Exploring Nurse Practitioner Students' Perceptions of a Sleep e-Learning Program.

AIM: The aim of this study was to explore nurse practitioner (NP) students' perceptions of a sleep e-learning program. BACKGROUND: Sleep assessment is uncommon as nursing curricula lack sleep education. By preparing NPs to conduct sleep assessment and screening and understand basic sleep diagnostics, sleep health is more likely to be part of the differential diagnosis. METHOD: The study is a qualitative descriptive study utilizing two focus groups. A directed content analysis, guided by the Kirkpatrick model, was used for analysis. RESULTS: Twenty-four students participated in focus groups. Two overarching themes emerged: perceptions of course design and content. Asynchronous, case-based scenarios and quizzes were favorable. Students spoke of content relevance to themselves and patients and intentions to adopt sleep assessment practices. CONCLUSION: NP students embraced sleep education and declared intention to apply learned skills in practice. This study highlights the feasibility of increasing curricular exposure to sleep education and ensuring NPs have skills to recognize implications of poor and disordered sleep in patients.

A social media intervention for the families of young Black men with obstructive sleep apnoea.

Objective: To address positive airway pressure (PAP) adherence in adolescents diagnosed with obstructive sleep apnoea (OSA) by pilot testing a novel, online, facilitated, peer-support and health education programme for families. Design Setting and Methods: Families participated in separate Facebook peer-groups (adolescent [n=6] and parent [n=6]) for four weeks, followed by face-to-face interviews. Participants received OSA and PAP educational videos and posts, engaged with questions and polls, and viewed de-identified postings of peer PAP use data. Results: Adolescent participants were young Black males aged 13-17 years (n=6) with obesity (n=5), severe sleep apnoea (100%) and 4-15 months of prior PAP use. Parent participants were mothers (n=4) and fathers (n=2). Four of six young males increased their mean PAP use during the intervention period. Overall, parents were more engaged with the Facebook group page than adolescents, but interviews revealed the online group/peer-support and education provided was highly regarded and appreciated by families. Parents were particularly appreciative of being involved in care and diagnosis in this way. Conclusion: Results of this pilot trial provide important data regarding intervention design, content, and delivery approaches to be considered in the development of future interventions aiming to engage families and improve adolescent PAP adherence.

Coping Processes, Self-Efficacy, and CPAP Use in Adults With Obstructive Sleep Apnea.

Background: Coping strategies are predictive of 1 week CPAP use. Coping strategies may predict longer-term CPAP use among adults with obstructive sleep apnea (OSA). Objectives: To investigate the influence of two coping styles (active and passive) and individual coping processes on CPAP use at 1 week and 1 month; and explore the association between self-efficacy and coping on CPAP use. Participants: CPAP-naïve adults (52.3% male, 90.9% White) newly diagnosed with OSA (AHI ≥ 5 events/hr) from two U.S. clinical sleep centers (n = 66). Methods: A post-hoc analysis from a prospective, longitudinal study that examined influential factors on CPAP use among CPAP-naïve patients with newly diagnosed OSA. The Ways of Coping Questionnaire and the Self-Efficacy Measure for Sleep Apnea were completed immediately after CPAP titration polysomnography. Objective 1 week and 1 month CPAP use (mean hr/night) were the primary outcomes. Descriptive analyses and stepwise multiple linear regression analyses modeling for CPAP use (mean hr/night). Results: Active coping was significantly associated with greater CPAP use (mean hr/night) at 1 week, but not at 1 month (p = 0.0397; p = 0.0556, respectively). Higher Planful Problem Solving was significantly associated with greater average CPAP use at 1 week and 1 month (p = 0.0117, p = 0.0378, respectively). Self-efficacy was significantly associated with greater average CPAP use at 1 week (p = 0.0056) and 1 month (p = 0.0056). Conclusions: Self-efficacy and Planful Problem Solving coping are promising behavioral intervention targets to promote CPAP use in newly diagnosed OSA.

