Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea

Is video demonstration for type III sleep studies performance worse than technical face-to-face teaching?

PURPOSE

Obstructive sleep apnea (OSA) is the most common sleep-disordered breathing. The high prevalence makes its diagnosis a priority. To perform type III sleep studies, patients usually receive instructions from a technician. The switch to instructions through a video could save professionals time and make OSA diagnosis more accessible. This study aimed to compare the technical quality of type III sleep studies when instructions are provided by face-to-face technical teaching or via video.

METHODS

One hundred consecutive patients aged ≥ 18 years with suspected OSA were randomly assigned to receive device placement instructions in person by a technician or through video (50 in each group). The overall quality of the sleep studies was analyzed by determining the number of technically invalid studies. The recording quality of four sensors (pulse oximeter, nasal flow cannula, chest, and abdominal bands) was evaluated by checking for signal artifacts.

RESULTS

The majority (86%) of the studies were valid. 20% of the studies in the face-to-face group and 8% of the studies in the video-instruction group were technically invalid, but no statistically significant difference was found (p = 0.148). The quality of the oximetry signal was better in those who received video instructions (p = 0.05). Regarding the recording quality of the remaining sensors, no significant differences were found.

CONCLUSIONS

Type III sleep studies with previous explanation through a video are as effective as those with an explanation performed by a technician, with associated advantages, without increased errors. The quality of the oximetry signal was better in the video group, a critical signal for OSA diagnosis.

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.

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.

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.

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.

Protocol for a pragmatic trial testing a self-directed lifestyle program targeting weight loss among patients with obstructive sleep apnea (POWER Trial)

BACKGROUND

Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA.

METHODS

POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation.

CONCLUSIONS

The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost.

Sleep medicine in China: current clinical practice

The modern practice of sleep medicine in China was introduced in the 1980s and has undergone significant development over the past few decades. The field has witnessed an increase in sleep laboratories, the publication of guidelines for the diagnosis and treatment of sleep disorders, and the establishment of several sleep medicine associations. Despite these achievements, there is still much to be done in this field. By utilizing original national survey data, this study comprehensively discusses the current practice of sleep medicine in China, including sleep medicine training, diagnostic capacity, multidisciplinary care, clinical competence and standardization, sleep telemedicine, barriers to the practice of sleep medicine, and costs of sleep medicine. It is imperative for the Chinese health care authorities to enhance their attention and investment in the field of sleep medicine. Urgent implementation of standardized training programs and accreditation systems is necessary to promote the diagnosis and treatment of sleep disorders in China.

CITATION

Xu S, Li Y, Ye J, Han D. Sleep medicine in China: current clinical practice. J Clin Sleep Med. 2023;19(12):2125-2131.

Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration

BACKGROUND

Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers.

OBJECTIVE

The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented.

DESIGN

Retrospective, observational, utilizing administrative data.

SUBJECTS

VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT).

MAIN MEASURES

Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service.

KEY RESULTS

In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices.

CONCLUSIONS

Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers?

Quality of life (QoL) is one of the outcomes that can be measured as a component of the required standards for sleep facility accreditation by the American Academy of Sleep Medicine. Utilization of a psychometrically robust QoL instrument is recommended; however, clinicians face a challenge balancing psychometric properties with questionnaire completion and scoring characteristics. This article provides an overview of common QoL instruments as a reference for clinicians when selecting a QoL tool for use in the clinical setting for adult patients with obstructive sleep apnea.

CITATION

Colvin L, Collop N, Lorenz R, Morgenthaler T, Weaver TE. Examining the feasibility of adult quality-of-life measurement for obstructive sleep apnea in clinical settings: what is the path forward for sleep centers? J Clin Sleep Med. 2023;19(6):1145-1155.

Effects of telemedicine-based follow-up management on adults with obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVES

This meta-analysis aimed to investigate the effects of telemedicine-based follow-up management on adults with obstructive sleep apnea.

METHODS

Publications were searched in the Cochrane Library, PubMed, Scopus, Web of Science and Embase. Studies were selected according to the predefined screening criteria, and their qualities were assessed by the Revised Cochrane risk-of-bias tool for randomized trials. The statistical analyses were performed using Stata12.0 software. It was registered in PROSPERO with the number: CRD42021276414.

RESULTS

A total of 33 articles with 8,689 participants were included. Telemedicine-based follow-up management improved average daily continuous positive airway pressure usage by 36 min (weighted mean difference:0.61;95% confidence interval: 0.39 to 0.83), and the percentage of days with continuous positive airway pressure usage more than four hours by 10.67% in obstructive sleep apnea patients. The meta-analysis of good continuous positive airway pressure compliance showed telemedicine-based follow-up management did not lead to good continuous positive airway pressure compliance (odds ratio: 1.13;95% confidence interval: 0.72 to 1.76). The pooled mean difference of sleep quality was 0.15 (standardized mean difference:0.15; 95% confidence interval: -0.03 to 0.32), and daytime sleepiness was -0.26 (weighted mean difference: -0.26;95% confidence interval: -0.79 to 0.28). The pooled mean difference of apnea hypopnea index was -0.53 (95% confidence interval: -3.58 to 2.51). As for the overall quality of life, the pooled mean difference was -0.25 (standardized mean difference: -0.25;95% confidence interval: -0.25 to 0.76).

CONCLUSION

Telemedicine-based follow-up management was beneficial for continuous positive airway pressure compliance of obstructive sleep apnea patients within six months. However, it could not improve sleep quality, daytime sleepiness, the severity of obstructive sleep apnea, and quality of life in obstructive sleep apnea patients compared with traditional follow-up. Moreover, it was more cost-effective, but there was no consensus on whether it would increase the workload of medical staff.

Impact of mail-based continuous positive airway pressure initiation on treatment usage and effectiveness

PURPOSE

In-person visits with a trained therapist have been standard care for patients initiating continuous positive airway pressure (CPAP). These visits provide an opportunity for hands-on training and an in-person assessment of mask fit. However, to improve access, many health systems are shifting to remote CPAP initiation with equipment mailed to patients. While there are potential benefits of a mailed approach, relative patient outcomes are unclear. Specifically, many have concerns that a lack of in-person training may contribute to reduced CPAP adherence. To inform this knowledge gap, we aimed to compare treatment usage after in-person or mailed CPAP initiation.

METHODS

Our medical center shifted from in-person to mailed CPAP dispensation in March 2020 during the COVID-19 pandemic. We assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP in the months before (n = 433) and after (n = 186) this shift. We compared 90-day adherence between groups.

