Impact of mail-based continuous positive airway pressure initiation on treatment usage and effectiveness.

PURPOSE: In-person visits with a trained therapist have been standard care for patients initiating continuous positive airway pressure (CPAP). These visits provide an opportunity for hands-on training and an in-person assessment of mask fit. However, to improve access, many health systems are shifting to remote CPAP initiation with equipment mailed to patients. While there are potential benefits of a mailed approach, relative patient outcomes are unclear. Specifically, many have concerns that a lack of in-person training may contribute to reduced CPAP adherence. To inform this knowledge gap, we aimed to compare treatment usage after in-person or mailed CPAP initiation. METHODS: Our medical center shifted from in-person to mailed CPAP dispensation in March 2020 during the COVID-19 pandemic. We assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP in the months before (n = 433) and after (n = 186) this shift. We compared 90-day adherence between groups. RESULTS: Mean nightly PAP usage was modest in both groups (in-person 145.2, mailed 140.6 min/night). We did not detect between-group differences in either unadjusted or adjusted analyses (adjusted difference - 0.2 min/night, 95% - 27.0 to + 26.5). CONCLUSIONS: Mail-based systems of CPAP initiation may be able to improve access without reducing CPAP usage. Future work should consider the impact of mailed CPAP on patient-reported outcomes and the impact of different remote setup strategies.

Participant Characteristics and Attendance Patterns for a Multispecialty Veterans Affairs ECHO Program 2012-2018.

Introduction: The Veteran Integrated Service Network (VISN) 20 Veterans Affairs-Extension for Community Healthcare Outcomes (VA-ECHO) program connects specialty and primary care providers (PCPs) across large geographic areas, utilizing video-teleconferencing with the intention of increasing access to care among underserved and isolated populations. No previously published work describes participation patterns of a multispecialty ECHO program. We describe the development of VISN 20 VA-ECHO program to inform the design and evaluation of ECHO programs. Methods: The participant cohort included VA-affiliated licensed health care professionals, including trainees, who attended at least one VISN 20 VA-ECHO session between April 2012 and December 2018. Participant characteristics reported include gender, clinical location, clinical specialty, discipline, and rurality. Results: Over the 6-year time frame, VISN 20 VA-ECHO offered 945 sessions in 14 clinical specialties and recorded 17,893 hours of attendance. The cohort included 1,346 participants, 74.3% of whom were female, 85.2% employed in medical centers, and 40.7% affiliated with primary care. Most participants (62.3%) attended one specialty exclusively; among all participants, 40% attended five or more sessions. Discussion: Although VA-ECHO was implemented to develop single specialty expertise among PCPs, our participant cohort represented a more diverse audience from a range of disciplines and specialties. Our experience may be valuable to other teams implementing ECHO programs. Conclusions: Through adaptability and strategies that actively promoted inclusion of a diverse audience, VISN 20 VA-ECHO expanded to include multiple clinical specialties and successfully engaged an audience across a large geographic area and beyond PCPs.

Practical implementation of noninvasive ventilation in Amyotrophic Lateral Sclerosis: lessons learned from a clinical case series.

PURPOSE: Noninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population. METHODS: We created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year. RESULTS: We present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days). CONCLUSIONS: Our RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.

Assessment of Obstructive Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease in Primary Care.

