Assessment of Obstructive Sleep Apnea Among Patients With Chronic Obstructive Pulmonary Disease in Primary Care

Study Objectives

Observational studies link untreated obstructive sleep apnea (OSA) with adverse outcomes in chronic obstructive pulmonary disease (COPD). The first step in addressing OSA is a clinical assessment. However, given competing demands and a lack of high-quality evidence, it is unclear how often such assessments occur. We explored the documentation of OSA assessment among patients with COPD in primary care, and the patient and provider characteristics associated with these assessments.

Methods

We conducted a cross-sectional study of patients with clinically diagnosed COPD at 2 primary care practices. We abstracted charts to determine whether providers assessed OSA, defined as documentation of symptoms, treatment, or a referral to sleep medicine. We performed multivariable mixed-effects logistic regression to assess the associations of patient and provider characteristics with OSA assessment.

Results

Among 641 patients with clinically diagnosed COPD, 146 (23%) had OSA assessed over a 1-year period. Positive associations with OSA assessment included body mass index ≥ 30 (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-7.0), pulmonary subspecialist visits (OR 3.9, 95%CI 2.4-6.3), and a prior sleep study demonstrating OSA documented within the electronic medical record (OR 18.0, 95%CI 9.0-35.8). Notably, patients identifying as Black were less likely to have OSA assessed than those identifying as White (OR 0.5, 95%CI 0.2-0.9).

Conclusions

Providers document an assessment of OSA among a quarter of patients with COPD. Our findings highlight the importance of future work to rigorously test the impact of assessment on important health outcomes. Our findings also reinforce that additional strategies are needed to improve the equitable delivery of care.

Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary

This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence.

CITATION

Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.

International Consensus Statement on Obstructive Sleep Apnea

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.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Ambient Air Pollution Exposure and Sleep Quality in COPD

Rationale

Ambient air pollution exposure is associated with respiratory morbidity among individuals with chronic obstructive pulmonary disease (COPD), particularly among those with concomitant obesity. Although people with COPD report high incidence of poor sleep quality, no studies have evaluated the association between air pollution exposure, obesity, and sleep disturbances in COPD.

Methods

We analyzed data collected from current and former smokers with COPD enrolled in the Subpopulations and Intermediate Outcome Measures in COPD -Air Pollution ancillary study (SPIROMICS AIR). Socio-demographics and anthropometric measurements were collected, and 1-year mean historical ambient particulate matter (PM2.5) and ozone concentrations at participants' residences were estimated by cohort-specific spatiotemporal modeling. Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI), and regression models were constructed to determine the association of 1-year PM2.5 (1Yr-PM2.5) and 1-year ozone (1Yr-ozone) with the PSQI score, and whether obesity modified the association.

Results

In 1308 participants (age: 65.8±7.8 years, 42% women), results of regression analyses suggest that each 10µg/m3 increase in 1Yr-PM2.5 was associated with a 2.1-point increase in PSQI (P=0.03). Obesity modified the association between 1Yr-PM2.5 and PSQI (P=0.03). In obese and overweight participants, a 10µg/m3 increase in 1Yr-PM2.5 was associated with a higher PSQI (4.0 points, P<0.01, and 3.4 points, P<0.01, respectively); but no association in lean-normal weight participants (P=0.51). There was no association between 1 Yr-ozone and PSQI.

Conclusions

Overweight and obese individuals with COPD appear to be susceptible to the effects of ambient PM2.5 on sleep quality. In COPD, weight and ambient PM2.5 may be modifiable risk factors to improve sleep quality.

Racial Differences in Positive Airway Pressure Adherence in the Treatment of Sleep Apnea

Although data are limited, studies suggest on average lower positive airway pressure use in Black, indigenous, and people of color (BIPOC) compared with Whites in most but not all studies. Most of these observational studies are certainly limited by confounding by socioeconomic status and other unmeasured factors that likely contribute to differences. The etiology of these observed disparities is likely multifactorial, due in part to financial limitations, differences in sleep opportunity, poor sleep quality due to environmental disruptions, and so forth. These disparities in sleep health are likely related to chronic inequities, including experiences of racism, neighborhood features, structural, and contextual factors. Dedicated studies focusing on understanding adherence in BIPOC are lacking. Further research is needed to understand determinants of PAP use in BIPOC subjects and identify feasible interventions to improve sleep health and reduce sleep apnea treatment disparities.

