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Telemedicine in Sleep-Disordered Breathing

Expanding the Horizons
Open AccessPublished:July 02, 2021DOI:https://doi.org/10.1016/j.jsmc.2021.05.009

      Keywords

      Key points

      • Telemedicine has applications in all stages of the diagnosis, treatment, and follow-up of patients with sleep-disordered breathing. Diagnostic applications include telemonitored polysomnography, communication of test results and therapeutic options, and remote continuous positive airway pressure titration.
      • Online compliance monitoring results in similar and in some cases improved compliance when compared with traditional face-to-face evaluations. The impact of telemedicine on compliance depends on the preexisting organization of standard care in the routine setting.
      • Combining theory-driven behavioral approaches with telemedicine technology could hold the answer to increasing real-world adherence rates.
      • Targeted troubleshooting and support based on individual patient data, web-, and/or app-based teaching, and combinations via a smartphone app or coaching website is feasible.
      • Telemedicine is likely cost-effective but requires better evidence.

      Introduction

      Sleep medicine services have already undergone several disruptive changes related to new diagnostic and treatment technologies for the management of obstructive sleep apnea (OSA).
      • Freedman N.
      Counterpoint: does laboratory polysomnography yield better outcomes than home sleep testing? No.
      ,
      • Parish J.
      • Freedman N.
      • Manaker S.
      Evolution in reimbursement for sleep studies and sleep centers.
      Telemedicine, the remote delivery of care with the use of technology, is an emerging field in the twenty-first century and has currently received widespread acceptance among diverse medical specialties across the globe thanks to the rapid proliferation of mobile and home-based devices.
      • Venkateshiah S.B.
      • Hoque R.
      • Collop N.A.
      Legal aspects of sleep medicine in the 21th Century.
      Many sleep disorders are chronic conditions and require continuous treatment and monitoring of therapy success.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.
      Telemedicine provides flexibility for using e-care in none, some, or many of the steps in OSA evaluation, diagnosis, and management.
      Telemedicine-ready continuous positive airway pressure (CPAP) devices supporting the transmission of information on use time (hours per night), the apnea-hypopnea index (AHI), and leakage are available. The gathered data are sent via wireless networks to a secure server on the Internet, where it can be retrieved by the attending physician or sleep center. This opens new teleopportunities and e-opportunities for OSA care to replace, supplement, provide additional interim care and education, or improve practice workflows and costs for each of the different OSA treatments. Chronic management strategies, and big data deep learning applications may also be realized. With this, it is possible to serve patients better, to address problems early, and to inform on adverse side effects as well. In the end, this improves patient satisfaction and treatment adherence.
      A recent position paper from the American Academy of Sleep Medicine related to the use of telemedicine in sleep disorders stressed that “the practice of telemedicine should aim to promote a care model in which sleep specialists, patients, primary care providers, and other members of the healthcare team aim to improve the value of healthcare delivery in a coordinated fashion.”
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      Studies to date have used heterogeneous strategies and reported conflicting results.
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      • Schoch O.D.
      • Baty F.
      • Boesch M.
      • et al.
      Telemedicine for continuous positive airway pressure in sleep apnea. A randomized, controlled study.
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      Telehealth applications may be inserted in 1 or more of the workflow steps for diagnosis pathways, evaluation pathways, CPAP and non-CPAP treatments, and long-term follow-up. The current telemedicine applications are found to a smaller extent in the diagnostic procedures and to a much greater extent in the monitoring of therapy compliance for sleep apnea treatment. In this review, we will provide an overview of current practices, with the recent scientific progresses in telemonitoring for sleep-disordered breathing and their potential clinical applications for diagnosis and therapy, with emphasis on promising approaches to optimize adaptation and compliance:
      • Diagnostic telemedicine applications: teletriage, telemonitored polysomnography (telesupervision, teletransmission), telecommunication of test results and treatment options
      • Telemaskfitting and teleteaching (OSA and CPAP education)
      • Tele CPAP titration
      • Telemonitoring and problem solving:
        • Usual care
        • Remote monitoring CPAP therapy
        • Filter settings and fine-tuning of CPAP devices
      • Telecounseling and therapy reinforcement: by combining and integrating the most promising elements of both psychoeducational interventions and technological innovations (active calls, digitized human speech, web-based access for patients to own CPAP data, automated messaging, and patient engagement tools)
      • Telemanagement of comorbidities in OSA
      • Telemedicine in particular populations
      • Patient satisfaction and economic aspects (staff time, equipment, access to health care, addition of artificial intelligence, reimbursement, need for cost-benefit studies) will be highlighted.
      • Changing paradigms and expanding horizons will be discussed.
      Finally, also concerns related to telemedicine use and the remaining barriers and problems related to telemedicine implementation will also be addressed. In our opinion, all these telemedicine applications should be simple, with easy connectivity to external caregivers, achieving adequate training of nurses and physicians and should be directed to a specific group of patients.

      Diagnostic telemedicine applications

      Teletriage of Patients with Suspicion of Obstructive Sleep Apnea

      Patients with OSA enter sleep center workflows through different pathways. Before testing and diagnosis, patients initially may be evaluated by the general physician, by somnologists or other specialists, or eventually by self-referral.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      ,
      • Aurora R.N.
      • Quan S.F.
      Quality measure for screening for adult obstructive sleep apnea by primary care physicians.
      ,
      • Chai-Coetzer C.L.
      • Antic N.A.
      • Rowland L.S.
      • et al.
      Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: a randomized trial.
      Proper identification for possible comorbid apnea conditions and inherent risks during the assessment and before testing is important in the choice of any OSA workflow path.
      • Kapur V.K.
      • Auckley D.H.
      • Chowdhuri S.
      • et al.
      Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine Clinical Practice Guideline.
      Telemedicine enables the documentation of baseline and follow-up OSA symptoms, sleepiness, quality of life, blood pressure, body mass index, comorbid disorders and traffic accident assessment, by making use of sleep medicine questionnaires that may be completed by patients through E-health patient portals, OSA risk assessment software or by phone.
      • Chang Y.
      • Staley B.
      • Simonsen S.
      • et al.
      Transitioning from paper to electronic health record collection of Epworth sleepiness scale (ESS) for quality measures.
      Apart from the clinical guidelines for OSA test type, deep learning and artificial intelligence models using phenotyping, E-health record data, and other consumer or medical sensor devices and applications may provide insight for OSA risk assessment and test prioritization, or selection of tailored treatment paths.
      • Stretch R.
      • Ryden A.
      • Fung C.H.
      • et al.
      Predicting nondiagnostic home sleep apnea tests using machine learning.
      • Sunwoo B.Y.
      • Light M.
      • Malhotra A.
      Strategies to augment adherence in the management of sleep-disordered breathing.
      • Mencar C.
      • Gallo C.
      • Mantero
      • et al.
      Application of machine learning to predict obstructive sleep apnea syndrome (OSAS) severity.
      • Budhiraja R.
      • Thomas R.
      • Kim M.
      • et al.
      The role of big data in the management of sleep-disordered breathing.
      • Schutte-Rodin S.
      Telehealth, telemedicine, and obstructive sleep apnea.
      A thorough physical examination is not always possible when the patient is at home. In the assessment for possible OSA, tonsils can be difficult to estimate in size in 2-dimensional viewing. The clearest view of the oropharynx can be obtained if the patient or partner takes a photo on the smartphone and texts or emails it to the clinician. Also, the video from the camera on the back-side of the smartphone may be more likely to provide a clearer view of the oropharynx than the selfie view. Other important parts of the physical examination that are missing on virtual visits are overall appearance, evaluation of nasal turbinates, molar occlusion, heart, lungs, and eventually blood pressure. This difficulty can be overcome by creating special telemedicine hubs that include tools and equipment, including an intraoral camera, and a medical assistant who facilitates the transmission of this information.
      • Spaulding R.
      • Stevens D.
      • Velasquez S.E.
      Experience with telehealth for sleep monitoring and sleep laboratory management.
      Finally, coordination of care is more straightforward at the physical checkout counter, where appointments can be scheduled and paperwork can be printed and provided directly to the patient.

      Telediagnosis (Teletransmission, Telesupervision)

      Telemonitored polysomnography (PSG) has the premise to overcome the disadvantages of home recordings and could provide an organizational solution to the overloading of specialized sleep centers. Telemedicine can be used in the context of sleep studies for 2 purposes.
      • Bruyneel M.
      Telemedicine in the diagnosis and treatment of sleep apnoea.
      The first is to facilitate swift transmission of data of home PSG for further analysis. The second purpose for the application of telemedicine for sleep recording has been to ensure the quality of unattended PSG, by intermittent or continuous remote supervision of recording. Dedicated technicians regularly verify, at a distance, the quality of the PSG recordings by means of periodic access to the PSG monitoring device. From their telemonitoring control panel, they are able to insert comments in the recording, adjust transducer gain and, in the event of an artifact or an undesirable accident (disconnected wires, misplaced equipment), inform the patient by telephone.
      • Pelletier-Fleury N.
      • Lanoé J.L.
      • Philippe C.
      • et al.
      Economic studies and ‘technical’ evaluation of telemedicine: the case of telemonitored polysomnography.
      However, evidence on the efficacy of telemonitored (P)SG is weak. Gagnadoux and colleagues
      • Gagnadoux F.
      • Pelletier-Fleury N.
      • Philippe C.
      • et al.
      Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial.
      reported that PSG performed in a local hospital and telemonitored by a sleep laboratory was clearly superior to unattended home PSG. Kristo and colleagues
      • Kristo D.A.
      • Eliasson A.H.
      • Poropatich R.K.
      • et al.
      Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online.
      proposed a telemedicine protocol for the online transfer of PSGs from a remote site to a centralized sleep laboratory, that had practitioners for diagnosis, which provided a cost-saving approach for the diagnosis of OSA. Their system was based on the transmission of data using an Internet FTP protocol, which is the conventional system for file transfer. Kayyali and colleagues
      • Kayyali H.A.
      • Weimer S.
      • Frederick C.
      • et al.
      Remotely attended home monitoring of sleep disorders.
      presented a new compact telemetry-based sleep monitor (PSG@Home), consisting of a 14-channel wearable wireless monitor and a cell phone-based Gateway to transfer data, including video, in real time from the patient’s home to a remote sleep center. The monitor can easily be worn and transported, and it offers reliable recordings.
      • Kayyali H.A.
      • Weimer S.
      • Frederick C.
      • et al.
      Remotely attended home monitoring of sleep disorders.
      The receiver is a separate unit connected with the back of the display. Internal Bluetooth receivers, usually included in laptops, can also be used instead of a dedicated external Bluetooth receiver. A major problem encountered with home sleep studies is the potential loss of data in about 4.7% to 20.0% of the cases, which results in lower than expected cost savings.
      • Bruyneel M.
      • Sanida C.
      • Art G.
      • et al.
      Sleep efficiency during sleep studies: results of a prospective study comparing home-based and in-hospital based polysomnography.
      Using Sleepbox technology (Medatec, Brussels, Belgium), a wireless system able to communicate with the polysomnograph and with Internet through a WiFi/3G interface, and communicating via Skype, the authors were able to deliver recordings with excellent quality in 90% of the cases.
      • Bruyneel M.
      • Van den Broecke S.
      • Libert W.
      • et al.
      Real-time attended home-polysomnography with telematic data transmission.
      This opens an interesting perspective to decrease the failure rate of home sleep studies, although still problematic, and some technical aspects need to be improved. Pelletier-Fleury and collegues
      • Pelletier-Fleury N.
      • Gagnadoux F.
      • Philippe C.
      • et al.
      A cost-minimization study of telemedicine.
      comparatively evaluated the cost and effectiveness of PSG telemonitoring and PSG by conventional unsupervised home monitoring, and demonstrated that remote telemonitoring made the procedure clearly superior from a technical point of view and was preferred by the patients. They obtained a cost of $US244 for PSG telemonitoring, whereas the PSG with conventional unsupervised home monitoring was $US153. The health care infrastructure savings have to be taken into account as well. If we add up the working days that the patients did not lose and the roundtrip travel costs they avoided, we could estimate that the real cost would be similar or lower than that of conventional PSG.
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      Placement of polygraphy was performed by the local nursing staff, under remote supervision from a central sleep laboratory, in patients likely to suffer from OSA. Continuous video monitoring via a webcam was also included.
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      Masa and collegues
      • Masa J.F.
      • Corral J.
      • Pereira R.
      • et al.
      Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome.
      compared the costs made between device transportation and telematic transmission of data, with comparable results. Having devices moved by a transportation company or sent telematically as raw data proved cost effective and equally beneficial. Borsini and collegues
      • Borsini E.
      • Blanco M.
      • Bosio M.
      • et al.
      “Diagnosis of sleep apnea in network” respiratory polygraphy as a decentralization strategy.
      from Buenos Aires performed polygraphy at home, but fitted by nonexpert technicians. Raw data were sent by e-mail to the sleep center the following day. The failure rate was 4%, and 12% needed an additional in-laboratory PSG.
      These positive results can allow health care providers to enhance accessibility to sleep tests in large countries with few expert sleep centers and for patients who live a long way from the hospital or those with limited mobility.
      • Masa J.F.
      • Corral J.
      • Pereira R.
      • et al.
      Effectiveness of home respiratory polygraphy for the diagnosis of sleep apnoea and hypopnoea syndrome.
      ,
      • Borsini E.
      • Blanco M.
      • Bosio M.
      • et al.
      “Diagnosis of sleep apnea in network” respiratory polygraphy as a decentralization strategy.
      Fields and colleagues
      • Fields B.G.
      • Behari P.P.
      • McCloskey S.
      • et al.
      Remote ambulatory management of veterans with obstructive sleep apnea.
      demonstrated the feasibility of a comprehensive, telemedicine-based OSA evaluation and management pathway in comparison with a more traditional, in-person care model. They combined video consultation for intake with home sleep testing using a type 3 portable monitor with remote download, and autoCPAP titration with wireless modem technology. Patient satisfaction, CPAP adherence, and compliance and improvement in quality of life was similar in both groups.
      Although not applied routinely in current practice, these studies have confirmed the feasibility and the potential interest in telemonitored sleep studies. Moreover, this approach to diagnosis is considered to be more convenient for the patient than staying at a clinic overnight. The widespread use of telediagnosis is slowed down by the costs and the complexity of the technical aspects, and also requires a change to the current model of care delivery, because as it will become patient and home centered, rather than hospital centered. Such disruptive changes are going to take time to be effectuated.

