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Academic and private medicine partnership to improve care for sleep disorders, particularly insomnia in metropolitan Houston and surrounding areas. Personnel: Sudha Tallavajhula, M.D Asst. Professor, Dept. of Neurology University of Texas McGovern Medical School Houston, TX-77030 Email: [email protected] Mary Rose, PsyD Licensed Clinical Psychologist, CBSM Rehabilitation Psychology/Neuropsychology TIRR Memorial Hermann Rehabilitation Network Clinical Associate Professor, Department of Physical Medicine & Rehabilitation Baylor College of Medicine Email: [email protected] Key words: Sleep medicine Academic – private partnership Telehealth Cognitive Behavioral Therapy Introduction: Telehealth, of which telemedicine is a component, has been a rapidly expanding technology in the past decade. It has outpaced state legislation and clinical guidelines with regard to the legal and ethical practice of health care. Law and guidelines vary significantly from state to state currently. However, there is an increasing consensus that telehealth provides a valuable option for care to underserved areas, [1] to patients for whom travel is a limiting factor, [2] and as consultation between clinicians. Another little examined benefit telemedicine provides, is as a tool for fostering patient access to quality care by a broader range of clinicians, and specific clinician choices. It is also likely that as telehealth services expand it will be more palatable for clinicians to subspecialize in areas of health that even in a large city, may be difficult to provide an adequate patient volume to support. We present in this proposal, a mechanism to provide behavioral sleep medicine services in the Houston metropolitan area through a centralized hub and spoke system, using a telehealth model. According to national ambulatory medical care survey from 1999-2010, the number of office visits with insomnia as the stated reason went up by 13% in the decade whereas the number with any sleep disturbance increased by 29%. The number of prescriptions for any sleep medication rose up by 293%, a large number for hypnotic medications. Insomnia symptoms occur in approximately 33-50% of the adult population; insomnia symptoms with distress or impairment in 10-15%. According to the American Academy of sleep medicine guidelines, psychological and behavioral interventions are effective and recommended as a standard in the treatment of chronic primary and secondary insomnia. Short-term pharmacological measures may be used to supplement behavioral and cognitive techniques. However based on the above survey, hypnotic medications are often prescribed as long-term medications, mostly because of lack of awareness of cognitive and behavioral therapy for insomnia [CBT-I], its principles, indications and availability. This lack of awareness exists among both patients as well as prescribing providers. There is a paucity of trained providers for this modality of treatment, even in large cities. Several alternatives, including web-based and automated interventions are being evaluated and have been found to be effective. The Memorial Hermann network, one of the large healthcare providers in the Houston metropolitan area, collaborates with the University of Texas McGovern medical school in several domains. One of these is the sleep medicine services which contain sleep centers in a concentric pattern surrounding downtown Houston. The Texas Medical Center, a well-known cluster of prominent medical facilities, including the McGovern medical school is based in the center of the city. Access from distant areas of the city as well as surrounding areas, particularly for recurrent visits as might be required for CBT-I, is often cumbersome for patients. Figure 1: Locations of sleep medicine centers affiliated with Memorial Hermann Health System in Houston area Methods The purpose of this project is to utilize collaborative expertise between the sleep medicine physician, who is a faculty member in the Department of Neurology at the UT McGovern medical school and an experienced behavioral sleep medicine psychologist employed within the Memorial Hermann network to improve access via telehealth for sleep medicine services, primarily CBT in the city of Houston and surrounding areas. For this purpose, Vidyo, an institutionally approved and patient data safety compliant platform will be used. Educational material promoting awareness about sleep disorders, psychological techniques for treatment of insomnia, availability and pathway for referrals will be distributed among primary care physicians and other specialties particularly neurology, pulmonology and psychiatry [most likely to encounter patients with sleep disorders]. The Behavioral Sleep Medicine Specialist [psychologist] with background and training in general Sleep Medicine will provide services to patients referred for evaluation and treatment of insomnia, hypersomnia, and circadian rhythm disorder. Patients will be given the option of telemedicine if they live outside of the 15 mile radius of Texas Medical Center. Patients will be consented and initial New Office Visit information electronically provided to facilitate the initial assessment. Patients will be offered in person evaluation and treatment if they do not wish to utilize telehealth. Patient materials such as a sleep journal, cognitive behavioral treatment information, will additionally be provided during subsequent treatment visits. During the initial visit, questionnaires to assess mood, and to identify personal goals related to sleep will be administered. Research has suggested that some patients are more likely to reveal sensitive information when a veil of anonymity is experienced (via technology such as automated reporting or possibly even telemedicine). If insomnia alone is identified as the principal issue, the patient will continue to be provided cognitive and behavioral therapy. However, if a primary sleep disorders [such as obstructive sleep apnea, parasomnias, hypersomnia disorders] are identified, the patient will be referred to a local physician who is a sleep medicine specialist for appropriate testing and management. If insomnia is identified as a comorbid illness, CBT may still be provided simultaneously. Data collected will include a gentle medical history including comorbidities, vital signs particularly blood pressure, heart rate and blood glucose [abstracted from referring physician notes], sleep quality indices, scales of anxiety and depression, specific outcome indicators for sleep [including wake time after sleep onset, sleep onset latency, number of awakenings, sleep time or sleep efficiency, sleep-related psychological distress]. Additional data will include metrics obtained from sleep specific testing for example polysomnography [if conducted]. These data will be maintained on an institutionally available, data protected server used for clinical care. Figure 2: Proposed flow diagram for Sleep Disorders Telehealth Program. Analysis The variables mentioned above will be collected sequentially for each patient across successive encounters. Constant communication will be maintained with the referring physician, particularly regarding any unexpected changes in clinical status. Each patient is expected to be followed by the psychologist for 5-6 sessions. Multivariate analysis will be conducted using standard statistical techniques, specifically to compare changes from before and after intervention, impact of comorbidities, patient and referring physician satisfaction as well as frequency of prescription of hypnotics. Specific aims 1. To improve access to clinical care for sleep-related disorders within a large city using an academicprivate partnership and telehealth. 2. To study the effects of improving sleep health on physiological and psychological parameters at the level of individual. Hypotheses 1. The use of modern technology will help overcome barriers related to awareness of treatment options and availability to appropriate providers. 2. Improving sleep health with result in an overall improvement in physiological and psychological metrics. Significance Providing cost effective, yet comprehensive care has been a catch phrase in the recent medical ecosystem. Using modern technology to improve access for treatment of a relatively common, yet under treated set of disorders like sleep disorders is expected to have significant and sustainable impact on health in general. It is well known that undiagnosed and untreated sleep disorders are associated with several comorbidities including cardiac, neurological and psychological diseases. Collaboration between expertise associated with academic medicine and resources embedded in private healthcare systems is key to expand reach among under- served areas. The long-term goal of this project is to be able to provide a Center of excellence for comprehensive treatment of sleep disorders, in a costeffective manner.