Dose response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study

STUDY OBJECTIVES

Clinical benefits of PAP therapy for OSA are assumed to require adherent PAP usage, as defined by CMS as ≥ 4 hours of use ≥ 70% of nights. However, this is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and EDS from the HomePAP RCT.

METHODS

Participants ≥18 years with apnea hypopnea index ≥ 15 and baseline sleepiness (Epworth Sleepiness Scale (ESS) ≥ 12) received PAP therapy. Data were collected at baseline, 1-month, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10).

RESULTS

In 119 participants (age 49.4 ± 12.6 years, 66.4% male, 72.3% white), > 50% were PAP non-adherent per CMS criteria at 3 months. Percent of nights with PAP use ≥ 4 hours predicted ESS change (p = 0.023), but not when controlling for AHI. Percent of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (p = 0.007); those using PAP ≥ 4 hours had nearly 3-fold greater odds of ESS normalization (p = 0.025). At least 4 hours and 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73).

CONCLUSIONS

Although sub-adherent PAP usage may still confer some benefit for OSA patients, adherence to current criteria confers the highest likelihood for ESS change and normalization.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP); Identifier: NCT00642486; URL: http://clinicaltrials.gov/show/NCT00642486.

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.

Disparities in Sleep Health and Potential Intervention Models: A Focused Review

Disparities in sleep health are important but underrecognized contributors to health disparities. Understanding the factors contributing to sleep heath disparities and developing effective interventions are critical to improving all aspects of heath. Sleep heath disparities are impacted by socioeconomic status, racism, discrimination, neighborhood segregation, geography, social patterns, and access to health care as well as by cultural beliefs, necessitating a cultural appropriateness component in any intervention devised for reducing sleep health disparities. Pediatric sleep disparities require innovative and urgent intervention to establish a foundation of lifelong healthy sleep. Tapping the vast potential of technology in improving sleep health access may be an underutilized tool to reduce sleep heath disparities. Identifying, implementing, replicating, and disseminating successful interventions to address sleep disparities have the potential to reduce overall disparities in health and quality of life.

1007 Sociodemographic, Lifestyle and Dietary Correlates of Actigraphy-Measured Irregular Sleep Schedules in the Multi-Ethnic Study of Atherosclerosis

Introduction

Increasing evidence links daily variability in sleep schedules to increased cardiometabolic risk. Little is known, however, regarding sociodemographic and behavioral correlates of irregular sleep schedules that may help identify causes or consequences of irregular sleep.

Methods

Among 1,946 participants from the Multi-Ethnic Study of Atherosclerosis, we examined the cross-sectional associations of irregular sleep schedules with sociodemographic, lifestyle, dietary factors, and actigraphy-based indices of rest-wake rhythms using multiple linear regression with adjustment for age, sex, race/ethnicity, education, income, marital status and work schedules. Sleep regularity was assessed using standard deviations (SD) in actigraphy-measured sleep duration and sleep onset timing across 7 days.

Results

Compared to Whites, the 7-day sleep duration SD (95% CI) was 17.4min (12.6, 22.2) higher in African-Americans, 10.4min (4.8, 16.0) higher in Hispanics and 7.9min (1.3, 14.4) higher in Chinese. Shift versus regular work was associated with 11.4min (5.1, 17.7) higher sleep duration SD. Irregular sleep duration was associated with lower income (p=0.006), higher depressive symptoms (p&lt;0.0001), higher BMI (p=0.004) and current smoking (p=0.06). Higher sleep duration variability was associated with lower Alternative Healthy Eating Index (p=0.01), mainly due to suboptimal intakes of fruits, whole grains and nuts/legumes. No associations were observed for age, sex, education, marital status or number of meals per day. While sleep duration variability was not associated with self-reported physical activity level or actigraphy-measured 7-day mean activity count, sleep duration SD was inversely associated with relative amplitude (difference between the most versus the least active period; p&lt;0.0001) and inter-daily stability (synchronization between rest-activity patterns and environmental zeitgebers; p&lt;0.0001) of 24-h rest-activity patterns. Similar results were observed for sleep onset timing SD.

Conclusion

Substantial differences by sociodemographic factors exist regarding the consistency of day-to-day sleep schedules. Irregular sleep schedules are associated with overall circadian disruption across the day and some unhealthy lifestyle behaviors. Future studies are needed to understand temporal relationships of the observed associations.

