What Is the Future of Sleep Medicine in the United States?

Patient-reported Differences in Obstructive Sleep Apnea Care between Jurisdictions with and without Government Funding for Continuous Positive Airway Pressure

Rationale: Funding for obstructive sleep apnea (OSA) treatment may impact how patients access care, wait times, and costs of care. Objectives: The aim of this study was to compare differences in diagnosis and treatment of OSA between Canadian jurisdictions with and without public funding for continuous positive airway pressure (CPAP). Methods: We administered an anonymous internet survey to Canadian adults reporting a physician diagnosis of OSA. Responses were categorized on the basis of whether the respondent's province provided full or partial funding for CPAP therapy for all patients. We assessed wait times for diagnosis and treatment, patient-borne costs, and model of care delivery compared between jurisdictions with and without universal CPAP funding. Results: We received 600 responses representing all Canadian provinces and territories. The median (interquartile range) age was 59 (49-66) years; 57% were male, and 21% were from rural settings. Patients living in provinces without public CPAP funding (n = 419) were more likely to be diagnosed using home sleep apnea testing (69% vs. 20%; P = 0.00019). Wait times were similar after adjustment for demographics, disease characteristics, and model of care. Although patient-borne costs of care were similar between jurisdictions, patients from regions without CPAP funding reported that cost had a greater influence on the choice of therapy. Sleep specialists were more commonly involved in OSA care in regions with CPAP funding. There was no difference in the current use of therapy between jurisdictions with and without public funding. Conclusions: This survey study demonstrates that public funding for CPAP therapy impacts how Canadians access OSA care but is not associated with differences in wait times or costs. Future research is required to determine the impact of different funding models for OSA care on clinical outcomes.

National strategy on the integration of sleep and circadian rhythms into public health research and policies: Report from the Canadian Sleep and Circadian Network

Scientists in sleep and circadian rhythms, public health experts, healthcare providers, partners, and stakeholders convened in 2020 for a 2-day meeting organized by the Canadian Sleep and Circadian Network to develop a national strategy for the integration of sleep and circadian rhythms into public health and policies in Canada. The objective of this paper is to present the national strategy that emerged from this meeting of 60 participants from across Canada. The meeting focused on 4 key target priorities: (1) atypical working schedules, (2) sleep and circadian rhythms of children and adolescents, (3) insomnia, and (4) impact of sleep apnea on health. Following constructive discussions over 2 days, it was decided that the following 4 strategic objectives should be prioritized to accelerate the integration of sleep and circadian rhythms into public health policies in Canada: (1) Increase public health sleep and circadian rhythm research, (2) Increase public health education and knowledge mobilization on sleep, (3) Inform and support public health sleep interventions and policies, and (4) Promote sleep health training. The participants recommended that research and public health efforts should address the needs along the continuum of sleep health. The committee noted that strategies and interventions could differ across contexts, settings, sectors, and jurisdictions. The national strategy also identified high-priority research questions in public health and recommended mechanisms to build research capacity, providing a path forward for the integration of sleep and circadian rhythms into public health research and policies.

Clinical Predictors of Mixed Apneas in Patients with Obstructive Sleep Apnea (OSA)

Purpose

Mixed events in obstructive sleep apnea (OSA) patients (mixed-OSA) indicate respiratory regulation instability and are essential for OSA pathogenesis and prognosis. It also shows a decreased compliance with continuous positive airway pressure (CPAP). Using predictors to identify mixed-OSA has significant clinical guidance for OSA precise diagnosis and treatment. This study aimed to establish a simple and accessible method for rapid screening of mixed-OSA, thus promoting OSA precise diagnosis.

Patients and Methods

A total of 907 patients with suspected OSA were screened, of which 513 OSA patients, including 344 with pure-OSA and 169 with mixed-OSA, were finally included in the study. The clinical characteristics and polysomnography (PSG) parameters of the two OSA groups were compared. Multivariate logistic regression analysis was used to investigate the factors affecting the morbidity of mixed-OSA. The receiver operating characteristic (ROC) curve was used to explore if some convenient PSG parameters can be used to predict mixed-OSA.

