The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

This is a guideline for evaluation and management of obstructive sleep apnea and chronic insomnia developed by the VA and DoD. The recommendations are concise and useful. James W. Mold, MD, MPH

Free full text

View

Abstract

Description:

In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions.

Methods:

In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

Recommendations:

This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

The National Institutes of Health has estimated that insomnia and obstructive sleep apnea (OSA) are 2 of the most common sleep disorders in the general U.S. population and in the military and veteran populations (1). Insomnia symptoms are the most common sleep symptoms among U.S. adults, occurring in approximately 20% to 30% of adults, and the prevalence of chronic insomnia disorder ranges from 6% to 10% (2–6). The prevalence of OSA ranges from 9% to 38% and is associated with older age, higher body mass index, male sex, and menopause.

Sleep disorders are more prevalent in the populations served by the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) than in the general civilian population. In the RAND report “Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers,” 48.6% of military personnel surveyed had poor sleep quality (Pittsburgh Sleep Quality Index score >5) (7). The prevalence of insomnia symptoms has been reported to be as high as 41% in service members deployed to combat and 25% in noncombatants (8). In a large cohort of soldiers preparing for deployment, 19.9% met criteria for insomnia according to the Insomnia Severity Index (ISI) (8). A more recent study evaluated the incidence of insomnia and OSA in the entire population of U.S. Army soldiers from 1997 to 2011 (9) and showed unprecedented increases in the incidence of both conditions (652% and 600%, respectively) during this period. In military personnel referred for sleep evaluations, sleep-disordered breathing is the most frequently diagnosed disorder, and some studies have found that military personnel have high rates of comorbid insomnia and OSA (10, 11). Further, military personnel with sleep disorders often also have posttraumatic stress disorder (PTSD), symptoms of anxiety and depression, and traumatic brain injury, which can complicate diagnosis and management (11–13).

Sleep disturbances are also common in veterans (14–16). Similar to findings from active-duty service members, the National Veteran Sleep Disorder Study found that the number of veterans diagnosed with sleep disorders increased nearly 6-fold from 2000 to 2010. In this study, 4.5% of veterans were diagnosed with sleep-disordered breathing, and 2.5% were diagnosed with insomnia. However, the actual prevalence of insomnia disorder among veterans is likely to be considerably higher (17) because it is often not documented in the medical record (18, 19). Comorbid PTSD was associated with a 7.6-fold greater risk for OSA and a 6.3-fold greater risk for insomnia (15). Because veterans have high rates of cardiovascular disease and PTSD, and because OSA is more prevalent in patients with these disorders (20), there is likely a large percentage of veterans who have not yet been diagnosed with OSA (21).

Author/s:

Mysliwiec, V., Martin, J.L., Ulmer, J.S., Chowdhuri, S., Brock, M.S., Spevak, C.

Integrating Community Health Workers Into Health Care Teams Without Coopting Them

Tracy Ashby — Mon, 13 May 2019 05:00:00 +0000

Date Added:

May 13, 2019

Journal/Publication:

Health Affairs

Publisher:

Project HOPE: The People-to-People Health Foundation, Inc.

Publication Date:

May 10, 2019

URL:

Integrating Community Health Workers Into Health Care Teams Without Coopting Them

Type:

Community-Based Research Results

Format:

Article

DOI (1):

10.1377/hblog20190507.746358

Keywords

community health workers

primary health care

MeSH

community health workers

public health

delivery of health care

patient care team

An interesting article about community health workers and primary care practices. James W. Mold, MD, MPH

Commercial full text (fees may apply)

View

Community health workers (CHWs) are trusted laypeople who help their communities achieve health and well-being. For generations, they’ve worked in church basements, shelters, and food pantries to address a variety of health and social needs. In recent years, this workforce has captured the attention of health care organizations looking to hit value-based payment targets that are heavily influenced by the social determinants of health. As a result, they increasingly are transitioning from their grassroots, community-based origins to become integrated members of health care teams. The marriage of community health and formal health care is powerful, but it’s also tricky. If CHWs lose their identity and become medicalized, their effectiveness in the community is lessened. Health care leaders must grapple with a fundamental question: How do we integrate a grassroots workforce into health care without totally coopting it? We explore this tension and offer guidance for health care leaders, based on our experience with developing the IMPaCT CHW model, which has served 10,000 patients in greater Philadelphia and provides tools and technical assistance to more than 1,000 health care organizations across the country.

The challenges facing CHWs as they become part of health care teams can be thought of as falling into four categories: agenda, identity, scope of work, and integration.

Author/s:

Garfield, Cheryl, Kangovi, Shreya