424 Advanced gestational age is a predictor of non-completion of sleep apnea testing in pregnancy

Introduction Sleep apnea is emerging as an important and underdiagnosed comorbidity in pregnancy. Screening, diagnosis, and initiation of therapy are all time-sensitive processes during the dynamic progression of gestation. Completion of referral and testing for sleep apnea during pregnancy requires a significant commitment of time and effort on the part of the pregnant patient. We evaluated for predictors of non-completion of sleep apnea testing within our obstetric-sleep referral pipeline, in an effort to inform and optimize future referrals. Methods We performed a retrospective chart-review of 405 pregnant patient referrals for sleep apnea evaluation at the University of Wisconsin-Madison/UnityPoint sleep apnea pregnancy clinic. We used logistic regression analysis to determine predictors of lack of completion of sleep apnea testing. Results The vast majority of referrals (>95%) were triaged directly to home sleep apnea testing with the Alice PDX portable device, rather than a sleep clinic visit. The overall rate of referral non-completion was 59%. Predictors of non-completion of sleep apnea evaluation in our pregnant population included higher gestational age (GA) at referral (1–12 wks GA: 30%, 13–26 wks GA: 31%, and 27–40 wks GA: 57% non-completers, p=0.006) and multiparity with 1 or more living children (65% non-completers if any living children, compared to 45% non-completers if no living children, p=0.002). Age, race, and transportation were not predictors of failure to complete sleep apnea testing. Conclusion We have identified several predictors of pregnant patients’ failure to complete sleep apnea evaluation with objective home sleep apnea testing after referral from obstetrics. Not surprisingly, higher gestational age emerged as a strong negative predictor of referral completion, with >50% of patients referred in the third trimester not completing sleep apnea testing. Early screening and referral for sleep apnea evaluation in pregnancy should be prioritized, given the time-sensitive nature of diagnosis and therapy initiation, and demonstrated reduced completion of referrals in advanced pregnancy. Support (if any) None

410 Sleep and Stroke: Improved OSA Time to Diagnosis for Stroke Patients Using an Inpatient Diagnostic and Treatment Strategy

Introduction Obstructive sleep apnea (OSA) is an independent risk for development of stroke. Despite this known relationship there is insufficient screening of sleep apnea in many recognized stroke centers, including Geisinger. In 2016, 68 patients were admitted to Geisinger Wyoming Valley (GWV) with ischemic stroke. Less than 10% had a Sleep Medicine Referral. When referred, average time to CPAP initiation was 9–12 months. An ongoing quality improvement (QI) study implemented inpatient home sleep apnea testing (HSAT) for stroke patients and subsequent autoPAP, if positive. Interim analysis demonstrates high rates of OSA using this screening method, suggesting a viable mechanism for improved time to OSA diagnosis. Methods All patients at GWV evaluated by neurology due to acute neurologic change were considered for enrollment (9/1/2019-10/10/2020). Only patients 18 years and older hospitalized with diagnosis of ischemic stroke were included. Patients were consented for participation. The evening of enrollment an Alice NightOne HSAT device was applied by a respiratory technician. If OSA was identified, the patient was placed on APAP the following evening. Results A total of 302 patients were screened with 82 patients meeting criteria for enrollment (27%) and 64 consenting for participation and attempting HSAT (21%). 18 of the 82 (22%) eligible patients refused participation. 12 patients (19%) had insufficient HSAT studies to determine OSA diagnosis. Of the patients who successfully completed an adequate HSAT study 85% (44/52) had OSA identified. Conclusion OSA is highly prevalent in patients with ischemic stroke and represents a modifiable risk factor for recurrent stroke. At baseline, rate of and time to diagnosis of OSA was poor with less than 10% of stroke patients receiving a sleep referral and time to initiation of CPAP was approximately 1 year. Standard universal in hospital surveillance for OSA using an HSAT in admitted stroke patients appears to allow for an increased rate of capture, but perhaps also a shorter time to diagnosis. This data may also suggest that prevalence of OSA in this stroke population is similar to slightly higher than previously reported. Further analysis of this program is required to evaluate for statistical significance and impact of APAP use. Support (if any) Geisinger Health Plan