Study Objectives: Observational studies link untreated obstructive sleep apnea (OSA) with adverse outcomes in chronic obstructive pulmonary disease (COPD). The first step in addressing OSA is a clinical assessment. However, given competing demands and a lack of high-quality evidence, it is unclear how often such assessments occur. We explored the documentation of OSA assessment among patients with COPD in primary care, and the patient and provider characteristics associated with these assessments. Methods: We conducted a cross-sectional study of patients with clinically diagnosed COPD at 2 primary care practices. We abstracted charts to determine whether providers assessed OSA, defined as documentation of symptoms, treatment, or a referral to sleep medicine. We performed multivariable mixed-effects logistic regression to assess the associations of patient and provider characteristics with OSA assessment. Results: Among 641 patients with clinically diagnosed COPD, 146 (23%) had OSA assessed over a 1-year period. Positive associations with OSA assessment included body mass index ≥ 30 (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-7.0), pulmonary subspecialist visits (OR 3.9, 95%CI 2.4-6.3), and a prior sleep study demonstrating OSA documented within the electronic medical record (OR 18.0, 95%CI 9.0-35.8). Notably, patients identifying as Black were less likely to have OSA assessed than those identifying as White (OR 0.5, 95%CI 0.2-0.9). Conclusions: Providers document an assessment of OSA among a quarter of patients with COPD. Our findings highlight the importance of future work to rigorously test the impact of assessment on important health outcomes. Our findings also reinforce that additional strategies are needed to improve the equitable delivery of care.

Risks of Zolpidem among Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Nonbenzodiazepine benzodiazepine receptor agonists (NBZRA, e.g., zolpidem) are frequently used to treat insomnia among patients with chronic obstructive pulmonary disease (COPD). However, multiple observational studies find that patients with COPD who are prescribed NBZRAs have greater risks for mortality and respiratory complications than patients without such prescriptions. Without an active comparator, these studies are susceptible to confounding by indication. Objectives: Compare the risk of death or inpatient COPD exacerbation among patients receiving zolpidem relative to patients receiving other hypnotics. Methods: Using nationwide Veterans Health Administration (VA) data, we identified patients with clinically diagnosed COPD and new receipt of zolpidem or another hypnotic available on VA formulary without prior authorization (melatonin, trazodone, doxepin). We excluded those receiving traditional benzodiazepines or multiple concurrent hypnotics. We propensity-matched patients receiving zolpidem to other hypnotics on 32 variables, including demographics, comorbidities, and markers of COPD severity. We compared risk of the primary composite outcome of death or inpatient COPD exacerbation over 1 year. In secondary analyses, we propensity-matched patients receiving zolpidem to those without hypnotic receipt. Results: Among 283,740 patients meeting inclusion criteria, 1,126 (0.4%) received zolpidem and 3,057 (1.1%) received other hypnotics. We propensity-matched patients receiving zolpidem 1:1 to peers receiving other hypnotics. We did not find a difference in the primary composite outcome of death or inpatient exacerbation (hazard ratio, 0.97; 95% confidence interval [CI], 0.77-1.23). In secondary analyses comparing patients receiving zolpidem to matched peers without hypnotic receipt, we observed greater risk of death or inpatient exacerbation with zolpidem (hazard ratio, 1.40; 95% CI, 1.09-1.81). Conclusions: Among patients with COPD, we did not observe greater risks after new receipt of zolpidem relative to other hypnotics. However, we did observe greater risks relative to those without hypnotic receipt. This latter finding may reflect: 1) residual, unmeasured confounding related to insomnia; or 2) true adverse effects of hypnotics across classes. Future work is needed to better understand the risks of hypnotics in COPD.

Improving adherence to PAP therapy: A brief PAP coaching intervention for health care providers.

Objectives: To evaluate a training program for non-specialist health care providers in a brief coaching intervention to improve positive airway pressure (PAP) usage in Veterans with sleep apnea. Methods: We conducted a national webinar training designed for non-specialist providers to implement a brief telephone coaching intervention to improve PAP adherence. The curriculum was crafted by experts in sleep medicine and behavioral sleep medicine based on principles of PAP desensitization. Providers who participated in this training were asked to complete evaluations at 30 days and 1 year. Results: Provider surveys indicated that most respondents had incorporated the intervention into their clinical practice and felt comfortable counseling patients about sleep apnea and adherence to PAP. Provider feedback suggested that future training programs should include refresher trainings, more training on PAP equipment specifics, and facilitated collaboration with local sleep medicine staff. Conclusions: This pilot training program demonstrated that a webinar format was a feasible method to increase training in PAP adherence among non-specialist health care providers. Innovation: Non-specialists can be trained as PAP coaches in webinar format, improving patients' access to effective strategies and support to be successful with PAP therapy.