RESULTS

Mean nightly PAP usage was modest in both groups (in-person 145.2, mailed 140.6 min/night). We did not detect between-group differences in either unadjusted or adjusted analyses (adjusted difference - 0.2 min/night, 95% - 27.0 to + 26.5).

CONCLUSIONS

Mail-based systems of CPAP initiation may be able to improve access without reducing CPAP usage. Future work should consider the impact of mailed CPAP on patient-reported outcomes and the impact of different remote setup strategies.

Virtual consultations for patients with obstructive sleep apnoea: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease 2019 pandemic has accelerated the adoption of virtual care strategies for the management of patients with obstructive sleep apnoea/hypopnoea syndrome (OSAHS).

RESEARCH QUESTION

What is the effectiveness of virtual consultations compared to in-person consultations for the management of continuous positive airway pressure (CPAP) therapy in adult patients with OSAHS?

METHODS

A systematic review and meta-analysis (PROSPERO; CRD42022297532) based on six electronic databases plus manually selected journals was conducted in January 2022. Two researchers independently selected, quality appraised and extracted data. The co-primary outcomes were patient-reported sleepiness, assessed by the Epworth Sleepiness Scale (ESS), and reported cost-effectiveness.

RESULTS

12 studies (n=1823 adults) were included in the review. Seven studies (n=1089) were included in the meta-analysis which showed no difference in the magnitude of improvement in patient-reported sleepiness scores between virtual and in-person consultations (mean difference -0.39, 95% CI -1.38-0.60; p=0.4), although ESS scores improved in both groups. Virtual care strategies modestly increased CPAP therapy adherence and were found to be less costly than in-person care strategies in the three Spanish trials that reported cost-effectiveness.

CONCLUSION

The findings of this review suggest that virtual care delivered by telephone or video consultations is as effective as in-person consultations for improving subjective sleepiness in patients with OSAHS treated with CPAP. This clinical management strategy may also improve CPAP adherence without increasing the costs, supporting its potential as a follow-up management strategy, where patients prefer this approach.

Does unconscious socioeconomic bias influence tele-evaluation of obstructive sleep apnea? An exploratory analysis

STUDY OBJECTIVES

We examined the association between a patient's income and a provider's ability to identify risk for obstructive sleep apnea (OSA) when assessed in-person versus via telemedicine.

METHODS

We utilized data from a randomized interrater reliability study of 58 patients who were referred to a university sleep center. Participants volunteered their annual income bracket as part of data collection, although raters were blinded to these data. We assessed the inter-method reliability between the clinical impressions of a telemedicine rater and those of an in-person rater for pretest probability of OSA, stratified by income levels.

RESULTS

Inter-method reliabilities, assessed using weighted kappa, were 0.83, 0.24, and 0.66 for subjects with low (<$50,000/year), moderate ($50,000-$100,000/year) and high (>$100,000) incomes, respectively. The kappa statistics were significantly different (p = 0.005) between the low and moderate income groups.

CONCLUSIONS

There was a significant difference in the reliability values of telemedicine versus in-person assessments between the low and middle income brackets. This is despite the raters being unaware of the patients' income levels. This association might suggest possible unconscious bias in evaluating for OSA. With telemedicine in early development, it is important to create processes that will minimize bias that might result from patients' economic disparities.

Telemedicine compared to standard face-to-face care for CPAP treatment: real-world Australian experience

STUDY OBJECTIVES

We tested a telemedicine model of care to initiate continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA) living in remote Western Australia.

METHODS

A prospective study comparing telemedicine for CPAP initiation in a remote population versus standard face-to-face CPAP initiation in a metropolitan population. The primary outcome was average nightly CPAP use in the final week of a CPAP trial.

RESULTS

A total of 186 participants were allocated to either telemedicine (n=56) or standard care (n=130). The average distance from the study centre for the telemedicine group was 979 km (±792km) compared to 19km (±14km) for the standard care group. The CPAP trial duration in the standard care group was less than the telemedicine group (37.6 vs 69.9 days, p<0.001). CPAP adherence in the telemedicine group was not inferior to standard care (Standard 4.7±0.2 hours, Telemedicine 4.7±0.3 hours, p=0.86). No differences were found between groups in residual apnea-hypopnea index, symptom response, sleep specific quality of life at the end of the trial and continued CPAP use (3 to 6 months). Participant satisfaction was high in both groups. Total health care costs of the telemedicine model were less than the standard model of care. An estimated A$4,538 per participant in travel costs was saved within the telemedicine group by reducing the need to travel to the sleep center for in-person management.

CONCLUSIONS

In remote dwelling adults starting CPAP for the treatment of OSA, outcomes using telemedicine were comparable to in-person management in a metropolitan setting.

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.

Telemedicine and virtual respiratory care in the era of COVID-19

The World Health Organization defines telemedicine as “an interaction between a health care provider and a patient when the two are separated by distance”. The COVID-19 pandemic has forced a dramatic shift to telephone and video consulting for follow up and routine ambulatory care for reasons of infection control. Short Message Service (“text”) messaging has proved a useful adjunct to remote consulting allowing transfer of photographs and documents. Maintaining non-communicable diseases care is a core component of pandemic preparedness and telemedicine has developed to enable (for example) remote monitoring of sleep apnoea, telemonitoring of chronic obstructive pulmonary disease, digital support for asthma self-management, remote delivery of pulmonary rehabilitation. There are multiple exemplars of telehealth instigated rapidly to provide care for people with COVID-19, to manage the spread of the pandemic, or to maintain safe routine diagnostic or treatment services.

Despite many positive examples of equivalent functionality and safety, there remain questions about the impact of remote delivery of care on rapport and the longer-term impact on patient/professional relationships. Although telehealth has the potential to contribute to universal health coverage by providing cost-effective accessible care, there is a risk of increasing social health inequalities if the “digital divide” excludes those most in need of care. As we emerge from the pandemic, the balance of remote versus face-to-face consulting, and the specific role of digital health in different clinical and healthcare contexts will evolve. What is clear is that telemedicine in one form or another will be part of the “new norm”.

In-person versus video hookup instructions: a comparison of home sleep apnea testing quality

STUDY OBJECTIVES

The high prevalence of obstructive sleep apnea (OSA) in the general population makes diagnosing OSA a high priority. Typically, patients receive in-person instructions to hook up the home sleep apnea test (HSAT) devices. Using recorded video instructions would save healthcare personnel time and improve access to OSA diagnostics for patients in remote areas. The aim of this study was to compare the quality of HSAT recordings when using in-person and video hookup instructions in a randomized study.

