Shared responsibility for managing fatigue: Hearing the pilots.

In commercial aviation, fatigue is defined as a physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase, and/or workload. The International Civil Aviation Organisation mandates that responsibility for fatigue risk management is shared between airline management, pilots, and support staff. However, to date, the majority of research relating to fatigue mitigations in long range operations has focused on the mitigations required or recommended by regulators and operators. Little research attention has been paid to the views or operational experience of the pilots who use these (or other) mitigations. This study focused on pilots' views and experiences of in-flight sleep as the primary fatigue mitigation on long range flights. It also sought information about other fatigue mitigation strategies they use. Thematic analysis was used to explore written comments from diary and survey data collected during long range and ultra-long range trips (N = 291 pilots on three different aircraft types, 17 different out-and-back trips, and four airlines based on three continents). The findings indicate that the recommended fatigue mitigation strategies on long-haul flights (particularly in-flight sleep) are effective and well-utilised, consistent with quantitative findings from the same trips. Importantly however, the analyses also highlight areas that require further investigation, including flight preparation strategies in relation to the uncertainty of in-flight break allocation. There were two strategies for sleep prior to a flight: maximising sleep if pilots were expecting later breaks in the flight; or minimising sleep if they were expecting breaks earlier or at unfavourable times in the circadian cycle. They also provide a broader view of the factors that affect the amount and quality of pilots' in-flight sleep, about which evidence has previously been largely anecdotal. The study underscores the value of including the views and experience of pilots in fatigue risk management.

Continuous positive airway pressure treatment for obstructive sleep apnoea: Maori, Pacific and New Zealand European experiences.

INTRODUCTION: Continuous positive airway pressure (CPAP) is an effective treatment of obstructive sleep apnoea (OSA), but can be limited by poor adherence. In New Zealand (NZ), ethnicity has been shown to be a predictor of CPAP adherence. This study aimed to explore Maori , Pacific and NZ European patients' experience of CPAP treatment. METHODS: Patients identifying as Maori , Pacific, or NZ European ethnicity referred for CPAP treatment for OSA attended separate, 1.5-hour group discussions facilitated by a health care worker of the same ethnic group, using an interview template. Thematic analysis was applied to the discussion transcripts independently by two investigators, following published guidelines. FINDINGS: Five Maori , five Pacific, and eight NZ Europeans participated (mean age 47, range 30-71 years, mean ± standard deviation CPAP adherence 6.32 ± 1.25 hours/night). Patients in all three groups reported that they had little knowledge of OSA or CPAP prior to treatment initiation. All groups identified barriers to treatment (both at the CPAP initiation phase and long term), reported feelings of being 'overwhelmed' with information during the initial CPAP education session, and discussed the importance of successful role models. Family and friends were generally reported as being supportive of CPAP therapy. CONCLUSION: The three groups all reported similar initial CPAP experiences, highlighting access barriers to publicly funded assessment and treatment pathways, and sleep health knowledge as key issues. Educational resources to improve access, enable self-management, and increase community awareness of OSA would help overcome some of the issues identified in this study.

Insomnia treatment in New Zealand.

AIM: To describe insomnia treatment in New Zealand and estimate the annual societal costs of insomnia among New Zealanders aged 20-59 years. METHOD: Twenty-one interviews were conducted with insomnia treatment providers in New Zealand using a snowballing recruitment method. Information from the interviews and the international literature was used to estimate treatment profiles, availability, uptake and costs, as the basis for a decision analytic model with micro costing of each potential outcome. Sensitivity analyses were conducted with 10,000 Monte Carlo simulations randomly varying between each model parameter between minimum and maximum estimates. RESULTS: The treatment provider interviews highlighted the unstructured nature of insomnia treatment in New Zealand. The net cost of treating a person with insomnia was estimated to be -$482. The net annual benefit (saving) for treating insomniacs aged between 20-59 yrs was estimated at $21.8 million. CONCLUSION: The estimated total societal costs per QALY gained by treating insomnia is substantially lower than the average QALY cost-effectiveness threshold ($6,865) of PHARMAC funding decisions for new pharmaceuticals. Thus, these analyses strongly support the cost-effectiveness of insomnia treatment.

Ethnic disparities in CPAP adherence in New Zealand: effects of socioeconomic status, health literacy and self-efficacy.

STUDY OBJECTIVES: We aimed to investigate the influence of ethnicity on adherence with continuous positive airway pressure (CPAP) in a sample of New Zealand patients. DESIGN: Observational study over one month. SETTING: A university-based sleep laboratory. PATIENTS: 126 consecutively consenting CPAP-naïve patients (19.8% Maori, mean±SD apnea-hypopnea index 57.9 ± 38.9 events/h, CPAP 11.1 ± 3.1 cm H2O). INTERVENTIONS: Patients underwent a 4-week supervised home trial of CPAP following pressure titration. MEASUREMENTS AND RESULTS: Self-identified ethnicity (Maori/non-Maori), Epworth Sleepiness Scale, Self-Efficacy Measure for Sleep Apnea, Rapid Estimate of Adult Literacy in Medicine, New Zealand Deprivation Index (calculated from residential address), New Zealand Individual Deprivation Index (validated 8-item questionnaire), educational history, income, and employment assessed at baseline were compared to objective CPAP adherence after one month. Maori demonstrated significantly lower usage than non-Maori (median 5.11, interquartile range 2.24 h/night compared with median 5.71, interquartile range 2.61 h/night, P = 0.05). There were no significant relationships between adherence and subjective sleepiness, health literacy, or self-efficacy. In a multivariate logistic regression model incorporating 5 variables (ethnicity, eligibility for government-subsidized healthcare, individual deprivation scores, income, and education), non-completion of tertiary education, and high individual socioeconomic deprivation remained significant independent predictors of average CPAP adherence not reaching ≥ 4 h (odds ratio 0.25, 95% CI 0.08-0.83, P = 0.02; odds ratio 0.10, 95% CI 0.02-0.86, P = 0.04, respectively). The overall model explained approximately 23% of the variance in adherence. CONCLUSIONS: The disparity in CPAP adherence demonstrated between Maori and non-Maori can be explained in part by lower education levels and socioeconomic status.

