sleep in veterans - amazon s3 · • prior sleep evaluations, osa treatment, or other sleep...

© Associated Professional Sleep Societies, LLC 1

Sleep in VeteransKathleen Sarmiento, MD


Conflict of Interest Disclosures for Speakers1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

X 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support Jazz Pharmaceuticals

Consultant

Speakers’ Bureaus

Financial support

Other

X 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1.

2.

3.


Objectives• Understand the sleep needs of Veterans

– Insomnia, sleep apnea, PTSD & TBI• Review provision of current sleep care

– Resources available– Models of care

• Introduce Innovation in VA Sleep– REVAMP– Thinking outside the box: boots on the ground


Who We Serve• 21million veterans, 8.2million enrolled• Combat veterans are eligible for 5 years of

care after separation• High prevalence of sleep complaints

among service members– 32% insufficient sleep in theater (MHAT V, 2008)

– 25% insufficient sleep (MHAT 9, 2013)

• Unknown prevalence of OSA in OIF/OEF/OND Veterans


Sleep: Not a PriorityBarriers to promoting healthy sleep in active duty• Military cultural attitudes undermining the

importance of sleep• Low institutional priority of war-related health

issues• Suboptimal environmental conditions• Shift work, deployment and travel schedules

disrupt sleep and promote persistence of insomnia

• Lack of knowledge of good sleep practices


Consequences of Sleep Disruption• Conditioning to not sleep (learned

hyperarousal)• Short term fixes that perpetuate sleep

difficulties– Use of stimulants, energy drinks– Engaging in wakefulness promoting activities– OTC and prescription sleeping aids

• Reinforces vigilance and alertness• Results in persistence of inability to sleep


Consequences of Sleep DisruptionSleep affects health• Cognitive function• Physical health• Mental health

Sleeping difficulties are manifest of PTSD, TBI, mood disorders, but may also worsen these conditions and increase the risk of suicide.


Prevalence of Sleep Disorders• Approx 40% of Veterans in primary care1 have

probable insomnia (vs. 19% general community2)

• Increased prevalence rates in:– Depression - Other sleep disorders– PTSD - Pain/medical disorders– Substance Use - Aging

• Insomnia is associated with significant distress and reduced quality of life1 Mustafa et al 2005, Sleep Breath.; 2 Ohayon 2002, Sleep Medicine Reviews


Sleep and PTSD

• Sleep disturbance is part of the diagnostic criteria for PTSD– Nightmares as a reexperiencing symtpom– Insomnia as a hyperarousal symptom

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PTSD and insomnia

• 44% of Vietnam Veterans w/PTSD reported difficulty falling asleep sometimes or very frequently vs 6% w/o PTSD (Neylan et al. 1998)

• 91% of Vietnam Veterans w/PTSD rated sometimes or very frequent difficulty maintaining sleep vs. 63% w/o PTSD and 53% of civilians

• PTSD community sample more disrupted sleep (47% vs 18%) and wake too early (43% vs13%).

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PTSD and Nightmares

• 52% of Vietnam Veterans w/ PTSD had nightmares sometimes or very frequently compared to 5% w/o PTSD

• Community PTSD sample 19% vs 4% (Ohayon and Shapiro 2000)

• Female sexual or physical assault survivors w/PTSD reported nightmares on average 5 nights a week (Krakow, Schrader, et al., 2002).

• Veterans with PTSD more likely to have nightmares that are replays of actual life experiences

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Why treat insomnia?• General psychotherapy is not effective for sleep

– Insomnia and nightmares are common residual symptoms after successful treatment of PTSD

• Targeted treatment with Cognitive Behavioral Treatment for Insomnia (CBT-I) is effective– Compared to control therapy and delayed treatment

control– Better long-term efficacy than sleep medications

• CBT-I is generally considered to be the first-line treatment of choice

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• Lack of awareness of non-pharmacologic treatment options

• Lack of trained providers– Few graduate and post doctoral fellowships provide

training in CBT-I– VA National roll-out of CBT-I is increasing pool of

providers– Access still very limited, especially in rural areas

• Clinical video telehealth is one means of increasing access to treatment

Barriers to availability of CBT‐I


Genesis of the tele‐insomnia program• Began in June of 2010 to make treatment

available at a CBOC using VTel system• Treatment delivered to groups of 6-8

Veterans• 6-session manualized format• Co-led by an on-site provider as a means of

training• Means of increasing both access and training

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Tele‐insomnia program

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Programmatic Efforts• CBT-i roll-out

