Patient satisfaction with sleep study experience: findings from the Sleep Apnea Patient-Centered Outcomes Network

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1 SLEEPJ, 2018, 1 7 doi: /sleep/zsy093 Advance Access publication Date: 8 May 2018 Original Article Original Article Patient satisfaction with sleep study experience: findings from the Sleep Apnea Patient-Centered Outcomes Network Vishesh K. Kapur 1,2, *, James C. Johnston 2, Michael Rueschman 2,3, Jessie P. Bakker 2,3,4, Lucas M. Donovan 1, Mark Hanson 2, Zinta Harrington 2,5, Jia Weng 3 and Susan Redline 2,3,4,6 1 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, 2 Sleep Apnea Patient- Centered Outcomes Network, 3 Division of Sleep and Circadian Disorders, Brigham and Women s Hospital, Boston, MA, 4 Division of Sleep Medicine, Harvard Medical School, Boston, MA, 5 University of New South Wales, Sydney, Australia and 6 Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA *Corresponding author: Vishesh K. Kapur, UW Medicine Sleep Center, PO Box , 325 Ninth Ave, Seattle, WA vkapur@uw.edu. Abstract Study Objectives: Home sleep apnea testing (HSAT) is increasingly used as an alternative to laboratory-based polysomnography (PSG) for the diagnosis of obstructive sleep apnea. Patient satisfaction with sleep testing performed at home or in the lab has been sparsely assessed, despite its potentially pivotal role in determining patients acceptance of sleep apnea treatment. We hypothesize that satisfaction in clinical practice may differ from what has been previously reported within the research setting. Methods: We analyzed survey data including responses to questions regarding diagnostic sleep study type and sleep study experience satisfaction from 2563 sleep apnea patients enrolled in the Sleep Apnea Patient-Centered Outcomes Network. Results: Patients (mean age 57 years; 54% male) who underwent in-lab PSG were more likely to be satisfied with their study experience than patients who had a HSAT (71% vs 60%; p < 0.01). Furthermore, the 38 per cent diminished odds of satisfaction in patients having HSAT (OR: 0.62; 95% CI: ) persisted after adjustment for potential confounders (OR: 0.41, 95% CI; ). Greater sleep apnea symptom burden and satisfaction with CPAP therapy were associated with greater study satisfaction. Effect modifications on study types by college degree education and tiredness as a study trigger were detected. Conclusions: Patients receiving care in the community who underwent PSG reported greater satisfaction with study experience than patients who underwent HSAT in contrast to findings from randomized controlled trials. Our findings, based on data from contemporary real-world settings, suggest that assumptions about the generalizability of early reports comparing in-lab PSG to home-based paradigms need to be revisited. Statement of Significance This is the first study to assess patient satisfaction with sleep study experience in a large sample of patients receiving care outside a structured research setting. In contrast to prior findings from randomized controlled trials, patients who underwent polysomnography (PSG) were more likely to be satisfied with their study experience than those who had a home sleep apnea test. Assumptions about the generalizability of prior findings comparing in-lab PSG to home-based paradigms need to be reexamined. Additional real -world studies assessing patient preferences and satisfaction regarding sleep apnea care that include more information regarding patient characteristics and details of clinical care are needed. Key words: home sleep apnea test; polysomnography; patient; satisfaction; sleep apnea Submitted: 19 June, 2017; Revised: 28 February, 2018 Sleep Research Society Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please journals.permissions@oup.com. 1

