Sequential Multilocus Repetitive Transcranial Magnetic Stimulation for Treatment of Tinnitus With and Without Comorbid Major Depressive Disorder.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) is a promising treatment for tinnitus, although outcomes are highly variable. We previously described a multilocus sequential rTMS treatment protocol for tinnitus involving stimulation of both prefrontal and auditory targets. In this study, we report results using this approach in an open-label treatment study of tinnitus with and without comorbid major depressive disorder (MDD). MATERIALS AND METHODS: Forty patients with chronic tinnitus (mean age 56 years, ten female) and with (n = 17) or without (n = 23) MDD received multilocus rTMS administered sequentially to 1) left dorsolateral prefrontal cortex, followed by 2) auditory cortex (Heschel's gyrus). Patients completed weekly self-report ratings using the Tinnitus Functional Index (TFI) and Tinnitus Handicap Inventory, and patients with MDD completed the Inventory of Depressive Symptomatology Self-Report 30-item. RESULTS: Patients showed significant mean improvement in tinnitus at sessions 5 (mean TFI improvement 6.8 points ± 12.2, p = 0.002) and 10 (mean improvement 9.2 points ± 14.1, p = 0.002), with 48% of patients responding within ten treatment sessions. Responders were significantly older than nonresponders (61.5 ± 15 years vs 51.3 ± 16 years), and there was a trend toward decreased likelihood of response in subjects with comorbid MDD compared with subjects without comorbidity (odds ratio = 0.28, p = 0.06). Patients with comorbid MDD reported significantly less improvement after ten sessions than did those with tinnitus alone (4.3 ± 10.3 vs 14.7 ± 15.0 points, p = 0.04). Post hoc analyses suggested that the comorbid group achieved improvement comparable to that of the tinnitus-only group after 30 treatments. CONCLUSIONS: Patients showed significant improvement in tinnitus from multilocus sequential rTMS treatment, and those with tinnitus alone improved more quickly. Those with depression who continued rTMS through a full 30-session course further improved, indicating that tinnitus with comorbid MDD may respond with extended treatment.

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.

BACKGROUND: Obstructive sleep apnea (OSA) is a very common and serious health condition which is highly prevalent among U.S. military Veterans. Because the demand for sleep medicine services often overwhelms the availability of such services, it is necessary to streamline diagnosis and treatment protocols. The goals of this study are to, (1) assess the efficacy of de-implementing the initial provider encounter for diagnosis and treatment of OSA; (2) determine the negative predictive value (NPV) of home sleep apnea testing (HSAT); (3) develop HSAT usage recommendations for various at-risk patient populations. METHODS: This is a large, pragmatic study that will take place in 3 VA sleep medicine programs: San Francisco, CA; Portland, OR; and Pittsburgh, PA. All Veterans referred for new sleep apnea evaluations at these sites will be included in this four-year study. Outcomes will include time from referral for OSA to sleep testing and treatment; positive airway pressure (PAP) treatment adherence measures; patient-reported clinical outcomes and measures of satisfaction; determination of the NPV of HSAT; HSAT usage recommendations for at-risk patient populations. DISCUSSION: The DREAM (Direct Referral for Apnea Monitoring) Project will inform sleep medicine providers and clinical organizations regarding strategies to streamline diagnosis and treatment protocols for OSA. Results of this study should have significant impact on clinical practices and professional guidelines. Trial registration The majority of this project is an observational study of clinical procedures. Therefore, clinical trial registration is not required.

A Prospective, Multicenter Study to Assess the Safety and Efficacy of Translingual Neurostimulation Plus Physical Therapy for the Treatment of a Chronic Balance Deficit Due to Mild-to-Moderate Traumatic Brain Injury.

