Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement.

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

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.

Exploring the associations between shift work disorder, depression, anxiety and sick leave taken amongst nurses.

This study aimed to evaluate the association between shift work disorder and mental health in hospital-based nurses. Staff completed an online survey comprising demographic questions, the Shift Work Disorder Questionnaire, Patient Health-9 and the General Anxiety Disorder-7 scale. Sick leave data were collected from archival records from the Human Resources Department. Two hundred and two nurses (95% female; age M = 35.28 years ± SD = 12) participated (42% of eligible staff). Those at high risk of shift work disorder had higher depression (M = 7.54 ± SD = 4.28 vs. M = 3.78 ± SD = 3.24; p < 0.001) and anxiety (M = 5.66 ± SD = 3.82 vs. M = 2.83 ± SD = 3.33, p < 0.001) compared to those at low risk. Linear regression models showed that being at high risk of shift work disorder was the most significant predictor of depression, explaining 18.8% of the variance in depression (R2  = 0.188, adjusted R2  = 0.184, F(1, 200) = 46.20, p < 0.001). Shift work disorder combined with the number of night shifts and alcoholic drinks on non-work days accounted for 49.7% of the variance in anxiety scores (R2  = 0.497, adjusted R2  = 0.453, F(3, 35) = 11.51, p < 0.001). Mean sick leave in those with high risk of shift work disorder was 136.17 hr (SD = 113.11) versus 103.98 hr (SD = 94.46) in others (p = 0.057). Depression and years of shift work accounted for 18.9% of the variance in sick leave taken (R2  = 0.189, adjusted R2  = 0.180, F(2, 175) = 20.36, p < 0.001). Shift work disorder is strongly associated with depression and anxiety, providing a potential target to improve mental health in shift workers. Depression, in turn, is a significant contributing factor to sick leave.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial.

Importance: Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated. Objective: To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed. Design, Setting, and Participants: Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018. Interventions: Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51). Main Outcomes and Measures: Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS. Results: Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood). Conclusions and Relevance: In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.

Diagnostic accuracy of a two-stage model for detecting obstructive sleep apnoea in chronic tetraplegia.

BACKGROUND: Obstructive sleep apnoea (OSA) is highly prevalent in people with spinal cord injury (SCI). Polysomnography (PSG) is the gold-standard diagnostic test for OSA, however PSG is expensive and frequently inaccessible, especially in SCI. A two-stage model, incorporating a questionnaire followed by oximetry, has been found to accurately detect moderate to severe OSA (MS-OSA) in a non-disabled primary care population. This study investigated the accuracy of the two-stage model in chronic tetraplegia using both the original model and a modified version for tetraplegia. METHODS: An existing data set of 78 people with tetraplegia was used to modify the original two-stage model. Multivariable analysis identified significant risk factors for inclusion in a new tetraplegia-specific questionnaire. Receiver operating characteristic (ROC) curve analyses of the questionnaires and oximetry established thresholds for diagnosing MS-OSA. The accuracy of both models in diagnosing MS-OSA was prospectively evaluated in 100 participants with chronic tetraplegia across four international SCI units. RESULTS: Injury completeness, sleepiness, self-reported snoring and apnoeas were included in the modified questionnaire, which was highly predictive of MS-OSA (ROC area under the curve 0.87 (95% CI 0.79 to 0.95)). The 3% oxygen desaturation index was also highly predictive (0.93 (0.87-0.98)). The two-stage model with modified questionnaire had a sensitivity and specificity of 83% (66-93) and 88% (75-94) in the development group, and 77% (65-87) and 81% (68-90) in the validation group. Similar results were demonstrated with the original model. CONCLUSION: Implementation of this simple alternative to full PSG could substantially increase the detection of OSA in patients with tetraplegia and improve access to treatments. TRIAL REGISTRATION NUMBER: Results, ACTRN12615000896572 (The Australian and New Zealand Clinical Trials Registry) and pre-results, NCT02176928 (clinicaltrials.gov).

Physician Decision Making and Clinical Outcomes With Laboratory Polysomnography or Limited-Channel Sleep Studies for Obstructive Sleep Apnea: A Randomized Trial.

