2019 HSR&D/QUERI National Conference

1152 — Impact of Community Care on Time to Treatment in Veterans Diagnosed with Obstructive Sleep Apnea

Lead/Presenter: Bhavika Kaul
All Authors: Kaul B (San Francisco VA Health Care System), Smith C, PhD (Portland VA Healthcare System, Oregon Health Sciences University), Sarmiento KF, MD MPH (San Francisco VA Health Care System)

Veterans with suspected obstructive sleep apnea (OSA) have consistently experienced unacceptably long wait times and treatment delays due to insufficient resources both within VA and in the community. Diagnostic sleep testing is frequently outsourced through Community Care. Little is known, however, whether outsourcing diagnostic sleep testing actually improves timeliness to treatment with continuous positive airway pressure (CPAP). CPAP is the standard therapy for OSA and must be obtained through VA. The objective of this study was to evaluate timeliness from initial sleep consult to provision of PAP therapy in Veterans diagnosed with OSA through community care.

This is a retrospective study of all Veterans who underwent diagnostic sleep testing between 2012-2018 at the San Francisco VA. The primary outcome was time from initial sleep consultation to CPAP initiation among Veterans diagnosed with OSA. Veterans who underwent in-house testing were compared to those tested through Community Care. A SQL query of the VA Corporate Data Warehouse was developed to identify all patients with sleep consults, sleep studies, and a prosthetics order for CPAP. Community Care data was obtained directly from VHA Office of Community Care. Manual chart review was done to confirm the accuracy of data extraction.

A total of 1,358 in-house, and 103 community care studies had complete data for analysis. Mean time from initial consult to CPAP provision in-house was significantly shorter than through community care 262d vs. 474d (p < 0.0001, 95%CI -284, -140). Accounting for major outliers showed similar results, with median time to care delivery being significantly shorter in-house compared to community care, 131d vs. 269d (p < 0.0001, 95%CI -158,-73).

Outsourcing of sleep apnea care at the San Francisco VA resulted in significant delays in initiation of PAP therapy in Veterans diagnosed with OSA.

This study informs 1) Program Office efforts to evaluate interventions targeting reduced outsourced sleep care, 2) innovative strategies to improve care coordination when care must be outsourced, 3) validation of the SQL algorithms used to compare in-house and community care data, and 4) provides the basis for additional qualitative evaluation of Veterans' experiences with community care.