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QUERI Evaluation of Sleep Disorder Treatment in Alignment with the STRONG Veterans Act

To help VA improve sleep medicine services for Veterans and address Section 502 of the STRONG Veterans Act of 2022, Measurement Science QUERI is partnering with the National Sleep Medicine Program Office, Office of Specialty Care Services, and the Deputy Assistant Under Secretary for Health for Discovery, Education and Affiliate Networks to evaluate VA’s sleep medicine services.

The prevalence of sleep disorders—particularly obstructive sleep apnea and insomnia—among Veterans has grown exponentially during the last two decades and continues to rise.^[1] Sleep disorders are associated with poor quality of life and adverse clinical outcomes, especially among Veterans with co-existing mental health disorders. In 2022, sleep disorders drew the attention of Senator Jon Tester, Chairman of the Senate Veterans Affairs Committee, who championed the Support the Resiliency of our Nation’s Great (STRONG) Veterans Act (initially introduced by House Committee on Veterans’ Affairs Ranking Member Mike Bost and Chairman Mark Takano) to support Veterans’ mental health and well-being. The STRONG Veterans Act, signed into law in December 2022, included a section dedicated to “Improvement of Sleep Disorder Care furnished by the Department of Veterans Affairs” that states: “The Secretary of Veterans Affairs shall conduct an analysis of the ability of the Department of Veterans Affairs (VA) to treat sleep disorders among veterans, including:

1. assessment and treatment options for such disorders;
2. barriers to care for such disorders, such as wait time, travel time, and lack of staffing;
3. the efficacy of the clinical practice guidelines of the Department of Veterans Affairs and the Department of Defense for such disorders; and
4. the availability of and efficacy of the use by the Department of Veterans Affairs of cognitive behavioral therapy for insomnia (CBTI).”

To conduct these analyses, PI Mary Whooley, MD, and other members of the Measurement Science QUERI team at San Francisco VA are extracting data from the VA Corporate Data Warehouse to determine the prevalence of sleep disorders and the proportion of Veterans who receive testing for and treatment of sleep disorders in VA facilities and community care settings. Treatment for sleep disorders can include continuous positive airway pressure, oral appliances, nerve stimulation, positional devices (to prevent sleeping on the back), sleep hygiene, light therapy, acupuncture, cognitive behavioral therapy for insomnia, desensitization, and/or sedating medications. Barriers to care will be assessed using metrics such as the ratio of sleep provider FTE to number of Veterans with sleep disorders at each facility, past-due consults and past-due return to clinic orders, and appointment availability.

Evaluating staffing capability for the treatment of sleep disorders can be challenging because sleep medicine providers come from multiple disciplines, including pulmonary medicine, family medicine, internal medicine, neurology, psychiatry, anesthesia, otolaryngology, behavioral health, oral and maxillofacial surgery, and dentistry. Thus, there is no single “Product Department” that can be used to calculate provider capacity or evaluate sleep medicine workload by the Office of Productivity, Efficiency, and Staffing (OPES). Measurement Science QUERI hopes to quantify VA’s current capacity to treat sleep disorders and inform future staffing models to optimize access to care for Veterans with sleep disorders.

To determine the efficacy of VA and Department of Defense (VA/DoD) clinical practice guidelines (CPGs) for sleep disorders, Measurement Science QUERI is collaborating with Drs. Connie Fung, Jennifer Runnals, Jennifer Martin, Tracy Chisholm, Carl Stepnowsky, Christi Ulmer, Jeff Belkora, and Paul Pfeiffer to administer a survey and conduct qualitative interviews with primary care physicians and VA sleep providers. VA/DoD CPGs provide a comprehensive approach to diagnosis and management of obstructive sleep apnea and chronic insomnia disorder, including discussion of the sequencing of diagnostic approaches and evidence-based treatment options. Interviews will focus on adoption of key recommendations, such as use of cognitive-behavioral therapy for insomnia disorder (CBT-I), and awareness of recommendations for the diagnosis and treatment of sleep disorders. In addition, the VA Healthcare Analysis and Information Group (HAIG) will administer a provider survey to evaluate awareness of CPG recommendations, barriers to implementation, and prescribing patterns among VA sleep providers.

^[1] Prevalence and management of sleep disorders in the Veterans Health Administration - PubMed (nih.gov)