0543 Implementing Insomnia Care Paths for Older Adults and People with Dementia

Introduction

Despite the high prevalence of insomnia in older adults and those with dementia, screening and treatment remain inconsistent and suboptimal. Implementing a care path in a health system, though, is difficult. To determine what issues are relevant for implementation, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building.

Methods

All N=20 participants, representing a wide range of stakeholders including research, industry, sleep, primary care, implementation science, and others, voted whether they agreed or disagreed with 36 different statements regarding what issues are important for implementing geriatric insomnia care paths. These represented a range of items addressing strategies for identifying and incentivizing stakeholders, identifying patients in most need and who would receive benefit, addressing comorbidities and multiple specialties, understanding how specific organizations make decisions about and changes to care, size and scope of the care path, determining the process for implementation, how it will improve outcomes, addressing specific needs of primary care, and addressing costs, reimbursements, and liabilities. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree).

Results

Despite the diversity among attendees, median rate of agreement for was 95% (IQR=90-95%). All items were endorsed by >=80% of respondents. Mean score was 0.48 (SD=1.85). 95%CIs were computed for each proportion and compared to the mean. The only item that significantly differed from the mean score indicated that understanding benefits of a care path to the general community is less important of an issue than others (M=0.85).

Conclusion

Implementing an insomnia care path for older adults in an institution will likely require addressing a wide range of issues, including questions about stakeholders, the health system/context, patients, and practical considerations.

Support

Merck Research Labs provided support

0624 Voice of the Patient: A Patient-Centered Exploration of Factors Influencing Obstructive Sleep Apnea Care

Introduction

Despite widely available efficacious treatments for obstructive sleep apnea (OSA), patients commonly report frustration in accessing and adhering to treatments. Sparse research has explored factors influencing OSA care from the patient perspective, which may limit provision of patient-centered care: care responsive to patient preferences, needs, and values. To this end, we conducted qualitative research to identify factors, voiced by patients, that influence OSA treatment initiation and adherence.

Methods

We performed semi-structured interviews with 15 patients previously diagnosed with OSA from Boston, MA and a national patient portal (MyApnea.Org). Patients were asked about barriers and facilitators to their diagnosis and treatment as well as about their preferences and values that informed their treatment decisions. Interviews were audio-recorded and transcribed. A qualitative content analysis was performed to identify themes. After developing a codebook, interviews were coded. Codes were then audited and finalized by study team consensus.

Results

Our sample was aged 25-74 years; 71% identified as female. Among participants, 57.1% identified as White, 14.3% Black, 14.3% Asian, and 14.3% Other. Major themes were broadly classified as (1) facilitators (provision of useful information on treatment options, participation in shared decision-making, continued clinician support); (2) barriers (inconvenience of treatment, difficulty of habit formation, treatment side effects, competing comorbid conditions); (3) motivators (value of improving chronic health, family support, positive treatment effects); (4) contextual factors (insufficient knowledge/awareness of OSA, navigating healthcare systems, access to informational resources). Awareness of OSA symptoms and treatments, and ongoing support were cited as the most common factors influencing the patient experience.

Conclusion

This formative research highlights that diverse factors impact the OSA evaluation and treatment patient experience. Further research should test interventions that promote effective patient-centered care for OSA, such as shared decision-making tools.

Support

Brigham and Women’s Hospital Research Institute Patient-Centered Comparative Effectiveness Research Center Grant

0363 Racial/Ethnic Differences in Actigraphy, Questionnaire, and Polysomnography-Measured Indicators of Sleep Health and Sleep Quality: The Multi-Ethnic Study of Atherosclerosis

Introduction

Paradigm shifts in sleep research suggest the importance of considering multi-dimensional sleep health, compared to single metrics, to promote physical and mental well-being and to understand racial/ethnic disparities in sleep.

