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Natsky AN, Vakulin A, Chai-Coetzer CL, McEvoy RD, Adams RJ, Kaambwa B. Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea in the adult population: a systematic review. Sleep Med Rev 2022; 62:101608. [DOI: 10.1016/j.smrv.2022.101608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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Abstract
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.
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Affiliation(s)
- Johan Verbraecken
- Department of Pulmonary Medicine and Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, University of Antwerp, Drie Eikenstraat 655, Edegem, Antwerp 2650, Belgium.
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Natsky AN, Vakulin A, Coetzer CLC, McEvoy RD, Adams RJ, Kaambwa B. Economic evaluation of diagnostic sleep studies for obstructive sleep apnoea: a systematic review protocol. Syst Rev 2021; 10:104. [PMID: 33836806 PMCID: PMC8035771 DOI: 10.1186/s13643-021-01651-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/26/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Obstructive sleep apnoea (OSA) is a significant public health problem affecting a large proportion of the population and is associated with adverse health consequences and a substantial economic burden. Despite the existence of effective treatment, undiagnosed OSA remains a challenge. The gold standard diagnostic tool is polysomnography (PSG), yet the test is expensive, labour intensive and time-consuming. Home-based, limited channel sleep study testing (levels 3 and 4) can advance and widen access to diagnostic services. This systematic review aims to summarise available evidence regarding the cost-effectiveness of limited channel tests compared to laboratory and home PSG in diagnosing OSA. METHODS Eligible studies will be identified using a comprehensive strategy across the following databases from inception onwards: MEDLINE, PsychINFO, SCOPUS, CINAHL, Cochrane Library, Emcare and Web of Science Core Collection and ProQuest databases. The search will include a full economic evaluation (i.e. cost-effectiveness, cost-utility, cost-benefit, cost-consequences and cost-minimisation analysis) that assesses limited channel tests and PSG. Two reviewers will screen, extract data for included studies and critically appraise the articles for bias and quality. Meta-analyses will be conducted if aggregation of outcomes can be performed. Qualitative synthesis using a dominance ranking matrix will be performed for heterogeneous data. DISCUSSION This systematic review protocol uses a rigorous, reproducible and transparent methodology and eligibility criteria to provide the current evidence relating to the clinical and economic impact of limited channel and full PSG OSA diagnostic tests. Evidence will be examined using standardised tools specific for economic evaluation studies. TRIAL REGISTRATION PROSPERO (CRD42020150130).
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Affiliation(s)
- Andrea N Natsky
- Department of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia. .,National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.
| | - Andrew Vakulin
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Sleep and Circadian Research Group, Woolcock Institute of Medical Research, University of Sydney, Camperdown, New South Wales, Australia
| | - Ching Li Chai Coetzer
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - R D McEvoy
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - Robert J Adams
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Bedford Park, South Australia, Australia
| | - Billingsley Kaambwa
- Department of Health Economics, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia.,National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, South Australia
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Freedman N. Treatment of Obstructive Sleep Apnea: Choosing the Best Positive Airway Pressure Device. Sleep Med Clin 2020; 15:205-218. [PMID: 32386695 DOI: 10.1016/j.jsmc.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.
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Affiliation(s)
- Neil Freedman
- Pulmonary, Critical Care, Allergy and Immunology, Department of Medicine, North Shore University Health System, 2650 Ridge Avenue, Evanston, IL 60201, USA.
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Pandian TNG, Sehra R, Narayan S. Breath variability increases in the minutes preceding obstructive sleep apneic events. Sleep Breath 2020; 25:271-280. [PMID: 32506203 DOI: 10.1007/s11325-020-02094-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE It is unclear if there is a consistent signature in breath patterns prior to an impending obstructive apneic event in patients with sleep-disordered breathing (SDB). OBJECTIVE To use continuous recordings of ambient sound in sleep using a smartphone to track auditory signatures of breaths and measure their regularity preceding apneic events. METHODS We studied 50 patients evaluated for SDB in whom sound was recorded using smartphones concurrently with polysomnography (PSG). Whole-night sound files were analyzed for time and frequency domain analyses of breath periodicity during periods of normal and sleep-disordered breathing. RESULTS Fifty patients (44% women, 42.0 ± 9.4 years old, BMI 32.8 ± 10.8 kg/m2) recorded sound, of whom 30 were diagnosed with OSA and 20 were not. We analyzed a total of 497 apneic (≥10 s) and 481 non-apneic intervals, confirmed by PSG. Interbreath intervals were 3.75 ± 0.62 s for 1 min in quiet breathing, with SD 1.11 ± 0.48 s that increased to 4.16 ± 3.06 s in successive 60-s epochs up to apnea (p < 0.001). Interbreath SD in the 60 s immediately preceding apnea was higher than the SD in random non-apneic periods (p < 0.01, ANOVA). Interbreath SD ≥1.49 s gave 87.3% sensitivity and 86.5% specificity for predicting apnea in the next minute (c-statistic 0.94). CONCLUSIONS Breaths increase in variability minutes before proven obstructive apnea in patients with suspected SDB. These results suggest that it may be possible to predict and thus potentially avert apneic events and provide insights into events leading to SDB. TRIAL REGISTRATION NCT03288376, clinicaltrials.org.