– From in-person to tele-training– Group CBT-i training

• Joint efforts between DoD and VA


FTEE 2012 2014

Physician 112.1 241

Nurse PractitionerPhysician Assistant

20.4 15.4

4815

Respiratory Therapy

115.3 221

Sleep Tech 100.4 377

Sleep Service Provided Programs

Home Sleep Testing 65%

Polysomnography 72%

Telemedicine 32%

Shared Appointments 20%

Group Testing 25%

Medical Sleep Programs

• 361,637 Sleep Encounters• $166m in Sleep PAP & Supplies

Sleep Program Resources


Sleep Apnea

0

20000

40000

60000

80000

100000

120000

140000

FY12 Encounters FY13 Encounters FY14 Encounters FY15 Encounters

Sleep Testing

66,278

117,355

86,072

74,082


• OSA is common in VA• VA is ill‐equipped to manage OSA in the conventional way– Few labs relative to numbers of patients– Geographic disparities for access

• Necessary to think creatively to solve this problem• Believed that home dx and treatment MUST be a part of this

Kuna et al, AJRCCM 2011

Lessons from the Veterans Sleep Apnea Treatment Trial (VSATT)


Inclusion criteria:• Patients referred for a sleep evaluation for suspected sleep apnea• Age 18 years• Living within 90 miles of the sleep center

Exclusion criteria:• Unable or unwilling to provide informed written consent• Inability to complete the Assessment Battery• Lack of telephone access or inability to return for follow‐up testing.• Prior sleep evaluations, OSA treatment, or other sleep disorder • A clinically unstable chronic medical condition as defined by a new diagnosis

or change in medical management in the previous 3 months of cardiac disease, thyroid disease, diabetes, depression or psychosis, cirrhosis, or recently diagnosed cancer

• Individuals on long term oxygen therapy or requiring BIPAP• Rotating shift work or irregular work schedules over the last 6 months• Suspected or confirmed to be pregnant

Inclusion/Exclusion Criteria


Clinic F/U

In‐lab PSG(n=35)

AHI < 15 (n=23)

CPAP PSG (n=84)

Home autoCPAP titration (n=119)

In‐lab PSG(n=141)

Home sleep study(n=139)

CPAP set‐up (n=110)

One month FU (n=92)

Baseline Assessment and Randomization (n=296)

CPAP set‐up (n=113)

Dx’ic PSG (n=99)

Split PSG (n=42)

In‐lab PSG(n=18)

Non‐OSA(n=9)

Non‐OSA(n=9)

One month FU (n=103)

Three month FU (n=86)

Three month FU (n=96)


Home Testing (n=113)

In-Lab Testing (n=110)

Factor Mean ± SD Mean ± SD P-valueAge (yrs) 55.1 ± 10.3 51.8 ± 10.4 0.02BMI (kg/m2) 35.0 ± 7.5 34.2 ± 5.2 0.34FOSQ total score 15.0 ± 3.2 14.7 ± 2.9 0.55ESS score 12 ± 5 13 ± 5 0.21CES-D 23.3 ± 7.8 25.0 ± 8.8 0.13SF-12 physical score†

36.7 ± 10.9 38.2 ± 10.2 0.29

SF-12 mental health score

44.4 ± 10.8 41.1 ± 10.7 0.02


Home (N=105)In-Lab (N=96)

TimeBaseline Month 3

Mea

n (S

D)

FOSQ

Tot

al S

core

0

5

10

15

20

25

Functional Outcomes


Endpoint Home adjusted mean change1

(n=113)

In-Lab adjusted mean change1

(n=110)

Adjusted difference in mean changes (SE)1

P-value2

Lower bound of 90% CI for difference in mean changes

Mean CPAP (hours/day)

3.42 2.99 0.42 (0.32) 0.180 - 0.10

1 Adjusted mean changes and adjusted differences in mean changes were estimated as site-total-sample-size weighted values controlling.2 P-value from Type II sum of squares estimated by way of analysis of covariance. To produce site weighted comparisons the ANCOVA model included main effects for type of study (home vs in-lab) and site.

Kuna et al, AJRCCM 2011

PAP Adherence


Functional improvement with CPAP for OSA is not worse when treated in the home setting vs. the sleep laboratory

VSATT Conclusions


Models of VA Sleep Care• Shared Medical Appointments• CPAP clinics • Electronic Consultations• Telemedicine


• AKA group clinics• Long pedigree of seeing patients collectively• Focus on Hypertension and diabetes• Less data in Sleep

– Pittsburgh showed no difference in group vs. traditional clinics on ability to do a home test successfully

Shared Medical Appointments


Clinicians• Clinical efficiency• See 6‐8 patients in 2 hours• No loss in data gathering; if

anything it enhances it• Medical literature is

conclusive that outcomes are equal

Patients• Sharing of concerns,

experiences (especially follow up visits)