Sleep Testing and Mortality in a Propensity-matched Cohort of Patients with Chronic Obstructive Pulmonary Disease.

Rationale: Many advocate the application of propensity-matching methods to real-world data to answer key questions around obstructive sleep apnea (OSA) management. One such question is whether identifying undiagnosed OSA impacts mortality in high-risk populations, such as those with chronic obstructive pulmonary disease (COPD). Objectives: Assess the association of sleep testing with mortality among patients with COPD and a high likelihood of undiagnosed OSA. Methods: We identified patients with COPD and a high likelihood of undiagnosed OSA. We then distinguished those receiving sleep testing within 90 days of index COPD encounters. We calculated propensity scores for testing based on 37 variables and compared long-term mortality in matched groups. In sensitivity analyses, we compared mortality using inverse propensity weighting and instrumental variable methods. We also compared the incidence of nonfatal events including adverse outcomes (hospitalizations and COPD exacerbations) and routine services that are regularly indicated in COPD (influenza vaccination and pulmonary function testing). We compared the incidence of each nonfatal event as a composite outcome with death and separately compared the marginal probability of each nonfatal event independently, with death as a competing risk. Results: Among 135,958 patients, 1,957 (1.4%) received sleep testing. We propensity matched all patients with sleep testing to an equal number without testing, achieving excellent balance on observed confounders, with standardized differences < 0.10. We observed lower mortality risk among patients with sleep testing (incidence rate ratio, 0.88; 95% confidence interval [CI], 0.79-0.99) and similar results using inverse propensity weighting and instrumental variable methods. Contrary to mortality, we found that sleep testing was associated with a similar or greater risk for nonfatal adverse events, including inpatient COPD exacerbations (subhazard ratio, 1.29; 95% CI, 1.02-1.62) and routine services like influenza vaccination (subhazard ratio, 1.26; 95% CI, 1.17-1.36). Conclusions: Our disparate findings can be interpreted in multiple ways. Sleep testing may indeed cause both reduced mortality and greater incidence of nonfatal adverse outcomes and routine services. However, it is also possible that our findings stem from residual confounding by patients' likelihood of accessing care. Given the limitations of propensity-based analyses, we cannot confidently distinguish these two possibilities. This uncertainty highlights the limitations of using propensity-based analyses to guide patient care and policy decisions.

Staff Experiences with a Team-based Approach to Sleep Medicine Referrals: A Qualitative Evaluation.

Rationale: Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. To manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. Although prior work shows that the RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. Objectives: To assess staff experiences with a team-based approach to sleep medicine referrals. Methods: From June 2019 to September 2020, we conducted semistructured interviews with staff members who interacted with the RCI in sleep medicine. We recruited a variety of staff, including RCI team members (nurses and medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. Results: We conducted 48 interviews among 35 unique staff members and identified six themes: 1) efficiency, in which staff described the impacts of the RCI program regarding efficient use of staff time and resources; 2) patient access and experience, in which staff noted improvements to patients' ability to receive care; 3) staff well-being and satisfaction, in which specialists and RCI staff described how the RCI mitigated the adverse impact of triage volume on staff well-being; 4) sharing specialty knowledge, in which nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage; 5) nurse autonomy, in which staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy; and 6) coordination and communication, in which staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. Conclusions: Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff well-being.

Impact of Sleep Telementorship in Primary Care: Sleep VA-ECHO (Veterans Affairs-Extension for Community Healthcare Outcomes).