METHODS

A total of 100 patients aged 18 to 70 years with suspected OSA were randomized to receive either in-person or video hookup instructions for the Nox T3 device (Nox Medical, Reykjavik, Iceland). The overall quality of the resulting sleep studies was analyzed by determining the number of technically invalid studies. The recording quality of four sensors (pulse oximeter, nasal cannula, thorax and abdominal respiratory inductance plethysmography belts) was assessed by checking for signal artifacts.

RESULTS

No significant difference was found between the two groups in any quality index. Only 1 (2%) and 2 (3.9%) sleep studies were technically invalid in the in-person and video instructions group, respectively. The average ± standard deviation recording quality of the four sensors combined was 94.8% ± 13.6% for the in-person and 96.0% ± 11.0% for the video instructions group.

CONCLUSIONS

This study found no difference in HSAT recording quality between the two groups. Video hookup instructions are therefore viable, and an important step towards a telemedicine-based way of diagnosing OSA.

Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems

STUDY OBJECTIVES

To assess the effectiveness of continuous positive airway pressure (CPAP) management guided by CPAP machine downloads in newly diagnosed patients with obstructive sleep apnea (OSA) using electronic health record-derived health care utilization, biometric variables, and laboratory data.

METHODS

Electronic health record data of patients seen at the University of Utah Sleep Program from 2012-2015 were reviewed to identify patients with new diagnosis of OSA in whom CPAP adherence and residual apnea-hypopnea index as measured by a positive airway pressure adherence tracking device data for ≥ 1 year were available. Biometric data, laboratory data, and system-wide charges were compared in the 1 year before and after CPAP therapy. Subgroups were divided by whether patients met tracking criteria, mean nightly usage, and OSA severity.

RESULTS

976 consecutive, newly diagnosed participants with OSA (median age 55 years, 56.6% male) met inclusion criteria. There was a mean decrease of systolic blood pressure (BP) of 1.2 mm Hg and diastolic BP of 1.0 mm Hg within a year of initiation of CPAP therapy. BP improvements in the subgroup meeting CPAP tracking targets were 1.36 mmHg (systolic) and 1.37 mmHg (diastolic). No significant change was noted in body mass index, glycated hemoglobin, or serum creatinine values within a year of starting CPAP therapy, and health care utilization increased (mean acute care visits 0.22 per year to 0.53 per year; mean charges of $3,997 per year to $8,986 per year).

CONCLUSIONS

An improvement in BP was noted within a year of CPAP therapy in newly diagnosed patients with OSA, with no difference in the magnitude of improvement between those meeting tracking system adherence targets.

CITATION

Locke BW, Neill SE, Howe HE, Crotty MC, Kim J, Sundar KM. Electronic health record-derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems. J Clin Sleep Med. 2022;18(3):885-894.

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.

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.

Patient experiences with telehealth in sleep medicine: a qualitative evaluation

STUDY OBJECTIVES

The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients' experiences receiving sleep care by telehealth.

METHODS

From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories.

RESULTS

The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting).

CONCLUSIONS

Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience.

CITATION

Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645-1651.

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.

Interrater reliability between in-person and telemedicine evaluations in obstructive sleep apnea

STUDY OBJECTIVES

We examined how telemedicine evaluation compares to face-to-face evaluation in identifying risk for sleep-disordered breathing.

METHODS

This was a randomized interrater reliability study of 90 participants referred to a university sleep center. Participants were evaluated by a clinician investigator seeing the patient in-person, then randomized to a second clinician investigator who performed a patient evaluation online via audio-video conferencing. The primary comparator was pretest probability for obstructive sleep apnea.

RESULTS

The primary outcome comparing pretest probability for obstructive sleep apnea showed a weighted kappa value of 0.414 (standard error 0.090, P = .002), suggesting moderate agreement between the 2 raters. Kappa values of our secondary outcomes varied widely, but the kappa values were lower for physical exam findings compared to historical elements.

CONCLUSIONS

Evaluation for pretest probability for obstructive sleep apnea via telemedicine has a moderate interrater correlation with in-person assessment. A low degree of interrater reliability for physical exam elements suggests telemedicine assessment for obstructive sleep apnea could be hampered by a suboptimal physical exam. Employing standardized scales for obstructive sleep apnea when performing telemedicine evaluations may help with risk-stratification and ultimately lead to more tailored clinical management.

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.

One-Year Adherence to Continuous Positive Airway Pressure With Telemonitoring in Sleep Apnea Hypopnea Syndrome: A Randomized Controlled Trial

Study Objective: Telemedicine (TM) for continuous positive airway pressure (CPAP) treated patients may save health-care resources without compromising treatment effectiveness. We assessed the effect of TM (AirView Online System, ResMed) during the CPAP habituation phase on 3-month and 1-year treatment adherence and efficacy in patients with moderate-to-severe obstructive sleep apnea (OSA).

Methods: At CPAP initiation, 120 patients diagnosed with OSA were randomized to either usual care (UC) or TM during the habituation phase (clinical registration: ISRCTN12865936). Both groups received a first face-to-face appointment with a sleep care giver at CPAP initiation. Within the following month, 2 other physical visits were scheduled in the UC group whereas two phone consultations were planned in the TM group, in which CPAP parameters were remotely adapted. Additional physical visits were programmed at the patient's request. Face-to-face consultations were scheduled at 3 and 12 months after CPAP initiation. The primary outcome was the mean CPAP daily use over the course of 12 months.

Results: Twenty of 60 patients stopped CPAP therapy in the UC group vs. 14 of 60 in the TM group (p = 0.24). In per protocol analysis, mean [95% CI] daily CPAP use among 86 patients still using CPAP at 12 months was 279 [237; 321] min in the 38 patients on UC and 279 [247; 311] min in the 43 patients on TM, mean difference [95% CI]: 0 [−52; 52] min, P = 0.99. Total consultation time per patient was not different between groups, TM: 163 [147; 178] min, UC: 178 [159; 197] min, difference: −15 [−39; 9] min, p = 0.22.

Conclusions: Telemedicine during the CPAP habituation phase did not alter daily CPAP use or treatment adherence and did not require more healthcare time. Telemedicine may support clinic attendance for CPAP titration.

Clinical Trial Registration: [ISRCTN], identifier [ISRCTN12865936].

