All right, good morning, everyone. Thanks so much for joining the Tell Us Sleep session. This is really a culmination of about a decade of work that's been done to bring sleep to veterans across the country and then hopefully find ways to also apply this to non-veteran populations. So take a minute. I'm going to poll you guys regarding your practice. I see some phones still up. OK, very good. All right, so we're going to spend the next hour understanding what Tell Us Sleep across the VA looks like and what it took to build that program and then, of course, the cornerstones of Tell Us Sleep, right? What do we do to diagnose these patients without bringing them in? How do we treat them with PAP? And how do we provide insomnia treatment all through telemedicine? OK, question number one. Telehealth comprises the following amount of my clinical care. None to 25%, about a quarter to a half, half to 75%, or 75% to 100%. OK, very good. All right, let's move on to the next question. My feelings on clinical televisits. I love them. They're fine. I don't like using them, but I use them anyway. And forget it, I just don't use them at all. All right, very good. And finally, we're interested, is this audience a VA audience? Yes, I currently have a VA position. I've worked for the VA in the past, but not currently. I've never worked or trained at the VA. I've never had an attending position, but I did train at the VA. All right, I think that represents that most trainees, right, as they go through their training will spend some time at a VA institution. All right, so we're going to have Katie Sarmiento come up. Katie has been spending the last decade creating tele-sleep at the VA, pounding the pavement and begging for money. And she'll put the last 10 years in review. You have to click on the bottom there. Thanks, Michelle, for doing the poll. What I was reading into that was recruitment opportunity for VA providers to come to the dark side. OK, so I'm kicking off today's session talking more about the structure of the VA tele-sleep enterprise-wide initiative, as well as another type of care delivery system called the Clinical Resource Hub. I'll touch on both of those briefly. I'm based at the San Francisco VA Health Care System in San Francisco, although I live in Hawaii. In my next talk, I'm going to talk about how to be employed somewhere, live remotely, see patients all over the country, and how to make that work for your career path. But today, it's just about the tele-health program. I don't have anything to disclose. And my main goal today is to provide a greater understanding about the strategies and considerations related to implementing new clinical care. And so one of the questions that always comes up is, like, we talk about VA sleep all the time. We talk about VA sleep. Well, we talk about it because there are certain things that I just love about the VA system that you can't get in other health care systems. Kaiser's a close second, but VA really is unique in this sense. We are the largest integrated health care system in the country. This is the largest integrated health care system in the United States. We are the largest integrated health care system in the country. This means we have one very large data set to be working with at the enterprise level. We do many things. Even though there's 170 different facilities, we do many things at the enterprise level, which helps with implementation and scalability. VA does align with CMS policies and society guidance where it makes sense. But it does also have the flexibility to shift care delivery models to meet access needs and to trial de-implementing low-value steps in patient care, especially when those perceived low-value steps don't have much evidence tied to them. So one of the things that I think is critically important when building a program is to understand the network or system that you're working in. So all of these are questions. I'm not going to read through them, but these are the questions that we asked along the way. How are we going to make this a financially sustainable and viable program over time? How are we going to structure the program to meet the needs of the various stakeholders? And who are those stakeholders that we need to bring into the mix and get advice from and keep as standing partners in this process? And then what limits? Importantly, because I love to push boundaries, what limits and barriers can be tested to support innovation and growth in health care delivery? So for us in the VA, these are the new six health care priorities. These do change every couple of years. And so we always want to stay up to date on what is the current climate, what's the direction the organization is being taken in. And so we need to make sure that if we're not aligned with some of these priorities, that we add them and we start to fold in parts of our program that speak to these priorities. The only one here that doesn't touch us is really the hire faster and more competitively. We feel the effects, but we don't actually do the hiring. But the rest of them are all things that clinical programs can engage with to accomplish. The ones we've been most focused on have been connecting veterans to the soonest and best care, and that's where telehealth comes into play. And then we've always had a mandate to prevent veteran suicide. So through improving sleep, we hope to reduce sleep-related risk factors that are associated with suicide. We also have three laws that impact our program and how we develop the program. So the first one was passed in 2019, and Mission Act really set the standards for access. This includes primarily drive times that veterans can get care if they're beyond a certain drive time or distance, and wait times longer than 28 days for specialty care. So if your wait times aren't within these measures or they don't live within that distance from a facility or ability to get in-home care, then they can choose to get care in the community. Telehealth is not, veterans are not required to accept telehealth in lieu of these access metrics, but they can select it if they want to engage in telehealth. If they decline telehealth, they still can choose to go to the community. The second piece is Strong Act, and this was passed in December of 2022. This act focuses on suicide prevention and mandates an increase in access to home sleep apnea testing, as well as general improved access to sleep disorder diagnosis and management, with kind of a nod to the role and importance of sleep in overall