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Nokes B, Sarmiento KF, Owens RL. Philips leaving the United States: what does that mean for physicians, patients and everyone in between? J Clin Sleep Med 2024. [PMID: 38656814 DOI: 10.5664/jcsm.11188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Brandon Nokes
- Sleep Medicine Section, Veterans Affairs San Diego Healthcare System, San Diego, CA
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego (UCSD), CA
| | - Kathleen F Sarmiento
- Department of Medicine, University of California, San Francisco, San Francisco, California
- Pulmonary, Critical Care, and Sleep Medicine, San Francisco VA Health Care System, San Francisco, California
| | - Robert L Owens
- Division of Pulmonary, Critical Care, Sleep Medicine and Physiology, University of California, San Diego (UCSD), CA
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2
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Sarmiento KF, Gomez A, Atwood CW. Time for a unified federal sleep health care workforce? J Clin Sleep Med 2024. [PMID: 38597894 DOI: 10.5664/jcsm.11158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Kathleen F Sarmiento
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA
| | - Alexander Gomez
- Department of Medicine, San Francisco VA Health Care System, San Francisco, CA
| | - Charles W Atwood
- Division of Sleep Medicine, Department of Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, UPMC, Pittsburgh, PA
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3
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Belkora JK, Ortiz DeBoque L, Folmer RL, Totten AM, Williams K, Whooley MA, Boudreau E, Atwood CW, Zeidler M, Rezayat T, Chilakamarri P, Sarmiento KF. Sustainment of the TeleSleep program for rural veterans. Front Health Serv 2023; 3:1214071. [PMID: 38028943 PMCID: PMC10668014 DOI: 10.3389/frhs.2023.1214071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023]
Abstract
Background In fiscal year 2021, the Veterans Health Administration (VHA) provided care for sleep disorders to 599,966 Veterans, including 189,932 rural Veterans. To further improve rural access, the VA Office of Rural Health developed the TeleSleep Enterprise-Wide Initiative (EWI). TeleSleep's telemedicine strategies include tests for sleep apnea at the Veteran's home rather than in a sleep lab; Clinical Video Telehealth applications; and other forms of virtual care. In 2017 and 2020, VHA provided 3-year start-up funding to launch new TeleSleep programs at rural-serving VA medical facilities. Methods In early 2022, we surveyed leaders of 24 sites that received TeleSleep funding to identify successes, failures, facilitators, and barriers relevant to sustaining TeleSleep implementations upon expiration of startup funding. We tabulated frequencies on the multiple choice questions in the survey, and, using the survey's critical incident framework, summarized the responses to open-ended questions. TeleSleep program leaders discussed the responses and synthesized recommendations for improvement. Results 18 sites reported sustainment, while six were "on track." Sustainment involved medical centers or regional entities incorporating TeleSleep into their budgets. Facilitators included: demonstrating value; aligning with local priorities; and collaborating with spoke sites serving rural Veterans. Barriers included: misalignment with local priorities; and hiring delays. COVID was a facilitator, as it stimulated adoption of telehealth practices; and also a barrier, as it consumed attention and resources. Recommendations included: longer startup funding; dedicated funding for human resources to accelerate hiring; funders communicating with local facility leaders regarding how TeleSleep aligns with organizational priorities; hiring into job classifications aligned with market pay; and obtaining, from finance departments, projections and outcomes for the return on investment in TeleSleep.