Effects of telemedicine interventions in improving continuous positive airway pressure adherence in patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials

PURPOSE

This meta-analysis was conducted to assess the effects of telemedicine interventions on continuous positive airway pressure (CPAP) adherence in patients with obstructive sleep apnoea (OSA).

METHODS

The PubMed, Cochrane Library, OVID, Web of Science and EBSCO host databases were searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. The study inclusion criteria were RCTs that compared patients who received telemedicine interventions with a control group and reported a change in CPAP adherence. The primary outcome was the improvement in CPAP adherence.

RESULTS

In total, there were 11 RCTs (n = 1358) with quantitative analyses. Intervention times ranged from 1 to 6 months. Compared to controls, the telemedicine group exhibited better adherence to CPAP therapy (pooled mean difference (MD) = 0.57, 95% CI = 0.33 to 0.80, I² = 7%, p < 0.00001). We performed sensitivity analyses by the type of telemedicine intervention, comorbidity burden, and OSA severity to explore whether or not their effect sizes may have affected the time of CPAP application. We performed subgroup analyses by follow-up duration, age, and OSA Epworth sleepiness scale (ESS) symptoms to determine if their effect sizes may have affected the time of CPAP application. However, these analyses did not change the statistical significance of the pooled estimate.

CONCLUSIONS

The use of telemedicine for up to 6 months may enhance CPAP adherence in patients with OSA, when compared to no intervention. Our study was searched from January 2004 to February 2020 for randomised controlled trials (RCTs) that assessed the effects of telemedicine interventions on CPAP adherence in patients with OSA. Future studies can continue to search for articles after February 2020.

The most used questionnaires for evaluating telemedicine services

Background

Questionnaires are commonly used tools in telemedicine services that can help to evaluate different aspects. Selecting the ideal questionnaire for this purpose may be challenging for researchers. This study aims to review which questionnaires are used to evaluate telemedicine services in the studies, which are most common, and what aspects of telemedicine evaluation do they capture.

Methods

The PubMed database was searched in August 2020 to retrieve articles. Data extracted from the final list of articles included author/year of publication, journal of publication, type of evaluation, and evaluation questionnaire. Data were analyzed using descriptive statistics.

Results

Fifty-three articles were included in this study. The questionnaire was used for evaluating the satisfaction (49%), usability (34%), acceptance (11.5%), and implementation (2%) of telemedicine services. Among telemedicine specific questionnaires, Telehealth Usability Questionnaire (TUQ) (19%), Telemedicine Satisfaction Questionnaire (TSQ) (13%), and Service User Technology Acceptability Questionnaire (SUTAQ) (5.5%), were respectively most frequently used in the collected articles. Other most used questionnaires generally used for evaluating the users’ satisfaction, usability, and acceptance of technology were Client Satisfaction Questionnaire (CSQ) (5.5%), Questionnaire for User Interaction Satisfaction (QUIS) (5.5%), System Usability Scale (SUS) (5.5%), Patient Satisfaction Questionnaire (PSQ) (5.5%), and Technology Acceptance Model (TAM) (3.5%) respectively.

Conclusion

Employing specifically designed questionnaires or designing a new questionnaire with fewer questions and more comprehensiveness in terms of the issues studied provides a better evaluation. Attention to user needs, end-user acceptance, and implementation processes, along with users' satisfaction and usability evaluation, may optimize telemedicine efforts in the future.

Leveraging Telehealth to improve access to care: a qualitative evaluation of Veterans' experience with the VA TeleSleep program

Background

Obstructive sleep apnea is common among rural Veterans, however, access to diagnostic sleep testing, sleep specialists, and treatment devices is limited. To improve access to sleep care, the Veterans Health Administration (VA) implemented a national sleep telemedicine program. The TeleSleep program components included: 1) virtual clinical encounters; 2) home sleep apnea testing; and 3) web application for Veterans and providers to remotely monitor symptoms, sleep quality and use of positive airway pressure (PAP) therapy. This study aimed to identify factors impacting Veteran’s participation, satisfaction and experience with the TeleSleep program as part of a quality improvement initiative.

Methods

Semi-structured interview questions elicited patient perspectives and preferences regarding accessing and engaging with TeleSleep care. Rapid qualitative and matrix analysis methods for health services research were used to organize and describe the qualitative data.

Results

Thirty Veterans with obstructive sleep apnea (OSA) recruited from 6 VA telehealth “hubs” participated in interviews. Veterans reported positive experiences with sleep telemedicine, including improvements in sleep quality, other health conditions, and quality of life. Access to care improved as a result of decreased travel burden and ability of both clinicians and Veterans to remotely monitor and track personal sleep data. Overall experiences with telehealth technology were positive. Veterans indicated a strong preference for VA over non-VA community-based sleep care. Patient recommendations for change included improving scheduling, continuity and timeliness of communication, and the equipment refill process.

Conclusions

The VA TeleSleep program improved patient experiences across multiple aspects of care including a reduction in travel burden, increased access to clinicians and remote monitoring, and patient-reported health and quality of life outcomes, though some communication and continuity challenges remain. Implementing telehealth services may also improve the experiences of patients served by other subspecialties or healthcare systems.

Comparing VA and Community-Based Care: Trends in Sleep Studies Following the Veterans Choice Act

BACKGROUND

To address concerns about access to care, the Veterans Access, Choice, and Accountability Act of 2014 was enacted to make care available in the community when Veterans Health Administration (VA) care was unavailable or not timely. This paper examined VA referrals for diagnostic sleep studies from federal fiscal year (FY) 2015-2018.

DESIGN

Sleep studies completed between FY2015 and 2018 for Veterans tested within VA facilities (VAF) or referred to VA community care (VACC) providers were identified using VA administrative data files. Sleep studies were divided into laboratory and home studies.

KEY RESULTS

The number of sleep studies conducted increased over time; the proportion of home studies increased in VAF (32 to 47%). Veterans were more likely to be referred for a sleep study to VACC if they lived in a rural or highly rural area (ORs = 1.47 and 1.55, respectively), and had public or public and private insurance (ORs = 2.01 and 1.35), and were less likely to be referred to VACC if they were age 65+ (OR = 0.72) and were in the highest utilization risk based on Nosos score (OR = 0.78). Regression analysis of sleep study type revealed that lab studies were much more likely for VACC referrals (OR = 3.16), for persons living in rural areas (OR = 1.21), with higher comorbidity scores (OR = 1.28) and for ages 44-54, 55 to 64, and 65+ (ORs = 1.12, 1.28, 1.45, respectively) compared to younger Veterans. Veterans with some or full VA copayments (ORs = 0.91 and 0.86, respectively), and overweight Veterans (OR = 0.94) were less likely to have lab studies.