mental health and suicide risk reduction. PACT Act is the last one, and this was more recently passed. It focuses on toxic exposures, and we anticipate that this is going to impact us in terms of demand for increased capacity to perform overnight sleep testing or oximetry, and potentially polysomnography as well. So I always include silos, because this is what we really were 10 years ago. Each facility operating in its own orbit and sphere, not really caring too much what the next VA did. There was very little connection between sites. I added this Lotus seed pod, partly because my son's name is partially derived from Lotus as one of the meanings. But here, the seed pod also, in the same health care system, has multiple different seeds that are facilities that don't actually connect. And we were looking more like a seed pod, where we never connected. We never did anything together to create something. Now, I think we're much more interconnected with patient care. And so we're able to offer care across facilities, image on the right. And as a VA community, we've really come together to cross-pollinate ideas, share innovation, share best practices. And we've created more of a beautiful garden, if you will, that grows from the murky depths of muddy waters, which might could sometimes be perceived as the federal government. I'm not reading through this. But this is just to highlight some of the milestones of the journey of the last 10 years and how things really started organically in the field to develop community. We figured out who our stakeholders were. We door-knocked regularly every three months to try to, as Michelle said, get money from people who could help to fund our initiatives. And then finally, in fiscal year 17, it was a game changer when the Office of Rural Health decided to fund this enterprise-wide initiative for the Office of Rural Health mandates that they had to bring care to the 34% of veterans who live in rural and highly rural areas. Through this grant, this clinical grant, we also had a separate pot of funding that was allocated to evaluation. So we were able to take those funds and really put them into thinking about, how are we measuring sleep services? What data do we need to make visible? How do we vet the data at a national level? And we started to create some really neat tools that our sites can use. And then last year, we actually had a separation and formal recognition of sleep medicine as a specialty within VA's Specialty Care Program Office, which is fantastic. Gives us a little bit more of a voice. So on the left here, you'll see how we started in 2017, 2018. And this is representative of the seven hubs that we began with and the multiple spokes served. It looks like an intergalactic space war by the time we reach fiscal year 22. And this is because of the expanded number of hubs that we pulled into the program and the number of spokes that we were able to reach. There are three pillars of the EWI. We're really looking to establish effectiveness of the hub-spoke models of telehealth-based sleep care. We want to push out home sleep apnea testing as one of those priority areas because it's partially mandated by law, but it also makes sense for a lot of veterans who are almost all considered relatively high pretest. And a lot of veteran patients test positive for sleep apnea when that's the question being asked. And then the last one is to support expansion of remote monitoring of PAP devices. In the very first year, we didn't have much of a focus on behavioral sleep medicine, but this has been an increasing part of the program over the last three years. And so I'm just touching on implementation. You're gonna hear more about behavioral sleep medicine soon as well as home sleep apnea testing and then from Michelle, the effectiveness of the tele strategies. What I am gonna talk about a little more is some of the outcomes. So we use the RE-AIM framework, which is Reach, Effectiveness, Implementation, Adoption and Maintenance to evaluate all of our programs. And so from a reach perspective, this program was really effective of getting care out to communities that previously didn't have access to care or were driving far distances to obtain that care in person. It's really hard to maybe see, but we included fiscal year 17 to 22. On the top in orange are rural veterans that we reached. On the top left, it's rural veterans through our ORH network. And on the right, it's rural veterans in sites that did not participate in this program that didn't get funding. And on the bottom, this includes urban and rural veterans. On the left for our enterprise wide initiative programs and on the right, it would be for non ORH networks. And what I really wanted to highlight is that this program was really meant to be structured to teach people how to fish proverbially. So how to get these tools to deliver care out to programs so they could turn around and see patients who needed sleep care, but we didn't want them to limit it just to the target population that we needed for reporting purposes. We wanted them to adopt it and really change how they practice clinically. And so we expected and did see that these hub sites were applying the same methods to get care out to their urban veterans and sites that are really hard to get to an hour of traffic to get across town and to other remote locations that may not be rural, but where there were still long distances involved in driving. And we did see in our ORH network that we had a much greater adoption of virtual and a hybrid of virtual and in-person care compared to the sites that didn't participate in the network. Obviously in fiscal year 20, when the pandemic hit, everybody switched to telehealth. So we saw everybody jump up. What we're seeing now is many of those non rural health programs going back to in-person care, but a sustainment of the telepathways in those sites that are in our network. This table gives you some of the numbers for the volumes of home sleep apnea testing and polysomnography done over the fiscal years, just preceding the launch of this program up through the last fiscal year, based on one of our initiatives that we're kind of most proud of, which is figuring out how to get the agency to centralize resourcing for equipment at the national level. And so this took us a few different iterations and tries to get right, but to date they've resourced, well through fiscal year 22, 3,500 sleep testing devices. There were another 500 that were resourced this fiscal year to a total now