Diagnosis and management of sleep disorders in shift workers, with patient informed solutions to improve health services research and practice.

BACKGROUND: The combination of shift work and an unmanaged sleep disorder carries health and safety risks. Yet, diagnosis rates for sleep disorders are low in shift workers. The aim of this study was to understand the experience of sleep disorder diagnosis and treatment in shift workers, and consider patient informed solutions to improve access to health services. METHODS: Semi-structured interviews were conducted with 16 Australian shift workers with a diagnosed sleep disorder. Patient journey mapping and reflexive thematic analysis were used to understand diagnosis and management experiences. RESULTS: There were highly variable experiences with diagnosis and management, often taking >5 years to seek help from a health care provider (HCP) after noticing symptoms of a sleep disorder. Three themes were constructed, including 'the cause of the problem', 'prioritising work', and '(dis)satisfaction and (dis)connection'. Extent of patient and HCP awareness of sleep disorders, and a prevailing attitude of shift work being 'the problem' impacted diagnosis, as did organisational needs (including rostering, which had both positive and negative influences on help seeking). Relationships with HCPs were important, and living on non-standard time was both a barrier and an enabler to sleep disorder care. Participants identified the need for education and awareness, prompts and easy access to screening and referral pathways, and tailored models of care. CONCLUSION: Education and awareness initiatives for shift workers, their employers and HCPs, together with development of a model of care for shift workers with sleep disorders may address some of the unique barriers to diagnosis and management.

Improving sleep health management in primary care: A potential role for community nurses?

AIMS: To explore community nurses sleep health practices and their perspectives on improving sleep health care provision. DESIGN: An exploratory study utilizing the qualitative description methodology. METHODS: Semi-structured interviews were conducted with community nurses from May 2019 - October 2021. Interviews were audio-recorded, transcribed, and subjected to an inductive thematic analysis using a constructivist-interpretive paradigm. RESULTS: Twenty-three Australian community nurses were interviewed. Participants frequently encountered sleep disturbances/disorders in their patients. Data analysis yielded three main themes: (1) Sleep health in the community serviced, (2) sleep health awareness and management, and (3) community nurses' A to Z of improving sleep health. The most common sleep disorder presentations were insomnia and sleep apnea. Although most community sleep apnea cases were appropriately managed, insomnia was often mismanaged. Participants described their sleep health knowledge as deficient, with the majority advocating for increased sleep-related education tailored to their profession. Other important factors needed for improving sleep health provision were standardized patient treatment/referral pathways, increased interprofessional collaboration, and sufficient time for patient consults. CONCLUSION: Community nurses service a patient population that requires increased sleep health care. However, they are currently underequipped to do so, leading to suboptimal treatment provision. Providing community nurses with the appropriate resources, such as increased sleep-related education and standardized treatment frameworks, could enable them to better manage sleep disturbance/disorder presentations, such as insomnia. IMPACT: Little is known about how community nurses care for patients with sleep disturbance/sleep disorders. This study found that contemporary sleep health care was lacking due to knowledge deficits, competing challenges, and a need for standardized care pathways. These findings can inform the development of targeted education/training and standardized guidelines for community nurses providing sleep health care to patients as well as the design of future practice models of care provision. PATIENT OR PUBLIC CONTRIBUTION: Previous research by authors has involved extensive engagement with patients and health professionals, such as community pharmacists, general practitioners, and naturopaths who play a role in sleep health in the primary health care sector. These previous research projects built a significant understanding of the patient and health practitioner experience and have provided the background to the concept and design of this study.

Barriers and facilitators for the implementation of nurse-delivered chronic disease management within general practice: a mixed methods systematic review protocol.

