Effect of Telemonitoring and As Needed Patient Support on PAP Adherence

Obstructive sleep apnea (OSA) is an increasingly recognized condition affecting patient health and public welfare. While positive airway pressure (PAP) therapy has remained the preferred treatment for OSA since 1981, PAP therapy adherence rates have also remained stubbornly suboptimal. Measures for improving PAP therapy adherence have been under constant study, and current literature demonstrates telemonitoring interventions to be promising. Furthermore, the American Academy of Sleep Medicine (AASM) suggests that telemonitoring interventions be integrated into standard practice to support patients as they initiate and acclimate to PAP therapy. This quality improvement project examined the effect of interval PAP data telemonitoring and as needed (data triggered) patient support via telephone consultation(s) at two- and/or four-weeks post therapy initiation in patients with moderate to severe OSA. Compared to standard practice, this intervention resulted in significantly higher mean PAP adherence and a greater percentage of participants demonstrating continued PAP usage at 90 days post therapy initiation. The project’s results reflected those reported in the literature but did not result in a statistically significant increase in what is considered and defined as “good PAP adherence.

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

Telehealth Appointments to Increase Therapy Compliance in Patients with MOSA

Background: At the VA Puget Sound Healthcare System, care as usual for patients with a new diagnosis of mild obstructive sleep apnea (MOSA) is a letter directing the patient to call the continuous positive airway pressure (CPAP) clinic to establish ongoing care. Local Problem: This model has resulted in low therapy compliance and does not afford patients the ability to discuss their diagnosis and treatment options with a licensed healthcare provider. A literature review showed telemedicine interventions increase therapy compliance in patients with MOSA. Context: The Doctor of Nursing Practice project implemented an evidence-based practice change to improve therapy compliance for patients with a diagnosis of MOSA utilizing telehealth appointments. The aim was to increase compliance by 10%. Interventions: The interventions in this implementation project consisted of screening patients who met inclusion criteria for telemedicine appointments with a registered nurse (RN). The RN verified eligibility and sent a list of patients to the medical support assistant for scheduling. The RN conducted counseling sessions with the patient at the scheduled times to educate them on their diagnosis and treatment options and to answer their questions. The sleep medicine provider cosigned all encounters and made recommendations to the plan of care, as needed. Outcome Measures: Outcome measures included assessment of patient satisfaction with telemedicine appointments using a five- to eight-question survey. Therapy compliance was assessed via usage reports for CPAP, body mass index for patients who elect lifestyle changes, and patient self-reports. Reimbursement rates were assessed to determine long-term feasibility. Results: Sixteen patients from both the intervention group and the care as the usual group participated in the follow-up survey. Patient satisfaction was rated higher for the telehealth intervention group than the care as a usual group; 96% of respondents in the intervention group were satisfied with their care, while only 74% in the care as usual group were satisfied with their care

The Concomitant Relationship Shared by Sleep Disturbances and Type 2 Diabetes: Developing Telemedicine as a Viable Treatment Option

Individually, sleep disturbances and type 2 diabetes pose pervasive challenges to health. In addition, the negative symptomology associated with each condition is exacerbated further when presenting concomitantly. This relationship formulates a destructive loop wherein those with diabetes experience decreased sleep quality, which, in turn, worsens a wide range of health threats experienced by those with diabetes, including obesity and glucose intolerance. Because major lifestyle changes and daily care are needed to effectively manage both diabetes and sleep disturbances, an efficient and timely modality of treatment is essential. Advanced technology incorporating telemedicine and telehealth has the potential to enhance treatment by delivering accepted standard of care, medical monitoring, and education quickly and seamlessly—even in rural locations. This type of intervention has the added potential benefit of fostering patient empowerment

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

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

Enhancing the Diagnosis and Management of Obstructive Sleep Apnoea in Atrial Fibrillation Patients