Sleep VA-ECHO (Veterans Affairs-Extension for Community Healthcare Outcomes) is a national telementorship program intended to improve knowledge about sleep disorders among non-specialty providers. The project goal was to describe the characteristics of Sleep VA-ECHO participants from primary care and their use of program-obtained knowledge in practice. Sleep VA-ECHO consisted of 10 voluntary, 75-min teleconference sessions combining didactics and case discussion. Out of 86 participants, 21 self-identified as primary care team members and completed a program evaluation. Participants self-reported their application of knowledge gained, including changes to practice as a result of program participation. These 21 participants represented 18 sites in 11 states and attended a median of 5.0 sessions. They included physicians (29%), nurse practitioners (24%), and registered nurses (24%). Nearly all participants (95%) reported using acquired knowledge to care for their own patients at least once a month; 67% shared knowledge with colleagues at least once a month. Eighty-five percent reported improved quality of sleep care for their patients, and 76% reported an expanded clinical skillset. The greatest self-reported change in practice occurred in patient education about sleep disorders (95%) and non-pharmacologic management of insomnia (81%).

Nurse-led triage of new sleep referrals is associated with lower risk of potentially contraindicated sleep testing: a retrospective cohort study.

BACKGROUND: The volume of specialty care referrals often outstrips specialists' capacity. The Department of Veterans Affairs launched a system of referral coordination to augment our workforce, empowering registered nurses to use decision support tools to triage specialty referrals. While task shifting may improve access, there is limited evidence regarding the relative quality of nurses' triage decisions to ensure such management is safe. OBJECTIVE: Within the specialty of sleep medicine, we compared receipt of contraindicated testing for obstructive sleep apnoea (OSA) between patients triaged to sleep testing by nurses in the referral coordination system (RCS) relative to our traditional specialist-led system (TSS). METHODS: Patients referred for OSA evaluation can be triaged to either home sleep apnoea testing (HSAT) or polysomnography, and existing guidelines specify patients for whom HSAT is contraindicated. In RCS, nurses used a decision support tool to make triage decisions for sleep testing but were instructed to seek specialist oversight in complex cases. In TSS, specialists made triage decisions themselves. We performed a single-centre retrospective cohort study of patients without OSA who were referred to sleep testing between September 2018 and August 2019. Patients were assigned to triage by RCS or TSS in quasirandom fashion based on triager availability at time of referral. We compared receipt of contraindicated sleep tests between groups using a generalised linear model adjusted for day of the week and time of day of referral. RESULTS: RCS triaged 793 referrals for OSA evaluation relative to 1787 by TSS. Patients with RCS triages were at lower risk of receiving potentially contraindicated sleep tests relative risk 0.52 (95% CI 0.29 to 0.93). CONCLUSION: Our results suggest that incorporating registered nurses into triage decision-making may improve the quality of diagnostic care for OSA.

Disparities in Sleep Health and Potential Intervention Models: A Focused Review.

Disparities in sleep health are important but underrecognized contributors to health disparities. Understanding the factors contributing to sleep heath disparities and developing effective interventions are critical to improving all aspects of heath. Sleep heath disparities are impacted by socioeconomic status, racism, discrimination, neighborhood segregation, geography, social patterns, and access to health care as well as by cultural beliefs, necessitating a cultural appropriateness component in any intervention devised for reducing sleep health disparities. Pediatric sleep disparities require innovative and urgent intervention to establish a foundation of lifelong healthy sleep. Tapping the vast potential of technology in improving sleep health access may be an underutilized tool to reduce sleep heath disparities. Identifying, implementing, replicating, and disseminating successful interventions to address sleep disparities have the potential to reduce overall disparities in health and quality of life.

Patient experiences with telehealth in sleep medicine: a qualitative evaluation.

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients' experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645-1651.

Agreement of sleep specialists with registered nurses' sleep study orders in supervised clinical practice.

STUDY OBJECTIVES: Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. METHODS: Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. RESULTS: Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74-0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). CONCLUSIONS: More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes.