OBJECTIVE: The objective of this review is to identify the barriers and facilitators for the implementation of nurse-delivered models of care for chronic diseases to inform the development and evaluation of nurse-delivered models of care for chronic sleep disorders. INTRODUCTION: Increasing prevalence of sleep disorders and subsequent demand for specialist-led sleep services has prompted investigation into the management of uncomplicated sleep disorders by general practitioners. Models of sleep health care with enhanced roles for general practice nurses have been investigated within the context of randomized controlled trials; however, it is unclear how best to implement these models into clinical practice. With limited research exploring the implementation of nurse-delivered models of sleep health care within general practice, this review will examine the barriers and facilitators for the implementation of nurse-delivered models of care for chronic disease. This will inform the integration of new nurse-delivered models of care for chronic sleep disorders into routine general practice. INCLUSION CRITERIA: Studies that report barriers and facilitators for the implementation of nurse-delivered models of care for chronic diseases for adults into a general practice setting will be included. METHODS: Six databases will be searched: MEDLINE, CINAHL, Embase, Scopus, Cochrane Library, and Emcare. The search will be limited to qualitative, quantitative, and mixed methods studies. Studies will be included if they contain data that report on barriers and facilitators for implementation of nurse-delivered models of care for chronic diseases. This review will be conducted in accordance with the JBI approach to mixed methods convergent integrated systematic reviews. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021273346.

Comorbidities and quality of life in Australian men and women with diagnosed and undiagnosed high-risk obstructive sleep apnea.

STUDY OBJECTIVES: In a population-based survey, we determined sex differences in health profiles and quality of life between individuals who have a confirmed diagnosis of obstructive sleep apnea (OSA) and those who are at high risk of OSA yet remain undiagnosed. METHODS: An online survey of Australian adults ≥ 18 years (n = 3,818) identified participants with self-reported diagnosed OSA (n = 460) or high-risk, undiagnosed OSA (OSA50 score ≥ 5, n = 1,015). Ever-diagnosed comorbidities, sociodemographics, and quality of life (EQ-5D-5L, Functional Outcomes of Sleep Questionnaire-10) were assessed. RESULTS: Women were more frequently represented in the high-OSA-risk group compared with those with diagnosed OSA (55.5%, n = 563, versus 43%, n = 198; P < .001). In sex-specific logistic regression analyses, diagnosed OSA was associated with increased likelihoods of ≥ 1 cardiovascular condition (odds ratio: 3.0; 95% confidence interval: 2.0-4.5), hypertension (1.9; 1.3-2.8), gout (1.8; 1.1-2.9), and chronic obstructive pulmonary disease (3.8; 2.1-6.9) in men. In women, an association with asthma (2.0; 1.3-3.0) was seen. Diabetes, arthritis, mental health conditions (ever-diagnosed), and all EQ-5D-5L dimensions were associated with an OSA diagnosis regardless of sex, except for EQ-5D-5L anxiety/depression, which was only associated with an OSA diagnosis in women. A diagnosis of OSA was associated with sleepiness-related impairment (lowest quartile of Functional Outcomes of Sleep Questionnaire-10) in men (1.6; 1.01-2.5) and women (2.2; 1.4-3.6). CONCLUSIONS: Sex-specific health conditions may drive diagnosis of OSA; however, clinical suspicion of OSA needs to be increased in men and women. The impaired quality of life and persistent sleepiness in participants with diagnosed OSA observed at a population level requires greater clinical attention. CITATION: Krishnan S, Chai-Coetzer CL, Grivell N, et al. Comorbidities and quality of life in Australian men and women with diagnosed and undiagnosed high-risk obstructive sleep apnea. J Clin Sleep Med. 2022;18(7):1757-1767.

Assessment, referral and management of obstructive sleep apnea by Australian general practitioners: a qualitative analysis.

BACKGROUND: The high and increasing demand for obstructive sleep apnea (OSA) care has exceeded the capacity of specialist sleep services prompting consideration of whether general practitioners could have an enhanced role in service delivery. However, little is known about the current involvement, experiences and attitudes of Australian general practitioners towards OSA. The purpose of this study was to provide an in-depth analysis of Australian general practitioners' experiences and opinions regarding their care of patients with OSA to inform the design and implementation of new general practice models of care. METHODS: Purposive sampling was used to recruit participants with maximum variation in age, experience and location. Semi-structured interviews were conducted and were analysed using Thematic Analysis. RESULTS: Three major themes were identified: (1) General practitioners are important in recognising symptoms of OSA and facilitating a diagnosis by others; (2) Inequities in access to the assessment and management of OSA; and (3) General practitioners currently have a limited role in the management of OSA. CONCLUSIONS: When consulting with patients with symptoms of OSA, general practitioners see their primary responsibility as providing a referral for diagnosis by others. General practitioners working with patients in areas of greater need, such as rural/remote areas and those of socio-economic disadvantage, demonstrated interest in being more involved in OSA management. Inequities in access to assessment and management are potential drivers for change in future models of care for OSA in general practice.

