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IIR 15-339 – HSR Study

IIR 15-339
Improving Access to Sleep Apnea Care: A Pragmatic Study of New Consultation Models
Kathleen Fumiko Sarmiento, MD MPH
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: August 2020 - September 2025


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.

External Links for this Project

NIH Reporter

Grant Number: I01HX002198-01A2

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Journal Articles

  1. Chang YHA, Folmer RL, Shasha B, Shea JA, Sarmiento K, Stepnowsky CJ, Lim D, Pack A, Kuna ST. Barriers and facilitators to the implementation of a novel web-based sleep apnea management platform. Sleep. 2021 Apr 9; 44(4). [view]
  2. Sarmiento KF, Boudreau EA, Smith CJ, Kaul B, Johnson N, Folmer RL. Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs. Federal practitioner : for the health care professionals of the VA, DoD, and PHS. 2020 Aug 1; 37(8):368-374. [view]
  3. Folmer RL, Smith CJ, Boudreau EA, Hickok AW, Totten AM, Kaul B, Stepnowsky CJ, Whooley MA, Sarmiento KF. Prevalence and management of sleep disorders in the Veterans Health Administration. Sleep Medicine Reviews. 2020 Dec 1; 54:101358. [view]
  4. Mazzotti DR, Haendel MA, McMurry JA, Smith CJ, Buysse DJ, Roenneberg T, Penzel T, Purcell S, Redline S, Zhang Y, Merikangas KR, Menetski JP, Mullington J, Boudreau E. Sleep and circadian informatics data harmonization: a workshop report from the Sleep Research Society and Sleep Research Network. Sleep. 2022 Jun 13; 45(6). [view]
  5. Folmer RL, Smith CJ, Boudreau EA, Totten AM, Chilakamarri P, Atwood CW, Sarmiento KF. Sleep disorders among rural Veterans: Relative prevalence, comorbidities, and comparisons with urban Veterans. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2023 Jun 1; 39(3):582-594. [view]
  6. Folmer RL, Boudreau EA, Atwood CW, Smith CJ, Totten AM, Tock JL, Chilakamarri P, Sarmiento KF. Study protocol to assess de-implementation of the initial provider encounter for diagnosis and treatment of obstructive sleep apnea: the DREAM (Direct Referral for Apnea Monitoring) Project. BMC pulmonary medicine. 2022 Apr 2; 22(1):123. [view]
  7. Hahn Z, Hotchkiss J, Atwood C, Smith C, Totten A, Boudreau E, Folmer R, Chilakamarri P, Whooley M, Sarmiento K. Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration. Journal of general internal medicine. 2023 Jul 1; 38(Suppl 3):805-813. [view]
  8. Folmer RL. Unresolved Issues Associated with Transcranial Magnetic Stimulation (TMS) Treatment of Chronic Tinnitus. Journal of clinical medicine. 2023 Jul 12; 12(14). [view]
  9. Salinsky M, Evrard C, Joos S, Boudreau E. Utility of mental health and sleep screening questionnaires for patients admitted to a seizure monitoring unit. Epilepsy & Behavior : E&B. 2021 Oct 1; 123:108237. [view]
  10. Chun VS, Whooley MA, Williams K, Zhang N, Zeidler MR, Atwood CW, Folmer RL, Totten AM, Smith CJ, Boudreau EA, Reichert JM, Sarmiento KF. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2023 May 1; 19(5):913-923. [view]
Journal Other

  1. Atwood CW, Boudreau EA, Folmer RL, Kuna ST, Pineda L, Reichert J, Sarmiento K, Thompson W, Whooley M, Zhang N, Yarbrough WC. 1170 Trends in Sleep Apnea Testing Among Veterans Participating in a Rural Health-Focused Telesleep Medicine Program. [Abstract]. Sleep Medicine Reviews. 2020 Apr 1; 43(Supplement 1):A447. [view]
  2. Atwood W, Smith C, Totten A, Boudreau EA, Sarmiento K, Hahn Z, Folmer RL, Tock J, Hotchkiss J. Good Sleep Care: Geospatial Optimization of Distant Sleep Care in the VA. [Abstract]. Sleep. 2022 Jun 1; 45(Suppl 1):A164. [view]
  3. Sarmiento K, Kuna S, Boudreau EA, Atwood C, Pineda L, Thompson W, Zeidler M, Fields B, Uzzaman A, Totten A, Smith C, Folmer RL, Williams K, Zhang N, Whooley M. VHA's TeleSleep Program improves rural Veteran access to sleep care through expansion of telehealth networks. [Abstract]. Sleep. 2021 May 3; 44(Suppl 2):A317-A318. [view]

DRA: Health Systems
DRE: Treatment - Observational, TRL - Applied/Translational
Keywords: Clinical Diagnosis and Screening, Guideline Development and Implementation, Outcomes - System
MeSH Terms: None at this time.

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