Clinical Trials Logo

Clinical Trial Summary

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. The investigators 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.

Clinical Trial Description

Obstructive sleep apnea (OSA) is estimated to be the third most common chronic disease in Veterans and is associated with an increased risk of hypertension, heart attacks, strokes, depression, and driving accidents. Current in-person management at a sleep center limits Veterans' access to care, prolongs patient wait times, and requires Veterans living in remote areas to travel long distances. This proposal will evaluate an innovative web-based clinical pathway to diagnose and manage Veterans with OSA. In FY13, the investigative team received a VHA Innovation Award to create the Remote Veteran Apnea Management Portal (REVAMP), a personalized, interactive website that, when combined with other emerging telehealth technologies, is designed to improve access to care, reduce patient wait times, and allow Veterans to receive care without travelling to a sleep center. Veterans complete intake and follow-up questionnaires on the REVAMP website and perform an unattended home sleep test (HST) without in-person instructions. Sleep specialists review the findings with the patient during an initial phone clinic. REVAMP auto-populates the Veteran's questionnaire responses into templated progress notes that are exported to CPRS, the electronic medical record. Veterans diagnosed with OSA are treated with automatically adjusting positive airway pressure (APAP) units. These devices transmit data wirelessly to the website where treatment use and its effectiveness can be monitored by both Veterans and practitioners, thereby promoting patient self-management and productive patient-practitioner interactions. The investigators' proposed prospective, randomized intervention will compare the clinical and cost-effectiveness of REVAMP management of Veterans with OSA to in-person care. Aim 1 will determine if management with REVAMP is clinically non-inferior to in-person care in terms of improvement in functional outcomes and APAP adherence. Non-inferiority of clinical effectiveness following 3 months of APAP treatment will be expressed in terms of improvement in the score of the Functional Outcomes of Sleep Questionnaire (FOSQ-10), the investigators' primary outcome measure. Adherence to APAP will be objectively monitored by wireless transmission of data from the participant's home unit. In Aim 2, patient preference, medical service use and cost will be collected every 3 months for the entire observation period to compare cost effectiveness of the two managements. Preference will be assessed by the SF-6D,6 and the EQ-5D.7, 8 Differences in the ratio of cost and quality-adjusted life years saved by REVAMP compared to in-person management will test the hypothesis that REVAMP management will have lower cost and equivalent outcomes. The results of Aims 1 and 2 will provide evidence to support widespread dissemination of REVAMP. Formative evaluation in Aim 3 will use qualitative (targeted phone interviews) and quantitative measures (attrition, work alliance, and patient satisfaction) to inform clinicians, administrators and other stakeholders how to implement this innovative chronic disease pathway. Aim 1 (primary). To compare functional outcomes following 3 months of APAP treatment in Veterans with OSA randomized to REVAMP versus in-person management. The primary outcome measure in this modified intent-to-treat analysis (i.e., subjects initiated on APAP with at least one FOSQ follow-up score) will be the change from baseline in the FOSQ-10 score. Analysis will also compare the mean daily hours of APAP use in participants in the two groups initiated on APAP treatment. Hypothesis 1a: Mean change in FOSQ-10 score among participants randomized to REVAMP management will be no more than one point less than that in participants receiving in-person management. Hypothesis 1b: Mean daily hours of APAP use among participants receiving REVAMP management will be no more than 0.75 hour less than that in participants randomized to in-person management. Aim 2 (secondary): To compare the differences in cost and quality-adjusted life years (QALY) between REVAMP management and in-person management. The perspective of the analysis will be that of the VA and the intention to treat analysis set will include all randomized participants. Hypothesis 2a: Average total health-care delivery cost will be lower for participants receiving REVAMP compared to in-person management. Hypothesis 2b: The 90% lower limit of cost per QALY ratio comparing in-person versus REVAMP manage-ment will be > $100,000 (i.e., the investigators will have 90% confidence that REVAMP is good value for the cost). Aim 3 (exploratory): To conduct a mixed methods formative evaluation that will guide REVAMP's widespread implementation. Quantitative component: The investigators will track quantitative outcome measures across both groups including attrition, participant- and practitioner-rated therapeutic alliance (Working Alliance Inventory-Short Revised [WAI-SR]),9 and participant treatment satisfaction (Client Satisfaction Questionnaire [CSQ-8]).10 The investigators will compare the scores of the WAI-SR and CSQ-8 and attrition rates between treatment arms. Qualitative component: The investigators will explore participant- and practitioner-level perspectives, attitudes, and preferences regarding REVAMP versus in-person management, as well as barriers and facilitators to participation in either clinical pathway through phone interviews with participants from the two intervention groups, participants who withdraw from either intervention, and staff who provide care through REVAMP. ;

Study Design

Related Conditions & MeSH terms

NCT number NCT03007745
Study type Interventional
Source VA Office of Research and Development
Status Completed
Phase N/A
Start date October 24, 2017
Completion date January 31, 2021

See also
  Status Clinical Trial Phase
Active, not recruiting NCT03574480 - Smartphone Applications to Improve Lifestyles in Olders Over 65 Years N/A
Not yet recruiting NCT04070066 - Educational Strategy IN Exchange Transfusion N/A
Recruiting NCT04045054 - Home-based Transitional Telecare for Older Veterans N/A
Recruiting NCT04652674 - Impact of Postoperative Telemedicine Visit vs In-person Visit on Patient Satisfaction During the COVID-19 Pandemic N/A
Completed NCT03295474 - Telemonitoring in Pulmonary Rehabilitation: Feasibility and Acceptability of a Remote Pulse Oxymetry System.
Not yet recruiting NCT04983329 - Systematic Quality Improvement With Realtime Event Support N/A
Completed NCT02196428 - Medical Telemonitoring Plus Individual Teleconsultation in Elderly N/A
Completed NCT03025217 - Total Lifestyle Coaching Pilot Study (TLC) N/A
Completed NCT01820234 - Evaluation of Store-and-Forward Teledermatology Versus a Face-to-Face Assessment During a Skin Cancer Screening Event N/A
Recruiting NCT04392518 - Telerehabilitation in Proximal Muscle Weakness N/A
Not yet recruiting NCT04444297 - 3D Telemedicine During COVID-19: Non-clinical Validation N/A
Not yet recruiting NCT04863521 - Evaluation of MHP 3.0 in Two Clinical Settings N/A
Not yet recruiting NCT04513496 - Telemedicine in HIV Care in Buenos Aires
Active, not recruiting NCT03474692 - Virta Health Registry
Completed NCT04789798 - The Efficiency of Telemedicine to Optimize Metabolic Control in Patients With Diabetes in Turkey N/A
Active, not recruiting NCT01324687 - Study Of Telemedicine Consultation at Home For Older Adults N/A
Completed NCT00692497 - Electronic Referral and Booking of Outpatient Day Case Surgery Compared With Traditional Referral Routines. N/A
Completed NCT00527254 - Telemedicine Influence in the Follow up of the Type 2 Diabetes Patient N/A
Completed NCT04312321 - Audiovisual Consultations in Prehospital Emergency Care: Randomised Controlled Trial N/A
Not yet recruiting NCT04591873 - Using Telemedicine to Optimize Teamwork and Infection Control of Critical and Highly-infectious Patients in an Emergency Department