© Associated Professional Sleep Societies, LLC 1 Sleep in Veterans Kathleen Sarmiento, MD
© Associated Professional Sleep Societies, LLC 1
Sleep in VeteransKathleen Sarmiento, MD
© Associated Professional Sleep Societies, LLC 2
Conflict of Interest Disclosures for Speakers1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR
X 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support Jazz Pharmaceuticals
Consultant
Speakers’ Bureaus
Financial support
Other
X 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:
1.
2.
3.
© Associated Professional Sleep Societies, LLC 3
Objectives• Understand the sleep needs of Veterans
– Insomnia, sleep apnea, PTSD & TBI• Review provision of current sleep care
– Resources available– Models of care
• Introduce Innovation in VA Sleep– REVAMP– Thinking outside the box: boots on the ground
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Who We Serve• 21million veterans, 8.2million enrolled• Combat veterans are eligible for 5 years of
care after separation• High prevalence of sleep complaints
among service members– 32% insufficient sleep in theater (MHAT V, 2008)
– 25% insufficient sleep (MHAT 9, 2013)
• Unknown prevalence of OSA in OIF/OEF/OND Veterans
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Sleep: Not a PriorityBarriers to promoting healthy sleep in active duty• Military cultural attitudes undermining the
importance of sleep• Low institutional priority of war-related health
issues• Suboptimal environmental conditions• Shift work, deployment and travel schedules
disrupt sleep and promote persistence of insomnia
• Lack of knowledge of good sleep practices
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Consequences of Sleep Disruption• Conditioning to not sleep (learned
hyperarousal)• Short term fixes that perpetuate sleep
difficulties– Use of stimulants, energy drinks– Engaging in wakefulness promoting activities– OTC and prescription sleeping aids
• Reinforces vigilance and alertness• Results in persistence of inability to sleep
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Consequences of Sleep DisruptionSleep affects health• Cognitive function• Physical health• Mental health
Sleeping difficulties are manifest of PTSD, TBI, mood disorders, but may also worsen these conditions and increase the risk of suicide.
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Prevalence of Sleep Disorders• Approx 40% of Veterans in primary care1 have
probable insomnia (vs. 19% general community2)
• Increased prevalence rates in:– Depression - Other sleep disorders– PTSD - Pain/medical disorders– Substance Use - Aging
• Insomnia is associated with significant distress and reduced quality of life1 Mustafa et al 2005, Sleep Breath.; 2 Ohayon 2002, Sleep Medicine Reviews
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Sleep and PTSD
• Sleep disturbance is part of the diagnostic criteria for PTSD– Nightmares as a reexperiencing symtpom– Insomnia as a hyperarousal symptom
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PTSD and insomnia
• 44% of Vietnam Veterans w/PTSD reported difficulty falling asleep sometimes or very frequently vs 6% w/o PTSD (Neylan et al. 1998)
• 91% of Vietnam Veterans w/PTSD rated sometimes or very frequent difficulty maintaining sleep vs. 63% w/o PTSD and 53% of civilians
• PTSD community sample more disrupted sleep (47% vs 18%) and wake too early (43% vs13%).
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PTSD and Nightmares
• 52% of Vietnam Veterans w/ PTSD had nightmares sometimes or very frequently compared to 5% w/o PTSD
• Community PTSD sample 19% vs 4% (Ohayon and Shapiro 2000)
• Female sexual or physical assault survivors w/PTSD reported nightmares on average 5 nights a week (Krakow, Schrader, et al., 2002).