Poor Outcomes Among Patients With Chronic Obstructive Pulmonary Disease With Higher Risk for Undiagnosed Obstructive Sleep Apnea in the LOTT Cohort.

STUDY OBJECTIVES: Evaluate consequences of intermediate to high risk of undiagnosed obstructive sleep apnea (OSA) among individuals with chronic obstructive pulmonary disease (COPD). METHODS: Using data from the Long Term Oxygen Treatment Trial (LOTT), we assessed OSA risk at study entry among patients with COPD. We compared outcomes among those at intermediate to high risk (modified STOP-BANG score ≥ 3) relative to low risk (score < 3) for OSA. We compared risk of mortality or first hospitalization with proportional hazard models, and incidence of COPD exacerbations using negative binomial regression. We adjusted analyses for demographics, body mass index, and comorbidities. Last, we compared St. George Respiratory Questionnaire and Quality of Well-Being Scale results between OSA risk groups. RESULTS: Of the 222 participants studied, 164 (74%) were at intermediate to high risk for OSA based on the modified STOP-BANG score. Relative to the 58 low-risk individuals, the adjusted hazard ratio of mortality or first hospitalization was 1.61 (95% confidence interval 1.01-2.58) for those at intermediate to high risk of OSA. Risk for OSA was also associated with increased frequency of COPD exacerbations (adjusted incidence rate ratio: 1.78, 95% confidence interval 1.10-2.89). Respiratory symptoms by St. George Respiratory Questionnaire were 5.5 points greater (P = .05), and Quality of Well-Being Scale scores were .05 points lower (P < .01) among those at intermediate to high risk for OSA, indicating more severe respiratory symptoms and lower quality of life. CONCLUSIONS: Among individuals with COPD, greater risk for undiagnosed OSA is associated with poor outcomes. Increased recognition and management of OSA in this group could improve outcomes.

Risk of Cardiovascular Disease Related to Smoking Is Greater Among Women With Sleep-Disordered Breathing.

STUDY OBJECTIVES: Although both sleep-disordered breathing (SDB) and smoking are associated with cardiovascular disease (CVD), the potential for an interactive effect on CVD risk has not been explored. Our objective was to determine if smoking-related risk for CVD rises with greater SDB severity. METHODS: Polysomnography and smoking history were obtained in 3,852 men and women in the Sleep Heart Health Study without baseline CVD. Fine-Gray proportional hazard models accounting for competing risk were used to calculate risk of incident CVD associated with SDB severity (defined by clinical cutoffs of the apnea-hypopnea index), smoking status (never, former, and current) and their interaction adjusting for potential confounders. RESULTS: Over a mean (standard deviation) follow-up period of 10.3 (3.4) years, there were 694 incident CVD events. We found a significant three-way interaction of sex, current smoking, and moderate to severe SDB (P = .039) in the adjusted proportional hazards model. In adjusted analyses, women who were current smokers with moderate to severe SDB had a hazard ratio for incident CVD of 3.5 (95% confidence interval 1.6-8.0) relative to women who were nonsmokers without SDB. No such difference in CVD risk was observed in men or women of other strata of smoking and SDB. CONCLUSIONS: In women, smoking-related risk for CVD is significantly higher among individuals with moderate to severe SDB.

Veteran Preferences Regarding Wireless Management of Positive Airway Pressure for Obstructive Sleep Apnea at a Tertiary Health-Care System.