Methods

We used data from the Multi-Ethnic Study of Atherosclerosis (MESA; n = 1,740) to create a Sleep Health Score (SHS), including questionnaire (quality, sleepiness); 7-day actigraphy (total sleep time, sleep continuity [sleep maintenance efficiency], timing consistency [midpoint variability], fragmentation, wake after sleep onset, sleep onset latency); and in-home polysomnography (%N3 sleep, %REM sleep, AHI). Sleep parameters were dichotomized based on prior literature or by healthiest quartile(s), with positive values denoting healthier sleep (e.g. Epworth scores < 10). All 11 dichotomized parameters were summed to calculate the SHS (mean=4.9, sd=1.58). We used modified Poisson and linear regression for individual sleep outcomes and the SHS, respectively, adjusting for age and sex.

Results

The sample was older (mean age=68.28, sd=9.08) and 54% female. SHSs were associated with Black race (β=-0.60 [-0.78, -0.42]) and Hispanic ethnicity (β=-0.40 [-0.59, -0.21]), but not Chinese ethnicity (β=-0.16 [-0.41, 0.08]). Compared to Whites (n=644), Blacks (n=485) showed lower adjusted probability of obtaining favorable levels of: sleep continuity, fragmentation, timing consistency, alertness/sleepiness, and sleep depth (%N3 sleep). Chinese respondents (n=202) had lower probability of obtaining favorable levels of: sleep continuity and timing consistency, but higher probability of quality. Hispanics (n=409) had lower probability of obtaining healthy levels of: sleep continuity, timing consistency, and fragmentation. Neither healthy total sleep time (middle quartiles) nor AHI (<30) differed by race/ethnicity.

Conclusion

Among MESA-Sleep participants, summary SHSs were lowest in Blacks, followed by Hispanics. Multiple dimensions of sleep - particularly related to continuity and timing consistency - were less favorable across race/ethnic minority groups. A summary SHS may help monitor sleep health across populations, while measurement of specific sleep components may help identify modifiable targets.

Support

Joon Chung is supported by a T-32 NIH training grant.

1185 Developing A Care Pathway For Insomnia In Older Adults And Adults With Dementia: Results Of A Consensus Meeting

Introduction

Insomnia among older adults and dementia patients carries a high public health burden. Yet, treatment is inconsistent or absent. Standardized, programmatic carepaths can be implemented in clinics/systems/communities to address this after tailoring to local environments. To determine what elements should be included, a consensus meeting was convened, which included discussion, voting on components, and further consensus-building among diverse stakeholders.

Methods

Participants represented a wide range of stakeholders and specialties, including academic research, clinical care, industry, government, payors, sleep medicine, primary care, geriatrics, psychiatry, neurology, nursing, pharmacy, quality, and implementation science. 27 statements regarding key components of carepaths for insomnia in elderly and dementia populations were presented and discussed. These represented items addressing identification of patients, screening and assessment, deciding treatment modality and delivery, providing behavioral treatment, providing pharmacotherapy, addressing combined therapy, addressing comorbidities, and incorporating outcome evaluation. All N=20 participants voted individually whether they agreed or disagreed with each statement. Items were scored as 0=strongly agree, 1=agree, 2=disagree, and 3=strongly disagree. Mean scores were evaluated and responses were dichotomized to agree/disagree.

Results

Despite diversity among attendees, median rate of agreement was 95% (IQR=85-95%). Mean score was 0.69 (SD=0.31). 95%CIs were computed for each proportion and compared to the mean. The following elements were significantly different from the mean (p<0.05): medication decision trees (M=0.25), accounting for comorbidities (M=0.26), include outcome evaluation (M=0.30), utilization of EMR (M=0.40), incorporate caregiver (M=0.42), and differ across parts of the system (M=1.79).

Conclusion

Insomnia carepaths for older adults should address identification, screening and assessment, treatment decisions, treatment type and delivery, and evaluation. Organizations should consider these elements when designing carepaths for insomnia among older adults and dementia patients. Consensus-building should begin during the process of prioritizing care path components.

Support

Merck Research Labs provided support