2 2 SLEEPJ, 2018, Vol. 41, No. 8 Introduction Home sleep apnea testing (HSAT) is increasingly used as an alternative to laboratory-based polysomnography (PSG) for the diagnosis of obstructive sleep apnea (OSA). The American Academy of Sleep Medicine s recent clinical practice guideline on diagnostic testing for OSA recommends that either HSAT or PSG be used for diagnosing OSA in uncomplicated patients presenting with signs and symptoms suggesting moderate to severe disease [1]. These guidelines further specify the appropriate context for using HSAT, including provider expertise and acceptable device types. The guidelines are based on evidence from several randomized controlled trials (RCTs) conducted in well-established academic sleep centers that demonstrate that HSAT and PSG, when used in a specific context, lead to similar continuous positive airway pressure (CPAP) adherence and patient-reported outcomes [2 5]. The guidelines also recommend that the clinician s choice of study type for a particular patient should incorporate patient preferences, while noting that there is insufficient data about diagnostic testing preferences, particularly in real world settings. Patient satisfaction, an often neglected though important indicator of the outcome of medical care and one that influences adherence to therapy and quality of life is related to preference [6]. Furthermore, the extent to which medical treatment is aligned with patient s preferences may determine satisfaction which, in turn, likely motivates adherence to medical therapy [7]. Patient satisfaction with diagnostic sleep testing has been sparsely assessed, despite its potentially pivotal role in determining patients acceptance of OSA treatment recommendations and optimizing treatment outcomes. To better understand patient satisfaction with HSAT and PSG sleep testing experiences in routine practice (rather than RCTs performed in academic settings), we analyzed data from 2563 patient surveys collected from the Sleep Apnea Patient- Centered Outcomes Network (SAPCON), representing a broad group of patients receiving sleep services in the community. We explored patient demographics and characteristics associated with study type and satisfaction and assessed whether specific patient characteristics might be associated with satisfaction for a specific study type. Methods SAPCON and its web portal (MyApnea.Org), a patient-centered research network affiliated with the Patient-Centered Outcomes Research Institute, were developed by clinician-researchers in conjunction with patients to promote comparative effectiveness research [8]. The database includes more than 9000 members from across 42 countries, with the majority of members (94%) coming from the United States. Upon joining, members indicate their role (e.g. patient with sleep apnea), are asked to provide online informed consent for collection of research survey data and are invited to share experiences, learn from expert commentary, and suggest research topics. The study is approved by Partners Health Human Research Committee. Surveys and analytic sample Data from several MyApnea.org surveys were used in this study: demographics ( About Me ); sleep apnea diagnosis and prediagnosis symptoms ( My Sleep Apnea ); medical conditions ( My Health Conditions ); and treatment ( My Sleep Apnea Treatment ). The analytic sample (N = 2563) consisted of patients with sleep apnea who responded to two key questions between October 2014 and November Exposure was defined by responses to the following: What type of sleep study did you have when first diagnosed with sleep apnea? with a response of sleep study at my home (portable study) or sleep study in a sleep lab/center. Patients who responded prefer not to answer were excluded (N = 28). The outcome was defined by the following: How satisfied were you with the experience of getting a sleep study? Responses were measured using a 7-point Likert scale ranging from very dissatisfied to very satisfied. Patients who responded prefer not to answer were excluded (N = 13). From the About Me survey, information was evaluated on age, gender, race/ethnicity, educational level, income level, height, weight, marital status, and how hard it is to pay for basics like food, rent or mortgage, heating, etc. The My Sleep Apnea survey asked Which of the following symptoms triggered you to be evaluated for sleep apnea? with 14 choices listed (snoring, sleepiness, tiredness, driving or work accident, shortness of breath