Reviewing people with Obstructive Sleep Apnoea Hypopnoea Syndrome: telehealth and templates
Introduction Obstructive Sleep Apnoea Hypopnoea Syndrome (OSAHS) is estimated to affect one billion people globally, carrying a substantial risk of road traffic accidents due to daytime sleepiness with additional other adverse health impacts. Continuous positive airway pressure (CPAP) is an effective treatment but requires long-term adherence. Regular clinical review of CPAP therapy users is important to address any problems, assess symptom relief, and specifically to review implications for driving. Reviews can be face-to-face, by telephone, or via teleconsultation with remote telemonitoring of CPAP usage. My PhD addresses the mode of delivery and content of CPAP reviews for people with OSAHS in three distinct but interlinked projects. Aims and objectives: 1)Systematic review: To review the evidence for the effectiveness of teleconsultation combined with telemonitoring in the review of people with OSAHS receiving CPAP therapy compared to face-to-face care. 2)e-Delphi: i)To reach consensus amongst a panel of international sleep clinicians, academics, and CPAP users on the most important components to include in a CPAP review, and how often a review should take place. ii)To develop a structured sleep medicine review template that records the important components identified by the e-Delphi consensus panel. 3)Implementation study To introduce the template in three diverse sleep medicine Centres for use in face-to-face or remote consultations and observe implementation using mixed methods. Systematic review I followed Cochrane methodology and I searched ten electronic databases, trial registries, and reference lists for studies that included interventions that combined remote consultations with telemonitoring of CPAP usage. Outcome measures were: the proportion of CPAP users who had a review, adherence to CPAP, symptom control, satisfaction / acceptability, and cost-effectiveness. From 362 potentially relevant papers, I identified four randomised controlled trials and one controlled clinical trial (including 269 patients). The risk of bias was moderate in one, and moderate to high in four trials. Two trials reported the number and duration of reviews with inconsistent results. The teleconsultation / telemonitoring improved CPAP adherence in two trials; two reported no between-groups differences. Two trials, both at moderate to high risk of bias, showed no between-group differences in the Epworth Sleepiness Scale. Satisfaction was generally positive in all five trials; one trial reported that the teleconsultation / telemonitoring patients were ‘more likely to continue’ with CPAP therapy and one trial reported that CPAP teleconsultation / telemonitoring was cost-effective. e - Delphi and template development I recruited an international expert panel to identify the core components of a CPAP review derived from thirteen OSAHS guidelines and asked participants to score components (scale of one to five) over three rounds. Consensus was defined as ≥75% agreement for scores of ≥4. Free-text comments were analysed thematically. 40 participants completed all three scoring rounds. Of 36 potential components, 17 achieved consensus: treatment acceptability, sleep quality, symptom resolution (including reduction in apnoea-hypopnoea index), assessment of sleepiness (including when driving), technical issues (mask fit / humidification / cleaning / filters), CPAP adherence, and quality of life. Participants suggested reviews should be 12 to 18 monthly (more frequent when in early treatment) or “on demand / request.” Free text comments emphasised that reviews should be multidisciplinary, flexible (including telehealth), and focus on symptom control. Based on the consensus findings I devised a CPAP review template that included the core components suggested by the participants. Implementation study I recruited three Centres: City, Urban / Rural, and Rural to a mixed-methods implementation study. There were four stages: I.Development of a tailored implementation strategy II.Implementation III.Evaluation IV.Refining Effectiveness of the implementation strategy was assessed by template uptake, feasibility of use, and fields completed. Analysis of the quantitative data was descriptive. Nine clinicians participated in final semi-structured interviews which were analysed thematically. 219 anonymised templates were returned for analysis; all were completed voluntarily by nursing staff. The average completion time was 14 minutes; with six of the eight fields completed in over 90% of reviews. Six themes emerged from nine interviews. The template: 1) Facilitated a structured, standardised review, reducing variation in practice. 2) Was not perceived to affect clinical autonomy or person-centred care. 3) The decision to participate was made at organisational level and individuals in the departments were free to decide whether, or not, to use the template in any / all of their consultations. 4) Use of the template did not impact on how the review was conducted though template completion extended review time in one Centre where double data entry was required. 5) From a service perspective, the template was perceived as improving efficiency and promoting better patient outcomes whether in face-to-face reviews or teleconsultations. 6) The template was seen as potentially contributing to multidisciplinary team working. With the rapid deployment of Microsoft Teams and NHS Near Me during the COVID -19 pandemic, the template supported remote consultations and might be useful for education and training purposes. Adaptations (structure, content, and layout) were highlighted. An electronic template was suggested, integrated with the electronic health record, obviating the requirement to dictate letters and reducing administrative processes. Conclusions and context The three studies add to the evidence base on the regular review of CPAP users. Telemedicine is an option for CPAP reviews for people with OSAHS. The international consensus group identified important components that should be recorded in a CPAP review informing development of a structured review template. Implementation of the template was achieved in three Centres and was considered to provide structure to both face-to-face reviews and teleconsultations with a potentially important role in training staff and standardising care. Teleconsultation has come of age in the midst of a global pandemic for routine CPAP reviews, and electronic templates adapted to the local setting could support safe and effective care and promote efficient communication.