OBJECTIVES: Translingual neurostimulation (TLNS) studies indicate improved outcomes in neurodegenerative disease or spinal cord injury patients. This study was designed to assess the safety and efficacy of TLNS plus targeted physical therapy (PT) in people with a chronic balance deficit after mild-to-moderate traumatic brain injury (mmTBI). MATERIALS AND METHODS: This international, multicenter, randomized study enrolled 122 participants with a chronic balance deficit who had undergone PT following an mmTBI and had plateaued in recovery. Randomized participants received PT plus either high-frequency pulse (HFP; n = 59) or low-frequency pulse (LFP; n = 63) TLNS. The primary efficacy and safety endpoints were the proportion of sensory organization test (SOT) responders (SOT composite score improvement of ≥15 points) and fall frequency after five weeks of treatment, respectively. RESULTS: The proportion of SOT responders was significant in the HFP + PT (71.2%) and LFP + PT (63.5%) groups compared with baseline (p < 0.0005). For the pooled population, the SOT responder rate was 67.2% (p < 0.00005), and there were clinically and statistically significant improvements in SOT composite scores after two and five weeks (p < 0.0005). Both groups had reductions in falls and headache disability index scores. Mean dynamic gait index scores in both groups also significantly increased from baseline at weeks 2 and 5. CONCLUSIONS: Significant improvements in balance and gait, in addition to headaches, sleep quality, and fall frequency, were observed with TLNS plus targeted PT; in participants who had a chronic balance deficit following an mmTBI and had plateaued on prior conventional physiotherapy.

MRI Verification of a 10-20 Targeting Protocol Used During Transcranial Magnetic Stimulation Sessions for Tinnitus.

Langguth et al. (2006) described a method for targeting primary auditory cortex (PAC) during transcranial magnetic stimulation (TMS) using the 10-20 electroencephalography system. Study aims were to measure the degree of accuracy in placing the TMS coil on the scalp overlying PAC using the 10-20 method and determine the extent to which accuracy depends on the hemisphere of the coil placement. Twelve participants underwent anatomical magnetic resonance imaging (MRI) of their head in a 3T scanner. Before imaging, a fiducial marker was placed on their scalp corresponding to the TMS coil position. MRI scans were analyzed to determine the distance from the fiducial marker to PAC for each participant. On average, the 10-20 method resulted in distances in the medial-lateral, anterior-posterior, and inferior-superior dimensions that were within a few millimeters (~ 4 mm) of each other between the left and right hemispheres. The fiducial marker was, on average, 10.4 mm superior and 10.8 mm posterior to the optimal scalp location that minimized the distance to PAC. Individual asymmetries and other systematic differences found in this study raise important considerations to keep in mind that might necessitate using an MRI-guided method of coil-positioning when targeting PAC for TMS.

Hearing impairment and tinnitus: prevalence, risk factors, and outcomes in US service members and veterans deployed to the Iraq and Afghanistan wars.

Hearing loss and tinnitus are the 2 most prevalent service-connected disabilities among veterans in the United States. Veterans of Operations Enduring Freedom, Iraqi Freedom, and New Dawn have been exposed to multiple hazards associated with these conditions, such as blasts/explosions, ototoxic chemicals, and most notably high levels of noise. We conducted a systematic literature review of evidence on 1) prevalence of, 2) risk and protective factors for, and 3) functional and quality-of-life outcomes of hearing impairment and tinnitus in US Operations Enduring Freedom, Iraqi Freedom, and New Dawn veterans and military personnel. We identified studies published from 2001 through 2013 using PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendation. Peer-reviewed English language articles describing studies of 30 or more adults were included if they informed one or more key questions. A total of 839 titles/abstracts were reviewed for relevance by investigators trained in critical analysis of literature; 14 studies met inclusion criteria. Of these, 13 studies presented data on prevalence and 4 on risk/protective factors, respectively. There were no included studies reporting on outcomes. Findings from this systematic review will help inform clinicians, researchers, and policy makers on future resource and research needs pertaining to hearing impairment and tinnitus in this newest generation of veterans.

Hearing loss associated with long-term exposure to high-speed dental handpieces.

The purpose of this study was to record and compare audiometric pure tone thresholds of dental clinicians (DCs), dental professionals (DPs), and dental students (DSs); determine the percentage of these groups who use hearing protection devices while at work in the clinic; and measure the sound intensities generated by a few representative high-speed handpieces while they are being used on patients. Participants included DCs who regularly used these handpieces (n = 16), DPs who did not use these handpieces (n = 13), and DSs (n = 8). A questionnaire was used to collect demographic information, assess occupational and recreational noise exposure, and note the level of hearing protection used. A sound level meter was used to measure the sound intensity generated by dental instruments near a clinician's ear. Results showed that DCs who regularly used high-speed handpieces had worse hearing than did members of the other study groups. These results indicate that the implementation of protective strategies should help to reduce the prevalence of occupational hearing loss among DCs.