during sleep, stopped breathing during sleep, forgetfulness, depressed mood, irritability, heart disease, high blood pressure, anxiety disorder, concerned friend or spouse, and healthcare provider s suggestion). Dichotomous variables (0, 1) were created for each symptom and then a sum of triggers was created. In addition, this survey included a question about whether the subject had any kind of health care coverage. The My Health Conditions survey asked Has a doctor or health care professional ever told you that you had any of the following? with a list of 17 common health conditions. The following conditions listed as follows: allergies, asthma, attention deficit disorder, attention deficit hyperactivity disorder, cancer, chronic obstructive lung disease, depression, diabetes, epilepsy or seizure disorder, high blood pressure, heart disease, insomnia, narcolepsy, pulmonary fibrosis, restless leg syndrome, and stroke. Response options included yes, no, don t know, and prefer not to answer. Valid options for our analyses were yes or no. The My Sleep Apnea Treatment survey asked What treatment(s) are you currently using for your sleep apnea? with the following options listed: never been treated, CPAP, autotitrating positive airway pressure (APAP), Bilevel positive airway pressure (BPAP), adaptive servo ventilation (ASV), mandibular advancement device (MAD), behavioral therapy, tongue stimulation, tonsillectomy, uvulopalatorpharyngoplasty (UPPP), nasal deviation surgery, tongue surgery, jaw surgery, bariatric surgery, and prefer not to answer. Dichotomous variables (0 = not checked; 1 = checked) were created for each treatment type. CPAP and APAP options were combined to create a composite variable for CPAP with a yes response indicating those reporting use of either of these. In addition, upper airway surgery options were combined under the variable upper airway surgeries to indicate if any of the surgical options were used. Statistical analyses Responses to the outcome variable, satisfaction with sleep study experience, were evaluated as a full Likert scale and a dichotomized outcome. Responses on the Likert scale were centered around the middle response ( neutral ) which was assigned a value of zero. Responses above neutral were

3 Kapur et al. 3 sequentially assigned positive integer values (slightly satisfied = 1, satisfied = 2, very satisfied = 3), whereas those below neutral were sequentially assigned negative integer values ( 1, 2, 3). The dichotomized outcome was created as follows: Being satisfied was defined by combining slightly to very satisfied categories. Not being satisfied was defined by combining neutral to very dissatisfied categories. Participant characteristics were presented by study type (Table 1) and by satisfaction with the study (Table 2) using chisquared test and analysis of variance (ANOVA) or Mann Whitney tests wherever applicable. To assess the association between study type and patient satisfaction, logistic regression with the outcome variable (study satisfaction) was used to determine the unadjusted and adjusted odds of satisfaction. Linear regression was used to model the satisfaction outcome, expressed according to the numerical values for the Likert scale, with study type, in both unadjusted and adjusted analyses. The linear regression analysis as performed assumes that adjacent Likert-score responses have equal differences in magnitude. Covariates included in the final model were selected from variables that were associated with study type or satisfaction (p < 0.05). Patient characteristics that appeared to be differentially associated with a particular study type were identified by inspection of dichotomized and Likert-scale satisfaction outcomes stratified by study type. Effect modifications for study type on Likertscale satisfaction were formally tested with linear regression. Effect modifications for study type on satisfaction (dichotomized) were formally tested with logistic regression on multiplicative and additive scale using Relative Excess Risk Due to Interaction (RERI) [9, 10]. Results The patients had a mean age of 57 (11.9) years, were predominantly white (88%), and had a relatively equal sex distribution (54% male). Three hundred eighty-six (15%) patients had a sleep study at home, whereas 2,177 (85%) had a study in a sleep laboratory. Patients who had a sleep study at home were slightly younger (55 vs. 57 years; p=0.03) and less likely to have healthcare coverage (93% vs. 96%; p = 0.02) (Table 1). Patient characteristics and treatment according to sleep study type Self-reported triggers (symptoms, health conditions, and input by others) that led to sleep apnea testing were compared between patients receiving each study type. Only concern regarding heart disease and sleepiness differed between groups (Table 1); that is, patients undergoing a lab study were more likely to report heart disease (19% vs. 14%; p < 0.05) and sleepiness (88% vs 84%; p< 0.05) as triggers. In contrast, the prevalence of several doctor-diagnosed conditions (reported independently of their recognition as a trigger for sleep apnea testing) differed by study type (Table 1). Specifically, patients who underwent a lab study were more likely to report diagnoses of cancer (14% vs. 8%), COPD (7% vs. 3%), depression (46% vs. 40%), diabetes (21% vs. 14%), hypertension (56% vs. 50%), heart disease (15% vs. 11%), and restless leg syndrome (22% vs. 13%) (all p values < 0.05). The vast majority of patients reported current use of positive airway pressure (PAP) therapy, with CPAP (fixed pressure or Table 1. Participant characteristics by test type Home study (n = 386) auto titrating) as the most common type (79%) (Table 1). Patients who underwent a home study were less likely to receive therapy of any type (87% vs 92%; p < 0.01) including specific non-cpap therapies: BPAP (7% vs. 13%; p < 0.01), MAD (5% vs. 8%; p < 0.05), and upper airway surgeries (3% vs. 9%; p < 0.01). Among those who were prescribed CPAP, satisfaction with CPAP therapy did not differ by diagnostic study type (71% vs. 66%; p = 0.18). Patient satisfaction with sleep study type Lab-study (n = 2177) Age in years (mean)** 55.4 ± ± 11.9 Male 50.8% 54.2% Black 3.6% 4.6% College educated 53.4% 54.9% Married 72.2% 71.7% Income > 50K* 68.8% 62.9% Has health care 92.8% 95.7% coverage** Not hard to pay for 64.1% 63.9% basics Risk factors and triggers BMI (mean) 33.8 ± ± 8.3 Snoring 87.9% 86.9% Sleepiness** 83.8% 87.7% Tiredness* 88.2% 91.1% Stop breathing 71.1% 73.5% Heart disease** 14.2% 18.8% Hypertension 47.4% 49.4% Depressed 51.8% 51.1% # Triggers (mean) 7.46 ± ± 2.9 Medical conditions Cancer*** 7.7% 14.1% COPD*** 2.8% 6.5% Depression** 39.8% 46.2% Diabetes*** 13.5% 20.7% Hypertension** 49.6% 55.8% Heart disease** 10.7% 15.4% Stroke 2.5% 3.5% Insomnia 21.5% 25.4% RLS*** 12.8% 21.5% Treatments PAP, MAD, or surgery*** 87.3% 91.6% CPAP 81.0% 78.8% BPAP*** 6.6% 13.4% ASV 0.6% 1.5% MAD** 5.0% 8.2% Upper airway 3.0% 9.4% surgeries(combined)*** % satisfied with CPAP 70.8% 66.3% Number of responses per variable range from 2019 to 2420 except % satisfied with CPAP (N = 1664). Comparison of bivariate outcome by group using the chi-square test (*p < 0.1; **p < 0.05; ***p < 0.01; ANOVA used for no. of triggers). Regardless of study type, patients tended to be satisfied with the sleep study experience with a response of very satisfied (Likert score = 3) as the most common (Figure 1). The mean and median Likert scores were 1.3 and 2.0, respectively, corresponding to a bit more than a slightly satisfied level and satisfied level of satisfaction. Home-studied patients were less likely to

4 4 SLEEPJ, 2018, Vol. 41, No. 8 Table 2. Factors associated with study satisfaction Satisfied with study Demographics Male**, 67.7% 1.18 (2) Female 71.7% 1.38 (2) College**, 67.5% 1.16 (2) No college 72.0% 1.41 (2) Married*, 68.5% 1.24 (2) Not married 72.5% 1.39 (2) Risk factors and triggers Snoring **, 70.3% 1.32 (2) No snoring 63.6% 1.03 (2) Sleepiness***, 70.8% 1.32 (2) No sleepiness 62.7% 1.03 (2) Tiredness***, 70.4% 1.32 (2) No tiredness 59.9% 0.86 (2) Stop breathing***, 72.2% 1.39 (2) Didn t stop breathing 61.9% 0.97 (2) Hypertension 70.7% 1.32 (2) No hypertension 67.9% 1.21 (2) Depressed**, 71.0% 1.34 (2) Not depressed 67.3% 1.18 (2) # Triggers*** 7.7 ± 2.86 