of 91 sites. We started this process with ORH funds and we now have a partner office with Connected Care that has taken over sustainment of this resourcing initiative. So every year they do a call, they manage the logistics, the contracting office purchases the devices and we get these devices delivered to our facilities in a timely and efficient manner. And this saved our sites a lot of time in trying to procure and fill out paperwork at the local level, which was one of the barriers being identified prior to the launch of this EWI. And this here just shows the impact of centralized resourcing on everybody adopting home sleep apnea testing. So this was true from the rural health network and non-rural health network. This is partly due to our sort of philosophy and approach of anything we build for this network, we're gonna make available to all sites. We provide implementation support, we provide guidance on how to set up clinics and how to deliver that care. But what we do see in these graphs is that the sites that didn't participate in the network went back to significant use of polysomnography and we don't see that happening in the rural health location. So there's still a predominance of home sleep testing rather than polys being done. What are some of the factors influencing success of the program? They're listed here and I'm not gonna read through them, but really I think it was regular and open communication, it was shared problem solving, it was cross-pollination of ideas, it was centralized funding and support from our partner program offices. I'm not reading through this table either, but for future reference and looking through some of the ways we approach the goals, the implementation strategy and the product or tool kit associated with each of those goals, I think this is laid out very nicely. Same thing here, this is just for reference and trying to figure out, and my point is it takes multiple program offices to make every single goal a success or to address one barrier. There might be five stakeholders involved and to really have a broad lens on how to problem solve. Again, healthcare delivery, this is really a learning health system model. So we did it one way one year, learned some lessons, did it a different way the next year, pandemic threw a twist in things, we adapted programs to meet the new rules about in-person care. And just, I think this is how it really works in the real world and having that adaptability and flexibility built in from the start is really important in the success and sustainment of a program. I just have a couple of slides on what now is becoming more of a new way to do business in VA. In fiscal year 21, our program in the West Coast in Northern California broke off and started a clinical resource hub which is a network, there's 18 networks in the VA. So our network decided to fund and build out a tele-sleep program as well with a slightly different purpose. And that was to stabilize staffing in our vision where we had some sites with no sleep providers, others with one provider, they would leave, program would collapse, everything would get outsourced, someone would come in and spend a year rebuilding it. And then also to pull some of that care back in and improve care coordination. So these are the sites that we currently provide care at. Yank me off when I'm getting close. We're within network to California, Nevada, Hawaii, Guam, American Samoa, as well as outside of our network in Vision 19 with Wyoming and Colorado. We share mostly personnel in the shared resource model but also equipment. We augment gaps in care both short-term and long-term. And then we have a particular focus on the financial piece of pulling care back in and figuring out how to do the make versus buy and help a facility understand what to invest in in terms of resources. Our primary metric, not just for sleep, but for all of these programs is really the number of visits that we have with veterans. And so this just is a snapshot of this past fiscal year. And what you see in this slide is that it's a very dynamic type of program. So someone might go out for six weeks, they need a ramping up of coverage and support, and then someone comes back and someone else retires and we shift resources to that program. In order to be a really agile care delivery system as a virtual team, we have to have a high degree of standardization between facilities and we have to have very standardized workflows to be able to partner very rapidly between hubs and spokes. So this is where we're delivering care and the volume of care, and that has changed tremendously over that 12 month period. We also, this dashboard is one that supports the field. It's our sleep Power BI dashboard. Here, this is our team for CRH over the last three years since inception. This is what we expected to see, a really slow start with few staff building the plane as we were flying it and then getting more into the growth phase. And now we're kind of fully up and operating in the performing stage of TeleSleep in this model. I eventually, I'm just gonna, to mention with my last couple of minutes that what I see happening, what I see happening is building on the CRH model and scaling that to kind of plug in as more CRH programs come online across the 18 networks, really plugging them in so that we have a unified way of doing business in VA. That makes the most sense so that we can help each other no matter what these boundaries are to carve out these networks. And so I'm hoping that as you listen to the next three sessions, you'll start to see how that'll be possible since these care strategies, I think they work. So thank you very much for your attention and please don't forget to evaluate the session. Thank you so much, Katie. All right, next, Charlie's gonna talk to us about the logistics and the evidence in sleep diagnostics via TeleSleep. All right, good morning, everybody. I'm Charlie Atwood from the VA in Pittsburgh. I'm gonna talk about efficacy, not efficacy or whatever it was misspelled on in the title. Sorry about that, it's like a highly embarrassing boo-boo. But anyway, I'm gonna talk about TeleSleep diagnostics, meaning really home sleep apnea testing. This is me, I'm the Chief of the Sleep Medicine Division at the VA Pittsburgh and also work at UPMC and the University of Pittsburgh. So my task is to talk about, just very briefly, I'll say 10 seconds on the VA's priorities for virtual care, discuss home sleep apnea testing, compared to lab testing, how VA's transformed home