Background: Atrial fibrillation (AF), is the most common sustained cardiac arrhythmia, and significantly increases the risk of stroke and cardiovascular mortality. It is strongly associated with obstructive sleep apnoea (OSA). Aims: 1. Examine the epidemiology of OSA in a hospital cohort with AF. 2. Compare the diagnostic accuracy of clinical screening tools for OSA in patients with AF. 3. Compare cardiac autonomic function in AF patients with and without OSA. 4. Conduct a pilot study of mandibular advancement splint (MAS) therapy for OSA in AF patients. Methods: 107 AF patients were recruited. The diagnostic accuracy of screening tools including a level 3 (portable) sleep study device as compared to polysomnography in AF patients was assessed. Cardiac autonomic function as a potential mechanistic link between OSA and AF was assessed using Heart Rate Variability (HRV). A pilot study of OSA treatment in AF patients using MAS therapy was conducted. Results: 62.6% of patients were newly diagnosed with OSA. Patients with moderate to severe OSA showed an increased BMI, neck circumference and Mallampati score, but were not significantly different in terms of daytime somnolence. Oxygen desaturation index (ODI) derived from a Level 3 portable sleep study device performed best for the diagnosis of moderate to severe and severe OSA, with excellent diagnostic accuracy (AUC 0.899, 95% CI 0.838 – 0.960 and AUC 0.925, 95% CI 0.859 – 0.991 respectively). We found a chronic increase in parasympathetic nervous activity in paroxysmal AF patients with OSA. MAS therapy showed high rates of acceptance, compliance and efficacy in AF patients. Conclusions: This thesis contributes to our understanding of the association between AF and OSA across a spectrum o

Practice Guidelines for Continuous Pulse Oximetry Monitoring for Obstructive Sleep Apnea Patients

As the rate of obesity has increased in the United States to include approximately 40% of the adult population, there has been a corresponding rise in the number of patients with obstructive sleep apnea (OSA). The OSA population is at risk for adverse perioperative respiratory depression. Continuous pulse oximetry monitoring is indicated for these patients upon discharge from the recovery room into other treatment settings and when cared for by telemetry or by trained hospital staff in the patient\u27s room. The practice question was whether an evidence-based practice guideline could be developed to help ensure safe postoperative monitoring of patients with OSA on the medical-surgical units. Guided by the Iowa model as the framework, a 13-member team from respiratory, anesthesiology, and technology departments participated in the guideline development. Three members of the 13-member interdisciplinary team evaluated the guideline using the AGREE II tool with the highest level of agreement on 6 of 6 domains; 100% of the team members agreed to move the developed guideline to the relevant hospital quality improvement committees. Availability of an evidence-based practice guideline for hospital nursing staff on general medical units has the potential to ensure safe management of patients with OSA while achieving cost savings when higher level of care settings may be unavailable for the growing number of patients with OSA. If safely implemented, these guidelines could be adapted in other healthcare facilities to ensure optimal health outcomes for patients with OSA

The Sleep Revolution project : the concept and objectives

Funding Information: This work is supported by the European Union's Horizon 2020 Research and Innovation Programme under Grant 965417. Publisher Copyright: © 2022 European Sleep Research Society.Obstructive sleep apnea is linked to severe health consequences such as hypertension, daytime sleepiness, and cardiovascular disease. Nearly a billion people are estimated to have obstructive sleep apnea with a substantial economic burden. However, the current diagnostic parameter of obstructive sleep apnea, the apnea–hypopnea index, correlates poorly with related comorbidities and symptoms. Obstructive sleep apnea severity is measured by counting respiratory events, while other physiologically relevant consequences are ignored. Furthermore, as the clinical methods for analysing polysomnographic signals are outdated, laborious, and expensive, most patients with obstructive sleep apnea remain undiagnosed. Therefore, more personalised diagnostic approaches are urgently needed. The Sleep Revolution, funded by the European Union's Horizon 2020 Research and Innovation Programme, aims to tackle these shortcomings by developing machine learning tools to better estimate obstructive sleep apnea severity and phenotypes. This allows for improved personalised treatment options, including increased patient participation. Also, implementing these tools will alleviate the costs and increase the availability of sleep studies by decreasing manual scoring labour. Finally, the project aims to design a digital platform that functions as a bridge between researchers, patients, and clinicians, with an electronic sleep diary, objective cognitive tests, and questionnaires in a mobile application. These ambitious goals will be achieved through extensive collaboration between 39 centres, including expertise from sleep medicine, computer science, and industry and by utilising tens of thousands of retrospectively and prospectively collected sleep recordings. With the commitment of the European Sleep Research Society and Assembly of National Sleep Societies, the Sleep Revolution has the unique possibility to create new standardised guidelines for sleep medicine.Peer reviewe