Sleep Disordered Breathing Clinical Trial
Official title:
Evaluation of a "Fast Track" Respiratory Therapy Clinic for Patients With Suspected Severe Sleep-Disordered Breathing
Access to medical care for patients with breathing disorders during sleep is a major problem
for Canadians. Recently, there has been increasing interest in how health care providers who
are not physicians can help to improve access to medical care for these patients, but it is
unclear whether patients with severe sleep-disordered breathing who receive care from these
non-physician providers have the same response to treatment as patients who receive care from
physicians. Since these severe have a high risk of developing cardiac and respiratory
complications and of being hospitalized, an initiative to improve access such as the use of
non-physician providers could be of great benefit to individual patients and the health care
system.
The objectives of this project are:
1. to determine whether patients with severe breathing disorders during sleep have the same
response to treatment when cared for by non-physician health care providers (respiratory
therapists) as they do when cared for by physicians;
2. to determine the effects of non-physician health care provider treatment to patient
access;
3. to determine health care utilization and related costs associated with non-physician
health care provider treatment.
The difficulty in providing timely access to sleep specialists is widespread. These delays
are particularly important for patients with severe SDB due to the increased risk of adverse
clinical outcomes and potential associated healthcare costs. The lack of timely access has
sparked an interest in the use of alternate care providers (ACPs) to manage patients with
SDB. Our group and others have demonstrated that ACPs are an effective and efficient
substitute for physicians for patients with uncomplicated SDB. However, the role of ACPs in
the management of patients with severe SDB remains unclear.
Prompted by wait times that far exceed current Canadian guidelines, we have recently
implemented an ACP-led "Fast Track" clinic for patients who are referred to the Foothills
Medical Centre (FMC) Sleep Centre with suspected severe SDB. In this clinic, patients with
suspected severe SDB are assessed by a sleep-trained registered respiratory therapist
functioning as an ACP. Decisions regarding further sleep testing and treatment are made by
the patient and ACP, under the guidance of a sleep physician. This model of care differs from
a physician-led model that is used at the FMC Sleep Centre.
To evaluate this novel care delivery model, we have designed a randomized trial comparing
outcomes for patients in the "Fast Track" clinic to those who undergo conventional,
physician-led care. The specific goals of this study are:
1. to compare the clinical effectiveness of an ACP-led clinic for patients with suspected
severe SDB to physician-led management;
2. to determine whether cycle times from referral to diagnosis and treatment for patients
referred with suspected severe SDB can be reduced by an ACP-led clinic;
3. to determine the impact of an ACP-led clinic on the demand for sleep physicians, ACPs
and diagnostic testing;
4. to compare the cost-effectiveness of these models of care using data on healthcare
utilization, costs, and patient reported health-related quality of life (HRQOL).
Patients in the "Standard Management" arm will be assessed by a sleep respirologist and
follow a management plan that is determined by the sleep physician and patient. This plan may
involve polysomnography or the initiation of PAP therapy. If further testing is ordered,
follow-up may occur with the physician or with an ACP, at the physician's discretion. For
patients initiating PAP therapy, the decision to delegate follow-up to an ACP will be left up
to the physician, as the intent of this study is to observe real-world practice and not to
change the management of individual patients.
In the "Fast Track" arm, an ACP will perform the initial assessment and will determine the
management plan with the patient. To ensure patient safety, the management plan will be
discussed with a sleep respirologist, who will be designated as the patient's primary sleep
physician. This sleep physician will be available at the FMC Sleep Centre during the "Fast
Track" clinic to assist with the assessment of patients who appear unwell (e.g. severe
hypoxemia, decompensated cardiorespiratory failure, etc.). As in the "Standard Management"
arm, follow-up visits to review test results, discuss and initiate treatment, or to assess
treatment response may occur with the ACP who performed the initial assessment or may be
delegated to any other ACP.
As is usual procedure at the FMC Sleep Centre, ambulatory sleep test requisitions will be
completed by ACPs or physicians, whereas all polysomnogram requisitions will be completed by
the primary sleep physician to ensure adequate blinding of patient assignment. The research
associate will ensure that all tests are interpreted in advance of clinic visits. Patients
who are followed by ACPs in either arm can be referred to the primary sleep physician for
assessment of non-respiratory sleep disorders, or for persistent symptoms such as daytime
sleepiness.
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