Results

About 33% of OSA patients were identified as mixed-OSA. Multivariate logistic regression analysis showed that apnea hypopnea index (AHI) and lowest oxygen saturation (LSO2) were independently associated with mixed-OSA after adjusting for age, sex, body mass index (BMI), smoking, drinking, hypertension, and Epworth Sleepiness Score (ESS) (AHI: OR=1.046, 95% CI 1.032-1.060, P < 0.001; LSO2: OR=0.958, 95% CI 0.936-0.981, P < 0.001). ROC curve analysis showed that AHI > 47 or LSO2 < 77% indicated mixed-OSA. The sensitivity and specificity of AHI> 47 was 0.952 and 0.652, respectively, and 0.822 and 0.675 for LSO2 < 77%, respectively.

Conclusion

Our research found that AHI > 47 or LSO2 < 77% are independently associated with mixed-OSA and can be used to quickly identify the occurrence of mixed-OSA. Therefore, this study can help detect mixed-OSA and precise individual diagnosis of OSA patients.

Primary vs. Specialist Care for Obstructive Sleep Apnea: A Systematic Review and Individual Participant Data Level Meta-Analysis

RATIONALE

Primary care clinicians may be well placed to play a greater role in obstructive sleep apnea management.

OBJECTIVES

To evaluate the outcomes and cost-effectiveness of sleep apnea management in primary versus specialist care, using an individual-participant data meta-analysis to determine whether age, gender, severity of OSA and daytime sleepiness impacted outcomes.

METHODS

Data sources were CINAHL, CENTRAL, MEDLINE Ovid SP, Scopus, ProQuest, US NIH Ongoing Trials Register, ISRCTN registry [inception until 09-25-2019]. Hand-searching was undertaken. Two authors independently assessed articles and included trials that randomized adults with a suspected diagnosis of sleep apnea to primary versus specialist management within the same study and reported daytime sleepiness using the Epworth Sleepiness Scale (range 0-24; >10 indicates pathological sleepiness; minimum clinically important difference two units) at baseline and follow-up.

RESULTS

The primary analysis combined data from 970 (100%) participants (four trials). Risk of bias was assessed (Cochrane Tool). One-stage intention-to-treat analysis showed a slightly smaller decrease in daytime sleepiness (0.8; 0.2 to 1.4), but greater reduction in diastolic blood pressure in primary care (-1.9; -3.2 to -0.6 mmHg), with similar findings in the per protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (-$448.51 USD), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for sub-groups in both management settings.

CONCLUSIONS

Similar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea. Registration: PROSPERO (CRD42020154688).

Perspectives on primary care management of obstructive sleep apnea: a qualitative study of patients and health care providers

STUDY OBJECTIVES

Difficulties in providing timely access to care have prompted interest in primary care delivery models for obstructive sleep apnea (OSA). Sustainable implementation of such models requires codesign with input from key stakeholders. The purpose of this study was to identify patient and provider perspectives on barriers and facilitators to optimal, patient-centered management of OSA in a primary care setting.

METHODS

This study was conducted in Alberta, Canada. Data from key stakeholders were collected through an online survey of primary care providers (n = 119), focus groups and interviews with patients living with OSA (n = 28), and workshops with primary care and sleep providers (n = 36). Quantitative survey data were reported using descriptive statistics, and qualitative data were analyzed using an inductive thematic approach.

RESULTS

Several barriers were identified, including poor specialist access, variable primary care providers knowledge of OSA, and lack of clarity about provider roles for OSA management. Barriers contributed to patients being poorly informed about OSA, leading them to separate OSA from their overall health and eroding trust in the system. Suggestions for improvement included integration of care providers in a comprehensive model of care, facilitated by improved system navigation and more effective use of technology. Themes were consistent across data collection methods and between stakeholder groups.

CONCLUSIONS

Although primary care delivery models may improve access to OSA management, stakeholders identified important challenges in the current system. Innovative models of care, developed with input from patients and providers, may mitigate barriers and support optimal primary care management of OSA.

