Remote Sleep Apnea Management
Remote Ambulatory Management of Veterans With Sleep Apnea
調査の概要
状態
詳細な説明
Obstructive sleep apnea (OSA) is estimated to be the third most common chronic disease in Veterans and is associated with an increased risk of hypertension, heart attacks, strokes, depression, and driving accidents. Current in-person management at a sleep center limits Veterans' access to care, prolongs patient wait times, and requires Veterans living in remote areas to travel long distances. This proposal will evaluate an innovative web-based clinical pathway to diagnose and manage Veterans with OSA. In FY13, the investigative team received a VHA Innovation Award to create the Remote Veteran Apnea Management Portal (REVAMP), a personalized, interactive website that, when combined with other emerging telehealth technologies, is designed to improve access to care, reduce patient wait times, and allow Veterans to receive care without travelling to a sleep center. Veterans complete intake and follow-up questionnaires on the REVAMP website and perform an unattended home sleep test (HST) without in-person instructions. Sleep specialists review the findings with the patient during an initial phone clinic. REVAMP auto-populates the Veteran's questionnaire responses into templated progress notes that are exported to CPRS, the electronic medical record. Veterans diagnosed with OSA are treated with automatically adjusting positive airway pressure (APAP) units. These devices transmit data wirelessly to the website where treatment use and its effectiveness can be monitored by both Veterans and practitioners, thereby promoting patient self-management and productive patient-practitioner interactions.
The investigators' proposed prospective, randomized intervention will compare the clinical and cost-effectiveness of REVAMP management of Veterans with OSA to in-person care. Aim 1 will determine if management with REVAMP is clinically non-inferior to in-person care in terms of improvement in functional outcomes and APAP adherence. Non-inferiority of clinical effectiveness following 3 months of APAP treatment will be expressed in terms of improvement in the score of the Functional Outcomes of Sleep Questionnaire (FOSQ-10), the investigators' primary outcome measure. Adherence to APAP will be objectively monitored by wireless transmission of data from the participant's home unit. In Aim 2, patient preference, medical service use and cost will be collected every 3 months for the entire observation period to compare cost effectiveness of the two managements. Preference will be assessed by the SF-6D,6 and the EQ-5D.7, 8 Differences in the ratio of cost and quality-adjusted life years saved by REVAMP compared to in-person management will test the hypothesis that REVAMP management will have lower cost and equivalent outcomes. The results of Aims 1 and 2 will provide evidence to support widespread dissemination of REVAMP. Formative evaluation in Aim 3 will use qualitative (targeted phone interviews) and quantitative measures (attrition, work alliance, and patient satisfaction) to inform clinicians, administrators and other stakeholders how to implement this innovative chronic disease pathway.
Aim 1 (primary). To compare functional outcomes following 3 months of APAP treatment in Veterans with OSA randomized to REVAMP versus in-person management. The primary outcome measure in this modified intent-to-treat analysis (i.e., subjects initiated on APAP with at least one FOSQ follow-up score) will be the change from baseline in the FOSQ-10 score. Analysis will also compare the mean daily hours of APAP use in participants in the two groups initiated on APAP treatment.
Hypothesis 1a: Mean change in FOSQ-10 score among participants randomized to REVAMP management will be no more than one point less than that in participants receiving in-person management.
Hypothesis 1b: Mean daily hours of APAP use among participants receiving REVAMP management will be no more than 0.75 hour less than that in participants randomized to in-person management.
Aim 2 (secondary): To compare the differences in cost and quality-adjusted life years (QALY) between REVAMP management and in-person management. The perspective of the analysis will be that of the VA and the intention to treat analysis set will include all randomized participants.
Hypothesis 2a: Average total health-care delivery cost will be lower for participants receiving REVAMP compared to in-person management.
Hypothesis 2b: The 90% lower limit of cost per QALY ratio comparing in-person versus REVAMP manage-ment will be > $100,000 (i.e., the investigators will have 90% confidence that REVAMP is good value for the cost).
Aim 3 (exploratory): To conduct a mixed methods formative evaluation that will guide REVAMP's widespread implementation. Quantitative component: The investigators will track quantitative outcome measures across both groups including attrition, participant- and practitioner-rated therapeutic alliance (Working Alliance Inventory-Short Revised [WAI-SR]),9 and participant treatment satisfaction (Client Satisfaction Questionnaire [CSQ-8]).10 The investigators will compare the scores of the WAI-SR and CSQ-8 and attrition rates between treatment arms. Qualitative component: The investigators will explore participant- and practitioner-level perspectives, attitudes, and preferences regarding REVAMP versus in-person management, as well as barriers and facilitators to participation in either clinical pathway through phone interviews with participants from the two intervention groups, participants who withdraw from either intervention, and staff who provide care through REVAMP.