A Tailored Intervention for PAP Adherence: The SCIP-PA Trial.

OBJECTIVE/BACKGROUND: Positive airway pressure (PAP) is highly efficacious treatment but nonadherence is prevalent with little improvement over the last 15 years. Tailored interventions show promise for promoting adherence to other treatments. The study objective was to examine feasibility and acceptability of a tailored intervention to promote PAP adherence. PARTICIPANTS: The convenience sample met inclusion criteria: newly diagnosed OSA; treatment-naïve; ≥ 18 years. EXCLUSION CRITERIA: previous obstructive sleep apnea (OSA) diagnosis and treatment; new psychiatric diagnosis; use of oxygen/bilevel PAP; secondary sleep disorder. Adults (n = 118) were randomized to tailored intervention (TI; n = 61) or usual care (UC; n = 57); application of a priori exclusion criteria resulted in 30 participants per assignment who were middle-aged (51.3 ± 11.1 years) adults (70% male) with severe OSA (apnea hypopnea index [AHI], 35.9 ± 25.2). METHODS: Randomized, double-blind, single-site pilot controlled trial. A multiphased tailored intervention targeting social cognitive perceptions of OSA-PAP treatment was delivered at four intervals. Descriptive analysis, group differences, and self-efficacy change scores by t-test, and thematic analysis of acceptability data are reported. RESULTS: One-week PAP use among TI was 35 min greater than UC condition (p = 0.20; Cohen's d = 0.336). Treatment use decreased at 1 month and 3 months (NS). Per-protocol delivery of face-to-face intervention delivery was 100% but lower for telephone intervention delivery. Personalized approach was valued by participants. CONCLUSIONS: A tailored intervention approach is acceptable to participants and feasibly implemented in a clinical sleep center setting. The intervention effect size at 1 week is consistent with other educational PAP adherence interventions but was not sustained; further pilot testing is warranted to address pilot RCT limitations.

Heart Failure Self-care Within the Context of Patient and Informal Caregiver Dyadic Engagement: A Mixed Methods Study.

BACKGROUND: Recent heart failure (HF) patient and informal caregiver (eg, dyadic) studies have either examined self-care from a qualitative or quantitative perspective. To date, the 2 types of data have not been integrated. OBJECTIVE: The aim of this study was to understand HF self-care within the context of dyadic engagement. METHODS: This was a cross-sectional, mixed methods (quantitative/qualitative) study. Heart failure self-care was measured with the Self-care of Heart Failure Index (v.6) dichotomized to adequate (≥70) or inadequate (<69). Dyadic symptom management type was assessed with the Dyadic Symptom Management Type scale. Interviews regarding self-care were conducted with both dyad members present. Content analytic techniques were used. Data were integrated using an information matrix and triangulated using Creswell and Plano Clark's methods. RESULTS: Of the 27 dyads, HF participants were 56% men, with a mean age of 77 years. Caregivers were 74% women, with a mean age of 66 years, representing spouses (n = 14) and adult children (n = 7). Quantitatively, few dyads scored as adequate (≥70) in self-care; the qualitative data described the impact of adequacy on the dyads' behavior. Dyads who scored higher, individually or both, on self-care self-efficacy and self-care management were less likely to change from their life course pattern. Either the patient or dyad continued to handle all self-care as they always had, rather than trying new strategies or reaching out for help as the patient's condition deteriorated. CONCLUSIONS: Our data suggest links that should be explored between dyadic adequacy and response to patients' symptoms. Future studies should assess dyadic adequacy longitudinally and examine its relationship to event-free survival and health services cost.

Association Between Positive Airway Pressure Adherence and Health Care Costs Among Individuals With OSA.