Support

NIH grants K01HL143034, R35HL135818

Physical and Social Environment Relationship With Sleep Health and Disorders

Sleep health is a multidimensional construct that includes adequate duration, quality, and appropriately timed sleep that may be influenced by environmental factors. In this review, we focus on how an individual's living and sleeping environment, both the surrounding neighborhood physical and social features and the atmosphere around them, may impact their sleep health. We explore the associations of the physical environment (urban density, recreational facilities, green space, mixed land use, and healthy food stores), neighborhood deprivation (disadvantage and disorder), and the social environment (social cohesion, safety, and stigma) with sleep in both adult and pediatric populations. We investigate how physical and social environmental features may lead to alterations in the timing, duration, and quality of sleep and contribute to the most prevalent sleep disorders: insomnia, sleep apnea, and circadian rhythm disorders. We also review how ambient factors such as artificial light, environmental noise, and air pollution may contribute to sleep pathology. We have included key studies and recent emerging data regarding how the differential distribution of environmental factors that may affect sleep health may contribute to sleep health disparities.

Risk of Cardiovascular Disease Related to Smoking Is Greater Among Women With Sleep-Disordered Breathing

STUDY OBJECTIVES

Although both sleep-disordered breathing (SDB) and smoking are associated with cardiovascular disease (CVD), the potential for an interactive effect on CVD risk has not been explored. Our objective was to determine if smoking-related risk for CVD rises with greater SDB severity.

METHODS

Polysomnography and smoking history were obtained in 3,852 men and women in the Sleep Heart Health Study without baseline CVD. Fine-Gray proportional hazard models accounting for competing risk were used to calculate risk of incident CVD associated with SDB severity (defined by clinical cutoffs of the apnea-hypopnea index), smoking status (never, former, and current) and their interaction adjusting for potential confounders.

RESULTS

Over a mean (standard deviation) follow-up period of 10.3 (3.4) years, there were 694 incident CVD events. We found a significant three-way interaction of sex, current smoking, and moderate to severe SDB (P = .039) in the adjusted proportional hazards model. In adjusted analyses, women who were current smokers with moderate to severe SDB had a hazard ratio for incident CVD of 3.5 (95% confidence interval 1.6-8.0) relative to women who were nonsmokers without SDB. No such difference in CVD risk was observed in men or women of other strata of smoking and SDB.

CONCLUSIONS

In women, smoking-related risk for CVD is significantly higher among individuals with moderate to severe SDB.

The Effect of Sleeping Environment and Sleeping Location Change on Positive Airway Pressure Adherence

STUDY OBJECTIVES

Poor adherence undermines the effectiveness of positive airway pressure (PAP) therapy for sleep apnea. Disparities exist in PAP adherence by race/ethnicity and neighborhood socioeconomic status (SES), but the etiology of these differences is poorly understood. We investigated whether home environmental factors contribute to PAP adherence and whether identified factors explain disparities in adherence by SES.

METHODS

Adult patients with sleep apnea were surveyed at clinic visits about their sleep environment. Medical records were abstracted for demographic data, sleep apnea severity, comorbidities, and objective PAP adherence. We evaluated the association between aspects of home sleep environment with PAP adherence using multivariate linear and logistic regression, and assessed effect modification by SES factors.

RESULTS

Participants (n = 119) were diverse, with 44% nonwhite and 35% uninsured/Medicaid. After adjusting for age, sex, race/ethnicity, insurance, neighborhood SES, education, and marital status, participants who endorsed changing sleeping location once per month or more (18%, n = 21) had 77% lower odds of meeting PAP adherence criteria (> 4 h/night for 70% of nights) and less PAP use (median -11 d/mo, 95% confidence intervals -15.3, -6.5). Frequency of sleeping location change was the only environmental factor surveyed associated with PAP adherence.

CONCLUSIONS

Frequent change in sleeping location is associated with reduced PAP adherence, independent of sociodemographic factors. This novel finding has implications for physician-patient dialogue. PAP portability considerations in device selection and design may modify adherence and potentially improve treatment outcomes. Prospective investigation is needed to confirm this finding and inform design of possible interventions.