BACKGROUND: The clinical utility of limited-channel sleep studies (which are increasingly conducted at home) versus laboratory polysomnography (PSG) for diagnosing obstructive sleep apnea (OSA) is unclear. OBJECTIVE: To compare patient outcomes after PSG versus limited-channel studies. DESIGN: Multicenter, randomized, noninferiority study. (Australian New Zealand Clinical Trials Registry: ACTRN12611000926932). SETTING: 7 academic sleep centers. PARTICIPANTS: Patients (n = 406) aged 25 to 80 years with suspected OSA. INTERVENTION: Sleep study information disclosed to sleep physicians comprised level 1 (L1) PSG data (n = 135); level 3 (L3), which included airflow, thoracoabdominal bands, body position, electrocardiography, and oxygen saturation (n = 136); or level 4 (L4), which included oxygen saturation and heart rate (n = 135). MEASUREMENTS: The primary outcome was change in Functional Outcomes of Sleep Questionnaire (FOSQ) score at 4 months. Secondary outcomes included the Epworth Sleepiness Scale (ESS), the Sleep Apnea Symptoms Questionnaire (SASQ), continuous positive airway pressure (CPAP) compliance, and physician decision making. RESULTS: Change in FOSQ score was not inferior for L3 (mean difference [MD], 0.01 [95% CI, -0.47 to 0.49; P = 0.96]) or L4 (MD, -0.46 [CI, -0.94 to 0.02; P = 0.058]) versus L1 (noninferiority margin [NIM], -1.0). Compared with L1, change in ESS score was not inferior for L3 (MD, 0.08 [CI, -0.98 to 1.13; P = 0.89]) but was inconclusive for L4 (MD, 1.30 [CI, 0.26 to 2.35; P = 0.015]) (NIM, 2.0). For L4 versus L1, there was less improvement in SASQ score (-17.8 vs. -24.7; P = 0.018), less CPAP use (4.5 vs. 5.3 hours per night; P = 0.04), and lower physician diagnostic confidence (P = 0.003). LIMITATION: Limited-channel studies were simulated by extracting laboratory PSG data and were not done in the home. CONCLUSION: The results support manually scored L3 testing in routine practice. Poorer outcomes with L4 testing may relate, in part, to reduced physician confidence. PRIMARY FUNDING SOURCE: National Health and Medical Research Council and Repat Foundation.

Ambulatory management strategies for obstructive sleep apnea.

The prevalence of obstructive sleep apnea (OSA) has been steadily rising over recent decades and patient access to laboratory-based sleep services and specialist consultations have become increasingly limited, resulting in potential delays in treatment. As a result, there has been growing interest in the use of non-sleep laboratory methods for diagnosing and managing OSA, including the use of screening questionnaires, portable sleep monitoring devices, and home autotitrating continuous positive airway pressure. There is also evidence in support of a role for alternative health care professionals, such as sleep-trained nurses and primary care physicians in the diagnosis and treatment of OSA. In this review, we compare the different types of home monitoring devices, discuss the limitations of portable monitoring compared with full laboratory polysomnography, and summarize the results from published comparative effectiveness studies which have evaluated ambulatory models of care for the management of OSA. We also consider how future models of care that may be needed to deal with the burden of disease will evolve and some of the issues that prevent the translation of such models of care in many countries.

Diagnosis of obstructive sleep apnoea in primary care.

BACKGROUND: Obstructive sleep apnoea (OSA) is a highly prevalent condition associated with significant adverse health consequences affecting multiple organ systems. As the first point of contact for most patients with OSA, general practitioners (GPs) have an important role in the diagnosis of this common sleep disorder. OBJECTIVE: The aim of this paper is to improve awareness of common risk factors for and clinical presentation of OSA in primary care to improve patient health outcomes. We seek to understand how screening tools, such as the OSA50 questionnaire and the Epworth Sleepiness Scale, can help GPs identify patients who are at high risk for OSA with significant daytime sleepiness. DISCUSSION: Patients at high risk of symptomatic moderate-severe OSA should proceed to further investigation with sleep study testing. Referral to a sleep physician should be considered for patients with complex presentations or other suspected sleep disorders, commercial drivers, and those who fail to comply with or respond to initial OSA treatments.

Management of obstructive sleep apnoea in primary care.

BACKGROUND: Obstructive sleep apnoea (OSA) is common in the community and is increasing in prevalence. Primary care plays a pivotal role in the diagnosis and management of OSA. OBJECTIVE: This article focuses on the management options for a patient with an established diagnosis of OSA and provides a guide for driving licensing requirements. Indications for continuous positive airway pressure (CPAP) are discussed and tips provided to consider when conducting a review appointment, including trouble shooting. DISCUSSION: There are several treatment options available for patients with an established diagnosis of OSA. Selecting the optimal therapy involves aligning the symptoms and severity of OSA with the presence of comorbidities. CPAP is a highly effective therapy for symptomatic adults with moderate-to-severe OSA and for some symptomatic patients with mild OSA. Early trouble shooting of side effects and using supportive interventions increases the probability of long-term adherence, which is key to symptomatic improvement.

Management of Sleep-Disordered Breathing in a Spinal Cord Injury Rehabilitation Center: Model of Care Adaptation and Implementation.