Medical conditions Depression*, 71.8% 1.37 (2) No depression 68.6% 1.23 (2) Hypertension 70.6% 1.32 (2) No hypertension 69.4% 1.26 (2) Stroke** 82.3% 1.66 (2) No stroke 69.5% 1.27 (2) RLS 71.1% 1.37 (2) No RLS 69.9% 1.28 (2) Treatments CPAP treatment***, 71.2% 1.36 (2) No CPAP 64.4% 1.03 (2) MAD treatment***, 60.2% 0.76 (1) No MAD 70.6% 1.3 (2) Satisfied with CPAP***, 75.8% 1.56 (2) Not satisfied with CPAP 56.2% 0.64 (1) Mean (Median) Likert score Comparison of dichotomized outcome by group using the chi-square test (*p < 0.1; **p < 0.05; ***p < 0.01; ANOVA used for no. of triggers). Comparison of 7-point Likert scale outcome by group using the Mann Whitney Test ( p < 0.1; p < 0.05; p < 0.01). #Triggers in those not satisfied with study = 7.23 ± Number of responses per variable range from 2019 to 2420 except % satisfied with CPAP (N = 1664). be at least slightly satisfied [60% vs. 71%]; p-value < 0.01) and had lower mean Likert scores (1.0 vs 1.3; p-value < 0.001), but median values were the same (2.0). We examined factors that might be associated with study experience satisfaction (Table 2). Negative associations with satisfaction (p < 0.05) for both dichotomized and Likert scale satisfaction variables included the following: male sex (68% vs. 72%; mean Likert 1.2 vs 1.4), college education (68% vs. 72%; mean Likert 1.2 vs 1.4), and treatment with an MAD appliance (60% vs. 71%; 0.8 vs 1.3). For the Likert-scale satisfaction variable only, the mean Likert value was lower for married subjects (1.2 vs 1.4). In contrast, positive associations with study satisfaction for both dichotomized and Likert scale satisfaction variables included the following: presence of snoring (70% vs. 64%; mean Likert 1.3 vs 1.0), sleepiness (71% vs. 63%; mean Likert 1.3 vs 1.0), tiredness (70% vs. 60%; 1.3 vs 0.9), stop breathing as a study trigger (72% vs. 62%; 1.4 vs 1.0), higher total number of study triggers (7.7 vs 7.2), CPAP therapy (71% vs. 64%; 1.4 vs 1.0), and satisfaction with CPAP therapy (76% vs. 56%; 1.6 vs 0.6). Positive association with dichotomized study satisfaction was only seen for stroke diagnosis (82% vs. 70%), whereas positive association with Likertscale satisfaction was only seen for depression diagnosis (1.4 vs 1.2). The unadjusted odds ratio (OR) for likelihood of satisfaction (using dichotomized variable) with a home study relative to a lab study was 0.62 (95% CI: ). The reduced odds persisted (0.41 [95% CI: ]) in an adjusted model that included variables that showed appreciable differences or statistical associations by study type or satisfaction: age, sex, education level, marital status, income level, healthcare coverage, symptoms/ triggers (snoring, sleepiness, tiredness, stop breathing, heart disease), number of triggers, conditions (cancer, COPD, depression, diabetes hypertension, heart disease, insomnia, restless legs and stroke), and satisfaction with CPAP. The unadjusted difference in Likert-scale satisfaction was 0.38 (95% CI: ) and the adjusted difference in Likertscale satisfaction was 0.63 (95% CI: ). Factors differentially associated with study type The associations between study satisfaction and patient characteristics for those who underwent lab vs. home studies were compared. Tables 3 and 4 include those characteristics that by inspection appeared to be differentially associated with a particular study type. Patients studied at home who had completed a college degree or did not report snoring, sleepiness, or tiredness as a study trigger reported lower satisfaction than expected, whereas patients with depression as a trigger for study or diagnosis of insomnia had higher satisfaction than expected. Married patients studied in the lab reported lower satisfaction than expected. Having attained a college degree significantly interacted with study type when evaluated for interaction using an unadjusted linear regression model with Likert-scale satisfaction outcome. With dichotomized satisfaction outcome, potential effect modifications were tested using logistic regression models on both multiplicative and additive scales. Although none of the interaction terms were significant on multiplicative