      New Simplified Diagnostic Telemedicine Applications

      In clinical practice, the use of PSG is a standard procedure to assess sleep-disordered breathing. However, PSG is not suitable for chronic monitoring in the home environment and not very convenient to the patient. New telemedicine applications have become available using a home appliance as a precautionary measure for monitoring snoring and OSA. Seo and collegues
      • Seo J.
      • Choi J.
      • Choi b.
      • et al.
      The development of a nonintrusive home-based physiologic signal measurement system.
      developed a nonintrusive health monitoring home system to monitor patients’ ECG results, weight, motor activity, and snoring. Choi and collegues

      Choi JM, Choi BH, Seo JW, et al. A system for ubiquitous health monitoring in the bedroom via a Bluetooth network and wireless LAN. Engineering in Medicine and Biology Society 2004. EMBC 2004, conference proceedings. 26th Annual International Conference of the IEEE, 2004;2:3362-3365. San Francisco, September 1-5, 2004.

      proposed a ubiquitous health monitoring system in a bedroom, which monitors the electrocardiogram, body movements, and snoring with nonconscious sensors. Böhning and collegues
      • Boehning N.
      • Zucchini W.
      • Hörstmeier O.
      • et al.
      Sensitivity and specificity of telemedicine-based long-term pulse-oximetry in comparison with cardiorespiratory polygraphy and polysomnography in patients with obstructive sleep apnoea syndrome.
      evaluated the feasibility of night-time pulse oximetry telemedicine to screen patients at risk for OSA. They concluded the technique seemed to be suitable and cost effective, with high sensitivity and specificity. This approach can be applied in a telemedicine referral network for early diagnosis of OSA, where the reading could be transmitted to the relevant sleep laboratory, examined, and the results returned to the referring physician.
      • Boehning N.
      • Blau A.
      • Kujumdshieva B.
      • et al.
      Preliminary results from a telemedicine referral network for early diagnosis of sleep apnoea in sleep laboratories.
      Of note, several consumer device technologies with pulse oximetry, heart rate variability, actigraphy and deep learning algorithms are undergoing US Food and Drug Administration evaluation as home sleep apnea testing devices.
      American Academy of sleep medicine clinical resources for #SleepTechnology.
      Devices available today offer a wireless transmission of recording modules to the main body unit worn at the chest (by Blue-tooth technology), also called body area network.
      • Penzel T.
      Sleep quality challenges and opportunities.
      In some cases, a Bluetooth application can be used to send data to a smartphone or a tablet for online continuous monitoring. Also, the storage of data is wireless by making use of cloud-based storing.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.

      Telecommunication of Test Results and Treatment Options

      In line with OSA best practice and quality measure guidelines, the communication of the test results and treatment options with the patient may be done at face-to-face visits or using telemedicine tools such as videoconferencing, teleconferencing, and e-health portal messaging.
      • Fields B.G.
      • Behari P.P.
      • McCloskey S.
      • et al.
      Remote ambulatory management of veterans with obstructive sleep apnea.
      In Spain, Coma-del-Corral and collegues
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      applied teleconsultation in patients with confirmed OSA. After a telemonitored polygraphy, patients were randomised to receive either a teleconsultation or a face-to-face consultation to receive the results of their sleep study. The teleconsultation was organized via video conferencing. In those patients that finally were treated with CPAP, adherence was not different between the groups: 85% for the face-to-face consultation and 75% for the teleconsultation group. In many telehealth services, there is considerable variation in who communicates the test results to patients, among them somnologists or other specialists, nurses, physician assistants, sleep laboratory technicians, respiratory therapists, noninvasive ventilation therapists, or other trained staff.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      ,
      • Schutte-Rodin S.
      Telehealth, telemedicine, and obstructive sleep apnea.
      ,
      • Fields B.G.
      • Behari P.P.
      • McCloskey S.
      • et al.
      Remote ambulatory management of veterans with obstructive sleep apnea.
      ,
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      The impact of communicating test results cannot enough be emphasized. When patients view results of their diagnostic study with an explanation of the frequency and duration of respiratory events, it results in increased compliance of 0.7 to 1.2 hours per night on average.
      • Nadeem R.
      • Rishi M.A.
      • Srinivasan L.
      • et al.
      Effect of visualization of raw graphic polysomnography data by sleep apnea patients on adherence to CPAP therapy.
      • Jurado-Gamez B.
      • Bardwell W.A.
      • Cordova-Pacheco L.J.
      • et al.
      A basic intervention improves CPAP adherence in sleep apnoea patients: a controlled trial.
      • Falcone V.A.
      • Damiani M.F.
      • Quaranta V.N.
      • et al.
      Polysomnograph chart view by patients: a new educational strategy to improve CPAP adherence in sleep apnea therapy.
      Clinicians can show raw data and trends from the PSG virtually by the share screen feature to visually explain the extent and severity of the sleep-disordered breathing.

      Teletherapy

      Tele-Mask Fitting and Teleteaching (Obstructive Sleep Apnea and Continuous Positive Airway Pressure)

      In standard care, CPAP setup and teaching is offered by trained sleep technicians and respiratory therapists, which is recognized to be labor intensive, but critical for final compliance. Switching to video CPAP setups and remote education may offer decreased labor time while maintaining improved or equivalent CPAP compliance and satisfaction.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      Facial recognition software, application of mask sizers, mask fit packs and artificial intelligence analysis of mask fitting selection phenotypes may support remote CPAP mask selection and setup options.
      • Rowland S.
      • Aiyappan V.
      • Hennessy C.
      • et al.
      Comparing the efficacy, mask leak, patient adherence, and patient preference of three different CPAP interfaces to treat moderate-severe obstructive sleep apnea.
      Although early educational interventions before CPAP initiation are strongly recommended, the effect of tele-education alone on overall compliance does not seem robust, which could be explained by confounding factors such as the variability of the initial and following tele-education deliveries, and easy availability of Internet-based OSA and CPAP educational resources for patients with OSA.
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      Different authors found improved compliance for patients given Web access to their data and companion educational resources.
      • Hardy W.
      • Powers J.
      • Jasko J.G.
      • et al.
      DreamMapper white paper: a mobile application and website to engage sleep apnea patients in PAP therapy and improve adherence to treatment.
      • Lynch S.
      • Blasé A.
      • Erikli L.
      • et al.
      Retrospective descriptive study of CPAP adherence associated with use of the ResMed myAir application.
      • Shaughnessy G.F.
      • Morgenthaler T.I.
      The effect of patient-facing applications on positive airway pressure therapy adherence: a systematic review.
      Smith and collegues
      • Smith C.E.
      • Dauz E.R.
      • Clements F.
      • et al.
      Telehealth services to improve nonadherence: a placebo-controlled study.
      tested a teleconferencing approach in which a nurse visually assessed mask fit and patients’ CPAP procedures and provided counseling and reinforcement to patients who were trying CPAP again after an initial 3-month period of poor compliance. Although the patient education materials supplied during the initial period did not impact adherence rates, the nurse teleconferencing sessions during the second trial period substantially improved the adherence of the intervention group (9 of 10 patients vs 4 of 9 in the placebo intervention group), suggesting that intensity of one-on-one counseling and feedback by a care provider is a relevant variable.
      • Smith C.E.
      • Dauz E.R.
      • Clements F.
      • et al.
      Telehealth services to improve nonadherence: a placebo-controlled study.
      Isetta and colleagues49 performed a randomized controlled trial (RCT) in which 20 patients with OSA received standard face-to-face training, and another 20 received the CPAP training via videoconference. Patients demonstrated comparable knowledge about OSA and CPAP therapy, while performance of practical skills (mask and headgear placement, leak avoidance) and knowledge related to OSA was also similar between the 2 groups (94% correct answers in the videoconference groups vs 92%).
      • Isetta V.
      • Leon C.
      • Torres M.
      • et al.
      Telemedicine-based approach for obstructive sleep apnea management: building evidence.
      In another study of the same group in 139 patients with OSA, similar levels of CPAP compliance, and improved daytime sleepiness, quality of life, side effects and degree of satisfaction was found in a telemedicine-based CPAP follow-up strategy (televisits via video conference based on Skype, e-mail, web tool support) compared with face-to-face management.
      • Isetta V.
      • Negrin M.A.
      • Monasterio C.
      • et al.
      A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial.
      Interestingly, the telemedicine group made more extra visits than the face-to-face group, but most of them were not OSA related.

      Tele Continuous Positive Airway Pressure Titration

      An exploratory study was set up to perform real-time titration of domiciliary CPAP.
      • Dellaca R.
      • Montserrat J.M.
      • Govoni L.
      • et al.
      Telemetric CPAP titration at home in patients with sleep apnea-hypopnea syndrome.
      The novelty of this approach is that a telemetry unit is connected to a commercially available CPAP device to allow a low-cost, 2-way communication channel in real time between the sleep laboratory technician and the CPAP device in the patient’s home. The approach requires no special telemedicine approach, nor does it require the patient’s active cooperation or any kind of communication infrastructure (computer or the Internet) in the patient’s home. This interesting exploratory study allowed sleep technicians to avoid potential failures of automatic positive airway pressure (APAP) trials at home. Unfortunately, no larger scale trials have been performed. However, in times of home-APAP titration, it can be wondered whether it is really necessary to obtain a remote real-time control of titration. In contrast, a routine visit to the hospital shortly after home APAP titration to check the CPAP device data can be avoided with a remote-attended titration strategy. A barrier to this approach could be related to the contraindications rather than to technical aspects. In our local experience, the proportion of patients who can benefit from home APAP titration is less than 40% (unpublished data). The presence of comorbidities (neuropsychiatric, cardiorespiratory comorbidities and comorbid insomnia and morbid obesity) also restricts access to this pathway.
      • Morgenthaler T.I.
      Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007.
      Nevertheless, it permits flexibility in resetting the therapy remotely through online pressure adjustments as clinically needed.
      • Morgenthaler T.I.
      Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007.
      • Patil S.P.
      • Ayappa I.A.
      • Caples S.M.
      • et al.
      Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine Systematic review, meta-Analysis, and GRADE assessment.
      • Patil S.P.
      • Ayappa I.A.
      • Caples S.M.
      • et al.
      Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline.

      Telemonitoring of Continuous Positive Airway Pressure Compliance and Adherence and Problem Solving

      Usual care (or standard care)

      Because CPAP is a self-administered treatment, its efficacy is critically dependent on the patient’s willingness to use the device and apply the nasal mask during sleep, regardless of how well a CPAP machine corrects apnea. In this context, the term adherence is used to describe continued use of the machine (uptake), and compliance expresses the use of CPAP for a certain amount of time.
      • Collard Ph
      • Pieters Th
      • Aubert G.
      • et al.
      Compliance with nasal CPAP in obstructive sleep apnea patients.
      Unfortunately, these terms are often inadequately used and mutually exchanged. A user is defined as a patient that uses his device for more than 4 hours per night. Commonly used definitions of adequate compliance are use of more than 4 hours per night for 70% of days or more than 4 hours per night for more than 5 days per week.
      • Engleman H.M.
      • Wild M.R.
      Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS).
      ,
      • Pépin J.L.
      • Krieger J.
      • Rodenstein D.
      • et al.
      Effective compliance during the first 3 months of continuous positive airway pressure. A European prospective study of 121 patients.
      Early compliance (at 1 week or 1 month) is associated with better compliance at 6 months, indicating that early interventions and support should be offered to patients.
      • Aloia M.S.
      • Arnedt J.T.
      • Stanchina M.
      • et al.
      How early in treatment is PAP adherence established ? Revisiting night-to-night variability.
      Different studies have shown that the rates of CPAP use are between 30% and 60%. Of importance, patients who become nonadherent in the first days of CPAP treatment generally remain nonadherent.
      • Weaver T.E.
      • Kribbs N.B.
      • Pack A.I.
      • et al.
      Night to night variability in CPAP use over first three months of treatment.
      Without optimal CPAP use, patients will fail to achieve the full cardiovascular and symptomatic benefits of therapy. Hence, compliance for CPAP should be regarded as the main determinant for success.
      • Collard Ph
      • Pieters Th
      • Aubert G.
      • et al.
      Compliance with nasal CPAP in obstructive sleep apnea patients.
      Usually, the patient is seen by a qualified sleep professional to assess CPAP use (hours of use and hours of application), to check the machine settings, and to ensure the interface (mask, pillows, and so forth) is in good condition. Short-term and long-term follow-up are crucial to adherence and compliance, but monitoring efficacy is also critical to adherence, compliance, and successful therapy. In one study, compliance monitoring, including consistent follow-up, troubleshooting, and feedback to both patients and physicians, achieved good CPAP compliance rates (>4 hours per night) of more than 80% over 6 months.
      • Chervin R.D.
      • Theut S.
      • Bassetti C.
      • et al.
      Compliance with nasal CPAP can be improved by simple interventions.
      In contrast, close follow-up has not been consistently shown to improve compliance, but is worth doing.
      • Isetta V.
      • Leon C.
      • Torres M.
      • et al.
      Telemedicine-based approach for obstructive sleep apnea management: building evidence.
      Even more effective is to establish adherence and compliance patterns early in treatment initiation, which can help to resolve problems in a timely manner and is essential in the effort to establish a pattern of treatment adherence and good compliance.
      • Meurice J.C.
      Improving compliance to CPAP in sleep apnea syndrome: from coaching to telemedicine.
      Intervention early in therapy may improve the patient’s early response to CPAP therapy and increase the likelihood that the patient will become a regular and compliant user, thereby enhancing clinical outcome. CPAP follow-up appointments vary from 3 months to yearly, according to physician preferences and availability of resources, without check-ups between follow-up visits. For those patients who are doing well with their current therapy, the annual compliance visit may deliver little value because many visits are not associated with any meaningful changes in management.
      • Nannapaneni S.
      • Morgenthaler T.I.
      • Ramar K.
      Assessing and predicting the likelihood of interventions during routine annual follow-up visits for management of obstructive sleep.
      This model results in lost time at work for patients, decreased productivity for their employers, and less space in a busy clinician’s agenda to manage more complex patients.
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      ,
      • Isetta V.
      • Negrin M.A.
      • Monasterio C.
      • et al.
      A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial.
      ,
      • Parikh R.
      • Touvelle M.N.
      • Wang H.
      • et al.
      Sleep telemedicine: patient satisfaction and treatment adherence.
      Finally, it can be frustrating for patients and clinicians when the patient is seen in office yet forgets to bring their problematic mask, tubing, or machine.

