A Randomized Controlled Trial of Telemedicine for Long-Term Sleep Apnea Continuous Positive Airway Pressure Management

Association between the Monthly Visit Behavior and CPAP Adherence in OSAS Patients

Objective Obstructive Sleep Apnea Syndrome (OSAS) causes multiple breathing interruptions during sleep and increases mortality if left untreated. Continuous positive airway pressure (CPAP) therapy improves the prognosis of OSAS; however, patient adherence is often poor. This study investigated the relationship between monthly hospital visits and CPAP adherence to CPAP therapy in patients with OSAS. Methods We studied 119 patients (93 men and 26 women) at the Minami Kyoto Hospital between June 2022 and May 2023. CPAP adherence was measured daily. Hospital/clinic visits were categorized as "Last minute visits at the end of the month" (≥25th of the month) and analyzed in relation to CPAP adherence. Results The average duration of CPAP use duration were 5 h, 47 min, and 43 s. Patients visiting on or after the 25th of month had significantly lower CPAP use (4 h, 17 min, 05 s) compared to those visiting before the 25th of month (6 h, 01 min, 47 s, p=0.003). No significant correlation was found between the visit frequency and adherence to CPAP therapy, with a lower visit frequency unexpectedly corresponding to longer CPAP use (p=0.04). Conclusion The timing of monthly clinic visits significantly affected CPAP adherence, with late-month visits associated with poorer adherence. Visit frequency showed no clear correlation with adherence, suggesting that other factors may have influenced CPAP use. Further supportive interventions can enhance adherence and improve the treatment outcomes.

Multidimensional prediction of continuous positive airway pressure adherence

OBJECTIVE

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea (OSA). Unsatisfactory adherence to CPAP is an important clinical issue to resolve. Cluster analysis is a powerful tool to distinguish subgroups in a multidimensional fashion. This study aimed to investigate the use of cluster analysis for predicting CPAP adherence using clinical polysomnographic (PSG) parameters and patient characteristics.

PATIENTS/METHODS

Participants of this multicenter observational study were 1133 patients with OSA who were newly diagnosed and implemented CPAP. Ward's method of cluster analysis was applied to in-laboratory diagnostic PSG parameters and patient characteristics. CPAP adherence was assessed during 90- and 365-day periods after CPAP initiation in each cluster. We adopted the Centers for Medicare and Medicaid Services criterion for CPAP adherence, i.e., CPAP use ≥4 h per night for 70 % or more of the observation period. Logistic regression analysis was performed to stratify clusters according to CPAP adherence.

RESULTS

Five clusters were identified through cluster analysis. Clustering was significantly associated with CPAP adherence at 90- and 365-day periods after CPAP initiation. Logistic regression revealed that the cluster with features including apnea predominant sleep-disordered breathing, high apnea-hypopnea index, and relatively older age demonstrated the highest CPAP adherence.

CONCLUSION

Cluster analysis revealed hidden connections using patient characteristics and PSG parameters to successfully identify patients more likely to adhere to CPAP for 90 days and up to 365 days. When prescribing CPAP, it is possible to identify patients with OSA who are more likely to be non-adherent.

Effect of telemonitoring and as-needed patient support on positive airway pressure therapy adherence

BACKGROUND

Obstructive sleep apnea (OSA) affects patient health and public welfare. Positive airway pressure (PAP) therapy is the preferred treatment of OSA, but therapy adherence rates remain suboptimal. Current literature demonstrates telemonitoring interventions to support improved PAP therapy adherence.

PURPOSE

To evaluate the effect of interval telemonitoring of PAP therapy data at 2 and 4 weeks after treatment initiation in patients with moderate-to-severe obstructive sleep apnea with as-needed patient support and troubleshooting by telephone consultation.

METHODOLOGY

Ninety-nine participants were enrolled in this study, 50 in the control group and 49 in the intervention group. Data were analyzed using descriptive and inferential statistics using SPSS 28.0 software. The primary outcome of interest was 90-day PAP adherence.

RESULTS

Mean PAP adherence scores diverged at 90 days after PAP initiation, with the intervention group having a significantly higher mean score (M = 49.24, SD = 38.18) relative to the control group (M = 36.38, SD = 37.69). Likewise, continued PAP usage at 90 days after therapy initiation diverged between participant groups, with the intervention group having a significantly higher mean score (M = 89.80, SD = 30.58) relative to the control group (M = 72.00, SD = 45.36).