CONCLUSIONS

The number of sleep studies performed on Veterans increased from 2015 to 2018. Access to sleep studies improved through a combination of providing care through the Veteran Choice Program, predominantly used by rural Veterans, and increased use of home sleep studies by VA.

The Impact of Telehealth on the Organization of the Health System and Integrated Care

Sleep medicine is a rapidly developing field of medicine that is well-suited to initiatives such as Telehealth to provide safe, effective clinical care to an expanding group of patients. The increasing prevalence of sleep disorders has resulted in long waiting lists and lack of specialist availability. Telemedicine has potential to facilitate a move toward an integrated care model, which involves professionals from different disciplines and different organizations working together in a team-oriented way toward a shared goal of delivering all of a person's care requirements. Issues around consumer health technology and nonphysician sleep providers are discussed further in the article.

Telehealth, Telemedicine, and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) telehealth management may improve initial and chronic care access, time to diagnosis and treatment, between-visit care, e-communications and e-education, workflows, costs, and therapy outcomes. OSA telehealth options may be used to replace or supplement none, some, or all steps in the evaluation, testing, treatments, and management of OSA. All telehealth steps must adhere to OSA guidelines. OSA telehealth may be adapted for continuous positive airway pressure (CPAP) and non-CPAP treatments. E-data collection enhances uses for individual and group analytics, phenotyping, testing and treatment selections, high-risk identification and targeted support, and comparative and multispecialty therapy studies.

Global burden of sleep-disordered breathing and its implications

One-seventh of the world's adult population, or approximately one billion people, are estimated to have OSA. Over the past four decades, obesity, the main risk factor for OSA, has risen in striking proportion worldwide. In the past 5 years, the WHO estimates global obesity to affect almost two billion adults. A second major risk factor for OSA is advanced age. As the prevalence of the ageing population and obesity increases, the vulnerability towards having OSA increases. In addition to these traditional OSA risk factors, studies of the global population reveal select contributing features and phenotypes, including extreme phenotypes and symptom clusters that deserve further examination. Untreated OSA is associated with significant comorbidities and mortality. These represent a tremendous threat to the individual and global health. Beyond the personal toll, the economic costs of OSA are far-reaching, affecting the individual, family and society directly and indirectly, in terms of productivity and public safety. A better understanding of the pathophysiology, individual and ethnic similarities and differences is needed to better facilitate management of this chronic disease. In some countries, measures of the OSA disease burden are sparse. As the global burden of OSA and its associated comorbidities are projected to further increase, the infrastructure to diagnose and manage OSA will need to adapt. The use of novel approaches (electronic health records and artificial intelligence) to stratify risk, diagnose and affect treatment are necessary. Together, a unified multi-disciplinary, multi-organizational, global approach will be needed to manage this disease.

Evaluating the feasibility of implementing a Telesleep pilot program using two-tiered external facilitation

BACKGROUND

Obstructive sleep apnea (OSA) can negatively impact patients' health status and outcomes. Positive airway pressure (PAP) reverses airway obstruction and may reduce the risk of adverse outcomes. Remote monitoring of PAP (as opposed to in-person visits) may improve access to sleep medicine services. This study aimed to evaluate the feasibility of implementing a clinical program that delivers treatment for OSA through PAP remote monitoring using external facilitation as an implementation strategy.

METHODS

Participants included patients with OSA at a Veteran Affairs Medical Center (VAMC). PAP adherence and clinical disease severity on treatment (measured by the apnea hypopnea index [AHI]) were the preliminary effectiveness outcomes across two delivery models: usual care (in-person) and Telehealth nurse-delivered remote monitoring. We also assessed visit duration and travel distance. A prospective, mixed-methods evaluation examined the two-tiered external facilitation implementation strategy.

RESULTS

The pilot project included N = 52 usual care patients and N = 38 Telehealth nurse-delivered remote monitoring patients. PAP adherence and disease severity were similar across the delivery modalities. However, remote monitoring visits were 50% shorter than in-person visits and saved a mean of 72 miles of travel (median = 45.6, SD = 59.0, mode = 17.8, range 5.4-220). A total of 62 interviews were conducted during implementation with a purposive sample of 12 clinical staff involved in program implementation. Weekly external facilitation delivered to both front-line staff and supervisory physicians was necessary to ensure patient enrollment and treatment. Synchronized, "two-tiered" facilitation at the executive and coordinator levels proved crucial to developing the clinical and administrative infrastructure to support a PAP remote monitoring program and to overcome implementation barriers.

CONCLUSIONS

Remote PAP monitoring had similar efficacy to in-person PAP services in this Veteran population. Although external facilitation is a widely-recognized implementation strategy in quality improvement projects, less is known about how multiple facilitators work together to help implement complex programs. Two-tiered facilitation offers a model well-suited to programs where innovations span disciplines, disrupt professional hierarchies (such as those between service chiefs, clinicians, and technicians) and bring together providers who do not know each other, yet must collaborate to improve access to care.

Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea

BACKGROUND

Although highly effective in the treatment of obstructive sleep apnoea (OSA), continuous positive airway pressure (CPAP) is not universally accepted by users. Educational, supportive and behavioural interventions may help people with OSA initiate and maintain regular and continued use of CPAP.

OBJECTIVES

To assess the effectiveness of educational, supportive, behavioural, or mixed (combination of two or more intervention types) strategies that aim to encourage adults who have been prescribed CPAP to use their devices.

SEARCH METHODS

Searches were conducted on the Cochrane Airways Group Specialised Register of trials. Searches are current to 29 April 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that assessed intervention(s) designed to inform participants about CPAP/OSA, to support them in using CPAP, or to modify their behaviour to increase use of CPAP devices.

DATA COLLECTION AND ANALYSIS

We assessed studies to determine their suitability for inclusion in the review. Data were extracted independently and were entered into RevMan for analysis. 'Risk of bias' assessments were performed, using the updated 'Risk of bias 2' tool, for the primary outcome, CPAP usage. Study-level 'Risk of bias' assessments were performed using the original 'Risk of bias' tool. GRADE assessment was performed using GRADEpro.