      Rationale for improving compliance

      The challenge with CPAP therapy is to obtain adequate adherence and compliance, usually defined as use of CPAP during at least 4 hours per night and for more than 70% of the nights.
      • Weaver T.E.
      • Maislin G.
      • Dinges D.F.
      • et al.
      Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.
      This threshold is somewhat arbitrary and has been debated because a dose–response relationship between PAP use and clinical outcomes in OSA has been demonstrated. However, there is general acknowledgment that more is better with respect to CPAP use. A systematic review of 66 clinical trials and cohort studies published between 1994 and 2015 found a weighted average compliance of 4.5 hours per night, with no meaningful improvement in compliance rates over the 2 decades of data available since objective CPAP monitoring was introduced.
      • Rotenberg B.W.
      • Murariu D.
      • Pang K.P.
      Trends in CPAP adherence over twenty years of data collection: a flattened curve.
      The literature to date suggests a dose–response relationship between CPAP use and a range of outcomes, including sleepiness, functional status, and blood pressure. Weaver and collegues
      • Weaver T.E.
      • Maislin G.
      • Dinges D.F.
      • et al.
      Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning.
      could demonstrated that when using the Functional Outcomes of Sleep Questionnaire, a greater improvement in memory was obtained when CPAP was used more than 6 hours per night in comparison with less than 2 hours. In a Spanish study, Barbé and collegues
      • Barbe F.
      • Duran-Cantolla J.
      • Capote F.
      • et al.
      Long-term effect of continuous positive airway pressure in hypertensive patients with sleep apnea.
      demonstrated in a cohort of 359 patients with OSA that nightly use longer than 5.65 hours achieved better blood pressure and sleepiness reduction. Gasa and collegues
      • Gasa M.
      • Tamisier R.
      • Launois S.H.
      • et al.
      Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure.
      reported that the prevalence of residual excessive sleepiness is significantly lower in individuals using CPAP more than 6 hours per night compared with those who use the device less than 4 hours per night (8.7% vs 18.5%). A recent randomized study in a cohort of 3100 CPAP-treated patients, randomized in intensive versus standard interventions, also confirmed the positive effect of a greater CPAP use (6.9 vs 5.2 hours per night) on cardiovascular outcomes, indicating that a regular 5 to 6 hours of use per night is required.
      • Bouloukaki I.
      • Giannadaki K.
      • Mermigkis C.
      • et al.
      Intensive versus standard follow-up to improve continuous positive airway pressure compliance.
      In a recent Cochrane Database Systematic Review that pooled data from 30 low-to-moderate quality studies it was reported that supportive, educational, and behavioral therapy increases compliance by a respective amount of 50, 35, and 104 minutes per night, resulting in a greater proportion of patients using CPAP for more than 4 hours per night.
      • Wozniak D.R.
      • Lasserson T.J.
      • Smith I.
      Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.
      A meta-analysis of 12 trials (572 patients) concluded that each 1-hour improvement in CPAP compliance was associated with a reduction in mean blood pressureof 1.4 mm Hg.
      • Haentjens P.
      • Van Meerhaeghe A.
      • Moscariello A.
      • et al.
      The impact of continuous positive airway pressure on blood pressure in patients with obstructive sleep apnea syndrome: evidence from a meta-analysis of placebo-controlled randomized trials.
      Bratton and collegues
      • Bratton D.J.
      • Gaisl T.
      • Wons A.M.
      • et al.
      CPAP vs mandibular advancement devices and blood pressure in patients with obstructive sleep apnea: a systematic review and meta-analysis.
      showed that a 1-hour per night increase in mean CPAP use was associated with an additional decrease in the systolic blood pressure of 1.5 mm Hg and an additional reduction in diastolic blood pressure of 0.9 mm Hg. CPAP compliance is usually defined as simply hours per night rather than as a proportion of total sleep time, which is usually not measured.
      • Bianchi M.T.
      • Alameddine Y.
      • Mojica J.
      Apnea burden: efficacy versus effectiveness in patients using positive airway pressure.
      Therefore, it is unclear as to whether short sleep duration (eg, 4 h) with 100% CPAP compliance would lead to greater impairment than longer sleep duration (eg, 8 h) with 50% CPAP compliance, even though the CPAP use is identical in both instances. Finally, suboptimal CPAP use has prevented a thorough understanding of important trials designed to clarify the impact of OSA on cardiovascular risk and the role of CPAP in mitigating that risk.
      • Bradley T.D.
      • Logan A.G.
      • Kimoff R.J.
      • et al.
      Continuous positive airway pressure for central sleep apnea and heart failure.
      ,
      • McEvoy R.D.
      • Antic N.A.
      • Heeley E.
      • et al.
      CPAP for prevention of cardiovascular events in obstructive sleep apnea.

      (Cloud-based) remote compliance monitoring: Technical aspects

      Many CPAP devices have an integrated digital storage to record patient use data, which allows to download previously recorded data.
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      ,
      • Smith C.E.
      • Dauz E.R.
      • Clements F.
      • et al.
      Telehealth services to improve nonadherence: a placebo-controlled study.
      ,
      • Chervin R.D.
      • Theut S.
      • Bassetti C.
      • et al.
      Compliance with nasal CPAP can be improved by simple interventions.
      ,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      It allows recording with little subject interference under normal and experimental conditions.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.
      CPAP devices are now equipped with simple global system for mobile communication modules to transmit exactly these use and aggregated diagnostic data to medical service providers. Patients can transmit CPAP data on a daily basis into a database (eg, the Encore Anywhere database, Philips; ResTraxx database, ResMed), where data extraction takes place. Because PAP manufacturers use proprietary cloud-based data platforms and use different algorithms for respiratory event detection, this can be a potential non–patient-related barrier to telemedicine adoption (Table 1). As a result, health care professionals may require access to several different databases and because not all patients use the same brand of CPAP devices, technical standards are needed to enable aggregation into one’s health care record.
      • Shaughnessy G.F.
      • Morgenthaler T.I.
      The effect of patient-facing applications on positive airway pressure therapy adherence: a systematic review.
      In the past, a universal telemonitoring unit was available (T4P, SRETT Medical, France), which offered the possibility to be added to the majority of CPAP devices, and to be switched from one patient to another for a determined duration, according to the patient needs.
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      This system also made use of a telemedicine web platform (T4P Vision Web Portal) that was the same for all patients. Unfortunately, the company does not exist anymore. Another universal telemonitoring unit is called NOWAPI, but is poorly examined.
      • Leger D.
      • Elbaz M.
      • Piednoir B.
      • et al.
      Evaluation of the add-on NOWAPI(R) medical device for remote monitoring of compliance to continuous positive airway pressure and treatment efficacy in obstructive sleep apnea.
      An apnea was considered when a tidal volume of less than 20% of the patient reference tidal volume was detected (for ≥10s), whereas a hypopnea was counted if a tidal volume between 20% and 50% of the patient reference tidal volume was found (for ≥10 s). Of interest, there was a concern related to low satisfaction rate of the patients about the traffic light indicator.
      Table 1Problems with the platforms for CPAP telemonitoring
      ProblemComment
      Communication protocol depends on manufacturerIdeally, communication software should adapt to different manufacturers. In practice, a universal system is not feasible, also taking into account the implementation of data encryption by the communication device.
      Type and quality of measured data depend on manufacturer’s technologyPAP devices detect snoring and respiratory events by airway pressure vibrations or flow changes.
      Detection of respiratory events is dictated by algorithms developed by the PAP manufacturerCriteria for respiratory events are based on the magnitude reduction of the flow signal (<50% for hypopneas; <10% for apneas). However, baseline value is not adequately defined and even does not remain constant during sleep.

      Fine tuning of continuous positive airway pressure devices and filter settings for interventions during telemonitoring

      One of the capabilities of telemedicine is probably the early detection of problems (such as persistent respiratory events or leakage), thus facilitating appropriate interventions, and thereby improving the patients early experience with CPAP.
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      Hoet and collegues
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      showed that telemonitoring significantly reduced the delay to the first intervention for CPAP treatment (29 ± 25 vs 47 ± 30 days). For this purpose, the data have to be analyzed against a set of preestablished criteria or filters. The dataset can be scanned for multiple criteria and compared with thresholds for adherence and compliance, trends, AHI, periodic breathing, occurrence of central apneas and mask leaks.
      • Leger D.
      • Elbaz M.
      • Piednoir B.
      • et al.
      Evaluation of the add-on NOWAPI(R) medical device for remote monitoring of compliance to continuous positive airway pressure and treatment efficacy in obstructive sleep apnea.
      A selection of filter settings reported in the literature or by companies is shown in Table 2.
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      ,
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      ,
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      ,
      • Frasnelli M.
      • Baty F.
      • Niederman
      • et al.
      Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome—a controlled pilot study.
      ,
      • Chumpangern W.
      • Muntham D.
      • Chirakalwasan N.
      Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea.
      ,
      • Turino C.
      • de Batlle J.
      • Woehrle H.
      • et al.
      Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
      ,
      • Prigent A.
      • Gentina T.
      • Launois S.
      • et al.
      [Telemonitoring in continuous positive airway pressure-treated patients with obstructive sleep apnoea syndrome: an algorithm proposal].
      Table 2Proposed filter settings for interventions during telemonitoring
      ComplianceLeaksResidual AHI
      Fox et al,
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      2012
      <4 h use on 2 consecutive days (check every week day)Mask leak >40 L/min for >30% of the night>10 events/h, and 90th percentile of pressure >16 cm H2O
      Frasnelli et al,
      • Frasnelli M.
      • Baty F.
      • Niederman
      • et al.
      Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome—a controlled pilot study.
      2016
      <4 h use on 2 consecutive days>30 L/min for more than 2 dNot included
      Munafo et al,
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      2016
      No CPAP data for 2 consecutive days

      <4 h use for 3 consecutive days
      >30 L/min for >2 d>15/h for 5 consecutive days
      Chumpangern et al,
      • Chumpangern W.
      • Muntham D.
      • Chirakalwasan N.
      Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea.
      2021
      <4 h use on 2 consecutive days>27 L/min on 2 consecutive days>5/h on 2 consecutive days
      Hoet et al,
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      2017
      <3 h use on 3 consecutive days>50 L/min>10/h
      Turino et al,
      • Turino C.
      • de Batlle J.
      • Woehrle H.
      • et al.
      Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
      2017
      <4 h use on 2 consecutive days>30 L/min for >30% of the nightNA
      Prigent et al,
      • Prigent A.
      • Gentina T.
      • Launois S.
      • et al.
      [Telemonitoring in continuous positive airway pressure-treated patients with obstructive sleep apnoea syndrome: an algorithm proposal].
      2020
      <4 h use over a period of 7 consecutive days.

      During the initiation period: compliance check each 72 h
      • 1 h of relevant leaks (Philips)
      • Nonintentional leaks:
        • ith 95th percentile >24 L/min (nasal mask ResMed)
        • With 95th percentile >36 L/min (oronasal mask ResMed)
      • Overall leakage >60 L/min (Fisher and Paykel)
      • Overall leakage of >95 L/min (Devilbiss)
      • Nonintentional leaks with a mean ≥ 20 L/min
      • Nonintentional leaks with 95th percentile ≥60 L/min
      • Percent elevated leakage ≥15% (Löwenstein)
      • ≥5% of the use time above the leakage limit (Sefam)
      ≥10/h in a progressive window of 7 d
      For example, CPAP data are automatically sent to the health care provider on a daily basis and trigger automatic alarms in case of poor use for 2 consecutive nights (<4 h) or excessive mask leakage (>0.5 L/s).
      • Prigent A.
      • Gentina T.
      • Launois S.
      • et al.
      [Telemonitoring in continuous positive airway pressure-treated patients with obstructive sleep apnoea syndrome: an algorithm proposal].
      Automatically triggered clinical actions can then be scheduled (Fig. 1). The final goal of such a platform is to proactively identify and address issues that can negatively influence CPAP adherence and compliance. By providing patient data early in the course of CPAP treatment, it is believed that this technology would be extremely useful in improving compliance and acceptance of the device in patients with sleep apnea.
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      ,
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      ,
      • Smith C.E.
      • Dauz E.R.
      • Clements F.
      • et al.
      Telehealth services to improve nonadherence: a placebo-controlled study.
      ,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      ,

      Isetta V, Thiebaut G, Navajas D, et al. E-telemed 2013: Proceedings Fifth International Conference on E-Health, Telemedicine and Social Medicine 2013; 156-161. Nice, February 24 - March 1, 2013.

      • Lankford D.A.
      Wireless CPAP patient monitoring: accuracy study.
      • DeMolles D.A.
      • Sparrow D.
      • Gottlieb D.J.
      • et al.
      A pilot trial of a telecommunications system in sleep apnea management.
      • Kwiatkowska M.
      • Idzikowski A.
      • Matthews L.
      Telehealth-based framework for supporting the treatment of obstructive sleep apnea.
      • Fraysse J.L.
      • Delavillemarque N.
      • Gasparutto B.
      • et al.
      Home telemonitoring of CPAP: a feasibility study.
      All that is needed is a personal computer, an Internet connection, and the proprietary software. Detailed reports can be generated to show use information and then forwarded electronically to referral laboratories or physicians without generating additional paperwork. Wireless applications with an in-built telemonitoring module connects the CPAP unit in the patient's home with a server each evening and transmits adherence and compliance data on a daily base. This technology eliminates the need for data cards or home telephone lines, and frequent patient visits. The compliance server analyzes the data and notifies the physician of any patients with poor CPAP use. Patient confidentiality is secured through a password and login-protected system that provides protection for the patients' information. Such system provides accurate, thorough, and advanced information to the clinician and ensures that each patient is receiving the maximum benefit from CPAP therapy. A patient’s own data can be checked at a glance with physician summary reports. Visual color coding allows the caregiver to easily identify patients who require attention. Remote settings changes are available to fine tune therapy and optimize patient management. Historical data can be searched at any time to retrieve data that were not transmitted via the monitoring schedule. Telemonitoring of CPAP data may enable early identification of central sleep apnea or Cheyne–Stokes breathing and congestive heart failure occurrence or progression.
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      ,
      • Tung P.
      • Levitzky Y.S.
      • Wang R.
      • et al.
      Obstructive and central sleep apnea and the risk of incident atrial fibrillation in a community cohort of men and women.
      This technology has the potential also to be used for noninvasive ventilation in other types of patients and in more advanced devices for respiratory support.
      • Jiang W.P.
      • Wang L.
      • Lin Song Y.
      Titration and follow-up for home noninvasive positive pressure ventilation in chronic obstructive pulmonary disease: the potential role of Tele-monitoring and the Internet of things.
      Telemonitoring may be useful in patients with sleep apnea who require other modes of PAP therapy. Patients with noninvasive ventilation require a much closer therapy control protocol compared with patients with sleep apnea.
      Figure thumbnail gr1
      Fig. 1A decision tree for telemonitoring of PAP therapy.
      One of the drawbacks of CPAP unit residual AHI is that this parameters is based on recording time and may include snoring and vibration in the total residual event calculation (CPAP AHI is not similar to PSG AHI).
      • Stepnowsky C.
      • Zamora T.
      • Barker R.
      • et al.
      Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup.
      ,
      • Rotty M.C.
      • Mallet J.P.
      • Suehs C.M.
      • et al.
      Is the 2013 American Thoracic Society CPAP-tracking system algorithm useful for managing non-adherence in long-term CPAP-treated patients?.
      Again, we have to take into account that major differences exist between manufacturer definitions of residual events (see Table 1) and that an AHI flow is not associated with nonadherence.
      • Rotty M.C.
      • Mallet J.P.
      • Suehs C.M.
      • et al.
      Is the 2013 American Thoracic Society CPAP-tracking system algorithm useful for managing non-adherence in long-term CPAP-treated patients?.
      • Huang H.C.
      • Hillman D.R.
      • McArdle N.
      Control of OSA during automatic positive airway pressure titration in a clinical case series: predictors and accuracy of device download data.
      • Reiter J.
      • Zleik B.
      • Bazalakova M.
      • et al.
      Residual events during use of CPAP: prevalence, predictors, and detection accuracy.
      The key advantage of this technology is that the individual’s CPAP data are now automatically collected, remotely accessible, and actionable by both providers and patients.
      • Hwang D.
      Monitoring progress and adherence with positive airway pressure therapy for obstructive sleep apnea: the roles of telemedicine and mobile health applications.
      However, it suffers from the limitation that it leads to data overload when trying to manage a large patient population.

      Fine tuning of continuous positive airway pressure devices: Responsibilities

      If such a feature is implemented, additional regulations have to be considered. Who is liable if the pressure adjustment is not functioning properly? Is this a matter of data transmission, or was the device in use with another patient? Before bidirectional telemedicine is implemented in the therapy of sleep apnea on a large scale, several legal questions need to be clarified.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.
      Roles, expectations, and responsibilities of providers involved in the delivery of such services should be defined and communicated, including those at originating sites and distant sites.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      The assumptions parties may have in such encounters and roles should be explicitly documented. In general, the standards for supervision should follow the same general guidelines as those for technicians, respiratory care practitioners, and nurses working with physicians in the live setting. All providers involved have to review their facilities’ and institutions’ bylaws and human resource documents. Moreover, relevant regulatory documents related to the provision of care are to be followed, and organizations and providers are to ensure such care is consistent with policies regarding scope of practice and state licensing laws of all involved parties.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      ,
      • Schwab R.J.
      • Badr S.M.
      • Epstein L.J.
      • et al.
      An official American Thoracic Society Statement: continuous positive airway pressure adherence tracking systems. The optimal monitoring strategies and outcome measures in adults.
      However, it is questionable whether a service provider could be allowed to fine tune CPAP settings independently, because changing treatment regimens is the physician’s privilege and responsibility for centuries. To overcome this problem, the physician must be available by telephone to provide assistance and direction if needed. Telemedicine could be readily used to augment general supervision, and asynchronous methods could be used.
      • Singh J.
      • Badr M.S.
      • Diebert W.
      • et al.
      American Academy of Sleep Medicine (AASM) Position paper for the use of telemedicine for the diagnosis and treatment of sleep disorders.
      One more barrier, in some countries, is that CPAP fitting and troubleshooting is not eligible for reimbursement, when performed via telemedicine by respiratory therapists and sleep technologists.
      • Singh J.
      • Badr S.
      • Epstein L.
      • et al.
      Sleep telemedicine implementation guide.
      Who gets access to these data with personal use information also varies from country to country according to local medical data regulations. Some countries regulations are very restrictive and require a clear distinction of tasks among health Insurance, service provider, and sleep physician.