CONCLUSIONS

The intervention resulted in significantly higher mean PAP adherence and a greater percentage of participants demonstrating continued PAP usage at 90 days after therapy initiation but did not result in a statistically significant increase in what is considered and defined as "good PAP adherence" (adherence of ≥70%).

IMPLICATIONS

Data-triggered telemonitoring protocols offer supplementary support to patients in need and improve PAP adherence.

Evaluation of continuous positive airway pressure adherence and its contributing factors

BACKGROUND

Continuous positive airway pressure (CPAP) adherence may vary based on the study design and country.

OBJECTIVES

To investigate long-term CPAP adherence and elucidate associated factors.

METHODS

A multicenter retrospective observational cohort study was conducted over two years. The study included patients diagnosed with obstructive sleep apnea who were prescribed CPAP (n = 1261). Adherence was assessed for 90 days and 365 days. Centers for Medicare and Medicaid Services (CMS) criteria (≥4 h/night on ≥70 % of nights) and research adherence criteria (≥4 h/night during the observational period) were used. Factors influencing CPAP adherence (CMS criteria) during 90 and 365 days were also evaluated. Continuous variables were categorized into low, middle, and high classes, and logistic regression analysis with interaction was performed.

RESULTS

CPAP adherence to CMS criteria for 90 and 365 days was 45.6 % and 44.7 %, respectively, whereas adherence to research criteria was 57.0 % and 54.1 %, respectively. Middle age, high age, and high apnea ratio independently increased CPAP adherence. Conversely, a high rapid eye movement apnea-hypopnea index ratio decreased CPAP adherence. Although high body mass index (BMI) had no independent effect on adherence, its interaction with high 3 % oxygen desaturation index increased 90-day CPAP adherence. However, high BMI decreased 90-day CPAP adherence in males. The interaction between middle age and high BMI was associated with decreased CPAP adherence over 365 days.

CONCLUSIONS

Adherence to CPAP in real-world settings is modest. Various factors influence CPAP adherence. BMI may exert varied effects on CPAP adherence depending on the accompanying factors.

Telemedicine management of obstructive sleep apnea disorder in China: a randomized, controlled, non-inferiority trial

PURPOSE

Previous studies assessed different components of telemedicine management pathway for OSA instead of the whole pathway. This randomized, controlled, and non-inferiority trial aimed to assess whether telemedicine management is clinically inferior to in-person care in China.

METHODS

Adults suspected of OSA were randomized to telemedicine (web-based questionnaires, self-administered home sleep apnea test [HSAT], automatically adjusting positive airway pressure [APAP], and video-conference visits) or in-person management (paper questionnaires, in-person HSAT set-up, APAP, and face-to-face visits). Participants with an apnea-hypopnea index (AHI) ≥ 15 events/hour received APAP for 3 months. The non-inferiority analysis was based on the change in Functional Outcomes of Sleep Questionnaire (FOSQ) score and APAP adherence. Cost-effectiveness analysis was performed.

RESULTS

In the modified intent-to-treat analysis set (n = 111 telemedicine, 111 in-person), FOSQ scores improved 1.73 (95% confidence interval [CI], 1.31-2.14) points with telemedicine and 2.05 (1.64-2.46) points with in-person care. The lower bound of the one-sided 95% non-inferiority CI for the difference in change between groups of - 0.812 was larger than the non-inferiority threshold of - 1. APAP adherence at 3 months was 243.3 (223.1-263.5) minutes/night for telemedicine and 241.6 (221.3-261.8) minutes/night for in-person care. The lower bound of the one-sided 95% non-inferiority CI of - 22.2 min/night was higher than the non-inferiority delta of - 45 min/night. Telemedicine had lower total costs than in-person management (CNY 1482.7 ± 377.2 vs. 1912.6 ± 681.3; p < 0.0001), driven by patient costs, but no significant difference in QALYs.

CONCLUSIONS

Functional outcomes and adherence were not clinically inferior in patients managed by a comprehensive telemedicine approach compared to those receiving in-person care in China.

CLINICAL TRIAL REGISTRATION

https://www.chictr.org.cn , Registration number ChiCTR2000030546. Retrospectively registered on March 06, 2020.

