Lessons learned from a qualitative evaluation of Veterans' experience with the VA tele-PAP program during the COVID pandemic.

Introduction: Obstructive sleep apnea (OSA), a disorder caused by repeated collapse of the upper airway resulting in pauses in breathing, is highly prevalent among United States (US) Veterans. Prior to the COVID pandemic, telehealth for clinical appointments and diagnostic testing for OSA was used within the U.S. Department of Veterans Affairs (VA); however, experience was limited with telehealth for initiation of PAP (Positive Airway Pressure), mailing the device to the Veteran, and educating on use through a phone or video visit. Limited literature is available evaluating patients' experience with this "tele-PAP" setup. The aim of this study is to understand the experiences of Veterans with OSA with Tele-PAP or face-to-face PAP setup ("FTF-PAP") in the US using qualitative methods. Methods: We conducted semi-structured phone interviews with a convenience sample of 40 Veterans. Interviews included six domains: delivery of PAP device, knowledge of OSA, equipment setup process, challenges using the device, preferred setup modality, and suggestions for improvement. Four investigators coded transcripts using qualitative analysis software. Themes were identified through iterative discussion and consensus. Each transcript was independently coded by at least two coders, and illustrative quotes were identified. Results: Forty Veterans with an even mix of PAP initiation modalities (Tele-PAP; FTF-PAP) were interviewed. While both delivery and training modalities were generally well received, we identified several patient factors associated with a preference for one modality over the other. These included patients' preferred learning style, the cost of traveling to the clinic, preexisting otolaryngological problems, and concurrent psychological factors such as post-traumatic stress disorder (PTSD) and claustrophobia. Regardless of modality, many Veterans had trouble recalling who to contact for troubleshooting or refills. Discussion: Based on Veteran interviews, tele-PAP initiation to treat OSA improved accessibility to sleep medicine and reduced costs for Veterans. Successful PAP therapy initiation depends on several factors that should be identified early in the PAP initiation process to enable selection of the optimal mode of care (Tele-PAP vs. FTF-PAP). Our qualitative data, while limited in number and focused on the Veteran population, document patients' acceptance of tele-PAP and illustrate that the approach is a viable alternative to F2F-PAP.