Twelve-Month Follow-Up and Economic Evaluation of an Alternative Care Provider Clinic for Severe Sleep-Disordered Breathing.

Abstract

Use of nonphysician alternative care providers (ACPs) can improve timely access to sleep-disordered breathing (SDB) care, and previous studies have demonstrated beneficial short-term clinical outcomes. Longer-term clinical and economic impacts of an ACP model for patients with severe SDB have not been evaluated. Is ACP-led care of SDB effective and cost-effective compared with standard care by a sleep physician? One-year follow-up data from a randomized controlled trial conducted among patients with severe SDB, randomized 1:1 to physician- or ACP (respiratory therapist)-led management is reported. Clinical outcomes included adherence to positive airway pressure therapy and patient-reported outcomes including sleepiness, quality of life, and care satisfaction. A cost-utility analysis was conducted using trial data and health administrative data, with costs calculated from the perspective of the Canadian public payer and quality-adjusted life years (QALYs) using Health Utility Index scores. Willingness to pay for incremental cost-effectiveness ratio estimates were summarized with cost-effectiveness acceptability curves. Referral wait times and polysomnogram use were evaluated in subgroup analyses. Adherence, treatment efficacy, and patient-reported outcomes were similar among ACP-led and standard care arms. Mean utility scores improved over the 1-year period in both groups. The estimated incremental cost-effectiveness ratio associated with the ACP-led group compared with standard care was -$34,580 per QALY. The probability the ACP-led clinic was cost-effective compared with standard care was 61.9% at a willingness to pay threshold of $50,000/QALY. Subgroup and sensitivity analyses did not alter results. Our results show that the ACP-led management strategy demonstrated similar clinical outcomes 1 year after treatment initiation. This model is likely to be cost-effective relative to standard care among patients with severe SDB. Results were robust to sensitivity analysis and support implementation of the ACP care model in this population.