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Affiliation(s)
| | - Ruchir Sehra
- Resonea Inc., 16580 N. 92nd Street #3001, Scottsdale, AZ, 85260, USA
| | - Sanjiv Narayan
- Resonea Inc., 16580 N. 92nd Street #3001, Scottsdale, AZ, 85260, USA.
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Rosenberg R, Hirshkowitz M, Rapoport DM, Kryger M. The role of home sleep testing for evaluation of patients with excessive daytime sleepiness: focus on obstructive sleep apnea and narcolepsy. Sleep Med 2019; 56:80-89. [PMID: 30803831 DOI: 10.1016/j.sleep.2019.01.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/13/2018] [Accepted: 01/15/2019] [Indexed: 11/18/2022]
Abstract
Excessive daytime sleepiness (EDS) is a common complaint in the general population, which may be associated with a wide range of sleep disorders and other medical conditions. Narcolepsy is a sleep disorder characterized primarily by EDS, which involves a substantial burden of illness but is often overlooked or misdiagnosed. In addition to identifying low cerebrospinal fluid (CSF) hypocretin (orexin) levels, evaluation for narcolepsy requires in-laboratory polysomnography (PSG). Polysomnography is the gold standard for diagnosis of obstructive sleep apnea (OSA) as well as other sleep disorders. However, the use of home sleep apnea testing (HSAT) to screen for OSA in adults with EDS has increased greatly based on its lower cost, lower technical complexity, and greater convenience, versus PSG. The most commonly used, types 3 and 4, portable monitors for HSAT lack capability for electroencephalogram recording, which is necessary for the diagnosis of narcolepsy and other sleep disorders and is provided by PSG. These limitations, combined with the increased use of HSAT for evaluation of EDS, may further exacerbate the under-recognition of narcolepsy and other hypersomnias, either as primary or comorbid disorders with OSA. Adherence to expert consensus guidelines for use of HSAT is essential. Differential clinical characteristics of patients with narcolepsy and OSA may help guide correct diagnosis. Continued EDS in patients diagnosed and treated for OSA may indicate comorbid narcolepsy or another sleep disorder. Although HSAT may diagnose OSA in appropriately selected patients, it cannot rule out or diagnose narcolepsy. Therefore, at present, PSG and MSLT remain the cornerstone for narcolepsy diagnosis.
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Affiliation(s)
| | | | | | - Meir Kryger
- Yale Pulmonary and Critical Care Medicine, New Haven, CT, USA.
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Noncontact identification of sleep-disturbed breathing from smartphone-recorded sounds validated by polysomnography. Sleep Breath 2018; 23:269-279. [PMID: 30022325 DOI: 10.1007/s11325-018-1695-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 06/12/2018] [Accepted: 06/27/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE Diagnosis of obstructive sleep apnea by the gold-standard of polysomnography (PSG), or by home sleep testing (HST), requires numerous physical connections to the patient which may restrict use of these tools for early screening. We hypothesized that normal and disturbed breathing may be detected by a consumer smartphone without physical connections to the patient using novel algorithms to analyze ambient sound. METHODS We studied 91 patients undergoing clinically indicated PSG. Phase I: In a derivation cohort (n = 32), we placed an unmodified Samsung Galaxy S5 without external microphone near the bed to record ambient sounds. We analyzed 12,352 discrete breath/non-breath sounds (386/patient), from which we developed algorithms to remove noise, and detect breaths as envelopes of spectral peaks. Phase II: In a distinct validation cohort (n = 59), we tested the ability of acoustic algorithms to detect AHI < 15 vs AHI > 15 on PSG. RESULTS Smartphone-recorded sound analyses detected the presence, absence, and types of breath sound. Phase I: In the derivation cohort, spectral analysis identified breaths and apneas with a c-statistic of 0.91, and loud obstruction sounds with c-statistic of 0.95 on receiver operating characteristic analyses, relative to adjudicated events. Phase II: In the validation cohort, automated acoustic analysis provided a c-statistic of 0.87 compared to whole-night PSG. CONCLUSIONS Ambient sounds recorded from a smartphone during sleep can identify apnea and abnormal breathing verified on PSG. Future studies should determine if this approach may facilitate early screening of SDB to identify at-risk patients for definitive diagnosis and therapy. CLINICAL TRIALS NCT03288376; clinicaltrials.org.