A Case of Headache Treated by Online Telemedicine in Collaboration With a Midwifery Home

Midwifery centers are places where midwives not only provide antenatal checkups and delivery care but also offer a wide range of health guidance to pregnant women, postpartum mothers, newborns, and older women. In recent years, midwives have also provided onsite and online health guidance. However, diagnosis and prescribing medication are impossible in midwifery centers because no doctor is present. If the midwife determines that the patient should consult doctors, the patient may have to go to a hospital and see doctors in person, which can be burdensome. Online telemedicine facilitates midwife-doctor collaboration and may solve this problem. We report a case of headache management by telemedicine that minimized the patient's travel burden by collaborating with a midwifery center that provides onsite, visiting, and online health guidance for patients who have difficulty visiting a hospital due to postpartum period, childcare, and breastfeeding. A 29-year-old woman and her husband were raising an infant in Sado City (a remote island across the sea), Niigata Prefecture. She developed acute back pain and was bedridden for several days due to immobility. She consulted a midwife because of stress and anxiety caused by childcare and acute back pain, as well as newly occurring headaches. The midwife visited her and provided on-site health guidance. The midwife decided that a doctor's diagnosis and treatment with painkillers were desirable for the headache and back pain, so she contacted a doctor based on the patient's request. The doctor provided online telemedicine across the sea, diagnosed her headache as a tension-type headache, and prescribed acetaminophen 500 mg as an abortive prescription. The prescription was faxed to a pharmacy on the island, and the original was sent by post. The midwife picked up the medication and delivered it to the patient. After taking the medication, the patient's back pain and headache went into remission. Collaboration between midwifery centers that provide onsite, visiting, and online health guidance and medical institutions that offer online telemedicine can potentially improve accessibility to medical care. It differs from conventional online telemedicine in the midwife's coordination practice by monitoring the patient's condition and requesting the physician based on the patient's request.

Distance follow-up by a remote medical care centre improves adherence to CPAP in patients with obstructive sleep apnoea over the short and long term

BACKGROUND

Adherence to continuous positive air pressure (CPAP) in patients with obstructive sleep apnoea (OSA) has remained invariably low over the last decades. Remote monitoring of the nocturnal CPAP treatment, within telemedicine (TM)-based follow-up programs, in these patients has been suggested as a potential tool to improve adherence and release the workload of sleep units. The aim of this study was therefore to assess whether a follow-up program carried out by a Remote Medical Care Centre (RMCC), outside the sleep unit, improves adherence to CPAP in the short and long term in patients with OSA.

METHODS

In this pilot protocol, we enrolled 37 patients starting CPAP in our Sleep Centre (SC). After three months of standard care in our SC, patients initiated a six-month remote follow-up carried out by the RMCC, functioning as an intermediary between patients and SC. Monthly reports and indication for face-to-face visits were sent to the SC for six months. After this period patients returned to usual care for one year. Results were compared with those obtained in 38 patients (controls) followed with usual care over the same time range.

RESULTS

Mean nightly use of CPAP increased from 3.2 ± 2.4 h pre-RMCC to 5.2 ± 1.9 h post-RMCC (p < 0.0001). Nights/month of CPAP use improved from 19.8 ± 9.2 to 25.2 ± 2.5 (p < 0.05) and nights/month with CPAP use >4 h from 12.5 ± 10 to 21.03 ± 8.9 (p < 0.05). This improvement remained stable after 12 months from the return of patients to usual care. No significant changes in CPAP use were observed in controls over the time.

CONCLUSION

A six-month follow-up through a remote facility can significantly improve adherence to CPAP in the short and long term. This pilot study provides a solid base for the design of multicentre randomized trials focusing on new models which are able to increase the long-term efficacy of TM programs.

Boosting obstructive sleep apnea therapy by non-pharmacological approaches: A network meta-analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is the most common breathing-related sleep disorder with a considerable economic burden, low diagnosis and treatment rates. Continuous positive airway pressure (CPAP/PAP) is the principal therapy for OSA treatment; nevertheless, effectiveness is often limited by suboptimal adherence. The present network meta-analysis aims to systematically summarize and quantify different interventions' effects on CPAP/PAP adherence (such as mean usage CPAP or PAP in hours per night) in OSA patients, comparing Behavioral, Educational, Supportive and Mixed interventions in Randomized Control Trials (RCT).

METHODS

We conducted a computer-based search using the electronic databases of Pubmed, Psycinfo, Scopus, Embase, Chinal and Medline until August 2022, selecting 50 RCT.

RESULTS

By means of a random effect model network meta-analysis, results suggested that the most effective treatment in improving CPAP/PAP adherence was the Supportive approach followed by Behavioral Therapy focused on OSA treatment adherence.

