Obstructive Sleep Apnea Clinical Trial
Official title:
Remote Monitoring in Obstructive Sleep Apnea Management in Military Veterans
Obstructive sleep apnea (OSA) among Veterans is a condition that imparts a great burden to the patient in terms of serious co-morbidities and results in a great cost to the VA Health Care System to treat the co-morbidities, which include heart disease, stroke and neuropsychiatric disorders. Positive airway pressure (PAP) is used to treat sleep apnea and studies have shown a poor adherence to treatment. The investigators hypothesize that using wireless technology will lead to early detection of problems of treatment use and will translate into early remedial action which will improve the use and effectiveness of treatment. The investigators will compare two methods. Usual care involves downloading data from PAP machines at designated 3-month intervals, requiring a face-to-face clinician visit. Wireless care involved more frequent monitoring and intervention in the event of anomalies in treatment use or effectiveness.
Prior to enrollment, patients were seen by a clinician at the Veterans Administration (VA)
Hospital in West Haven, Connecticut. Either a facility-based diagnostic polysomnogram or
unattended home sleep testing was performed at the evaluating clinician's discretion.
Clinicians that saw the patient determined whether PAP therapy was needed, and either
auto-titrating continuous positive airway pressure (CPAP) or set pressures of CPAP were
ordered for the patient. Patients received education about OSA and about their equipment from
a respiratory therapist and physician's assistant within the VA who then provided the
equipment for them. Patients coming to this internal Durable Medical Equipment (DME) provider
were screened for participation in the study.The study was overseen by the Institutional
Review Board at the Veterans Affairs Connecticut Health Care in West Haven, Connecticut.
Informed consent was obtained from all participants.
Patients were included in the study if they were diagnosed with OSA (defined as AHI or
apnea-hypopnea index greater than five per hour with symptoms, or AHI greater than 15/hour),
and if they were being exposed to PAP for the first time. Patients who were previously
treated with PAP, had central apnea, chronic respiratory failure, recent in-patient hospital
admissions (=< 2 weeks), or were living outside cellular network coverage area were excluded
from the study.
Patients that met study inclusion criteria were provided ResMed S9 devices with wireless
modems. Their usage and treatment data was tracked using EasyCare Online, a cloud-based
system for the ResMed devices. After the initial setup and educational settings, the patients
received supplies as needed and troubleshooting of side effects of treatment as needed.
Devices were not removed after 3 months if they were not adherent.
Patients in the usual care group were monitored on a 3-month, 6-month, 9-month and 12-month
intervals with scheduling face-to-face visits. Adherence and efficacy data were only assessed
by the clinician at these intervals.
Patients in the wireless care group were monitored more frequently using wireless modems as
the method to obtain adherence and efficacy data.
We then determined adherence using CMS (Centers for Medicare & Medicaid Services) criteria at
3 months, and at 12 months. To obtain this data, we evaluated whether the PAP devices were
used for 4 or more hours per night on 70% of nights during a consecutive 30-day period
anytime during the first 3 months of initial use, and then a consecutive 30-day period in
months 4-12. We also examined the daily use from the first to last day looking of overall
patterns of utilization monthly, quarterly, semiannually and annually. Data was collected and
maintained in a REDCap database (REDCap is a secure web application for building and managing
online surveys and databases). Sensitivity and specificity calculations were then performed
to evaluate predictability of adherence at 1 year using adherence at 3 months. Fisher's exact
test was also used to evaluate the association between adherence at 3 months and 1 year and
the association between AHI (Apnea -Hypopnea Index) and adherence.
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