Background: Obstructive sleep apnea (OSA) is highly prevalent and poorly managed in spinal cord injury (SCI). Alternative management models are urgently needed to improve access to care. We previously described the unique models of three SCI rehabilitation centers that independently manage uncomplicated OSA. Objectives: The primary objective was to adapt and implement a similar rehabilitation-led model of managing OSA in an SCI rehabilitation center in Australia. Secondary objectives were to identify the local barriers to implementation and develop and deliver tailored interventions to address them. Methods: A clinical advisory group comprised of rehabilitation clinicians, external respiratory clinicians, and researchers adapted and developed the care model. A theory-informed needs analysis was performed to identify local barriers to implementation. Tailored behavior change interventions were developed to address the barriers and prepare the center for implementation. Results: Pathways for ambulatory assessments and treatments were developed, which included referral for specialist respiratory management of complicated cases. Roles were allocated to the team of rehabilitation doctors, physiotherapists, and nurses. The team initially lacked sufficient knowledge, skills, and confidence to deliver the OSA care model. To address this, comprehensive education and training were provided. Diagnostic and treatment equipment were acquired. The OSA care model was implemented in July 2022. Conclusion: This is the first time a rehabilitation-led model of managing OSA has been implemented in an SCI rehabilitation center in Australia. We describe a theory-informed method of adapting the model of care, assessing the barriers, and delivering interventions to overcome them. Results of the mixed-methods evaluation will be reported separately.

Sleep apnea multi-level surgery trial: long-term observational outcomes.

STUDY OBJECTIVES: The sleep apnea multi-level surgery (SAMS) randomized clinical trial showed surgery improved outcomes at 6 months compared to ongoing medical management in patients with moderate or severe obstructive sleep apnea (OSA) who failed continuous positive airway pressure therapy. This study reports the long-term outcomes of the multi-level surgery as a case series. METHODS: Surgical participants were reassessed >2 years postoperatively with the same outcomes reported in the main SAMS trial. Primary outcomes were apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS), with secondary outcomes including other polysomnography measures, symptoms, quality of life, and adverse events. Long-term effectiveness (baseline to long-term follow-up [LTFU]) and interval changes (6 month to LTFU) were assessed using mixed effects regression models. Control participants were also reassessed for rate of subsequent surgery and outcomes. RESULTS: 36/48 (75%) of surgical participants were reevaluated (mean (standard deviation)) 3.5 (1.0) years following surgery, with 29 undergoing polysomnography. AHI was 41/h (23) at preoperative baseline and 21/h (18) at follow-up, representing persistent improvement of -24/h (95% CI -32, -17; p < 0.001). ESS was 12.3 (3.5) at baseline and 5.5 (3.9) at follow-up, representing persistent improvement of -6.8 (95% CI -8.3, -5.4; p < 0.001). Secondary outcomes were improved long term, and adverse events were minor. Interval change analysis suggests stability of outcomes. 36/43 (84%) of the control participants were reevaluated, with 25 (69%) reporting subsequent surgery, with symptom and quality of life improvements. CONCLUSION: Multi-level upper airway surgery improves OSA burden with long-term maintenance of treatment effect in adults with moderate or severe OSA in whom conventional therapy failed. CLINICAL TRIAL: Multi-level airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true; ACTRN12614000338662.

Ambulatory models of care for obstructive sleep apnoea: Diagnosis and management.

The high prevalence of obstructive sleep apnoea (OSA) and increasing awareness of its potential health consequences has placed significant pressure on laboratory-based sleep services leading to growing waiting lists and delays in diagnosis and treatment. Consequently, there has been increasing interest in the use of simplified, ambulatory models of care involving clinical prediction tools, portable sleep monitoring and home autotitrating continuous positive airway pressure. Researchers are also exploring the potential role for a wider range of health-care providers, including trained nurses and general practitioners, in the primary management of OSA. Recent randomized, controlled studies evaluating the clinical effectiveness of ambulatory management strategies versus traditional laboratory-based care for patients with OSA have consistently demonstrated that comparable patient outcomes can be achieved. The cost-effectiveness of these strategies is currently being debated, and further research examining the long-term economic implications of ambulatory models of care is needed.

Obstructive sleep apnoea in adults.