Environmental Determinants of Insufficient Sleep and Sleep Disorders: Implications for Population Health

PURPOSE OF REVIEW

Sleep is important for overall health and well-being. Insufficient sleep and sleep disorders are highly prevalent among adults and children and therefore a public health burden, particularly because poor sleep is associated with adverse health outcomes. Emerging evidence has demonstrated that environmental factors at the household- and neighborhood-level can alter healthy sleep. This paper will (1) review recent literature on the environmental determinants of sleep among adults as well as children and adolescents; and (2) discuss the opportunities and challenges for advancing research on the environment and sleep.

RECENT FINDINGS

Epidemiologic research has shown that social features of environments, family, social cohesion, safety, noise, and neighborhood disorder can shape and/or impact sleep patterns; and physical features such as light, noise, traffic, pollution, and walkability can also influence sleep and is related to sleep disorders among adults and children. Prior research has mainly measured one aspect of the environment, relied on self-reported sleep, which does not correlate well with objective measures, and investigated cross-sectional associations. Although most studies are conducted among non-Hispanic white populations, there is growing evidence that indicates that minority populations are particularly vulnerable to the effects of the environment on insufficient sleep and sleep disorders.

SUMMARY

There is clear evidence that environmental factors are associated with insufficient sleep and sleep disorders. However, more research is warranted to evaluate how and which environmental factors contribute to sleep health. Interventions that target changes in the environment to promote healthy sleep should be developed, tested, and evaluated as a possible pathway for ameliorating sleep health disparities and subsequently health disparities.

Effect of Continuous Positive Airway Pressure on Stroke Rehabilitation: A Pilot Randomized Sham-Controlled Trial

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) predicts poor functional outcome after stroke and increases the risk for recurrent stroke. Less is known about continuous positive airway pressure (CPAP) treatment on stroke recovery.

METHODS

In a pilot randomized, double-blind, sham-controlled trial, adult stroke rehabilitation patients were assigned to auto-titrating or sham CPAP without diagnostic testing for OSA. Change in Functional Independence Measure (FIM), a measure of disability, was assessed between rehabilitation admission and discharge.

RESULTS

Over 18 months, 40 patients were enrolled and 10 withdrew from the study: 7 from active and 3 from sham CPAP (p > 0.10). For the remaining 30 patients, median duration of CPAP use was 14 days. Average CPAP use was 3.7 h/night, with at least 4 h nightly use among 15 patients. Adherence was not influenced by treatment assignment or stroke severity. In intention-to-treat analyses (n = 40), the median change in FIM favored active CPAP over sham but did not reach statistical significance (34 versus 26, p = 0.25), except for the cognitive component (6 versus 2.5, p = 0.04). The on-treatment analyses (n = 30) yielded similar results (total FIM: 32 versus 26, p = 0.11; cognitive FIM: 6 versus 2, p = 0.06).

CONCLUSIONS

A sham-controlled CPAP trial among stroke rehabilitation patients was feasible in terms of recruitment, treatment without diagnostic testing and adequate blinding-though was limited by study retention and CPAP adherence. Despite these limitations, a trend towards a benefit of CPAP on recovery was evident. Tolerance and adherence must be improved before the full benefits of CPAP on recovery can be assessed in larger trials.

Neighborhood Walking Environment and Activity Level Are Associated With OSA: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

There has been growing interest in understanding how neighborhoods may be related to cardiovascular risk. Neighborhood effects on sleep apnea could be one contributing mechanism. We investigated whether neighborhood walking environment and personal activity levels are related to OSA.

METHODS

Data were analyzed from a subpopulation of the Multi-Ethnic Study of Atherosclerosis (MESA), including subjects who participated in both the MESA Sleep and Neighborhood studies (N = 1,896). Perceived neighborhood walking environment and subjects' objective activity were evaluated in multivariate, multilevel models to determine any association with sleep apnea severity as defined by using the apnea-hypopnea index. Sex, race/ethnicity, and obesity were examined as moderators.

RESULTS

Residing in the lowest quartile walking environment neighborhoods (score < 3.75) was associated with more severe sleep apnea (mean, 2.7 events/h greater AHI [95% CI, 0.7 to 4.6]), after adjusting for demographic characteristics, BMI, comorbidities, health behaviors, neighborhood socioeconomic status, and site. Associations were stronger among obese and male individuals. Approximately 1 SD greater objective activity in men was associated with a lower AHI (mean, -2.4 events/h [95% CI, -3.5 to -1.3]). This association was partially mediated by BMI (P < .001).