MAIN RESULTS

Forty-one studies (9005 participants) are included in this review; 16 of these studies are newly identified with updated searches. Baseline Epworth Sleepiness Scale (ESS) scores indicate that most participants suffered from excessive daytime sleepiness. The majority of recruited participants had not used CPAP previously. When examining risk of bias for the primary outcome of hourly machine usage/night, 58.3% studies have high overall risk (24/41 studies), 39.0% have some concerns (16/41 studies), and 2.4% have low overall risk (1/41 studies). We are uncertain whether educational interventions improve device usage, as the certainty of evidence was assessed as very low. We were unable to perform meta-analyses for number of withdrawals and symptom scores due to high study heterogeneity. Supportive interventions probably increase device usage by 0.70 hours/night (95% confidence interval (CI) 0.36 to 1.05, N = 1426, 13 studies, moderate-certainty evidence), and low-certainty evidence indicates that the number of participants who used their devices ≥ 4 hours/night may increase from 601 to 717 per 1000 (odds ratio (OR), 1.68, 95% CI 1.08 to 2.60, N = 376, 2 studies). However, the number of withdrawals may also increase from 136 to 167 per 1000 (OR 1.27, 95% CI 0.97 to 1.66, N = 1702, 11 studies, low-certainty evidence). Participants may experience small improvements in symptoms (ESS score -0.32 points, 95% CI -1.19 to 0.56, N = 470, 5 studies, low-certainty evidence), and we are uncertain whether quality of life improves with supportive interventions, as the certainty of evidence was assessed as very low. When compared with usual care, behavioural interventions produce a clinically-meaningful increase in device usage by 1.31 hours/night (95% CI 0.95 to 1.66, N = 578, 8 studies, high-certainty evidence), probably increase the number of participants who used their machines ≥ 4 hours/night from 371 to 501 per 1000 (OR 1.70, 95% CI 1.20 to 2.41, N = 549, 6 studies, high-certainty evidence), and reduce the number of study withdrawals from 146 to 101 per 1000 (OR 0.66, 95% CI 0.44 to 0.98, N = 939, 10 studies, high-certainty evidence). Behavioural interventions may reduce symptoms (ESS score -2.42 points, 95% CI -4.27 to -0.57, N = 272, 5 studies, low-certainty evidence), but probably have no effect on quality of life (Functional Outcomes of Sleep Questionnaire (FOSQ), standardised mean difference (SMD) 0.00, 0.95% CI -0.26 to 0.26, N = 228, 3 studies, moderate-certainty evidence). We are uncertain whether behavioural interventions improve apnoea hypopnoea index (AHI), as the certainty of evidence was assessed as very low. We are uncertain if mixed interventions improve device usage, increase the number of participants using their machines ≥ 4 hours/night, reduce study withdrawals, improve quality of life, or reduce anxiety symptoms, as the certainty of evidence for these outcomes was assessed to be very low. Symptom scores via the ESS could not be measured due to considerable heterogeneity between studies.

AUTHORS' CONCLUSIONS

In CPAP-naïve people with OSA, high-certainty evidence indicates that behavioural interventions yield a clinically-significant increase in hourly device usage when compared with usual care. Moderate certainty evidence shows that supportive interventions increase usage modestly. Very low-certainty evidence shows that educational and mixed interventions may modestly increase CPAP usage. The impact of improved CPAP usage on daytime sleepiness, quality of life, and mood and anxiety scores remains unclear since these outcomes were not assessed in the majority of included studies. Studies addressing the choice of interventions that best match individual patient needs and therefore result in the most successful and cost-effective therapy are needed.

Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials

Background:

This was a meta-analysis of continuous positive airway pressure (CPAP) compliance. We compared telemonitor (TM) care with usual care and supervised PAP titration (SPT) in the sleep unit with home auto-adjusting pressure titration (HAPT) in patients with obstructive sleep apnea (OSA).

Methods:

We searched PubMed, Web of Science, Scopus, and Medline for appropriate randomized controlled trials (RCTs) that compared TM care with usual care for patients with OSA. Review Manager 5.3 was used for all comparisons and analyses.

Results:

Our meta-analysis included 19 studies involving a total of 2464 patients with OSA; CPAP compliance was significantly higher in the TM care group [mean difference (MD) 0.68 h, 95% confidence interval (CI) 0.48–0.89 h, I² = 49%] compared with the usual care group. When we compared SPT and HAPT, two groups did not exhibit significantly different levels of CPAP compliance (MD −0.34 h, 95% CI −0.72–0.05 h, I² = 91%). Subgroup analysis comparing the SPT with HAPT in CPAP compliance was grouped by follow-up time (⩾3 months or <3 months). Once again, there were no between-group differences in either long-term (MD = 0.56 h, 95% CI = 1.39–0.26 h, I² = 91%), or short-term (MD = 0.34 h, 95% CI = 0.26–0.27 h, I² = 14%) follow up.

Conclusions:

TM care was associated with significantly greater CPAP compliance compared with usual care. Also, HAPT was not inferior to SPT for CPAP compliance.

Effectiveness of eHealth Interventions in Improving Treatment Adherence for Adults With Obstructive Sleep Apnea: Meta-Analytic Review

Background

Poor adherence to continuous positive airway pressure (CPAP) treatment by adults with obstructive sleep apnea (OSA) is a common issue. Strategies delivered by means of information and communication technologies (ie, eHealth) can address treatment adherence through patient education, real-time monitoring of apnea symptoms and CPAP adherence in daily life, self-management, and early identification and subsequent intervention when device or treatment problems arise. However, the effectiveness of available eHealth technologies in improving CPAP adherence has not yet been systematically studied.

Objective

This meta-analytic review was designed to investigate the effectiveness of a broad range of eHealth interventions in improving CPAP treatment adherence.

Methods

We conducted a systematic literature search of the databases of Cochrane Library, PsycINFO, PubMed, and Embase to identify relevant randomized controlled trials in adult OSA populations. The risk of bias in included studies was examined using seven items of the Cochrane Collaboration risk-of-bias tool. The meta-analysis was conducted with comprehensive meta-analysis software that computed differences in mean postintervention adherence (MD), which was defined as the average number of nightly hours of CPAP use.

Results

The meta-analysis ultimately included 18 studies (N=5429 adults with OSA) comprising 22 comparisons between experimental and control conditions. Postintervention data were assessed at 1 to 6 months after baseline, depending on the length of the experimental intervention. eHealth interventions increased the average nightly use of CPAP in hours as compared with care as usual (MD=0.54, 95% CI 0.29-0.79). Subgroup analyses did not reveal significant differences in effects between studies that used eHealth as an add-on or as a replacement to care as usual (P=.95), between studies that assessed stand-alone eHealth and blended strategies combining eHealth with face-to-face care (P=.23), or between studies of fully automated interventions and guided eHealth interventions (P=.83). Evidence for the long-term follow-up effectiveness of eHealth adherence interventions remains undecided owing to a scarcity of available studies and their mixed results.