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Affiliation(s)
- Jeffrey K. Belkora
- San Francisco VA Health Care System, San Francisco, CA, United States
- Institute for Health Policy Studies and Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | | | - Robert L. Folmer
- VA Portland Health Care System, Portland, OR, United States
- Department of Otolaryngology, Oregon Health & Science University, Portland, OR, United States
| | - Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
| | - Katherine Williams
- Measurement Science Quality Enhancement Research Initiative, San Francisco VA Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Mary A. Whooley
- Measurement Science Quality Enhancement Research Initiative, San Francisco VA Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Eilis Boudreau
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States
- Department of Neurology, Oregon Health & Science University, Portland, OR, United States
| | - Charles W. Atwood
- Pulmonary Section and Sleep Medicine, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Division of Pulmonary, Allergy, Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, PA, United States
| | - Michelle Zeidler
- Pulmonary, Critical Care, and Sleep Medicine, VA Greater Los Angeles Health Care System, Los Angeles, CA, United States
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Talayeh Rezayat
- San Francisco VA Health Care System, San Francisco, CA, United States
- Department of Medicine, University of Nevada, Reno, NV, United States
| | - Priyanka Chilakamarri
- San Francisco VA Health Care System, San Francisco, CA, United States
- Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| | - Kathleen F. Sarmiento
- San Francisco VA Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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4
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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5
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Chun VS, Whooley MA, Williams K, Zhang N, Zeidler MR, Atwood CW, Folmer RL, Totten AM, Smith CJ, Boudreau EA, Reichert JM, Sarmiento KF. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. J Clin Sleep Med 2023; 19:913-923. [PMID: 36708262 PMCID: PMC10152352 DOI: 10.5664/jcsm.10488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/17/2022] [Accepted: 12/20/2022] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES The Veterans Health Administration cares for many veterans with sleep disorders who live in rural areas. The Veterans Health Administration's Office of Rural Health funded the TeleSleep Enterprise-Wide Initiative (EWI) to improve access to sleep care for rural veterans through creation of national telehealth networks. METHODS The TeleSleep EWI consists of (1) virtual synchronous care, (2) home sleep apnea testing, and (3) REVAMP (Remote Veterans Apnea Management Platform), a patient- and provider-facing web application that enabled veterans to actively engage with their sleep care and sleep care team. The TeleSleep EWI was designed as a hub-and-spoke model, where larger sites with established sleep centers care for smaller, rural sites with a shortage of providers. Structured formative evaluation for the TeleSleep EWI is supported by the Veterans Health Administration's Quality Enhancement Research Initiative and was critical in assessing outcomes and effectiveness of the program. RESULTS The TeleSleep EWI launched with 7 hubs and 34 spokes (2017) and rapidly expanded to 13 hubs and 63 spokes (2020). The TeleSleep EWI resulted in a significant increase in rural veterans accessing sleep care by utilizing home sleep apnea testing to establish a diagnosis of obstructive sleep apnea and virtual care for follow-up. Rates of virtual care utilization were greater in hubs and spokes participating in the TeleSleep EWI compared with non-EWI sleep programs. Additionally, veterans expressed satisfaction with their virtual care TeleSleep experiences. CONCLUSIONS The TeleSleep EWI successfully increased sleep care access for rural veterans, promoted adoption of virtual care services, and resulted in high patient satisfaction. CITATION Chun VS, Whooley MA, Williams K, et al. Veterans Health Administration TeleSleep Enterprise-Wide Initiative 2017-2020: bringing sleep care to our nation's veterans. J Clin Sleep Med. 2023;19(5):913-923.
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Affiliation(s)
- Victor S. Chun
- Pulmonary, Critical Care, and Sleep Medicine, Veterans Administration (VA) Greater Los Angeles Health Care System, Los Angeles, California
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Mary A. Whooley
- Measurement Science Quality Enhancement Research Initiative, San Francisco VA Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Katherine Williams
- Measurement Science Quality Enhancement Research Initiative, San Francisco VA Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Ning Zhang
- Measurement Science Quality Enhancement Research Initiative, San Francisco VA Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Michelle R. Zeidler
- Pulmonary, Critical Care, and Sleep Medicine, Veterans Administration (VA) Greater Los Angeles Health Care System, Los Angeles, California
- Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Charles W. Atwood
- Sleep Medicine Program and Pulmonary Section, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
- Division of Pulmonary, Allergy, Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert L. Folmer
- VA Portland Health Care System, Portland, Oregon
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon
| | - Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Connor J. Smith
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Eilis A. Boudreau
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
- Sleep Medicine and Epilepsy Program, VA Portland Health Care System, Portland Oregon
| | | | - Kathleen F. Sarmiento
- Department of Medicine, University of California, San Francisco, San Francisco, California
- Pulmonary, Critical Care, and Sleep Medicine, San Francisco VA Health Care System, San Francisco, California
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Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med 2023; 19:857-863. [PMID: 36692162 PMCID: PMC10152361 DOI: 10.5664/jcsm.10430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common sleep disturbance in individuals with posttraumatic stress disorder (PTSD), with an emerging literature showing that treating OSA with positive airway pressure (PAP) therapy has a moderate effect on decreasing PTSD severity. Unfortunately, PAP adherence among individuals with PTSD is low. Our study examined how baseline PTSD cluster subscores predict 6-month PAP adherence and how PAP adherence predicts change in PTSD cluster subscores over time. METHODS We examined PTSD and PAP adherence in 41 veterans with PTSD newly diagnosed with OSA over 6 months of PAP use (mean age = 50.27 years; 73.7% White; 13.6% female). The Posttraumatic Stress Disorder Checklist-Specific (PCL-S) was used to examine PTSD and subscales (re-experiencing, avoidance, and hyperarousal). We used longitudinal analyses to examine PTSD subscores on PAP adherence and PAP adherence predicting changes in PTSD subscores at 6-month follow-up. RESULTS Among veterans with PTSD, higher levels of re-experiencing and hyperarousal, but not avoidance, predicted lower PAP use. Overall, the high-adherent group showed a 14.36-point decrease on the PCL-S, while the low-adherent group averaged just a 3.66-point decrease. More days of PAP use were associated with greater improvement in hyperarousal and avoidance subscores but not re-experiencing. CONCLUSIONS Our findings reaffirm the importance of PAP use among patients with comorbid PTSD and sleep apnea, as well as the difficulty in achieving adherent PAP use in this population. Directly addressing heightened re-experiencing and hyperarousal in PTSD may increase PAP adherence among veterans with PTSD and requires future research. CITATION Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med. 2023;19(5):857-863.