testing with strategic purchases of HSAT equipment. Katie already covered that in some detail. And then understand how TeleSleep care decreases the burden for care on veterans and improves the position of other stakeholders. So first of all, VA has a very large commitment to virtual care. These are three goals from the strategic plan of the Office of Connected Care, which is the office that really promotes telehealth, defines telehealth for the VA and provides the tools for telehealth. So the first is support veterans in managing their own health. Secondly, empower the VA's workforce to deliver virtual care in the home. Thirdly, modernize connected care infrastructure, which started from scratch and was kind of crude to begin with, but it gets better and better regularly. And then finally, enhance connected care operations and authority. So they really wanna give the local practitioners the authority and the tools to deliver this virtual care. Let's talk about sleep disorders and sleep apnea. So they're very common in veterans. The OSA prevalence in the VA has been estimated to be around 25%. So it's a very high prevalence of this disorder. Insomnia is also very prevalent. Tracy will talk about that in a little bit. And then there's the variety of all the other sleep disorders that we manage. And then if you look, if you just add that all together, you come up with about 45 to 50% of veterans have some sleep disorder. So one in two, you can see why in terms of requests for consults, sleep consults is the third most common consult in medicine service lines in the VA, only behind dermatology, which we're not gonna count that as medicine necessarily. Cardiology is just slightly ahead of us, but at our rate of growth, we will surpass cardiology at some point. So why are home diagnostics essential for VA? Well, this graph shows the growth in home sleep apnea testing in blue bars and the orange bars are polysomnograms, and the gray line is the trend line showing growth. And from 2015 to 23, we had a 35% increase in testing for sleep apnea. And you can see that we started out being PSG predominant in 2015, but now seven, eight years later, we are now home sleep apnea testing predominant. And that trend is only going to continue. The title of this talk is about efficacy. So efficacy, or you could say effectiveness also, I'll kind of use those, although they have different meanings, I'll just kind of lump them together as is the test doing a good job? And there's a pretty rich database of this that I'm just gonna summarize fairly briefly, but I'll summarize with my own study, which was published in 2011 in the Blue Journal, along with my colleague and counterpart at the Philadelphia VA, Sam Kuna. And we studied 296 veterans at two sites. It was a randomized trial demonstrating that the home sleep apnea testing pathway, when we compared these two pathways of home testing versus lab testing, was not inferior to lab testing when it came to CPAP adherence, which is what everybody kind of wants to know about. If you prescribe CPAP on the basis of one pathway over the other, which one does better? And this study was tested, was set up to be a non-inferiority trial. So we can't say one is better than the other. We can just say that there's that home testing, which was the thing we were studying compared to the comparator was not inferior. But it was also not inferior for things like the EPRA scale, for the functional outcomes of sleep questionnaire, for the psychomotor vigilance test, and a number of other metrics that we use. There were, and this was the first large, but I'll say large-scale study to show that there was no significant difference between the two modes of diagnosing sleep apnea and beginning CPAP. But it's not the only evidence for it. And there's a evidence base that goes back even further, back to around 2007. What I think of as sort of the seminal study in getting this field kicked off was the Mulgrew study from British Columbia, which was, again, a home approach versus a lab approach in a very, very highly, highly selected group of patients that were really cherry-picked for very, almost certainly having sleep apnea. And it showed equivalent outcomes in a small study. Rich Berry, another VA sleep doc at the Gainesville VA, also showed in a home versus lab paradigm in veterans that there were equivalent outcomes. And the subject's sample size was about 100. Skomro, also from Canada, from Saskatchewan in 2010, showed a kind of a similar paradigm of lab versus home study in a small study, showed that outcomes were equivalent. And then finally, our study, the study that Sam and I did was the least selected. We basically did not select on any sleep metrics, such as sleepiness or likelihood, some likelihood measure of having sleep apnea. We basically took all comers that were referred for sleep apnea. And then finally, the Rosen study, Carol Rosen from Cleveland, in a study that was sponsored by the American Academy of Sleep and Medicine's Foundation in a number of academic medical centers across the country, showed basically similar findings to the study that we did. So this idea of home study versus lab study has been, for the provision of CPAP, has been now replicated in at least five different randomized trials. And there's actually more than this that have gone further along that I didn't cover. But the key point here is that in all of these studies, even though the trends were not statistically significant, in every one of these studies, there was a trend towards the home sleep apnea testing and CPAP initiation arm having better outcomes than the lab testing. The studies weren't powered for that, weren't intended to look for that, but that was what was found. Well, another way of doing business in the VA is just send everything out to the community. We call that care in the community or CITC. And this graph shows, it's kind of hard to read, but basically it shows for the various fiscal years from 2018 to 2023, the amount of community care that's been done for home testing or lab versus what's done in the VA. So the much taller bar is the VA, the little short bar next to it for each year is care in the community. Most every VA really works hard to avoid sending patients to the community for as much as possible. It's not always possible, but we do our best. We have found, and through Dr. Sarmiento's work in San Francisco has shown that in a really nice study published in medical care, maybe the leading health services journal in the country, that care in