Cost Effectiveness of Ambulatory Management for Veterans With Sleep Apnea
This research study is comparing home and in-laboratory testing of veterans with suspected obstructive sleep apnea, a common breathing disorder during sleep. It is hoped that home testing will be equally effective in improving quality of life but have lower cost than in-lab testing. These findings will allow veterans to have greater access to diagnosis and treatment of their sleep apnea.
Objective: Our overall goal is to improve access to care for veterans with suspected obstructive sleep apnea (OSA), a breathing disorder during sleep characterized by repetitive closure of the pharyngeal airway. Portable monitors are commercially available to diagnose participants with suspected OSA and establish the continuous positive airway pressure (CPAP) setting needed for treatment. Their application to home testing is not widely accepted because it is not known whether home testing, when compared to conventional in-lab polysomnograms, is cost effective and produces similar outcomes with regard to participant adherence to CPAP treatment and improvements in functional impairment. The specific goals of the proposed research are to address these barriers by comparing the functional impact, cost, and cost-effectiveness of evaluating veterans with suspected OSA using home versus in-lab testing.
Research Design: In this prospective randomized control trial of equivalency, participants referred to the Philadelphia and Pittsburgh VA Medical Centers for evaluation for OSA will be randomized to either exclusively in-lab or home testing following baseline assessment.
Methodology: In-lab polysomnograms will be performed to diagnose OSA and titrate the pressure setting for subsequent CPAP therapy. Self-administered home testing will consist of an overnight unattended sleep study followed by a 1-week autoCPAP titration trial. Objectively assessed CPAP adherence and its consequent effects on subjective and objective daytime sleepiness, disease specific and general functional impairment, and participant preference will be obtained at 1- and 3-months after starting CPAP treatment and 3-monthly thereafter to the end of study follow-up. Medical service use and cost will be collected for the entire observation period.
Aim 1 will determine if participants with suspected OSA who receive home testing have the same adherence to subsequent CPAP treatment and the same functional outcomes as participants receiving in-lab testing. Primary outcome measures will be 1) objectively measured adherence to CPAP treatment and 2) the global score on the Functional Outcomes of Sleep Questionnaire (FOSQ) to assess the consequent effects of adherence on disease specific functional impairment. Secondary functional outcome measures will assess subjective (Epworth Sleepiness Scale) and objective (Psychomotor Vigilance Test) daytime sleepiness, and general quality of life (SF-12). Hypothesis 1: Despite differences between in-lab versus home testing in terms of technology, time participants interact with health care professionals, and environment, there is no clinically significant decline in mean CPAP adherence and no clinically significant reduction in functional outcomes in participants receiving home versus in-lab testing.
Aim 2 will compare the differences in cost and quality-adjusted life years saved (QALYS) between home versus in-lab testing to estimate a cost-effectiveness ratio. Participant preference will be assessed with the EuroQol (EQ-5D) and Health Utilities Index 2 (HUI). Hypothesis 2a: Average total health-care delivery cost is lower for veterans receiving home testing relative to those receiving in-lab testing. Hypothesis 2b: Because we believe that at-home testing will have lower costs and equivalent outcomes, we will be 90% confident that the cost per QALY ratio comparing at-home testing with in-lab testing will be less than $100,000.
Clinical Relationship: We need to determine the most cost effective way to diagnose veterans with OSA and initiate them on CPAP treatment. If the results show that home testing produces clinical outcomes that are not significantly clinically inferior and similar or reduced costs compared with in-lab testing, decision makers can be confident that home monitors can be used to diagnose and treat OSA and that improving veterans' access to care for OSA need not require construction of additional, costly sleep labs.
Anticipated Findings: We anticipate that the results will demonstrate that 1) participants receiving in-lab versus home testing have similar clinical outcomes, and 2) home testing is more cost effective than in-lab testing. These anticipated answers will lead to wide acceptance of home portable monitor testing and increase veteran access to care.
Allocation: Randomized, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Diagnostic
Obstructive Sleep Apnea
Continuous positive airway pressure apparatus
VA Medical Center, Philadelphia
Active, not recruiting
Department of Veterans Affairs
Results (where available)
- Source: http://clinicaltrials.gov/show/NCT00880165
- Information obtained from ClinicalTrials.gov on July 15, 2010
Medical and Biotech [MESH] Definitions
Sleep Apnea, Central
A condition associated with multiple episodes of sleep apnea which are distinguished from obstructive sleep apnea (SLEEP APNEA, OBSTRUCTIVE) by the complete cessation of efforts to breathe. This disorder is associated with dysfunction of central nervous system centers that regulate respiration. This condition may be idiopathic (primary) or associated with lower brain stem lesions; chronic obstructive pulmonary disease (LUNG DISEASES, OBSTRUCTIVE); HEART FAILURE, CONGESTIVE; medication effect; and other conditions. Sleep maintenance is impaired, resulting in daytime hypersomnolence. Primary central sleep apnea is frequently associated with obstructive sleep apnea. When both forms are present the condition is referred to as mixed sleep apnea (see SLEEP APNEA SYNDROMES). (Adams et al., Principles of Neurology, 6th ed, p395; Neurol Clin 1996;14(3):611-28)
Sleep Apnea Syndromes
Disorders characterized by multiple cessations of respirations during sleep that induce partial arousals and interfere with the maintenance of sleep. Sleep apnea syndromes are divided into central (see SLEEP APNEA, CENTRAL), obstructive (see SLEEP APNEA, OBSTRUCTIVE), and mixed central-obstructive types.
Sleep Apnea, Obstructive
A disorder characterized by recurrent apneas during sleep despite persistent respiratory efforts. It is due to upper airway obstruction. The respiratory pauses may induce HYPERCAPNIA or HYPOXIA. Cardiac arrhythmias and elevation of systemic and pulmonary arterial pressures may occur. Frequent partial arousals occur throughout sleep, resulting in relative SLEEP DEPRIVATION and daytime tiredness. Associated conditions include OBESITY; ACROMEGALY; MYXEDEMA; micrognathia; MYOTONIC DYSTROPHY; adenotonsilar dystrophy; and NEUROMUSCULAR DISEASES. (From Adams et al., Principles of Neurology, 6th ed, p395)
Continuous Positive Airway Pressure
A technique of respiratory therapy, in either spontaneously breathing or mechanically ventilated patients, in which airway pressure is maintained above atmospheric pressure throughout the respiratory cycle by pressurization of the ventilatory circuit. (On-Line Medical Dictionary [Internet]. Newcastle upon Tyne(UK): The University Dept. of Medical Oncology: The CancerWEB Project; c1997-2003 [cited 2003 Apr 17]. Available from: http://cancerweb.ncl.ac.uk/omd/)
Intermittent Positive-pressure Ventilation
Application of positive pressure to the inspiratory phase when the patient has an artificial airway in place and is connected to a ventilator.
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