      (Cloud-based) remote compliance monitoring: evidence

      Unlike pill-based treatments, CPAP is unique in that detailed, night-by-night compliance data are collected routinely and can be made available in real time to both patients and providers.
      Some study results suggest that the use of telemonitored CPAP compliance and efficacy data seems to be as good as standard care in its effect on compliance rates and outcomes in new CPAP users, although conflicting data remain.
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      ,
      • Aardoom J.J.
      • Loheide-Niesmann L.
      • Ossebaard H.C.
      • et al.
      Effectiveness of eHealth interventions in improving treatment adherence for adults with obstructive sleep apnea: meta-analytic review.
      ,
      • Chen C.
      • Wang J.
      • Pang L.
      • et al.
      Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials.
      However, the results from other RCTs regarding improvement in compliance are disappointing (Table 3), given many studies do not show any improvement in compliance with telemonitoring. In contrast, in some of these studies, despite the application of telemonitoring, compliance remained extremely low, questioning the level of usual care in these centers.
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      ,
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      Nevertheless, telemonitoring offers the possibility for the sleep medicine providers to detect “problematic” patient and to act properly. Stepnowsky and collegues
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      demonstrated that a telemonitored clinical care group had a compliance rate of 4.1 hours per night after 2 months, which represents a 46% increase in compliance over the mean compliance level of the standard clinical care group (2.8 hours per night). However, this trial was certainly underpowered to reach significance (P<.07) but provided a rationale for conducting larger clinical and cost-effectiveness trials. There were also some concerns regarding the potential loss of data through wireless transmission. However, the loss was negligible and once the wireless unit was properly connected, data from previous nights stored on the flow generator device could be retransmitted and obtained wirelessly. Anttalainen and collegues
      • Anttalainen U.
      • Melkko S.
      • Hakko S.
      • et al.
      Telemonitoring of CPAP therapy may save nursing time.
      compared a group of wireless telemonitored CPAP users with a usual care group, after CPAP titration. They found equal CPAP compliance and residual AHI at the 1-year follow up. The median nursing time was 39 minutes in the telemonitored group and shorter compared with that of 58 minutes per patient in the usual care group. Fernandes and collegues
      • Fernandes M.
      • Antunes C.
      • Martinho C.
      • et al.
      Evaluation of telemonitoring of continuous positive airway pressure therapy in obstructive sleep apnoea syndrome: TELEPAP pilot study.
      reported that in the presence of a comprehensive educational program during positive airway pressure adaptation, telemonitoring patients did not show significant benefits concerning compliance and efficacy. A larger follow-up period was proposed to evaluate the long-term results of a telemonitoring program.
      Table 3Randomized studies comparing telemedicine monitoring versus standard care in CPAP therapy
      NAHITelemonitoring MethodFollow-upCompliance TMCompliance UCP Value
      Taylor et al,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      2006
      114>5Internet support + feedback1 mo4.3 h4.2 hNS
      Stepnowsky et al,
      • Stepnowsky Jr., C.J.
      • Palau J.J.
      • Marler M.R.
      • et al.
      Pilot randomized trial of the effect of wireless telemonitoring on compliance and treatment efficacy in obstructive sleep apnea.
      2007
      45>15Interactive web site with own CPAP data and instructions for troubleshooting2 mo4.1 h3.4 hS
      Sparrow et al,
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      2010
      250>10Interactive voice response system6 mo2.4 h1.48 hS
      Fox et al,
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      2012
      75>15Feedback by phone3 mo3.2 h1.7 hS
      Isetta et al,
      • Isetta V.
      • Negrin M.A.
      • Monasterio C.
      • et al.
      A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial.
      2015
      139Mean 49Feedback by webtools6 mo4.4 h4.2 hNS
      Anttalainen et al,
      • Anttalainen U.
      • Melkko S.
      • Hakko S.
      • et al.
      Telemonitoring of CPAP therapy may save nursing time.
      2016
      111Mean 34Nurse-adjusted phone/visits12 mo6.4 h6.1 hNS
      Frasnelli et al,
      • Frasnelli M.
      • Baty F.
      • Niederman
      • et al.
      Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome—a controlled pilot study.
      2016
      22337 (TM)Telemonitoring and messaging1 mo53 h4.6 hS
      40 (UC)
      Munafo et al,
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      2016
      13234 (TM)Multimedia approach to contact patient about their CPAP use1 mo5.1 h4.7 hNS
      27 (UC)
      Turino et al,
      • Turino C.
      • de Batlle J.
      • Woehrle H.
      • et al.
      Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
      2017
      14052 (TM)Telemonitoring3 mo5.1 h4.9 hNS
      53 (UC)
      Hostler et al,
      • Hostler J.M.
      • Sheikh K.L.
      • Andrada T.F.
      • et al.
      A mobile, web-based system can improve positive airway pressure adherence.
      2017
      6119 (TM)Telemonitoring, patient engagement tool11 wk4.0 h2.7 hNS
      18 (UC)
      Hwang et al,
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      2018
      145523 (TM)Telemonitoring, messaging, web-based OSA education3 mo4.8 h3.8S
      23 (TE)
      22 (UC)
      Hoet et al,
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      2017
      4650 (TM)Telemonitoring3 mo5.74.2S
      49 (UC)
      Kotzian et al,
      • Kotzian S.T.
      • Saletu M.T.
      • Schwarzinger A.
      • et al.
      Proactive telemedicine monitoring of sleep apnea treatment improves adherence in people with stroke- a randomized controlled trial (HOPES study).
      2019
      3337 (TM)CPAP training + monitoring3 mo6.3 h5.0 hS
      37 (UC)12 mo5.9 h5.1 hNS
      Nilius et al,
      • Nilius G.
      • Schroeder M.
      • Domanski U.
      • et al.
      Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial.
      2019
      8041 (TM)Short telephone calls6 mo4.4 h2.1 hS
      38 (UC)
      Pépin et al,
      • Pépin J.L.
      • Jullian-Desayes I.
      • Sapène M.
      • et al.
      Multimodal remote monitoring of high cardiovascular risk patients with OSA initiating CPAP: a randomized trial.
      2019
      30647 (TM)Multimodal telemonitoring

      Home blood pressure and physical activity
      6 mo5.28 h4.75 hS
      45 (UC)
      Fernandes et al,
      • Fernandes M.
      • Antunes C.
      • Martinho C.
      • et al.
      Evaluation of telemonitoring of continuous positive airway pressure therapy in obstructive sleep apnoea syndrome: TELEPAP pilot study.
      2019
      5138 (TM)Remote monitoring and intervention4 wk5.0 h5.1 hNS
      36 (UC)
      36 (PC)
      Schoch et al,
      • Schoch O.D.
      • Baty F.
      • Boesch M.
      • et al.
      Telemedicine for continuous positive airway pressure in sleep apnea. A randomized, controlled study.
      2019
      24037 (TM)Remote monitoring and phone calls6 mo5.6 h4.8 hNS
      46 (UC)
      Tamisier et al,
      • Tamisier R.
      • Treptow E.
      • Joyeux-Faure M.
      • et al.
      Impact of a multimodal telemonitoring intervention on CPAP adherence in symptomatic OSA and low cardiovascular risk: a randomized controlled trial.
      2020
      20645 (TM)Multimodal telemonitoring6 mo4.73 h5.08 hNS
      42 (UC)
      Murase et al,
      • Murase K.
      • Tanizawa K.
      • Minami T.
      • et al.
      A randomized controlled trial of telemedicine for long-term sleep apnea continuous positive airway pressure management.
      2020
      483161 (TM)Remote monitoring and phone calls6 mo5.455.12NS
      166 (UC)
      Chumpangern et al,
      • Chumpangern W.
      • Muntham D.
      • Chirakalwasan N.
      Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea.
      2021
      5749 (TM)Remote monitoring and intervention4 wk5.164.42NS
      52 (UC)
      Abbreviations: NS, not significant; S, significant; TM, telemonitoring; UC, usual care.

      Long-term follow-up

      Because OSA may change with aging, weight, menopause, and intake of some medications, long-term OSA monitoring for all treatments is indicated.
      • Bixler E.O.
      • Vgontzas A.N.
      • Ten Have T.
      • et al.
      Effects of age on sleep apnea in men: I. Prevalence and severity.
      ,
      • Newman A.B.
      • Foster G.
      • Givelber R.
      • et al.
      Progression and regression of sleep-disordered breathing with changes in weight: the Sleep Heart Health Study.
      Studies confirmed the feasibility of teleconsultation as a parallel route to face-to-face consultations, not only during the critical CPAP habituation phase, but also on the long run. This type of telemedicine seems to be easier to practice, because it does not require changes in the model of care delivery, just a pragmatic teleconference platform. This approach is associated with numerous advantages for patients, including the removal of the need to travel to and from the sleep medicine center. Baig and collegues
      • Baig M.M.
      • Antonescu-Turcu A.
      • Ratarasarn K.
      Impact of sleep telemedicine protocol in management of sleep apnea: a 5-year VA experience.
      demonstrated the long-term effectiveness of a 5-year telemedicine program: the delay to obtain CPAP was reduced from more than 2 months to less than 1 week, the total number of sleep consultations decreased, and the waiting list time for the sleep clinic shortened. Murphie and colleagues. reported high satisfaction in a Scottish cohort, and Isetta and colleagues found similar satisfaction rates after video-based PAP follow-up encounters.
      • Isetta V.
      • Leon C.
      • Torres M.
      • et al.
      Telemedicine-based approach for obstructive sleep apnea management: building evidence.
      ,
      • Murphie P.
      • Paton R.
      • Scholefield C.
      • et al.
      Telesleep medicine review—patient and clinician experience.
      In contrast, the limitation of synchronous telemedicine is that it still requires face-to-face provider time, and its impact on care efficiency is modest at the best.
      • Hwang D.
      Monitoring progress and adherence with positive airway pressure therapy for obstructive sleep apnea: the roles of telemedicine and mobile health applications.
      To be so, it requires adoption of elements that largely fall under the umbrella of asynchronous telemedicine. Parikh and colleagues
      • Parikh R.
      • Touvelle M.N.
      • Wang H.
      • et al.
      Sleep telemedicine: patient satisfaction and treatment adherence.
      compared teleconsultation delivered by video conferencing with face-to-face consultation for follow-up of CPAP therapy in 90 patients. The proportion of compliant patients and levels of patient satisfaction were not different between the 2 groups. Nevertheless, the ideal frequency of face-to-face follow-up for maintenance of CPAP adherence remains to be elucidated. Murase and colleagues
      • Murase K.
      • Tanizawa K.
      • Minami T.
      • et al.
      A randomized controlled trial of telemedicine for long-term sleep apnea continuous positive airway pressure management.
      could demonstrate a favorable effect of a telemedicine intervention on treatment adherence in long-term CPAP users, and found that visits every 3 months with a monthly telemedicine intervention had a beneficial change in adherence similar to monthly visits. This finding may suggest that telemedicine interventions can assume some of the merits of close face-to-face follow-up for the maintenance of CPAP adherence. No improvement was found in CPAP compliance data. Because those participants were familiar with using CPAP, they probably appreciated the decrease in the number of clinic visits. The greater level of satisfaction in the telemedicine group may be a strong rationale to promote this approach.
      Telemedicine monitoring of sleep apnea therapy is currently limited to CPAP and related ventilator-support devices. However, alternative treatment modalities are coming in place, like mandibular advancement device and sleep position trainers. For example, it has been shown that mandibular advancement devices can be monitored objectively as well by in-built thermosensors, with wireless transmission of adherence and compliance data.
      • Dieltjens M.
      • Braem M.
      • Vroegop A.
      • et al.
      Objectively measured vs. self-reported compliance during oral appliance therapy for sleep-disordered breathing.
      For these devices, ongoing remote data monitoring of adherence is needed as well. However, the frequency of follow-up testing for these non-CPAP therapies does not seem clear. Altogether, telemedicine technologies could change the classical visits toward an outside clinic visit program, with shorter and more frequent visits realized by different communication methods.

      Patient counseling and therapy reinforcement

      The use of telemedicine has the ability to quickly collect, transmit, and incorporate data, making it a swift and viable means of communication between patients and their providers.
      • Seibert P.S.
      • Valerio J.
      • DeHaas C.A.
      The concomitant relationship shared by sleep disturbances and type 2 diabetes: developing telemedicine as a viable treatment option.
      These features have a significant potential for the management of patients with OSA, particularly for education and counseling, apart from optimizing CPAP adherence and close monitoring of effective compliance. This type of intervention also has the added potential benefit of fostering patient empowerment. Patients who take ownership, who are involved in their own care, and possess the knowledge and skills to manage their disease are more likely to comply with lifestyle modifications and treatment regimens, which in turn improves clinical outcomes.
      • Gellis Z.D.
      • Kenaley B.
      • McGinty J.
      • et al.
      Outcomes of a telehealth intervention for homebound older adults with heart or chronic respiratory failure: a randomized controlled trial.
      In this way, telemedicine can have a substantial impact on health care use, strengthen the sleep professional–patient interaction, and enhance self-management skills.
      • Paré G.
      • Jaana M.
      • Sicotte C.
      Systematic review of home telemonitoring for chronic diseases: the evidence base.

      Patient Counseling and Personalized Feedback (Video and Teleconferencing)

      Video and telephone contacts provide both direct and indirect benefits to patients. Direct benefits include decreased waiting time, and increased physician availability. Indirect benefits include avoidance of barriers to in-person visits, such as the cost and time associated with travel or missed work.
      • Kelly J.M.
      • Schwamm L.H.
      • Bianchi M.T.
      Sleep telemedicine: a survey study of patient preferences.
      Video visits could accommodate chronic routine follow-up appointments. Patient specific data, such as diaries for insomnia and CPAP machine downloads for OSA, could be reviewed at such visits, as could routine challenges with equipment or medications.
      • Kelly J.M.
      • Schwamm L.H.
      • Bianchi M.T.
      Sleep telemedicine: a survey study of patient preferences.
      As mentioned elsewhere in this article, a concern could be that the doctor might need to perform some physical examination. However, in sleep medicine it may be that stable patients could be adequately assessed without performing a physical examination that requires the physician to be present in the same room. In addition, certain elements of the examination, such as weight or blood pressure measurement could be performed at home or by the family physician. In a series of 90 patients with OSA, 56 were seen by a physician at the sleep center and 34 by videoconference. Satisfaction did not differ between the groups.
      • Parikh R.
      • Touvelle M.N.
      • Wang H.
      • et al.
      Sleep telemedicine: patient satisfaction and treatment adherence.
      A successful telemedicine encounter should mirror the live visits as much as possible.
      • Singh J.
      • Badr S.
      • Epstein L.
      • et al.
      Sleep telemedicine implementation guide.
      Therefore, close attention should be paid to the technical quality of the encounter, starting with the video and audio specifications.
      Video teleconferencing may improve access to care without compromising important clinical outcomes. Cost and provider time analyses have not been not undertaken so far.

