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


BACKGROUND
This study is registered with clinicaltrials.gov with identifier # NCT00390572.
National Jewish Health, Denver, CO.|Duke University Medical Centers, Durham, NC.
Jack D
JD
Edinger
VA, Durham, NC.
Janet
J
Grubber
VA, Durham, NC.|Duke University Medical Centers, Durham, NC.
Christi
C
Ulmer
VA, Durham, NC.
Jennifer
J
Zervakis
VA, Durham, NC.|Duke University Medical Centers, Durham, NC.
Maren
M
Olsen
D056044:Actigraphy; D003299:Cooperative Behavior; D019468:Disease Management; D005221:Fatigue; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017286:Polysomnography; D011320:Primary Health Care / Q000379:methods*; D011788:Quality of Life; D012017:Referral and Consultation; D057566:Self Report; D056508:Sleep Medicine Specialty / Q000379:methods*; D012894:Sleep Stages; D012893:Sleep Wake Disorders / Q000175:diagnosis* / Q000523:psychology / Q000628:therapy*; D014851:Wakefulness
collaborative care; primary and specialty care; sleep disorders