BACKGROUND: The impact of positive airway pressure (PAP) therapy for OSA on health care costs is uncertain. RESEARCH QUESTION: Are 3-year health care costs associated with PAP adherence in participants from the Tele-OSA clinical trial? STUDY DESIGN AND METHODS: Participants with OSA and prescribed PAP in the Tele-OSA study were stratified into three PAP adherence groups based on usage patterns over 3 years: (1) high (consistently ≥ 4 h/night), (2) moderate (2-3.9 h/night or inconsistently ≥ 4 h/night), and (3) low (< 2 h/night). Using data from 3 months of the Tele-OSA trial and 33 months of posttrial follow up, average health care costs (2020 US dollars) in 6-month intervals were derived from electronic health records and analyzed using multivariable generalized linear models. RESULTS: Of 543 participants, 25% were categorized as having high adherence, 22% were categorized as having moderate adherence, and 52% were categorized as having low adherence to PAP therapy. Average PAP use mean ± SD was 6.5 ± 1.0 h, 3.7 ± 1.2 h, and 0.5 ± 0.5 h for the high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average covariate-adjusted 6-month health care costs ± SE ($3,207 ± $251) compared with the moderate ($3,638 ± $363) and low ($4,040 ± $304) adherence groups. Significant cost differences were observed between the high and low adherence groups ($832; 95% CI, $127 to $1,538); differences between moderate and low adherence were nonsignificant ($401; 95% CI, -$441 to $1,243). INTERPRETATION: In participants with OSA, better PAP adherence was associated with significantly lower health care costs over 3 years. Findings support the importance of strategies to enhance long-term PAP adherence.

Cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure use.

OBJECTIVES: To evaluate the cost-effectiveness of a 3-year tele-messaging intervention for positive airway pressure (PAP) use in obstructive sleep apnea (OSA). STUDY DESIGN: A post hoc cost-effectiveness analysis (from US payers' perspective) of data from a 3-month tele-OSA trial, augmented with 33 months of epidemiologic follow-up. METHODS: Cost-effectiveness was compared among 3 groups of participants with an apnea-hypopnea index of at least 15 events/hour: (1) no messaging (n = 172), (2) messaging for 3 months (n = 124), and (3) messaging for 3 years (n = 46). We report the incremental cost (2020 US$) per incremental hour of PAP use and the fraction probability of acceptability based on a willingness-to-pay threshold of $1825 per year ($5/day). RESULTS: The use of 3 years of messaging had similar mean annual costs ($5825) compared with no messaging ($5889; P = .89) but lower mean cost compared with 3 months of messaging ($7376; P = .02). Those who received messaging for 3 years had the highest mean PAP use (4.11 hours/night), followed by no messaging (3.03 hours/night) and 3 months of messaging (2.84 hours/night) (all P < .05). The incremental cost-effectiveness ratios indicated that 3 years of messaging showed lower costs and greater hours of PAP use compared with both no messaging and 3 months of messaging. Based on a willingness-to-pay threshold of $1825, there is a greater than 97.5% chance (ie, 95% confidence) that 3 years of messaging is acceptable compared with the other 2 interventions. CONCLUSIONS: Long-term tele-messaging is highly likely to be cost-effective compared with both no and short-term messaging, with an acceptable willingness-to-pay threshold. Future long-term cost-effectiveness studies in a randomized controlled trial setting are warranted.

Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students.