      Promotion and Reinforcement of Patient Adherence and Compliance

      The optimal use of CPAP requires a level of patient engagement that exceeds what is needed to follow a pill-based regimen. Although teaching is likely necessary to provide foundational knowledge for behavior change, information may not be enough to induce significant and sustained behavior changes. Also, it can be questioned whether technology-based delivery of education can be a more cost-effective approach. Instead, addition of motivational elements such as personalized goal setting or other methods such as accountability may be essential.
      Behavioral determinants explain up to approximately 20% of the total variance in CPAP compliance emphasizing the complexity of compliance behaviors and providing an explanation for why simplistic interventions such as alternative pressure modes have not made a substantial impact on compliance.
      • Stepnowsky Jr., C.J.
      • Marler M.R.
      • Ancoli-Israel S.
      Determinants of nasal CPAP compliance.
      • Stepnowsky C.J.
      • Marler M.R.
      • Palau J.
      • et al.
      Socialcognitive correlates of CPAP adherence in experienced users.
      • Ayas N.T.
      • Patel S.R.
      • Malhotra A.
      • et al.
      Auto-titrating versus standard continuous positive airway pressure for the treatment of obstructive sleep apnea: results of a meta-analysis.
      • Bakker J.P.
      • Weaver T.E.
      • Parthasarathy S.
      • et al.
      Adherence to CPAP: what should we be aiming for, and how can we get there?.
      • Bogan R.K.
      • Wells C.
      A randomized crossover trial of a pressure relief technology (SensAwake) in continuous positive airway pressure to treat obstructive sleep apnea.
      A Cochrane meta-analysis of nontechnical methods to improve CPAP compliance in the general OSA population showed that supportive and educational interventions can modestly increase use and that cognitive behavioral therapies may lead to a larger increase of machine use.
      • Wozniak D.R.
      • Lasserson T.J.
      • Smith I.
      Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.
      In most studies where telemedicine was used, a cognitive behavioral intervention was applied by telephone,
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      ,
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      ,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      ,
      • Lankford D.A.
      Wireless CPAP patient monitoring: accuracy study.
      ,
      • DeMolles D.A.
      • Sparrow D.
      • Gottlieb D.J.
      • et al.
      A pilot trial of a telecommunications system in sleep apnea management.
      ,
      • Leseux L.
      • Rossin N.
      • Sedkaoui K.
      • et al.
      Education of patients with sleep apnea syndrome: feasibility of a phone coaching procedure. Phone coaching and SAS.
      the Internet,
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      ,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      or videoconference.
      • Spaulding R.
      • Stevens D.
      • Velasquez S.E.
      Experience with telehealth for sleep monitoring and sleep laboratory management.
      ,
      • Smith C.E.
      • Dauz E.R.
      • Clements F.
      • et al.
      Telehealth services to improve nonadherence: a placebo-controlled study.
      ,
      • Parikh R.
      • Touvelle M.N.
      • Wang H.
      • et al.
      Sleep telemedicine: patient satisfaction and treatment adherence.

      Active calls and automated telephone-linked communication/digitized human speech

      Demolles and colleagues
      • DeMolles D.A.
      • Sparrow D.
      • Gottlieb D.J.
      • et al.
      A pilot trial of a telecommunications system in sleep apnea management.
      used a daily computer-based telephone system to monitor patients’self-reported compliance behavior and provided automated counseling through a structured dialogue. The impact of the intervention was not significant in comparison to standard care. However, the findings suggest that concurrent education and reinforcement during the initial and early treatment period are effective countermeasures to patient-reported attenuated compliance. Sparrow and colleagues
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      applied an automated telemedicine intervention system, based on an algorithmic interactive voice response system designed to improve CPAP adherence and compliance. The system monitors CPAP-related symptoms and patients’ self-reported behavior and provides feedback and counseling through a structured dialogue to promote CPAP use. The monitor uses digitized human speech to speak to the patients and the patients communicate via the touch-tone keypad of their telephones. Each call began with an assessment of the self-reported duration and frequency of CPAP use during the past week, followed by one of several motivational counseling modules. If the participant reported excessive side effects or OSA symptoms, the system then recommended the patient to contact his or her physician to discuss the problems. The computer system called the patients if they did not make a call at the expected times. Routine printed reports were sent to the participants’ physician biweekly during the first month and the month thereafter. It was found that this telemedicine approach resulted in a median CPAP use that was 0.9 hours per night (at 6 months) and 2.0 hours per night (at 12 months) higher than that of an attention control group.
      • Sparrow D.
      • Aloia M.
      • Demolles D.A.
      • et al.
      A telemedicine intervention to improve adherence to continuous positive airway pressure: a randomised controlled trial.
      Chervin and colleagues performed an RCT among 33 patients of 2 interventions to improve compliance: 1 group received weekly telephone calls to uncover any problems and encourage use, a second group received written information about OSA and the importance of CPAP adherence, and finally, a third group served as a control group. The authors reported that intervention improved CPAP compliance and that the effect was especially strong when intervention occurred during the first month of CPAP treatment.
      • Chervin R.D.
      • Theut S.
      • Bassetti C.
      • et al.
      Compliance with nasal CPAP can be improved by simple interventions.
      Isetta and colleagues
      • Isetta V.
      • Leon C.
      • Torres M.
      • et al.
      Telemedicine-based approach for obstructive sleep apnea management: building evidence.
      found in a series of 50 consecutive patients with OSA that most of them were satisfied with the teleconsultation method, and 66% agreed that the teleconsultation could replace more than half of their CPAP follow-up visits. Finally, Coma del Corral and colleagues
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      found that the level of good CPAP compliance was 85% at 6 months in patients attending the sleep center for a face-to-face meeting, whereas it was 75% in the teleconsultation arm.
      Sedhaoui and colleagues performed an RCT in 379 patients with OSA, comparing standard support completed or not within 3 months of coaching sessions, based on telephone-based counseling by competent staff. Of the patients in the standard group, 65% showed a compliance rate of greater than 3 hours per night versus 75% for the coached group. The mean CPAP use was 26 minutes longer in the coached group versus standard group.
      • Sedkaoui K.
      • Leseux L.
      • Pontier S.
      • et al.
      Efficiency of a phone coaching program on adherence to continuous positive airway pressure in sleep apnea hypopnea syndrome: a randomized trial.
      These automated interventions improved adherence in part by improving motivation, altering the perception of treatment efficacy, and affect psychological constructs that determine behavior change.

      Web-based access to own positive airway pressure data

      Kuna and collegues
      • Kuna S.T.
      • Shuttleworth D.
      • Chi L.
      • et al.
      Web-based access to positive airway pressure usage with or without an initial financial incentive improves treatment use in patients with obstructive sleep apnea.
      tracked website use and found in an RCT that providing patients with daily web-based access to their own PAP use improves compliance (4.7 ± 3.3 hours in the usual care group, 5.9 ± 2.5 hours, and 6.3 ± 2.5 hours in the web access groups with and without financial incentive respectively). However, only about one-half of the participants logged in during the first week, and the proportion of patients using the website decreased with time. Inclusion of a financial incentive in the first week had no additive effect in improving compliance. These findings are consistent with a similar study evaluating the effect on compliance when an interactive website providing PAP data to both patients and providers is used.
      • Stepnowsky C.
      • Zamora T.
      • Barker R.
      • et al.
      Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup.
      This website, called MyCPAP, included the following components: (1) basic education regarding OSA and CPAP, (2) patient access to their own data, (3) questionnaires to assess subjective symptoms, (4) interactive guide to learn about practical solutions to their identified CPAP problem, and (5) education regarding how to use and care for CPAP and accessories.
      • Stepnowsky C.
      • Zamora T.
      • Barker R.
      • et al.
      Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup.
      Taylor and colleagues
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      used computers to provide daily Internet-based informational support and feedback (Health Buddy, daily survey) for problems experienced during CPAP use. Questions related to CPAP use, hours of sleep and quality of sleep were sent to the participants via a computer. The patient’s responses were monitored by the sleep medicine practitioner, and the patient telephoned if deemed necessary. They found no significant differences between the telemedicine intervention and standard care group at 30 days in patient functional status and satisfaction with CPAP. This intervention only provided self-reported data to the health care provider, whereas objective compliance and detailed physiologic information may have been more useful in effectively troubleshooting problems and may have improved CPAP compliance.
      • Spaulding R.
      • Stevens D.
      • Velasquez S.E.
      Experience with telehealth for sleep monitoring and sleep laboratory management.
      ,
      • Taylor Y.
      • Eliasson A.
      • Andrada T.
      • et al.
      The role of telemedicine in CPAP compliance for patients with obstructive sleep apnea syndrome.
      ,
      • Kwiatkowska M.
      • Idzikowski A.
      • Matthews L.
      Telehealth-based framework for supporting the treatment of obstructive sleep apnea.
      Furthermore, in a RCT, Fox and colleagues
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      demonstrated improved CPAP compliance with a web-based telemedicine monitoring system. An autoCPAP machine transmitted physiologic data (residual AHI, air leak, compliance) daily to a website that could be reviewed. In case problems were identified from data from the website, the patient was contacted by telephone as necessary.
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      After 3 months, the mean compliance rate was significantly greater in the telemedicine arm (191 min/d), compared with the usual care arm (105 minutes), but even then CPAP compliance was low. In contrast, 67 minutes of technician time was spent on the patients in the telemedicine arm compared with the standard approach.

      Automated messaging (reinforcement emails or texts)

      Various forms of telecommunication, which may include automated message data alerts, coaching and reinforcement emails, texts, and calls, as well as online educational and motivational support, have shown similar or increased CPAP compliance.
      • Schutte-Rodin S.
      Telehealth, telemedicine, and obstructive sleep apnea.
      It is particularly interesting that this feedback process (sending positive or warning messages in the case of good or poor compliance, respectively) can be performed automatically, therefore minimizing health staff cost. Frasnelli and collegues
      • Frasnelli M.
      • Baty F.
      • Niederman
      • et al.
      Effect of telemetric monitoring in the first 30 days of continuous positive airway pressure adaptation for obstructive sleep apnoea syndrome—a controlled pilot study.
      used short text messages by SMS with treatment reinforcement was sent out weekly, if no phone calls were necessary. The Tele-OSA study of automated messaging associated with telemonitoring gave early improvement in CPAP adherence, but this effect gradually declined after discontinuation of automated feedback messaging.
      • Hwang D.
      Monitoring progress and adherence with positive airway pressure therapy for obstructive sleep apnea: the roles of telemedicine and mobile health applications.
      The majority preferred to receive messages via email (31.7%), followed by text messaging (17.5%), and phone (2.3%), whereas 40% preferred a combination of approaches.
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      In the study of Hwang and colleagues,
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      the overall improvement in adherence with telemonitoring was substantial, but the degree of response varied between individual patients. In a prospective, open, multi-center study involving 122 patients with OSA, effectiveness and coaching costs were evaluated using U-Sleep, a web-based automated telehealth program.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      In this study, the telehealth group received emails and/or text messages, whereas in the standard care arm, follow-up consisted of scheduled phone calls on days 1, 7, 14, and 30. Results of this study revealed that there was no statistically significant difference in CPAP compliance, CPAP efficacy or change in Epworth Sleepiness Scale scores between telehealth and standard care groups, but the trend favored the telehealth group. The coaching time required was significantly lower in the telehealth Group, making it a time-efficient option. The authors concluded that this automated telemedicine strategy needs to be continued indefinitely for sustained effect. Altogether, the use of technology-based approaches should be considered as 1 solution among a larger set of management strategies to personalize the care for individual patients. The potential impact of changing thresholds to increase message frequency or the possibility of personalizing automated messages for each patient, based specifically on what would motivate them the most, and individual goal setting have to be further explored.