the community is not always faster and is associated with slower initiation of CPAP therapy, which is an important metric, as well as timeliness of care, which is an important metric. Sleep labs in the community are really busy. They're not really oriented towards taking care of veterans. Many of them will do it for a variety of reasons, but they're not as good at it as the VA is in terms of taking care of veterans in terms of these relevant metrics. How does the VA promote home testing programs? We talked earlier, Katie talked earlier about the Office of Rural Health Program, the strategic purchasing of large numbers, over 3,500 of home sleep apnea testing units, which we just give to the field. A couple of millions of dollars over years of home testing equipment. We have monthly webinars that reinforce VA practice approaches to the field, and those are pretty well attended. We've developed regional communities of practice in our regional networks called Veterans Integrated Service Networks. So each VISN is tasked with having a community of practice around sleep medicine, and those are helpful. There are a number of benefits to home testing for the VA as well. So it allows us to test many, many more patients than we would if we simply relied on laboratory testing. We would be far, far behind in terms of the amount of patients that we have treated. And if you test more people, you'll treat more people. One of the other somewhat, if you think about it, it's a logical outcome, but it's not one we expected initially, is just the massive amount of travel that veterans have to do to come see us that we've avoided by doing care in the home. Our group, a group that I work with, Zach Hahn and others have looked at this, and we've just published a paper in the Journal of General Internal Medicine showing that we've saved millions of dollars of veterans' dollars by avoiding lengthy travel to and from medical centers. We've also shown in a paper that will come out later this year or early next year, fragmentation of care is way less if we can keep everything in the VA. The patients do better, dollars are saved, patients are happier when we can deliver the care to them in their own home. And then it's more cost effective, because VA care is always less expensive than care in the community. So how are we doing? Right now, 10 out of the 18 regional networks have home sleep apnea testing in large measure. There's actually only one network that has none, and probably by 2026, our goal is to have all of the networks have a substantial amount of home testing available. This graph on the right just shows the steady growth every year from 2015 to 2023 for total number of sleep encounters in orange and unique patients in blue. So every year you can see we just find more and more sleep disorder patients. And while this is a great thing and we're happy about it, it does create, in some sense, a burden for the VA sites to deliver the care to these patients. And it's becoming harder and harder to do that with a relatively small workforce and a growing number of patients, like something has to give somewhere. But on the other hand, you can look at this as sort of crisis of care availability results in opportunity for creating new ways to deliver care that hopefully we would hope would work, would be cost-effective, and would be veteran-friendly. So that's what I wanted to say about home sleep apnea therapy, the efficacy of AutoCPAP and the way that we deliver it in the VA. And thanks for your attention. So I'm going to talk about TelePAP. I have nothing to disclose. I am stationed out in Los Angeles, both between the VA and in UCLA. And we'll review the current data on efficacy of TelePAP, the cost efficacy, and we're going to spend a minute or two on patient's perspective, and then on some lessons learned. Here we go. Okay. So I feel that TelePAP can be as effective as face-to-face PAP setup in my patients, yes or no? One person thinks so. One person does not think so. Okay. All right. So let me see what you guys think after this talk. So traditionally, right, we set up PAP face-to-face, and we feel that the interaction between the respiratory therapist and the patients, allowing them to touch it, put on the mask, is very effective. But there's a lot of burdens, right? There are patients who live really far away. There are also patients who are homebound or caretakers, and it's very hard for them to come in. And the problem is that we really don't have a lot of data at this point to tell us if setting up a patient remotely is doing them a disservice. Now, we know that a lot of our DMV companies are dropshipping these PAPs, right? We just don't know how that's working out for the patient. So I live and work down in Los Angeles, all the way at the bottom. But at the VA, I am tasked with taking care of patients that are up to 200 miles away. So I'll tell you, when I was a fellow, if you look at San Luis Obispo, I'd have this guy with an ESS of 15 with severe sleep apnea drive three hours to come and for me to tell them, oh, I think you have sleep apnea. Go back home. I'll call you when we have a home sleep test ready for you. And they would do this drive back and forth until we finally got them CPAP. And clearly, this is very inefficient. And so I would talk to my sleep manager and say, Katya, this isn't working, right? Let's just mail them out a PAP. And she would say, Michelle, I don't have the infrastructure. I don't have the mailing budget. And I don't know if I'm doing them a disservice. And so we would put this away until another day. Well, that came on March 4, 2020, when our stay-at-home order was put into place. So we didn't have enough PPE to bring the patients in. And the last thing we were going to do was bring the patient in and put on a PAP and turn that thing on. And so guess what? Like most other VAs, we started mailing out devices. And out of this emerged the TelePAP VA study. And we're a pretty large center. San Francisco is a pretty large center. And we said, you know what? Let's combine our data. And let's decide, at the end of this pandemic, if we can effectively treat patients with PAP that was mailed out compared to our controls, which were individuals who were treated face-to-face before the pandemic. And we looked at PAP adherence and efficacy by looking at PAP hours of use, days of use, and residual HI at both 30 days and 90 days. So the first thing we asked ourselves, is there any data to evaluate TelePAP? Now, Charlie's study that he talked about, this