STUDY OBJECTIVES: Primary care nurse practitioners (NPs) receive little sleep education in graduate programs but are often first-line providers for patients presenting with sleep-related symptoms. A pre-/postevaluation study was conducted using asynchronous, case-based sleep education modules in a cohort of primary care NP students enrolled in a single academic institution's nursing master's degree program. METHODS: Six virtual, case-based modules addressed adult sleep health and disorders, prioritized based on prevalence and primary care presentation. Kirkpatrick Training Evaluation Model guided outcome selection. Descriptive and paired comparative analyses were conducted. RESULTS: Participants were first-year NP students (n = 149; 88% female; 82% ≤ 35 years of age) in an adult primary care program that included psychiatric/mental health track. Participants reacted positively to course delivery methods and content. Insomnia was endorsed by 87% as most relevant to practice with healthy sleep (88%) and obstructive sleep apnea (50%) also frequently endorsed as practice relevant. Posttest knowledge scores significantly improved for all modules (P < .001). Self-rated confidence for future practice application was high. CONCLUSIONS: This novel asynchronous, virtual curriculum met Kirkpatrick levels 1 and 2 (positive reaction and knowledge transfer) in NP students who predicted an impact on their practice (Kirkpatrick level 3). Studies are needed to assess the benefits of increasing primary care NP knowledge in sleep medicine on quality of care and access to care (Kirkpatrick level 4). Future use of this novel sleep curriculum in other professional curricula, new-to-sleep clinical researchers, and practicing primary care providers may further potentiate care quality and sleep care access. CITATION: Sawyer AM, Saconi B, Lyons MM, et al. Case-based, asynchronous sleep education outcomes among primary care nurse practitioner students. J Clin Sleep Med. 2022;18(10):2367-2376.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Intervention Design and Trial Protocol: Mindfulness-based Exposure for PAP-associated Claustrophobia.

Positive airway pressure (PAP) associated claustrophobia is common among obstructive sleep apnea patients and plays a prominent role in low adherence and treatment failure. As there are no evidence-based interventions for PAP-associated claustrophobia, the objective of the present research is to pilot test Mindfulness-based Exposure for PAP-associated Claustrophobia, in sleep apnea adults that present with treatment non-adherence and claustrophobia. This approach combines Mindfulness-based Stress Reduction with exposure-based treatment components to target this treatment-associated claustrophobia. The present article outlines the mindfulness exposure intervention design and methods and reports the pilot trial study protocol. Trial findings are intended to: (a) develop a preliminary effect size of the intervention on PAP-associated claustrophobia; (b) explore differences in treatment adherence by group (intervention vs control); and (c) establish feasibility for expanded protocol implementation, delivery, and participant acceptability of the intervention to support subsequent design of a fully powered randomized controlled trial.

Where to Next for Optimizing Adherence in Large-Scale Trials of Continuous Positive Airway Pressure?

Large-scale randomized trials of positive airway pressure (PAP) efficacy have been largely negative but PAP adherence was notably suboptimal across the trials. To address this limitation, evidence-based PAP adherence protocols embedded within the larger trial protocol are recommended. The complexity of such protocols depends on adequacy of resources, including funding and inclusion of behavioral scientist experts on the scientific team, and trial-specific considerations (eg, target population) and methods. Recommendations for optimizing PAP adherence in large-scale trials are set forth that address rigor and reproducibility.

Positive airway pressure adherence in pediatric obstructive sleep apnea: A systematic scoping review.

Positive airway pressure (PAP) therapy is a commonly prescribed treatment for pediatric obstructive sleep apnea (OSA). Negative health consequences associated with untreated OSA make understanding the utilization of PAP therapy imperative. The aim of this review was to describe PAP use in children and adolescents with OSA, explore factors that influence use, and describe published scientific or clinical approaches to improve use. Among 20 studies, average PAP adherence was 56.9% (range, 24-87%). PAP use averaged 4.0 h (SD = 3.1) to 5.2 h (SD = 3.4) per night. Cautious consideration of summary estimates of PAP use is necessary as studies were heterogeneous and adherence definitions widely varied across studies. Age, sex, and developmental delay were the only factors associated with PAP use in more than one study. The majority of approaches to improve use were program evaluations rather than scientifically tested interventions. This review identified critical gaps in the existing literature and sets forth a research agenda for the future.

Executive Function Impairments in Adolescents With Obesity and Obstructive Sleep Apnea Syndrome.

