Association between a Recalled Positive Airway Pressure (PAP) Device and Incident Cancer: A Population-Based Study.

BACKGROUND: The real-world consequences of a Philips/Respironics recall for positive airway pressure (PAP) devices distributed between 2009 and 2021 are unknown. METHODS: We conducted a retrospective population-based study using health administrative databases (Ontario, Canada) on all new adult PAP users identified through the provincial funding system, free of cancer at baseline, who initiated (claimed) PAP treatment between 2012 and 2018. Everyone was followed from the PAP claim date to the earliest of incident cancer diagnosis, death, or the end of the follow-up (March 2022). We used inverse probability of treatment weighting to balance baseline characteristics between individuals on recalled devices and those on devices from other manufacturers. Weighted hazard ratios of incident cancer were compared between groups. RESULTS: Of 231 692 individuals identified, 58 204 (25.1%) claimed recalled devices, and 173 488 (74.9%) from other manufacturers. A meaningful baseline difference between groups (standardised difference≥0.10) was noted only by location-relevant covariates; other variables were mostly equally distributed (standardised differences≤0.06). Over a median follow-up of 6.3 years (IQR: 4.9-8.0), 11 166 (4.8%) developed cancer: unadjusted rates per 10 000 Person-Year (95 CI%) of 78.8 (76.0-81.7) in the recall group versus74.0 (72.4-75.6) in others (p=0.0034). Propensity score weighting achieved excellent balance in baseline characteristics between groups (standardised differences≤0.07). On a weighted sample, there was no statistical difference in the hazard of incident cancer between groups: cause-specific hazard ratio (recalled versus others) of 0.97, 95% CI: 0.89-1.06. CONCLUSION: In our real-world population study, compared to other manufacturers and adjusting for confounders, recalled devices do not appear to be independently associated with developing cancer.

Association of clinically significant obstructive sleep apnoea with risks of contracting COVID-19 and serious COVID-19 complications: a retrospective population-based study of health administrative data.

RATIONALE/OBJECTIVES: Despite plausible pathophysiological mechanisms, more research is needed to confirm the relationship between obstructive sleep apnoea (OSA) and the risk of COVID-19 infection or COVID-19-related serious complications. METHODS: We conducted a retrospective population-based cohort study using provincial health administrative data (Ontario, Canada). Adults with physician-diagnosed OSA who received positive airway pressure therapy in the 5 years prepandemic (OSA group) were propensity score matched by baseline characteristics to individuals in the general population at low risk of OSA (non-OSA group) using inverse probability of treatment weighting. Weighted HRs of (1) a positive COVID-19 test and (2) COVID-19-related emergency department (ED) visits, hospitalisations, intensive care unit (ICU) admissions and mortality, within 12 months of pandemic onset, were compared between groups. We also evaluated the impact of comorbid cardiometabolic or chronic airways disease. RESULTS: We identified and matched 324 029 individuals in the OSA group to 4 588 200 individuals in the non-OSA group. Compared with the non-OSA group, those in the OSA group were at a greater hazard of testing positive for COVID-19 (HR=1.17, 95% CI 1.13 to 1.21), having a COVID-19-related ED visit (HR=1.62, 95% CI 1.51 to 1.73), hospitalisation (HR=1.50, 95% CI 1.37 to 1.65) or ICU admission (HR=1.53, 95% CI 1.27 to 1.84). COVID-19-related 30-day mortality was not different (HR=0.98, 95% CI 0.82 to 1.16).We found that for the OSA group, comorbid airways disease but not cardiometabolic conditions increased the hazards of COVID-19-related outcomes, including mortality. CONCLUSION: In this large population-based study, we demonstrated that a recent diagnosis of OSA requiring treatment was associated with an increased hazard of testing positive for COVID-19 and serious COVID-19-related complications, particularly in those with co-existing chronic airways disease.

Description of a Multi-faceted COVID-19 Pandemic Physician Workforce Plan at a Multi-site Academic Health System.