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Affiliation(s)
- Peter J. Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
- VA Center of Excellence for Stress and Mental Health, San Diego, California
- National Center for PTSD, White River Junction, Vermont
| | - Lizabeth A. Goldstein
- San Francisco VA Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
| | - Kathleen F. Sarmiento
- San Francisco VA Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Belkora JK, Fields B, Shamim-Uzzaman QA, Stratford D, Alfandre D, Hollingshaus S, Yackel E, Geppert C, Nechanicky P, Nichols A, Williams K, Reichert J, Whooley MA, Francis J, Sarmiento KF. Veterans Health Administration response to 2021 recall of Philips Respironics devices: A case study. Front Sleep 2023; 2:10.3389/frsle.2023.1129415. [PMID: 38585370 PMCID: PMC10996451 DOI: 10.3389/frsle.2023.1129415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
This case study describes, for the time frame of June 2021 through August 2022, the U.S. Veterans Health Administration (VHA) organizational response to a manufacturer's recall of positive airway pressure devices used in the treatment of sleep disordered breathing. VHA estimated it could take over a year for Veterans to receive replacement devices. Veterans awaiting a replacement faced a dilemma. They could continue using the recalled devices and bear the product safety risks that led to the recall, or they could stop using them and bear the risks of untreated sleep disordered breathing. Using a program monitoring approach, we report on the processes VHA put in place to respond to the recall. Specifically, we report on the strategic, service, and operational plans associated with VHA's response to the recall for Veterans needing replacement devices. In program monitoring, the strategic plan reflects the internal process objectives for the program. The service plan articulates how the delivery of services will intersect the customer journey. The operational plan describes how the program's resources and actions must support the service delivery plan. VHA's strategic plan featured a clinician-led, as opposed to primarily legal or administrative response to the recall. The recall response team also engaged with VHA's medical ethics service to articulate an ethical framework guiding the allocation of replacement devices under conditions of scarcity. This framework proposed allocating scarce devices to Veterans according to their clinical need. The service plan invited Veterans to schedule visits with sleep providers who could assess their clinical need and counsel them accordingly. The operational plan distributed devices according to clinical need as they became available. Monitoring our program processes in real time helped VHA launch and adapt its response to a recall affecting more than 700,000 Veterans.