CONCLUSIONS

Living in neighborhoods with a low walking environment score is associated with greater severity of sleep apnea, especially in male and obese individuals. In men, greater activity level is associated with less severe sleep apnea, independent of BMI, comorbidities, and socioeconomic status. Neighborhood-level interventions that increase walkability and enable increased physical activity may potentially reduce the severity of sleep apnea.

Circadian dysrhythmias in the intensive care unit

Circadian rhythms underlie nearly all physiologic functions and organ systems. Circadian abnormalities have attendant implications for critical illness survival. The intensive care unit (ICU) environment, with its lack of diurnal variation in sound, light, and social cues, may precipitate circadian dysrhythmias. Additional features of critical care, including mechanical ventilation and sedation, likely perpetuate circadian misalignment. Critical illness itself, from sepsis to severe brain injury, can compromise circadian health. Use of daylight, time-restricted feedings, and administration of melatonin can possibly restore circadian rhythm. However, further study is necessary to assess the effectiveness of these interventions and their impact on ICU outcomes.

Psychometric performance and responsiveness of the functional outcomes of sleep questionnaire and sleep apnea quality of life instrument in a randomized trial: the HomePAP study

STUDY OBJECTIVES

Measures of health-related quality of life (HRQL) specific for sleep disorders have had limited psychometric evaluation in the context of randomized controlled trials (RCTs). We investigated the psychometric properties of the Functional Outcomes of Sleep Questionnaire (FOSQ) and Sleep Apnea Quality of Life Instrument (SAQLI). We evaluated the FOSQ and SAQLI construct and criterion validity, determined a minimally important difference, and assessed for associations of responsiveness to baseline subject characteristics and continuous positive airway pressure (CPAP) adherence in a RCT population.

DESIGN

Secondary analysis of data collected in a multisite RCT of home versus laboratory-based diagnosis and treatment of obstructive sleep apnea (HomePAP trial).

PARTICIPANTS

Individuals enrolled in the HomePAP trial (n = 335).

INTERVENTIONS

N/A.

MEASUREMENT AND RESULTS

The FOSQ and SAQLI subscores demonstrated high reliability and criterion validity, correlating with Medical Outcomes Study 36-Item Short Form Survey domains. Correlations were weaker with the Epworth Sleepiness Scale (ESS). Both the FOSQ and SAQLI scores improved after 3 mo with CPAP therapy. Averaging 4 h or more of CPAP use was associated with an increase in the FOSQ beyond the minimally important difference. Baseline depressive symptoms and sleepiness predicted FOSQ and SAQLI responsiveness; demographic, objective obstructive sleep apnea (OSA) severity and sleep habits were not predictive in linear regression.

CONCLUSIONS

The FOSQ and SAQLI are responsive to CPAP intervention, with the FOSQ being more sensitive to differences in CPAP adherence than the SAQLI. These instruments provide unique information about health outcomes beyond that provided by changes in physiological measures of OSA severity (apnea-hypopnea index).

CLINICAL TRIAL INFORMATION

Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) URL: http://clinicaltrials.gov/show/NCT00642486. NIH clinical trials registry number: NCT00642486.

A dozen years of American Academy of Sleep Medicine (AASM) International Mini-Fellowship: program evaluation and future directions

Sleep medicine remains an underrepresented medical specialty worldwide, with significant geographic disparities with regard to training, number of available sleep specialists, sleep laboratory or clinic infrastructures, and evidence-based clinical practices. The American Academy of Sleep Medicine (AASM) is committed to facilitating the education of sleep medicine professionals to ensure high-quality, evidence-based clinical care and improve access to sleep centers around the world, particularly in developing countries. In 2002, the AASM launched an annual 4-week training program called Mini-Fellowship for International Scholars, designed to support the establishment of sleep medicine in developing countries. The participating fellows were generally chosen from areas that lacked a clinical infrastructure in this specialty and provided with training in AASM Accredited sleep centers. This manuscript presents an overview of the program, summarizes the outcomes, successes, and lessons learned during the first 12 years, and describes a set of programmatic changes for the near-future, as assembled and proposed by the AASM Education Committee and recently approved by the AASM Board of Directors.

CITATION

Ioachimescu OC; Wickwire EM; Harrington J; Kristo D; Arnedt JT; Ramar K; Won C; Billings ME; DelRosso L; Williams S; Paruthi S; Morgenthaler TI. A dozen years of American Academy of Sleep Medicine (AASM) international mini-fellowship: program evaluation and future directions.