BACKGROUND: The evolving COVID-19 pandemic has and continues to present a threat to health system capacity. Rapidly expanding an existing acute care physician workforce is critical to pandemic response planning in large urban academic health systems. INTERVENTION: The Medical Emergency-Pandemic Operations Command (MEOC)-a multi-specialty team of physicians, operational leaders, and support staff within an academic Department of Medicine in Calgary, Canada-partnered with its provincial health system to rapidly develop a comprehensive, scalable pandemic physician workforce plan for non-ventilated inpatients with COVID-19 across multiple hospitals. The MEOC Pandemic Plan comprised seven components, each with unique structure and processes. METHODS: In this manuscript, we describe MEOC's Pandemic Plan that was designed and implemented from March to May 2020 and re-escalated in October 2020. We report on the plan's structure and process, early implementation outcomes, and unforeseen challenges. Data sources included MEOC documents, health system, public health, and physician engagement implementation data. KEY RESULTS: From March 5 to October 26, 2020, 427 patients were admitted to COVID-19 units in Calgary hospitals. In the initial implementation period (March-May 2020), MEOC communications reached over 2500 physicians, leading to 1446 physicians volunteering to provide care on COVID-19 units. Of these, 234 physicians signed up for hospital shifts, and 227 physicians received in-person personal protective equipment simulation training. Ninety-three physicians were deployed on COVID-19 units at four large acute care hospitals. The resurgence of cases in September 2020 has prompted re-escalation including re-activation of COVID-19 units. CONCLUSIONS: MEOC leveraged an academic health system partnership to rapidly design, implement, and refine a comprehensive, scalable COVID-19 acute care physician workforce plan whose components are readily applicable across jurisdictions or healthcare crises. This description may guide other institutions responding to COVID-19 and future health emergencies.

Recruitment of patients with chronic kidney disease and obstructive sleep apnoea for a clinical trial.

Obstructive sleep apnoea is common in chronic kidney disease (CKD) and may accelerate the decline in kidney function. Recruitment for a randomised controlled trial to address whether treatment of sleep apnoea with continuous positive airway pressure (CPAP) slows the progression of kidney failure may be challenging because sleep apnoea is often asymptomatic in this patient population. The present report outlines recruitment challenges and how to address them. Adult patients with CKD were recruited for a 12-month randomised, controlled, non-blinded, parallel clinical trial to evaluate the impact of CPAP therapy on kidney function. Patients completed a home sleep apnoea test and those that met pre-specified sleep apnoea and nocturnal hypoxaemia severity criteria were randomised to receive CPAP or no therapy. Although 1,665 patients were eligible to participate in the study over 3 years, only 57 (3.4%) were ultimately randomised. The sequential reasons (and number of patients) for recruitment failure were: no show at clinic appointment (137), insufficient recruiters to approach every eligible patient (461), on therapy for sleep apnoea (122), unable to provide informed consent (67), refused consent (645), home sleep apnoea test not completed (47) or inclusion criteria not met (116), and declined pre-randomisation education session (12). Many challenges limit effective recruitment, which may be addressed by hiring additional recruiters and increasing the awareness of sleep apnoea among patients with CKD. These findings can be used to improve recruitment strategies and the design of future studies.

Effectiveness of a standardized electronic admission order set for acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Variation in hospital management of patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) may prolong length of stay, increasing the risk of hospital-acquired complications and worsening quality of life. We sought to determine whether an evidence-based computerized AECOPD admission order set could improve quality and reduce length of stay. METHODS: The order set was designed by a provincial COPD working group and implemented voluntarily among three physician groups in a Canadian tertiary-care teaching hospital. The primary outcome was length of stay for patients admitted during order set implementation period, compared to the previous 12 months. Secondary outcomes included length of stay of patients admitted with and without order set after implementation, all-cause readmissions, and emergency department visits. RESULTS: There were 556 admissions prior to and 857 admissions after order set implementation, for which the order set was used in 47%. There was no difference in overall length of stay after implementation (median 6.37 days (95% confidence interval 5.94, 6.81) pre-implementation vs. 6.02 days (95% confidence interval 5.59, 6.46) post-implementation, p = 0.26). In the post-implementation period, order set use was associated with a 1.15-day reduction in length of stay (95% confidence interval - 0.5, - 1.81, p = 0.001) compared to patients admitted without the order set. There was no difference in readmissions. CONCLUSIONS: Use of a computerized guidelines-based admission order set for COPD exacerbations reduced hospital length of stay without increasing readmissions. Interventions to increase order set use could lead to greater improvements in length of stay and quality of care.