CONCLUSION

This network meta-analysis might encourage the most experienced clinicians and researchers in the field to collaborate and implement treatments for improving CPAP/PAP treatment adherence. Moreover, these results support the importance of multidisciplinary approaches for OSA treatment, which should be framed within a biopsychological model.

A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia

Obstructive sleep apnoea (OSA) is highly prevalent in mild cognitive impairment (MCI) and Alzheimer's disease (AD). The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Long-term, well-powered efficacy trials are required to understand whether CPAP could slow cognitive decline in individuals with MCI/AD, but its tolerability in this group remains uncertain. The present review investigates CPAP adherence among individuals with OSA and MCI/AD. Electronic searches were performed on 8 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Six independent studies and four secondary analyses included 278 unique participants (mean age = 72.1 years). In five of the retained studies, around half of participants (45% N = 85 MCI, 56% N = 22 AD) were adherent to CPAP, where ≥4 h use per night was considered adherent. Three of the retained studies also reported average CPAP use to range between 3.2 and 6.3 h/night. CPAP adherence in individuals with MCI and AD is low, albeit similar to the general elderly population. Reporting adherence in future studies as both average duration as well as using a binary cut-off would improve our understanding of the optimum CPAP use in dementia clinical trials and care.

Telemedicine for obstructive sleep apnea syndrome: An updated review

Telemedicine (TM) is a new medical service model in which computer, communication, and medical technologies and equipment are used to provide "face-to-face" communication between medical personnel and patients through the integrated transmission of data, voice, images, and video. This model has been increasingly applied to the management of patients with sleep disorders, including those with obstructive sleep apnea syndrome (OSAS). TM technology plays an important role in condition monitoring, treatment compliance, and management of OSAS cases. Herein, we review the concept of TM, its application to OSAS, and the related effects and present relevant application suggestions and strategies, which may provide concepts and references for OSAS-related TM development and application.

Beneficial Effects of Early Intervention Telemedicine-based Follow-Up in Sleep Apnea: A Randomized Controlled Multicenter Trial

Rationale: Positive airway pressure (PAP) is standard treatment for obstructive sleep apnea. Telemedicine has been introduced for improved PAP follow-up. Objectives: Our study aim was to evaluate the clinical utility of and patient satisfaction with PAP follow-up with an early intervention telemedical protocol. Methods: A randomized controlled trial was conducted at four sleep clinics of the same county. Treatment-naive patients with obstructive sleep apnea were randomized to standard PAP follow-up (203 patients, fixed follow-up procedures) or early intervention telemedical follow-up (AirView, ResMed; 206 patients, continuous follow-up) for 3 months. Evaluated variables included PAP adherence at 3 months, patient-reported outcome measures (Epworth Sleepiness Scale, 36-item Short Form Health Survey, Insomnia Severity Index, Hospital Anxiety and Depression Scale), and staff time. Group differences were analyzed with linear mixed regression models adjusted for age, body mass index, apnea-hypopnea index, and study center. Results: The study groups were comparable at baseline (N = 409; mean age, 59 ± 12 yr; body mass index, 31.9 ± 6 kg/m2, apnea-hypopnea index, 41.5 ± 21 events/h). PAP adherence was higher in the proactive telemedicine group than in the control group (4.3 ± 2.4 and 4.1 ± 2.6 h/night; P = 0.01, respectively), and mean mask pressure at follow-up was significantly lower in the telemedicine group than in the control group (8.7 ± 2.1 cm H2O vs. 9.2 ± 2.5 cm H2O; P = 0.028). In post hoc analysis, the difference in PAP adherence between groups was most pronounced in patients with depression (4.8 ± 2.6 h/night vs. 2.7 ± 2.3 h/night; P = 0.03). Relevant mask leakage (>24 L/min) was lower in the telemedicine group (5.4% vs. 12.1%, P = 0.024). Improvement of patient-reported outcome measures and patient satisfaction was equivalent between groups. Conclusions: Proactive telemedical management of the initial follow-up of PAP treatment compared favorably with conventional follow-up in terms of adherence, pressure level, and mask leakage. Patients with depression may particularly benefit from telemedical follow-up. Specific clinical routines are required to establish this practice in sleep clinics. Clinical trial registered with www.clinicaltrials.gov (NCT03446560).

