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Background: Difficulty falling asleep and staying asleep are common problems that affect over 30 million Americans. Additionally, we know that military personnel and Veterans often have insomnia problems post deployment. Home sleep monitors can be used to diagnose sleep disorders and determine if the sleep issue cause is a physical issue, such as obstructive sleep apnea. Some non-physiological causes may be improved by focusing on behavioral change, which can be assisted by mobile health (mHealth) technologies. In addition, mHealth apps are an increasingly popular method to deliver behavioral change interventions for a variety of conditions, with the cognitive behavioral therapy for Insomnia Coach app (CBT-i Coach) being particularly popular (it has been downloaded over 80,000 times in 86 countries). Objective: In this pilot trial we assessed the usability and feasibility of mobile health information technologies (HITs) designed to reduce sleep problems in post-9/11 Veterans with chronic insomnia. We used the CBT-i Coach mobile app (based on cognitive behavioral therapy for insomnia) and supplemented it with usage instructions to enhance self-management. Participants also used a home-based sleep monitor (WatchPAT) to obtain objective sleep data to assess possible sleep apnea and to provide subjects with objective data to motivate behavioral change. Methods: Thirty-eight post-9/11 Veterans met criteria for insomnia on the Insomnia Severity Index (ISI). We assessed feasibility and usability of the HITs over a 6-week intervention with a pre-post design. The WatchPAT was used to screen for sleep apnea, and those with moderate to severe apnea were withdrawn from the trial and referred for further assessment. Participants were given a self-management guide which detailed when to use different elements of the CBT-i Coach app, including guidance to complete a sleep diary each morning. Assessments were completed at the beginning, middle, and end of the 6-week intervention. Results: Of the 38 enrolled, 18 participants were withdrawn for moderate or severe sleep apnea as measured by the WatchPAT, and 9 withdrew for personal reasons. Post-intervention qualitative interviews revealed that many participants found both the CBT-i Coach app and WatchPAT easy to use. Participants also liked tracking their daily sleep and seeing graphical results of their sleep changes over time, with only 2 of the final 11 participants completing CBT-I Coach sleep diaries less than 85% of the time. Exploratory analyses on the 11 completers also revealed significant but modest differences between baseline ISI scores (M=16.63, SD = 5.55) and post-intervention follow-up (M=12.82, SD = 3.74; t (10) = 4.14, P

Background: The Veterans Health Administration (VA) strives to increase access and patient-centered care. “Annie” is VA’s first national automated text messaging system aimed to give patients a self-management tool to take charge of their health and become more engaged in their own care. We examined early patient/provider experiences with Annie as part of a limited field test and subsequently examined if the texting system would improve outcomes. Objective: To understand early experiences using Annie and subsequently pilot and evaluate automated text messages to improve Veteran self-management and adherence to medications and appointments. Methods: We conducted a national two-phase study in VA. In Phase 1, five sites conducted limited field testing and engaged 43 respondents (23 patients, 20 providers). Respondents completed surveys and qualitative interviews focused on provider adoption, integration into clinic workflow, patient ease of use, perceptions of program effectiveness, and barriers to use. In Phase 2, seven sites implemented Annie. Four intervention sites received a toolkit of materials and facilitation calls intended to enhance Annie implementation. An additional three sites received Annie without implementation support and two matched comparison sites did not receive Annie. A mixed-methods evaluation is underway, and includes pre and post patient and provider surveys and interviews, medical chart abstraction, and process measure analysis. Results: Analysis of Phase 1 data revealed that all participating Veterans felt positive about their ability to receive a text message. All but one Veteran used a smart phone and had been using a cell phone for four years or more, with 83% sending and receiving text messages several times a day. Sixty-seven percent of Veterans agreed that Annie was easy to use, 11% felt they needed to learn a lot to use Annie, 46% felt Annie helped them take better care of their health and become more connected with their clinical team, and 91% would recommend Annie to another Veteran. Among providers, 67% agreed leadership and management would support Annie implementation and 60% would recommend Annie to another provider. Analysis of Phase 1 interviews revealed five lessons to support implementation: 1) the importance of identifying a resource person who is able to bridge technology and clinical issues; 2) promoting the evidence, innovation, and patient empowerment associated with Annie to providers; 3) focusing early Annie enrollment efforts on patients comfortable with technology and who do not need intensive follow up; 4) advertising the adaptability of Annie texting protocols; and 5) the value of Annie as a health coaching tool. In Phase 2 of Annie implementation we are collecting data on patient and provider experiences with Annie, including usability, clinical workflow fit, and clinical benefits such as improved medication adherence and fewer missed labs and visits. Conclusions: Technologies develop rapidly and hold the allure of efficiently doing things that were once cumbersome or not possible to do in a busy clinical setting. The Annie automated text-messaging system may be able to help in this regard by offering support through self-management, coaching, and education outside of clinical encounters. Findings will inform iterative development of Annie and its national rollout. [iproc 2017;3(1):e55]

Background: Sleep disorders are a serious national health issue. Insomnia and sleep apnea are the most commonly diagnosed, with serious negative impacts including increased mortality, performance problems, accidents, and health-care utilization. Given a high level of apnea in persons with insomnia (29%), the incorporation of objective measures of sleep for at-home sleep monitoring for clinical trials may assist in potential sleep apnea detection and treatment for persons with insomnia. This may be particularly important for military personnel, as a 372% increase in insomnia encounters and a 517% increase in apnea encounters was recently reported for this population. Objective: The primary goal of this pilot trial was to assess usability and feasibility of mobile health information technologies (HITs) designed to reduce insomnia in post-9/11 Veterans. As this pilot focused on insomnia treatment with HITs, veterans with an objective sleep measure indicating moderate to severe sleep apnea were withdrawn. Participants used a home-based sleep monitor (WatchPAT) which has been validated against polysomnography and derives the Apnea-Hypopnea Index (AHI) from arterial tonometry, pulse oximetry and snoring. We report here on the positive screening rate for sleep apnea in our sample of Veterans with insomnia, a secondary but clinically significant finding within this HIT pilot. Methods: Thirty-eight Veterans were enrolled who met criteria for insomnia on the Insomnia Severity Index, with 33 Veterans in total engaging in the first night of sleep monitoring. A WatchPAT device provided screening results based on AHI scores over 1-2 nights of home use. Those with sleep apnea above the mild range, i.e., AHI > 15 (moderate or severe), were withdrawn from the trial and referred for further assessment. Results: Of the 33 veterans who completed the first night of sleep monitoring at home, a total of eighteen (54.5%) were identified as having moderate to severe sleep apnea as indicated through WatchPAT measurement. Demographic predictors of apnea were also explored, as apnea rates increase with age and occur more frequently in higher weight individuals. Results were unexpected given the mean age of the final sample (43.8 years, SD = 11.3), as age did not differ between those with no/mild apnea vs. moderate/severe apnea (t (31) = 0.89, ns). However, those with moderate/severe apnea had a significantly higher body mass index (BMI; 30.7, SD = 4.5 vs. 26.8, SD = 2.9; t (31) = 2.88, P