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Freedman N. Doing It Better for Less: Incorporating OSA Management Into Alternative Payment Models. Chest 2018; 155:227-233. [PMID: 29981717 DOI: 10.1016/j.chest.2018.06.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 06/10/2018] [Accepted: 06/28/2018] [Indexed: 12/19/2022] Open
Abstract
As the cost of health care continues to escalate, payers are adapting by moving away from models based on traditional fee-for-service reimbursement to models focused on rewarding care delivery that reduces costs and improves quality. These alternative payment models (APMs) are being introduced by government and commercial payers and will likely become the norm over time. Recent changes in sleep medicine related to advances in technology and approaches by payers for the management of OSA make this an appropriate time to incorporate the delivery of sleep medicine services into APMs. For OSA, the approaches that should lead to success include the appropriate use of home sleep apnea testing and automatic positive airway pressure; lower cost providers to manage less complex patients; evolving technologies including cloud-based positive airway pressure adherence monitoring, telemedicine, and Internet-based coaching to improve adherence with treatments; data analytics to better identify high-risk populations and to more appropriately allocate resources; and appropriate referrals of more complex cases to sleep specialists for management. All of these approaches should improve the value of care for payers, providers, and patients while allowing sleep specialists to more appropriately allocate their efforts to overseeing APM program development and administration and allowing them to focus on the management of more complicated patients.
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Affiliation(s)
- Neil Freedman
- Division of Pulmonary, Critical Care, Allergy and Immunology, Department of Medicine, Northshore University Health System, Evanston, IL.
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Abstract
Positive airway pressure (PAP) remains primary therapy for most patients with obstructive sleep apnea (OSA). CPAP, APAP, and BPAP are all reasonable therapies that can be used for patients with uncomplicated OSA across the spectrum of disease severity. BPAP should be considered for patients who are nonadherent to CPAP or APAP therapy because of pressure intolerance. Several additional factors should be considered when choosing the type of PAP device for a given patient, including associated symptoms and comorbid medical problems, cost, access to online data management and patient portals, and the portability for the device for patients who travel frequently.
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POINT: Is It Time for Pulmonary Concierge Practices? Yes. Chest 2017; 151:255-257. [DOI: 10.1016/j.chest.2016.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/21/2016] [Indexed: 12/25/2022] Open
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Khalyfa A, Gileles-Hillel A, Gozal D. The Challenges of Precision Medicine in Obstructive Sleep Apnea. Sleep Med Clin 2016; 11:213-26. [DOI: 10.1016/j.jsmc.2016.01.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Novel concepts and technological advances have the potential to change the landscape on which clinical sleep medicine is practiced. Screening for sleep apnea will take advantage of readily available mobile telephone technology (sound, accelerometers) to enable widespread recognition of sleep-disordered breathing. Advanced computer-assisted scoring algorithms will improve efficiency and reliability of sleep apnea diagnoses. As the field adopts a personalized approach to therapies, methods to determine the mechanisms of sleep apnea in individuals will be developed-utilizing simplified tests and available recordings-with the promise of predicting outcomes of novel therapies.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital and Harvard Medical School, 221 Longwood Avenue, Boston, MA 02115, USA; Department of Allergy, Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, 55 Commercial Road, Prahran, Victoria 3181, Australia.
| | - Robert L Owens
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9500 Gilman Dr La Jolla, CA 92093, USA
| | - Atul Malhotra
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, 9500 Gilman Dr La Jolla, CA 92093, USA
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Pack AI. Rebuttal From Dr Pack. Chest 2015; 148:310-311. [DOI: 10.1378/chest.15-0478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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