History of Tinnitus Research at the VA National Center for Rehabilitative Auditory Research (NCRAR), 1997-2021: Studies and Key Findings.

The Veterans Affairs (VA) Rehabilitation Research & Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) was first funded by the RR&D Service in 1997 and has been funded continuously since that time. The overall purpose of the NCRAR is to "improve the quality of life of Veterans and others with hearing and balance problems through clinical research, technology development, and education that leads to better patient care" ( www.ncrar.research.va.gov ). An important component of the research conducted at the NCRAR has been a focus on clinical and rehabilitative aspects of tinnitus. Multiple investigators have received grants to conduct tinnitus research and the present article provides an overview of this research from the NCRAR's inception through 2021.

Unresolved Issues Associated with Transcranial Magnetic Stimulation (TMS) Treatment of Chronic Tinnitus.

Transcranial magnetic stimulation (TMS) has been investigated as a potential treatment for chronic tinnitus for 20 years. Numerous studies have reported that repetitive TMS (rTMS) has demonstrated efficacy for reducing the severity of tinnitus and its associated co-conditions such as depression, anxiety, and insomnia. However, some researchers have reported that active rTMS is no more effective than sham (placebo) rTMS as a tinnitus treatment method. There are numerous unresolved issues in this field that need to be addressed before rTMS can become a viable treatment for tinnitus. These issues include the type or brand of TMS system and its configuration; coil type, orientation, and placement method; scalp or neural target; laterality of rTMS application; dual site vs. single site stimulation; stimulation frequency and intensity; number of sessions; number of pulses per session; determination of the resting motor threshold (rMT); characteristics of the study population and their tinnitus; and outcome measures and follow-up assessments. To address and resolve these issues, large-scale, multi-site clinical trials of rTMS for tinnitus need to be conducted to determine which rTMS protocols are the most effective. In the absence of such investigations, the issues that need to be studied and addressed remain unresolved and continue to impede the clinical application of this treatment method.

Sleep disorders among rural Veterans: Relative prevalence, comorbidities, and comparisons with urban Veterans.

PURPOSE: To describe and compare demographic characteristics and comorbidities of rural and urban Veterans diagnosed with sleep disorders, and to evaluate whether rurality is a disparity for sleep care among Veterans. METHODS: Numbers of Veterans with sleep disorders and comorbid conditions were determined using the Department of Veterans Affairs (VA's) Corporate Data Warehouse, a database that contains detailed clinical information for all Veterans who receive VA health care. Comparisons between urban and rural Veterans were conducted for fiscal years (FY) 2010-2021. FINDINGS: The prevalence of diagnosed sleep disorders was similar among rural and urban Veterans from FY2010 to 2021 and increased for both groups during this time period. The prevalence of chronic pulmonary disease, congestive heart failure, and diabetes mellitus was higher for rural Veterans with sleep disorders compared to their urban counterparts. From 2012 to 2021, the percentage of rural Veterans who received sleep care at VA facilities was lower than the percentage of urban Veterans who received VA sleep care during the same time span. CONCLUSIONS: Although rural Veterans exhibited a higher prevalence of 3 comorbid conditions associated with sleep disorders, the prevalence of sleep disorder diagnoses was similar between rural and urban Veterans. Therefore, it is possible that sleep disorders are underdiagnosed among rural Veterans. The fact that rural Veterans received VA sleep care at a lower rate compared to urban Veterans indicates that rurality is a disparity in access to care in this population. VA is addressing this disparity through a variety of programs, including telehealth initiatives.

Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans.

STUDY OBJECTIVES: The Veterans Health Administration cares for many veterans with sleep disorders who live in rural areas. The Veterans Health Administration's Office of Rural Health funded the TeleSleep Enterprise-Wide Initiative (EWI) to improve access to sleep care for rural veterans through creation of national telehealth networks. METHODS: The TeleSleep EWI consists of (1) virtual synchronous care, (2) home sleep apnea testing, and (3) REVAMP (Remote Veterans Apnea Management Platform), a patient- and provider-facing web application that enabled veterans to actively engage with their sleep care and sleep care team. The TeleSleep EWI was designed as a hub-and-spoke model, where larger sites with established sleep centers care for smaller, rural sites with a shortage of providers. Structured formative evaluation for the TeleSleep EWI is supported by the Veterans Health Administration's Quality Enhancement Research Initiative and was critical in assessing outcomes and effectiveness of the program. RESULTS: The TeleSleep EWI launched with 7 hubs and 34 spokes (2017) and rapidly expanded to 13 hubs and 63 spokes (2020). The TeleSleep EWI resulted in a significant increase in rural veterans accessing sleep care by utilizing home sleep apnea testing to establish a diagnosis of obstructive sleep apnea and virtual care for follow-up. Rates of virtual care utilization were greater in hubs and spokes participating in the TeleSleep EWI compared with non-EWI sleep programs. Additionally, veterans expressed satisfaction with their virtual care TeleSleep experiences. CONCLUSIONS: The TeleSleep EWI successfully increased sleep care access for rural veterans, promoted adoption of virtual care services, and resulted in high patient satisfaction. CITATION: Chun VS, Whooley MA, Williams K, et al. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. J Clin Sleep Med. 2023;19(5):913-923.

