Telehealth, Telemedicine, and Obstructive Sleep Apnea

Patient Engagement and Provider Effectiveness of a Novel Sleep Telehealth Platform and Remote Monitoring Assessment in the US Military: Pilot Study Providing Evidence-Based Sleep Treatment Recommendations

BACKGROUND

Sleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care.

OBJECTIVE

The purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers.

METHODS

Patients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey.

RESULTS

In total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system.

CONCLUSIONS

Military patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

Integrating digital inhalers into clinical care of patients with asthma and chronic obstructive pulmonary disease

Modernizing inhaled medications through digital technology can help address persistent problems of non-adherence and poor inhaler technique in patients with obstructive lung diseases. With a growing body of supportive clinical studies, advances in digital inhaler sensors and platforms, greater support from payers and healthcare organizations, significant growth with these technologies is expected. While all digital (smart) inhalers record adherence, these are distinguished by their compatibility with commercial inhalers, capabilities to guide inhaler technique, use of patient-reported outcomes, and user-friendliness for both the healthcare professional (HCP) and patient. Due to the complexity and novelty of employing digital inhalers, collaboration with multiple entities within health systems is necessary and a well-planned integration is needed. For HCPs and patients, cybersecurity and privacy are critical, it will require review by each healthcare organization. In the US, some payers reimburse for remote monitoring using digital inhalers, but reimbursement is currently unavailable in other countries. There are several models for remote patient care, as employing an active, ongoing digital interface between the HCP and patient or they may choose to only review data at clinical encounters. Personalization of therapies and feedback are key to success. While digital inhaler malfunction uncommonly occurs, patient attrition over a year is significant. Some patients will be challenged to use digital platforms or have the necessary technology. Additional research is needed to address cost-effectiveness, in vivo accuracy of inspiratory measurement capable devices, ability to teach inhaler technique, their application for monitoring lung function, and lastly real-world adoption and implementation in routine clinical practice.

Brazilian Thoracic Association Consensus on Sleep-disordered Breathing

Sleep is essential for the proper functioning of all individuals. Sleep-disordered breathing can occur at any age and is a common reason for medical visits. The objective of this consensus is to update knowledge about the main causes of sleep-disordered breathing in adult and pediatric populations, with an emphasis on obstructive sleep apnea. Obstructive sleep apnea is an extremely prevalent but often underdiagnosed disease. It is often accompanied by comorbidities, notably cardiovascular, metabolic, and neurocognitive disorders, which have a significant impact on quality of life and mortality rates. Therefore, to create this consensus, the Sleep-Disordered Breathing Department of the Brazilian Thoracic Association brought together 14 experts with recognized, proven experience in sleep-disordered breathing.

Changes in the societal burden caused by sleep apnoea in Finland from 1996 to 2018: A national registry study

Background

In the current century, sleep apnoea has become a significant public health problem due to the obesity epidemic. To increase awareness, improve diagnostics, and improve treatment, Finland implemented a national sleep apnoea programme from 2002 to 2010. Here, we present changes in the societal burden caused by sleep apnoea from 1996 to 2018.

Methods

National register data were collected from the Care Register for Health Care, Statistics Finland, the Social Insurance Institution of Finland, and the Finnish Centre for Pensions. Disease prevalence, use of healthcare and social services, and societal costs were estimated.

Findings

The number of sleep apnoea patients increased in secondary care from 8 600 in 1996 to 61 000 in 2018. There was a continuous increase in outpatient visits in secondary care from 9 700 in 1996 to 122 000 in 2018 (1 160%) and in primary care from 10 000 in 2015 to 29 000 in 2018 (190%). Accordingly, the cumulative annual number of days off work for sleep apnoea increased from 1 100 to 46 000. However, disability pensions for sleep apnoea decreased from 820 to 550 (33%) during the observation period. Societal costs per patient decreased over 50% during the observation period (€2 800 to €1 200).