研究の種類
入学 (実際)
段階
- 適用できない
連絡先と場所
研究場所
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California
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San Diego、California、アメリカ、92161
- VA San Diego Healthcare System, San Diego, CA
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Georgia
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Decatur、Georgia、アメリカ、30033
- Atlanta VA Medical and Rehab Center, Decatur, GA
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Pennsylvania
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Philadelphia、Pennsylvania、アメリカ、19104
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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-
参加基準
適格基準
就学可能な年齢
健康ボランティアの受け入れ
受講資格のある性別
説明
Inclusion Criteria:
Veterans must meet the following inclusion criteria prior to enrollment:
- Referral to one of the participating sleep centers for evaluation of suspected OSA
- Access in the home to the internet, e-mail, and phone on all days
- Fluent in English as assessed on the initial phone contact
Exclusion Criteria:
Veterans will be excluded from the study for the following reasons:
- Unable or unwilling to provide informed consent and complete required questionnaires
Previous diagnosis of:
- obstructive sleep apnea (OSA)
- central sleep apnea (50% of apneas on diagnostic testing are central apneas)
- Cheyne-Stokes breathing
- obesity hypoventilation syndrome
- narcolepsy
- Previous treatment with positive airway pressure, non-nasal surgery for OSA, or current use of supplemental oxygen
A clinically unstable medical condition in the previous 2 months as defined by a new diagnosis, e.g.:
- pneumonia
- myocardial infarction
- congestive heart failure
- unstable angina
- thyroid disease
- depression or psychosis
- ventricular arrhythmias
- cirrhosis
- surgery
- recently diagnosed cancer
- Night shift workers in situations or occupations where they regularly experience jet lag, or have irregular work schedules by history over the last 3 months
- Women who are pregnant or women who are sexually active and of child-bearing age who are not using some form of contraceptive
- Unable to perform tests due to inability to communicate verbally, inability to read and write, and visual, hearing or cognitive impairment
研究計画
研究はどのように設計されていますか?
デザインの詳細
- 主な目的:処理
- 割り当て:ランダム化
- 介入モデル:並列代入
- マスキング:なし(オープンラベル)
武器と介入
参加者グループ / アーム |
介入・治療 |
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実験的:REVAMP
Veterans randomized to this arm will have access to the Remote Veteran Apnea Management Platform (REVAMP) a personalized, interactive website that allows Veterans to be evaluated for OSA without travelling to the sleep center.
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Participants in both arms who are diagnosed with obstructive sleep apnea will be treated with autoadjusting continuous positive airway pressure
他の名前:
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アクティブコンパレータ:In-person management
Veterans randomized to this arm will receive standard in-person management of their sleep apnea in the sleep center.
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Participants in both arms who are diagnosed with obstructive sleep apnea will be treated with autoadjusting continuous positive airway pressure
他の名前:
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この研究は何を測定していますか?
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
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Functional Outcome of Sleep Questionnaire - Short Form (FOSQ-10)
時間枠:3 months
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Self-administered disease specific quality of life questionnaire
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3 months
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二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
---|---|---|
Epworth Sleepiness Scale (ESS)
時間枠:3 months
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Self-administered subjective measure of daytime sleepiness
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3 months
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Heath Survey Short Form - 12 (SF-12)
時間枠:3 months
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Self administered quality of life questionnaire
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3 months
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Center for Epidemiological Studies Depression questionnaire (CES-D)
時間枠:3 months
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Self-administered assessment of depression
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3 months
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Insomnia Severity Index (ISI)
時間枠:3 months
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Self-administered assessment of insomnia
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3 months
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Health Utilities Index (HUI)
時間枠:3 months to 2.5 years
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Self-administered questionnaire on overall functional health
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3 months to 2.5 years
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EuroQol
時間枠:3 months to 2.5 years
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Self-administered questionnaire on quality of life
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3 months to 2.5 years
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Worker Alliance Inventory - Short Revised (WAI-SR)
時間枠:3 months
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Assessment of patient-rated alliance with the practitioner
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3 months
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Client Satisfaction Questionnaire (CSQ-8)
時間枠:3 months
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Self-administered questionnaire assessing patient satisfaction with care delivered
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3 months
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Adherence to autoadjusting CPAP treatment
時間枠:3 months
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Objective assessment of treatment adherence and efficacy
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3 months
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協力者と研究者
捜査官
- 主任研究者:Samuel T. Kuna, MD、Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
出版物と役立つリンク
研究記録日
主要日程の研究
研究開始 (実際)
一次修了 (実際)
研究の完了 (実際)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (見積もり)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
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