      Mobile device applications: Patient engagement tools

      With increasing Internet access, there is a developing role for web-based patient engagement applications to assist patients in self-management of OSA. Recently, manufacturers of CPAP devices have designed and implemented such theory-driven coaching and support services, including a dashboard summarizing therapy data, troubleshooting and educational videos, and goal-focused automated e-mails/texting. These tools are described as patient engagement tools, self-management platforms or patient-facing applications, and should ideally include the following components: (1) remote electronic delivery, (2) personalized invitation, (3) interactive, (4) viewable on demand and as often as desired, and (5) concise and easy to understand.
      • Hwang D.
      Monitoring progress and adherence with positive airway pressure therapy for obstructive sleep apnea: the roles of telemedicine and mobile health applications.
      These platforms operate through mobile device applications (U-Sleep and MyAir: ResMed, Australia; SleepMapper later DreamMapper: Philips, Amsterdam, the Netherlands), sync automatically with the CPAP vendors software program, providing personal CPAP data in comprehensive graphs to each patients, and also incorporating CPAP troubleshooting materials. The data are transferred from the patients’ CPAP to a remote database, the same platform used by sleep professionals to access a comprehensive report of CPAP treatment data to monitor patients. At the same time, all these patients have access to their personal CPAP data via a mobile device application or via a web portal.
      • Suarez-Giron M.
      • Bonsignore M.R.
      • Montserrat J.M.
      New organisation for follow-up and assessment of treatment efficacy in sleep apnoea.
      These systems also use structured motivational enhancement techniques such as feedback and goal setting, to encourage use. Patients receive positive feedback by sending text messages to congratulate participants about their successful CPAP adherence. In contrast, feedback to patients with a poor night of adherence may motivate improved use on the subsequent night. These concepts are part of social cognitive theory, which considers self-efficacy as a major determinant of behavior change.
      • Aloia M.S.
      • Arnedt J.T.
      • Stanchina M.
      • et al.
      How early in treatment is PAP adherence established ? Revisiting night-to-night variability.
      ,
      • Aloia M.S.
      • Smith K.
      • Arnedt J.T.
      • et al.
      Brief behavioral therapies reduce early positive airway pressure discontinuation rates in sleep apnea syndrome: preliminary findings.
      ,
      • Aloia M.S.
      • Arnedt J.T.
      • Strand M.
      • et al.
      Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: a randomized controlled trial.
      Strong self-efficacy beliefs are associated with the ability to withstand treatment failure and persist in efforts.
      • Bandura A.
      Self-efficacy: toward a unifying theory of behavioral change.
      ,
      • Bourbeau J.
      • Nault D.
      • Dang-Tan T.
      Self-management and behaviour modification in COPD.
      Altogether, these patient engagement tools enhance self-monitoring by providing the patient with easy-to-view reports of trends in use, AHI, and feedback about mask leak. MyAir also monitors mask off/on events in addition, and gives a summary score based on proprietary weighting of the aforementioned factors. Although MyCPAP provides troubleshooting tips and educational materials, they must be selected by the patient. In contrast, the commercial platforms serve up educational suggestions, based on the monitoring as well as suggestions for selecting intermediate goals of care, possibly better equipping patients to problem solve and to set goals.
      • Shaughnessy G.F.
      • Morgenthaler T.I.
      The effect of patient-facing applications on positive airway pressure therapy adherence: a systematic review.
      As said, these applications also serve as a portal to educational videos about OSA and CPAP therapy, which facilitate patients to trouble shoot as problems arise.
      Such an approach has shown benefit when delivered by health care providers in different studies (Table 4).
      • Hardy W.
      • Powers J.
      • Jasko J.G.
      • et al.
      DreamMapper white paper: a mobile application and website to engage sleep apnea patients in PAP therapy and improve adherence to treatment.
      ,
      • Stepnowsky C.
      • Zamora T.
      • Barker R.
      • et al.
      Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup.
      ,
      • Hostler J.M.
      • Sheikh K.L.
      • Andrada T.F.
      • et al.
      A mobile, web-based system can improve positive airway pressure adherence.
      ,
      • Pittard J.
      • Yarascavitch J.
      • Jasko J.
      • et al.
      The use of SleepMapper (a patient self-management application) improves CPAP adherence in Australian patients.
      ,
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      ,
      • Malhotra A.
      • Crocker M.E.
      • Willes L.
      • et al.
      Patient engagement using new technology to improve adherence to positive airway pressure therapy: a retrospective analysis.
      Table 4Patient engagement tools and compliance
      NAHIPatient Engagement ToolFollow-upCompliance Patient Engagement ToolsCompliance Usual CareP Value
      Stepnowsky et al,
      • Stepnowsky C.
      • Zamora T.
      • Barker R.
      • et al.
      Accuracy of positive airway pressure device-measured apneas and hypopneas: role in treatment followup.
      2013
      24136MyCPAP120 d3.9 h3.2 hS
      Pittard et al,
      • Pittard J.
      • Yarascavitch J.
      • Jasko J.
      • et al.
      The use of SleepMapper (a patient self-management application) improves CPAP adherence in Australian patients.
      2015
      2173N/ADreamMapper60 d5 h3.9 hS
      Hardy et al,
      • Hardy W.
      • Powers J.
      • Jasko J.G.
      • et al.
      DreamMapper white paper: a mobile application and website to engage sleep apnea patients in PAP therapy and improve adherence to treatment.
      2016
      172678N/ADreamMapper90 d5 h3.9 hS
      Hostler et al,
      • Hostler J.M.
      • Sheikh K.L.
      • Andrada T.F.
      • et al.
      A mobile, web-based system can improve positive airway pressure adherence.
      2017
      6118–19SleepMapper77 d4 h2.7 hS
      Woehrle et al,
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      2018
      1000N/AmyAir180 d5.4 h4.2 hS
      Malhotra et al,
      • Malhotra A.
      • Crocker M.E.
      • Willes L.
      • et al.
      Patient engagement using new technology to improve adherence to positive airway pressure therapy: a retrospective analysis.
      2018
      128037N/AmyAir90 d5.9 h4.9 hS
      Abbreviation: N/A, not applicable.
      Engleman and colleagues
      • Engleman H.
      • Stitt C.
      • Creswick L.
      • et al.
      Effects on CPAP use of a patient support mobile app.
      presented a retrospective study (data from Philips) comparing CPAP use in an old-fashioned OSA cohort versus a new feature OSA cohort, including remote monitoring, device display and a patient support phone app. In the 817 included patients, the implementation of multiple telemedicine supporting tools resulted in an increase in daily CPAP use of 1.1 hours per night during the first 12 weeks of CPAP therapy. Pittard and colleagues
      • Pittard J.
      • Yarascavitch J.
      • Jasko J.
      • et al.
      The use of SleepMapper (a patient self-management application) improves CPAP adherence in Australian patients.
      reported similar significant results with the DreamMapper. Hardy and colleagues reported that 78% of those who used SleepMapper were compliant at 90 days compared with 56% of those who did not, and they used CPAP for an average of 1.4 hours longer per night.
      • Lynch S.
      • Blasé A.
      • Erikli L.
      • et al.
      Retrospective descriptive study of CPAP adherence associated with use of the ResMed myAir application.
      U-Sleep patients do have a better CPAP use at 3 months (83% vs 73%), but without statistical significance.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      However, they found that fewer coaching minutes were required during the 3-month follow-up period for the U-Sleep (24 vs 58 minutes for usual care). This suggests that U-Sleep could be a cost-effective solution by potentially replacing traditional follow-up protocols without drop-off in CPAP adherence. Hostler and colleagues reported an 18% increase in nights with more than 4 hours of use, and patients in the SleepMapper Group were more than 3 times as likely to meet adherence criteria (>4 hours per night for 70% of nights), a trend that just missed statistical significance (P = .06). This should translate into significant improvements at the individual and population level.
      • Hostler J.M.
      • Sheikh K.L.
      • Andrada T.F.
      • et al.
      A mobile, web-based system can improve positive airway pressure adherence.
      A retrospective analysis of 1000 patients found that 77% of those who opted to engage with such a tool used CPAP for 4 hours or more per night, compared with 63% of those who opted out. A retrospective review of 15.000 patients in a database showed 78% of those who used SleepMapper were compliant at 90 days and used CPAP.
      • Hwang D.
      Monitoring progress and adherence with positive airway pressure therapy for obstructive sleep apnea: the roles of telemedicine and mobile health applications.
      Similarly, a retrospective analysis of 128,037 patients found that a greater proportion of those who opted into the same patient engagement technology were compliant compared with those who did not (87.3% vs 70.4%, respectively).
      • Malhotra A.
      • Crocker M.E.
      • Willes L.
      • et al.
      Patient engagement using new technology to improve adherence to positive airway pressure therapy: a retrospective analysis.
      In a study that used data from a large German home care provider, it was shown that the use of a proactive patient management program supported by remote access to PAP therapy data significantly lowered therapy termination rate (5.4% vs 11.0%) and time to therapy termination was significantly longer (348 vs 337 days).
      • Woehrle H.
      • Ficker J.H.
      • Graml A.
      • et al.
      Telemedicine-based proactive patient management during positive airway pressure therapy: impact on therapy termination rate.
      In another study, Woehrle and colleagues
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      also reported that the therapy termination rate was lower in the patient engagement group, with higher device use and lower leak. The AHI was equal in both groups. The addition of a patient engagement tool was associated with a significant improvement in device use in patients receiving CPAP therapy for the first time. Increases were seen in both the number of days with device use and in the hours of device use each night. Moreover, there was a significant reduction in leak in patients managed using a patient engagement approach compared with telemonitoring alone.
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      Potential explanations for this observation include better education and feedback compared with usual care. Patient engagement tools add another level to telemonitoring. Patients can get involved via shared decision-making with their health care givers and by increasing their health literacy (accessing, understanding and implementing health information). Moreover, the use of real-time feedback could help to keep patients actively engaged with their therapy, and remind and motivate them to use their device. Also, such technology facilitates the input of real-time clinical data and allows real-time responses that incorporate personalized recommendations based on the data received. Key features of patients engagement tools are (1) the patient believes that they have an important role to play in their own health care, (2) the patient is provided with the confidence and knowledge to take action, (3) the patient takes action to maintain and improve their health, and (4) the patient persists with the program even during times of stress.
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      ,
      • Hibbard J.H.
      • Stockard J.
      • Mahoney E.R.
      • et al.
      Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers.
      Hwang and colleagues
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      demonstrated that Web-OSA education added to an automated CPAP follow-up program impacted CPAP adherence to a greater degree than either of those platforms used in isolation.
      Apart from an improved adherence to PAP therapy, patient engagement tools are inexpensive, do not draw on health care resources, and show promise in improving PAP therapy for OSA.
      • Shaughnessy G.F.
      • Morgenthaler T.I.
      The effect of patient-facing applications on positive airway pressure therapy adherence: a systematic review.
      Use of these platforms was associated with using PAP for significantly more hours per night (range of 0.7–1.3 hours more). In contrast, it could be that this difference has a minimal effect on symptom improvement, because the scores could be affected by coexisting conditions. Traditional telemonitoring systems require health care professional-initiated patient contact and deployment of health care resources, whereas patient engagement tools engage patients directly without placing additional burden on health care.
      • Shaughnessy G.F.
      • Morgenthaler T.I.
      The effect of patient-facing applications on positive airway pressure therapy adherence: a systematic review.
      In a real-life big data study with 4.181.490 patients, those who registered to use an engagement tool consistently had better adherence (80%–85%) than those who did not (65%–70%).
      • Drager L.F.
      • Malhotra A.
      • Yan Y.
      • et al.
      medXcloud Group
      Adherence with positive airway pressure therapy for obstructive sleep apnea in developing vs. developed countries: a big data study.
      Patient engagement tool use was associated with a greater than 2-fold increase in the probability of achieving sufficient adherence. The possibility arises that some patients may have been experienced PAP users before joining trials with patient engagement tools rather than new PAP users.
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.
      ,
      • Malhotra A.
      • Crocker M.E.
      • Willes L.
      • et al.
      Patient engagement using new technology to improve adherence to positive airway pressure therapy: a retrospective analysis.
      Such patients might behave differently to patient engagement tools than PAP-naïve patients. However, prior studies show that PAP use is established soon after PAP initiation, and it seems unlikely that providing feedback data and recommendations to experienced users would result in greater improvement in PAP adherence than what was observed in PAP-naïve patients.
      • Kuna S.T.
      • Shuttleworth D.
      • Chi L.
      • et al.
      Web-based access to positive airway pressure usage with or without an initial financial incentive improves treatment use in patients with obstructive sleep apnea.
      Further efforts are needed to identify key features, their effect on outcomes of interest, and which patients would benefit from them most.

      Telemanagement of comorbidities

      Improved outcomes have been reported using telemedicine in conditions like diabetes mellitus, hypertension, stroke, and HIV.
      • Paré G.
      • Jaana M.
      • Sicotte C.
      Systematic review of home telemonitoring for chronic diseases: the evidence base.
      ,
      • Billiard A.
      • Rohmer V.
      • Roques M.
      • et al.
      Telematic transmission of computerized blood glucose profiles for IDDM patients.
      • Friedman R.H.
      • Kazis L.E.
      • Jette A.
      • et al.
      A telecommunications system for monitoring and counseling patients with hypertension: impact on medication adherence and blood pressure control.
      • Schwamm L.H.
      • Audebert H.J.
      • Amarenco P.
      Stroke recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association.
      • Gustafson D.H.
      • Hawkins R.
      • Boberg E.
      • et al.
      Impact of a patientcentered, computer-based health information/support system.
      This opens new horizons for patients with OSA and comorbidities. Obesity is the most frequent condition associated with OSA, which deserves close attention.
      Appel and colleagues
      • Appel L.J.
      • Clark J.M.
      Comparative effectiveness of weight-loss interventions in clinical practice.
      evaluated the effectiveness of a telemedicine behavioral weight loss intervention among 415 obese patients with at least one cardiovascular risk factor for 2 years. Participants were randomized to the following groups: (1) remote weight loss support (by telephone, website, and email), (2) in-person support together with the 3 remote means of support, and (3) a control group with self-directed weight-loss management. After 2 years, the mean change in weight from baseline and percentage of participants who lost 5% or more of their initial weight was significantly greater in the remote support groups (with or without additional in-person interventions), when compared with the control group (with self-directed weight-loss management). Hence, the remote support interventions facilitated greater weight loss, and did not require in-person support. Another known comorbidity associated with OSA is diabetes, which has also been looked into with the use of telemedicine. Wang and colleagues
      • Wang G.
      • Zhang Z.
      • Feng Y.
      • et al.
      Telemedicine in the management of Type 2 diabetes mellitus.
      evaluated the use of U-health care, a remote platform based on an Internet interface that transmits glycemic data immediately through a glucometer. The intervention group received information about medicines, diet, and exercise through the platform, whereas the control group received conventional medical treatment without any additional intervention. After 18 months follow up, the intervention group achieved better glycemic control, improved hemoglobin A1c levels and decreased triglyceride levels. This approach also improved patients' adherence to the medical team's instructions.
      Heart failure can also be associated with OSA, and is one of the first fields where telemedicine has been applied. Bashi and colleagues
      • Bashi N.
      • Karunanithi M.
      • Fatehi F.
      • et al.
      Remote monitoring of patients with heart failure: an overview of systematic reviews.
      analyzed 19 systematic reviews of remote interventions that focused on the control of heart failure. The use of telemonitoring of physiologic parameters (heart rate, blood pressure, electrocardiogram, and weight) showed a reduction in heart failure hospitalization, all-cause hospitalization, mortality and an improvement in quality of life. However, there is a lack of evidence to support the effectiveness of interventions involving mobile phone use, videoconferences, or other devices.
      Nevertheless, the application of new technologies is not suitable for all populations.
      • Gregersen T.L.
      • Green A.
      • Frausing E.
      • et al.
      Do telemedical interventions improve quality of life in patients with COPD? A systematic review.
      ,
      • Takahasi P.Y.
      • Pecina J.L.
      • Upatising B.
      • et al.
      A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits.
      Therefore, it is mandatory to choose wisely the appropriate outcomes and patient populations for telehealth strategies.