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Affiliation(s)
- Jeffrey K. Belkora
- Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Barry Fields
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA, United States
- Atlanta Veterans Affairs Medical Center, Decatur, GA, United States
| | - Q. Afifa Shamim-Uzzaman
- Department of Internal Medicine and Neurology, Veterans Affairs Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, United States
| | - Donna Stratford
- Office of Quality and Patient Safety, Veterans Health Administration, Washington, DC, United States
| | - David Alfandre
- Department of Medicine and Population Health, New York University School of Medicine, New York, NY, United States
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, United States
| | - Scott Hollingshaus
- Division of Pulmonary Medicine, Department of Medicine, Salt Lake City Veterans Affairs Medical Center, University of Utah, Salt Lake City, UT, United States
| | - Edward Yackel
- National Center for Patient Safety, Veterans Health Administration, Ann Arbor, MI, United States
| | - Cynthia Geppert
- National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC, United States
- Department of Psychiatry and Internal Medicine, Ethics Education, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Penny Nechanicky
- Prosthetic and Sensory Aids Services, Veterans Health Administration, Washington, DC, United States
| | - Ardene Nichols
- Prosthetic and Sensory Aids Services, Veterans Health Administration, Washington, DC, United States
| | - Katherine Williams
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jill Reichert
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
| | - Mary A. Whooley
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Joe Francis
- Office of Reporting Analytics, Performance, Improvement and Deployment, Veterans Health Administration, Washington, DC, United States
| | - Kathleen F. Sarmiento
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Folmer RL, Smith CJ, Boudreau EA, Totten AM, Chilakamarri P, Atwood CW, Sarmiento KF. Sleep disorders among rural Veterans: Relative prevalence, comorbidities, and comparisons with urban Veterans. J Rural Health 2022. [DOI: 10.1111/jrh.12722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Robert L. Folmer
- National Center for Rehabilitative Auditory Research (NCRAR) VA Portland Healthcare System Portland Oregon USA
- Department of Otolaryngology Oregon Health & Science University Portland Oregon USA
| | - Connor J. Smith
- Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland Oregon USA
| | - Eilis A. Boudreau
- Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland Oregon USA
- Department of Neurology Oregon Health & Science University Portland Oregon USA
| | - Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University Portland Oregon USA
| | - Priyanka Chilakamarri
- San Francisco VA Health Care System San Francisco California USA
- Department of Neurology University of California San Francisco California USA
| | - Charles W. Atwood
- Pulmonary Section and Sleep Medicine VA Pittsburgh Healthcare System Pittsburgh Pennsylvania USA
- Division of Pulmonary Allergy Critical Care Medicine UPMC and University of Pittsburgh Pittsburgh Pennsylvania USA
| | - Kathleen F. Sarmiento
- San Francisco VA Health Care System San Francisco California USA
- Department of Medicine University of California San Francisco California USA
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Goldstein LA, Purcell N, Sarmiento KF, Neylan TC, Maguen S. Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study. Transl Behav Med 2022; 12:870-877. [PMID: 35640475 DOI: 10.1093/tbm/ibac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.
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Affiliation(s)
- Lizabeth A Goldstein
- San Francisco Veterans Affairs Health Care System, Mental Health Service, San Francisco, CA, USA.,San Francisco Veterans Affairs Health Care System, Research Service, San Francisco, CA, USA.,University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, San Francisco, CA, USA
| | - Natalie Purcell
- San Francisco Veterans Affairs Health Care System, Integrative Health Service, San Francisco, CA, USA.,University of California, San Francisco, Department of Social and Behavioral Sciences, San Francisco, CA, USA
| | - Kathleen F Sarmiento
- San Francisco Veterans Affairs Health Care System, Medical Service, San Francisco, CA, USA.,University of California, San Francisco, Department of Medicine, San Francisco, CA, USA
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System, Mental Health Service, San Francisco, CA, USA.,University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, San Francisco, CA, USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, Mental Health Service, San Francisco, CA, USA.,University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, San Francisco, CA, USA
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10
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Folmer RL, Boudreau EA, Atwood CW, Smith CJ, Totten AM, Tock JL, Chilakamarri P, Sarmiento KF. Study protocol to assess de-implementation of the initial provider encounter for diagnosis and treatment of obstructive sleep apnea: the DREAM (Direct Referral for Apnea Monitoring) Project. BMC Pulm Med 2022; 22:123. [PMID: 35366836 PMCID: PMC8976272 DOI: 10.1186/s12890-022-01899-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Obstructive sleep apnea (OSA) is a very common and serious health condition which is highly prevalent among U.S. military Veterans. Because the demand for sleep medicine services often overwhelms the availability of such services, it is necessary to streamline diagnosis and treatment protocols. The goals of this study are to, (1) assess the efficacy of de-implementing the initial provider encounter for diagnosis and treatment of OSA; (2) determine the negative predictive value (NPV) of home sleep apnea testing (HSAT); (3) develop HSAT usage recommendations for various at-risk patient populations.
Methods This is a large, pragmatic study that will take place in 3 VA sleep medicine programs: San Francisco, CA; Portland, OR; and Pittsburgh, PA. All Veterans referred for new sleep apnea evaluations at these sites will be included in this four-year study. Outcomes will include time from referral for OSA to sleep testing and treatment; positive airway pressure (PAP) treatment adherence measures; patient-reported clinical outcomes and measures of satisfaction; determination of the NPV of HSAT; HSAT usage recommendations for at-risk patient populations.
