A Collaborative Paradigm for Improving Management of Sleep Disorders in Primary Care: A Randomized Clinical Trial

Abstract

Objectives: To test a collaborative care model for interfacing sleep specialists with primary care providers to enhance patients' sleep disorders management.

Methods: This study used a randomized, parallel group, clinical intervention trial design. A total of 137 adult (29 women) VA outpatients with sleep complaints were enrolled and randomly assigned to (1) an intervention (INT) consisting of a one-time consultation with a sleep specialist who provided diagnostic feedback and treatment recommendations to the patient and the patient's primary care provider; or (2) a control condition consisting of their usual primary care (UPC). Provider-focused outcomes included rates of adherence to recommended diagnostic procedures and sleep-focused interventions. Patient-focused outcomes included measures taken from sleep diaries and actigraphy; Pittsburgh Sleep Quality Index (PSQI) scores; and self-report measures of sleepiness, fatigue, mood, quality of life, and satisfaction with health care.

Results: The proportions of provider-initiated sleep-focused interventions were significantly higher in the INT group than in the UPC group for polysomnography referrals (49% versus 6%; P < 0.001) and mental health clinic referrals (19% versus 6%; P = 0.02). At the 10-mo follow up, INT recipients showed greater estimated mean reductions in diary total wake time (-17.0 min; 95% confidence interval [CI]: -30.9, -3.1; P = 0.02) and greater increases in sleep efficiency (+3.7%; 95% CI: 0.8, 6.5; P = 0.01) than did UPC participants. A greater proportion of the INT group showed ≥ 1 standard deviation decline on the PSQI from baseline to the 10-mo follow-up (41% versus 21%; P = 0.02). Moreover, 69% of the INT group had normal (≤ 10) Epworth Sleepiness Scale scores at the 10-mo follow-up, whereas only 50% of the UPC group fell below this clinical cutoff (P = 0.03).

Conclusions: A one-time sleep consultation significantly increased healthcare providers' attention to sleep problems and resulted in benefits to patients' sleep/wake symptoms.

Clinical trials registration: This study is registered with clinicaltrials.gov with identifier # NCT00390572.

Keywords: collaborative care; primary and specialty care; sleep disorders.

Figure 1

Sleep consultation study CONSORT flow chart. ^†Reasons for exclusions: prior specialty sleep treatment (n = 44); exclusionary Axis I diagnosis (n = 26); no primary care provider at the medical center (n = 22); unstable health status (n = 21); unstable living situation/homelessness (n = 18); ongoing substance abuse treatment (n = 11); no clear sleep problem (n = 10); non-veteran status (n = 6). ^††Had survey, sleep log, and/or actiwatch data available.

Figure 2

Group comparisons across tests of clinically significant outcomes. (A) Proportions of intervention and usual primary care groups rated as improved or unimproved on the basis of their PSQI score changes. (B) Proportions of intervention and usual primary care groups showing normal daytime alertness and excessive sleepiness on the Epworth Sleepiness Scale by the 10-month follow-up.