scale, an additive scale tiredness is suggested to have positive effect modification across study types (RERI estimate 0.580; 95% CI: ). Discussion In the largest study to date to evaluate patient satisfaction with sleep study experience, patients who underwent in-lab PSG were more likely to be satisfied than patients who had a HSAT (71% vs 60%; 2.0 vs 1.3 by Likert mean). Furthermore, the diminished odds of satisfaction in patients having HSAT persisted after adjustment for possible confounders including satisfaction with CPAP therapy (OR: 0.41). This study is among the first to explore the factors associated with satisfaction with study experience; finding that the presence of greater sleep apnea symptom burden and better satisfaction with CPAP therapy was positively associated with study satisfaction. Finally, we evaluated potential effect modifications by study type for satisfaction. When modeling Likert-scale satisfaction as a continuous

5 Kapur et al. 5 Table 3. Characteristics differentially related to satisfaction with study type: Lab study College* No College Married**, Not Married Snore*, No snore Sleepiness***, No sleepiness Tired***, Not tired Depressed Not depressed Insomnia No insomnia, Satisfied with study Mean (median) Likert score 69.7% 73.2% 70.1% 74.5% 71.7% 65.9% 72.4% 64.3% 72.0% 60.8% 72.1% 69.7% 72.2% 71.7% 1.25 (2) 1.43 (2) 1.30 (2) 1.45 (2) 1.36 (2) 1.13 (2) 1.38 (2) 1.04 (2) 1.38 (2) 0.86 (2) 1.39 (2) 1.26 (2) 1.31 (2) 1.36 (2) Table 4. Characteristics differentially related to satisfaction with study type: Home study College* No college Married Not married Snore No snore Sleepiness No sleepiness Tired Not tired Depressed**, Not depressed Insomnia No insomnia, Satisfied with study Mean (median) Likert score 54.9% 65.3% 59.9% 61.4% 62.6% 50.0% 61.4% 55.9% 60.9% 56.1% 64.9% 54.3% 67.1% 57.8% 0.66 (1) 1.28 (2) 0.93 (2) 1.07 (2) 1.09 (2) 0.45 (0.5) 0.98 (2) 0.95 (2) 0.99 (2) 0.88 (2) 1.11 (2) 0.75 (1) 1.21 (2) 0.86 (2) Comparison of dichotomized outcome by group using the chi-square test (*p < 0.1; **p < 0.05; ***p < 0.01). Comparison of 7-point Likert scale outcome by group using the Mann Whitney Test ( p < 0.1; p < 0.05; p < 0.01). Number of responses per variable range from 1915 to Comparison of dichotomized outcome by group using the chi-square test (*p < 0.1; **p < 0.05; ***p < 0.01). Comparison of 7-point Likert scale outcome by group using the Mann Whitney Test ( p < 0.1; p < 0.05; p < 0.01). Number of responses per variable range from 348 to 365. outcome, we found that patients with at least a college degree studied at home are less likely to be satisfied than the combined individual effect of both of these exposures. When modeling satisfaction as a binary outcome, we found that patients being tired and studied in lab are more likely to be satisfied than the combined individual effect of both of these exposures. In contrast, three prior studies that compared patient satisfaction with HSAT to PSG did not find significant differences [2, 11, 12]. An RCT comparing PSG with HSAT on satisfaction with monitoring equipment comfort and sleep quality found nonsignificant differences that favored HSAT (6.5 vs 5.6 [2 10 scale]) [2]. A randomized cross-over study of HSAT and PSG in 75 urban African Americans found high levels for satisfaction with both test types (4.28 vs 4.26 [0 5 scale]: p = 0.5) [11]. Another study found no significant differences in satisfaction and preference was found in 39 patients who underwent PSG and 25 patients who had HSAT and completed satisfaction questionnaires that rated discomfort of sleep, confidence in study result, influence of the diagnostic process on personal decision on therapy, and satisfaction with diagnostic process. Sleep tests were performed as a part of routine care in a regional Israeli healthcare system that had its own sleep clinic and lab system [12]. Differences in the study population and clinical setting between prior studies and the current report may explain discrepant findings. Although participants in the prior studies were studied in established sleep centers (at least two centers were Figure 1. Satisfaction by study type.