      Telemedicine in particular populations

      It is remarkable that primarily those telemedicine concepts were able to increase use time in which the control group used the CPAP device for less than 4 hours per night. In contrast, when the control group is greater than the threshold of 4 hours per night, usually no further improvement is achieved.
      A recent meta-analysis revealed that telemedicine care was associated with significantly greater CPAP compliance compared with usual care, with a pooled mean difference of 0.68 hours per night.
      • Chen C.
      • Wang J.
      • Pang L.
      • et al.
      Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials.
      However, the findings need to be interpreted with caution, given the varying methodologic quality of the included studies, the high heterogeneity of the recruited studies, as well as the fat that the included type and intensity of both usual care and experimental interventions varied considerably. Another meta-analysis included 22 studies, and showed that telemedicine interventions are able to increase adherence to CPAP treatment.
      • Aardoom J.J.
      • Loheide-Niesmann L.
      • Ossebaard H.C.
      • et al.
      Effectiveness of eHealth interventions in improving treatment adherence for adults with obstructive sleep apnea: meta-analytic review.
      However, in 10 studies no significant effect was found on compliance, although 57% of the patients were from a single center that was in favor of telemonitoring. Hence, the exact level of educational and supportive concepts in the control groups contributed to the additional effect of telemedical interventions. Probably, a ceiling effect regarding educational actions must be considered.
      • Nilius G.
      • Schroeder M.
      • Domanski U.
      • et al.
      Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial.
      Similarly, Schoch and colleagues
      • Schoch O.D.
      • Baty F.
      • Boesch M.
      • et al.
      Telemedicine for continuous positive airway pressure in sleep apnea. A randomized, controlled study.
      concluded that the telemedicine intervention did not significantly improve CPAP use in an unselected OSA population, which was explained by a relatively high adherence in the control arm. In contrast, the same group found a positive impact on CPAP use in a subgroup of patients with a milder form of OSA. Also, significant improvement in quality of life was found, which was not related to the hours of CPAP use, but was most pronounced in the telemedicine arm. This brings us to a more general aspect concerning the target population, namely whether the whole CPAP-treated population should be included, or only particular phenotypes that are better served for different aspects of telehealth options.
      • Farré R.
      • Navajas D.
      • Montserrat J.M.
      Is telemedicine a key tool for improving continuous positive airway pressure adherence in patients with sleep apnea?.
      It could be argued that telemonitoring might be more useful in specific populations (eg, poorly adherent patients or those with few symptoms) and also reinforces the concept that better adherence and treatment effectiveness can only be ensured by using distinctive tailored management strategies, with or without telemonitoring, according to the OSA phenotype.
      • Sutherland K.
      • Kairaitis K.
      • Yee B.J.
      • et al.
      From CPAP to tailored therapy for obstructive sleep apnoea.
      For patients with comorbid insomnia, telemedicine also opens opportunities to exchange and automatically process sleep diaries, smartphone applications of sleep-wake data and follow online programs related to cognitive behavioral therapy.
      • Ritterband L.M.
      • Thorndike F.P.
      • Gonder-Frederick L.A.
      • et al.
      Efficacy of an Internet-based behavioral intervention for adults with insomnia.
      • Espie C.A.
      • Kyle S.D.
      • Williams C.
      • et al.
      A randomized, placebocontrolled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich Web application.
      • Zia S.
      • Fields B.G.
      Sleep telemedicine: an emerging field's latest frontier.
      This way, the insomnia field can probably be transitioned from evaluating more basic, noninteractive online programs to personalized, interactive online programs. For example, the group of Espie and colleagues
      • Espie C.A.
      • Kyle S.D.
      • Williams C.
      • et al.
      A randomized, placebocontrolled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich Web application.
      used a virtual therapist to help deliver a web-based cognitive behavioral therapy-i program. Such approach may likely have more important roles in managing insomnia in the future. Apart from insomnia, it has been shown that the cognitive behavioral therapy approach is also effective in a context of OSA to improve CPAP adherence.
      • Richards D.
      • Bartlett D.J.
      • Wong K.
      • et al.
      Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial.
      In case of inadequate sleep hygiene, platforms can be programmed with automated messages to encourage behavioral change, without direct interaction with the sleep provider.
      • Stepnowsky C.
      • Sarmiento K.F.
      • Amdur A.
      Weaving the internet of sleep: the future of patient-centric collaborative sleep health management using web-based platforms.
      One major limitation in telemonitoring studies is the failure to reach a sufficient sample size. In a recent French study it was found that 1646 patients would have been needed to reach a power of 0.8 to show a significant difference of 0.34 hour per night in compliance, whereas 788 patients would have been needed to meet a threshold of greater than 0.5 hours with a power of 0.80.
      • Tamisier R.
      • Treptow E.
      • Joyeux-Faure M.
      • et al.
      Impact of a multimodal telemonitoring intervention on CPAP adherence in symptomatic OSA and low cardiovascular risk: a randomized controlled trial.
      This may also suggest that it is unlikely that a meaningful increase in CPAP adherence of less than 30 minutes is clinically significant.
      Hence, the American Academy of Sleep Medicine guideline recommends telemonitoring-guided interventions during the initial period of PAP therapy in adults with OSA, but only at conditional level of recommendation.
      • Patil S.P.
      • Ayappa I.A.
      • Caples S.M.
      • et al.
      Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine Systematic review, meta-Analysis, and GRADE assessment.
      ,
      • Patil S.P.
      • Ayappa I.A.
      • Caples S.M.
      • et al.
      Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline.
      It seems that a wise balance between enthusiasm and skepticism, which is inherently linked with solid science, would be the best way to consolidate useful results for routine application of telemedicine for PAP follow-up in OSA. The field is at a very early stage for pediatric patients compared with adult ones, and no systematic reviews have been carried out on telemedicine for pediatric OSA. So, it is unclear whether the results could be generalized to younger populations. Finally, in stroke patients, Kotzian and colleagues
      • Kotzian S.T.
      • Saletu M.T.
      • Schwarzinger A.
      • et al.
      Proactive telemedicine monitoring of sleep apnea treatment improves adherence in people with stroke- a randomized controlled trial (HOPES study).
      reported a higher compliance in telemonitored patients after 3 months, after 1 year there was no significant difference. Nilius and colleagues
      • Nilius G.
      • Schroeder M.
      • Domanski U.
      • et al.
      Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial.
      studied stroke patients as well and found a higher compliance after 6 months of home therapy.

      Patient satisfaction

      There are a multitude of potential benefits to incorporating telemedicine into adult sleep practices, including and not limited to saving travel time and costs, less missed work time, and eventually bringing multiple caregivers together. Smartphones allow almost all health care professionals to connect seamlessly and attend telemedicine appointments. Such approach may also decrease appointment no-show rates. Surprisingly, in the study of Turino and colleagues telemonitoring system was unexpectedly associated with lower patient satisfaction. The study observed no significant difference in neither percentage of patients with good adherence nor 3-month use hour per night between the 2 groups. This finding was explained by the lack of in-person contact in the intervention arm, whereas clinical appointments were only scheduled for the control arm.
      • Turino C.
      • de Batlle J.
      • Woehrle H.
      • et al.
      Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
      Also, in the study of Bros and colleagues,
      • Bros J.S.
      • Poulet C.
      • Arnol N.
      • et al.
      Acceptance of telemonitoring among patients with obstructive sleep apnea syndrome: how is the perceived interest by and for patients?.
      a majority (78%) of patients expressed a favorable attitude toward telemonitoring, but nearly 40% considered the telemonitoring device like intrusive. Telemonitoring also encompasses the risk to mask some aspects of care, by relying excessively on technical parameters, forgetting the clinical context.
      • Bruyneel M.
      Telemedicine in the diagnosis and treatment of sleep apnoea.
      This could result in a decrease in medical quality and dehumanization of care, missing the fact that monitoring CPAP use can be satisfying, but in a patient suffering from residual excessive daytime sleepiness, it is not the complete picture.
      • Gasa M.
      • Tamisier R.
      • Launois S.H.
      • et al.
      Residual sleepiness in sleep apnea patients treated by continuous positive airway pressure.
      Whereas dehumanization of care with telemonitoring is a significant concern for the physician–patient relationship, this parallel route should not be underestimated. Moreover, it is very unlikely that telemedicine will completely replace face-to-face contacts. Importantly, the perfect match of both routes (with and without in-person visits) will likely improve health care as a whole.
      • Luz P.L.D.
      Telemedicine and the doctor/patient relationship.

      Economic approach

      Cost effectiveness is an important factor to consider when discussing the role of telemedicine in OSA, keeping in mind the ever-increasing health care expenses. Telemedicine can contribute to the improved cost effectiveness of OSA management during both the diagnostic and therapeutic phases. However, we must be cautious when applying these methods to the clinical setting, given that some studies have described that the intervention could not always be cost effective or even could induce negative outcomes. The evidence for unequivocally positive outcomes on patient health is still limited. Costs mostly depend on staff time and hardware expenses. Nevertheless, in a simulation of the cost effect, it was shown that if half of the patients were managed by telemedicine, the nationwide annual cost for management of patients with OSA would decrease with 17%.
      • Murase K.
      • Tanizawa K.
      • Minami T.
      • et al.
      A randomized controlled trial of telemedicine for long-term sleep apnea continuous positive airway pressure management.

      Staff Time

      Telemonitoring could be a time- and human resource-intensive tool for sleep centers and homecare providers. Frequent involvement of staff through in-person contacts or automated feedback triggering may counteract cost-effectiveness, because the same effects might be achieved through routine phone calls without the use of telemedicine device.
      • Schoch O.D.
      • Baty F.
      • Boesch M.
      • et al.
      Telemedicine for continuous positive airway pressure in sleep apnea. A randomized, controlled study.
      Reviewing the downloaded information every week day is labor intensive and may not be feasible in all settings. One misunderstanding could be that patients consider their physicians to be routinely monitoring their data on a regular basis. However, such expectations cannot be met without having intermediary support (such as respiratory therapists or home-care providers) to assign certain trigger thresholds for the PAP compliance data to trigger when compliance is not being met.
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      Fox and colleagues
      • Fox N.
      • Hirsch-Allen A.J.
      • Goodfellow E.
      • et al.
      The impact of telemedicine monitoring system on positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial.
      quantified provider time and found that an additional 67 minutes on overage per patient was spent managing the patients that were remotely monitored. A much greater number of interventions can be expected in the telemonitored patients. In patients with OSA with at least 1 intervention, an overall 59% increase in the number of physician interventions and 54% increase in the number of homecare provider’s interventions was shown.
      • Tamisier R.
      • Treptow E.
      • Joyeux-Faure M.
      • et al.
      Impact of a multimodal telemonitoring intervention on CPAP adherence in symptomatic OSA and low cardiovascular risk: a randomized controlled trial.
      This finding emphasizes the need for a cost-effectiveness validation of such a strategy, given the greater burden of caregivers’ interventions for both medical (persistent high residual AHI, residual sleepiness) and technical (masks, humidifiers) reasons. It could be speculated that a usual care intervention might be more efficient from a cost perspective, given that an average of 30 minutes may be necessary to respond to or to manage each alert.
      • Tamisier R.
      • Treptow E.
      • Joyeux-Faure M.
      • et al.
      Impact of a multimodal telemonitoring intervention on CPAP adherence in symptomatic OSA and low cardiovascular risk: a randomized controlled trial.
      In contrast, multimedia approaches could also help save nursing time, which could inherently allow more patients to be managed with the same manpower.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      ,
      • Anttalainen U.
      • Melkko S.
      • Hakko S.
      • et al.
      Telemonitoring of CPAP therapy may save nursing time.
      Recent studies demonstrated a reduction in labor requirements, nursing time and cost owing to telemedical care.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      ,
      • Turino C.
      • de Batlle J.
      • Woehrle H.
      • et al.
      Management of continuous positive airway pressure treatment compliance using telemonitoring in obstructive sleep apnoea.
      ,
      • Anttalainen U.
      • Melkko S.
      • Hakko S.
      • et al.
      Telemonitoring of CPAP therapy may save nursing time.
      Office staff telemonitoring of voluminous nightly data from entire practices of patients is daunting and generally not reimbursable. However, telemedicine may provide a pragmatic solution for practices attempting to manage huge amounts of nightly CPAP data for PAP patients over years. It is also not clear how long special patient groups, like people who had a stroke, might benefit from telemedicine while treated with PAP. In stroke patients, the costs seemed to be low, since the use increase was achieved with an average of 4.7 contacts per patient over a period of 6 months.
      • Nilius G.
      • Schroeder M.
      • Domanski U.
      • et al.
      Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial.
      The telemedicine concept led to a reduction of daytime sleepiness and blood pressure and might help increase quality of life after the stroke. Thanks to targeting of interventions to patients with problems observed, one can focus precious working hours on those PAP patients who really need additional support.

      Equipment

      Furthermore, telemedicine is rather expensive, and this is related to the complex technology required to implement telecare. These costs could be decreased by wider use of telemedicine in the future. As discussed earlier, Coma-del-Corral and colleagues
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      investigated telemonitored polygraphy in patients with clinical suspicion of OSAS. Telemedicine-polygraphy was performed on 40 patients, in a virtual sleep unit, in another hospital some 80 km from the central sleep laboratory. The sleep laboratory nurses performed real-time continuous telemedicine-polygraphy check. Continuous video monitoring (via a webcam) was also available. No polygraphy failure was observed, but data transmission failed for 2.5% of the recordings. The cost analysis showed also that telemedicine is associated with additional costs: telemedicine-polygraphy cost 277 € compared with 145 € for a PSG.
      • Coma-del-Corral M.J.
      • Alonso-Alvarez M.L.
      • Allende M.
      • et al.
      Reliability of telemedicine in the diagnosis and treatment of sleep apnea Syndrome.
      ,
      • Bruyneel M.
      Technical developments and clinical use of telemedicine in sleep medicine.

      Access to health care

      Another interesting aspect is that telemedicine can improve the efficiency of health care delivery in terms of costs and time. Of course, when setting up a telemedicine visit, the patients should be reassured that they will still receive the same level of care as they would get face to face. Studies reported a decrease in travel costs and office room rentals, which will likely not apply in all countries, because economic times and public transportation policies strongly differ. Russo and colleagues
      • Russo J.E.
      • McCool R.R.
      • Davies L.V.A.
      Telemedicine: an analysis of cost and time savings.
      analyzed the savings associated with a telemedicine program conducted between 2005 and 2013. This program was associated with average travel savings of 145 miles and 142 minutes per visit, and access to health care services was streamlined and made more convenient for patients. Other wider benefits include decreased fuel consumption and carbon emissions associated with traveling to a clinical review. It is clear that these cost savings are most substantial for individuals in rural areas or areas without a sleep clinic.
      • Spaulding R.
      • Stevens D.
      • Velasquez S.E.
      Experience with telehealth for sleep monitoring and sleep laboratory management.
      Surprisingly, the use of supporting tools generally results in better adherence, although it is not effective to change lifestyle and behaviors.
      • Pépin J.L.
      • Jullian-Desayes I.
      • Sapène M.
      • et al.
      Multimodal remote monitoring of high cardiovascular risk patients with OSA initiating CPAP: a randomized trial.
      Furthermore, the application of advanced devices depends largely on individual income, and thus is not useful for most patients of lower socioeconomic status.
      • Chen C.
      • Wang J.
      • Pang L.
      • et al.
      Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials.
      A few studies were conducted among Asian patients with OSA. Murase and colleagues
      • Murase K.
      • Tanizawa K.
      • Minami T.
      • et al.
      A randomized controlled trial of telemedicine for long-term sleep apnea continuous positive airway pressure management.
      showed the noninferiority of a telemonitoring system at 3-month follow-up in CPAP adherence, whereas Chumpangern and colleagues
      • Chumpangern W.
      • Muntham D.
      • Chirakalwasan N.
      Efficacy of a telemonitoring system in continuous positive airway pressure therapy in Asian obstructive sleep apnea.
      ,
      • Huang W.
      • Lee P.
      • Liu Y.
      • et al.
      0495 Prediction of obstructive sleep apnea using machine learning technique.
      ,
      • Huang W.C.
      • Lee P.-L.
      • Liu Y.
      • et al.
      Support vector machine prediction of obstructive sleep apnea in a large-scale Chinese clinical sample.
      reported an insignificantly higher CPAP compliance, and adherence was significantly higher in the telemonitoring group.

      More Efficient Management of Resources: Addition of Artificial Intelligence

      Telemedicine and Internet of things provide unprecedented opportunities for integrating comanagement approaches, multi-actor interactions and patient empowerment, and will generate a data deluge that could be addressed by advanced analytics.
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      Integrating information from diagnostic testing and positive airway pressure compliance databases could allow providers and systems to more efficiently manage resources. As an example, artificial intelligence could phenotype certain patient groups based on demographics or comorbidities and help providers allocate resources to those patients who have more complex diseases while providing lower cost care to patients who are doing well and unlikely to benefit from the more resource intensive model of care.
      • Freedman N.
      Doing it better for less: incorporating OSA management into alternative payment models.
      Instead of managing all patients in a similar fashion, data-driven decision-making could allow providers to better allocate resources, maintain or improve quality, reduce the cost of care, and improve value for insurers, providers, and patients.
      • Freedman N.
      Doing it better for less: incorporating OSA management into alternative payment models.
      In such a model, coordination of care with improved quality and efficiency will be valued more than the quantity of care that currently drives the traditional fee-for-service system.

      Reimbursement

      The promise of expanded OSA telemedicine applications is accompanied with cautious considerations. Practical implementation into clinical OSA workflows requires an understanding of local payment for teleservices as well as assessment of available resources.
      Practices may want to project potential lost in-person clinic revenue during telemedicine clinics and balance potential financial gains, because telemedicine visits may not be reimbursed at parity with in-person visits. Reimbursement at a relevant level for services rendered is the cornerstone of long-term revenue. Nevertheless, telemonitoring-guided support for PAP-treated patients reduces the number of patients terminating therapy, can improve PAP use, reduce the workload associated with follow-up for care providers, and will improve the economic model of treating sleep apnea patients at the end.
      • Woehrle H.
      • Arzt M.
      • Graml A.
      • et al.
      Effect of a patient engagement tool on positive airway pressure adherence: analysis of a German healthcare provider database.