Validity of administrative data for identification of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common condition associated with significant morbidity and health-care utilization. We determined the validity of an algorithm derived from administrative data for identifying OSA using the respiratory disturbance index (RDI) as the reference standard. We conducted a retrospective cohort study of adults in Alberta, Canada referred for facility and community-based sleep diagnostic testing between July 2005 and August 2007. Validity indices were estimated for several case definitions of OSA derived from outpatient physician billing claims and hospital discharge codes. For each algorithm, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated against several reference standards for OSA (RDI ≥ 5 h-1 , RDI ≥ 15 h-1 or RDI ≥ 30 h-1 ). For the 2149 patients included in the study, an algorithm requiring one hospital discharge code or two outpatient billing claims identifying OSA in a 2-year period had a sensitivity of 24.1%, specificity of 67.8%, PPV of 74.8% and NPV of 18.3% (reference standard RDI ≥ 5 h-1 ). When comorbidities were included in the case definition, the specificity was 90.5% and PPV was 83.3% (reference standard RDI ≥ 5 h-1 ). Similar findings were observed using RDI ≥ 15 h-1 and ≥30 h-1 as the reference standard. We identify a claims-based algorithm that identifies OSA with a high degree of specificity in patients referred for sleep diagnostic testing. This validated algorithm has a good PPV and may be useful when identifying patients with OSA for population studies within a single-payer health-care system.

Integrated versus fragmented implementation of complex innovations in acute health care.

BACKGROUND: Increased demand and escalating costs necessitate innovation in health care. The challenge is to implement complex innovations-those that require coordinated use across the adopting organization to have the intended benefits. PURPOSE: We wanted to understand why and how two of five similar hospitals associated with the same health care authority made more progress with implementing a complex inpatient discharge innovation whereas the other three experienced more difficulties in doing so. METHODOLOGY: We conducted a qualitative comparative case study of the implementation process at five comparable urban hospitals adopting the same inpatient discharge innovation mandated by their health care authority. We analyzed documents and conducted 39 interviews of the health care authority and hospital executives and frontline managers across the five sites over a 1-year period while the implementation was ongoing. FINDINGS: In two and a half years, two of the participating hospitals had made significant progress with implementing the innovation and had begun to realize benefits; they exemplified an integrated implementation mode. Three sites had made minimal progress, following a fragmented implementation mode. In the former mode, a semiautonomous health care organization developed a clear overall purpose and chose one umbrella initiative to implement it. The integrative initiative subsumed the rest and guided resource allocation and the practices of hospital executives, frontline managers, and staff who had bought into it. In contrast, in the fragmented implementation mode, the health care authority had several overlapping, competing innovations that overwhelmed the sites and impeded their implementation. PRACTICE IMPLICATIONS: Implementing a complex innovation across hospital sites required (a) early prioritization of one initiative as integrative, (b) the commitment of additional (traded off or new) human resources,

An observational study of the effectiveness of alternative care providers in the management of obstructive sleep apnea.