Discussion The DREAM (Direct Referral for Apnea Monitoring) Project will inform sleep medicine providers and clinical organizations regarding strategies to streamline diagnosis and treatment protocols for OSA. Results of this study should have significant impact on clinical practices and professional guidelines. Trial registration The majority of this project is an observational study of clinical procedures. Therefore, clinical trial registration is not required. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01899-y.
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11
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Nicosia FM, Kaul B, Totten AM, Silvestrini MC, Williams K, Whooley MA, Sarmiento KF. Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans' experience with the VA TeleSleep program. BMC Health Serv Res 2021; 21:77. [PMID: 33478497 PMCID: PMC7818059 DOI: 10.1186/s12913-021-06080-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 01/12/2021] [Indexed: 12/26/2022] Open
Abstract
Background Obstructive sleep apnea is common among rural Veterans, however, access to diagnostic sleep testing, sleep specialists, and treatment devices is limited. To improve access to sleep care, the Veterans Health Administration (VA) implemented a national sleep telemedicine program. The TeleSleep program components included: 1) virtual clinical encounters; 2) home sleep apnea testing; and 3) web application for Veterans and providers to remotely monitor symptoms, sleep quality and use of positive airway pressure (PAP) therapy. This study aimed to identify factors impacting Veteran’s participation, satisfaction and experience with the TeleSleep program as part of a quality improvement initiative. Methods Semi-structured interview questions elicited patient perspectives and preferences regarding accessing and engaging with TeleSleep care. Rapid qualitative and matrix analysis methods for health services research were used to organize and describe the qualitative data. Results Thirty Veterans with obstructive sleep apnea (OSA) recruited from 6 VA telehealth “hubs” participated in interviews. Veterans reported positive experiences with sleep telemedicine, including improvements in sleep quality, other health conditions, and quality of life. Access to care improved as a result of decreased travel burden and ability of both clinicians and Veterans to remotely monitor and track personal sleep data. Overall experiences with telehealth technology were positive. Veterans indicated a strong preference for VA over non-VA community-based sleep care. Patient recommendations for change included improving scheduling, continuity and timeliness of communication, and the equipment refill process. Conclusions The VA TeleSleep program improved patient experiences across multiple aspects of care including a reduction in travel burden, increased access to clinicians and remote monitoring, and patient-reported health and quality of life outcomes, though some communication and continuity challenges remain. Implementing telehealth services may also improve the experiences of patients served by other subspecialties or healthcare systems.
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Affiliation(s)
- Francesca M Nicosia
- San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA. .,University of California, San Francisco, San Francisco, USA.
| | - Bhavika Kaul
- San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA.,University of California, San Francisco, San Francisco, USA
| | | | | | - Katherine Williams
- San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA.,University of California, San Francisco, San Francisco, USA
| | - Mary A Whooley
- San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA.,University of California, San Francisco, San Francisco, USA
| | - Kathleen F Sarmiento
- San Francisco VA Medical Center, 4150 Clement Street, 151-R, San Francisco, CA, 94121, USA.,University of California, San Francisco, San Francisco, USA
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12
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Sarmiento KF, Boudreau EA, Smith CJ, Kaul B, Johnson N, Folmer RL. Effects of Computer-Based Documentation Procedures on Health Care Workload Assessment and Resource Allocation: An Example From VA Sleep Medicine Programs. Fed Pract 2020; 37:368-374. [PMID: 32908344 DOI: 10.12788/fp.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Computer-based documentation (CBD) is used commonly throughout the world to track patient care and clinical workloads. However, if capture of clinical services within the electronic health record (EHR) is not implemented properly, patient care services and workload credit will be inaccurate, which impacts business decisions related to demand for care and resources allocated to meet the demand. Understaffing of medical personnel can contribute to delays in treatment, missed treatments, and workforce turnover. Objective To illustrate the impact of CBD procedures on health care workload assessment and resource allocation, this article uses data from the US Department of Veterans Affairs Corporate Data Warehouse to provide examples from the Veterans Health Administration (VHA) sleep medicine programs. Discussion Inaccurate CBD led to underreporting of sleep medicine services provided at VHA facilities nationwide and contributed to insufficient allocation of resources and personnel. Recent modifications in CBD protocols (Stop Codes) improved the accuracy of data capture and reporting while providing VHA sleep programs with data they can use to advocate for workforce expansion to meet patient care needs. Conclusions Inaccurate CBD of clinical workloads can result in inadequate allocation of health care personnel and resources to meet the needs of patients. Untreated sleep disorders are associated with increased risk of depression, anxiety, impaired neurocognitive functions, cardiovascular disease, motor vehicle accidents, and premature death. Educating health care providers and administrators on the importance of accurate designation of clinical services within the EHR is necessary to facilitate improvements in health care availability and delivery.