BACKGROUND: Timely monitoring of obstructive sleep apnea (OSA) therapy can be a challenge amid conflicting pressures of rising patient volume and shortage of sleep medicine providers. Positive airway pressure (PAP) devices with wireless modem technology have the potential to improve patient access to care and streamline work load, yet little is known about patient attitudes toward telehealth integration among veterans with sleep apnea. As part of a larger quality improvement initiative at the Veterans Affairs (VA) Puget Sound Health Care System, we elicited veterans' preferences toward modem versus traditional PAP data download, including patient attitudes and factors affecting those preferences. METHODS: We conducted an anonymous survey of veterans without previous CPAP experience presenting for initial device setup and training at VA Puget Sound PAP clinics. Surveys assessed subject demographics, PAP download preferences (modem vs mail), and Likert-type scale ratings of importance placed on factors including convenience and information privacy. Using multinomial logistic regression, we examined the association between convenience rating and download preference, adjusting for information privacy rating, age, and commute time. RESULTS: Of 444 surveys analyzed, respondents were primarily male with a mean age of 52 y. Most respondents reported taking ≥ 30 min to commute to the PAP clinic. Convenience was rated as the most important factor affecting download preferences. Veteran preferences regarding PAP download method were mixed, with 47% preferring modem, 38% preferring memory card mail-in, and 15% undecided. A higher rating of convenience was significantly associated with modem preference, both before and after adjustment for information privacy rating, commute time, and veteran age (adjusted relative risk ratio 1.67, P < .001, 95% CI 1.40-1.99). CONCLUSIONS: PAP data download preferences were mixed among new veteran users. Veterans placed a high value on the potentially competing concerns of convenience and information privacy. Veterans preferring modem factored convenience as important in their decision making, independent of privacy concerns.

Development of a Sleep Telementorship Program for Rural Department of Veterans Affairs Primary Care Providers: Sleep Veterans Affairs Extension for Community Healthcare Outcomes.

RATIONALE: Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access. OBJECTIVES: The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine. METHODS: ECHO creates a virtual learning community through video-teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance. MEASUREMENTS AND MAIN RESULTS: Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers. CONCLUSIONS: Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.

Sleep Disturbance in Smokers with Preserved Pulmonary Function and with Chronic Obstructive Pulmonary Disease.

RATIONALE: Sleep disturbance frequently affects patients with chronic obstructive pulmonary disease (COPD), and is associated with reduced quality of life and poorer outcomes. Data indicate that smokers with preserved pulmonary function have clinical symptoms similar to those meeting spirometric criteria for COPD, but little is known about the driving factors for sleep disturbance in this population of emerging interest. OBJECTIVES: To compare the magnitude and correlates of sleep disturbance between smokers with preserved pulmonary function and those with airflow obstruction. METHODS: Using cross-sectional data from the COPD Outcomes-Based Network for Clinical Effectiveness and Research Translation multicenter registry, we identified participants clinically identified as having COPD with a smoking history of at least 20 pack-years and either preserved pulmonary function or airflow obstruction. We quantified sleep disturbance by T-score measured in the sleep disturbance domain of the Patient-Reported Outcomes Information System questionnaire, and defined a minimum important difference as a T-score difference of two points. We performed univariate and multivariable linear regression to evaluate correlates within each group. RESULTS: We identified 100 smokers with preserved pulmonary function and 476 with airflow obstruction. The sleep disturbance T-score was 4.1 points greater among individuals with preserved pulmonary function (95% confidence interval [CI], 2.0-6.3). In adjusted analyses, depression symptom T-score was associated with sleep disturbance in both groups (airflow obstruction: ß, 0.61 points; 95% CI, 0.27-0.94; preserved pulmonary function: ß, 0.25 points; 95% CI, 0.12-0.38). Of note, lower percent predicted FEV1 was associated with greater sleep disturbance among those with preserved pulmonary function (ß, -0.19 points; 95% CI, -0.31 to -0.07), whereas higher FEV1 was associated with greater sleep disturbance among individuals with airflow obstruction (ß, 0.06 points; 95% CI, 0.01-0.10). CONCLUSIONS: Among smokers with clinically identified COPD, the severity of sleep disturbance is greater among those with preserved pulmonary function compared with those with airflow obstruction. Nonrespiratory symptoms, such as depression, were associated with sleep disturbance in both groups, whereas the relationship of sleep disturbance with FEV1 differed.