Medicare long-term CPAP coverage policy: a cost-utility analysis

STUDY OBJECTIVES

CPAP is an effective treatment for OSA that may reduce health care utilization and costs. Medicare currently reimburses the costs of long-term CPAP therapy only if the patient is adherent during a 90-day trial. If not, Medicare requires a repeat polysomnogram (PSG) and another trial which seems empirically not cost-effective. We modeled the cost-effectiveness of current Medicare policy compared to an alternative policy (clinic-only) without the adherence criterion and repeat PSG.

DESIGN

Cost-utility and cost-effectiveness analysis.

SETTING

U.S. Medicare Population.

PATIENTS OR PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

We created a decision tree modeling (1) clinic only follow-up vs. (2) current Medicare policy. Costs were assigned based on Medicare reimbursement rates in 2012. Sensitivity analyses were conducted to test our assumptions. We estimated cumulative costs, overall adherence, and QALY gained for a 5-year time horizon from the perspective of Medicare as the payer. Current Medicare policy is more costly than the clinic-only policy but has higher net adherence and improved utility. Current Medicare policy compared to clinic-only policy costs $30,544 more per QALY.

CONCLUSIONS

Current CMS policy promotes early identification of those more likely to adhere to CPAP therapy by requiring strict adherence standards. The policy effect is to deny coverage to those unlikely to use CPAP long-term and prevent wasted resources. Future studies are needed to measure long-term adherence in an elderly population with and without current adherence requirements to verify the cost-effectiveness of a policy change.

Early diagnosis and treatment of obstructive sleep apnea after stroke: Are we neglecting a modifiable stroke risk factor?

Sleep-disordered breathing is an increasingly recognized disorder that is particularly prevalent among stroke patients. Obstructive sleep apnea, a form of sleep-disordered breathing, is associated with multiple major stroke risk factors but is also an independent risk factor for stroke. In addition, untreated sleep apnea is associated with poor functional outcome after stroke. Sleep apnea is amenable to treatment and should be considered a modifiable stroke risk factor, though long-term compliance remains a major barrier. A better understanding of the relationship between sleep apnea and stroke may prompt providers to pursue the early diagnosis and treatment of underlying sleep-disordered breathing to both improve the chance of recovery from stroke in the short term and to reduce the risk of recurrent stroke in the long term.

Is the relationship between race and continuous positive airway pressure adherence mediated by sleep duration?

STUDY OBJECTIVES

Black race has been associated with decreased continuous positive airway pressure (CPAP) adherence. Short sleep duration, long sleep latency, and insomnia complaints may affect CPAP adherence as they affect sleep and opportunity to use CPAP. We assessed whether self-reported sleep measures were associated with CPAP adherence and if racial variations in these sleep characteristics may explain racial differences in CPAP adherence.

DESIGN

Analysis of data from a randomized controlled trial (HomePAP), which investigated home versus laboratory-based diagnosis and treatment of obstructive sleep apnea.

SETTING

Seven American Academy of Sleep Medicine-accredited sleep centers in five cities in the United States.

PATIENTS OR PARTICIPANTS

Enrolled subjects (n = 191) with apnea-hypopnea index ≥ 15 and sleepiness (Epworth Sleepiness Scale > 12).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Multivariable regression was used to assess if subjective sleep measures and symptoms predicted 3-mo CPAP use. Mediation analysis was used to assess if sleep measures mediated the association of race with CPAP adherence. Black participants reported shorter sleep duration and longer sleep latency at baseline than white and Hispanic participants. Shorter sleep duration and longer sleep latency predicted worse CPAP adherence. Sleep duration mediated the association of black race with lower CPAP adherence. However, insomnia symptoms were not associated with race or CPAP adherence.

CONCLUSIONS

Among subjects with similar severity of obstructive sleep apnea and sleepiness, baseline self-reported sleep duration and latency, but not perceived insomnia, predicted CPAP adherence over 3 mo. Sleep duration explains some of the observed differences in CPAP use by race. Sleep duration and latency should be considered when evaluating poor CPAP adherence.

CLINICAL TRIAL INFORMATION

PORTABLE MONITORING FOR DIAGNOSIS AND MANAGEMENT OF SLEEP APNEA (HOMEPAP) URL: http://clinicaltrials.gov/show/NCT00642486. NIH clinical trials registry number: NCT00642486.