6 6 SLEEPJ, 2018, Vol. 41, No. 8 affiliated with academic centers), we used a volunteer sample that likely experienced a wide range of sleep services as may occur across diverse community settings. In this regard, prior survey research has shown that board-certified sleep medicine physicians and accredited sleep centers receive greater satisfaction ratings than noncertified physicians and nonaccredited centers [13]. Furthermore, comparative effectiveness research has demonstrated that patients who receive care from accredited centers and certified physicians are more likely to be adherent to PAP therapy and that patient satisfaction is associated with physician certification, greater education provided by physician, and less delays in care [14]. With regard to differences between clinical and research settings, RCT participants have consented to participate in a trial in which they know that PSG and/or HSAT may be applied, whereas patients may not be offered alternatives because of provider or insurance preferences. RCTs also often provide higher level of support than seen in routine care. In clinical practice, there may be variations in satisfaction based on healthcare personnel skill levels, level of patient education, and access to care or patient expectations. The patients in our study received care in a variety of settings, and therefore, our findings may represent more contemporary estimates of the experiences patients have in routine practice. For example, the delivery of HSAT is increasingly delegated to third party providers or subjected to resource constraints. Satisfaction differences we found could relate to underlying differences in patient health status, insurance, or social characteristics that influenced which sleep study they received. However, our multivariable analyses showed that higher levels of satisfaction persisted after considering confounders. It is possible that our findings were influenced by selection biases related to web-based patient recruitment. For example, it is possible that patients with extreme levels of motivation because of positive or negative experiences selectively participated in this study and diagnosed patients who gave up therapy quickly did not. The large sample size and wide range of satisfaction levels attenuate concern over this bias. Furthermore, patients participating in digital research may be more educated and we found that greater education was differentially associated with satisfaction with PSG. Concern of this bias is reduced by our multivariate analysis which adjusted for college degree. The greater satisfaction associated with in-lab compared with home testing may reflect several factors. Satisfaction with the sleep study experience may most directly relate to patient preference, comfort of equipment, environment, and convenience. It may also be related to a variety of factors including perceived competence of personnel involved, perceived value, cost, test result, and treatment outcome. Our findings, based on data from contemporary real-world settings, suggest that assumptions about the generalizability of early reports comparing in-lab PSG with home-based paradigms need to be revisited. Over the past 5 years, market forces have displaced more home-based testing to third party vendors where levels of patient support are likely much less than what had been provided in early RCTs. There is a need for ongoing evaluation of the processes by which in-home services are provided, and further explication of the impact of specific services on patient satisfaction and outcomes. To the best of our knowledge, our study is the first to explore the factors that are associated with satisfaction with study experience. Not surprisingly the presence of greater sleep apnea symptom burden and better satisfaction with CPAP therapy was positively associated with study satisfaction. More education for less symptomatic patients on potential benefits of CPAP may positively influence satisfaction. Furthermore, our results suggest that patients with a college degree may have a lower tendency for satisfaction with HSAT and patients with tiredness may have a tendency for higher satisfaction with PSG. These findings suggest potential value from further research addressing how sleep services can be adapted to the psychological and health needs of individual patients, i.e. personalizing treatment. Our study did not assess preference, a concept that is related to satisfaction: presumably, if patients are provided care that aligns with their preferences, greater satisfaction results. Several previously described studies show that HSAT was preferred by selected patient groups in specific settings [8, 11, 12]. Those preferring HSAT cited the advantage of sleeping in a familiar environment and the ease of monitoring while those preferring PSG appreciated close observation by trained staff and more detailed information obtained from PSG. Preference has not yet been evaluated