Subspecialty training of neurology residents and junior neurologists in the Baltic States

BACKGROUND

Neurology is a field of increasing subspecialization. There is no published data regarding the proportion of neurology subspecialists in the Baltic States. The aim of this cross-sectional study was to identify factors associated with neurology subspecialty choice, to examine possible differences between neurology residents' and junior neurologists' view of subspecialty, and to assess perceived subspecialty acquisition opportunities and subspecialty attractiveness.

METHODS

The research was conducted as an anonymous online survey between December 28, 2020, and January 24, 2021 of neurology residents and neurologists who completed their residency during the last 5 years in the Baltic States.

RESULTS

In total, 72 residents and 65 neurologists participated. "Cerebrovascular diseases" and "multiple sclerosis and autoimmune diseases of the nervous system" were rated as the two most attractive subspecialties by residents, whereas "headache" and "clinical neurophysiology" were the most attractive among junior neurologists. "Vertigo and dizziness" and "dementia" were ranked the least attractive among both groups. "Cerebrovascular diseases" were perceived as having the most acquisition opportunities. The two most common determinants of subspecialty choice were "medical content of the subspecialty" and "influence of mentor during undergraduate studies or residency".

CONCLUSIONS

Two-thirds of junior neurologists subspecialize in at least one subspecialty, and one-third of residents are already determined to pursue subspecialty training. Junior neurologists rated most outpatient-related subspecialties as more attractive than neurology residents. Between the Baltic States' universities, there was a significant difference in the number of residents who were determined to pursue subspecialty training.

Alternative Care Pathways for Obstructive Sleep Apnea and the Impact on Positive Airway Pressure Adherence: Unraveling the Puzzle of Adherence

The high burden of obstructive sleep apnea (OSA), combined with inadequate supply of sleep specialists and constraints on polysomnography resources, has prompted interest in alternative models of care to improve access and treatment effectiveness. In appropriately selected patients, ambulatory clinical pathways and use of nonphysicians or primary care providers to manage OSA can improve timely access and costs without compromising adherence or other clinical outcomes. Although initial studies show promising results, there are several potential barriers that must be considered before broad implementation, and further implementation research and economic evaluation studies are required.

Dental sleep medicine: Time to incorporate sleep apnoea education in the dental curriculum

Dental sleep medicine is a discipline that includes conditions such as sleep breathing disorders (eg snoring and sleep apnoea), sleep bruxism, orofacial pain and sleep-related complaints, and to some extent gastro-oesophageal reflux disorder and/or insomnia. Obstructive sleep apnoea (OSA) is a life-threatening condition that dentists need to identify and manage when indicated in order to increase patient well-being and to be taken in consideration in the dental curriculum. The main objective of this paper is to highlight the relevance of dental sleep medicine in the context of dental education, and to discuss potential educational content for integration in the dental curriculum with a focus on OSA, a condition that is not yet integrated in many dental training curricula around the world.

Enhancing the patient and family experience during pediatric sleep studies

STUDY OBJECTIVES

Pediatric polysomnography can result in suboptimal patient and provider (physician and advanced practice provider) experiences. We embarked on a project aimed at increasing the proportion of maximal satisfaction survey scores by a minimum of 10% in 1 year without adding personnel or major expenses.

METHODS

We used a Six Sigma framework, define, measure, analyze, improve, and control (DMAIC), to conduct our analysis. For measurement, we designed a project-specific survey that was given to caregivers of children who underwent PSG in February 2018 and repeated the survey after interventions in February 2019. Lean and Six Sigma quality improvement tools were used to define important processes that influence patient satisfaction, including: supplier, input, process, output, customer, and requirements (SIPOC-R); journey mapping; 1-2-4-All brainstorming; and views solicited from our center's Patient and Family Advisory Council. We analyzed the relationships between identified processes and outcomes using usual descriptive statistics. We prioritized interventions using a Kano model and a quality function deployment (QFD) technique to rank priorities for interventions. Multiple opportunities to improve patient and family satisfaction before, during, and after a pediatric polysomnography were identified. Many were simple, one-step interventions and were implemented simultaneously. For those that required substantial training and/or scheduling changes, pilots were performed and plan, do, study, act (PDSA) cycles were used to check effectiveness.