Adolescents with obesity and obstructive sleep apnea syndrome (OSAS) are at high risk of poor physical and cognitive health consequences. The purpose of this study was to explore executive function (EF) in adolescents with obesity and OSAS, describe physical activity and sleep duration, and explore the relationships between EF and physical activity and sleep duration. Participants comprised 20 adolescents (ages 11-17 years) with obesity (body mass index [BMI] ≥ 95th percentile) and OSAS (apnea-hypopnea index [AHI] ≥ 1.5 events/hr) participated in this observational pilot study with a prospective 1-week measurement protocol. Outcome measures included EF by the Behavior Rating Inventory of Executive Function-2, physical activity by Previous Day Physical Activity Recall, and sleep by Consensus Sleep Diary and actigraphy. Adolescents with obesity and OSAS had significantly worse EF by self- and parent-report than the normative sample (p ≤ .003), 45% had impaired EF and up to 30% had clinically significant impairments. Participants spent approximately 14.3 hr/day in light-intensity activity, and 33% did not engage in moderate-to-vigorous-intensity activity for at least 60 min on any days of data collection. Adolescents had insufficient sleep duration, averaging 6.9 hr/night. No significant relationships were identified between physical activity or sleep duration and EF. Providers should have a heightened awareness for EF impairments in obese adolescents with OSAS and consider how EF deficits may affect uptake and adherence to complex lifestyle and/or medical interventions among these patients.

Pattern Versus Change: Community-Based Dyadic Heart Failure Self-Care.

It is imperative that dyadic heart failure (HF) self-care be carefully examined so we can develop interventions which improve patient outcomes. The purpose of this study was to qualitatively examine how patient/informal caregiver dyads mutually engage in managing the patient's HF at home. Twenty-seven dyads were interviewed using a theoretically derived interview guide. All interviews were digitally recorded and professionally transcribed, and iterative thematic analysis was conducted. Three descriptive themes emerged-Mutual engagement in self-care involves maintaining established patterns of engagement across the life course of the relationship, changing patterns according to whether it is day-to-day care or symptom management, and mobilizing the help of a third party as consultant. These themes reveal the dyadic conundrum-whether to change or remain the same in the face of a dynamic and progressive condition like HF. The themes suggest potential targets for intervention-interventions focused on the relationship or caregiver activation.

Clinical Trial Enrollment Enrichment in Resource-Constrained Research Environments: Multivariable Apnea Prediction (MAP) Index in SCIP-PA Trial.

STUDY OBJECTIVES: Determine the Multivariable Apnea Prediction (MAP) index predictive utility for enrollment enrichment in a clinical trial wherein enrollment was prior to obstructive sleep apnea diagnosis. METHODS: Secondary analysis of screening data (n = 264) from randomized, double-blind, pilot trial. Clinical sleep center patients with complete screening and polysomnography data were included. To determine diagnostic test accuracy of the MAP index using apnea-hypopnea index criterion ≥ 10 events/h (primary) and ≥ 5, ≥ 15, and ≥ 30 events/h (secondary), sensitivity, specificity, negative and positive predictive values, likelihood positive and negative ratios, and receiver operating characteristic curves were calculated. Predictive utility was examined by characteristic variables. RESULTS: Middle-aged, overweight or obese, men and women were included. Employing a MAP index threshold ≥ 0.5, sensitivity for obstructive sleep apnea (apnea-hypopnea index ≥ 10 events/h) was 83.6%; specificity was 46.4%; area under the curve = 0.74. Sensitivity was higher in males than females (95.3%, 68.7%, respectively); specificity was lower in males than females (30.4%, 57.6%, respectively) with similar area under the curve (0.74 versus 0.72, respectively). MAP accuracy was higher in younger versus older adults (younger than 50 years, or 50 years or older; area under the curve 0.82 versus 0.63, respectively). Varied apnea-hypopnea index criteria produced stable accuracy estimates. CONCLUSIONS: Recruitment/enrollment is a high-cost endeavor. Screening procedures may confer resource savings but careful evaluation prior to study implementation assures effectiveness and efficiency. CLINICAL TRIAL REGISTRATION: The secondary analysis reports data from the SCIP-PA Trial (NCT 01454830); study information available at: https://clinicaltrials.gov.