Insomnia and Insomnia-Related Care in the Department of Veterans Affairs: An Electronic Health Record Analysis

Abstract

The objective was to examine insomnia and insomnia-related care within a regional network of Department of Veterans Affairs (VA) facilities since the VA roll-out of cognitive behavioral therapy for insomnia (CBT-I) in 2011. A retrospective analysis of VA electronic health records (EHR) data from 2011 to 2019 was conducted. The annual and overall prevalence of four insomnia indicators was measured: diagnoses, medications, consultations for assessment/treatment, and participation in CBT-I. Also examined were sociodemographic and clinical differences among veterans with and without an insomnia indicator, as well as differences among the four individual insomnia indicators. The sample included 439,887 veterans, with 17% identified by one of the four indicators; medications was most common (15%), followed by diagnoses (6%), consults (1.5%), and CBT-I (0.6%). Trends over time included increasing yearly rates for diagnoses, consults, and CBT-I, and decreasing rates for medications. Significant differences were identified between the sociodemographic and clinical variables across indicators. An evaluation of a large sample of veterans identified that prescription sleep medications remain the best way to identify veterans with insomnia. Furthermore, insomnia continues to be under-diagnosed, per VA EHR data, which may have implications for treatment consistent with clinical practice guidelines and may negatively impact veteran health.

Insomnia in chronic obstructive pulmonary disease and associations with healthcare utilization and costs

“…The study also has several limitations. First, insomnia is frequently treated but not often diagnosed [ 26 ]. We attempted to address this discrepancy by identifying insomnia through prescription fills for sedative-hypnotics; however, the indication for the prescribed medications could not be determined.…”

“…Proper management of COPD and other comorbid conditions may help to resolve insomnia symptoms; however, routine assessment of insomnia and initiation of insomnia treatment should be considered. Insomnia is often undiagnosed [ 26 ] and could be a potentially modifiable target for reducing the burden of COPD on patients and healthcare systems.…”

“…From this population of patients with COPD, we identified two populations: those with insomnia and those without insomnia. Patients were classified as having insomnia if they met the following criteria: (1) insomnia diagnosis on at least one occasion between FY2012 and FY2017 based on ICD-9-CM and ICD-10-CM codes utilized in a prior study of veterans [ 26 ] or (2) had a prescription fill for > 30 doses in a given fiscal year of at least one of the following sedative-hypnotic medications: zolpidem, zaleplon, eszopiclone, temazepam, triazolam, ramelteon, trazodone, amitriptyline and doxepin (including only doses < 100 mg per day of the last three medications). The insomnia medications were selected based on clinical practice guidelines [ 27 ], on- and off-label use of medications for insomnia treatment, and everyday clinical practice.…”

“…The insomnia medications were selected based on clinical practice guidelines [ 27 ], on- and off-label use of medications for insomnia treatment, and everyday clinical practice. We chose to identify insomnia by either having a diagnosis or prescription fills for sedative-hypnotic medications as recent studies suggest that insomnia is underdiagnosed in VA electronic health records and that sedative-hypnotics are commonly prescribed in the absence of a formal insomnia diagnosis [ 26 , 28 , 29 ]. The index date for those with insomnia was the first date when dual criteria for COPD and insomnia was met.…”

Digital CBTI Hubs as a Treatment Augmentation Strategy in Military Clinics: Study Protocol for a Pragmatic Randomized Clinical Trial

“…Despite efforts to increase the number of providers trained in CBTI, geographic limitations remain [25,26]. Further, the extent to which providers outside of a specialty sleep clinic who are trained in CBTI consistently add a CBTI component to structured group or individual outpatient treatment programs is also uncertain [27]. Thus, developing and leveraging digital health tools to support the provision and implementation of reliable sleep assessments and delivery of CBTI in a wider range of clinical settings and by a broader group of providers, could help to support the insomnia treatment needs of service members.…”