Interpretation

The number of sleep apnoea patients in Finland increased remarkably during the observation period. To control this burden, diagnostic methods and treatment were revised and follow up was reorganised. Consequently, there was a significant decrease in societal costs per patient. The decrease in disability pensions suggests earlier diagnosis and improved treatment. The national sleep apnoea programme was one of the initiators for these improved outcomes.

Funding

The Finnish Institute for Health and Welfare and the Hospital District of Helsinki and Uusimaa (HUH), Helsinki, Finland.

Telemetric Assessment of Continuous Positive Airways Pressure (CPAP) Effectiveness and Adherence in Obstructive Sleep Apnea during COVID-19 Pandemic

Obstructive sleep apnea is the most common sleep-related breathing disorder. In the pandemic times of the new coronavirus SARS-CoV-2, CPAP (Continuous Positive Airway Pressure) therapy of obstructive sleep apnea became even more challenging. After the pandemic outbreak in March 2020, most CPAP treatment recommendations changed because of rising concerns about CPAP usage safety for patients and their families. Therefore, we examined the effectiveness of CPAP and adherence to the therapy of 149 adults with obstructive sleep apnea in the period of two years from 4 March 2019 to 3 March 2021 (before pandemic breakout and during the first year of pandemic). Data on CPAP parameters and adherence to therapy were obtained via a telemetric system. Together, our results demonstrated that the COVID-19 pandemic had no significant impact on CPAP therapy parameters and adherence in whole study group. However, detailed analysis acknowledged that some demographic and clinical features influenced CPAP therapy. The results showed that across subgroups of patients differentiated on the basis of age, gender, co-existing diabetes mellitus, or hypertension, the COVID-19 pandemic seemed to affect CPAP effectiveness. Our results provide a good starting point for discussion on CPAP therapy recommendations during pandemic times.

Towards remote leadership in health care: Lessons learned from an integrative review

AIM

To gather and synthesize current empirical evidence on remote leadership and to provide knowledge that can be used to develop successful remote leadership in health care.

DESIGN

A integrative literature review with an integrated mixed methods design.

DATA SOURCES

The literature search was carried out between February and March 2019 in the CINAHL, Medline (Ovid), PsycInfo, Scopus, SocIndex, Web of Science and Business Source Elite (EBSCO) databases.

REVIEW METHODS

An integrative review was conducted to identify relevant studies published from 2010 to 2019. Of the 88 eligible studies, 21 studies met the inclusion criteria and were selected for the final review. The included studies were analysed using mixed methods synthesis, more specifically, data-based convergent synthesis.

RESULTS

The performed analysis identified three main themes: characteristics of successful remote leadership; enhancing the leader-member relationship; and challenges in remote leadership. The first theme included the following sub-themes: remote leader characteristics; trust; communication; and leading the team culture. The second theme covered the importance of organizing regular face-to-face meetings, clear communication policies and the connection between positive team spirit and good remote leader-member relationship, while the third theme emphasized leader- and member-related challenges for remote work.

CONCLUSIONS

As none of the identified studies had been conducted in a health care setting, future remote leadership research must also specifically consider the health care context. This will be pivotal to exploring how remote work can foster a safe workplace culture, empower health care workers, increase job satisfaction and improve patient outcomes.

IMPACT

Remote leadership has rarely been studied in the health care context. Trust, communication, team spirit and a leader's characteristics are central to remote leadership, a finding which is useful for re-evaluating and improving the current culture at health care organizations.