among a broad sample of patients who obtained care in a diversity of contexts. Despite the large size and wide geographic distribution of this patient-centered study, the limitations guide us to future research designs oriented toward satisfaction and preference. The study would have benefited from additional information on patient characteristics and the context of clinical care, including evaluation in accredited centers, involvement of a board-certified sleep medicine physician, level of education provided, access to care, whether in-lab testing was performed as a split-night, how CPAP was titrated, specificity regarding whether weight loss therapy was used, and other details on the healthcare delivery and health insurance. We do not know whether care aligned with recent evidence-based clinical guidelines. Moreover, this large sample may not be representative of typical sleep clinic cohorts; the web-based elements mean that the sample needed a level of technology literacy to participate. The single questions assessing satisfaction did not allow us to assess specific components of the sleep testing experience. Future research that provides opportunities for patients to add their own words on these important topics might provide deeper insights. In summary, our study is the first to assess patient satisfaction with sleep study experience in a large sample of patients receiving care outside a structured research setting. Based on data from real-world settings, we find that patients who underwent PSG were more likely to be satisfied with their study experience than those who had HSAT. Furthermore, we identify patient factors that may be associated with greater satisfaction. This study highlights the need for future studies on patient preferences and satisfaction regarding sleep apnea care that are designed, implemented, and analyzed with broad patient input. Acknowledgments We gratefully acknowledge members of SAPCON s multistakeholder panel (Judith Owens MD, Nancy Rothstein MBA, Kathy Page, Si Baker-Goodwin EdD, Matt Epstein JD, Sarah Gorman, Sherry Hanes, and Barbara Zarrella) and the participants in SAPCON. Funding This study was supported in part by PCOR PPRN Dr. Redline was also supported by HL Dr. Bakker

7 Kapur et al. 7 was supported by an American Heart Association Scientist Development Grant (14SDG ). Notes Conflict of interest statement. As of June 12, 2017, Dr. Bakker, an investigator on this study, is a full-time employee of Phillips Respironics, which is a company that focuses on sleep and respiratory care. This position began after all data collection and analysis contained in this publication was completed. Dr. Bakker also has part-time appointment at Brigham and Women s Hospital and on the faculty of Harvard Medical School. Dr. Bakker s interests were reviewed and are managed by BWH and Partners HealthCare in accordance with their conflict of interest policies. References 1. Kapur VK, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American academy of sleep medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3): Berry RB, et al. Portable monitoring and autotitration versus polysomnography for the diagnosis and treatment of sleep apnea. Sleep. 2008;31(10): Rosen CL, et al. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep. 2012;35(6): Kuna ST, et al. Noninferiority of functional outcome in ambulatory management of obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183(9): Skomro RP, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest. 2010;138(2): Ross CK, et al. The importance of patient preferences in the measurement of health care satisfaction. Med Care. 1993;31(12): Konerding U. Which kind of psychometrics is adequate for patient satisfaction questionnaires? Patient Prefer Adherence. 2016;10: Redline S, et al.; Sleep Apnea Patient-Centered Outcomes Network. Patient partnerships transforming sleep medicine research and clinical care: perspectives from the sleep apnea patient-centered outcomes network. J Clin Sleep Med. 2016;12(7): Rothman KJ. Modern Epidemiology. 1st ed. Boston, MA: Little, Brown and Company; VanderWeele TJ, et al. A tutorial on interaction. Epidemiol Methods. 2014;3(1): Garg N, et al. Home-based diagnosis of obstructive sleep apnea in an urban population. J Clin Sleep Med. 2014;10(8): Safadi A, et al. The effect of the transition to home monitoring for the diagnosis of OSAS on test availability, waiting time, patients satisfaction, and outcome in a large health provider system. Sleep Disord. 2014;2014: Parthasarathy S, et al. A national survey of the effect of sleep medicine specialists and American Academy of Sleep Medicine Accreditation on management of obstructive sleep apnea. J Clin Sleep Med. 2006;2(2): Parthasarathy S, et al. A multicenter prospective comparative effectiveness study of the effect of physician certification and center accreditation on patient-centered outcomes in obstructive sleep apnea. J Clin Sleep Med. 2014;10(3):