Patient Partnerships Transforming Sleep Medicine Research and Clinical Care: Perspectives from the Sleep Apnea Patient-Centered Outcomes Network

Is cognitive behavioral therapy for insomnia (CBTi) efficacious for treating insomnia symptoms in shift workers? A systematic review and meta-analysis

Shift workers commonly report insomnia symptoms. Cognitive behavioral therapy for insomnia (CBTi) is the first line treatment for insomnia, however efficacy in shift workers is not well understood. This systematic review and meta-analysis evaluates existing trials of CBTi in shift working populations. A systematic literature search was conducted across seven electronic databases (n = 2120). Fifty-two full-text articles were reviewed and of these, nine studies (across ten publications with a total of 363 participants) were deemed suitable for inclusion. Heterogeneity was considerable between studies, with variability in study design, style and delivery of intervention, and follow-up times. Small sample sizes were common and attrition was high. Some studies modified aspects of CBTi for use in shift workers, while others were limited to psycho-education as part of larger intervention studies. Mean differences (MD) pre and post CBTi were modest for both the insomnia severity index (ISI; MD: -3.08, 95% CI: -4.39, -1.76) and the Pittsburgh sleep quality index (PSQI; MD: -2.38, 95% CI: -3.55, -1.21). Neither difference was of a magnitude considered to reflect a clinically significant improvement. Tailored approaches to CBTi are needed for shift workers to improve efficacy, ideally including co-production with workers to ensure interventions meet this population's needs.

Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems

STUDY OBJECTIVES

To assess the effectiveness of continuous positive airway pressure (CPAP) management guided by CPAP machine downloads in newly diagnosed patients with obstructive sleep apnea (OSA) using electronic health record-derived health care utilization, biometric variables, and laboratory data.

METHODS

Electronic health record data of patients seen at the University of Utah Sleep Program from 2012-2015 were reviewed to identify patients with new diagnosis of OSA in whom CPAP adherence and residual apnea-hypopnea index as measured by a positive airway pressure adherence tracking device data for ≥ 1 year were available. Biometric data, laboratory data, and system-wide charges were compared in the 1 year before and after CPAP therapy. Subgroups were divided by whether patients met tracking criteria, mean nightly usage, and OSA severity.

RESULTS

976 consecutive, newly diagnosed participants with OSA (median age 55 years, 56.6% male) met inclusion criteria. There was a mean decrease of systolic blood pressure (BP) of 1.2 mm Hg and diastolic BP of 1.0 mm Hg within a year of initiation of CPAP therapy. BP improvements in the subgroup meeting CPAP tracking targets were 1.36 mmHg (systolic) and 1.37 mmHg (diastolic). No significant change was noted in body mass index, glycated hemoglobin, or serum creatinine values within a year of starting CPAP therapy, and health care utilization increased (mean acute care visits 0.22 per year to 0.53 per year; mean charges of $3,997 per year to $8,986 per year).

CONCLUSIONS

An improvement in BP was noted within a year of CPAP therapy in newly diagnosed patients with OSA, with no difference in the magnitude of improvement between those meeting tracking system adherence targets.

CITATION

Locke BW, Neill SE, Howe HE, Crotty MC, Kim J, Sundar KM. Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems. J Clin Sleep Med. 2022;18(3):885-894.

A Health Communication Assessment of Web-based Obstructive Sleep Apnea Patient Education Materials

Background

Objective

Methods

Results

Conclusion

Prevalence of sleepiness and associations with quality of life in patients with sleep apnea in an online cohort

STUDY OBJECTIVES

Excessive daytime sleepiness (EDS) is a treatment target for many patients with obstructive sleep apnea (OSA). We aimed to understand the prevalence, risk factors and quality of life associated with EDS in a non-clinical, "real world" sample of patients with OSA.

METHODS

Cross-sectional survey of patients with OSA participating in an online peer support community, assessing demographics, comorbidities, treatment, and quality of life. Differences in those with and without EDS (Epworth Sleepiness Scale [ESS] > and ≤ 10) were assessed.

