledge questions. Survey items were combined to form three separate scales, including: provider attitudes, provider-perceived organizational barriers and provider-perceived patient barriers to management of insomnia. The internal consistency of the scale items was assessed using Cronbach's alpha. Scale scores were computed by averaging the items composing the scale. Providers' responses to survey items related to pre-determined best practices for assessment and treatment of insomnia were compared to knowledge scores, mean scores for attitude questions, and mean scores for provider-perceived organizational and patient barriers scales using bivariate associations (e.g., crosstabulations, t-tests, one-way ANOVA).
The provider survey was emailed to 978 providers in 4 VISNs. A total of 123 providers (12.6% of the sample) responded to the on-line survey, and 114 completed all items on the survey. Respondents included 63 (55.3%) physicians and 51 (44.7%) NP/PAs, and were nearly equally distributed between hospital-based (50.9%) and CBOC (49.1%) facilities. The majority of survey items showed good variance among responses. Providers' mean knowledge score was 1.94 (SD 1.09, range 0-4).
Scales were created for provider-perceived organizational barriers (10 items; alpha = 0.83) and patient barriers (3 items; alpha = 0.78). There was inadequate internal consistency between the 13 items related to providers' attitudes, so these items were considered individually without development of a scale.
The mean scores for the organizational barrier and patient barrier scales were 2.01 (SD 0.61, range 1-4) and 2.67 (SD 0.82, range 1-4), respectively (lower scores indicative of fewer barriers). There were no differences on these scales by type of provider or type of facility. Overall, 40% of providers reported difficulty accessing behavioral treatment options for insomnia. Compared to their confidence in managing other conditions (i.e., hypertension and diabetes), providers were significantly less confident in their management of both short-term and chronic insomnia (both p<.001).
Providers identified as being in the highest (best) quartile for meeting best practices for assessment of insomnia (21% of providers) were significantly more confident in managing short-term insomnia (p=0.02), were more likely to agree that insomnia has a significant impact on their patients' quality of life (p=.001), and were more likely to report that insomnia screening was a high priority in their own practice (p<.001), compared to providers in the lowest quartile (26% of providers). Only 25% of providers reported that their own practice met all four key indicators for best practices for treatment of insomnia. Compared to providers who did not meet key indicators for best practices for insomnia, providers in the highest (best) quartile for best practices also had higher insomnia knowledge scores (p=.004) and were more likely to report that their facility had sufficient resources to manage insomnia in older adults (p=.007).
The findings of this pilot project suggest that there is variation in provider knowledge, attitudes, and practices related to insomnia care for older Veterans. These findings suggest the importance of future research to develop and test strategies to encourage implementation of evidence-based best practices for insomnia care within VHA primary care.
- Fung CH, Martin JL, Igodan U, Jouldjian S, Alessi C. The association between difficulty using positive airway pressure equipment and adherence to therapy: a pilot study. Sleep & Breathing = Schlaf & Atmung. 2013 May 1; 17(2):853-9.