RESULTS

After implementation, top box scores rose 20%, from 51% (n = 47) in 2018 to 71% (n = 50) in 2019.

CONCLUSIONS

Various quality improvement techniques employed in business, engineering, and manufacturing were used to identify and address areas of improvement in the pediatric polysomnography experience.

Critical Issues in Dental and Medical Management of Obstructive Sleep Apnea

This critical review focuses on obstructive sleep apnea (OSA) and its management from a dental medicine perspective. OSA is characterized by ≥10-s cessation of breathing (apnea) or reduction in airflow (hypopnea) ≥5 times per hour with a drop in oxygen and/or rise in carbon dioxide. It can be associated with sleepiness and fatigue, impaired mood and cognition, cardiometabolic complications, and risk for transportation and work accidents. Although sleep apnea is diagnosed by a sleep physician, its management is interdisciplinary. The dentist’s role includes 1) screening patients for OSA risk factors (e.g., retrognathia, high arched palate, enlarged tonsils or tongue, enlarged tori, high Mallampati score, poor sleep, supine sleep position, obesity, hypertension, morning headache or orofacial pain, bruxism); 2) referring to an appropriate health professional as indicated; and 3) providing oral appliance therapy followed by regular dental and sleep medical follow-up. In addition to the device features and provider expertise, anatomic, behavioral, demographic, and neurophysiologic characteristics can influence oral appliance effectiveness in managing OSA. Therefore, OSA treatment should be tailored to each patient individually. This review highlights some of the putative action mechanisms related to oral appliance effectiveness and proposes future research directions.

Digital Health and Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis

STUDY OBJECTIVES

Sleep disorders in most individuals remain undiagnosed and without treatment. The use of novel tools and mobile technology has the potential to increase access to diagnosis. The objective of this study was to perform a quantitative and qualitative analysis of the available literature evaluating the accuracy of smartphones and portable devices to screen for sleep-disordered breathing (SDB).

METHODS

A literature review was performed between February 18, 2017 and March 15, 2017. We included studies evaluating adults with SDB symptoms through the use mobile phones and/or portable devices, using standard polysomnography as a comparison. A qualitative evaluation of studies was performed with the QUADAS-2 rating. A bivariate random-effects meta-analysis was used to obtain the estimated sensitivity and specificity of screening SDB for four groups of devices: bed/mattress-based, contactless, contact with three or more sensors, and contact with fewer than three sensors. For each group, we also reported positive predictive values and negative predictive values for mild, moderate, and severe obstructive sleep apnea (OSA) screening.

RESULTS

Of the 22 included studies, 18 were pooled in the meta-analysis. Devices that were bed/mattress-based were found to have the best sensitivity overall (0.921, 95% confidence interval [CI] 0.870, 0.953). The sensitivity of contactless devices to detect mild OSA cases was the highest of all groups (0.976, 95% CI 0.899, 0.995), but provided a high false positive rate (0.487, 95% CI 0.137, 0.851). The remaining groups of devices showed low sensitivity and heterogeneous results.

CONCLUSIONS

This study evidenced the limitations and potential use of portable devices in screening patients for SDB. Additional research should evaluate the accuracy of devices when used at home.

Change is the Only Constant in Life (and in Sleep Medicine)

ABSTRACT

Heraclitus, a philosopher who lived nearly 500 years before the common era, made the assertion that "Life is Flux," meaning that change is the only constant in life. Modern medicine, inclusive of the field of sleep medicine, has undergone dramatic changes over the last 10 years. For the American Academy of Sleep Medicine (AASM) specifically, the last year has been one of great change. Yes, change happens, but with great change comes even greater opportunity. As AASM president, I have been focused on staying abreast of the changes in our health care system while anticipating and preparing to adapt to challenges in our field. In June 2017, given all the changes in our health care delivery system, I challenged the AASM membership and our field to adapt our models of care to reduce the number of patients with undiagnosed and untreated obstructive sleep apnea (OSA) by 10% over 5 years. This article will provide a brief update describing how the AASM board of directors has responded to my challenge and capitalized on change in the areas of the physician pipeline, patient access, advocacy, new technology and strategic research. Change is inevitable and often beyond our control, but how we anticipate and respond to change is entirely within our power. As sleep specialists, it is our responsibility not only to respond to change so that we can deliver the best possible care for our patients, but also to be the leading voice for change so that we all achieve better health through optimal sleep.