Current situation of telemedicine research for cardiovascular risk in Japan

Hypertension continues to be a principal risk factor for the occurrence of cardiovascular disorders, stroke, and kidney diseases. Although more than 40 million subjects suffer from hypertension in Japan, its optimal control is achieved only a subpopulation of patients, highlighting the need for novel approaches to manage this disorder. Toward the better control of blood pressure, the Japanese Society of Hypertension has developed the Future Plan, in which the application of the state-of-art information and communication technology, including web-based resources, artificial intelligence, and big data analysis, is considered as one of the promising solutions. In fact, the rapid advance of digital health technologies, as well as ongoing coronavirus disease 2019 pandemic, has triggered the structural changes in the healthcare system globally, increasing demand for the remote delivery of the medical services. Nonetheless, it is not entirely clear what evidence exists that support the widespread use of telemedicine in Japan. Here, we summarize the current status of telemedicine research, particularly in the field of hypertension and other cardiovascular risk factors. We note that there have been very few interventional studies in Japan that clearly showed the superiority or noninferiority of telemedicine over standard care, and that the methods of online consultation considerably varied among studies. Clearly, more evidence is necessary for wide implementation of telemedicine in hypertensive patients in Japan, and also those with other cardiovascular risk factors.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Impact of a telerehabilitation programme combined with continuous positive airway pressure on symptoms and cardiometabolic risk factors in obstructive sleep apnea patients

Background

Obstructive sleep apnea syndrome is a common sleep-breathing disorder associated with adverse health outcomes including excessive daytime sleepiness, impaired quality of life and is well-established as a cardiovascular risk factor. Continuous positive airway pressure is the reference treatment, but its cardiovascular and metabolic benefits are still debated. Combined interventions aiming at improving patient's lifestyle behaviours are recommended in guidelines management of obstructive sleep apnea syndrome but adherence decreases over time and access to rehabilitation programmes is limited. Telerehabilitation is a promising approach to address these issues, but data are scarce on obstructive sleep apnea syndrome.

Methods

The aim of this study is to assess the potential benefits of a telerehabilitation programme implemented at continuous positive airway pressure initiation, compared to continuous positive airway pressure alone and usual care, on symptoms and cardiometabolic risk factors of obstructive sleep apnea syndrome. This study is a 6-months multicentre randomized, parallel controlled trial during which 180 obese patients with severe obstructive sleep apnea syndrome will be included. We will use a sequential hierarchical criterion for major endpoints including sleepiness, quality of life, nocturnal systolic blood pressure and inflammation biological parameters.

Discussion

m-Rehab obstructive sleep apnea syndrome is the first multicentre randomized controlled trial to examine the effectiveness of a telerehabilitation lifestyle programme in obstructive sleep apnea syndrome. We hypothesize that a telerehabilitation lifestyle intervention associated with continuous positive airway pressure for 6 months will be more efficient than continuous positive airway pressure alone on symptoms, quality of life and cardiometabolic risk profile. Main secondary outcomes include continuous positive airway pressure adherence, usability and satisfaction with the telerehabilitation platform and medico-economic evaluation.

Trial registration

Clinicaltrials.gov Identifier: NCT05049928. Registration data: 20 September 2021.

Multidisciplinary care of patients with narcolepsy during coronavirus disease 2019 pandemic in Italy via televisit: the TElemedicine for NARcolepsy feasibility study

STUDY OBJECTIVES

Narcolepsy is a rare chronic central disorder of hypersomnolence with frequent endocrine-metabolic comorbidities. To address the complex care needs of patients during the COVID-19 emergency, we carried out a feasibility study of the TElemedicine for NARcolepsy (TENAR) protocol with the aim of assessing the feasibility of a multidisciplinary care approach via televisit for patients with narcolepsy.

METHODS

A feasibility single open-arm study on the multidisciplinary care of children (>7 y.o.) and adults with narcolepsy who required a follow-up visit was realized during the COVID-19 pandemic emergency period in Italy. The study included a sleep, metabolic, and psychosocial assessment via televisit at baseline, at 6, and at 12 months from the study inclusion period (15th May-26th June 2020).

RESULTS

In total 39 out of 44 eligible patients (89%) entered the study (30 adults, nine children); 37 patients (95%) ended the 12-month follow-up. At baseline, the median Epworth sleepiness scale score (ESS) was 10 (IQR 8-14), and the median body mass index (BMI) was 25.6 (IQR 22.1-30.9). During the follow-up period, the ESS score decreased from the 6th month onward (p = 0.003), and BMI decreased at the 1-year follow-up (p = 0.047), while there were no differences in depressive and anxiety symptoms, quality of life, compliance with treatment, adverse drug reactions, or accidents.