• HIPAA issues?• Education about disease

Benefits of SMA


• 7 patients scheduled• Sign HIPAA waivers• Complete questionnaires (include ESS, SACS)• Watch video on OSA and PAP• Group introduction• Meet with each individual (5‐7 min/person)

– Review questionnaires, clarify history, brief exam, opportunity to ask questions

Pittsburgh: SMA + HSAT


Tech demonstrates set up of HSAT equipment• Emphasize –

A. Do recording that night or next night

B. UPS mailerC. Stick to normal routineD. Record unusual activities

from overnight recordE. Call lab at night if there

are problems with set up

EXAM: VS, neck circ, comprehensive head/neck• Heart and lungs• Ext for edema• Neuro exam• Enter note (dictate or template)

Logistics of Testing


Education• Review OSA (again)• CPAP tips• Resources available to ptsExamination• Limited PE, vitalsForms• Full Sleep Histories• Goals of Care• Study enrollment if appl.PAP set-up• Mask fitting, instructionNotes: Templates/boilerplates

Check in, VitalsCheck in, Vitals

Education Education

Physicals, Form Completion

Physicals, Form CompletionCPAP set upCPAP set up

Closing remarksClosing remarks

MD or PA/NP, 2 RTs

SMA: Initial


Education•CPAP tips•Share experiences in groupExamination•Limited PE, vitalsForms•Interval history form•Goals of Care•Study enrollment if appl.PAP Use Review•Compliance downloaded for each pt ahead of visit or during visit if staff available

Check in, VitalsCheck in, Vitals

Education Education



PAP download reviewed

PAP download reviewed

Closing remarksClosing remarks

SMA: Follow up


• Group clinics – moderately easy to do• Examples in private sector:

– bariatric surgery– Diabetes clinics– Various mental health clinics

• Focus on similarities between patients rather than differences

Non-VA SMAs


CMS position on SMA

“Under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face‐to‐face E/M visit (CPT code 99213 or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary."

Coding/Reimbursement


Technologist or RT driven – Expands “boots on the ground” for Sleep– Focus on equipment issues for relatively stable established patients

– Common in VAs; unheard of in FFS – no reimbursement

– Could change if RRTs become LIPs– MD or NP/PA available for consultation if needed

CPAP Clinics


0

20000

40000

60000

80000

100000

120000


CPAP Clinics

20,557

30,964

44,399

113,973


Electronic Consultations

• Facilitate communication between referring and treating providers without the need for face-to-face visits

• Provide reference notation of recommendations/plan of care in the medical record

• Reduce wait time for initial assessment and plan of care


0

1000

2000

3000

4000

5000

6000


Store & Forward

0

2000

4000

6000

8000

10000

12000

14000

16000


Clinical Videoteleconferencing

3,884

9,593

15,052 15,063

117 562 999

5,139

Sleep Telemedicine


Sleep Telemedicine

Telephone Clinics• Increase the number of patients managed• Appointments of 10-15min duration• Scheduled to provide accountability for

time spent on patient care


Innovation in VA Sleep• Web-based Model of care (REVAMP)• Improve capture of sleep-focused data in

the medical record– Reminder Dialog Template– VA-wide collection of AHI, patient reported

outcomes – PAP Compliance data


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Current management of OSA

Philips Resmed DeVilbiss Fisher & PaykelComing Soon

PAP-generated data

Typed Progress Notes• Multiple interfaces• Inefficient clinics

• Manual data entry• Lower information security

Patient-generated data

Estimated 55% of

VA Market

Estimated 40% of

VA Market

Sleep Practitioners

Paper and pencil questionnaires

Estimated 5% of

VA Market


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Management by REVAMP

Philips Resmed DeVilbiss Fisher & PaykelComing Soon

PAP-generated data

Port 443 *encrypted transmissionVA Firewall

MVI

Single Sign On

Patient-generated data + PAP-generated data

Patient Traits

IAMAutopopulatedprogress notes

Vista interface

• One primary interface• More efficient clinics

• Much less data entry• Information security

Patient-generated data

Estimated 55% of

VA Market

Estimated 40% of

VA Market

Estimated 5% of

VA Market


Sleep Opportunities• Improve education of providers to screen for sleep

disorders, co-manage OSA, & promote sleep health• Encourage weight management strategies to

reduce OSA• Promote the appropriate use of stimulants and

sleep aids for insomnia• Expand training for proven non-pharmacologic

insomnia therapies: CBT-i and IRT• Establish policies supporting sleep medicine training

and practices• Collaboration between DoD and VA for continuity

during transition from active duty to veteran status

sleep in veterans - amazon s3 · • prior sleep evaluations, osa treatment, or other sleep...

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