RESULTS

The sample (n=422) was 54.2% male, 65.9% were ≥ 55 years, and 43.3% reported sleeping ≤ 6 hours/night. EDS was identified among 31.0% of respondents and 51.7% reported sleepiness as a precipitating factor for seeking initial OSA treatment. EDS was more prevalent in individuals reporting asthma, insomnia symptoms, positive airway pressures (PAP) use less than 6 hours/night on ≥ 5 nights/week, or sleep duration < 6 hours/night. After adjusting for demographics and comorbidities, patients with EDS reported poorer mental and physical health and well-being, lower disease-specific functional status, more activity and work impairment, and more driving impairment (p values < 0.05). In the sub-sample (n=265) with high PAP adherence, 26.0% reported EDS, and similar associations between EDS and outcomes were observed.

CONCLUSIONS

These "real-world" data suggest that patients seeking online OSA support experience a high prevalence of EDS, which was associated with poorer quality of life and worse functional status. Associations persisted among respondents with high self-reported PAP-adherence, potentially driving these individuals to seek online support for sleepiness-related symptoms.

MicroRNAs to guide medical decision-making in obstructive sleep apnea: A review

Obstructive sleep apnea (OSA) is a common and frequently underdiagnosed sleep disorder tightly associated with a wide range of morbidities and an elevated risk of the main causes of mortality. This condition represents a major public health concern due to its increasing worldwide prevalence and its serious pathological consequences. Current clinical guidelines support the importance of effective diagnosis and treatment of OSA and emphasize the unmet need for biomarkers to guide medical decision-making. In recent years, the noncoding transcriptome has emerged as a new opportunity for biomarker discovery. In this review, we provide a brief overview of the current understanding of noncoding RNAs, specifically microRNAs (miRNAs). Then, we carefully address the potential role of miRNAs as novel indicators for the management of both pediatric and adult OSA, highlighting their translational applicability, particularly for diagnosis and therapy allocation. Finally, we identify the gaps in the research state-of-art, discuss current methodological and conceptual limitations and propose future key steps and perspectives for the incorporation of miRNAs into routine clinical practice.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Where to Next for Optimizing Adherence in Large-Scale Trials of Continuous Positive Airway Pressure?

Large-scale randomized trials of positive airway pressure (PAP) efficacy have been largely negative but PAP adherence was notably suboptimal across the trials. To address this limitation, evidence-based PAP adherence protocols embedded within the larger trial protocol are recommended. The complexity of such protocols depends on adequacy of resources, including funding and inclusion of behavioral scientist experts on the scientific team, and trial-specific considerations (eg, target population) and methods. Recommendations for optimizing PAP adherence in large-scale trials are set forth that address rigor and reproducibility.

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence: Unraveling the Puzzle of Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

Effects of exercise on sleep symptoms in patients with severe obstructive sleep apnea

Objective:

To investigate the extent to which exercise is associated with symptoms in patients with severe obstructive sleep apnea (OSA).

Methods:

We included subjects with an apnea-hypopnea index (AHI) > 30 events/h who completed validated sleep and exercise questionnaires. We compared symptom frequency/scores between exercisers and nonexercisers, adjusting for the usual confounders.

Results:

The sample included 907 nonexercisers and 488 exercisers (mean age, 49 ± 14 years; mean AHI, 53 ± 20 events/h; 81% men). Nonexercisers and exercisers differed significantly in terms of obesity (72% vs. 54%), the mean proportion of sleep in non-rapid eye movement stage 3 sleep (9 ± 8% vs. 11 ± 6%), and tiredness (78% vs. 68%). Nonexercisers had a higher symptom frequency/scores and poorer sleep quality. Adjustment for exercise weakened the associations between individual symptoms and the AHI, indicating that exercise has a mitigating effect. In binary logistic models, exercise was associated with approximately 30% lower adjusted questionnaire¹ score > 2, tiredness; poor-quality sleep, unrefreshing sleep, and negative mood on awakening. Although the odds of an Epworth Sleepiness Scale score > 10 were lower in exercisers, that association did not withstand adjustment for confounders.

Conclusions:

Exercise is associated with lower frequency/intensity of symptoms in patients with severe OSA. Because up to one third of patients with severe OSA might exercise regularly and therefore be mildly symptomatic, it is important not to rule out a diagnosis of OSA in such patients.