Alternative care providers have been proposed as a substitute for physician-based management of obstructive sleep apnea. The purpose of this study was to describe the clinical course of patients with a new diagnosis of obstructive sleep apnea who were treated with continuous positive airway pressure and followed by alternative care providers at a tertiary care sleep clinic. It was hypothesized that care by alternative care providers would result in improvement of daytime sleepiness and satisfactory treatment adherence, and that a specific number of follow-up visits could be identified after which clinical outcomes no longer improved. The Epworth Sleepiness Scale score was measured for each patient at baseline and at each alternative care provider visit. Patients were discharged when they demonstrated a significant improvement in sleepiness and were adherent to therapy. The Epworth Sleepiness Scale score decreased by 3.9 points from baseline to discharge. Patients with three or more visits required more follow-up time to achieve the same clinical improvement as those with only two visits. Continuous positive airway pressure adherence was comparable to previous studies of physician-led care and improved with ongoing alternative care provider follow-up. The current results suggest that clinical care by alternative care providers leads to continued improvements in sleepiness in patients with obstructive sleep apnea who are treated with continuous positive airway pressure, and that a minority of patients require longer follow-up to achieve a satisfactory clinical response to therapy.

Using patient flow simulation to improve access at a multidisciplinary sleep centre.

The lack of timely access to diagnosis and treatment for sleep disorders is well described, but little attention has been paid to understanding how multiple system constraints contribute to long waiting times. The objectives of this study were to identify system constraints leading to long waiting times at a multidisciplinary sleep centre, and to use patient flow simulation modelling to test solutions that could improve access. Discrete-event simulation models of patient flow were constructed using historical data from 150 patients referred to the sleep centre, and used to both examine reasons for access delays and to test alternative system configurations that were predicted by administrators to reduce waiting times. Four possible solutions were modelled and compared with baseline, including addition of capacity to different areas at the sleep centre and elimination of prioritization by urgency. Within the model, adding physician capacity improved time from patient referral to initial physician appointment, but worsened time from polysomnography requisition to test completion, and had no effect on time from patient referral to treatment initiation. Adding respiratory therapist did not improve model performance compared with baseline. Eliminating triage prioritization worsened time to physician assessment and treatment initiation for urgent patients without improving waiting times overall. This study demonstrates that discrete-event simulation can identify multiple constraints in access-limited healthcare systems and allow suggested solutions to be tested before implementation. The model of this sleep centre predicted that investments in capacity expansion proposed by administrators would not reduce the time to a clinically meaningful patient outcome.

The Cost-Effectiveness of Sleep Apnea Management: A Critical Evaluation of the Impact of Therapy on Health Care Costs.

TOPIC IMPORTANCE: OSA is a widespread condition that significantly affects both health and health-related quality of life (HRQoL). If left untreated, OSA can lead to accidents, decreased productivity, and medical complications, resulting in significant economic burdens including the direct costs of managing the disorder. Given the constraints on health care resources, understanding the cost-effectiveness of OSA management is crucial. A key factor in cost-effectiveness is whether OSA therapies reduce medical costs associated with OSA-related complications. REVIEW FINDINGS: Treatments for OSA have been shown to enhance HRQoL, particularly for symptomatic patients with moderate or severe disease. Economic studies also have demonstrated that these treatments are highly cost-effective. However, although substantial empirical evidence shows that untreated OSA is associated with increased medical costs, uncertainty remains about the impact of OSA treatment on these costs. Randomized controlled trials of positive airway pressure (PAP) therapy have failed to demonstrate cost reductions, but the studies have had important limitations. Observational studies suggest that PAP therapy may temper increases in costs, but only among patients who are highly adherent to treatment. However, the healthy adherer effect is an important potential source of bias in these studies. SUMMARY: OSA management is cost-effective, although uncertainties persist regarding the therapy's impact on medical costs. Future studies should focus on reducing bias, particularly the healthy adherer effect, and addressing other confounding factors to clarify potential medical cost savings. Promising avenues to further understanding include using quasiexperimental designs, incorporating more sophisticated characterization of OSA severity and symptoms, and leveraging newer technologies (eg, big data, wearables, and artificial intelligence).

Longer-term impacts of the COVID-19 pandemic on obstructive sleep apnoea (OSA)-related healthcare: a province-based study.

