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

BACKGROUND: Current continuous positive airway pressure (CPAP) devices can be monitored remotely; however, in-person visits are kept for clinical follow-up in order to promote CPAP use and resolve potential side-effects. Mobile health is a promising way to provide remote and easy clinical control for CPAP follow-up and support. We aimed to evaluate the feasibility and acceptance by obstructive sleep apnoea (OSA) patients and healthcare professionals of a newly designed mobile app (Appnea-Q) to promote clinical control through a self-monitoring tool for patients with CPAP supervised by sleep professionals. METHODS: Appnea-Q incorporates a simple follow-up questionnaire with automated responses, together with frequent problems and lifestyle recommendations sections. Feasibility, acceptance and usefulness were assessed. First, an internal validation was performed during outpatient CPAP follow-up visits with sleep professionals from various sleep units. Second, an external validation was performed in a subgroup of 15 patients at home. RESULTS: Most patients (n=75) considered the app useful and were willing to use it and recommend it (72-88%). Up to 64.87% agreed on its capacity to reduce hospital visits. Appnea-Q was rated as acceptable (79.37±19.29) by the system usability score. Sleep professionals (n=30) concurred on its usefulness for OSA patient follow-up, particularly during the first month of CPAP therapy. The external validation showed its feasibility among 11 out of 15 patients and their data were received accordingly on the professionals' web platform. CONCLUSIONS: According to our validation process, and the viewpoints of the patients and professionals, our new mobile app is a feasible and well-received tool for personal OSA management. Future clinical trials should substantiate its performance and cost-effectiveness in the clinical arena.

Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome / Concordancia intra e inter-médico en la decisión terapéutica para el síndrome de apnea del sueño

Background: Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHÍ < 40 events/h. Methods: Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss’ Kappa statistics (Kappa). Results: A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa = 0.83, 95% CI, 0.75-0.90, p < 0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa = 0.46, 95% CI, 0.42-0.51, p < 0.001). Nevertheless, it was especially low when considering AHÍ < 15 events/h. Conclusions: This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols

Introducción: La gran variedad de procedimientos diagnósticos y recomendaciones de tratamiento puede dificultar el manejo del síndrome de apnea obstructiva del sueño (SAHS), y del mismo modo comprometer la correcta interpretación de los resultados de ensayos clínicos multicéntricos, especialmente en pacientes con SAHS no grave. El objetivo de este estudio fue analizar la decisión terapéutica de distintos médicos expertos en sueño en pacientes con el índice de apnea hipopnea < 40 eventos/h. Métodos: Se pidió a seis especialistas con amplia experiencia en sueño de diferentes centros de España que tomaran una decisión terapéutica (terapia de presión positiva continua en las vías respiratorias o CPAP) basada en datos anónimos de los pacientes con sospecha de SAHS en los que previamente se había llevado a cabo un estudio del sueño. Los datos clínicos procedían de una base de datos online e incluían características antropométricas, cuestionarios clínicos, comorbilidades, examen físico y resultados del estudio del sueño. La concordancia intra- e interobservador de la toma de decisiones se analizó mediante el estadístico Fleiss' Kappa (Kappa). Resultados: Se analizaron un total de 720 decisiones médicas para evaluar el consenso entre profesionales del sueño. De manera global, la fiabilidad de la evaluación intraobservador fue casi perfecta (Kappa = 0,83; 95% CI; 0,75 a 0,90, p < 0,001). Sin embargo, la concordancia global interobservador disminuyó hasta alcanzar un grado moderado de consenso (Kappa = 0,46; 95% CI; 0,42 a 0,51, p < 0,001), que fue especialmente bajo cuando se tuvo en cuenta un índice de apnea hipopnea < 15 eventos/h. Conclusiones: Este estudio demuestra una buena concordancia intraobservador en la toma de decisiones terapéuticas de distintos médicos expertos en sueño que tratan a pacientes con SAHS leve o moderado. Sin embargo, los resultados relativos al acuerdo interobservador fueron notablemente peores. Estos hallazgos señalan la importancia de desarrollar mejores protocolos consensuados de manejo

Intra- and Inter-Physician Agreement in Therapeutic Decision for Sleep Apnea Syndrome.

