Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act

Clinical Management of Sleep Disturbances in Post-9/11 Men and Women Veterans: A 20-year Prospective Cohort Study

INTRODUCTION

Sleep disorders and chronic conditions that are comorbid with disordered sleep represent a high burden to the U.S. population, and Veterans have a particularly high risk for disordered sleep. Sleep disorders also present differently by sex and there is a rapidly growing proportion of women Veterans. Among the most recent Veteran cohort (i.e., discharged post-9/11), the extent of sleep disorders and how those conditions are managed is unknown. The objectives were to characterize the frequency of sleep assessment, diagnosis, and treatment among post-9/11 Veterans served by the Veterans Health Administration (VA), the timing of sleep management, and to determine if there were sex-based disparities in all sleep care.

METHODS

This prospective cohort study included all post-9/11 Veterans who enrolled in VA care, and completed ≥ 1 outpatient encounter, 10/1/2001-9/30/2021. Diagnostic and procedural codes, health factors, and dates were used to extract variables for assessment (e.g., behavioral, polysomnography), diagnoses (i.e., insomnia, sleep-related breathing [SRBD], comorbid insomnia and SRBD [COMISA], sleep-related movement [SRMD], or Other disorders), treatment of insomnia or SRBD, and time to sleep assessment, diagnosis, and treatment. Logistic regressions assessed likelihood of sleep care by sex.

RESULTS

The final sample included 1,113,633 patients (12% women, 61% White). Overall, 39% had sleep disorders - 27% with SRBD, 18% with insomnia, 8% with COMISA, 2% with SRMD, and 6% with Other. Men were more likely to have any diagnosis, especially SRBD. Women were assessed up to one year later than men and had greater odds of insomnia or SRMD. Women also had greater odds of insomnia treatment and those with SRBD were 31% less likely to receive treatment than men.

CONCLUSIONS

As managing sleep health is central to patient-centered care, concerted efforts are required to implement existing VA guidelines concerning sleep, bridging men and women Veteran's sleep needs with available resources.

Stated patient preferences for overnight at-home diagnostic assessment of sleep disorders

PURPOSE

The diagnostic workup for assessment of sleep disorders commonly involves overnight testing to assess sleep patterns and pathological events. So far, little is known about preferences for provision of home sleep tests to patients with sleep disorders. This study aims to close this gap by eliciting preferences for home sleep testing using a discrete choice experiment (DCE).

METHODS

A DCE with seven attributes of at-home sleep testing and three levels per attribute was developed using a fractional factorial design. Patients with and without previous sleep testing experience were recruited from two large sleep centers in Germany. Coefficients for attribute levels were calculated using a conditional logit model to estimate their influence on choice decisions and calculate the relative importance of each attribute.

RESULTS

305 patients (54.5 ± 13,1 years, 65.3% male) were enrolled, and 288 surveys with complete data included for analysis. Attributes with greatest relevance were Waiting time to discuss sleep study results; Waiting time to conduct sleep study, and Sleep quality during measurement. Of lowest importance was Diagnostic accuracy of sleep study, followed by Effort to apply sleep study device. Significant heterogeneity in choice behavior was found, including differences by gender, willingness-to-pay for sleep studies, and previous experience with sleep studies. Preferred location for conducting sleep testing was at-home in 50.7% and in-lab in 46.9%.

CONCLUSIONS

Preferences and relative importance of home sleep test attributes vary among different subgroups. Considering those preferences can be important for clinicians and policymakers when designing care pathways and planning of testing policies for sleep disorders.

Implementing TeleSleep at Veterans Healthcare Administration: an organizational case study of adaptation and sustainment

Veteran access to sleep medicine is of paramount importance to the Veterans Health Administration (VA). To increase access, VA has created community referral policies and programs, as well as telehealth programs. In 2017, the Office of Rural Health (ORH) funded a TeleSleep initiative focused on reaching rural Veterans with unmet sleep needs. ORH provided 3-6 years of funding to help 19 hubs support 98 spoke sites serving rural Veterans. As ORH funding concluded, each hub identified its path to sustainment. This case study follows one TeleSleep hub in VA's western geographic region as it transitioned from ORH funding sustainment as a regional Sleep Clinical Resource Hub. This case study describes the real-world process of adaptation in care delivery strategies. One key area of adaptation revolved around whether to deliver care via the patient's home facility or the provider's home facility. In early 2021, the TeleSleep team implemented an innovative provider transfer model, where temporary reinforcements from the TeleSleep hub increased the workforce capacity of spoke sites, similar to the concept of locum tenens. In this provider transfer model, TeleSleep clinicians scheduled, documented, and billed for each encounter at the Veteran's home facility. Positioning TeleSleep clinicians as local providers facilitated communication and referrals and promoted continuity and quality of care for Veterans in their home facility. This provider transfer model reduced the administrative burden of providers and schedulers and supported patient-side-only documentation of care. While this mirrors current locum tenens practice, transferring providers did not fit VA's financial model as implemented by the western region's Sleep Clinical Resource Hub. Therefore, in December 2021, VA aligned TeleSleep with VA's preferred practice of patient rather than provider transfers. In the patient transfer model, providers schedule and document in both the provider and patient electronic health records, and bill in the provider's facility. However, reflecting on this period of innovation, TeleSleep team members concluded that the provider transfer model could improve patient safety and care coordination while reducing the administrative burden of frontline clinicians. Further research and development are needed to align the provider transfer model with VA's financial model.