was an ambulatory management of patients. Actually, this is Barry Fields and Sam Kuna's study. And so they did a full tele-visit. They did home sleep apnea tests. But when they actually gave the patient the PAP, even though it was mailed to them, they sent over an RT to set them up. So this was an ambulatory management process, but it didn't include full TelePAP setup. Then, during the pandemic, Luke Donovan and Brian Palin also looked at this data. And when they just looked at usage again, in time, when they looked at leak and when they looked at HI, they didn't find any significant differences between the two. So we asked ourselves, well, let's look at a non-inferiority study. Can we set up TelePAP? And is it equivalent or non-inferior to face-to-face PAP? So we looked at individuals who only had first-time setup. We didn't want to look at individuals who already had a PAP with a replacement, because we knew they would probably do better. We looked at their baseline data. And then we looked at their data at 30 days and 90 days. And we looked at minutes per night, numbers of use per night. And then we, this is beyond the scope of this talk, but we also looked at categorical ever-users or non-users. Now, you may agree with this or not agree with this, but we sat down and we decided that if you were within 45 minutes of each other, that was non-inferior. If you were within five nights per month, that was non-inferior. And if you're residual to HI within five, that was non-inferior. Now, we're two big VA sites, so not surprisingly, these are mostly middle-aged men. Not very many women here. They were obese. They had moderately severe OSA. About 15% African-American, 15% Hispanic, and about 20% or a quarter of these people were rural by the RUCA definitions. Okay, ESS was about 10, and minimal comorbidity score. All right. So if you look at this, you see month one and month three. The dashed line is a non-inferiority difference of 45 minutes, so we're seeing that month one and month three in minutes of use. TelePAP is non-inferior to face-to-face PAP. And same for the difference in nights of CPAP use. Here are the numbers for you to review. Now, these numbers are low, but they actually line up very well with studies from the VA. Veterans are known to use their PAP less in general than the general population. They also sleep less than the general population. So if you look at month one and month three, TelePAP actually did a little better than face-to-face PAP, and also minutes used seemed pretty equivalent, and we found that TelePAP is non-inferior to face-to-face PAP. This is the data on the AHI. Same results. We found that TelePAP residual AHI was non-inferior to face-to-face, and it was about five events per hour in both groups. We then had one of our fellows, Ben Murray, take a look at the rural data. We're very interested in rural patients. Again, this is defined the way they do it by the Census Bureau through RUCA, and this wasn't powered for non-inferiority, but their numbers looked very, very similar. We then had one of our previous fellows, now attendings, look at costs, and on the left is TelePAP, and on the right is face-to-face, and the take-home from this is the following. When you do TelePAP, we found that what you used more of is a respiratory therapy time initially and also for follow-up problems, but what we found is that there's a learning curve. This improved from 1.3 hours to one hour at the beginning and mid-pandemic. Initially, our mailing costs were expensive, but thanks to our national group, we centralized, and now the costs are taken over by the main logistics center, so our costs decreased. Actually, when you look at the face-to-face, what you see is that our costs increased, because pre-pandemic, we had a lot of group setups, and after we lost those groups and we went to individual, and because of that, our costs increased. We didn't ask patients, well, if you had to do it again, would you? Some people would want to do it face-to-face. Some people would want to do it video. Some people didn't care, and some people just didn't want to answer us. There was one gentleman who loved it. He felt, I don't think I could have done any better by being there face-to-face. Another person told us, no, I'd really much rather be there face-to-face, and the bottom one is my favorite. Well, it seemed to work, and I'm pretty sure I don't need it, but if I do, it's right here on my kitchen floor. There were also lessons learned. We couldn't send out a PAP if we didn't call the patient first. We couldn't set up their appointment without really confirming with them that they're going to be at home. They're porch pirates, so LA found that we had to have a signature on receipt. San Francisco, that didn't work for them, and then there are patients who are older or very rural or just don't have any technology accessible to them, so we have to find workarounds for those patients. In conclusion, we found that telePAP is as effective or non-inferior as face-to-face in a predominantly male cohort in California. Cost is largely dependent on shipping costs, and RT time can improve, and patients are split on their preference of what they want. As always, it takes a village or fearless leader running one of our meetings on the left, Alex Gomez, who started the study in San Francisco, or Mont Wright in his younger years, and our group of fellows, and of course, thankful to the VA institutions and our veterans who have served. Lastly, we're going to have Tracy come up and talk about how we deliver telebehavioral therapy to these veterans. Good morning. Today I'll be talking about teleSLEEP for treatment of insomnia, effective or not. My name is Dr. Tracy Chisholm. I'm a clinical psychologist. I'm board certified in behavioral sleep medicine. I work at the Portland VA Medical Center, and I'm also a CBTI national training consultant for the VA's national rollout training program to teach other providers how to offer CBTI. For those of you who are not familiar, CBTI stands for Cognitive Behavioral Therapy for Insomnia, and it is the gold standard leading treatment for chronic insomnia disorder. So today, I hope to talk to you about first discussing the prevalence of insomnia within VA, identify some of the challenges and advantages of offering insomnia treatment over telehealth, and also look at some studies that review the comparative efficacy of telehealth versus face-to-face care, and then finally look at how trends have evolved for treatment of insomnia in VA over