RATIONALE: Following marked reductions in sleep medicine care early in the COVID-19 pandemic, there is limited information about the recovery of these services. We explored long-term trends in obstructive sleep apnoea (OSA) health services and service backlogs during the pandemic compared with pre-pandemic levels in Ontario (the most populous province of Canada). METHODS: In this retrospective population-based study using Ontario (Canada) health administrative data on adults, we compared rates of polysomnograms (PSGs), outpatient visits and positive airway pressure (PAP) therapy purchase claims during the pandemic (March 2020 to December 2022) to pre-pandemic rates (2015-2019). We calculated projected rates using monthly seasonal time series auto-regressive integrated moving-average models based on similar periods in previous years. Service backlogs were estimated from the difference between projected and observed rates. RESULTS: Compared with historical data, all service rates decreased at first during March to May 2020 and subsequently increased. By December 2022, observed service rates per 100 000 persons remained lower than projected for PSGs (September to December 2022: 113 vs 141, 95% CI: 121 to 163) and PAP claims (September to December 2022: 50 vs 60, 95% CI: 51 to 70), and returned to projected for outpatient OSA visits. By December 2022, the service backlog was 193 078 PSGs (95% CI: 139 294 to 253 075) and 57 321 PAP claims (95% CI: 27 703 to 86 938). CONCLUSION: As of December 2022, there was a sustained reduction in OSA-related health services in Ontario, Canada. The resulting service backlog has likely worsened existing problems with underdiagnosis and undertreatment of OSA and supports the adoption of flexible care delivery models for OSA that include portable technologies.

Patient-reported Differences in Obstructive Sleep Apnea Care between Jurisdictions with and without Government Funding for Continuous Positive Airway Pressure.

Rationale: Funding for obstructive sleep apnea (OSA) treatment may impact how patients access care, wait times, and costs of care. Objectives: The aim of this study was to compare differences in diagnosis and treatment of OSA between Canadian jurisdictions with and without public funding for continuous positive airway pressure (CPAP). Methods: We administered an anonymous internet survey to Canadian adults reporting a physician diagnosis of OSA. Responses were categorized on the basis of whether the respondent's province provided full or partial funding for CPAP therapy for all patients. We assessed wait times for diagnosis and treatment, patient-borne costs, and model of care delivery compared between jurisdictions with and without universal CPAP funding. Results: We received 600 responses representing all Canadian provinces and territories. The median (interquartile range) age was 59 (49-66) years; 57% were male, and 21% were from rural settings. Patients living in provinces without public CPAP funding (n = 419) were more likely to be diagnosed using home sleep apnea testing (69% vs. 20%; P = 0.00019). Wait times were similar after adjustment for demographics, disease characteristics, and model of care. Although patient-borne costs of care were similar between jurisdictions, patients from regions without CPAP funding reported that cost had a greater influence on the choice of therapy. Sleep specialists were more commonly involved in OSA care in regions with CPAP funding. There was no difference in the current use of therapy between jurisdictions with and without public funding. Conclusions: This survey study demonstrates that public funding for CPAP therapy impacts how Canadians access OSA care but is not associated with differences in wait times or costs. Future research is required to determine the impact of different funding models for OSA care on clinical outcomes.

Temporal and Regional Trends in Obstructive Sleep Apnea Using Administrative Health Data in Alberta, Canada.

Rationale: Obstructive sleep apnea (OSA) is a common treatable condition with important health and societal consequences. Objectives: We aimed to assess the annual incidence and prevalence of clinically recognized and geographic clustering of OSA in Alberta, Canada, using administrative health data case definitions. Methods: We used two administrative health databases in Alberta to identify ICD-9 and ICD-10 (International Classification of Diseases, Ninth and 10th Revisions, respectively) diagnostic codes for adults and children at least 2 years old diagnosed with OSA between 2003 and 2020. We defined OSA using an algorithm developed and validated in Alberta: at least three claims or one hospitalization within 2 years. We mapped residential postal codes to 70 subregional health authorities (SRHAs). Crude, age group- and sex-specific incidence and prevalence, and age group- and sex-standardized rates were calculated for Alberta and SRHAs. Spatial scan statistics identified clusters of SRHAs in which OSA cases were higher (hot spots) or lower (cold spots) than expected. Results: Between 2003 and 2020, OSA prevalence increased from 0.14% to 4.59%. The annual incidence of OSA increased after 2013. Incidence and prevalence were higher in older adults and children aged 2-11 years compared with 12-17 years. Cluster analysis revealed regional variation in OSA incidence and prevalence over time with no consistent pattern except for cold spots in one large metropolitan center (Calgary). Conclusions: From 2003 to 2020, the incidence and prevalence of clinically recognized OSA increased but varied by geography. Administrative health data can be used to guide interventions aimed at improving health service delivery and the quality of OSA care.