CONCLUSIONS

High response and retention rates, stability of ESS, and lack of side effects indicate that telemedicine is a feasible and safe approach for adults and children with narcolepsy.

Multimodal Telemonitoring for Weight Reduction in Patients With Sleep Apnea: A Randomized Controlled Trial

BACKGROUND

Telemonitoring the use of CPAP devices and remote feedback on device data effectively optimizes CPAP adherence in patients with OSA.

RESEARCH QUESTION

Can expanding the scope of telemonitoring and remote feedback to body weight (BW), BP, and physical activity enhance efforts for BW reduction in Patients with OSA receiving CPAP?

STUDY DESIGN AND METHODS

Participants were recruited from patients at 16 sleep centers in Japan with OSA and obesity who were receiving CPAP therapy. Obesity was defined as a BMI of ≥ 25 kg/m², based on Japanese obesity guidelines. Implementation of CPAP telemonitoring was enhanced with electronic scales, BP monitors, and pedometers that could transmit data from devices wirelessly. Participants were randomized to the multimodal telemonitoring group or the usual CPAP telemonitoring group and were followed up for 6 months. Attending physicians provided monthly telephone feedback calls to the usual CPAP telemonitoring group on CPAP data obtained remotely. In the multimodal telemonitoring group, physicians additionally encouraged participants to reduce their BW, after sharing the remotely obtained data on BW, BP, and step count. The primary outcome was set as ≥ 3% BW reduction from baseline.

RESULTS

One hundred sixty-eight participants (BMI, 31.7 ± 4.9 kg/m²) completed the study, and ≥ 3% BW reduction occurred in 33 of 84 participants (39.3%) and 21 of 84 participants (25.0%) in the multimodal telemonitoring and usual CPAP telemonitoring groups, respectively (P = .047). Whereas no significant differences were found between the two groups in the change in office and home BP, daily step counts during the study period were significantly higher in the multimodal telemonitoring group than in the usual CPAP telemonitoring group (4,767 steps/d [interquartile range (IQR), 2,864-6,617 steps/d] vs 3,592 steps/d [IQR, 2,117-5,383 steps/d]; P = .02) INTERPRETATION: Multimodal telemonitoring may enhance BW reduction efforts in patients with OSA and obesity.

TRIAL REGISTRY

UMIN Clinical Trials Registry; No.: UMIN000033607; URL: www.umin.ac.jp/ctr/index.htm.

Telehealth Technology Application in Enhancing Continuous Positive Airway Pressure Adherence in Obstructive Sleep Apnea Patients: A Review of Current Evidence

Obstructive sleep apnea (OSA) is a common type of sleep-disordered breathing associated with multiple comorbidities. Continuous positive airway pressure (CPAP) is the first choice for moderate-severe OSA but poor compliance brings a great challenge to its effectiveness. Telehealth interventions ease the follow-up process and allow healthcare facilities to provide consistent care. Fifth-generation wireless transmission technology has also greatly rationalized the wide use of telemedicine. Herein, we review the efficacy of the telehealth system in enhancing CPAP adherence. We recommend applying telemonitoring in clinical practice and advocate the development of a biopsychosocial telemedicine model with the integration of several interventions. Big databases and promising artificial intelligent technologies make clinical decision support systems and predictive models based on these databases possible.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

New Paths in Respiratory Sleep Medicine: Consumer Devices, e-Health, and Digital Health Measurements

Sleep health and tracking sleep with contemporary wearables have become more popular. Sleep disorders, in particular, sleep-disordered breathing, have a higher prevalence than estimated previously. Many patients with apnea and hypopnea events suffer whereas others do not report complaints or show cardiovascular consequences. Assessment with wearables may support efforts to distinguish which type of apnea is related to aging and which to cardiovascular comorbidities. Innovative methods offer smart solutions for problems that are insufficiently addressed. Telemedical concepts help bring patients to sleep medicine expertise at an early stage. To use these methods clinically, they must be certified as medical devices.

