Comparative Effectiveness of Sleep Apnea Screening Instruments During Inpatient Rehabilitation Following Moderate to Severe TBI

Cost-Effectiveness of Sleep Apnea Diagnosis and Treatment in Hospitalized Persons With Moderate to Severe Traumatic Brain Injury

OBJECTIVE

To assess the cost-effectiveness of alternative approaches to diagnose and treat obstructive sleep apnea (OSA) in patients with traumatic brain injury (TBI) during inpatient rehabilitation.

SETTING

Data collected during the Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS) clinical trial (NCT03033901) on an inpatient rehabilitation TBI cohort were used in this study.

STUDY DESIGN

Decision tree analysis was used to determine the cost-effectiveness of approaches to diagnosing and treating sleep apnea. Costs were determined using 2021 Centers for Medicare and Medicaid Services reimbursement codes. Effectiveness was defined in terms of the appropriateness of treatment. Costs averted were extracted from the literature. A sensitivity analysis was performed to account for uncertainty. Analyses were performed for all severity levels of OSA and a subgroup of those with moderate to severe OSA. Six inpatient approaches using various phases of screening, testing, and treatment that conform to usual care or guideline-endorsed interventions were evaluated: (1) usual care; (2) portable diagnostic testing followed by laboratory-quality testing; (3) screening with the snoring, tiredness, observed apnea, high BP, BMI, age, neck circumference, and male gender (STOP-Bang) questionnaire; (4) Multivariable Apnea Prediction Index (MAPI) followed by portable diagnostic testing and laboratory-quality testing; (5) laboratory-quality testing for all; and (6) treatment for all patients.

MAIN MEASURES

Cost, Effectiveness, and Incremental Cost-Effectiveness Ratio (ICER).

RESULTS

Phased approaches utilizing screening and diagnostic tools were more effective in diagnosing and allocating treatment for OSA than all alternatives in patients with mild to severe and moderate to severe OSA. Usual care was more costly and less effective than all other approaches for mild to severe and moderate to severe OSA.

CONCLUSIONS

Diagnosing and treating OSA in patients with TBI is a cost-effective strategy when compared with usual care.

Enhancing Spinal Cord Injury Care: Using Wearable Technologies for Physical Activity, Sleep, and Cardiovascular Health

Wearable devices have the potential to advance health care by enabling real-time monitoring of biobehavioral data and facilitating the management of an individual's health conditions. Individuals living with spinal cord injury (SCI) have impaired motor function, which results in deconditioning and worsening cardiovascular health outcomes. Wearable devices may promote physical activity and allow the monitoring of secondary complications associated with SCI, potentially improving motor function, sleep, and cardiovascular health. However, several challenges remain to optimize the application of wearable technologies within this population. One is striking a balance between research-grade and consumer-grade devices in terms of cost, accessibility, and validity. Additionally, limited literature supports the validity and use of wearable technology in monitoring cardio-autonomic and sleep outcomes for individuals with SCI. Future directions include conducting performance evaluations of wearable devices to precisely capture the additional variation in movement and physiological parameters seen in those with SCI. Moreover, efforts to make the devices small, lightweight, and inexpensive for consumer ease of use may affect those with severe motor impairments. Overcoming these challenges holds the potential for wearable devices to help individuals living with SCI receive timely feedback to manage their health conditions and help clinicians gather comprehensive patient health information to aid in diagnosis and treatment.

Increased Risk for Clinically Significant Sleep Disturbances in Mild Traumatic Brain Injury: An Approach to Leveraging the Federal Interagency Traumatic Brain Injury Research Database

STUDY OBJECTIVES

The Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System contains individual-patient-level traumatic brain injury (TBI) data, which when combined, allows for the examination of rates and outcomes for key subpopulations at risk for developing sleep disturbance.

METHODS

This proof-of-concept study creates a model system for harmonizing data (i.e., combining and standardizing data) across FITBIR studies for participants with and without a history of TBI to estimate rates of sleep disturbance and identify risk factors.

RESULTS

Three studies were eligible for harmonization (N = 1753). Sleep disturbance was common among those with a history of mild TBI (63%). Individuals with mild TBI were two to four times more likely to have sleep disturbance compared to those with no history of TBI.