• Veterans with PTSD more likely to have nightmares that are replays of actual life experiences
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Why treat insomnia?• General psychotherapy is not effective for sleep
– Insomnia and nightmares are common residual symptoms after successful treatment of PTSD
• Targeted treatment with Cognitive Behavioral Treatment for Insomnia (CBT-I) is effective– Compared to control therapy and delayed treatment
control– Better long-term efficacy than sleep medications
• CBT-I is generally considered to be the first-line treatment of choice
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• Lack of awareness of non-pharmacologic treatment options
• Lack of trained providers– Few graduate and post doctoral fellowships provide
training in CBT-I– VA National roll-out of CBT-I is increasing pool of
providers– Access still very limited, especially in rural areas
• Clinical video telehealth is one means of increasing access to treatment
Barriers to availability of CBT‐I
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Genesis of the tele‐insomnia program• Began in June of 2010 to make treatment
available at a CBOC using VTel system• Treatment delivered to groups of 6-8
Veterans• 6-session manualized format• Co-led by an on-site provider as a means of
training• Means of increasing both access and training
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Tele‐insomnia program
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Programmatic Efforts• CBT-i roll-out
– From in-person to tele-training– Group CBT-i training
• Joint efforts between DoD and VA
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FTEE 2012 2014
Physician 112.1 241
Nurse PractitionerPhysician Assistant
20.4 15.4
4815
Respiratory Therapy
115.3 221
Sleep Tech 100.4 377
Sleep Service Provided Programs
Home Sleep Testing 65%
Polysomnography 72%
Telemedicine 32%
Shared Appointments 20%
Group Testing 25%
Medical Sleep Programs
• 361,637 Sleep Encounters• $166m in Sleep PAP & Supplies
Sleep Program Resources
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Sleep Apnea
0
20000
40000
60000
80000
100000
120000
140000
FY12 Encounters FY13 Encounters FY14 Encounters FY15 Encounters
Sleep Testing
66,278
117,355
86,072
74,082
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• OSA is common in VA• VA is ill‐equipped to manage OSA in the conventional way– Few labs relative to numbers of patients– Geographic disparities for access
• Necessary to think creatively to solve this problem• Believed that home dx and treatment MUST be a part of this
Kuna et al, AJRCCM 2011
Lessons from the Veterans Sleep Apnea Treatment Trial (VSATT)
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Inclusion criteria:• Patients referred for a sleep evaluation for suspected sleep apnea• Age 18 years• Living within 90 miles of the sleep center
Exclusion criteria:• Unable or unwilling to provide informed written consent• Inability to complete the Assessment Battery• Lack of telephone access or inability to return for follow‐up testing.• Prior sleep evaluations, OSA treatment, or other sleep disorder • A clinically unstable chronic medical condition as defined by a new diagnosis
or change in medical management in the previous 3 months of cardiac disease, thyroid disease, diabetes, depression or psychosis, cirrhosis, or recently diagnosed cancer
• Individuals on long term oxygen therapy or requiring BIPAP• Rotating shift work or irregular work schedules over the last 6 months• Suspected or confirmed to be pregnant
Inclusion/Exclusion Criteria
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Clinic F/U
In‐lab PSG(n=35)
AHI < 15 (n=23)
CPAP PSG (n=84)
Home autoCPAP titration (n=119)
In‐lab PSG(n=141)
Home sleep study(n=139)
CPAP set‐up (n=110)
One month FU (n=92)
Baseline Assessment and Randomization (n=296)
CPAP set‐up (n=113)
Dx’ic PSG (n=99)
Split PSG (n=42)
In‐lab PSG(n=18)
Non‐OSA(n=9)
Non‐OSA(n=9)
One month FU (n=103)
Three month FU (n=86)
Three month FU (n=96)
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Home Testing (n=113)
In-Lab Testing (n=110)
Factor Mean ± SD Mean ± SD P-valueAge (yrs) 55.1 ± 10.3 51.8 ± 10.4 0.02BMI (kg/m2) 35.0 ± 7.5 34.2 ± 5.2 0.34FOSQ total score 15.0 ± 3.2 14.7 ± 2.9 0.55ESS score 12 ± 5 13 ± 5 0.21CES-D 23.3 ± 7.8 25.0 ± 8.8 0.13SF-12 physical score†
36.7 ± 10.9 38.2 ± 10.2 0.29
SF-12 mental health score
44.4 ± 10.8 41.1 ± 10.7 0.02
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Home (N=105)In-Lab (N=96)
TimeBaseline Month 3
Mea
n (S
D)
FOSQ
Tot
al S
core
0
5
10
15
20
25
Functional Outcomes
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Endpoint Home adjusted mean change1
(n=113)
In-Lab adjusted mean change1
(n=110)
Adjusted difference in mean changes (SE)1
P-value2
Lower bound of 90% CI for difference in mean changes
Mean CPAP (hours/day)
3.42 2.99 0.42 (0.32) 0.180 - 0.10
1 Adjusted mean changes and adjusted differences in mean changes were estimated as site-total-sample-size weighted values controlling.2 P-value from Type II sum of squares estimated by way of analysis of covariance. To produce site weighted comparisons the ANCOVA model included main effects for type of study (home vs in-lab) and site.
