Abstract Introduction The prevalence of obstructive sleep apnea (OSA) among Veterans is rising, placing increasing demand on the Veterans Health Administration (VHA) and its limited sleep medicine resources. Because access to sleep specialists often constrains timely care, innovative models are needed to streamline OSA diagnosis and treatment. Currently, Medicare and most insurers mandate an in-person or virtual evaluation by a physician or licensed provider before home sleep testing and/or initiation of therapy. The “De-implementation of the Initial Provider Encounter for Diagnosis and Treatment of Obstructive Sleep Apnea: The DREAM (Direct Referral for Apnea Monitoring) Project” evaluates whether replacing the initial sleep provider visit with an electronic chart review or e-consult (the DREAM pathway) improves timeliness to diagnostic testing and initiation of positive airway pressure (PAP) therapy compared with the traditional care pathway. Methods This pragmatic study was conducted across three VA sleep medicine programs (San Francisco, CA; Portland, OR; and Pittsburgh, PA). Veterans referred for evaluation of suspected OSA were followed from the point of referral through diagnostic testing and PAP initiation. Participants were assigned to either the Traditional pathway, which included an initial sleep provider visit, or the DREAM pathway, which omitted this step and substituted an electronic chart review or e-consult. The primary outcomes were time from referral to sleep testing and time from referral to PAP initiation. Group comparisons were made using appropriate statistical tests. Results A total of 1,215 Veterans were included: 921 in the DREAM pathway and 294 in the Traditional pathway. The mean time from referral to sleep testing was 120.4 days (SD = 107.8) for DREAM versus 216.1 days (SD = 136.9) for Traditional care (p 0.0001). The mean time from referral to PAP initiation was 192.6 days (SD = 108.1) for DREAM and 252.7 days (SD = 121.4) for Traditional care (p 0.0001). Conclusion Preliminary findings demonstrate that substituting the initial sleep provider encounter with an electronic chart review or e-consult substantially improves timeliness to both diagnostic testing and PAP therapy initiation. Ongoing analyses will examine site-level variation, PAP adherence, and patient satisfaction to inform broader implementation within the VHA network. Support (if any) This work was supported by VA HSR&D Service Merit Award #IIR 15-339.
Sarmiento et al. (Fri,) studied this question.