CONCLUSIONS

This study established methods, harmonization code, and meta-databases that are publicly available on the FITBIR website. We demonstrated how the harmonization of FITBIR studies can answer TBI research questions, showing that associations between TBI and sleep disturbance may be influenced by demographic factors.

Exploring the relationship between sleep apnea and vestibular symptoms following traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a complex health problem in military veterans and service members (V/SM) that often involves comorbid vestibular impairment. Sleep apnea is another comorbidity that may exacerbate, and/or be exacerbated by, vestibular dysfunction.

OBJECTIVE

To examine the relationship between sleep apnea and vestibular symptoms in V/SM diagnosed with TBI of any severity.

DESIGN

Multicenter cohort study; cross-sectional sample.

SETTING

In-patient TBI rehabilitation units within five Veterans Affairs (VA) Polytrauma Rehabilitation Centers.

PARTICIPANTS

V/SM with a diagnosis of TBI (N = 630) enrolled in the VA TBI Model Systems study.

INTERVENTION

Not applicable.

METHODS

A multivariable regression model was used to evaluate the association between sleep apnea and vestibular symptom severity while controlling for relevant covariates, for example, posttraumatic stress disorder (PTSD).

MAIN OUTCOME MEASURES

Lifetime history of sleep apnea was determined via best source reporting. Vestibular disturbances were measured with the 3-item Vestibular subscale of the Neurobehavioral Symptom Inventory (NSI).

RESULTS

One third (30.6%) of the sample had a self-reported sleep apnea diagnosis. Initial analysis showed that participants who had sleep apnea had more severe vestibular symptoms (M = 3.84, SD = 2.86) than those without sleep apnea (M = 2.88, SD = 2.67, p < .001). However, when the data was analyzed via a multiple regression model, sleep apnea no longer reached the threshold of significance as a factor associated with vestibular symptoms. PTSD severity was shown to be significantly associated with vestibular symptoms within this sample (p < .001).

CONCLUSION

Analysis of these data revealed a relationship between sleep apnea and vestibular symptoms in V/SM with TBI. The significance of this relationship was affected when PTSD symptoms were factored into a multivariable regression model. However, given that the mechanisms and directionality of these relationships are not yet well understood, we assert that in terms of clinical relevance, providers should emphasize screening for each of the three studied comorbidities (sleep apnea, vestibular symptoms, and PTSD).

Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study

STUDY OBJECTIVES

To explore the relationship between polysomnography-derived respiratory indices and chronic pain status among individuals following traumatic brain injury (TBI).

METHODS

Participants (n = 66) with moderate to severe TBI underwent polysomnography during inpatient acute rehabilitation and their chronic pain status was assessed at 1- to 2-year follow-up as part of the TBI Model Systems Pain Collaborative Study. Pairwise comparisons across pain cohorts (ie, chronic pain, no history of pain) were made to explore differences on polysomnography indices.

RESULTS

Among our total sample, approximately three-quarters (74.2%) received sleep apnea diagnoses utilizing American Academy of Sleep Medicine criteria, with 61.9% of those endorsing a history of chronic pain. Of those endorsing chronic pain, the average pain score was 4.8 (standard deviation = 2.1), with a mean interference score of 5.3 (2.7). Pairwise comparisons revealed that those endorsing a chronic pain experience at follow-up experienced categorically worse indicators of sleep-related breathing disorders during acute rehabilitation relative to those who did not endorse chronic pain. Important differences were observed with elevations on central (chronic pain: 2.6; no pain: 0.8 per hour) and obstructive apnea (chronic pain: 15.7; no pain: 11.1 per hour) events, as well as oxygen desaturation indices (chronic pain: 19.6; no pain: 7.9 per hour).

CONCLUSIONS

Sleep-disordered breathing appears worse among those who endorse chronic pain following moderate-to-severe TBI, but additional research is needed to understand its relation to postinjury pain. Prospective investigation is necessary to determine how clinical decisions (eg, opioid therapy) and intervention (eg, positive airway pressure) may mutually influence outcomes.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome (C-SAS); URL: https://clinicaltrials.gov/ct2/show/NCT03033901; Identifier: NCT03033901.

CITATION

Martin AM, Pinto SM, Tang X, et al. Associations between early sleep-disordered breathing following moderate-to-severe traumatic brain injury and long-term chronic pain status: a Traumatic Brain Injury Model Systems study. J Clin Sleep Med. 2023;19(1):135-143.