Conclusions

eHealth interventions for adults with OSA can improve adherence to CPAP in the initial months after the start of treatment, increasing the mean nightly duration of use by about half an hour. Uncertainty still exists regarding the timing, duration, intensity, and specific types of eHealth interventions that could be most effectively implemented by health care providers.

Mobile health application to support CPAP therapy in obstructive sleep apnoea: design, feasibility and perspectives

Background

Current continuous positive airway pressure (CPAP) devices can be monitored remotely; however, in-person visits are kept for clinical follow-up in order to promote CPAP use and resolve potential side-effects. Mobile health is a promising way to provide remote and easy clinical control for CPAP follow-up and support. We aimed to evaluate the feasibility and acceptance by obstructive sleep apnoea (OSA) patients and healthcare professionals of a newly designed mobile app (Appnea-Q) to promote clinical control through a self-monitoring tool for patients with CPAP supervised by sleep professionals.

Methods

Appnea-Q incorporates a simple follow-up questionnaire with automated responses, together with frequent problems and lifestyle recommendations sections. Feasibility, acceptance and usefulness were assessed. First, an internal validation was performed during outpatient CPAP follow-up visits with sleep professionals from various sleep units. Second, an external validation was performed in a subgroup of 15 patients at home.

Results

Most patients (n=75) considered the app useful and were willing to use it and recommend it (72-88%). Up to 64.87% agreed on its capacity to reduce hospital visits. Appnea-Q was rated as acceptable (79.37±19.29) by the system usability score. Sleep professionals (n=30) concurred on its usefulness for OSA patient follow-up, particularly during the first month of CPAP therapy. The external validation showed its feasibility among 11 out of 15 patients and their data were received accordingly on the professionals' web platform.

Conclusions

According to our validation process, and the viewpoints of the patients and professionals, our new mobile app is a feasible and well-received tool for personal OSA management. Future clinical trials should substantiate its performance and cost-effectiveness in the clinical arena.

Comprehensive management of obstructive sleep apnea by telemedicine: Clinical improvement and cost-effectiveness of a Virtual Sleep Unit. A randomized controlled trial

Introduction

Obstructive sleep apnea (OSA) is a prevalent disease associated with significant morbidity and high healthcare costs. Information and communication technology could offer cost-effective management options.

Objectives

To evaluate an out-of-hospital Virtual Sleep Unit (VSU) based on telemedicine to manage all patients with suspected OSA, including those with and without continuous positive airway pressure (CPAP) therapy.

Methods

This was an open randomized controlled trial. Patients with suspected OSA were randomized to hospital routine (HR) or VSU groups to compare the clinical improvement and cost-effectiveness in a non-inferiority analysis. Improvement was assessed by changes in the Quebec Sleep Questionnaire (QSQ), EuroQol (EQ-5D and EQ-VAS), and Epworth Sleepiness Scale (ESS). The follow-up was 3 months. Cost-effectiveness was assessed by a Bayesian analysis based on quality-adjusted life-years (QALYs).

Results

The HR group (n: 92; 78% OSA, 57% CPAP) compared with the VSU group (n: 94; 83% OSA, 43% CPAP) showed: CPAP compliance was similar in both groups, the QSQ social interactions domain improved significantly more in the HR group whereas the EQ-VAS improved more in the VSU group. Total and OSA-related costs were lower in the VSU group than the HR. The Bayesian cost-effectiveness analysis showed that VSU was cost-effective for a wide range of willingness to pay for QALYs.

Conclusions

The VSU offered a cost-effective means of improving QALYs than HR. However, the assessment of its clinical improvement was influenced by the choice of the questionnaire; hence, additional measurements of clinical improvement are needed. Our findings indicate that VSU could help with the management of many patients, irrespective of CPAP use.

Redesigning Care for OSA

Constrained by a limited supply of specialized personnel, health systems face a challenge in caring for the large number of patients with OSA. The complexity of this challenge is heightened by the varied clinical presentations of OSA and the diversity of treatment approaches. Innovations such as simplified home-based care models and the incorporation of nonspecialist providers have shown promise in the management of uncomplicated patients, producing comparable outcomes to the resource-intensive traditional approach. However, it is unclear if these innovations can meet the needs of all patients with OSA, including those with mild disease, atypical presentations, and certain comorbid medical and mental health conditions. This review discusses the diversity of needs in OSA care, the evidence base behind recent care innovations, and the potential limitations of each innovation in meeting the diversity of care needs. We propose how these innovations can fit within the stepped care and hub and spoke models in a way that addresses the full spectrum of OSA, and we discuss future research directions to assess the deployment of these innovations.

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program

STUDY OBJECTIVES

(1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand.

METHODS

PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse.

RESULTS

Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014.

CONCLUSIONS

Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions.

CITATION

Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.

New organisation for follow-up and assessment of treatment efficacy in sleep apnoea

Obstructive sleep apnoea (OSA) is a highly prevalent disease, and there is an increased demand for OSA diagnosis and treatment. However, resources are limited compared with the growing needs for OSA diagnosis and management, and alternative strategies need to be developed to optimise the OSA clinical pathway. In this review, we propose a management strategy for OSA, and in general for sleep-disordered breathing, to be implemented from diagnosis to follow-up. For this purpose, the best current options seem to be: 1) networking at different levels of care, from primary physicians to specialised sleep laboratories; and 2) use of telemedicine. Telemedicine can contribute to the improved cost-effectiveness of OSA management during both the diagnostic and therapeutic phases. However, although the technology is already in place and different commercial platforms are in use, it is still unclear how to use telemedicine effectively in the sleep field. Application of telemedicine for titration of positive airway pressure treatment, follow-up to improve compliance to treatment through early identification and solution of problems, and teleconsultation all appear to be promising areas for improved OSA management.

Telemedicine could improve the management of sleep apnoea and other breathing disorders during sleep.http://bit.ly/2XPoPW1

Telemedicine Improves Continuous Positive Airway Pressure Adherence in Stroke Patients with Obstructive Sleep Apnea in a Randomized Trial

BACKGROUND

The prevalence of obstructive sleep apnea (OSA) is very high in stroke patients, whereas the acceptance of positive airway pressure (PAP) therapy is low. Although telemedicine offers new options to increase acceptance, effective concepts and patient groups are not yet known.