Race and residential socioeconomics as predictors of CPAP adherence

STUDY OBJECTIVES

There are few established predictors of CPAP adherence; poor adherence limits its effectiveness. We investigated whether race, education level, and residential economic status predict CPAP adherence in participants enrolled in a trial with standard access to treatment.

DESIGN

A multi-center randomized trial of home vs. lab-based evaluation and treatment of OSA assessing adherence to CPAP at 1 and 3 months.

SETTING

Seven AASM-accredited sleep centers in 5 U.S. cities.

PARTICIPANTS

Subjects with moderate to severe OSA (AHI ≥ 15 and Epworth Sleepiness Scale score > 12) who completed follow-up at 1 and/or 3 months (n = 135).

MEASUREMENTS AND RESULTS

Subjects' demographic data were collected upon enrollment; CPAP use at 1 and 3 months was assessed at clinic follow-up. In unadjusted analyses, CPAP adherence (average minutes per night of CPAP use) at 3 months was lower in black subjects and in subjects from lower socioeconomic status ZIP codes. In adjusted analyses using multivariate linear regression, black race was predictive of CPAP adherence at one month (P = 0.03). At 3 months, black race was predictive in analyses only when ZIP code SES was not adjusted for.

CONCLUSION

Black race and lower socioeconomic residential areas are associated with poorer adherence to CPAP in subjects with standardized access to care and treatment. Disparities remain despite provision of standardized care in a clinical trial setting. Future research is needed to identify barriers to adherence and to develop interventions tailored to improve CPAP adherence in at risk populations. Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) CLINICAL TRIAL INFORMATION: NIH CLINICAL TRIALS REGISTRY NUMBER: NCT00642486. URL: http://clinicaltrials.gov/show/NCT00642486.

The effect of the hidden curriculum on resident burnout and cynicism

INTRODUCTION

Residents learn and participate in care within hospital cultures that 5 tolerate unprofessional conduct and cynical attitudes, labeled the "hidden curriculum." We hypothesized that this hidden curriculum 5 have deleterious effects on residents' professional development and investigated whether witnessing unprofessional behavior during residency was associated with burnout and cynicism.

METHODS

We surveyed internal medicine residents at 2 academic centers for 3 years (2008-2010). Hidden curriculum items assessed exposure to unprofessional conduct. We used regression analyses to examine if hidden curriculum scores were associated with cynicism and the Maslach Burnout Inventory depersonalization and emotional exhaustion domain scores.

RESULTS

The response rate was 48% (337 of 708). In the 284 surveys analyzed, 45% of respondents met burnout criteria and had significantly higher hidden curriculum scores (26 versus 19, P < .001) than those not meeting criteria. In cross-sectional analyses, the hidden curriculum score was significantly associated with residents' depersonalization, emotional exhaustion, and cynicism scores. Cynicism scores were also associated with burnout.

CONCLUSIONS

Exposure to unprofessional conduct was associated with higher burnout and cynicism scores among internal medicine residents. We also found that cynicism and burnout were significantly associated and 5 be measures of similar but not necessarily identical responses to the challenges posed by residency. Measuring the hidden curriculum and cynicism 5 provide direction for educators attempting to reform hospital culture and improve resident well-being.

Determinants of medical students' perceived preparation to perform end-of-life care, quality of end-of-life care education, and attitudes toward end-of-life care

BACKGROUND

Medical students' learning about end-of-life care can be categorized into three learning modalities: formal curriculum, taught in lectures; informal curriculum, conveyed through clinical experiences; and "hidden curriculum," inferred from behaviors and implicit in medical culture. In this study, we evaluated associations between survey items assessing these learning modalities and students' perceptions of their preparation, quality of education, and attitudes toward end-of-life care.

METHODS

Data were collected from a national survey of fourth-year medical students (n = 1455) at 62 medical schools in 2001. Linear regression analyses were performed to assess associations between formal, informal and hidden end-of-life care curricula and students' perceived preparedness to provide end-of-life care, quality of end-of-life care education and attitudes toward end-of-life, controlling for students' demographics and clustered by school.

RESULTS

Students reporting more exposure to formal and informal curricula felt more prepared and rated their end-of-life care education higher. Students with more exposure to a hidden curriculum that devalued end-of-life care perceived their preparation as poorer and had poorer attitudes toward end-of-life care. Minority students had slightly more negative attitudes but no differences in perceived end-of-life care preparation.