Obstructive sleep apnea is associated with worse cognitive outcomes in acute moderate-to-severe traumatic brain injury: A TBI Model Systems study

OBJECTIVE

To examine the relationship between polysomnography-classified obstructive sleep apnea (OSA) severity and cognitive performance in acute moderate-to-severe traumatic brain injury (TBI).

METHOD

This was a cross-sectional, secondary analysis leveraging data from a clinical trial (NCT03033901) and TBI Model Systems. Sixty participants (mean age = 50 ± 18y, 72% male, 67% white) with moderate-to-severe TBI from five civilian rehabilitation hospitals were assessed at one-month post-injury. Participants underwent Level 1 polysomnography. OSA severity was classified as mild, moderate, and severe using the Apnea-Hypopnea Index (AHI). Associations between OSA metrics of hypoxemia (nadir and total time spent below 90%) and AHI with cognition were examined. Cognition was assessed with the Brief Test of Adult Cognition by Telephone (BTACT), which is comprised of six subtests assessing verbal memory, attention/working memory, processing speed, language, and executive function.

RESULTS

Over three-quarters of this acute TBI sample (76.7%) were diagnosed with OSA (no OSA n = 14; mild OSA n = 19; moderate/severe OSA n = 27). After adjustment for age, gender, and education, those with OSA had worse processing speed, working memory, and executive functioning compared to those without OSA. Compared to those with moderate/severe OSA, those with mild OSA had worse working memory and executive function.

CONCLUSIONS

OSA is highly prevalent during acute stages of TBI recovery, and even in mild cases is related to poorer cognitive performance, particularly in the domains of attention/working memory and executive functioning. Our results support the incorporation of OSA diagnostic tools and interventions into routine clinical care in rehabilitation settings.

Research Letter: Impact of Obstructive Sleep Apnea Disease Duration on Neuropsychological Functioning After Traumatic Brain Injury: A Veterans Affairs TBI Model Systems Study

OBJECTIVE

To examine the relationship between obstructive sleep apnea (OSA) disease duration and cognitive functioning in those with a history of traumatic brain injury (TBI). We hypothesized that longer OSA duration would predict poorer cognitive performance.

SETTING

Inpatient brain injury units at a Veterans Affairs (VA) Polytrauma Rehabilitation Center.

PARTICIPANTS

Participants in the VA TBI Model Systems multicenter longitudinal study who enrolled in a modular substudy (April 15, 2018, to January 15, 2021) examining cognition following TBI. All participants had received inpatient rehabilitation for TBI and reported a diagnosis of OSA ( n = 89, mean age = 40.8 years, 97% male, 81% White). Reported duration of OSA ranged from 2 to 7 years (mean = 4.2; SD = 3.9).

DESIGN

Retrospective analysis of prospective cohort, cross-sectional.

MAIN MEASURES

Brief Test of Adult Cognition by Telephone (BTACT).

RESULTS

Controlling for age, education, and time to follow commands, OSA disease duration was negatively associated with delayed verbal memory ( R2Δ = 0.053, F(1,84) = 5.479, P = .022). Performance in other cognitive domains was not significantly associated with OSA disease duration.

CONCLUSION

This study provides preliminary evidence that longer duration of OSA (ie, time since diagnosis) has a negative impact on verbal memory in those with a history of hospitalized TBI. This finding extends the literature (which focused on the general population) on the cognitive impact of OSA and is consistent with hypothesized mechanisms such as hippocampal damage and secondary impact of fatigue. Findings suggest that early OSA identification and treatment may be prudent for persons with TBI.

A comparison of agreement between actigraphy and polysomnography for assessing sleep during posttraumatic amnesia

STUDY OBJECTIVES

Sleep disturbance often emerges in the early recovery phase following a moderate to severe traumatic brain injury, known as posttraumatic amnesia. Actigraphy is commonly employed to assess sleep, as it is assumed that patients in posttraumatic amnesia (who display confusion, restlessness, and agitation) would better tolerate this measure over gold-standard polysomnography (PSG). This study evaluated the agreement between PSG and actigraphy for determining (sleep/wake time, sleep efficiency, sleep latency, and awakenings) in patients experiencing posttraumatic amnesia. It also compared the epoch-by-epoch sensitivity, specificity, and accuracy between the Actigraph device's 4 wake threshold settings (low, medium, high, and automatic) to PSG.