Acceptance of and adherence with long-term positive airway pressure treatment in adults with chronic obstructive pulmonary disease: A systematic review protocol.

BACKGROUND: Long-term noninvasive positive airway pressure (PAP) treatment is effective treatment for sleep-related breathing disorders and chronic hypercarbic respiratory failure secondary to chronic obstructive pulmonary disease (COPD). PAP treatment may be delivered as continuous positive airway pressure or noninvasive ventilation. Success in initiating PAP treatment and barriers to its use in adult patients with COPD are largely unknown. This systematic review aims to identify the acceptance of and adherence to PAP treatment prescribed for long-term use in adult patients with COPD and to summarize variables associated with these measures. METHODS: Seven online electronic databases will be searched by an experienced medical librarian to identify records containing the concepts "obstructive airways disease" and "noninvasive positive airway pressure" and "acceptance" or "adherence". Randomized and non-randomized studies of interventions will be included. Citation lists from relevant articles will be reviewed, and experts will be contacted regarding unpublished studies. Abstracts from key conferences between 2018-2023 and Google Scholar search results will be reviewed for inclusion. Titles, abstracts and full texts will be reviewed independently for inclusion by two reviewers. Data extraction will be completed by one author using a pre-established form and primary outcomes confirmed by a second author. Methodological quality will be evaluated. If sufficient data are available for meta-analysis, a pooled summary statistic for the primary outcome will be calculated using a random-effects generic inverse-variance meta-analysis, weighted proportion or weighted medians-based approach. Subgroup analysis will explore clinically meaningful sources of heterogeneity. Variables that are associated with acceptance and adherence will be described. DISCUSSION: Long-term PAP treatment is a complex intervention prescribed to patients with COPD for several indications. Synthesis of the evidence on success with PAP treatment and variables associated with acceptance or adherence will inform program and policy development for supporting patients with COPD who are prescribed this therapy. TRIAL REGISTRATION: Systematic review registration: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on July 13, 2021 (registration number CRD42021259262), with revisions submitted on April 17, 2023.

Vaccines for all: A formative evaluation of a multistakeholder community-engaged COVID-19 vaccine outreach clinic for migrant communities.

Background: Racialized, low-income, and migrant populations experience persistent barriers to vaccines against COVID-19. These communities in East and Northeast Calgary were disproportionately impacted by COVID-19, yet faced vaccine access barriers. Diverse multi-stakeholder coalitions and community partnerships can improve vaccine outreach strategies, but how stakeholders perceive these models is unknown. Methods: We conducted a formative evaluation of a low-barrier, community-engaged vaccine outreach clinic in Calgary, Alberta, Canada, on June 5-6, 2021. We delivered an online post-clinic survey to clinic stakeholders, to assess whether the clinic achieved its collectively derived pre-specified goals (effective, efficient, patient-centered, and safe), to asses whether the clinic model was scalable, and to solicit improvement recommendations. Survey responses were analyzed using descriptive statistics and thematic analysis. Results: Overall, 166/195 (85%) stakeholders responded. The majority were from non-healthcare positions (59%), between 30 and 49 years of age (87/136; 64%), and self-identified as racialized individuals (96/136; 71%). Respondents felt the clinic was effective (99.2%), efficient (96.9%), patient-centered (92.3%), and safe (90.8%), and that the outreach model was scalable 94.6% (123/130). There were no differences across stakeholder categories. The open-ended survey responses supported the scale responses. Improvement suggestions describe increased time for clinic planning and promotion, more multilingual staff, and further efforts to reduce accessibility barriers, such as priority check-in for people with disabilities. Conclusion: Diverse stakeholders almost universally felt that this community-engaged COVID-19 vaccine outreach clinic achieved its goals and was scalable. These findings support the value of community-engaged outreach to improve vaccine equity among other marginalized newcomer communities.

Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study.

STUDY OBJECTIVES: To determine whether adherence to continuous positive airway pressure (CPAP) in adults with uncomplicated obstructive sleep apnea differs by rural vs urban residential address. METHODS: In this prospective cohort study, we recruited adults who initiated CPAP for uncomplicated obstructive sleep apnea that was diagnosed by a physician using sleep specialist-interpreted diagnostic testing. Participants were classified as urban (community size > 100,000) or rural (community size < 100,000) by translating residential postal code into geographic census area. The primary outcome was mean daily hours of CPAP use compared between rural and urban patients. Secondary outcomes included the proportion of patients who were adherent to CPAP, change in Epworth Sleepiness Scale score, change in EuroQOL-5D visual analog score, and Visit-Specific Satisfaction Instrument score. All outcomes were measured 3 months after CPAP initiation. RESULTS: We enrolled 242 patients (100 rural) with a mean (standard deviation) age of 51 (13) years and a respiratory event index of 24 (18) events/h. The mean (95% confidence interval) CPAP use was 3.19 (2.8-3.58) hours/night and 35% were CPAP-adherent, with no difference between urban and rural patients. Among the 65% of patients who were using CPAP at 3 months, the mean CPAP use was 4.89 (4.51-5.28) hours/night and was not different between rural and urban patients. Improvement in the Epworth Sleepiness Scale score and patient satisfaction was similar between groups, but the EuroQOL-5D score improved to a greater extent in rural patients. Urban or rural residence was not associated with CPAP adherence according to multivariable regression analysis. CONCLUSIONS: Rural vs urban residence was not associated with differences in CPAP adherence among patients with uncomplicated OSA diagnosed by a physician using specialist-interpreted sleep diagnostic testing. CITATION: Corrigan J, Tsai WH, Ip-Buting A, et al. Treatment outcomes among rural and urban patients with obstructive sleep apnea: a prospective cohort study. J Clin Sleep Med. 2022;18(4):1013-1020.

Impact of wait times for treatment on clinical outcomes in patients with obstructive sleep apnoea: protocol for a randomised controlled trial.

Background: Obstructive sleep apnoea (OSA) is a common chronic condition that is associated with significant morbidity and economic cost. Prolonged wait times are increasingly being recognised as a barrier to diagnosis and treatment of many chronic diseases; however, no study to date has prospectively evaluated the impact of wait times on health outcomes in OSA. Objective: The purpose of this study is to determine whether treatment outcomes for individuals with OSA differ between patients managed using an expedited versus standard pathway. Methods: A pragmatic randomised controlled trial design will be used with a target sample size of 200 adults. Participants with clinically significant uncomplicated OSA will be recruited through referrals to a large tertiary care sleep centre (Calgary, AB, Canada) and randomised to either early management (within 1 month) or usual care (∼6 months) with a 1:1 allocation using a concealed computer-generated randomisation sequence. The primary outcome will be adherence to positive airway pressure (PAP) therapy at 3 months after treatment initiation. Secondary outcomes will include change in sleepiness, quality of life, patient satisfaction, and patient engagement with therapy from baseline to 3 months after PAP initiation, measured using validated questionnaires and qualitative methods. Anticipated results: This study will determine whether expedited care for OSA leads to differences in PAP adherence and/or patient-reported outcomes. More broadly, the findings of this study may improve the understanding of how wait time reductions impact health outcomes for other chronic diseases.