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Affiliation(s)
- Kathleen F Sarmiento
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
| | - Eilis A Boudreau
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
| | - Connor J Smith
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
| | - Bhavika Kaul
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
| | - Nancy Johnson
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
| | - Robert L Folmer
- is the National VHA TeleSleep Lead and is a Research Fellow, both at the San Francisco VA Healthcare System in California. is a Neurologist, and is a Research Investigator, both at VA Portland Healthcare system in Oregon. is an Informatics Research Associate, Eilis Boudreau is an Associate Professor of Neurology, and Robert Folmer is an Associate Professor of Otolaryngology, all at Oregon Health & Science University in Portland. is the Lead Clinical Analyst, Systems Design and Standardization in the Managerial Cost Accounting Office, VHA Office of Finance. Kathleen Sarmiento is an Associate Professor of Medicine, and Bhavika Kaul is a Critical Care Medicine Fellow, both at the University of California, San Francisco
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13
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Folmer RL, Smith CJ, Boudreau EA, Hickok AW, Totten AM, Kaul B, Stepnowsky CJ, Whooley MA, Sarmiento KF. Prevalence and management of sleep disorders in the Veterans Health Administration. Sleep Med Rev 2020; 54:101358. [PMID: 32791487 DOI: 10.1016/j.smrv.2020.101358] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 12/12/2022]
Abstract
The prevalence of diagnosed sleep disorders among Veterans treated at Veterans Affairs (VA) medical facilities increased significantly during fiscal years (FY) 2012 through 2018. Specifically, the prevalence of sleep-related breathing disorders (SRBD) increased from 5.5% in FY2012 to 22.2% in FY2018, and the prevalence of insomnia diagnoses increased from 7.4% in FY2012 to 11.8% in FY2018. Consequently, Veterans' demand for sleep medicine services also increased significantly between FY2012-2018, with steady increases in the annual number of VA sleep clinic appointments during this period (<250,000 in FY 2012; >720,000 in FY2018). Common co-morbid conditions among Veterans diagnosed with sleep disorders include obesity, diabetes, congestive heart failure, depression, post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). To address this healthcare crisis, the Veterans Health Administration (VHA) developed and/or implemented numerous innovations to improve the quality and accessibility of sleep care services for Veterans. These innovations include a TeleSleep Enterprise-Wide Initiative to improve rural Veterans' access to sleep care; telehealth applications such as the Remote Veteran Apnea Management Platform (REVAMP), Clinical Video Telehealth, and CBT-i Coach; increased use of home sleep apnea testing (HSAT); and programs for Veterans who experience sleep disorders associated with obesity, PTSD, TBI and other conditions.
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Affiliation(s)
- Robert L Folmer
- VA Portland Healthcare System, Portland, OR, USA; Department of Otolaryngology, Oregon Health & Science University, Portland, OR, USA.
| | - Connor J Smith
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, USA
| | - Eilis A Boudreau
- VA Portland Healthcare System, Portland, OR, USA; Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, USA; Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | | | - Annette M Totten
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, USA
| | - Bhavika Kaul
- San Francisco VA Healthcare System, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA
| | - Carl J Stepnowsky
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA; Department of Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Mary A Whooley
- San Francisco VA Healthcare System, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA
| | - Kathleen F Sarmiento
- San Francisco VA Healthcare System, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA
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14
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Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program. J Clin Sleep Med 2019; 15:1355-1364. [PMID: 31538607 PMCID: PMC6760390 DOI: 10.5664/jcsm.7934] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/01/2019] [Accepted: 06/03/2019] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVES (1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand. METHODS PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse. RESULTS Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014. CONCLUSIONS Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions. CITATION Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.