METHODS

The sample consisted of 24 inpatients recruited from a traumatic brain injury inpatient rehabilitation unit. Ambulatory PSG was recorded overnight at bedside and a Philips Actiwatch was secured to each patient's wrist for the same period.

RESULTS

There were poor correlations between PSG and actigraphy for all parameters (Lin's concordance correlation coefficient = < 0.80). The low threshold displayed the highest correlation with PSG for wake and sleep time, albeit still low. Actigraphy displayed low specificity (ranging from 17.1% to 36.6%). There appears to be a greater disparity between actigraphy and PSG for patients with increased wake time.

CONCLUSIONS

Actigraphy, while convenient, demonstrated poorer performance in determining sleep-wake parameters in patients with significantly disturbed sleep. Ambulatory PSG can provide a clearer understanding of the extent of sleep disturbances in these patients with reduced mobility during early rehabilitation. Study findings can help design future protocols of sleep assessment during posttraumatic amnesia and optimize treatment.

CITATION

Fedele B, McKenzie D, Williams G, Giles R, Olver J. A comparison of agreement between actigraphy and polysomnography for assessing sleep during posttraumatic amnesia. J Clin Sleep Med. 2022;18(11):2605-2616.

The Impact of Opioid Medications on Sleep Architecture and Nocturnal Respiration During Acute Recovery From Moderate to Severe Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVES

To describe patient and clinical characteristics associated with receipt of opioid medications and identify differences in sleep quality, architecture, and sleep-related respiration between those receiving and not receiving opioid medications.

SETTING

Acute inpatient rehabilitation care for moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

A total of 248 consecutive admissions for inpatient rehabilitation care following moderate to severe TBI (average age of 43.6 years), who underwent level 1 polysomnography (PSG) (average time since injury: 120 days) across 6 sites.

DESIGN

Cross-sectional, secondary analyses.

MAIN MEASURES

The PSG sleep parameters included total sleep time (TST), sleep efficiency (SE), wake after sleep onset, rapid eye movement (REM) latency, sleep staging, and arousal and awakening indices. Respiratory measures included oxygen saturation, central apnea events per hour, obstructive apnea and hypopnea events per hour, and total apnea-hypopnea index.

RESULTS

After adjustment for number of prescribed medication classes, those receiving opioid medications on the day of PSG experienced increased TST relative to those not receiving opioid medications (estimated mean difference [EMD] = 31.58; 95% confidence interval [CI], 1.9-61.3). Other indices of sleep did not differ significantly between groups. Among respiratory measures those receiving opioids on the day of PSG experienced increased frequency of central sleep apnea events during total (EMD = 2.92; 95% CI, 0.8-5.0) and non-REM sleep (EMD = 3.37; 95% CI, 1.0-5.7) and higher frequency of obstructive sleep apnea events during REM sleep (EMD = 6.97; 95% CI, 0.1-13.8). Compared with those who did not, receiving opioids was associated with lower oxygen saturation nadir during total sleep (EMD = -3.03; 95% CI, -5.6 to -0.4) and a greater number of oxygen desaturations across REM (EMD = 8.15; 95% CI, 0.2-16.1), non-REM (EMD = 7.30; 95% CI, 0.3-14.4), and total sleep (EMD = 8.01; 95% CI, 0.8-15.2) Greater total apnea-hypopnea index was observed during REM (EMD = 8.13; 95% CI, 0.8-15.5) and total sleep (EMD = 7.26; 95% CI, 0.08-14.4) for those receiving opioids.

CONCLUSION

Opioid use following moderate to severe TBI is associated with an increase in indicators of sleep-related breathing disorders, a modifiable condition that is prevalent following TBI. As sleep-wake disorders are associated with poorer rehabilitation outcomes and opioid medications may frequently be administered following traumatic injury, additional longitudinal investigations are warranted in determining whether a causal relation between opioids and sleep-disordered breathing in those following moderate to severe TBI exists. Given current study limitations, future studies can improve upon methodology through the inclusion of indication for and dosage of opioid medications in this population when examining these associations.