Sustainment of the TeleSleep program for rural veterans.

Background: In fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities. Methods: In early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement. Results: 18 sites reported sustainment, while six were "on track." Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.

The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus.

OBJECTIVES: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. DESIGN: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1.Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent-constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2.Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. RESULTS: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions.In the final TFI, Cronbach's alpha was 0.97 and test-retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. CONCLUSIONS: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

Reevaluating the Use of Sound Therapy for Tinnitus Management: Perspectives on Relevant Systematic Reviews.

PURPOSE: Tinnitus is a highly prevalent condition that can severely reduce health functioning. In spite of extant clinical practice guidelines (CPGs), implementation of these CPGs is relatively uncommon. As a result, patients seeking professional services for tinnitus often have no assurance of receiving evidence-based care. The purpose of this tutorial was to clarify the evidence for sound therapy so that it may be included in future CPGs for tinnitus. METHOD: "Best clinical evidence" is obtained from high-quality systematic reviews, which are generally considered the highest level of evidence. Our review of recent, comprehensive, high-quality systematic reviews of interventions for tinnitus concludes that cognitive behavioral therapy is the only effective intervention, though the strength of evidence was generally rated as low in these reviews. Although trials of sound therapy for tinnitus have been included in these reviews, they have been rated as having high risk of bias (RoB) and not included in syntheses or rated as insufficient strength of evidence. RESULTS: Conclusions from these and other reviews have influenced recommendations made in CPGs for tinnitus. These conclusions, however, can make it appear that an intervention for tinnitus is not effective, even if the opposite is true. We contend that the strict inclusion criteria for these reviews are counterproductive and have the effect of obscuring decades of evidence demonstrating the clinical effectiveness of sound therapies for tinnitus. Ultimately, this process has resulted in many patients not receiving sound therapy, despite what should be sufficient evidence that this is an effective form of intervention. CONCLUSION: If we rely on systematic reviews using contemporary RoB assessment criteria for studies published prior to these reporting guidelines, then we risk excluding important conclusions regarding interventions that could help patients in need.

Electrophysiological Evidence of Auditory and Cognitive Processing Deficits in Parkinson Disease.

BACKGROUND: Parkinson's disease (PD) patients are at increased risk for central auditory processing (CAP) deficits and cognitive dysfunction. However, behavioral assessments of CAP and cognitive processing used in a previous study by our research team found few significant differences in performance between early-stage PD patients and age-matched control subjects. The objective of this study is to use auditory event-related potentials (AERPs) to compare CAP and cognitive functions in a population of PD patients with a group of age-matched control subjects. METHODS: AERPs in response to tonal and speech stimuli were recorded from 35 adults who had a medical diagnosis of PD (23 males and 12 females; mean age = 66.9 ± s.d.11.2 years), and 35 age-matched control subjects who did not have PD or any other neurological disorders (31 males and 4 females; mean age = 65.4 ± s.d.12.3 years). Auditory stimuli included pure tones (500 and 1000 Hz) to elicit the P300 response and a dichotic digits paradigm to elicit the N200 processing negativity. RESULTS: Compared to control subjects, PD patients exhibited significantly longer latencies of P300 and N200 components and smaller amplitude N200 components. Latency and amplitude of the N200 component were significantly correlated with participants' age. N200 amplitude was correlated with results from the Rey Auditory Verbal Learning Test (RAVLT) of cognitive ability. Latency of the P300 and amplitude of the N200 components were significantly correlated with results from the Spatial Release From Masking (SRM) behavioral CAP assessment. CONCLUSIONS: AERP assessments used in this study appear to be sensitive indicators of CAP and cognitive deficits exhibited by early-stage PD patients. While few significant differences in performance on behavioral CAP and cognitive tests were previously observed between this population of PD patients and age-matched control subjects, N200 and P300 components recorded in the present study revealed impaired neural processing by the PD group.