Narcolepsy in New Zealand: pathway to diagnosis and effect on quality of life.

AIMS: There has been no attempt to survey New Zealanders with narcolepsy to determine their pathway to diagnosis, symptoms, treatment, or quality of life. We therefore aimed to develop a comprehensive questionnaire, and compare responses on measures of daytime sleepiness and quality of life between individuals with narcolepsy and the general New Zealand population. METHODS: A questionnaire was developed encompassing descriptive information, daytime sleepiness and sleep habits, general health and wellbeing, diagnosis and treatment of narcolepsy, symptoms, and quality of life. Ninety-two individuals were identified through medical specialists and a local support group. RESULTS: Complete responses were obtained from 54 individuals (63% female, mean age 54.7 ± 18.3 years). The mean Epworth Sleepiness Scale score was 16.4 ± 5.4 (/24). Symptoms first appeared at 20.7 ± 9.7 years of age on average, although diagnosis did not take place until 33.4 ± 13.8 years of age. Individuals with narcolepsy reported substantially lower health-related quality of life than the general New Zealand population. Less than half of those diagnosed with narcolepsy had undergone an objective evaluation including a sleep study. CONCLUSIONS: New Zealanders with narcolepsy suffer from an excessive level of daytime sleepiness, and have significantly poorer health-related quality of life than the general population. There are a number of inconsistencies between the diagnostic pathway in New Zealand and best-practice guidelines for diagnosis and treatment.

Insomnia - treatment pathways, costs and quality of life.

BACKGROUND: Insomnia is perhaps the most common sleep disorder in the general population, and is characterised by a range of complaints around difficulties in initiating and maintaining sleep, together with impaired waking function. There is little quantitative information on treatment pathways, costs and outcomes. The aims of this New Zealand study were to determine from which healthcare practitioners patients with insomnia sought treatment, treatment pathways followed, the net costs of treatment and the quality of life improvements obtained. METHODS: The study was retrospective and prevalence based, and was both cost effectiveness (CEA) and a cost utility (CUA) analysis. Micro costing techniques were used and a societal analytic perspective was adopted. A deterministic decision tree model was used to estimate base case values, and a stochastic version, with Monte Carlo simulation, was used to perform sensitivity analysis. A probability and cost were attached to each event which enabled the costs for the treatment pathways and average treatment cost to be calculated. The inputs to the model were prevalence, event probabilities, resource utilisations, and unit costs. Direct costs and QALYs gained were evaluated. RESULTS: The total net benefit of treating a person with insomnia was $482 (the total base case cost of $145 less health costs avoided of $628). When these results were applied to the total at-risk population in New Zealand additional treatment costs incurred were $6.6 million, costs avoided $28.4 million and net benefits were $21.8 million. The incremental net benefit when insomnia was "successfully" treated was $3,072 per QALY gained. CONCLUSIONS: The study has brought to light a number of problems relating to the treatment of insomnia in New Zealand. There is both inadequate access to publicly funded treatment and insufficient publicly available information from which a consumer is able to make an informed decision on the treatment and provider options. This study suggests that successful treatment of insomnia leads to direct cost savings and improved quality of life.

Sleep at simulated 2438 m: effects on oxygenation, sleep quality, and postsleep performance.

INTRODUCTION: Crewmembers on ultra long-range commercial flights have the opportunity for rest and sleep in onboard areas in which the barometric pressure is 75.3 kPa (565 mmHg) or higher, equivalent to a terrestrial altitude of 2438 m (8000 ft) or lower. Sleep at higher altitudes is known to be disturbed, resulting in postsleep neurobehavioral performance decrements. We investigated the effects of sleep at 2438 m on oxygen saturation, heart rate, sleep quantity, sleep quality, postsleep neurobehavioral performance, and mood. METHODS: Twenty men, 30-56 yr of age, participated in a blinded cross-over investigation conducted in a hypobaric chamber to compare the effects of sleep at altitude (ALT, 2438 m) and ground level (GND, 305 m). RESULTS: SpO2 measured before sleep was significantly lower at ALT than at GND, 90.7 +/- 2.0% (average +/- SD) and 96.2 +/- 2.0%, respectively. During sleep, SpO2 decreased further to 86.1 +/- 2.0% at ALT, and 92.3% +/- 2.0% at GND. The percent of time during which SpO2 was below 90% was 44.4% (3.6-86.9%) at ALT and 0.1% (0.0-22.9%) at GND. Objective and subjective measurements of sleep quantity and quality did not differ significantly with altitude, nor did postsleep neurobehavioral performance or mood. DISCUSSION: The absence of significant changes in sleep and post-sleep neurobehavioral performance associated with pronounced oxygen desaturation during sleep was unexpected. Further study is needed to determine if the same effects occur in women and to characterize the changes in respiratory physiology that occur during sleep at 2438 m in both sexes.