Telemonitoring for the Follow-Up of Obstructive Sleep Apnea Patients Treated with CPAP: Accuracy and Impact on Therapy

Challenges in Obstructive Sleep Apnea Management in Elderly Patients

With the aging of the population, obstructive sleep apnea (OSA) in elderly patients is now more commonly seen in clinical practice. In older people, sleepiness is less marked than in younger patients, but insomnia symptoms are more common. Comorbidities are numerous and related to cardiometabolic and cognitive conditions. Polygraphy can be used to establish the diagnosis in the vast majority of cases, but polysomnography is indicated in cases of comorbid sleep disorders. Continuous positive airway pressure (CPAP) remains the cornerstone of treatment, but compliance decreases with age, especially in those over 80, and when cognitive disorders are also present. In these patients, CPAP can be beneficial in terms of nighttime symptoms, sleepiness, mood, and cognition but can also prevent cardiovascular and cerebrovascular disorders, especially in severeOSA patients. For this reason, we should offer this treatment to elderly patients and devise strategies to support them with treatment difficulties (e.g., therapeutic education, adapted masks, and telemonitoring). In the future, we need prospective studies to help identify elderly patients who will gain the greatest long-term benefit from treatment. Dedicated sleep testing, OSA severity markers, and specific questionnaires need to be developed in this older, but large, OSA population.

Can the Use of Telemedicine in the Management of Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnea Reduce Clinical Time and Additional Appointments: A Randomized Controlled Trial

Introduction: Obstructive sleep apnea (OSA) is a common sleep breathing disorder and is associated with increased cardiovascular risk and daytime sleepiness. Continuous positive airway pressure (CPAP) is a treatment for OSA, which splints the airway open. The introduction of telemedicine in CPAP devices offers clinical staff an alternative method of reviewing patients, monitoring treatment, and reducing clinical time. Materials and Methods: A randomized control trial was conducted with patients randomized to one of three arms: Arm 1 (standard care), Arm 2 (modem and a virtual appointment), and Arm 3 (modem, smart device application DreamMapper™, and a virtual appointment). Ninety participants requiring treatment with CPAP following a diagnosis of OSA were recruited and data collected at baseline, 14 days, and 180 days. Additional contacts or appointments were also recorded. Results: Ninety participants (n = 90) were recruited (68% males and 32% females) with an average age of 52.0 ± 13.13 years and apnea/hypopnea index (AHI) 43.5 ± 21.92 (events/h). There was a statistically significant difference between the three arms in the average clinical time taken for the first follow-up appointment (p = 0.001). There was a statistically significant difference between the three arms in the number of additional appointments or contacts required (p = 0.03). Discussion and Conclusion: Telemedicine reduced clinical time at first follow-up, and in patients who received standard care or a smart device application to monitor their own CPAP treatment, there were significantly less additional appointments required when compared with telemedicine support in the form of a modem alone.

Economic evaluation of telemonitoring as a follow-up approach for patients with obstructive sleep apnea syndrome starting treatment with continuous positive airway pressure

Telemonitoring of obstructive sleep apnea patients is increasingly being adopted though its cost-effectiveness evidence base is scanty. This study investigated whether telemonitoring is a cost-effective strategy compared with the standard follow-up in patients with obstructive sleep apnea who are starting continuous positive airway pressure treatment. In total, 167 obstructive sleep apnea patients were randomised into telemonitoring (n = 79) or standard follow-up (n = 88), initiated continuous positive airway pressure treatment, and were followed up for 6 months. The frequencies of healthcare contacts, related costs (in USD 2021 prices), treatment effect and compliance were compared between the follow-up approaches using generalised linear models. The cost effectiveness analysis was conducted from a healthcare perspective and the results presented as cost per avoided extra clinic visit. Additionally, patient satisfaction between the two approaches was explored. The analysis showed no baseline differences. At follow-up, there was no significant difference in treatment compliance, and the mean residual apnea-hypoapnea index. There was no difference in total visits, adjusted incidence rate ratio 0.87 (0.72-1.06). Participants in the telemonitoring arm made eight times more telephone visits, 8.10 (5.04-13.84), and about 73% fewer physical healthcare visits 0.27 (0.20-0.36). This translated into significantly lower total costs for the telemonitoring approach compared with standard follow-up, -192 USD (-346 to -41). The form of follow-up seemed to have no impact on the extent of patient satisfaction. These results demonstrate the telemonitoring of patients with obstructive sleep apnea initiating continuous positive airway pressure treatment as a cost saving strategy and can be argued as a potential worthy investment.