Hearing Health Care Utilization Following Automated Hearing Screening.

BACKGROUND: The study examined follow-up rates for pursuing hearing health care (HHC) 6 to 8 months after participants self-administered one of three hearing screening methods: an automated method for testing of auditory sensitivity (AMTAS), a four-frequency pure-tone screener (FFS), or a digits-in-noise test (DIN), with and without the presentation of a 2-minute educational video about hearing. PURPOSE: The study aims to determine if the type of self-administered hearing screening method (with or without an educational video) affects HHC follow-up rates. RESEARCH DESIGN: The study is a randomized controlled trial of three automated hearing screening methods, plus control group, with and without an educational video. The control group completed questionnaires and provided follow-up data but did not undergo a hearing screening test. STUDY SAMPLE: The study sample includes 1,665 participants (mean age 50.8 years; 935 males) at two VA Medical Centers and at university and community centers in Portland, OR; Bay Pines, FL; Minneapolis, MN; Mauston, WI; and Columbus, OH. DATA COLLECTION AND ANALYSIS: HHC follow-up data at 6 to 8 months were obtained by contacting participants by phone or mail. Screening methods and participant characteristics were compared in relation to the probability of participants pursuing HHC during the follow-up period. RESULTS: The 2-minute educational video did not have a significant effect on HHC follow-up rates. When all participants who provided follow-up data are considered (n = 1012), the FFS was the only test that resulted in a significantly greater percentage of HHC follow-up (24.6%) compared with the control group (16.8%); p = 0.03. However, for participants who failed a hearing screening (n = 467), follow-up results for all screening methods were significantly greater than for controls. The FFS resulted in a greater probability for HHC follow-up overall than the other two screening methods. Moreover, veterans had higher follow-up rates for all screening methods than non-veterans. CONCLUSION: The FFS resulted in a greater HHC follow-up rate compared with the other screening methods. This self-administered test may be more motivational for HHC follow-up because participants who fail the screening are aware of sounds they could not hear which does not occur with adaptive assessments like AMTAS or the DIN test. It is likely that access to and reduced personal cost of audiological services for veterans contributed to higher HHC follow-up rates in this group compared with non-veteran participants.

Barriers and facilitators to the implementation of a novel web-based sleep apnea management platform.

STUDY OBJECTIVE: Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disorder affecting US military Veterans. The Remote Veterans Apnea Management Platform (REVAMP) is a web-based OSA management program created to improve access to care. REVAMP was launched within the Veterans Health Administration (VHA) in July 2017, with variable patient recruitment rates (from 0 to 573 patients per site) at the first 10 Veterans Affairs (VA) medical centers (Wave-1 sites). This study aimed to examine the contextual circumstances surrounding the implementation of REVAMP from the provider perspective to inform strategies to increase its uptake at future rollout sites. METHODS: A purposive sample of REVAMP site leaders from the Wave-1 sites was recruited with additional staff members being solicited as well. Semi-structured interviews were conducted. Two independent coders reviewed individual transcripts using content analysis to identify emerging themes. RESULTS: Fifteen individuals from Wave-1 sites were interviewed. Implementation of REVAMP was facilitated by the presence of leadership support, staff, and time dedicated to REVAMP, and perceived usefulness of REVAMP by staff as well as positive feedback from the Veterans using REVAMP. The difficulty of supporting Veteran creation of login credentials to the program and integrating REVAMP into the existing workflow were major barriers to its implementation. CONCLUSION: Improving leadership engagement, simplifying the enrollment process, and enhancing the medical staff experience through shared best practice alerts were identified as actions needed to improve the penetration of REVAMP at future rollout sites.

Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs.

