Survey of Resources in Behavioral Sleep Medicine Across the Department of Defense, Defense Health Agency.

INTRODUCTION: Insomnia affects approximately 40% of active duty service members and adversely affects health, readiness, and safety. The VA/DoD Clinical Practice Guideline for the management of insomnia recommends cognitive-behavioral treatment of insomnia (CBTI) or its abbreviated version (brief behavioral treatment of insomnia [BBTI]) as the first-line insomnia treatment. The goal of this study was to assess CBTI/BBTI resources at MTFs, perceived facilitators and barriers for CBTI/BBTI, and gaps in these treatments across the Defense Health Agency. MATERIALS AND METHODS: Between July and October 2022, we conducted an electronic survey of CBTI/BBTI resources across Contiguous United States and the District of Columbia (CONUS) and Outside Continental United States (OCONUS) MTFs. The survey was distributed to 154 military sleep health care providers from 32 MTFs, and a link to the survey was posted on two online military sleep medicine discussion forums. Fifteen providers from 12 MTFs volunteered to complete a 30-minute qualitative interview to explore their perception of barriers and facilitators of CBTI/BBTI at their facility. RESULTS: Fifty-two of 154 providers (33.8%) at 20 MTFs completed the survey. A majority of providers indicated that hypnotics remain the most common treatment for insomnia at their facility. Sixty-eight percent reported that CBTI/BBTI was available at their facility and estimated that less than 50% of the patients diagnosed with insomnia receive CBTI/BBTI. The main facilitators were dedicated, trained CBTI/BBTI providers and leadership support. Referrals to the off-post civilian network and self-help apps were not perceived as significant facilitators for augmenting insomnia care capabilities. The primary barriers to offering CBTI/BBTI were under-resourced clinics to meet the high volume of patients presenting with insomnia and scheduling and workflow limitations that impede repeated treatment appointments over the period prescribed by CBTI/BBTI protocols. Four primary themes emerged from qualitative interviews: (1) CBTI/BBTI groups can scale access to insomnia care, but patient engagement and clinical outcomes are perceived as inferior to individual treatment; (2) embedding trained providers in primary or behavioral health care could accelerate access, before escalation and referral to a sleep clinic; (3) few providers have the time to adhere to traditional CBTI protocols, and appointment scheduling often does not support weekly or bi-weekly treatment visits; and (4) the absence of quality and/or continuity of care measures dampens providers' enthusiasm for using external referral resources or self-help apps. CONCLUSIONS: Although there is a wide recognition that CBTI/BBTI is the first-line recommended insomnia treatment, the limited scalability of treatment protocols, clinical workflow limitations, and scarcity of trained CBTI/BBTI providers limit the implementation of the VA/DoD clinical guideline. Educating and engaging health care providers and leadership about CBTI, augmenting CBTI-dedicated resources, and adapting clinical workflows were identified as specific strategies needed to meet the current insomnia care needs of service members. Developing protocols for scaling the availability of CBTI expertise at diverse points of care, upstream from the sleep clinics, could accelerate access to care. Establishing standardized quality measures and processes across points of care, including for external providers and self-help apps, would enhance providers' confidence in the quality of insomnia care offered to service members.

Digital CBTI hubs as a treatment augmentation strategy in military clinics: study protocol for a pragmatic randomized clinical trial.

