Aims:

To review the experiences of healthcare professionals (HCPs) and service users on the provision and receipt of home enteral nutrition (HEN) in primary care settings, respectively.

Backgrounds:

HEN supports the nutritional needs of service users in primary care settings who are unable to meet their nutritional requirements through oral intake alone. While HEN supports service users to remain in their home, the provision of HEN services can be variable. The prevalence of HEN is increasing as health systems shift delivery of care from acute to primary care settings, and therefore the evolving needs of HCPs and service users in relation to HEN deserve exploration.

Methods:

Quantitative and qualitative studies were included if they described (1) practices that support best outcomes in adults on HEN and residing in their own homes and/or (2) service user and HCP experiences of HEN. Studies on the economics of HEN were included. Databases searched included MEDLINE/PubMed, EMBASE, Web of Science, and CINAHL. Publications up to March 2021 were included. A descriptive analytical approach was used to summarise the findings.

Findings:

Key themes included the importance of initial education to enable service users to adapt to HEN and the need for support from knowledgeable HCPs. Access to support from HCPs in primary care was limited, and some HCPs felt their knowledge of HEN was inadequate. Service users highlighted the significant impact of HEN on daily living and emphasised the need for support from a HEN team. HEN services were also associated with reduced hospital admissions, lengths of stay in hospital, and costs of hospitalisation.

Conclusions:

A specialist HEN service can manage enteral nutrition-related complications, reduce unnecessary hospital admissions, and improve quality of care and patient satisfaction. Further education of HCPs is needed on the provision of HEN.

Lowlanders sojourning at high altitude often experience sleep disturbances, which are driven by blood gases alterations and manifest as stress-related patterns, including frequent awakenings, apnoeas, reduction in sleep duration and possibly with the occurrence of periodic breathing. This study demonstrated clinical evidence of sleep disturbances at high altitude by using portable device during a Himalayan expedition. The home sleep apnoea test was conducted on 10 participants taking part in the "Lobuche Peak - Pyramid Exploration & Physiology". The longitudinal design included five assessments, before the expedition, at pre-expedition at Kathmandu (≈1400 m), at a peak altitude of ≈ 5000 m, upon return to Kathmandu and one month after return in Italy. Total sleep time was below 7 h of duration at the highest altitude in all participants. Nocturnal SpO2 dropped below daytime measurement and was greatly reduced at high altitude; conversely, heart rate increased. All participants experienced an increase in apnea-hypopnea index at high altitude, with seven out of 10 falling in moderate-to-severe grade. Periodic breathing pattern was clearly observed in two participants, of whom one developed acute mountain sickness and one did not. All the impairments were fully reversible once back at low altitude. Translationally, our findings underscore the importance of conducting home sleep apnoea tests at living altitude. Sleep-disordered breathing arises from a complex pattern that can be due to a wide range of responses, and the overall functions revealed by home sleep apnoea testing during a field expedition have the potential to increase the safety of high altitude sojourners, while advancing our knowledge of hypoxia as the red line linking respiratory and environmental physiology.

Objective | To determine whether continuous positive airway pressure (CPAP) adherence reduces health care-related costs or use in patients with obstructive sleep apnea (OSA) and comorbid cardiovascular disease (CVD).

Patients | A total of 23 million patients with CVD were identified in the Medicare fee-for-service database. Of the 65,198 who completed a sleep study between January 2016 and September 2018, 55,125 were diagnosed as having OSA and 1758 were identified in the 5% Medicare durable medical equipment (DME) database.

Methods | Patients with DME claims were categorized as adherent (AD, treatment evidenced ≥91 days after CPAP initiation; n=614) or nonadherent (nAD, n=242) to CPAP therapy. In addition, 9881 individuals with CVD who were not diagnosed as having OSA after sleep testing and without CPAP initiation were included as control patients. Propensity score matching balanced the groups for age, sex, and comorbidities (eg, diabetes mellitus), resulting in 241 participants per cohort. Dependent variables included total episode-of-care, inpatient, outpatient, skilled nursing, home health, and DME costs across 12 months.

Results | Total episode-of-care costs of AD participants ($6825) were lower than those of nAD ($11,312; P<.05) and control ($8102) participants. This difference (Δ) was attributable to fewer outpatient expenses (Δ$2290; P<.05) relative to the nAD group and fewer inpatient expenses (Δ$745) relative to the control group because skilled nursing costs were comparable between groups (P=.73).

Conclusion | Adherence to CPAP treatment reduces annual health care-related expenses by 40% in Medicare patients with CVD and OSA.

Background: There is a scarcity of published data on the global prevalence of obstructive sleep apnoea, a disorder associated with major neurocognitive and cardiovascular sequelae. We used publicly available data and contacted key opinion leaders to estimate the global prevalence of obstructive sleep apnoea.

Methods: We searched PubMed and Embase to identify published studies reporting the prevalence of obstructive sleep apnoea based on objective testing methods. A conversion algorithm was created for studies that did not use the American Academy of Sleep Medicine (AASM) 2012 scoring criteria to identify obstructive sleep apnoea, allowing determination of an equivalent apnoea-hypopnoea index (AHI) for publications that used different criteria. The presence of symptoms was not specifically analysed because of scarce information about symptoms in the reference studies and population data. Prevalence estimates for obstructive sleep apnoea across studies using different diagnostic criteria were standardised with a newly developed algorithm. Countries without obstructive sleep apnoea prevalence data were matched to a similar country with available prevalence data; population similarity was based on the population body-mass index, race, and geographical proximity. The primary outcome was prevalence of obstructive sleep apnoea based on AASM 2012 diagnostic criteria in individuals aged 30-69 years (as this age group generally had available data in the published studies and related to information from the UN for all countries).

Findings: Reliable prevalence data for obstructive sleep apnoea were available for 16 countries, from 17 studies. Using AASM 2012 diagnostic criteria and AHI threshold values of five or more events per h and 15 or more events per h, we estimated that 936 million (95% CI 903-970) adults aged 30-69 years (men and women) have mild to severe obstructive sleep apnoea and 425 million (399-450) adults aged 30-69 years have moderate to severe obstructive sleep apnoea globally. The number of affected individuals was highest in China, followed by the USA, Brazil, and India.

Interpretation: To our knowledge, this is the first study to report global prevalence of obstructive sleep apnoea; with almost 1 billion people affected, and with prevalence exceeding 50% in some countries, effective diagnostic and treatment strategies are needed to minimise the negative health impacts and to maximise cost-effectiveness.

Funding: ResMed.