Trends in obstructive sleep apnea disease severity over nearly two decades: update on the VA San Diego experience

Study Objectives

The Sleep Program at the VA San Diego Healthcare System (VASDHS) started a patient database over twenty years ago for its home sleep apnea testing (HSAT) program. An analysis of ten years of diagnostic HSAT data was reported on over 12 500 patients in 2014. Over this time period, severe obstructive sleep apnea (OSA) decreased in frequency. In contrast, mild OSA increased in frequency and was the most frequently reported severity in our analysis. In more recent times, the 2021 continuous positive airway pressure (CPAP) crisis created difficulties in dispersing CPAP therapies to individuals including Veterans with OSA, prompting our group to reexamine the HSAT database.

Methods

A retrospective review was performed of the local clinical database of HSAT diagnostic testing of 8,928 sleep studies from 2018 to 2022.

Results

The overall mean apnea-hypopnea index (AHI) decreased from 40.4/hour (2004) to 24.3/hour (2022) (p < .001). The two time periods were examined separately. For 2004-2013, it was found that the mean AHI in 2004 was not significantly different from the mean AHI in 2005, 2006, or 2007 but was significantly different from the mean AHI in each year from 2008 (mean AHI = 30.7/h) to 2013 (mean AHI = 26.1/hour). For 2019-2022, the mean AHI did not significantly differ between the 4 years.

Conclusions

These findings have implications for OSA therapies. Additionally, the high prevalence of mild sleep apnea, which is typically associated with lesser adherence to PAP therapy, further highlights the importance of non-PAP alternatives to improve treatment effectiveness.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6 weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

Hospital Readmissions Among Veterans Within 90 Days of Discharge Following Initial Hospitalization for COVID-19

INTRODUCTION

Some patients experience ongoing sequelae after discharge, including rehospitalization; therefore, outcomes following COVID-19 hospitalization are of continued interest. We examined readmissions within 90 days of hospital discharge for veterans hospitalized with COVID-19 during the first 10 months of the pandemic in the US.

METHODS

Veterans hospitalized with COVID-19 at a Veterans Health Administration (VA) hospital from March 1, 2020, through December 31, 2020 were followed for 90 days after discharge to determine readmission rates.

RESULTS

Of 20,414 veterans hospitalized with COVID-19 during this time period, 13% (n = 2,643) died in the hospital. Among survivors (n = 17,771), 16% (n = 2,764) were readmitted within 90 days of discharge, with a mean time to readmission of 21.6 days (SD = 21.1). Characteristics of the initial COVID-19 hospitalization associated with readmission included length of stay, mechanical ventilator use, higher comorbidity index score, current smoking, urban residence, discharged against medical advice, and hospitalized from September through December 2020 versus March through August 2020 (all P values <.02). Veterans readmitted from September through December 2020 were more often White, lived in a rural or highly rural area, and had shorter initial hospitalizations than veterans hospitalized earlier in the year.

CONCLUSION

Approximately 1 of 6 veterans discharged alive following a COVID-19 hospitalization from March 1 through December 31, 2020, were readmitted within 90 days. The longer the hospital stay, the greater the likelihood of readmission. Readmissions also were more likely when the initial admission required mechanical ventilation, or when the veteran had multiple comorbidities, smoked, or lived in an urban area. COVID-19 hospitalizations were shorter from September through December 2020, suggesting that hospital over-capacity may have resulted in earlier discharges and increased readmissions. Efforts to monitor and provide support for patients discharged in high bed-capacity situations may help avoid readmissions.

Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care

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Veterans' Use of Veterans Health Administration Primary Care in an Era of Expanding Choice

BACKGROUND

The Veterans Choice Program (VCP), aimed at improving access to care, included expanded options for Veterans to receive primary care through community providers.

OBJECTIVES

The objective of this study was to characterize and compare Veterans use of Veterans Health Administration (VA) primary care services at VA facilities and through a VA community care network (VA-CCN) provider.

RESEARCH DESIGN

This was a retrospective, observational over fiscal years (FY) 2015-2018.

SUBJECTS

Veterans receiving primary care services paid for by the VA.

MEASURES

Veteran demographic, socioeconomic and clinical factors and use of VA primary care services under the VCP each year.

RESULTS

There were 6.3 million Veterans with >54 million VA primary care visits, predominantly (98.5% of visits) at VA facility. The proportion of VA-CCN visits increased in absolute terms from 0.7% in 2015 to 2.6% in 2018. Among Veterans with any VA-CCN primary care, the proportion of VA-CCN visits increased from 22.6% to 55.3%. Logistic regression indicated that Veterans who were female, lived in rural areas, had a driving distance >40 miles, had health insurance or had a psychiatric/depression condition were more likely to receive VA-CCN primary care. Veterans who were older, identified as Black race, required to pay VA copayments, or had a higher Nosos score, were less likely to receive VA-CCN primary care.

CONCLUSION

As the VA transitions from the VCP to MISSION and VA facilities gain experience under the new contracts, attention to factors that impact Veterans' use of primary care services in different settings are important to monitor to identify access barriers and to ensure Veterans' health care needs are met.

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans' experience with the VA TeleSleep program

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.

Prevalence and management of sleep disorders in the Veterans Health Administration

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.