1177 Cost Effectiveness Of Diagnostic Approaches To Sleep Apnea Evaluation During Inpatient Rehabilitation For Moderate To Severe TBI

Introduction

Recent work has highlighted prevalent obstructive sleep apnea (OSA) after traumatic brain injury (TBI) when patients are vulnerable to disruption of neural repair. The recently completed clinical trial comparing screening and diagnostic tools for OSA during inpatient rehabilitation provided the opportunity to conduct economic modeling of phased approaches using actual trial findings to address one perspective (the payor) on the value of phased testing.

Methods

A cost-effectiveness analysis of four phased approaches to OSA diagnosis including initial utilization of portable sleep monitoring [HSAT] regardless of pre-test probability, determination of pre-test probability using two prediction models [STOPBANG, MAPI], and initial assessment using Level 1 polysomnography was conducted. The analyses were modeled assuming all participants were considered high risk thus a negative screen or portable diagnostic test would result in a participant being referred for Level 1 polysomnography. The cost aversion used in analyses were derived from a recent white paper on the economic modeling of untreated OSA. Trial data from 214 participants were used in analyses (mean age 44 [SD 18], 82% male, 75% white, with primarily motor-vehicle related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8 (SD 5).

Results

At AHI ≥15 (33.6%), the prediction models (STOPBANG [-$5,291], MAPI [-$5,262]) resulted in greater cost savings and effectiveness relative to the HSAT approach (-$5,210) and initial use of Level 1 PSG (-$5,011). Sensitivity analyses at AHI ≥5 (70.1%) revealed the initial use of HSAT (-$6,322.85) relative to the prediction models (MAPI [-$6,249.71], STOPBANG [-$6,237) and initial assessment with Level 1 PSG (-$5,977) resulted in greater savings and cost effectiveness.

Conclusion

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

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

1136 Polysomnography Is Feasible During Inpatient TBI Rehabilitation

Introduction

A recent meta-analytic report highlighted that obstructive sleep apnea was 12 times more prevalent in TBI (mixed severity) than in community-based samples. Recent studies highlight prevalent obstructive sleep apnea during acute inpatient rehabilitation which is a time of critical neural repair. Acute sleep disturbances are associated with therapy cooperation due to effects on daytime sleepiness and are associated with key rehabilitation outcomes. Given the high rates of OSA and risk for negative morbidity, this analysis sought to examine the feasibility of administering polysomnography (PSG) with EEG to diagnose sleep apnea during inpatient rehabilitation in persons with moderate to severe TBI.

Methods

This is a secondary analysis from a prospective diagnostic comparative effectiveness clinical trial (NCT03033901) that took place at six NIDILRR and one VA TBI Model System Centers. Participants were included if they met the TBI Model System case definition and slept at least 2 hours per night prior to PSG. PSG was conducted following AASM procedures in the participant’s hospital bed on the inpatient rehabilitation unit. Studies were scored by RPSGT staff and interpreted by a board certified sleep medicine physician at a centralized sleep scoring center in Tampa, FL.

Results

Of 896 potential TBI participants, 449 met initial eligibility and 345 consented for further screening; a final sample of 263 (76%) completed PSG during hospitalization. Primary reasons for not completing PSG included early discharge or medical instability (n=59) and last-minute withdrawal of consent for PSG (n=23). Of the 263 participants who completed PSG, 3 were excluded from analysis due to technical issues and 12 were excluded as the total sleep time (TST) was less than 120 minutes. Of the 248, 85.5% of the PSGs were rated as interpretable/scoreable by RPSGT and sleep physicians.

Conclusion

For a majority of participants, polysomnography is feasible during inpatient rehabilitation. Participants with shorter lengths of stay, medical instability, prolonged agitation may require polysomnography follow-up after discharge.

Support

Supported by PCORI (CER-1511-33005), VA TBIMS, DVBIC with subcontract from GDIT/GDHS (W91YTZ-13-C-0015, HT0014-19-C-0004), and NIDILRR (90DPTB00070, 90DPTB00130100, 90DPTB0008, 90DPT8000402, 90DPTB0001).

0606 Comparative Effectiveness of Sleep Apnea Screening Tools During Inpatient Rehabilitation for Moderate to Severe TBI

Introduction

Recent studies highlight prevalent obstructive sleep apnea after moderate to severe TBI during a time of critical neural repair. The purpose of this study is to determine the diagnostic sensitivity, specificity and comparative effectiveness of traditional sleep apnea screening tools in TBI neurorehabilitation admissions.

Methods

This is a prospective diagnostic comparative effectiveness trial of sleep apnea screening tools (STOPBANG, Berlin, MAPI [Multi-Apnea Prediction Index]) relative Level 1 polysomnography at six TBI Model System Inpatient Rehabilitation Centers. Between 05/2017 and 02/2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. The primary outcome was the Area Under the Curve (AUC) of screening tools relative to total apnea hypopnea index ≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (IQR 29-47).

Results

Participants were primarily young to middle age (AGE IQR 28,40,59), male (81%), white (74%), and had primarily severe TBI (IQR GCS 3,6,14). A subset (26%) had a history of military service. Results revealed that the Berlin high risk score (ROC-AUC=0.63) was inferior to the MAPI (ROC-AUC = 0.7802) (p=.0211, CI: 0.0181, 0.2233) and STOPBANG (ROCAUC = 0.7852) (p=.0006, CI: 0.0629, 0.2302); both of which had comparable AUC (p=.7245, CI: -0.0472, 0.0678). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI>5. The pattern was similar across TBI severity subgroups except for delirium or post-traumatic amnesia status wherein the MAPI outperformed the Berlin and STOPBANG. Youden’s Index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples.

Conclusion

This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for moderate to severe TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015; HT0014-19-C-0004)) for DVBIC, NIDILRR (NSDC Grant # 90DPTB00070, #90DP0084, 90DPTB0013-01-00, 90DPTB0008, 90DPT80004-02).

A lay person versus a trained endoscopist: can the preop endoscopy simulator detect a difference?

The purpose of this study was to establish construct validation of a flexible sigmoidoscopy simulator by comparing training-level grouped subjects. These included clerical staff (n = 10), residents (n = 19), and experts (n = 5). Each participant performed 3 scopes. The ANOVA group-based results for trainer-measured variables are shown in Table 1. These results demonstrate that the flexible sigmoidoscopy simulator distinguished the trained from the untrained and the resident from the expert. Although there was no statistically significant differences between the senior residents and the experts, the expert commonly outperformed the residents. Establishing the transferability of simulator training to real life is next. If the transfer of skill can be established, it may give rise to a new skills training approach.