OBJECTIVE

The aim of this study was to investigate the effect of a telemedicine concept consisting of telemonitoring and support when usage time drops.

METHODS

PAP naive stroke patients with apnea-hypopnea index (AHI) >15 were randomized in a prospective parallel design comparing home therapy with standard care (SC) as opposed to telemedicine care (TC) over a period of 6 months. The TC group received a standardized phone call to offer help and advice if the average weekly usage of PAP fell below 4 h/night.

RESULTS

Eighty patients were included, 5 were lost to follow-up, 75 (20 females, age: 57.0 ± 9.9, body mass index: 30.9 ± 6.0 kg/m2, AHI: 39.4 ± 18.6) were evaluated. While inpatient usage was similar in both groups, a significant difference was identified after 6 months of receiving home therapy (TC: 4.4 ± 2.5 h, SC: 2.1 ± 2.2 h; p < 0.000063). On average, 4.7 ± 3.1 interventional phone calls were needed (173 calls in total, ranging from 0 to 10 calls per patient), primarily for the purpose of motivation (61.3%), mask problems (16.2%), nasopharyngeal complaints or humidification issues (11.2%), and technical questions (10.6%). Sleepiness (Epworth Sleepiness Scale [ESS]) differed significantly (TC: 3.7 + 3.2, SC: 6.1 + 4.1; p = 0.008), as well as systolic blood pressure, which was available in a subgroup of 55 patients (TC: 129.5 + 15.2 mm Hg, SC: 138.8 + 16.1 mm Hg; p = 0.034).

CONCLUSION

A concept of telemonitoring and short telephone calls from the sleep lab raised PAP therapy adherence significantly in a group of stroke patients with moderate to severe OSA.

Development of a Sleep Telementorship Program for Rural Department of Veterans Affairs Primary Care Providers: Sleep Veterans Affairs Extension for Community Healthcare Outcomes

RATIONALE

Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access.

OBJECTIVES

The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine.

METHODS

ECHO creates a virtual learning community through video-teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance.

MEASUREMENTS AND MAIN RESULTS

Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers.

CONCLUSIONS

Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.

Mask Refills as a Measure of PAP Adherence

STUDY OBJECTIVES

Positive airway pressure (PAP) adherence data are a routine aspect of clinical care for obstructive sleep apnea (OSA), but not uniformly available. We hypothesized that mask refills are a measure of PAP adherence.

METHODS

We measured PAP use over the first 90 days of treatment in 123 patients with OSA. The number and timing of mask refills was assessed over 18 months. Demographic and medical information was obtained from the electronic medical record.

RESULTS

Average PAP use in the first week of more than 4 h/d was a predictor of adherence over the first 90 days (P < .0001). PAP use over 90 days was greater in datacard-derived data dependent on patients presenting a datacard to the clinic compared to modem-derived data (P = .0006). A mask refill within the first 30 days of treatment was associated with a 1.3 h/d lower PAP usage in the first 90 days (P = .0044). Conversely, the number of mask refills between 30 days and 18 months was associated with higher PAP adherence during the first 90 days, with an additional 0.61 h/d of use for each additional refill (P = .0015).

CONCLUSIONS

In a retrospective cohort of veterans with OSA, first week PAP use was a strong predictor of 90-day use. Use of autonomously transmitted modem data avoided potential selection bias in adherence estimates. Mask refills in the first month were associated with less 90-day PAP use, whereas more mask refills after 30 days were associated with greater PAP use.

Remote consulting with telemonitoring of continuous positive airway pressure usage data for the routine review of people with obstructive sleep apnoea hypopnoea syndrome: A systematic review

INTRODUCTION

Telehealth has the potential to offer more convenient care and reduce travel. We aimed to systematically review studies that assessed the effectiveness of teleconsultation plus telemonitoring in the review of people with obstructive sleep apnoea hypopnoea syndrome receiving continuous positive airway pressure therapy versus face-to-face care.

METHODS

Following Cochrane methodology, we searched 10 electronic databases (November 2015), trial registries, and reference lists of included studies, for trials testing interventions that combined remote consultations with telemonitoring of usage/continuous positive airway pressure data. Outcomes measures were: proportion reviewed, continuous positive airway pressure adherence, symptom control, and satisfaction/acceptability and cost effectiveness.

RESULTS

From 362 potentially relevant papers, we identified five randomised controlled trials ( n = 269 patients): four from North America and one from Spain. Risk of bias was moderate in one, and moderate/high in four trials. Two trials reported number/duration of reviews with inconsistent results. The teleconsultation/telemonitoring improved continuous positive airway pressure adherence in two trials ( n = 19; n = 75); two ( n = 114 and n = 75) reported no between-groups differences. Two studies, both at moderate/high risk of bias, showed no between-group difference in the Epworth Sleepiness Score. Satisfaction was generally reported positively in all five trials; one trial reported that the teleconsultation/telemonitoring patients were 'more likely to continue' with continuous positive airway pressure therapy treatment. One study reported teleconsultation/telemonitoring as cost effective.

DISCUSSION

The evidence for teleconsultation/telemonitoring in continuous positive airway pressure users is limited; however, no safety concerns have been raised. Adequately powered, well-designed trials are needed to establish whether real-time telemonitoring and remote teleconsultation is a clinically and cost effective option for people using continuous positive airway pressure therapy.

Telehealth and patient satisfaction: a systematic review and narrative analysis

BACKGROUND

The use of telehealth steadily increases as it has become a viable modality to patient care. Early adopters attempt to use telehealth to deliver high-quality care. Patient satisfaction is a key indicator of how well the telemedicine modality met patient expectations.

OBJECTIVE

The objective of this systematic review and narrative analysis is to explore the association of telehealth and patient satisfaction in regards to effectiveness and efficiency.

METHODS

Boolean expressions between keywords created a complex search string. Variations of this string were used in Cumulative Index of Nursing and Allied Health Literature and MEDLINE.

RESULTS

2193 articles were filtered and assessed for suitability (n=44). Factors relating to effectiveness and efficiency were identified using consensus. The factors listed most often were improved outcomes (20%), preferred modality (10%), ease of use (9%), low cost 8%), improved communication (8%) and decreased travel time (7%), which in total accounted for 61% of occurrences.

CONCLUSION

This review identified a variety of factors of association between telehealth and patient satisfaction. Knowledge of these factors could help implementers to match interventions as solutions to specific problems.