time. So generally, in the general population, we estimate insomnia disorder prevalence to be around 30%, but within VA, it's almost double that in our veteran population. And then when you start looking at patients who have other comorbidities, for example, PTSD, those prevalence rates could be as high as 93.3%. So really, really high proportion of our patients may be struggling with insomnia disorder. Now, in 2023, an article by Fulmer that came out showed that there were no significant differences in insomnia rates between urban versus rural veterans, and we estimate that almost half of veterans returning from Iraq and Afghanistan military deployments are returning to rural zip codes. So the ability to provide treatment for patients in those rural areas is important, not only now, but looking well into the future. Now, I'd like to first talk about some of the advantages of telehealth. There's the obvious advantages. You don't have to drive to a clinic. Financially, you're not spending money on gas. But there are, I think superlatively, in my subjective experience, there are some other more finer-tuned advantages that I found providing these services over telehealth. One is, I kind of have an embedded way to scan their sleep environment. I'll say, hey, take your phone or your laptop, take me with you. Let me see your bedroom. And I'll be able to see, all right, they have blinds up instead of blackout curtains. Or I see that they have an alarm clock right above their bed with giant red letters showing the time, and I say, we're getting rid of that, like, right away. There's also some perceived stigma with receiving a psychotherapy if you live in a rural community. There might be only one clinician in your town, if any, and they might be your neighbor or someone you see at church. So I've had some patients tell me, you know, being able to see you over webcam, it kind of feels like confessional. You know, nobody knows that I'm seeing you. It really can open the door for more patients being willing to engage in treatment when there's this less stigma perceived in pursuing care. Also, I found that employment can really be protected by offering telehealth services. As you all can imagine, being able to work is not only important financially for a patient, but also psychologically and emotionally, having a sense of purpose, a sense of meaning. And when patients are able to engage in care on their phone from their car during their lunch break, that they don't have to take off time from work. They don't have to try to gingerly explain to their boss why they need to see a clinician every single week, which is the standard for CBTI. So I found that telehealth services can also help protect employment. There's also shifts in hiring practices, especially now after the pandemic. More and more providers are saying, I want to telework. I want to be able to provide this service at home. So from a hiring perspective, you can actually have some more competitive employment opportunities if you're able to tell a clinician, sure, you can telework. You can offer your services from home, part-time, or full-time, and that may give you access to more specialists to offer those services. So now let's look at some studies. Gurman et al. in 2021 completed a randomized non-inferiority trial to determine whether telehealth delivered CBTI was non-inferior to face-to-face CBTI. And they had an eight-week waitlist control and broke these patients up into a telehealth CBTI group, face-to-face, or the waitlist. And non-inferiority would be declared if the mean change in ISI scores in the telehealth group was no more than three points lower than that of the face-to-face group at three-month follow-up. So the primary analysis used an intent-to-treat approach, and a secondary per-protocol analysis included only subjects who completed at least six sessions of CBTI. So in the primary non-inferiority analysis, the mean difference between groups on ISI total score at three-months follow-up controlling for baseline score was negative 1.80, indicating that telehealth treatment was not inferior to face-to-face. And then in the per-protocol analysis revealed a difference in change scores of 1.0 points, again within a specified a priori margin of 3.0, confirming non-inferiority. Now, within this particular study, they noted that the participants were relatively healthy and did not have significant comorbidities. Oh, and by the way, the ISI is the insomnia severity index. That is the main assessment measure that is used in every session in CBTI to track insomnia symptomatology. Now, in this next study by Arnett et al., they also completed a randomized controlled non-inferiority trial of CBTI delivered individually, either face-to-face or via telemedicine using the AASM SleepTM platform, which was a telemedicine platform rolled out at the beginning of the pandemic. So the non-inferiority margin was set at 4 points, so meaning up to a 4-point difference in ISI score would be considered non-inferior. And compared to baseline, the telehealth group showed an 8.80-point reduction on ISI at post-treatment versus 9.34-point reduction for the face-to-face group, again supporting non-inferiority. Now, secondary ISI outcomes were the percent of patients achieving treatment response, defined as an ISI score change of at least 7 points, or treatment remission, which would be a final raw score on the ISI of 7 or less at post-treatment and 3-month follow-up. So at 3-month follow-up, the minimal, there were, sorry, so as we can see here, there's no significant differences between the groups for responders or remitters. And also at 3-month follow-up, there were minimal changes in ISI scores for both groups, showing that these initial treatment gains were well-maintained. And also, a note from this study, the telemedicine appointments averaged 10 minutes shorter than the face-to-face appointments. They're actually more efficient, but yet the participant ratings on these therapeutic alliance questionnaires that they were given pre and post were similar between the telehealth and the face-to-face groups. So even though they were shorter and more efficient, there was no change in that, in the patient's perception of therapeutic alliance throughout treatment. That's a big question, is how do you do psychotherapy over webcam and still feel like you can connect with a patient? And this is one of a few different studies out there showing that there really is no compromising this. Also in the ARNET study, the majority of these