Obstructive sleep apnoea (OSA) is characterised by repetitive closure of the upper airway, repetitive oxygen desaturations and sleep fragmentation. The prevalence of adult OSA is increasing because of a worldwide increase in obesity and the ageing of populations. OSA presents with a variety of symptoms the most prominent of which are snoring and daytime tiredness. Interestingly though, a significant proportion of OSA sufferers report little or no daytime symptoms. OSA has been associated with an increased risk of cardiovascular disease, cognitive abnormalities and mental health problems. Randomised controlled trial evidence is awaited to confirm a causal relationship between OSA and these various disorders. The gold standard diagnostic investigation for OSA is overnight laboratory-based polysomnography (sleep study), however, ambulatory models of care incorporating screening questionnaires and home sleep studies have been recently evaluated and are now being incorporated into routine clinical practice. Patients with OSA are very often obese and exhibit a range of comorbidities, such as hypertension, depression and diabetes. Management, therefore, needs to be based on a multidisciplinary and holistic approach which includes lifestyle modifications. Continuous positive airway pressure (CPAP) is the first-line therapy for severe OSA. Oral appliances should be considered in patients with mild or moderate disease, or in those unable to tolerate CPAP. New, minimally invasive surgical techniques are currently being developed to achieve better patient outcomes and reduce surgical morbidity. Successful long-term management of OSA requires careful patient education, enlistment of the family's support and the adoption of self-management and patient goal-setting principles.

Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial.

IMPORTANCE: Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment. OBJECTIVE: To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. DESIGN, SETTING, AND PATIENTS: A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. INTERVENTIONS: Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only. MAIN OUTCOME AND MEASURES: The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was -2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs. RESULTS: There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P < .001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (P < .001). Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 (adjusted difference, -0.13; lower bound of 1-sided 95% CI, -1.5; P = .43). There were no differences in secondary outcome measures between groups. Seventeen patients (21%) withdrew from the study in the primary care group vs 6 patients (8%) in the specialist group. CONCLUSIONS AND RELEVANCE: Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000514303.

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.

Establishing the acute physiological and sleep disruption characteristics of wind farm versus road traffic noise disturbances in sleep: a randomized controlled trial protocol.

Study Objectives: Despite the global expansion of wind farms, effects of wind farm noise (WFN) on sleep remain poorly understood. This protocol details a randomized controlled trial designed to compare the sleep disruption characteristics of WFN versus road traffic noise (RTN). Methods: This study was a prospective, seven night within-subjects randomized controlled in-laboratory polysomnography-based trial. Four groups of adults were recruited from; <10 km away from a wind farm, including those with, and another group without, noise-related complaints; an urban RTN exposed group; and a group from a quiet rural area. Following an acclimation night, participants were exposed, in random order, to two separate nights with 20-s or 3-min duration WFN and RTN noise samples reproduced at multiple sound pressure levels during established sleep. Four other nights tested for continuous WFN exposure during wake and/or sleep on sleep outcomes. Results: The primary analyses will assess changes in electroencephalography (EEG) assessed as micro-arousals (EEG shifts to faster frequencies lasting 3-15 s) and awakenings (>15 s events) from sleep by each noise type with acute (20-s) and more sustained (3-min) noise exposures. Secondary analyses will compare dose-response effects of sound pressure level and noise type on EEG K-complex probabilities and quantitative EEG measures, and cardiovascular activation responses. Group effects, self-reported noise sensitivity, and wake versus sleep noise exposure effects will also be examined. Conclusions: This study will help to clarify if wind farm noise has different sleep disruption characteristics compared to road traffic noise.

Preferred Attributes of Care Pathways for Obstructive Sleep Apnoea from the Perspective of Diagnosed Patients and High-Risk Individuals: A Discrete Choice Experiment.

BACKGROUND: The current healthcare system is challenged with a large and rising demand for obstructive sleep apnoea (OSA) services. A paradigm shift in OSA management is required to incorporate the preferences of diagnosed patients and individuals at high risk of OSA. OBJECTIVES: This study aimed to provide empirical evidence of the values and preferences of individuals diagnosed with OSA and high-risk populations regarding distinct OSA care pathway features. METHODS: A discrete choice experiment was undertaken in two groups: those with a formal diagnosis of OSA (n = 421) and those undiagnosed but at high risk of having OSA (n = 1033). Participants were recruited from a large cross-sectional survey in Australia. The discrete choice experiment approach used mixed-logit regression models to determine preferences relating to eight salient features of the OSA management pathway, i.e. initial assessment provider, sleep study setting, diagnosis costs, waiting times, results interpretation, treatment options, provider of ongoing care and frequency of follow-up visits. RESULTS: The findings indicate that all eight attributes investigated were statistically significant factors for respondents. Generally, both groups preferred low diagnostic costs, fewer follow-up visits, minimum waiting time for sleep study results and sleep specialists to recommend treatment. Management of OSA in primary care was acceptable to both groups and was the most preferred option by the high-risk group for the initial assessment, sleep study testing and ongoing care provision. CONCLUSIONS: The discrete choice experiment results offer a promising approach for systematic incorporation of patient and high-risk group preferences into the future design and delivery of care pathways for OSA management.