Kuna et al, AJRCCM 2011
PAP Adherence
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Functional improvement with CPAP for OSA is not worse when treated in the home setting vs. the sleep laboratory
VSATT Conclusions
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Models of VA Sleep Care• Shared Medical Appointments• CPAP clinics • Electronic Consultations• Telemedicine
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• AKA group clinics• Long pedigree of seeing patients collectively• Focus on Hypertension and diabetes• Less data in Sleep
– Pittsburgh showed no difference in group vs. traditional clinics on ability to do a home test successfully
Shared Medical Appointments
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Clinicians• Clinical efficiency• See 6‐8 patients in 2 hours• No loss in data gathering; if
anything it enhances it• Medical literature is
conclusive that outcomes are equal
Patients• Sharing of concerns,
experiences (especially follow up visits)
• HIPAA issues?• Education about disease
Benefits of SMA
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• 7 patients scheduled• Sign HIPAA waivers• Complete questionnaires (include ESS, SACS)• Watch video on OSA and PAP• Group introduction• Meet with each individual (5‐7 min/person)
– Review questionnaires, clarify history, brief exam, opportunity to ask questions
Pittsburgh: SMA + HSAT
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Tech demonstrates set up of HSAT equipment• Emphasize –
A. Do recording that night or next night
B. UPS mailerC. Stick to normal routineD. Record unusual activities
from overnight recordE. Call lab at night if there
are problems with set up
EXAM: VS, neck circ, comprehensive head/neck• Heart and lungs• Ext for edema• Neuro exam• Enter note (dictate or template)
Logistics of Testing
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Education• Review OSA (again)• CPAP tips• Resources available to ptsExamination• Limited PE, vitalsForms• Full Sleep Histories• Goals of Care• Study enrollment if appl.PAP set-up• Mask fitting, instructionNotes: Templates/boilerplates
Check in, VitalsCheck in, Vitals
Education Education
Physicals, Form Completion
Physicals, Form CompletionCPAP set upCPAP set up
Closing remarksClosing remarks
MD or PA/NP, 2 RTs
SMA: Initial
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Education•CPAP tips•Share experiences in groupExamination•Limited PE, vitalsForms•Interval history form•Goals of Care•Study enrollment if appl.PAP Use Review•Compliance downloaded for each pt ahead of visit or during visit if staff available
Check in, VitalsCheck in, Vitals
Education Education
Physicals, Form Completion
Physicals, Form Completion
PAP download reviewed
PAP download reviewed
Closing remarksClosing remarks
SMA: Follow up
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• Group clinics – moderately easy to do• Examples in private sector:
– bariatric surgery– Diabetes clinics– Various mental health clinics
• Focus on similarities between patients rather than differences
Non-VA SMAs
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CMS position on SMA
“Under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face‐to‐face E/M visit (CPT code 99213 or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary."
Coding/Reimbursement
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Technologist or RT driven – Expands “boots on the ground” for Sleep– Focus on equipment issues for relatively stable established patients
– Common in VAs; unheard of in FFS – no reimbursement
– Could change if RRTs become LIPs– MD or NP/PA available for consultation if needed
CPAP Clinics
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0
20000
40000
60000
80000
100000
120000
FY12 Encounters FY13 Encounters FY14 Encounters FY15 Encounters
CPAP Clinics
20,557
30,964
44,399
113,973
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Electronic Consultations
• Facilitate communication between referring and treating providers without the need for face-to-face visits
• Provide reference notation of recommendations/plan of care in the medical record
• Reduce wait time for initial assessment and plan of care
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0
1000
2000
3000
4000
5000
6000
FY12 Encounters FY13 Encounters FY14 Encounters FY15 Encounters
Store & Forward
0
2000
4000
6000
8000
10000
12000
14000
16000
FY12 Encounters FY13 Encounters FY14 Encounters FY15 Encounters
Clinical Videoteleconferencing
3,884
9,593
15,052 15,063
117 562 999
5,139
Sleep Telemedicine
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Sleep Telemedicine
Telephone Clinics• Increase the number of patients managed• Appointments of 10-15min duration• Scheduled to provide accountability for
time spent on patient care
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Innovation in VA Sleep• Web-based Model of care (REVAMP)• Improve capture of sleep-focused data in
the medical record– Reminder Dialog Template– VA-wide collection of AHI, patient reported
outcomes – PAP Compliance data
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Current management of OSA
Philips Resmed DeVilbiss Fisher & PaykelComing Soon
PAP-generated data
Typed Progress Notes• Multiple interfaces• Inefficient clinics
• Manual data entry• Lower information security
Patient-generated data
Estimated 55% of
VA Market
Estimated 40% of
VA Market
Sleep Practitioners
Paper and pencil questionnaires
Estimated 5% of
VA Market
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Management by REVAMP
Philips Resmed DeVilbiss Fisher & PaykelComing Soon
PAP-generated data
Port 443 *encrypted transmissionVA Firewall
MVI
Single Sign On
Patient-generated data + PAP-generated data
Patient Traits
IAMAutopopulatedprogress notes
Vista interface
• One primary interface• More efficient clinics
• Much less data entry• Information security
Patient-generated data
Estimated 55% of
VA Market
Estimated 40% of
VA Market
Estimated 5% of
VA Market
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Sleep Opportunities• Improve education of providers to screen for sleep
disorders, co-manage OSA, & promote sleep health• Encourage weight management strategies to
reduce OSA• Promote the appropriate use of stimulants and
sleep aids for insomnia• Expand training for proven non-pharmacologic
insomnia therapies: CBT-i and IRT• Establish policies supporting sleep medicine training
and practices• Collaboration between DoD and VA for continuity
during transition from active duty to veteran status