Patient Engagement Using New Technology to Improve Adherence to Positive Airway Pressure Therapy: A Retrospective Analysis

BACKGROUND

Sleep apnea has major neurocognitive and cardiovascular and metabolic risks. Treatment of sleep apnea is suboptimal because of variable adherence to existing therapies.

METHODS

This trial compared positive airway pressure adherence among patients who were provided active patient engagement (APE) technology vs those who received usual care monitoring (UCM). The primary outcome was expressed by using the US Medicare definition of adherence. Adherence data from two cloud-based databases (AirView and myAir) were analyzed for patients with sleep apnea. Data were included if a patient's activation date in the APE tool was within 7 days of the therapy start date in the UCM database during a defined time window. Data were propensity matched in a 1:2 ratio (APE:UCM) based on baseline patient characteristics.

RESULTS

A total of 128,037 patients were analyzed. Baseline characteristics were typical of a sleep clinic cohort. APE was associated with more patients achieving adherence criteria (87.3%) compared with UCM patients (70.4%; P < .0001 for the difference). Average therapy usage was 5.9 h per night in the APE group vs 4.9 h per night in the matched UCM patients (P < .0001). Patients with sleep apnea "struggling" with therapy adherence had a 17.6% absolute improvement in adherence using APE compared with UCM.

CONCLUSIONS

Robust therapy adherence rates can be achieved by adding modern technology to usual care. Adopting advances in technology in care management may allow clinicians to more effectively and efficiently treat patients who have sleep apnea. Rigorous randomized controlled trials may be required before making strong clinical recommendations.

Validation of the System One RemStar Auto A-Flex for Obstructive Sleep Apnea Treatment and Detection of Residual Apnea-Hypopnea Index: A European Randomized Trial

STUDY OBJECTIVES

Autotitrating continuous positive airway pressure (CPAP) devices adjust pressure in response to changes in airflow and are an alternative to attended in-laboratory titration polysomnography (PSG) to determine optimal pressure levels. The aim of this study was to compare the performance of the System One RemStar Auto A-Flex (Philips Respironics, Murrysville, PA, USA) automatically adjusted positive airway pressure (APAP) mode to manually titrated, fixed pressure CPAP and to validate the device's breathing event detection capabilities against attended in-laboratory PSG.

METHODS

Sixty-one patients investigated in five centers for moderate to severe obstructive sleep apnea between May 2012 and June 2013 were invited to participate. Participants underwent two full-night attended polysomnograms in random order with manually titrated, fixed pressure CPAP versus APAP.

RESULTS

Fifty-three participants with a mean apnea-hypopnea index (AHI) of 45.9 ± 23 completed two sleep studies and were included in the analysis. There were significant but not clinically relevant differences between APAP and CPAP respectively: Apnea index [1.0 (2.8 ± 0.8), median (mean ± standard deviation)] versus [1.8 (5.3 ± 11.5)], p = 0.004; percentage of N1 sleep [12.3 (15.9 ± 0.5)] versus [14.3 (18.9 ± 12.7)], p = 0.028. AHI values differed between PSG [2.8 (5.5. ± 9.3)] and device [3.7 (6.0 ± 8.6)], p = 0.003). Regarding residual events detection, intraclass correlation coefficients for AHI were strong (0.956, p < 0.001) and the area under the curve was 0.988 (AHI cut-off value of 10).

CONCLUSIONS

The new APAP modality was effective and residual apnea-hypopnea indices calculated by the device strongly correlated to those assessed by PSG.

COMMENTARY

A commentary on this article appears in this issue on page 167.