BACKGROUND: Computer-based documentation (CBD) is used commonly throughout the world to track patient care and clinical workloads. However, if capture of clinical services within the electronic health record (EHR) is not implemented properly, patient care services and workload credit will be inaccurate, which impacts business decisions related to demand for care and resources allocated to meet the demand. Understaffing of medical personnel can contribute to delays in treatment, missed treatments, and workforce turnover. OBJECTIVE: To illustrate the impact of CBD procedures on health care workload assessment and resource allocation, this article uses data from the US Department of Veterans Affairs Corporate Data Warehouse to provide examples from the Veterans Health Administration (VHA) sleep medicine programs. DISCUSSION: Inaccurate CBD led to underreporting of sleep medicine services provided at VHA facilities nationwide and contributed to insufficient allocation of resources and personnel. Recent modifications in CBD protocols (Stop Codes) improved the accuracy of data capture and reporting while providing VHA sleep programs with data they can use to advocate for workforce expansion to meet patient care needs. CONCLUSIONS: Inaccurate CBD of clinical workloads can result in inadequate allocation of health care personnel and resources to meet the needs of patients. Untreated sleep disorders are associated with increased risk of depression, anxiety, impaired neurocognitive functions, cardiovascular disease, motor vehicle accidents, and premature death. Educating health care providers and administrators on the importance of accurate designation of clinical services within the EHR is necessary to facilitate improvements in health care availability and delivery.

Prevalence and management of sleep disorders in the Veterans Health Administration.

The prevalence of diagnosed sleep disorders among Veterans treated at Veterans Affairs (VA) medical facilities increased significantly during fiscal years (FY) 2012 through 2018. Specifically, the prevalence of sleep-related breathing disorders (SRBD) increased from 5.5% in FY2012 to 22.2% in FY2018, and the prevalence of insomnia diagnoses increased from 7.4% in FY2012 to 11.8% in FY2018. Consequently, Veterans' demand for sleep medicine services also increased significantly between FY2012-2018, with steady increases in the annual number of VA sleep clinic appointments during this period (<250,000 in FY 2012; >720,000 in FY2018). Common co-morbid conditions among Veterans diagnosed with sleep disorders include obesity, diabetes, congestive heart failure, depression, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). To address this healthcare crisis, the Veterans Health Administration (VHA) developed and/or implemented numerous innovations to improve the quality and accessibility of sleep care services for Veterans. These innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans' access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and CBT-i Coach; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.

Enhancing Screening Systems to Facilitate Hearing-Healthcare Access: A Qualitative Study.

BACKGROUND: Although hearing loss is a common health issue, hearing healthcare (HHC) is poorly accessed. Screening to identify hearing loss is an important part of HHC access, specifically for those who screen positive for hearing loss and would benefit from seeing a HHC provider. New technologies can be automated to provide information and recommendations that are tailored to the needs of individual users, potentially enhancing rates of HHC access after positive screens. A greater understanding of the facilitators of postscreening HHC access that could be leveraged in such systems is needed. PURPOSE: The purpose of this project was to identify facilitators of postscreening HHC access that can be used in automated screening systems. RESEARCH DESIGN: This qualitative study used focus groups (FGs) to understand perceived barriers, perceived benefits, and potential cues to action, as informed by the Health Belief Model, for accessing HHC after use of automated hearing screening systems. STUDY SAMPLE: Fifty individuals participated in one of seven FGs. FGs were conducted separately with three types of stakeholders: four FGs included adults who reported some degree of perceived hearing loss and had recently completed a hearing screening; two FGs included adults who had recently sought HHC for the first time because of hearing loss; and one FG involved significant others/family members of individuals with hearing loss. DATA COLLECTION AND ANALYSIS: FGs were 60-90 minutes in length and were led by a trained facilitator following a discussion guide. A research audiologist was present at each FG and served as a notetaker. FGs were recorded and transcribed by research team members, and transcripts were then coded in an iterative process by multiple team members. Qualitative content analysis was used to reduce data and to identify salient themes and subthemes, following an inductive approach. We focused on identifying themes that were related to facilitators of HHC access after positive screens for hearing loss and, separately, potential enhancements to automated hearing screening systems that would leverage these facilitators to improve HHC access. RESULTS: We identified five key themes related to HHC access after a positive screen for hearing loss, along with ideas for enhancing automated hearing screening systems based on these themes. The themes included knowledge, trust, access, quality of life, and interpersonal influence. CONCLUSIONS: The results of our work help inform the development of innovative hearing screening systems that can be automated to leverage individual facilitators of HHC access.

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program.

STUDY OBJECTIVES: (1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand. METHODS: PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse. RESULTS: Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014. CONCLUSIONS: Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions. CITATION: Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.