BACKGROUND: Chronic insomnia is the most prevalent sleep disorder among military service members, and it compromises readiness, performance, and physical and mental health. Cognitive behavioral treatment for insomnia (CBTI) is the standard of care for the treatment of insomnia recommended by the VA/DoD Clinical Practice Guideline, the American Academy of Sleep Medicine, and the American College of Physicians. CBTI is highly effective but has limited scalability. It is often unavailable in clinical settings where service members receive sleep care. Digital technologies offer unique opportunities to scale and broaden the geographic reach of CBTI services and support increased patient access and engagement in behavioral sleep care. This study aims to evaluate the impact and acceptability of digital CBTI hubs to augment military treatment facilities' capabilities in behavioral sleep medicine. METHODS: This is a multi-site, non-inferiority randomized clinical trial designed to compare the effects of in-person (face-to-face or virtual) insomnia care as usual at three military sleep clinics versus CBTI delivered remotely and asynchronously through digital CBTI hubs. Digital CBTI hubs are led by licensed, certified clinicians who use NOCTEM's® evidence-based clinical decision support platform COAST™ (Clinician Operated Assistive Sleep Technology). Changes in insomnia severity and daytime symptoms of depression and anxiety will be compared at baseline, at 6-8 weeks, and at 3-month follow-up. Patient satisfaction with insomnia care as usual versus digital CBTI hubs will also be examined. We hypothesize that digital CBTI hubs will be non-inferior to insomnia care as usual for improvements in insomnia and daytime symptoms as well as patient satisfaction with insomnia care. DISCUSSION: Digital technology has a high potential to scale CBTI accessibility and delivery options required to meet the insomnia care needs of military service members. Digital CBTI hubs using COAST offer a novel approach to broaden service members' access to CBTI and to serve as an augmentation strategy for existing sleep services at military treatment facilities. The pragmatic approach leveraging technology in this trial has the potential to rapidly inform clinical practice within the Defense Health Agency as well as other healthcare systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT05490550. Registered on 14 July 2023.

The use of telemedicine for the diagnosis and treatment of sleep disorders: an American Academy of Sleep Medicine update.

NONE: The COVID-19 pandemic led to widespread use of telemedicine and highlighted its importance in improving access to sleep care and advocating for sleep health. This update incorporates the lessons learned from such widespread utilization of telehealth to build on the American Academy of Sleep Medicine's 2015 position paper on the use of telemedicine for diagnosing and treating sleep disorders. Important key factors in this update include an emphasis on quality and value, privacy and safety, health advocacy through sleep telemedicine, and future directions.

Military Medicine Implements In-home Virtual Health in Europe.

OBJECTIVE: This report outlines a multispecialty implementation effort which included 12 specialty practices and 28 clinicians within Regional Health Command Europe (RHCE) and Landstuhl Regional Medical Center (LRMC) to pilot an in-home virtual health (VH) program using existing resources. METHODS AND MATERIALS: Synchronous VH encounters were performed using an Acano desktop conferencing client (Cisco Systems, Inc, San Jose, CA) and a USB web camera at the provider (distant) site and the patient's own computer or device in the home. A web real-time conferencing (Web RTC) server provided the connections. RESULTS: Between October 2016 and May 2018, 310 synchronous VH appointments to patients' homes in 23 geographic locations in 9 countries on 3 different continents were completed; 28 skill type I and II specialty providers at LRMC, SHAPE Belgium Army Health Clinic (AHC), and Vilseck AHC, Germany Primary Care Clinic participated. The providers represented 9 distinct specialties and primary care. Appointment types were as follows: 85 (39%) follow-up type appointments; 70 (32%) group type appointments; 65 (30%) initial specialty care appointments. The 3 most active clinics were Pediatric Gastroenterology with 88 (28%), the Nutrition Clinic with 82 (26%), and the Traumatic Brain Injury Clinic with 63 (20%) encounters. Full audio and video connectivity rate was 97%, excluding reconnects after dropped calls which occasionally occurred. Patient satisfaction scores were high 16/17 (94%) with 5% of patients surveyed. CONCLUSION: Low complexity synchronous VH appointments were successfully accomplished across a broad spectrum of health care services and appointment types. Landstuhl RMC specialists received consults from sites across a vast geographic area including Europe, the Middle East, and Africa. An in-home VH option gives providers a special tool to extend services far beyond traditional boundaries. This pilot project helped RHCE and LRMC providers gain valuable experience extending care to the home and will provide foundational knowledge for future VH efforts targeting groups and outcomes.