Background: Through a clinical award from the VHA Innovation Program, our research team has created the Remote Veterans Apnea Management Portal (REVAMP), a personalized, interactive web-based platform that allows Veterans to receive comprehensive management of obstructive sleep apnea (OSA) without traveling to a sleep center. REVAMP (1) allows Veterans to respond to intake and follow-up questionnaires on the website; (2) displays wireless data transmitted from the patient's automatically-adjusting positive airway pressure (APAP) unit to the website; (3) enables Veterans to self-monitor their APAP use and effectiveness; and (4) auto-populates the patient questionnaire and PAP results into progress notes that can be exported to CPRS. Objectives: This prospective, randomized intervention in Veterans with OSA will compare REVAMP manage- ment to in-person care.
Aim 1 will determine if REVAMP management is not clinically inferior to in-person care in terms of functional improvement and objectively monitored APAP adherence.
Aim 2 will compare differences in cost and quality-adjusted life years between the two models.
In Aim 3, patient- and practitioner-centered formative evaluations will assess potential barriers to REVAMP's widespread implementation. Methods: Veterans referred for OSA evaluation will be randomized to either REVAMP management or in- person care. Veterans randomized to REVAMP management will (1) complete questionnaires and have access to videos about OSA and home sleep testing on the website; (2) be mailed a portable monitor to perform the home sleep test and return it by mail; (3) be evaluated by a sleep practitioner via home video teleconferencing (HVT) or phone interview to review the questionnaire and sleep study results; (4) if diagnosed with OSA, be prescribed an APAP unit with wireless modem for adherence tracking; (5) be able to view, along with their practitioners, their APAP use on REVAMP and their response to treatment based on follow-up questionnaires on the website, and (6) receive HVT or phone follow-up evaluations. Veterans randomized to the in-person pathway will: (1) receive an initial in-person clinic evaluation and in-person instructions on how to perform the home sleep test; (2) complete questionnaires on the website to standardize data collection; (3) if diagnosed with OSA, be prescribed APAP and have in-person follow-up clinic visits; and (4) have their APAP adherence monitored by practitioners reviewing the wireless data on the APAP manufacturer's website.
Aim 1 's primary outcome will be the change in Functional Outcomes of Sleep Questionnaire (FOSQ-10) score following 3 months of APAP treatment. Objectively monitored APAP use will be a secondary outcome. Non- inferiority analyses will compare the effectiveness of the two arms. We hypothesize that the change in FOSQ- 10 score with REVAMP management will not be clinically inferior to that with in-person care.
In Aim 2, VA and non-VA total healthcare costs will be collected to test whether average cost is lower with REVAMP versus in- person care. Preference will be assessed by the SF-6D and EQ-5D. We will estimate the ratio of incremental costs to incremental quality-adjusted life years saved between REVAMP versus in-person management. to test whether REVAMP management will have lower cost and equivalent outcomes. Formative evaluation in Aim 3 will use qualitative (targeted phone interviews) and quantitative measures (attrition, work alliance, and patient satisfaction) to guide future implementation. Anticipated Impact on Veteran's Healthcare: Estimated to be the third most common chronic disease in Veterans, OSA is associated with an increased risk of hypertension, heart attacks, strokes, depression, and driving accidents. Current in-person management at a sleep center is limiting access to care and has resulted in long patient wait times. This proposal will evaluate an innovative website-based clinical pathway that will improve access to care of Veterans with OSA. The project may serve as the model for long-term care management for other common, chronic conditions in Veterans, including diabetes, obesity and hypertension.
Although obstructive sleep apnea, a breathing disorder during sleep, is prevalent and recognized as a major public health concern, most Veterans with this disorder are undiagnosed and therefore untreated. Access to sleep laboratories for testing is limited particularly for those Veterans living in rural areas and Veterans with disabilities that prevent travel to a sleep center. The goal of this study is to compare a web-based telehealth management strategy to in-person management. The telehealth pathway will enable Veterans to be diagnosed and treated without visiting a sleep center. We believe that telehealth management will increase Veterans' access to this specialized care at a cost that is less than in-person delivery but with similar improvements in daytime function.