Patient satisfaction with sleep study experience: findings from the Sleep Apnea Patient-Centered Outcomes Network

Study Objectives

Home sleep apnea testing (HSAT) is increasingly used as an alternative to laboratory-based polysomnography (PSG) for the diagnosis of obstructive sleep apnea. Patient satisfaction with sleep testing performed at home or in the lab has been sparsely assessed, despite its potentially pivotal role in determining patients' acceptance of sleep apnea treatment. We hypothesize that satisfaction in clinical practice may differ from what has been previously reported within the research setting.

Methods

We analyzed survey data including responses to questions regarding diagnostic sleep study type and sleep study experience satisfaction from 2563 sleep apnea patients enrolled in the Sleep Apnea Patient-Centered Outcomes Network.

Results

Patients (mean age 57 years; 54% male) who underwent in-lab PSG were more likely to be satisfied with their study experience than patients who had a HSAT (71% vs 60%; p < 0.01). Furthermore, the 38 per cent diminished odds of satisfaction in patients having HSAT (OR: 0.62; 95% CI: 0.49-0.77) persisted after adjustment for potential confounders (OR: 0.41, 95% CI; 0.27-0.63). Greater sleep apnea symptom burden and satisfaction with CPAP therapy were associated with greater study satisfaction. Effect modifications on study types by college degree education and tiredness as a study trigger were detected.

Conclusions

Patients receiving care in the community who underwent PSG reported greater satisfaction with study experience than patients who underwent HSAT in contrast to findings from randomized controlled trials. Our findings, based on data from contemporary "real-world" settings, suggest that assumptions about the generalizability of early reports comparing in-lab PSG to home-based paradigms need to be revisited.

Optimisation of follow-up after metabolic surgery

Bariatric surgery has many benefits beyond weight loss, including improved control of glycaemia, blood pressure, and dyslipidaemia; hence, such surgery has been rebranded as metabolic surgery. The operations are, unfortunately, also associated with major surgical and medical complications. The medical complications include gastro-oesophageal reflux disease, malnutrition, and metabolic complications deriving from vitamin and mineral malabsorption. The benefits of surgery can be optimised by implementing specific protocols before and after surgery. In this Review, we discuss the assessment of the risk of major cardiac complications and severe obstructive sleep apnoea before surgery, and the provision of adequate lifelong postsurgery nutritional, vitamin, and mineral supplementation to reduce complications. Additionally, we examine the best antidiabetic medications to reduce the risk of hypoglycaemia after gastric bypass and sleeve gastrectomy, and the strategies to improve weight loss or reduce weight regain. Although optimising clinical pathways is possible to maximise metabolic benefits and reduce the risks of complications and micronutrient deficiencies, evolution of these strategies can further improve the risk-to-benefit ratio of metabolic surgery.

Twelve Lessons Learned for Effective Research Partnerships Between Patients, Caregivers, Clinicians, Academic Researchers, and Other Stakeholders

Research increasingly means that patients, caregivers, health professionals, other stakeholders, and academic investigators work in partnership. This requires effective collaboration rooted in mutual respect, involvement of all participants, and good communication. Having conducted such partnered research over multiple projects, and having recently completed a project together funded by the Patient-Centered Outcomes Research Institute, we collaboratively developed a list of 12 lessons we have learned about how to ensure effective research partnerships. To foster a culture of mutual respect, hold early in-person meetings, with introductions focused on motivation, offer appropriate orientation for everyone, and maintain awareness of individual and project goals. To actively involve all team members, it is important to ensure sufficient funding for everyone's participation, to ask for and recognize diverse contributions, and to seek the input of quiet members. To facilitate good communication, teams should carefully consider labels, avoid jargon and acronyms, judiciously use homogeneous and heterogeneous subgroups, and keep progress visible. In offering pragmatic, actionable lessons we have learned through our separate and shared experiences, we hope to help foster more patient-centered research via productive and enjoyable research collaborations.

People-Centered Language Recommendations for Sleep Research Communication

The growing embrace of patient-centered outcomes research (PCOR) in sleep medicine is a significant step forward for the field. In engaging and incorporating the unique perspectives of people with sleep disorders, PCOR enhances the relevance of findings and facilitates the uptake of research into practice. While centering research design around what matters most to people with sleep disorders is critical, research communication must be similarly people-centered. One approach is using "people-centered language" in both professional and public communications. People-centered language is rooted in sociolinguistic research demonstrating that language both reflects and shapes attitudes. People-centered language puts people first, is precise and neutral, and respects autonomy. By adhering to the language guidelines described in this article, sleep researchers will better serve the field's most important stakeholders.