CONCLUSIONS

Medical students' sense of preparedness for end-of-life care and perceptions of educational quality are greater with more coursework and bedside teaching. By contrast, the hidden curriculum conveying negative messages may impair learning. Our findings suggest that implicit messages as well as intentional teaching have a significant impact on students' professional development. This has implications for designing interventions to train physicians to provide outstanding end-of-life care.

Medicine residents' self-perceived competence in end-of-life care

PURPOSE

Internal medicine residents frequently provide end-of-life care, yet feel inadequately trained and uncomfortable providing this care, despite efforts to improve end-of-life care curricula. Understanding how residents' experiences and attitudes affect their perceived competence in providing end-of-life care is important for targeting educational interventions.

METHOD

Medicine residents (74) at the University of Washington and Medical University of South Carolina enrolled in a trial investigating the efficacy of a communication skills intervention to improve end-of-life care. On entry to the study in the fall of 2007, residents completed a questionnaire assessing their prior experiences, attitudes, and perceived competence with end-of-life care. Multivariate regression analysis was performed to assess whether attitudes and experiences with end-of-life care were associated with perceived competence, controlling for gender, race/ethnicity, training year, training site, and personal experience with death of a loved one.

RESULTS

Residents had substantial experience providing end-of-life care. In an adjusted multivariate model including attitudes and clinical experience in end-of-life care as predictors, only clinical experience providing end-of-life care was associated with self-perceived competence (P=.015).

CONCLUSIONS

Residents with more clinical experience during training had greater self-perceived competence providing end-of-life care. Increasing the quantity and quality of the end-of-life care experiences during residency with appropriate supervision and role modeling may lead to enhanced skill development and improve the quality of end-of-life care. The results suggest that cultivating bedside learning opportunities during residency is an appropriate focus for educational interventions in end-of-life care education.

Acute constrictive pericarditis after lung transplantation for lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare, cystic, progressive lung disease with many extrapulmonary manifestations, which may complicate allograft function after transplantation. We present a LAM patient with new dyspnea and declining spirometry without rejection, infection or recurrence one year after bilateral lung transplantation. Investigation revealed acute constrictive pericarditis, which has not been reported previously in a lung transplant patient with LAM. This represents a novel complication likely due to progression of extrapulmonary LAM and should be considered in LAM transplant patients with dyspnea.

Prognostic Significance of Angiographically Confirmed Large Vessel Intracranial Occlusion in Patients Presenting With Acute Brain Ischemia

INTRODUCTION

Independent predictors of outcome for ischemic stroke include age and initial stroke severity. Intracranial large-vessel occlusion would be expected to predict poor outcome. Because large-vessel occlusion and stroke severity are likely correlated, it is unclear if largevessel occlusion independently predicts outcome or is simply a marker for stroke severity.

METHODS

A consecutive series of patients with suspected stroke or transient ischemic attack were imaged acutely with computed tomography angiography (CTA). CTAs were reviewed for intracranial large-vessel occlusion as the cause of the stroke. Baseline National Institutes of Health Stroke Scale (NIHSS) score, discharge modified Rankin score, and patient demographics were abstracted from hospital records. Poor neurological outcome was defined as modified Rankin score exceeding 2.

RESULTS

Seventy-two consecutive patients with acute ischemic stroke were imaged with CTA. The median (range) time from stroke symptom onset to CT imaging was 183 minutes (25 minutes to 4 days). Median NIHSS score was 6 (1-32) and intracranial large-vessel occlusion was found in 28 (38.9%) patients. Fifty-six percent of patients had a good neurological outcome. In multivariate logistic regression analysis, two variables predicted poor neurological outcome: baseline NIHSS score (OR 1.21, 95% CI [1.07-1.37]) and presence of intracranial large-vessel occlusion (OR 4.48, 95% CI [1.19-16.9]). The predictive value of large-vessel occlusion on outcome was similar to an 8-point increase in NIHSS score.

CONCLUSION

In patients presenting with acute brain ischemia, intracranial large-vessel occlusion independently predicts poor neurological outcome at hospital discharge, as does the presence of a high NIHSS score. Performing routine intracranial vascular imaging on acute stroke patients may allow for more accurate determination of prognosis and may also guide therapy.