Helping Veterans with obstructive sleep apnea determine "what matters most" in choosing a treatment option: a randomized trial

About This Grant

Significance to VA: Obstructive sleep apnea (OSA) poses a treatment challenge to older Veterans. A common cause of daytime sleepiness and poor sleep quality and a risk factor for cardiovascular disease, cognitive impairment, and mortality, OSA is typically treated with medical devices (e.g., positive airway pressure, oral appliances). Unfortunately, therapy nonacceptance is common. Devices can be uncomfortable and device maintenance problematic, especially in the context of comorbidity (e.g., limited mobility). Typical OSA care begins with telling patients what is wrong with them rather than asking what matters most to them (i.e., their priorities). The objective of this trial is to evaluate the benefits of the Decide2Rest+ program—a 4 session program (patient decision aid plus sessions directed at treatment adherence) for improving patient reported outcomes (PROs) and aligning OSA care for older adults with their health priorities and values. Our central hypothesis is that it will improve the “inputs” (e.g., knowledge, patient priorities) needed to move towards patient priority-directed care, increase activities associated with this care (e.g., decisions that reflect each patient’s priorities), and optimize adherence and PROs. The rationale is that understanding how disease- specific treatments affect overall health and clarifying priorities are critical to improving the selection of treatments with features that matter most to the Veteran and are most likely to improve sleep quality for the Veteran and to engaging in behaviors necessary to adhere to a chosen therapy. The proposed program aims to improve sleep PROs among older Veterans with OSA by helping them align priorities with their care, which is a VA national priority. The work is also responsive to the 2024 VA/DoD Clinical Practice Guidelines for OSA and Insomnia, which recommend shared decision making when initiating OSA therapy. Innovation and Impact: This alternative, person-centered approach is a key aspect of the VA's “age-friendly” transformation and could set a different tone for OSA treatment and adherence among older Veterans. Our goal is to align OSA-related treatment decisions with patients’ health priorities to improve PROs and support’ use of OSA therapy in older Veterans newly diagnosed with OSA. Specific Aims: The aims of the study are (1) to determine whether the Decide2Rest+ program will improve patient-reported sleep disturbance and daytime sleepiness, (2) to determine whether Decide2Rest+ improves OSA device therapy acceptance/adherence, and 3) assess the impact of Decide2Rest+ on the congruency between decisions and health priorities/values. Methodology: We propose a 5-year multi-site randomized controlled trial of Veterans aged 50+ years with untreated OSA (n=128) comparing the Decide2Rest+ to an active-control program that includes behavioral adherence components from a clinical program that is currently used in our sleep center. We used a user- centered approach to develop and refine the decision aid. It provides a mechanism for helping patients clarify what treatment feature matter most to them, reflect upon decisional needs, and identify their health priorities. Path to Translation/Implementation: This phase II trial (T2) will assess the efficacy of the DecideRest+ program for improving PROs and acceptance/adherence to OSA therapy. We use the Ready, Willing, and Able Model as framework for guiding implementation. We will obtain input from Veterans and clinicians and collect implementation measures. In prior related projects that inform our line of research, we have used strategies that will facilitate implementation including sending OSA educational links through secure messages to patients, providing an OSA decision aid in waiting rooms of sleep clinics, and training providers to deliver our behavioral interventions using the training model for the VA’s cognitive behavioral therapy for insomnia rollout. The proposed project in combination with our prior research inform a future type 2 hybrid design trial that will test the effectiveness of the program and potential for implementation (T3).