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Affiliation(s)
- Kathleen F Sarmiento
- San Francisco VA Healthcare System, San Francisco, California
- Department of Medicine, University of California, San Francisco, California
| | - Robert L Folmer
- VA Portland Healthcare System, Portland, Oregon
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon
| | - Carl J Stepnowsky
- VA San Diego Healthcare System, San Diego, California
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Mary A Whooley
- San Francisco VA Healthcare System, San Francisco, California
- Department of Medicine, University of California, San Francisco, California
| | - Eilis A Boudreau
- VA Portland Healthcare System, Portland, Oregon
- Department of Neurology, Oregon Health & Science University, Portland, Oregon
| | - Samuel T Kuna
- Philadelphia VA Medical Center, Philadelphia, Pennsylvania
- Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles W Atwood
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Connor J Smith
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - W Claibe Yarbrough
- Dallas VA Medical Center, Dallas, Texas
- Department of Medicine, UT Southwestern School of Medicine, Dallas, Texas
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15
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Stepnowsky C, Sarmiento KF, Bujanover S, Villa KF, Li VW, Flores NM. Comorbidities, Health-Related Quality of Life, and Work Productivity Among People With Obstructive Sleep Apnea With Excessive Sleepiness: Findings From the 2016 US National Health and Wellness Survey. J Clin Sleep Med 2019; 15:235-243. [PMID: 30736870 DOI: 10.5664/jcsm.7624] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Few population-based studies have explored how excessive sleepiness (ES) contributes to burden of illness among patients with obstructive sleep apnea (OSA). METHODS This study utilized data from the annual, cross-sectional 2016 US National Health and Wellness Survey. Respondents self-reporting an OSA diagnosis were categorized as having ES (Epworth Sleepiness Scale [ESS] score ≥ 11) or not having ES (ESS score < 11). Comorbidities, health-related quality of life (HRQoL), and productivity were examined in three groups: OSA with ES (n = 731), OSA without ES (n = 1,452), and non-OSA controls (n = 86,961). RESULTS The OSA with ES group had significantly higher proportions of respondents reporting depression (62.4% versus 48.0%), gastroesophageal reflux disease (39.0% versus 29.4%), asthma (26.3% versus 20.7%), and angina (7.8% versus 6.7%) compared to the OSA without ES group (P < .05). After controlling for covariates, the OSA with ES group had significantly lower (worse) scores for mental component score (41.81 versus 45.65 versus 47.81), physical component score (46.62 versus 48.68 versus 51.36), and SF-6D (0.65 versus 0.69 versus 0.73) compared with OSA without ES and non-OSA controls (all P < .001). The OSA with ES group had significantly higher (greater burden) mean rates of presenteeism (25.98% impairment versus 19.24% versus 14.75%), work impairment (29.41% versus 21.82% versus 16.85%), and activity impairment (31.09% versus 25.46% versus 19.93%) compared with OSA without ES and non-OSA controls (all P < .01) after controlling for covariates. CONCLUSIONS OSA with ES is associated with higher prevalence of comorbidities, reduced HRQoL, and greater impairment in productivity compared to OSA without ES and compared to non-OSA controls.
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Affiliation(s)
| | - Kathleen F Sarmiento
- San Francisco VA Health Care System, San Francisco, California.,University of California San Francisco, San Francisco, California
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16
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Goldstein LA, Colvonen PJ, Sarmiento KF. Advancing Treatment of Comorbid PTSD and OSA. J Clin Sleep Med 2017; 13:843-844. [PMID: 28454602 DOI: 10.5664/jcsm.6638] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 04/12/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Lizabeth A Goldstein
- San Francisco VA Medical Center, San Francisco, California.,Department of Psychiatry, University of California, San Francisco, San Francisco, California
| | - Peter J Colvonen
- VA San Diego Healthcare System, San Diego, California.,Center of Excellence for Stress and Mental Health, San Diego, California.,Department of Psychiatry, University of California San Diego, San Diego, California
| | - Kathleen F Sarmiento
- VA San Diego Healthcare System, San Diego, California.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, San Diego, California
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17
