Development of a Novel Shared Care Intervention to Address Obstructive Sleep Apnea in Rural West Virginia

Rationale: There is a critical need to create sustainable interventions for the nearly 80% of patients with undiagnosed obstructive sleep apnea (OSA), particularly in rural communities where notable health disparities exist. Objectives: The objective of this study is to use implementation science and community-engaged research methods to address OSA care disparity in West Virginia by designing an intervention to support primary care providers (PCPs) who treat patients in rural West Virginia. Our overall project is grounded in context-sensitive approaches to address the unique challenges of OSA management in the rural primary care setting. Here we describe the preimplementation work conducted to identify the determinants of implementation in rural settings and the selection of strategies that led to the initial program and will inform our prospective implementation effectiveness study. Methods: The Veterans Affairs Quality Enhancement Research Initiative implementation roadmap considers all levels of a healthcare system and provides a pragmatic approach to program implementation, which is carried out through three phases: preimplementation, implementation, and sustainment. Barriers and facilitators were mapped to the domains of the Consolidated Framework for Implementation Research (CFIR) to inform our implementation plan. We derived Expert Recommendations for Implementing Change strategies from the CFIR mapping exercise to identify the strategies that would improve implementation outcomes in rural primary care. Results: Themes identified from our previous mixed-methods community engagement study with PCPs were reviewed and mapped to CFIR domains and coded as implementation barriers or facilitators. Facilitators included provider recognition of the relative importance of OSA management, provider knowledge about OSA, and perceived patient receptivity to having a PCP evaluate and treat OSA. Predominant barriers included PCPs' relatively low self-reported confidence in their ability to identify or manage OSA, challenges with clinical process and workflow that facilitate program adoption, and a relative lack of community-based resources or networks to support patients in such a program. One major barrier mapped to the CFIR domain "inner setting" was lack of clinical processes to support OSA screening, testing, and referrals. The implementation strategy category that was identified to be most important for the OSA care program implementation was "Develop stakeholder interrelationships." Other important strategy categories included "Provide interactive assistance" and "Support for clinicians" in the targeted rural communities. Conclusions: Leveraging a community-engaged approach and using implementation science informed the development and implementation of a novel OSA program to educate and support PCPs in OSA diagnosis and management that is tailored to the realities of rural primary care. This program, the West Virginia Obstructive Sleep Apnea Academic Mentoring Partnership, is well positioned to address the care disparity for OSA in rural communities in a sustainable way.