Telemedicine interventions for CPAP adherence in obstructive sleep apnea patients: Systematic review and meta-analysis

Continuous positive airway pressure (CPAP) is the preferred therapy in patients with obstructive sleep apnea (OSA). However, data suggests treatment adherence is low. In recent years, telemedicine-based intervention (TM) has been evaluated to increase adherence. In this systematic review and meta-analysis of randomized controlled trials (RCTs), we evaluated the efficacy of TM on CPAP adherence in patients with OSA. Two independent reviewers explored five databases; the risk of bias (RoB) was evaluated using the Cochrane tool. Outcomes were defined as the mean difference (MD) in CPAP use per night and the proportion of patients with increased CPAP adherence of ≥4 h/night. The meta-analysis was conducted following the DerSimonian-Laird method, and the certainty of the evidence was rated according to GRADE. We included 16 RCTs including 3039 participants. The RoB was low in 12/16 studies. TM was associated with an increase in CPAP adherence of 29.2 min/night, I² =75% (p < 0.01), and CPAP adherence ≧4 h/night, RR: 1.09 (1.02-1.17), I² =22%. Subgroup analyses reported better results between three and 6 months, in the sleepy subgroup. Finally, based on the results obtained in this systematic review, there is favorable evidence regarding the treatment with TM in patients with OSA using CPAP. REVIEW REGISTRATION NUMBER: CRD42020165367.

Telemedicine Strategy to Rescue CPAP Therapy in Sleep Apnea Patients with Low Treatment Adherence: A Pilot Study

Patients with sleep apnea are usually treated with continuous positive airway pressure (CPAP). This therapy is very effective if the patient′s adherence is satisfactory. However, although CPAP adherence is usually acceptable during the first months of therapy, it progressively decreases, with a considerable number of patients accepting average treatment duration below the effectiveness threshold (4 h/night). Herein, our aim was to describe and evaluate a novel telemedicine strategy for rescuing CPAP treatment in patients with low adherence after several months/years of treatment. This two-week intervention includes (1) patient support using a smartphone application, phone and voice recorder messages to be answered by a nurse, and (2) daily transmission and analysis of signals from the CPAP device and potential variation of nasal pressure if required. On average, at the end of the intervention, median CPAP adherence considerably increased by 2.17 h/night (from 3.07 to 5.24 h/night). Interestingly, the procedure was able to markedly rescue CPAP adherence: the number of patients with poor adherence (<4 h/night) was considerably reduced from 38 to 7. After one month, adherence improvement was maintained (median 5.09 h/night), and only 13 patients had poor adherence (<4 h/night). This telemedicine intervention (103€ per included patient) is a cost-effective tool for substantially increasing the number of patients with CPAP adherence above the minimum threshold for achieving positive therapeutic effects.

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.

Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea

STUDY OBJECTIVES

A telemonitoring system is a promising wireless technology that possibly enhances adherence to CPAP therapy. The study aimed to determine the effect of a telemonitoring system on CPAP therapy adherence among Asian patients with moderate-to-severe OSA.

METHODS

A prospective randomized controlled trial enrolled 60 Asian adults (70% male) with moderate-to-severe OSA. Thirty patients each were randomized to a group using CPAP with a telemonitoring system or a group using CPAP with usual care. The telemonitoring system functioned by transferring CPAP-usage data via cellular network. When there were any triggers occurring 2 nights consecutively (usage hours < 4 hours per night; leakage > 27 L/min or AHI > 5 events/h), the investigator contacted the patients. The primary outcome was the 4-week CPAP usage hours per night. The secondary outcomes included the percentage of good adherence (defined as a 4-week period of therapy with CPAP usage > 4 hours/night on > 70% of total days), median leakage per night, adverse events from CPAP therapy, sleep quality improvement, and daytime sleepiness reduction.

RESULTS

The mean AHI was 50.3 events/h. The mean 4-week CPAP usage hours per night were insignificantly higher in the telemonitoring group (5.16 ± 1.47 hours/night vs 4.42 ± 1.91 hours/night; P = .18). However, the percentage of good adherence was significantly higher in the telemonitoring group (64.2% vs 34.4%; P = .024). Median leakage per night was also significantly lower in the telemonitoring group. Furthermore, significant sleep quality improvement was observed in the telemonitoring group. Overall adverse events and daytime sleepiness reduction were not different.

CONCLUSIONS

The telemonitoring system implementation showed a trend toward increasing CPAP nightly usage hours and significantly improved adherence and sleep quality among Asian patients with moderate-to-severe OSA.

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

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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.

International Consensus Document on Obstructive Sleep Apnea

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).