Continuum of care for patients with obstructive sleep apnea after one year from the COVID-19 pandemic onset: no time for further delays: practical issues for a safe and effective management

Since the SARS-CoV-2 pandemic onset, many routine medical activities have been put on hold and this has deeply affected the management of patients with chronic diseases such as obstructive sleep apnea. Untreated OSA is associated with increased mortality and difficulties in social functioning. A delay in initiating treatment may therefore have harmful consequences. Between February and April 2020, the so-called first wave of the pandemic, the overall activity of sleep centers in Europe was reduced by 80%. As the international infection control authorities released guidelines for SARS-CoV-2 outbreak control, many of the national sleep societies provided strategies for a gradual re-opening of sleep facilities. Most of these strategies were not evidences-based and, in a climate of general concern, worldwide it was strongly advised to post-pone any non-urgent sleep-related procedure. Despite the initial idea that the outbreak could be transient, after one year it is still ongoing and the price we are paying, not only includes deaths caused by COVID-19, but also deaths caused by missed or late diagnosis. As further delays in diagnosing and treating patients with sleep apnea are no more acceptable, a new arrangement of sleep facilities and resources, in order to operate safely and effectively, is now mandatory. In this article, we review most recent literature and guidelines in order to provide practical advice for a new arrangement of sleep laboratories and the care of patients with obstructive sleep apnea after one year from the onset of the COVID-19 pandemic.

Telemedicine in Sleep-Disordered Breathing: Expanding the Horizons

Interest in telemedicine has increased exponentially. There is a growing body of published evidence on the use of telemedicine for patients using continuous positive airway pressure. Telemedicine-ready devices can support the transmission on use time, apnea-hypopnea index, and leakage. This approach enables early activation of troubleshooting. Automated, personalized feedback for patients and patient access to their own data provide unprecedented opportunities for integrating comanagement approaches, multiactor interactions, and patient empowerment. Telemedicine is likely cost effective, but requires better evidence. Notwithstanding barriers for implementation that remain, telemedicine has to be embraced, leaving the physician and patient to accept it or not.

The use of telemedicine for the diagnosis and treatment of sleep disorders: an American Academy of Sleep Medicine update

NONE

The COVID-19 pandemic led to widespread use of telemedicine and highlighted its importance in improving access to sleep care and advocating for sleep health. This update incorporates the lessons learned from such widespread utilization of telehealth to build on the American Academy of Sleep Medicine's 2015 position paper on the use of telemedicine for diagnosing and treating sleep disorders. Important key factors in this update include an emphasis on quality and value, privacy and safety, health advocacy through sleep telemedicine, and future directions.

Sleep Neurology's Toolkit at the Crossroads: Challenges and Opportunities in Neurotherapeutics Lost and Found in Translation

We find ourselves at our present crossroads with a well-traveled toolkit, perhaps too well worn but with aspirational hopes and dreams for the field of sleep neurotherapeutics. This volume is organized thematically into six topical domains that parallel the major subspecialty areas of contemporary clinical sleep neurology practice, as well as novel directions and opportunities. The issue begins with an overview of the central disorders of hypersomnolence, including narcolepsy, idiopathic hypersomnia and other hypersomnia disorders, and the related use of the entire broad range of stimulant and wake-promoting pharmacotherapies. Next, the range of behavioral therapies, application of light and light restriction and melatonin therapies, and hypnotic pharmacotherapies useful in insomnia and circadian sleep-wake rhythm disorders are reviewed, followed by an overview of treatment options for sleep-related breathing disorders including positive airway pressure and the novel approach of hypoglossal neurostimulation for obstructive sleep apnea. The parasomnias and sleep-related movement disorders, including NREM disorders of arousal, REM parasomnias (nightmares and isolated sleep paralysis and idiopathic/isolated REM sleep behavior disorder, and restless legs syndrome are then discussed, and the applications of sleep neurotherapeutics in sleep and neurological disease are reviewed, including neurodevelopmental, epileptic, autoimmune encephalopathies, and neurodegenerative diseases. Last, the novel directions and opportunities in sleep neurology offered by cannabinoid therapies and machine learning/artificial intelligence methodology conclude this comprehensive survey of contemporary sleep neurology. We hope that you find this volume to be a useful and inspirational support tool for the work that matters most, your care of all our sleep neurology patients in the clinics.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.