Use of Telemonitoring for CPAP Therapy Control in OSA Patients: Impact on Cost and Process Improvements

Introduction

In Spain, 2 million people are treated for obstructive sleep apnoea. Continuous positive airway pressure, the gold-standard therapy, requires regular follow-up and periodic evaluation of the efficacy of the treatment via a titration examination, i.e. autoCPAP test. Telemonitoring use is increasing and this study aims to evaluate the cost impact of its use for therapy evaluation instead of the standard ambulatory autoCPAP test.

Methods

This prospective observational study includes 100 OSA patients under CPAP therapy who volunteered to test telemonitoring as an alternative therapy control tool. Costs for both the patients and the Sleep Unit were calculated and compared for the standard of care (ambulatory autoCPAP (SoC)), vs alternative telemonitoring option (TM).

Results

More than half (54%) of the patients preferred the TM option vs only 47.5% of the SoC patients. Patients inclining towards telemonitoring option were mainly reported to be more than 10 years youngers, mainly active workers (63%), travelling more distance to the Sleep Unit (16 vs 8 km) and spending more expenses in travel than those who preferred SoC (median 30€). 29% of active workers left their jobs to attend the SoC. The costs related to the use of the Sleep Unit resources were found to be lower in the TM option compared to the SoC option (0.47 vs 3.09 euros per patient attended).

Conclusions

The use of TM for follow-up CPAP therapy enables the patient to save travel costs and to reduce absenteeism but also to save assistential burden and therefore to reduce the Sleep Unit workload and optimize the care activity.

Remote Monitoring of Positive Airway Pressure Data: Challenges, Pitfalls, and Strategies to Consider for Optimal Data Science Applications

Over recent years, positive airway pressure (PAP) remote monitoring has transformed the management of OSA and produced a large amount of data. Accumulated PAP data provide valuable and objective information regarding patient treatment adherence and efficiency. However, the majority of studies that have analyzed longitudinal PAP remote monitoring have summarized data trajectories in static and simplistic metrics for PAP adherence and the residual apnea-hypopnea index by the use of mean or median values. The aims of this article are to suggest directions for improving data cleaning and processing and to address major concerns for the following data science applications: (1) conditions for residual apnea-hypopnea index reliability, (2) lack of standardization of indicators provided by different PAP models, (3) missing values, and (4) consideration of treatment interruptions. To allow fair comparison among studies and to avoid biases in computation, PAP data processing and management should be conducted rigorously with these points in mind. PAP remote monitoring data contain a wealth of information that currently is underused in the field of sleep research. Improving the quality and standardizing data handling could facilitate data sharing among specialists worldwide and enable artificial intelligence strategies to be applied in the field of sleep apnea.

Evaluation of CPAP adherence in bariatric patients diagnosed with obstructive sleep apnea: outcomes of a multicenter cohort study

Purpose

Obstructive sleep apnea (OSA) is highly prevalent but mostly undiagnosed in obese patients scheduled for bariatric surgery. To prevent cardiopulmonary complications, many clinics perform preoperative OSA screening. Consequently, adequate adherence to continuous positive airway pressure (CPAP) therapy is essential but challenging. We aimed to evaluate CPAP adherence and its influence on postoperative outcomes.

Methods

In a prospective multicenter cohort study, we compared different perioperative strategies for handling undiagnosed OSA in bariatric patients. In this subgroup analysis, patients newly diagnosed with OSA were compared to those with pre-existing OSA. We assessed inadequate CPAP adherence, defined as < 4 h/night, between the preoperative period and 6 months postoperative. Cardiopulmonary complications and (un)scheduled ICU admissions were also evaluated.

Results

In total, 272 patients with newly diagnosed OSA (67.4%) and 132 patients with pre-existing OSA (32.6%) were included. Before surgery, 41 newly diagnosed patients used CPAP inadequately, compared to 5 patients with pre-existing OSA (15% vs. 4%, p = 0.049). Six months after surgery, inadequate CPAP use increased to 73% for newly diagnosed patients and 39% for patients with pre-existing OSA, respectively (p < 0.001). Incidences of cardiopulmonary complications, scheduled, and unscheduled ICU admissions were similar in the two study groups (p = 0.600, p = 0.972, and p = 0.980, respectively).

Conclusion

Inadequate CPAP adherence is higher in bariatric patients newly diagnosed with OSA when compared to patients with pre-existing OSA. Strategies to increase CPAP adherence may be valuable when considering routine OSA screening and CPAP therapy in patients undergoing bariatric surgery. Further studies are needed to improve current guidelines on perioperative OSA management of obese patients.

Trial registration

POPCORN study, registered at Netherlands Trial Register, https://www.trialregister.nl/trial/6805. ID no: 6805.