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STUDY OBJECTIVES We tested a telemedicine model of care to initiate continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA) living in remote Western Australia. METHODS A prospective study comparing telemedicine for CPAP initiation in a remote population versus standard face-to-face CPAP initiation in a metropolitan population. The primary outcome was average nightly CPAP use in the final week of a CPAP trial. RESULTS A total of 186 participants were allocated to either telemedicine (n=56) or standard care (n=130). The average distance from the study centre for the telemedicine group was 979 km (±792km) compared to 19km (±14km) for the standard care group. The CPAP trial duration in the standard care group was less than the telemedicine group (37.6 vs 69.9 days, p<0.001). CPAP adherence in the telemedicine group was not inferior to standard care (Standard 4.7±0.2 hours, Telemedicine 4.7±0.3 hours, p=0.86). No differences were found between groups in residual apnea-hypopnea index, symptom response, sleep specific quality of life at the end of the trial and continued CPAP use (3 to 6 months). Participant satisfaction was high in both groups. Total health care costs of the telemedicine model were less than the standard model of care. An estimated A$4,538 per participant in travel costs was saved within the telemedicine group by reducing the need to travel to the sleep center for in-person management. CONCLUSIONS In remote dwelling adults starting CPAP for the treatment of OSA, outcomes using telemedicine were comparable to in-person management in a metropolitan setting.