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Orr JE, Smales C, Alexander TH, Stepnowsky C, Pillar G, Malhotra A, Sarmiento KF. Treatment of OSA with CPAP Is Associated with Improvement in PTSD Symptoms among Veterans. J Clin Sleep Med 2017; 13:57-63. [PMID: 27707436 DOI: 10.5664/jcsm.6388] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/04/2016] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVES Posttraumatic stress disorder (PTSD) is common among veterans of the military, with sleep disturbance as a hallmark manifestation. A growing body of research has suggested a link between obstructive sleep apnea and PTSD, potentially due to obstructive sleep apnea (OSA) related sleep disruption, or via other mechanisms. We examined the hypothesis that treatment of OSA with positive airway pressure would reduce PTSD symptoms over 6 months. METHODS A prospective study of Veterans with confirmed PTSD and new diagnosis of OSA not yet using PAP therapy were recruited from a Veteran's Affairs sleep medicine clinic. All subjects were instructed to use PAP each night. Assessments were performed at 3 and 6 months. The primary outcome was a reduction in PTSD symptoms at 6 months. RESULTS Fifty-nine subjects were enrolled; 32 remained in the study at 6 months. A significant reduction in PTSD symptoms, measured by PCL-S score was observed over the course of the study (60.6 ± 2.7 versus 52.3 ± 3.2 points; p < 0.001). Improvement was also seen in measures of sleepiness, sleep quality, and daytime functioning, as well as depression and quality of life. Percentage of nights in which PAP was used, but not mean hours used per night, was predictive of improvement. CONCLUSIONS Treatment of OSA with PAP therapy is associated with improvement in PTSD symptoms, although the mechanism is unclear. Nonetheless, PAP should be considered an important component of PTSD treatment for those with concurrent OSA. Improving PAP compliance is a challenge in this patient population warranting further investigation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02019914. COMMENTARY A commentary on this article appears in this issue on page 5.
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Affiliation(s)
- Jeremy E Orr
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA
| | | | - Thomas H Alexander
- Veterans Affairs San Diego Healthcare System, San Diego, CA.,Division of Otolaryngology-Head & Neck Surgery, University of California San Diego, San Diego, CA
| | | | - Giora Pillar
- Department of Sleep and Pediatrics, Carmel Medical Center, Haifa, Israel
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA
| | - Kathleen F Sarmiento
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, San Diego, CA.,Veterans Affairs San Diego Healthcare System, San Diego, CA
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Hepokoski ML, Wali AR, Sarmiento KF. Mechanisms and implications of the link between sleep apnoea and chronic kidney disease. Respirology 2016; 21:578-9. [PMID: 27030604 DOI: 10.1111/resp.12796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/07/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Mark L Hepokoski
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, San Diego, CA, USA
| | - Arvin R Wali
- School of Medicine, University of California San Diego, San Diego, CA, USA
| | - Kathleen F Sarmiento
- Division of Pulmonary, Critical Care & Sleep Medicine, University of California San Diego, San Diego, CA, USA
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Stepnowsky C, Sarmiento KF, Amdur A. Weaving the Internet of Sleep: The Future of Patient-Centric Collaborative Sleep Health Management Using Web-Based Platforms. Sleep 2015; 38:1157-8. [PMID: 26194574 DOI: 10.5665/sleep.4882] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 06/27/2015] [Indexed: 11/03/2022] Open
Affiliation(s)
- Carl Stepnowsky
- VA San Diego Healthcare System, San Diego, CA.,Division of General Internal Medicine, University of California, San Diego, La Jolla, CA
| | - Kathleen F Sarmiento
- VA San Diego Healthcare System, San Diego, CA.,Division of Pulmonary and Critical Care, University of California, San Diego, La Jolla, CA
| | - Adam Amdur
- American Sleep Apnea Association, Washington, DC
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20
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Orr JE, Ishman SL, Sarmiento KF. Stimulating Progress in the Upper Airway. Sleep 2015; 38:851-2. [PMID: 26039962 PMCID: PMC4434550 DOI: 10.5665/sleep.4724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 04/28/2015] [Indexed: 11/03/2022] Open
Affiliation(s)
- Jeremy E. Orr
- Division of Pulmonary and Critical Care, University of California, San Diego, La Jolla, CA
| | - Stacey L. Ishman
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati, Cincinnati, OH
| | - Kathleen F. Sarmiento
- Division of Pulmonary and Critical Care, University of California, San Diego, La Jolla, CA
- VA San Diego Healthcare System, San Diego, CA
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Schwartz EA, Hayes BD, Sarmiento KF. Development of Hepatic Failure Despite Use of Intravenous Acetylcysteine After a Massive Ingestion of Acetaminophen and Diphenhydramine. Ann Emerg Med 2009; 54:421-3. [DOI: 10.1016/j.annemergmed.2008.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 09/18/2008] [Accepted: 10/01/2008] [Indexed: 11/26/2022]
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