      Need for Cost–Benefit Studies

      Further studies are needed to clarify if personalized concepts with telemonitoring and direct patient contact or fully automated feedback messaging systems are more cost effective and achieve similar adherence results.
      • Nilius G.
      • Schroeder M.
      • Domanski U.
      • et al.
      Telemedicine improves continuous positive airway pressure adherence in stroke patients with obstructive sleep apnea in a randomized trial.
      The likelihood of improved adherence with telemedicine interventions will need to be balanced against the resources needed to implement the program and will require robust cost effectiveness evaluations. Well-designed and adequately powered trials are needed to establish whether this approach is a clinically effective and cost-effective option for CPAP management. Future studies could specifically adopt both societal and health care perspectives in examining cost effectiveness in comparison with usual care.

      Changing paradigms and expanding horizons

      Based on evidence from the literature discussed in this article, outcomes seem to favor telemedicine approaches. The evolution of sleep medicine care is full of incredible opportunities given its natural reliance of technology and relevance to so many medical specialties.
      • Pepin J.L.
      • Tamisier R.
      • Hwang D.
      • et al.
      Does remote monitoring change OSA management and CPAP adherence?.
      The potential for telemedicine to change and restructure current care management paradigms is immense. Telemedicine can provide the links between sleep specialists, primary care, industry, and the multidisciplinary sleep team.

      Management Outside the Office

      Evidence supports the noninferiority of synchronous telemonitoring compared with usual care for adherence. Using a combination of face-to-face telemedicine appointments, cloud-based positive airway pressure compliance monitoring, and Internet-based communications and coaching, it is likely that many patients with uncomplicated OSA could be managed successfully outside of the office setting.
      • Munafo D.
      • Hevener W.
      • Crocker M.
      • et al.
      A telehealth program for CPAP adherence reduces labor and yields similar adherence and efficacity when compared to standard of care.
      ,
      • Hwang D.
      • Chang J.W.
      • Benjafield A.V.
      • et al.
      Effect of telemedicine education and telemonitoring on continuous positive airway pressure adherence. The Tele-OSA randomized trial.
      ,
      • Hoet F.
      • Libert W.
      • Sanida C.
      • et al.
      Telemonitoring in continuous positive airway pressuretreated patients improves delay to first intervention and early compliance: a randomized trial.
      For those patients who are doing well with their positive airway pressure therapy (or other treatments), a simple tele-health visit or Internet-based communication could suffice, leaving more time for patients with more complex problems to be evaluated in an office setting.
      • He K.
      • Palen B.N.
      • Mattox E.A.
      • et al.
      Veteran preferences regarding wireless management of positive airway pressure for obstructive sleep apnea at a tertiary health-care system.
      Also, self-monitoring of blood pressure and weight is gaining interest. Mendelson and colleagues
      • Mendelson M.
      • Vivodtzev I.
      • Tamisier R.
      • et al.
      CPAP treatment supported by telemedicine does not improve blood pressure in high cardiovascular risk OSA patients: a randomized, controlled trial.
      showed the feasibility of patient entry of blood pressure, CPAP use, sleepiness and quality of life data for clinician review, and McManus and colleagues
      • McManus R.J.
      • Mant J.
      • Franssen M.
      • et al.
      Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial.
      reported that patient self-monitoring of blood pressure, with or without telemonitoring, decreased blood pressure values after 1 year. These trends will certainly modify the patient–physician relationships.

      Monitoring of Therapies Other Than Continuous Positive Airway Pressure

      Emerging technologies are available that have sleep (position) e-monitoring capabilities.
      • Dieltjens M.
      • Vanderveken O.M.
      Oral appliances in obstructive sleep apnea.
      For instance, telemonitoring of oral appliance compliance data is feasible, based on temperature-sensing data chips embedded in the oral appliance. When combining with triple axis accelerometer technologies, oral appliance use times as well as supine versus nonsupine data can be monitored, and eventually shared web based between patient and care giver.
      • Dieltjens M.
      • Vanderveken O.M.
      Oral appliances in obstructive sleep apnea.
      Similar developments take place for hypoglossal nerve stimulation devices.
      Inspire sleep apnea innovation: table of contents.

      Lifestyle Modification

      Telemonitoring of CPAP devices is now proposed as one component of a more complex and integrated strategy that use mobile health applications and wearable sensors to monitor physiologic parameters, such as blood pressure, body weight, sleep duration, and physical activity. This also emphasizes the changing perspective regarding sleep, as it is currently considered at least as important as exercise or diet in general health.
      • Mukherjee S.
      • Patel S.R.
      • Kales S.N.
      • et al.
      An official American Thoracic Society statement: the importance of healthy sleep. Recommendations and future priorities.
      As stated elsewhere in this article, regarding comorbidities, CPAP treatment supported by a telemedicine system that included monitoring of blood pressure and sent reminders for physical activity and healthy diet via smartphones did not demonstrate efficacy in reducing cardiovascular risk in patients with OSA when used as secondary prevention.
      • Mendelson M.
      • Vivodtzev I.
      • Tamisier R.
      • et al.
      CPAP treatment supported by telemedicine does not improve blood pressure in high cardiovascular risk OSA patients: a randomized, controlled trial.
      In another study, telemonitoring was not superior to usual CPAP care for improving home blood pressure in patients with OSA and high cardiovascular risk.
      • Pépin J.L.
      • Jullian-Desayes I.
      • Sapène M.
      • et al.
      Multimodal remote monitoring of high cardiovascular risk patients with OSA initiating CPAP: a randomized trial.
      CPAP compliance was 0.53 hours higher compared with usual care, which was statistically significant, but the modest difference in CPAP adherence between the 2 arms was probably not enough to induce a significant reduction in blood pressure. In contrast, total cholesterol and triglyceride levels were significantly lowered, and high-density lipoprotein cholesterol improved in the telemonitoring arm. Also, patient-centered outcomes, namely, sleepiness and quality of life, improved. In symptomatic patients with OSA with low cardiovascular risk, the implementation of multimodal telemonitoring did not give better CPAP adherence than usual care. The success of telemonitoring may be dependent on knowing who best responds to these new telemedicine approaches (age, education, geographic setting, race, phenotype, cluster).

      Expanding Applications of Smartphone Apps and Wearables

      Sleep apps remain among the most popular apps downloaded for Apple and Android devices.
      • Khosla S.
      • Deak M.C.
      • Gault D.
      • et al.
      Consumer sleep technology: an American Academy of Sleep Medicine position statement.
      The number of apps is continuously growing, and a multitude of them claim to track and define sleep-related metrics, improve sleep quality, and even screen for sleep disorders. Unfortunately, these apps lack minimal validation regarding the ability to accurately perform these functions. Equally, consumer sleep technologies (wearables) are self-described lifestyle/entertainment devices that are not subject to US Food and Drug Administration approval. Although patients may not be as concerned about this lack of validation, they seem to recognize some shortcomings of consumer health-related technology. At the best, these apps and wearables could be considered in the context of a comprehensive sleep evaluation, but should not replace validated diagnostic instruments. Also, minimal validation data exist regarding the ability of consumer sleep technologies to perform the functions that they purport to. However, these devices become increasingly sophisticated, some may undergo validation and ultimately have a role in clinical care. So, it is important to acknowledge them as adjuncts that may help with communication with patients, goal setting, and increasing patient engagement.
      • O'Donnell C.
      • Ryan S.
      • McNicholas W.T.
      The Impact of telehealth on the organization of the health system and integrated care.
      Even more, by making use of environmental factors, like ambient light, ambient noise, accelerometer analysis to detect nonmovement patterns, and smartphone use patterns allows clinicians to accurately estimate the owner’s wake and sleep behavior. One promising approach is to add low-cost oximetry probes to a smartphone. Given the need of a continuous oximetry curve over a full night, this would put additional demands on the system in terms of battery power. Also, beat-to-beat processing is important to maintain the rapid changes in oximetry, which are very typical for sleep apnea and not observed in other conditions.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.
      Apps could also be helpful to empower patients. Isetta and colleagues developed an mHealth app called APPnea, aimed at promoting patients self-monitoring of CPAP treatment. APPnea gave patients daily reminders to answer 3 questions about their OSA treatment (“Did you use your CPAP more than 4 hour last night? Did you perform any physical activity yesterday? Did you follow the dietary advice given? and once weekly the app prompted the user to answer “How much do you weigh?”). Those patients who used APPnea regularly showed a trend toward higher CPAP compliance (+0.5 hours per night).
      • Isetta V.
      • Torres M.
      • González K.
      • et al.
      A New mHealth application to support treatment of sleep apnoea patients.
      The world of wearables and apps is here to stay, and our job is to figure out how to unlock the unlimited possibilities. Integration of these wearable sensors may add further actionable data that can potentially facilitate disease management.

      Integration in the e-Health Sleep Record

      Ideally, the data from CPAP devices should to be incorporated with the data regarding the physical status of the patients into the e-health sleep record. In a later stage, other aspects of digital technology will most likely be incorporated. Among them, integration of relevant health-related data collected from everyday apparel, wearable sensors and household appliances, increased interactivity between patients and health care provider, anticipation, and thus, hopefully prevent, worsening of medical disease states based on validated algorithms. Moreover, some consumer sleep technologies, usually smartphone- or tablet-based, to track or modify sleep are becoming widely available.
      • Ko P.R.
      • Kientz J.A.
      • Choe E.K.
      • et al.
      Consumer sleep technologies: a review of the landscape.
      These applications are transitioning to reliably track snoring, sleep, oximetry, heart rate and presence of sleep apnea. At the same time, artificial intelligence algorithms and software to collect individual and group analysis of body weight, blood pressure, sleepiness, and other data for prediction models are advancing. Pathways need to be explored for special populations or patients with combination sleep, breathing, medical, or comorbid disorders. How to best incorporate these and other new entities into best-practice standard, hybrid, and telemedicine OSA workflows currently seems a moving average.

      Remaining Barriers in the Incorporation of Telemedicine into Routine Clinical Practice

      Generalization of the use of telemedicine has been hampered by multiple practical barriers, such as the use of different CPAP brands, the lack of standardization of parameters used by different providers, preventing interoperability for health care professionals and the management of data within the existing electronic patient files.
      • Suarez-Giron M.
      • Bonsignore M.R.
      • Montserrat J.M.
      New organisation for follow-up and assessment of treatment efficacy in sleep apnoea.
      Some concerns could be raised because of the limitation to perform a physical examination during teleconsultations. However, some elements of the examination, such as blood pressure or body weight can be easily obtained by the nurse or primary care physician.
      • Suarez-Giron M.
      • Bonsignore M.R.
      • Montserrat J.M.
      New organisation for follow-up and assessment of treatment efficacy in sleep apnoea.
      Moreover, elderly subjects, who may benefit most from telemedicine services, may be disadvantaged because of cultural and practical barriers.
      • Peleg M.
      • Michalowski W.
      • Wilk S.
      • et al.
      Ideating mobile health behavioral support for compliance to therapy for patients with chronic disease: a case study of atrial fibrillation management.
      Similarly, economic issues may prevent use of telemedicine services in subjects with low socioeconomic status. From a data safety and health care regulation point of view, there is ongoing discussion about which data have to be regarded as general wellness and lifestyle data and which data have to be regarded as health care data to be used for medical diagnostic purposes.
      • Penzel T.
      • Schöbel C.
      • Fietze I.
      New technology to assess sleep apnea: wearables, smartphones, and accessories.
      Many regulatory aspects are still open to this kind of application. Also, reimbursement issues remain.

      COVID-19: Changing the Interest in Telemedicine

      Since the start of the lockdown for COVID-19, the clinical activity regarding patients with sleep-disordered breathing has stopped owing to the limited access of patients to the hospital, and the risk of droplet dispersion associated with the use of ©PAP.
      • Schiza S.
      • Simonds A.
      • Randerath W.
      Sleep laboratories reopening and COVID-19: a European perspective.
      According to a multicenter European study, a minority of sleep centers used telemedicine regularly during the first COVID-19 lockdown, mostly to monitor compliance to treatment rather than for full clinical management.
      • Grote L.
      • McNicholas W.T.
      • Hedner J.
      • et al.
      Sleep apnoea management in Europe during the COVID-19 pandemic: data from the European sleep apnoea database (ESADA).
      Care for patients with OSA is a highly specialized, because they are often aged and have multiple comorbidities.
      • Bonsignore M.R.
      • Baiamonte P.
      • Mazzuca E.
      • et al.
      Obstructive sleep apnea and comorbidities: a dangerous liaison.
      The high prevalence of OSA in the general population is associated with long waiting lists, further lengthened during the pandemic. Telemedicine could potentially tackle this problem,
      • Bruyneel M.
      Telemedicine in the diagnosis and treatment of sleep apnoea.
      ,
      • Suarez-Giron M.
      • Bonsignore M.R.
      • Montserrat J.M.
      New organisation for follow-up and assessment of treatment efficacy in sleep apnoea.
      but has not been included yet among the services provided by many health care systems.
      • Schiza S.
      • Simonds A.
      • Randerath W.
      Sleep laboratories reopening and COVID-19: a European perspective.
      A paradigm shift in sleep medicine practice after the COVID-19 pandemic has been foreseen, not only for OSA, but also for other sleep problems.
      • Irfan M.
      • Khalil W.
      • Iber C.
      Practicing sleep medicine amidst a pandemic: a paradigm shift.
      Last year, interest in telemedicine for the management of patients with OSA is emerging, with identification of advantages and drawbacks.
      • Verbraecken J.
      Telemedicine applications in sleep disordered breathing: thinking out of the box.
      Studies have mostly addressed questions regarding the role of telemedicine in monitoring compliance to CPAP treatment, or follow-up after the initiation of treatment for OSA, but overall advantages over usual care were small, as the results of telemedicine care were comparable to, and costs were slightly lower than the usual sleep laboratory-centered management.
      • Isetta V.
      • Negrin M.A.
      • Monasterio C.
      • et al.
      A Bayesian cost-effectiveness analysis of a telemedicine-based strategy for the management of sleep apnoea: a multicentre randomised controlled trial.
      The COVID-19 pandemic has dramatically raised the issue of safety, changing the balance in favor of telemedicine, and will likely grow in the future. COVID-19 has also accelerated efforts to regulate but also to bill telehealth care, which will fasten the implementation of telemedicine.

      Summary

      In this review, we demonstrated that telemedicine applications can be useful to monitor and motivate sleep apnea patients on a large scale. However, the effect sizes for compliance for telemedicine approaches are not as large as what has been achieved with the use of theory-driven approaches such as cognitive behavioral therapy, and the impacts on patient and provider satisfaction and cost effectiveness are not yet clear. These aspects of OSA care do not require substantial changes in care programs and strategies. In contrast, remotely monitored sleep studies and CPAP titration require more resources together with a change in patient care management. Given the turning hospital strategies toward more ambulatory care, telemedicine is going to evolve and it is very likely that there will be an increasing development of tools and activities in all areas of sleep medicine. Currently, efforts are being made to regulate but also to bill telehealth care, which will accelerate the implementation of telemedicine. This will certainly change the daily clinical practice, but we have to take into account the limitations of these techniques.
      In future, large-scale adequately powered pragmatic clinical trials are needed to better understand the effectiveness and the role of the telemedicine approach in managing sleep-disordered breathing. Evidence for the long-term follow-up effectiveness of telemonitoring interventions in improving adherence to CPAP treatment remains undecided owing to a scarcity of available studies and their mixed results. What happens when patients are no longer monitored or followed-up by visits to the clinic after their first months using the CPAP machine? Challenges and growing pains are to be expected, but clinical needs, existing technology, and opportunities for growth abound.

      Clinics Care Points

      • Careful telemedicine management will provide a more seamless communication flow, to the benefit of