subjects did have a mental health disorder. About half of them had at least one chronic medical condition and about 40% used prescription or over-the-counter sleep aids. Now they noted that their therapist in the study had about 20 years of experience in CBTI, so how would this play out if you had clinicians who maybe were not as experienced? Well, now the pandemic hits, and the entire country is facing the same challenges to access that rural communities have been faced with since forever. And I'll note, at this point in 2020, I personally had been providing CBTI over telehealth for years, so there was a point there where I got really popular with my colleagues. They were reaching out saying, how do you do this over webcam? How do you exchange sleep diaries and assessment measures? And fortunately, at that time, I'd been working on a rural telehealth care team for several years, and we'd already troubleshooted a lot of those specific barriers that I'll talk about in another slide. So in this uncontrolled observational study in the early months of the COVID pandemic, we compared clinical outcomes of patients who did and did not have at least one face-to-face visit during the course of CBTI. So this is the CBTI's national training program in VA. So these 63 consultees are providers that are just learning CBTI for the first time. And so the average ISI change was 9.9 points in this study, and the training program's average before the pandemic was 9.7 points. So really pretty comparable, despite needing to pivot to telehealth in the middle of a major stressor like a global pandemic, both for the providers and for the patients, needing to navigate those bumps along the way. Now they used an ISI change difference of two points and a difference of 10% in response and remission rates as the non-inferiority margins. Telehealth non-inferiority was demonstrated for overall ISI change scores and remission rates. And overall 66% experienced clinically meaningful response and 43% experienced insomnia symptom remission. So now you might be thinking, what are some of the challenges with offering telehealth? Well, there are, in the VA we have two ways of delivering telehealth services. One is where the veteran will go to a small remote clinic over webcam and connect from an exam room to a clinician located elsewhere. The other is VVC, VA Video Connect, and that's where the patient can be seen over webcam from their home. So some of the challenges are, how do you exchange documents? Sleep diaries and assessment measures are used in every single session and needs to be exchanged between the clinician and the patients. Also, when you're working with CBOCS or these remote clinics, there's only so many exam rooms where patients can connect and how do you make sure that your appointment is locked in and no other clinician takes that hour space? Also, for at-home services, even more challenges. How do you exchange documents? Patients may not be familiar with webcam or might not even have access to internet. So since 2012, when I was on the Rural Telemental Health Care team, we troubleshooted a lot of these specific challenges and we found that having on-site technician assistance at the clinics was helpful. Also, having shared reservation calendars. Sometimes, with staffing shortages, we all know that sometimes creating those relationships with the support staff can be the make or break factor with really getting things done. And then, from the home, we figured out that in-home services actually were probably our best solution. Using secured messaging, which is the VA's kind of email feature through a secure portal, allowed patients and providers to exchange those documents. We had created e-fillable assessment measures and sleep diaries. VA was able to provide webcams and even iPads with internet access for these patients while they were engaged in treatment and then they would be returning those devices at the end of treatment. Also, if there were medical or psychiatric emergencies, we developed the E911 feature, having a patient support person and also having a secure online platform for generating a specific link for each appointment. So, to date, there have been 3.3 million instances of total CBTI template use. In our EMR, there is a specific national template that is recommended for clinicians to use whenever they are implementing the specific treatment. It is mandatory to use it while you are engaged in the six-month training program, but after that, it's really up to the clinician to decide if they want to. We've trained about 1,300 providers at this point, but the training program estimates currently only about 55% of providers who completed the program are still using the template. So, when you look at these numbers, we would expect the actual CBTI implementation is probably double what you see here. For unique patients, we've got almost half the number of rural patients as urban who have received at least one instance of CBTI. Overwhelmingly, rural patients seem to prefer in-home care over CBT or the clinic-based treatment. Now, this slide shows us that same metric for overall CBTI use and then broken down by if services were delivered over telehealth or in-person. So, obviously, we see in 2014, the numbers went up. That's the year I got trained. So, clearly, that's why that's there. But now we see in 2020, a precipitous decline in overall in-person CBTI services at the beginning of the pandemic. But very quickly, VA was able to pivot and switch to telehealth services because through the Office of Rural Health, we had other teams, such as the Rural Telemental Health Care team, that had already been troubleshooting these kinds of barriers for how to offer services over webcam. So, as soon as the pandemic hit, the VA was quickly able to switch over to this modality for delivering services. And now, what I really love to see on this slide is even now, telehealth is actually the predominant modality that this treatment is still provided by. So, in summary, telehealth modalities are non-inferior to traditional face-to-face for delivery of CBTI and even provide, I'd argue, some significant advantages over face-to-face care. This can help decrease disparities in healthcare access. Previously, groundwork for telehealth services allowed VA to quickly pivot to remote service delivery at the onset of the pandemic. And telehealth services remain the preferred and predominant treatment modality for CBTI across VHA. Thank you.

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