Primary care management of chronic insomnia: a qualitative analysis of the attitudes and experiences of Australian general practitioners.

BACKGROUND: Chronic insomnia is a highly prevalent disorder, with ten to thirty percent of Australian adults reporting chronic difficulties falling asleep and/or staying asleep such that it causes significant daytime impairment. Current Australian general practice guidelines recommend cognitive behavioural therapy for insomnia (CBTi) as first line treatment for insomnia, however research suggests that most general practice consultations for insomnia result in a prescription for hypnotic or sedative medicines. Although the first point of contact for patients experiencing symptoms of insomnia is often general practice, little is known about the current role, experiences and capacity of Australian general practitioners to manage insomnia. This study aimed to address that gap by exploring the attitudes and opinions of general practitioners regarding insomnia management, to inform the development and implementation of new models of best practice insomnia care within general practice. METHODS: A descriptive, pragmatic qualitative study. Purposive sampling was used to recruit practising Australian general practitioners, varying in age, years of experience and geographic location. Semi-structured interviews were conducted, and data analysed using thematic analysis.  RESULTS: Twenty-eight general practitioners participated in the study. Three major themes were identified: 1) Responsibility for insomnia care; 2) Complexities in managing insomnia; and 3) Navigating treatment pathways. Whilst general practitioners readily accepted responsibility for the management of insomnia, provision of care was often demanding and difficult within the funding and time constraints of general practice. Patients presenting with comorbid mental health conditions and insomnia, and decision-making regarding long-term use of benzodiazepines presented challenges for general practitioners. Whilst general practitioners confidently provided sleep hygiene education to patients, their knowledge and experience of CBTi, and access and understanding of specialised referral pathways for insomnia was limited.  CONCLUSIONS: General practitioners report that whilst assessing and managing insomnia can be demanding, it is an integral part of general practice. Insomnia presents complexities for general practitioners. Greater clarity about funding options, targeted education about effective insomnia treatments, and referral pathways to specialist services, such as benzodiazepine withdrawal support and psychologists, would benefit insomnia management within general practice.

A step-by-step model for a brief behavioural treatment for insomnia in Australian general practice.

BACKGROUND: Chronic insomnia is a prevalent and debilitating disorder managed in Australian general practice. The most effective and recommended first-line treatment for insomnia is cognitive behavioural therapy. This treatment has been translated to a condensed brief behavioural therapy for insomnia (BBTi), which is suitable for delivery in the general practice setting. There is evidence that BBTi improves insomnia, daytime functioning and quality of life, with effects persisting far beyond treatment cessation. BBTi appears to be a cost-effective treatment that is superior to sedative-hypnotic management. OBJECTIVE: The aim of this article is to present a step-by-step approach for Australian general practitioners to administer BBTi. DISCUSSION: BBTi is an effective treatment for insomnia that may be administered in the Australian general practice setting. General practitioners may choose to use existing funding support to administer BBTi to treat chronic insomnia according to guideline recommendations.

What is a Clinically Meaningful Target for Positive Airway Pressure Adherence?

Although good adherence to continuous positive airway pressure (PAP) traditionally is defined as greater than or equal to 4 hours/night, the origins and rationale for this remain unclear. Research studies report variation in optimal duration of PAP adherence, depending on outcome of interest. Evidence demonstrates benefit with PAP for daytime sleepiness, quality of life, neurocognitive outcomes, depression, and hypertension, predominantly in symptomatic, moderate-severe obstructive sleep apnea. Recent randomized controlled trials, however, have failed to demonstrate a reduction in cardiovascular and mortality risks. This review explores the question of what can be considered a clinically meaningful outcome for PAP adherence.