Effects of Wait Times on Treatment Adherence and Clinical Outcomes in Patients With Severe Sleep-Disordered Breathing
Authors: Christina S. Thornton, Willis H. Tsai, Maria J. Santana, Erika D. Penz, W. Ward Flemons, Kristin L. Fraser, Patrick J. Hanly, Sachin R. Pendharkar
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Sleep-disordered breathing (SDB) is common and associated with substantial adverse health consequences. Long wait times for SDB care are commonly reported; however, it is unclear whether wait times for care are associated with clinical outcomes. <h3>Objective</h3> To evaluate the association of wait times for care with clinical outcomes for patients with severe SDB. <h3>Design, Setting, and Participants</h3> This study is a secondary analysis of a randomized clinical noninferiority trial comparing management by alternative care practitioners (ACPs) with traditional sleep physician–led care between October 2014 and May 2017. The study took place at Foothills Medical Centre Sleep Centre, a tertiary care multidisciplinary sleep clinic at the University of Calgary. Patients with severe SDB (defined as a respiratory event index ≥30 events per hour during home sleep apnea testing, mean nocturnal oxygen saturation ≤85%, or suspected sleep hypoventilation syndrome) were recruited for the study. Patients were excluded if they were suspected of having a concomitant sleep disorder other than SDB or had previously been treated with positive airway pressure (PAP) therapy for SDB. Data were analyzed from October 2017 to January 2020. <h3>Main Outcomes and Measures</h3> Outcomes were assessed 3 months after treatment initiation with adherence to PAP therapy as the primary outcome. Secondary outcomes included Epworth Sleepiness Scale score, health-related quality of life, and patient satisfaction measured using the Visit-Specific Satisfaction Instrument–9. Multiple regression models were used to assess the associations between wait times and each of the outcomes.<i>t</i>tests were used to compare wait times for patients who were adherent to PAP therapy (≥4 hours per night for 70% of nights) with those for nonadherent patients. <h3>Results</h3> One hundred fifty-six patients (112 [71.8%] men; mean [SD] age, 56 [12] years) were included in the analysis. The mean time from referral to initial visit was 88 days (95% CI, 79 to 96 days), and the mean time to treatment was 123 days (95% CI, 112 to 133 days). Shorter wait time to treatment initiation was associated with adherence to PAP therapy (odds ratio, 0.99; 95% CI, 0.98 to 0.99;<i>P</i> = .04), greater improvement in Epworth Sleepiness Scale score (mean coefficient, −9.37; 95% CI, −18.51 to −0.24;<i>P</i> = .04), and higher Visit-Specific Satisfaction Instrument–9 score (mean coefficient, −0.024; 95% CI, −0.047 to −0.0015;<i>P</i> = .04) at 3 months. Compared with nonadherent patients, those who were adherent to treatment waited a mean of 15 fewer days (95% CI, 12 to 19 days) for initial assessment (<i>P</i> = .07) and 30 fewer days (95% CI, 23 to 35 days) for treatment initiation (<i>P</i> = .008). <h3>Conclusions and Relevance</h3> Earlier initiation of treatment for severe SDB was associated with better PAP adherence and greater improvements in daytime sleepiness and patient satisfaction. These findings suggest that system interventions to improve timely access may modify patient behavior and improve clinical outcomes. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02191085