BACKGROUND: Large variation in diagnostic procedures and treatment recommendations may hinder the management of obstructive sleep apnea (OSA) and also compromise correct interpretation of the results of multicenter clinical trials, especially in subjects with non-severe OSA. The aim of this study was to analyze the therapeutic decision-making between different sleep physicians in patients with AHI<40events/h. METHODS: Six experienced senior sleep specialists from different sleep centers of Spain were asked to make a therapeutic decision (CPAP treatment) based on anonymized recordings of patients with suspected OSA that has previously performed a sleep study. The clinical data was shown in an online database and included anthropometric features, clinical questionnaires, comorbidities, physical examination and sleep study results. Intra- and inter-observer decision-making were analyzed by the Fleiss' Kappa statistics (Kappa). RESULTS: A total of 720 medical decisions were taken to analyze the agreement between sleep professionals. Overall intra-observer evaluation reliability was almost perfect (Kappa=0.83, 95% CI, 0.75-0.90, p<0.001). However, overall inter-observer concordance decreased to moderate agreement (Kappa=0.46, 95% CI, 0.42-0.51, p<0.001). Nevertheless, it was especially low when considering AHI<15events/h. CONCLUSIONS: This study demonstrates a good intra-observer concordance in the therapeutic decision-making of different sleep physicians treating patients with low/moderate OSA. However, when analyzing inter-observer agreement the results were considerably worse. These findings underline the importance of developing improved consensus management protocols.

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

INTRODUCTION: Obstructive sleep apnea (OSA) is a prevalent disease associated with significant morbidity and high healthcare costs. Information and communication technology could offer cost-effective management options. OBJECTIVES: To evaluate an out-of-hospital Virtual Sleep Unit (VSU) based on telemedicine to manage all patients with suspected OSA, including those with and without continuous positive airway pressure (CPAP) therapy. METHODS: This was an open randomized controlled trial. Patients with suspected OSA were randomized to hospital routine (HR) or VSU groups to compare the clinical improvement and cost-effectiveness in a non-inferiority analysis. Improvement was assessed by changes in the Quebec Sleep Questionnaire (QSQ), EuroQol (EQ-5D and EQ-VAS), and Epworth Sleepiness Scale (ESS). The follow-up was 3 months. Cost-effectiveness was assessed by a Bayesian analysis based on quality-adjusted life-years (QALYs). RESULTS: The HR group (n: 92; 78% OSA, 57% CPAP) compared with the VSU group (n: 94; 83% OSA, 43% CPAP) showed: CPAP compliance was similar in both groups, the QSQ social interactions domain improved significantly more in the HR group whereas the EQ-VAS improved more in the VSU group. Total and OSA-related costs were lower in the VSU group than the HR. The Bayesian cost-effectiveness analysis showed that VSU was cost-effective for a wide range of willingness to pay for QALYs. CONCLUSIONS: The VSU offered a cost-effective means of improving QALYs than HR. However, the assessment of its clinical improvement was influenced by the choice of the questionnaire; hence, additional measurements of clinical improvement are needed. Our findings indicate that VSU could help with the management of many patients, irrespective of CPAP use.

The role of telemedicine in obstructive sleep apnea management.

INTRODUCTION: Obstructive sleep apnea (OSA) is a common disease that leads in notorious symptoms and comorbidities. Although general measures are important, continuous positive airway pressure (CPAP) is the best treatment option. However, compliance can be suboptimal and telemedicine may play a role to improve it. Areas covered: Review authors searched EMBASE, PubMed and Cochrane data bases using the following keywords: continuous positive airway pressure, Obstructive sleep apnea, telemedicine, respiratory telemedicine, information and communication technology. Papers published between 2000 and 2016 in English language were considered. Expert commentary: To improve OSA management, there is a pressing need to develop new cost-effective strategies, particularly those related to OSA treatment, from measures such as lifestyle changes to CPAP use. Two broad strategies should be implemented: 1) adequate pre-, peri-, and post-titration measures to ensure correct diagnosis, adequate training, and appropriate support during follow up; and 2) the use of technological advances including both the optimization of CPAP devices and the use of telemedicine, specially focused on the first days or weeks of treatment. Telemedicine can help with these processes, especially when it is personalized to the needs of each patient group.