P4 medicine approach to obstructive sleep apnoea

P4 medicine is an evolving approach to personalized medicine. The four Ps offer a means to: Predict who will develop disease and co-morbidities; Prevent rather than react to disease; Personalize diagnosis and treatment; have patients Participate in their own care. P4 medicine is very applicable to obstructive sleep apnoea (OSA) because each OSA patient has a different pathway to disease and its consequences. OSA has both structural and physiological mechanisms with different clinical subgroups, different molecular profiles and different consequences. This may explain why there are different responses to alternative therapies, such as intraoral devices and hypoglossal nerve stimulation therapy. Currently, technology facilitates patients to participate in their own care from screening for OSA (snoring and apnoea apps) to monitoring response to therapy (sleep monitoring, blood pressure, oxygen saturation and heart rate) as well as monitoring their own continuous positive airway pressure (CPAP) compliance. We present a conceptual framework that provides the basis for a new, P4 medicine approach to OSA and should be considered more in depth: predict and prevent those at high risk for OSA and consequences, personalize the diagnosis and treatment of OSA and build in patient participation to manage OSA.

Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review

Background

Intensivists’ clinical decision making pursues two main goals for patients: to decrease mortality and to improve quality of life and functional status in survivors. Patient-important outcomes are gaining wide acceptance in most fields of clinical research. We sought to systematically review how well patient-important outcomes are reported in published randomized controlled trials (RCTs) in critically ill patients.

Methods

Literature search was conducted to identify eligible trials indexed from January to December 2013. Articles were eligible if they reported an RCT involving critically ill adult patients. We excluded phase II, pilot and physiological crossover studies. We assessed study characteristics. All primary and secondary outcomes were collected, described and classified using six categories of outcomes including patient-important outcomes (involving mortality at any time on the one hand and quality of life, functional/cognitive/neurological outcomes assessed after ICU discharge on the other).

Results

Of the 716 articles retrieved in 2013, 112 RCTs met the inclusion criteria. Most common topics were mechanical ventilation (27%), sepsis (19%) and nutrition (17%). Among the 112 primary outcomes, 27 (24%) were patient-important outcomes (mainly mortality, 21/27) but only six (5%) were patient-important outcomes besides mortality assessed after ICU discharge (functional disability = 4; quality of life = 2). Among the 598 secondary outcomes, 133 (22%) were patient-important outcomes (mainly mortality, 92/133) but only 41 (7%) were patient-important outcomes besides mortality assessed after ICU discharge (quality of life = 20, functional disability = 14; neurological/cognitive performance = 5; handicap = 1; post-traumatic stress = 1). Seventy-three RCTs (65%) reported at least one patient-important outcome but only 11 (10%) reported at least one patient-important outcome besides mortality assessed after ICU discharge.

Conclusion

Patient-important outcomes are rarely primary outcomes in RCTs in critically ill patients published in 2013. Among them, mortality accounted for the majority. We promote the use of patient-important outcomes in critical care trials.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0243-z) contains supplementary material, which is available to authorized users.

Patient-centered care in obstructive sleep apnea: A vision for the future

Obstructive sleep apnea is a common condition, with multiple potential neurocognitive, cardiovascular, and metabolic consequences. Efficacious treatment is available, but patient engagement is typically required for treatment to be effective. Patients with sleep apnea are phenotypically diverse and have individual needs, preferences, and values that impact treatment decisions. There has been a shift in obstructive sleep apnea management from diagnosis to chronic care management. Making treatment decisions that incorporate an individual patient's values and preferences and are personalized for that patient's biology has the potential to improve patient outcomes. A patient-centered care approach in obstructive sleep apnea is reviewed including 1) determining patient-specific needs to guide treatment decisions, 2) understanding patient values, preferences, and other factors impacting treatment decisions and using shared decision-making, 3) enhancing patient education and support to improve treatment adherence, 4) promoting patient engagement, 5) optimizing care coordination, continuity of care, and access to care, and 6) determining and assessing patient-centered outcomes.