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PPO 10-101 – HSR&D Study

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PPO 10-101
Using Telemedicine to Improve Veteran Sleep Apnea Care
Carl J Stepnowsky, Jr. PhD
VA San Diego Healthcare System, San Diego, CA
San Diego, CA
Funding Period: June 2011 - May 2012

BACKGROUND/RATIONALE:
Obstructive sleep apnea (OSA) is highly prevalent in the Veteran population given the risk factors of male gender, being overweight, and increasing age. OSA is caused by upper airway obstruction, resulting in arousals from sleep and hypoxia. While continuous positive airway pressure (CPAP) is a highly efficacious treatment for OSA, compliance with treatment is suboptimal. Because research shows that adherence patterns are established early in treatment, we seek to use a technology that enables early and frequent productive interactions between patient and provider

OBJECTIVE(S):
The objective of this proposal is to explore the feasibility and initially evaluate the potential efficacy of a video teleconferencing system for patients with Obstructive Sleep Apnea syndrome (OSA) that facilitates patient- centered, collaborative management for patients who are prescribed the gold-standard treatment, continuous positive airway pressure (CPAP).

METHODS:
The evaluative aspect of this proposal was designed as a pilot randomized, controlled clinical trial of Video Teleconferencing (VTC) compared to Usual Care (UC). The key feature of the Video Teleconferencing intervention was the use of a telemedicine system that allows for audio/visual conferencing with the patient in their home environment from the start of treatment initialization. The provider is able provide more direct feedback to the patient based on the telemedicine interaction, and the patient benefits from increased contact with the provider. Specific inclusion and exclusion criteria included: age > 18 years; confirmed diagnosis of moderate-severe OSA; being newly prescribed CPAP therapy; having chronic symptoms as noted on screening symptom checklist; and fluency in English. Patients were recruited from the VA San Diego Healthcare System Pulmonary Sleep Clinic. Patients were enrolled for a 2-month time period. Groups were compared on quantitative and qualitative measures.

FINDINGS/RESULTS:
Twenty-three patients diagnosed with OSA and prescribed CPAP therapy were studied with 13 in the VTC group and 10 in the UC group. At baseline for the entire group (mean +/- SD for VTC, UC, p-value, respectively) mean age = 52.4+/-9.9 (54.9+/-8.3; 49.3+/-11.3; p=0.2), mean apnea-hypopnea index (AHI) = 40.3+/-21.8 (39.3+/-26.7; 41.3+/-16.1; p=0.8), mean body mass index (BMI) =33.7+/- 5.3 (35.4+/-4.9; 31.8+/-5.4; p=0.1), and mean Epworth Sleepiness Scale (ESS) = 12.0+/-4.7 (12.4+/-5.3; 11.7+/-4.2; p=0.7). There were no baseline differences in age, AHI, BMI, or ESS between the two groups.

Nightly CPAP adherence measured over the two-month period was 3.4 2.4 vs. 3.6 1.8 hours per night (p=0.8) for the VTC and UC groups, respectively. This means that substituting face-to-face clinic visits with VTC interactions resulted in no degradation of the primary outcomes measure, CPAP adherence, between the two groups. Stated conversely, the increased frequency of interactions through VTC in the pilot study did not result in an increase in CPAP adherence. The groups did not differ on other outcomes measures, including OSA symptoms, daytime sleepiness, sleep quality and depressive symptoms.

The study was extremely informative in revealing both the advantages and disadvantages associated with using video teleconferencing with research participants in theIr home enviroments. The following discussion will present both the advantages and disadvantages. The advantages were clear; VTC allowed for more frequent interactions between patient and provider. However, the VTC utlized in the present study relied on the patient using their home computer. If they worked, this meant that some interactions were scheduled in the evening and were not necessarily conveniently scheduled during the normal work day. Another advantage of VTC relative to phone calls was the ability of the clinician to "see" the patient and be able to assess the patient's non-verbal behaviors. However, some patients did not seem completely comfortable with the VTC interactions judging by their lack of eye contact. Upon questioning, it was clear this was a new technology that some simply were not used to using. Another advantage of the VTC system was the abilty to show or demonstrate mask fitting or use of the CPAP device. However, our project ran into significant technical difficulties, and mid-stream we needed to supplement the VA provided MOVI with Via3 software. This made an important difference in our ability to connect with our participants. Also, VTC is best conducted with fast internet speeds, and unfortunately many of our veterans have limited internet speeds. This results in poor VTC connections and dropped calls. Overall the quality of the VTC interaction is dependent on the quality of the connection.

To summarize, the key points that we learned from the use of the VTC in the current study was that (1) internet connections speeds in most home environments might be too slow to support VTC; (2) use of home desktop computers actually limit the use of VTC when compared to the use of VTC on a mobile device and (3) even minor decrements in call quality can negatively affect the clinical interaction. These lessons learned have informed a subsequent VA HSRD proposal on the use of a similar technology. Clearly, the OSA clinical care process is characterized by large gaps in patient education, support and follow-up. The use of VTC technology has the potential to overcome these issues, but only when the technology can support high-quality communications that are convenient to both patient and provider.

IMPACT:
The findings of this study have the potential to improve the quality of clinical care provided to Veteran patients with obstructive sleep apnea who are prescribed CPAP.

PUBLICATIONS:
None at this time.


DRA: Other Conditions
DRE: Treatment - Comparative Effectiveness
Keywords: Symptom Management, Telemedicine/Telehealth
MeSH Terms: none

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