Obstructive Sleep Apnea Risk Is Associated with Cognitive Impairment after Controlling for Mild Traumatic Brain Injury History: A Chronic Effects of Neurotrauma Consortium Study

The contribution of sleep disturbance to persistent cognitive symptoms following a mild traumatic brain injury (mTBI) remains unclear. Obstructive sleep apnea (OSA) is very common, yet its relationship between risk factors for developing OSA and cognitive performance in those with history of mTBI has not been investigated. The current study examined OSA risk levels and its association with cognitive performance in 391 combat-exposed, post-911 veterans and service members (median age = 37 years) enrolled in the Chronic Effects of Neurotrauma Consortium (CENC) prospective multi-center study. Participants included those with and without mTBI (n = 326 and 65, respectively). When using clinical cut-offs, those with history of mTBI were more likely to be categorized as high risk for OSA (mTBI positive = 65% vs. mTBI negative = 51%). After adjustment for TBI status and demographic variables, increased OSA risk was significantly associated with worse performance on measures of complex processing speed and executive functioning (Wechsler Adult Intelligence Scale Fourth Edition Coding, Trail Making Test, part B) and greater symptom burden (Neurobehavioral Symptom Inventory). Thus, OSA, a modifiable behavioral health factor, likely contributes to cognitive performance following mTBI. Accordingly, OSA serves as a potential point of intervention to improve clinical and cognitive outcomes after injury.

Concordance between current American Academy of Sleep Medicine and Centers for Medicare and Medicare scoring criteria for obstructive sleep apnea in hospitalized persons with traumatic brain injury: a VA TBI Model System study

STUDY OBJECTIVES

The objective of this study was to compare obstructive sleep apnea (OSA), demographic, and traumatic brain injury (TBI) characteristics across the American Academy of Sleep Medicine (AASM) and Centers for Medicare and Medicare (CMS) scoring rules in moderate to severe TBI undergoing inpatient neurorehabilitation.

METHODS

This is a secondary analysis from a prospective clinical trial of sleep apnea at 6 TBI Model System study sites (n = 248). Scoring was completed by a centralized center using both the AASM and CMS criteria for OSA. Hospitalization and injury characteristics were abstracted from the medical record, and demographics were obtained by interview by trained research assistants using TBI Model System standard procedures.

RESULTS

OSA was prevalent using the AASM (66%) and CMS (41.5%) criteria with moderate to strong agreement (weighted κ = 0.64; 95% confidence interval = 0.58-0.70). Significant differences were observed for participants meeting AASM and CMS criteria (concordant group) compared with those meeting criteria for AASM but not CMS (discordant group). At an apnea-hypopnea index ≥ 5 events/h, the discordant group (n = 61) had lower Emergency Department Glasgow Coma Scale Scores consistent with greater injury severity (median, 5 vs 13; P = .0050), younger age (median, 38 vs 58; P < .0001), and lower body mass index (median, 22.1 vs 24.8; P = .0007) compared with the concordant group (n = 103). At an apnea-hypopnea index ≥ 15 events/h, female sex but no other differences were noted, possibly because of the smaller sample size.

CONCLUSIONS

The underestimation of sleep apnea using CMS criteria is consistent with prior literature; however, this is the first study to report the impact of the criteria in persons with moderate to severe TBI during a critical stage of neural recovery. Management of comorbidities in TBI has become an increasing focus for optimizing TBI outcomes. Given the chronic morbidity after moderate to severe TBI, the impact of CMS policy for OSA diagnosis for persons with chronic disability and young age are considerable.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Comparison of Sleep Apnea Assessment Strategies to Maximize TBI Rehabilitation Participation and Outcome; Identifier: NCT03033901.

Cost-Benefit Analysis From the Payor's Perspective for Screening and Diagnosing Obstructive Sleep Apnea During Inpatient Rehabilitation for Moderate to Severe TBI

OBJECTIVE

To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor's perspective.

DESIGN

A cost-benefit analysis of phased approaches to sleep apnea diagnosis.

SETTING

Six TBI Model System Inpatient Rehabilitation Centers.

PARTICIPANTS

Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle-related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5).

INTERVENTION

Not applicable.

MAIN OUTCOME

Cost benefit.

RESULTS

At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [-$5291], Multivariable Apnea Prediction Index MAPI [-$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (-$5210) and initial use of laboratory-quality polysomnography (-$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (-$6323) relative to the screening models (MAPI [-$6250], STOPBANG [-$6237) and initial assessment with polysomnography (-$5977) resulted in greater savings and cost-effectiveness.

CONCLUSIONS

The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.