Identifying Signs and Symptoms of Obstructive Sleep Apnea in a Men’s Health Clinic: The Utility of Home Sleep Apnea Testing During COVID-19

The objective of the study was to identify symptoms of men presenting for an outpatient urology visit that prompted referral for a Home Sleep Apnea Test (HSAT) to assess for obstructive sleep apnea (OSA) by a single provider. To assess the proportion of patients referred for the HSAT who underwent the test and, out of these patients, the proportion of men diagnosed with sleep apnea, we performed a retrospective chart review of men 18–99 years old seen by a single provider in the Department of Urology referred for an HSAT to evaluate for presenting symptoms. Patients with a prior diagnosis of OSA were excluded. Eighteen patients were identified (mean age at time of referral 51 + SD 13 years). Half of patients reported erectile dysfunction/concerns, 56% reported nocturia, 44% had been diagnosed with testosterone deficiency, and 39% reported low libido. Nearly all (89%) of patients snored, all reported fatigue, 56% were over the age of 50, 44% had a BMI >35, and 78% had hypertension. Twelve patients completed the HSAT, all of whom were diagnosed with OSA for which continuous positive airway pressure (CPAP) therapy was initiated. Men presenting with genitourinary concerns to an outpatient urology clinic may also have OSA. About half of included patients reported genitourinary concerns. Hundred percent of patients who completed their sleep study were diagnosed with OSA. Genitourinary concerns, in addition to signs and symptoms commonly associated with OSA, should prompt consideration of sleep apnea evaluation.

814 VHA’s TeleSleep Program improves rural Veteran access to sleep care through expansion of telehealth networks

Introduction Rurality is a known contributor to health disparities, including Sleep medicine. Over 1 million (>350,000 rural, >650,000 non-rural) Veterans who received care from VHA in 2020 have obstructive sleep apnea (OSA). VHA’s Office of Rural Health (ORH) TeleSleep Program (FY17-20) aimed to increase access to sleep care for rural veterans by establishing telehealth services at 12 hubs and 63 spokes across the country. The TeleSleep program has three components: (1) Telemedicine; (2) Home Sleep Apnea Testing (HSAT); and (3) REVAMP (Remote Veterans Apnea Management Platform), a web-application for comprehensive sleep apnea care. Methods Each of the three TeleSleep components was evaluated independently using specific metrics. We report here on the impact of leveraging telemedicine to improve access to sleep care. Patient care encounters are defined by VA-specific stop codes and are thus identifiable as telehealth or in-person visits. Data used in the evaluation were obtained from the VA Corporate Data Warehouse. Results During FY20, 33,743 rural Veterans had 74,458 sleep encounters within the TeleSleep network. Visits included in-person care, virtual initial and follow up visits, electronic consultations, asynchronous telehealth (remote monitoring of PAP data and HSAT), remote PAP initiation by video or phone, and email exchanges between patients and providers. Between FY17-20, the number of rural Veterans seen for sleep-related disorders at TeleSleep sites tripled (from 10,702 to 33,743), and the number of encounters for sleep-related disorders more than doubled (from 32,894 to 74,458). In FY20, 72% (up from 53% in FY18) of rural Veterans at the TeleSleep hubs or spokes had at least one virtual sleep visit. This was significantly higher than non-TeleSleep VA sites where only 64% of rural Veterans had virtual visits (72% vs. 64%; p<0.001). In addition, the proportion of Veterans who had face-to-face only visits (28% at TeleSleep sites vs. 36% at non-TeleSleep sites; p<0.001) indicates that the TeleSleep program was highly successful in promoting virtual (instead of face-to-face) visits. Conclusion The ORH TeleSleep Program has improved access to comprehensive sleep care for rural Veterans by increasing the proportion and type of sleep visits conducted virtually vs. in person. Support (if any) Funding provided by VHA Office of Rural Health